scholarly journals Failure Analysis in Multiple TKA Revisions—Periprosthetic Infections Remain Surgeons’ Nemesis

2022 ◽  
Vol 11 (2) ◽  
pp. 376
Author(s):  
Stephanie Kirschbaum ◽  
Sarah Erhart ◽  
Carsten Perka ◽  
Robert Hube ◽  
Kathi Thiele

Background: The aim of this study was to categorize reasons for failure and to analyze the survivorship of multiple total knee arthroplasty (TKA) revisions. Methods: The study retrospectively evaluated all multiple TKA revisions performed between 2005 and 2015 at the authors’ institutions. Sixty-three patients (35 female, 28 male, age 64 ± 10 years, follow-up 55 ± 36 months) underwent a total of 157 re-revision TKA surgeries (range 2–5). The revision indications were divided up into main diagnoses. Survivorship was evaluated by mixed model analysis. Results: The main overall reason for re-revision was periprosthetic joint infection (PJI) (48%), followed by instability (12%), polyethylene wear (11%), malpositioning (8%), and aseptic loosening (8%). Survivorship shortened with an increasing number of revision surgeries (p = 0.003). While PJI was in 38% of all cases, the reason for the first revision, incidence increased constantly with the number of revisions (48% at second revision, 55% at third revision, 86% at fourth revision, and 100% at fifth revision, p = 0.022). If periprosthetic infection caused the first revision, patients showed an average of two more septic revisions at follow-up than patients with an aseptic first revision indication (p < 0.001). In 36% of cases, the reason for follow-up surgery in case of periprosthetic infection was again PJI. Conclusion: The probability of survival of the implanted knee arthroplasty is significantly reduced with each subsequent revision. Periprosthetic infection is the main cause of multiple revisions.

2018 ◽  
Vol 12 (1) ◽  
pp. 554-566
Author(s):  
Malcolm R. DeBaun ◽  
Stuart B. Goodman ◽  
David W. Lowenberg

Background and Objective: Persistent periprosthetic joint infection (PJI) is a devastating complication after Total Knee Arthroplasty (TKA). We hypothesize that our novel treatment algorithm utilizing a customized knee spanning recon nail combined with an antibiotic eluting cement spacer improves ambulation status and prevents recurrent PJI in patients with failed TKA and severe bone loss. Methods: In a retrospective case series, 15 consecutive patients who underwent knee arthrodesis after failed ipsilateral TKA secondary to infection from 2004-2017 with at least 1 year of follow-up were enrolled. The average age of patients at the time surgery was 68 (range 50-81) years with an average follow-up of 3.2 (range 1-6) years. Post-surgical ambulation status and eradication of index infection were analyzed as primary outcomes using McNemar’s test for before-and-after study design with p<0.05 for significance. Results: Cement arthrodesis significantly improved ambulation with 67% (10/15) of patients unable to ambulate before arthrodesis and 93% (14/15) of patients able to ambulate at final follow-up (p=0.004). The complication rate was 20% (3/15). There were no periprosthetic fractures. Amongst patients who presented with active PJI, 91% (10/11) had eradication of their index infection final follow-up (p=0.002). Overall prevention of recurrent index infection was 93% (14/15) (p=0.0001). Conclusion: Cement arthrodesis utilizing a custom knee spanning recon nail combined with an antibiotic eluting spacer improves ambulation status and prevents or treats recurrent infection in the majority of patients who have failed total knee arthroplasty.


2017 ◽  
Vol 5 (5_suppl5) ◽  
pp. 2325967117S0020
Author(s):  
Simon W Young ◽  
Chuan Kong Koh ◽  
Saiprasad Ravi ◽  
Mark Zhu ◽  
Kelly G Vince

