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Discussing Treatment Options

Capozzi, James D. MD; Rhodes, Rosamond PhD; Chen, Darwin MD

Journal of Bone & Joint Surgery - American Volume: 01 March 2009 - Volume 91 - Issue 3 - p 740–742
doi: 10.2106/JBJS.H.01104
Ethics in Practice

A sixty-year-old man presented to an orthopaedic surgeon with a periprosthetic infection after total knee arthroplasty performed by another surgeon. He underwent removal of the components, placement of an antibiotic spacer, and antibiotic suppression therapy. Eight weeks later, a revision total knee arthroplasty was performed. The patient did well initially but returned four months after the revision with periprosthetic reinfection. The revision components were removed, another antibiotic spacer was placed, and antibiotic suppression therapy was again administered. During the operation, the entire extensor mechanism, including the quadriceps tendon, patella, and patellar tendon, was found to be necrotic and required radical débridement. Five months later, another operation was performed to remove the spacer, and a plastic surgeon was consulted to assist in the wound closure because of the presence of extensive scar tissue. Intraoperative cultures were negative during these two most recent procedures.

The orthopaedic surgeon presented the patient with four treatment options: arthrodesis, resection arthroplasty, amputation, or revision total knee arthroplasty with extensor mechanism allograft and a possible flap closure (rotational or free flap). The patient refused a knee arthrodesis and voiced a strong preference for amputation over arthrodesis. The patient's first choice, however, was to save the knee and to have a second radical revision performed. The surgeon then discussed in detail the risks that would be involved with reconstruction, including the high risk of reinfection and other wound complications. An infection, he explained, could lead to amputation, sepsis, and death. The surgeon also informed the patient that the procedure was not commonly performed, had no proven success rate, and could be fraught with complications. The patient remained steadfast in his choice and elected to undergo radical reconstruction of the knee.

1Department of Orthopaedic Surgery, Winthrop University Hospital, 222 North Station Road, Mineola, NY 11501. E-mail address:

2Department of Bioethics Education, Mount Sinai School of Medicine, One Gustave Levy Place, New York, NY 10029

3Department of Orthopaedics, Mount Sinai Medical Center, Manhattan Orthopedic and Sports Medicine Group, 1065 Park Avenue, New York, NY 10128

Copyright 2009 by The Journal of Bone and Joint Surgery, Incorporated
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