Introduction and Aims: As national total knee arthroplasty (TKA) registries evolve, there is an increasing trend towards publication of hospital and surgeon-level outcome data, with the goal of stimulating efforts to optimise the results of TKA. Such efforts first require understanding of the current mechanisms of TKA failure. Previous reports on revision TKA from tertiary referral centres lack data on the overall denominator, thus the relative importance of each failure mechanism leading to TKA revision over long term follow up remains unclear. The aim of this study was to analyse reasons for revision following primary TKA, and assess their relative frequencies over long-term follow-up. Methodology: 11,134 primary TKA performed between 2000-2015 at one of three tertiary referral hospitals were identified. ‘Failure’ was defined as patients undergoing subsequent revision surgery involving change of of one or more components or reoperation for deep periprosthetic joint infection (PJI). Patients were identified from a combination of the New Zealand National Joint Registry and individual search of patient records and clinical coding (ICD-9 and ICD-10). All relevant clinical records, radiographs, and lab results were obtained from all New Zealand hospitals to identify the primary reason for revision according to a standardised protocol. Results: A total of 357 (3.2%) failures over the 15 year period were identified. Of these, 36% were revised within one year and 56% were revised within 2 years of primary TKA. Periprosthetic joint infection (PJI) encompassed 48% of all reasons for revision, followed by aseptic loosening (15%), secondary patella resurfacing (14%), tibio-femoral instability (9%), stiffness (5%), polyethylene wear (2.5%), periprosthetic fracture (2.3%), patella maltracking (1.9%) and extensor mechanism discontinuity (0.9%). In the first 5 years following primary TKA, the most common reason for revision was PJI (52%), from 5-10 years PJI and aseptic loosening (35% each), and from 10-15 years aseptic loosening (41%). Conclusion: In this large cohort of patients with comprehensive follow up, PJI was the dominant reason for failure particularly in the first 10 years. Aseptic loosening becomes more important after 10 years follow up. Efforts to improve outcomes following primary TKA should focus on these areas, particularly prevention of PJI.


Author(s):  
Sabrina Böhle ◽  
Sebastian Rohe ◽  
Julia Kirschberg ◽  
Olaf Brinkmann ◽  
Jörn Seeger ◽  
...  

AbstractPersistent periprosthetic infection following total knee arthroplasty is one of the most dreaded complications of orthopaedic surgery. Treatment strategies include arthrodesis of the knee joint, stable fistula, long-lasting antibiotic therapy, or above-knee amputation. The advantage of amputation in comparison to other treatment options is the possible cure of infection, because the source of infection is removed and no foreign material left in situ. The aim of the study is to examine whether a septic amputation of the femur in case of persistent periprosthetic infection at the knee joint leads to the healing of the patient. Moreover, the physical and mental state should be evaluated. All patients with above-knee amputation because of periprosthetic joint infection after primary total knee arthroplasty between 2016 and 2018 were included in this retrospective study. A questionnaire with the clinical scores visual analog scale, modified Lysholm, Western Ontario and McMaster Universities Osteoarthritis Index and 36-Item Short Form Survey has been designed. In addition, all characteristics and perioperative data were documented. Eleven patients were included in the study. One patient died after above-knee amputation; all other patients live with a marked impairment of quality of life but with absence of the infection of the leg. Two out of ten are able to walk regularly with an exoprosthesis with forearm crutches, 50% are in a wheelchair, while 30% are bedridden. Patients with above-knee amputation after persistent periprosthetic infections were free of infection and without signs of inflammation. However, this is associated with worse mobility and high mortality rate.


Author(s):  
Vasili Karas ◽  
Richard W. Rutherford ◽  
Thomas A. Herschmiller ◽  
Johannes F. Plate ◽  
Michael P. Bolognesi ◽  
...  

AbstractThe articulating antibiotic spacer is a treatment utilized for two-stage revision of an infected total knee arthroplasty. The original femoral component is retained and reused in one described variation of this technique. The purpose of this study is to determine the safety and efficacy of flash sterilization of the femoral component for reimplantation in an articulating antibiotic spacer for the treatment of chronic periprosthetic joint infection. A total of 10 patients were identified prospectively with a culture positive infected total knee arthroplasty. The patients underwent explantation, debridement, and placement of an articulating antibiotic spacer consisting of the explanted and sterilized femoral component and a new polyethylene tibial insert. The explanted tibial components were cleaned and flash-sterilized with the femoral components, but the components were then aseptically packaged and sent to our microbiology laboratory for sonication and culture of the sonicate for 14 days. Ten of 10 cleaned tibial components were negative for bacterial growth of the infecting organism after final testing and analysis. At 18-month follow-up, 9 of 10 of patients remained clear of infection. Among the 10 patients, 7 were pleased with their articulating spacer construct and had no intention of electively pursuing reimplantation. Also, 3 of 10 of patients were successfully reimplanted at a mean of 6.5 months after explantation. Autoclave sterilization and reimplantation of components may be a safe and potentially resource-sparing method of articulating spacer placement in two-stage treatment of PJI. Patient follow-up demonstrated clinical eradication of infection in 90% of cases with good patient tolerance of the antibiotic spacer.


2020 ◽  
Vol 8 (5_suppl5) ◽  
pp. 2325967120S0010
Author(s):  
Ng Bing Wui ◽  
Abdul Muttalib bin Abdul Wahid ◽  
Ong Kean Chao ◽  
Loi Kai Weng

Introduction: Treatment of comminuted intra-articular fractures around the knee in the elderly population could be challenging. Factors such as pre-existing comorbidities, osteoporosis, cartilage damage and deformity could make fracture reduction difficult. Patients outcome is guarded due to risk of delayed or non-union, delayed weight bearing and prolonged rehabilitation phase. Methods: We present a retrospective study on 12 patients who underwent early primary total knee replacement after sustaining intra-articular fracture around the knee from 2017 to 2019. Legacy Constrained Condylar Knee (LCCK) were used and patients were follow-up at 3, 6 and 12 months. Results: Mean follow-up period is 14 months. All except one patient received Posterior Stabilized insert while other patients had LCCK. Two patients were complicated with prosthetic joint infection requiring debridement and revision surgery. The remaining patients achieved full knee extension and average flexion of 100 degrees. Conclusion: Early knee arthroplasty is able to achieve excellent short-term outcome in treatment of comminuted intra-articular fractures around the knee in elderly patients


2021 ◽  
Vol 23 (6) ◽  
pp. 411-416
Author(s):  
Alpaslan Öztürk ◽  
Nazan Çevik ◽  
Yavuz Akalın ◽  
Oğuz Çetin ◽  
Özgür Avci( ◽  
...  

Background. This study evaluates 15 years’ results of the implantation of autoclaved femoral and tibial prosthesis components together with a new same brand polyethylene insert which were used as a temporary articulating spacer in patients with periprosthetic infection of total knee arthroplasty (TKA) in a two-stage reimplantation procedure in 6 patients.  Material and methods. The femoral and tibial prostheses of 6 patients with deep chronic periprosthetic infection of TKA who underwent elective two-stage exchange arthroplasty were autoclaved and reinserted with a new polyethylene insert of the same brand and bone cement mixed with tecoplanin in 2004. Results. Four patients were followed for 15 years. They were all female and between 47-70 years old. The infectious agent was meticillin-resistant Staphylococcus aureus (MRSA) in 3 and coagulase negative Staphy­lococcus in one patient. Patients were invited for second stage reimplantation, but they refused to undergo the second stage. Three of them had their second stage reimplantation after 15, 13 and 10 years while one patient was reinfected after 5 years, in 2009, and arthrodesis was performed. They were all happy with the result and infection free at last follow-up.  Conclusions. 1. Regarding the results of our patients, reinsertion of autoclaved femoral and tibial prostheses together with a new same brand polyethylene insert with teicoplanin loaded bone cement can be used cautiously in the management of periprosthetic deep infection of TKA. 2. That is because patients might not want the second stage reimplantation. 3. We believe that the refusal of patients to undergo the surgery shows that the single-stage treatment is effective.


2021 ◽  
Vol 103-B (6 Supple A) ◽  
pp. 177-184
Author(s):  
Mason E. Uvodich ◽  
Evan M. Dugdale ◽  
Douglas R. Osmon ◽  
Mark W. Pagnano ◽  
Daniel J. Berry ◽  
...  

Aims It remains difficult to diagnose early postoperative periprosthetic joint infection (PJI) following total knee arthroplasty (TKA). We aimed to validate the optimal cutoff values of ESR, CRP, and synovial fluid analysis for detecting early postoperative PJI in a large series of primary TKAs. Methods We retrospectively identified 27,066 primary TKAs performed between 2000 and 2019. Within 12 weeks, 169 patients (170 TKAs) had an aspiration. The patients were divided into two groups: those evaluated ≤ six weeks, or between six and 12 weeks postoperatively. The 2011 Musculoskeletal Infection Society (MSIS) criteria for PJI diagnosis in 22 TKAs. The mean follow-up was five years (two months to 17 years). The results were compared using medians and Mann-Whitney U tests and thresholds were analyzed using receiver operator characteristic curves. Results Within six weeks, the median CRP (101 mg/l vs 35 mg/l; p = 0.011), synovial WBCs (58,295 cells/μl vs 2,121 cells/μl; p ≤ 0.001), percentage of synovial neutrophils (91% vs 71% (p < 0.001), and absolute synovial neutrophil count (ANC) (50,748 cells/μl vs 1,386 cells/μl (p < 0.001) were significantly higher in infected TKAs. Between six and 12 weeks, the median CRP (85 mg/l vs 5 mg/l (p < 0.001)), ESR (33 mm/hr vs 14 mm/hr (p = 0.015)), synovial WBCs (62,247 cells/μl vs 620 cells/μl (p < 0.001)), percentage of synovial neutrophils (93% vs 54% (p < 0.001)), and ANC (55,911 cells/μl vs 326 cells/μl (p < 0.001)) were also significantly higher in infected TKAs. Optimal thresholds at ≤ six weeks were: CRP ≥ 82 mg/l (sensitivity 70%, specificity 77%), synovial WBCs ≥ 8,676 cells/μl (83%, 90%), percentage of synovial neutrophils ≥ 88% (67%, 78%), and ANC ≥ 8,346 cells/μl (83%, 91%). Between six and 12 weeks, thresholds were: CRP ≥ 34 mg/l (90%, 93%), synovial WBCs ≥ 1,983 cells/μl (80%, 85%), percentage of synovial neutrophils ≥ 76% (80%, 81%), and ANC ≥ 1,684 cells/μl (80%, 87%). Conclusion Early PJI after TKA should be suspected within six weeks if the CRP is ≥ 82 mg/l, synovial WBCs are ≥ 8,676 cells/μl, the percentage of synovial neutrophils is ≥ 88%, and/or the ANC is ≥ 8,346 cells/μl. Between six and 12 weeks, thresholds include a CRP of ≥ 34 mg/l, synovial WBC of ≥ 1,983 cells/μl, a percentage of synovial neutrophils of ≥ 76%, and/or an ANC of ≥ 1,684 cells/μl. Cite this article: Bone Joint J 2021;103-B(6 Supple A):177–184.


2021 ◽  
Vol 103-B (6 Supple A) ◽  
pp. 32-37
Author(s):  
Santiago Restrepo ◽  
Eric B. Smith ◽  
William James Hozack

Aims Cementless total knee arthroplasty (TKA) offers the potential for strong biological fixation compared with cemented TKA where fixation is achieved by the mechanical integration of the cement. Few mid-term results are available for newer cementless TKA designs, which have used additive manufacturing (3D printing). The aim of this study was to present mid-term clinical outcomes and implant survivorship of the cementless Stryker Triathlon Tritanium TKA. Methods This was a single institution registry review of prospectively gathered data from 341 cementless Triathlon Tritanium TKAs at four to 6.8 years follow-up. Outcomes were determined by comparing pre- and postoperative Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) scores, and pre- and postoperative 12-item Veterans RAND/Short Form Health Survey (VR/SF-12) scores. Aseptic loosening and revision for any reason were the endpoints which were used to determine survivorship at five years. Results At mid-term follow-up, the mean KOOS JR score improved significantly from 33.14 (0 t0 85, standard deviation (SD) 21.88) preoperatively to 84.12 (15.94 to 100, SD 20.51) postoperatively (p < 0.001), the mean VR/SF-12 scores improved significantly from physical health (PH), 31.21 (SD 5.32; 23.99 to 56.77) preoperatively to 42.62 (SD 10.72; 19.38 to 56.82) postoperatively (p < 0.001) and the mental health (MH), 38.15 (SD 8.17; 19.06 to 60.75) preoperatively to 55.09 (SD 9.64; 19.06 to 66.98) postoperatively (p < 0.001). A total of 11 revisions were undertaken, with an overall revision rate of 2.94%, including five for periprosthetic joint infection (1.34%), three for loosening (0.80%), two for instability (0.53%), and one for pain (0.27%). The overall survivorship was 97.06% and survivorship for aseptic loosening as the endpoint was 98.40%, with a 99.5% survivorship of the 3D-printed tibial component. Conclusion This 3D-printed cementless total knee system shows excellent survivorship at mid-term follow-up. This design and the ability to obtain cementless fixation offers promise for excellent long-term durability. Cite this article: Bone Joint J 2021;103-B(6 Supple A):32–37.


Joints ◽  
2014 ◽  
Vol 02 (03) ◽  
pp. 109-114 ◽  
Author(s):  
Giuseppe Solarino ◽  
Antonio Spinarelli ◽  
Massimiliano Carrozzo ◽  
Andrea Piazzolla ◽  
Giovanni Vicenti ◽  
...  

Purpose: to evaluate the differences in clinical outcome and survivorship of three different mobile bearings for total knee arthroplasty. Methods: a retrospective study was conducted in 60 patients (53 females, 7 males, mean age: 68 years and 5 months) each submitted to total knee replacement using one of the three different mobile bearings of the LCS system (Depuy Johnson & Johnson, Warsaw, IN). The diagnosis was knee osteoarthritis in 57 cases and rheumatoid arthritis in three cases. Three different groups of 20 cases each were identified: total knee arthroplasties with mobile menisci (group 1); total knee arthroplasties with the rotating platform (group 2); and total knee arthroplasties with the anteroposterior glide platform (group 3). As regards the component fixation, 33 implants were cementless, three were cemented, and in 24 only the tibial component was cemented. The patella was not replaced. Results: although the duration of follow-up differed between the three groups, the clinical and radiological results at final follow-up showed no revision of femoral and/or tibial components for mechanical or septic reasons, and no signs of impending failure. One meniscal bearing, showing polyethylene wear after 17 years, was successfully replaced. Conclusions: the present retrospective study confirmed the long-term effectiveness of knee implants with mobile bearings, in which the congruity of the surfaces makes it possible to overcome the problem of high contact stresses that may result in polyethylene wear and osteolysis; at the same time, these implants eliminate constraint forces thereby reducing the risk of mechanical loosening. Level of evidence: Level III, retrospective comparative study.


2021 ◽  
Vol 33 (1) ◽  
Author(s):  
Takashi Hoshino ◽  
Toshifumi Watanabe ◽  
Yusuke Nakagawa ◽  
Hiroki Katagiri ◽  
Nobutake Ozeki ◽  
...  

Abstract Purpose This study assessed the clinical outcomes of periprosthetic joint infection patients who underwent two-stage revision total knee arthroplasty with antibiotic-loaded cement spacers fabricated using a handmade silicone mold. Materials and methods This study included seven patients (average age 77 years, average follow-up time 54 months) who underwent surgery at our hospital between 2009 and 2013. Clinical outcomes including knee scores, function scores, knee range of motion, and walking ability at the final observation, period from the primary total knee arthroplasty to implant removal, period from implant removal to revision total knee arthroplasty, and follow-up period after revision total knee arthroplasty were investigated. Results At the final follow-up, the average knee range of motion was 99°, with no significant differences at each stage; average knee and function scores were 84 and 77, respectively. With cement spacers, five patients were able to walk with a t-cane. No recurrence of infection was observed. Conclusions The clinical outcomes of the current case series demonstrated good knee function with preserved walking ability, without any recurrence of periprosthetic joint infection. This study suggests that using a handmade silicone mold could be an effective option for periprosthetic joint infection after a total knee arthroplasty.


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