Background: Knee arthrodesis can be an effective treatment option for relieving pain and restoring some function after the failure of a total knee arthroplasty as the result of infection. The purpose of the present study was to review the outcome of a staged approach for arthrodesis of the knee with a long intramedullary nail after the failure of a total knee arthroplasty as the result of infection.
Methods: We reviewed the results for twelve patients who underwent knee arthrodesis after the removal of a prosthesis because of infection. The study group included seven women and five men who had an average age of sixty-eight years at the time of the arthrodesis. All patients were managed with a staged protocol. Implant removal, débridement, and insertion of antibiotic cement spacers was followed by the administration of systemic antibiotics. Provided that clinical and laboratory data suggested eradication of the infection, arthrodesis of the affected knee with use of a long intramedullary nail was carried out. Clinical and laboratory evaluation and radiographic analysis were performed after an average duration of follow-up of 4.1 years.
Results: Solid union was achieved in ten of the twelve knees. The average time to union was 5.5 months. One patient had an above-the-knee amputation because of recurrence of infection. In another patient, nail breakage occurred three years following implantation. The average limb-length discrepancy was 5.5 cm. The mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score improved from 41 to 64 points. None of the seven patients who underwent arthrodesis with a technique involving convex-to-concave reamers had a complication, and the average time to union for these seven patients was shorter than that for the remaining five patients (4.3 compared with 7.4 months).
Conclusions: We believe that obtaining large surfaces of bleeding contact bone during arthrodesis following staged treatment of an infection at the site of a failed total knee arthroplasty contributes to stability and enhances bone-healing. Staged arthrodesis with use of a long intramedullary nail and convex-to-concave preparation of bone ends provided a painless functional gait with low complication and reoperation rates in this challenging group of patients.
Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.
1 Federal North, 1307 Federal North Street, Pittsburgh, PA 15212. E-mail address for K. Bargiotas: email@example.com. E-mail address for N.G. Sotereanos: firstname.lastname@example.org
Failure of total knee arthroplasty as the result of infection is the main indication for knee arthrodesis1,2. In the case of a severely compromised knee, arthrodesis can restore some function and can relieve pain1-4.
Failure and reinfection rates are substantially higher after repeat revisions performed because of infection at the site of a total knee arthroplasty, and functional outcome may be poorer compared with that after a successful knee arthrodesis5-9. It appears that intramedullary nailing is associated with superior rates of fusion as compared with external fixation10. Also, arthrodesis following eradication of infection before nail insertion has been associated with a higher fusion rate and reduced healing time as compared with the findings after a one-stage procedure11. Achieving stability of the arthrodesis site and maximum contact between viable bone surfaces are the key factors to obtaining union12,13. The purpose of the present study was to determine the results of staged arthrodesis following the failure of total knee arthroplasty as the result of infection.
Materials and Methods
Forty-eight patients were admitted to our institution for the treatment of an infection at the site of a total knee arthroplasty from 1999 to 2003. Twelve of these patients eventually underwent a knee arthrodesis. In all twelve cases, a long intramedullary nail was used for fixation. All procedures were performed by the senior author (N.G.S.). Eleven patients were followed for a minimum of two years (range, two to six years; mean, 4.1 years), and one patient died eighteen months after the arthrodesis from unrelated causes.
Hospital records and serial radiographs of all patients were reviewed to evaluate patient status and the results of the operation.
The patients included seven women and five men who had a mean age of sixty-eight years (range, sixty-one to seventy-seven years) at the time of the arthrodesis. The number of previous procedures per patient, comorbidities, and bacteria causing the infections are shown in Table I.
The treatment goals were the eradication of infection and the achievement of a solid knee fusion. All patients were carefully assessed monthly until fusion occurred, both for healing of the arthrodesis site and for signs of infection.
The C-reactive protein level, erythrocyte sedimentation rate, and white blood-cell count were determined at each visit, followed by a thorough clinical evaluation.
Clinical and radiographic union was defined as the ability to walk without pain with no tenderness at the arthrodesis site, combined with the appearance of circumferential bridging callus on both anteroposterior and lateral radiographs14,15.
In order to assess functional outcome, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)16 was determined before the removal of implants and again at the time of the final office visit. At the same time, the limb-length discrepancy was recorded.
In all patients, the procedures were carried out through previously utilized anterior approaches. All patients underwent the same staged procedure. After the removal of implants, thorough soft-tissue débridement, and removal of infected necrotic bone, antibiotic-loaded polymethylmethacrylate spacers were prepared and inserted. We used 6 g of tobramycin and 6 g of vancomycin per 40 g of polymethylmethacrylate.
In three patients, débridement and exchange of spacers had to be carried out twice because of evidence of recurrence of infection. On the basis of cultures and the results of sensitivity testing, appropriate intravenous antibiotics were administered for a period of four to six weeks, followed by an observation period of four to eight weeks.
Knee arthrodesis was not performed until clinical and laboratory data suggested eradication of infection. These data included a normal C-reactive protein level and erythrocyte sedimentation rate after the discontinuation of intravenous antibiotics as well as evidence that the wound had healed and had remained quiescent.
At the time of the proposed arthrodesis, the spacers were removed. Débridement of the soft tissue and the medullary canals was performed and the bone end cuts were freshened, followed by thorough irrigation with pulsed lavage. Tissue samples were obtained from multiple sites (including the medullary canal of both the tibia and the femur) for frozen-section analysis. If the polymorphonuclear leukocyte count was less than ten per high-power field17, knee arthrodesis was then carried out.
In the first five cases, parallel tibial and femoral bone cuts were made in order to achieve maximum contact of viable bleeding cancellous bone. An effort was made to make the bone cuts parallel, with no or minimal gaps. Some knees required substantial shortening to achieve maximum bone contact, viability, and stability.
Because we used a curved nail with an 18° radius in the sagittal plane, achievement of maximum contact was technically difficult at the arthrodesis site. Therefore, in the next seven cases, we used a different technique. A pair of matched convex-to-concave reamers were used to prepare the tibial and femoral surfaces. This technique created a ball-and-socket configuration that provided large contact areas of viable bleeding bone (Figs. 1-A and 1-B), improved stability, and maintained congruency after the insertion of the bowed nail (Figs. 2-A and 2-B). The tibia was reamed to its maximum diameter, and then an intramedullary nail (Biomet, Warsaw, Indiana) with a diameter of 1.0 to 1.5 mm less than the diameter of the last reamer was chosen. The femur was then prepared to the same size as the last reamer used on the tibia, and the long intramedullary nail was inserted and locked distally with two cross-locking screws. Finally, to ensure apposition and compression, the nail was hammered in reverse and then was statically locked proximally.
Two patients with excessive scarring due to multiple skin incisions or previous sinuses had a local flap transfer for wound coverage at the time of arthrodesis. In the remaining ten patients, wound closure over a drain was carried out in a routine fashion.
All patients were allowed to walk with an aid on the second postoperative day, with partial weight-bearing as tolerated.
Mean values and standard deviations for the time to fusion, the WOMAC score, and limb-length discrepancy were calculated with use of a standard computer spreadsheet program (Excel; Microsoft, Redmond, Washington). Institutional review board approval was obtained, and all patients were informed that data concerning their cases would be submitted for publication.
Ten of the twelve patients had achievement of a solid radiographic and clinical fusion, were able to walk with no pain, and had no evidence of instability or recurrent infection (Figs. 2-A and 2-B). One patient underwent an above-the-knee amputation. Despite débridement and exchange of the intramedullary nail, the infection persisted. Two months after the index arthrodesis, the patient was diagnosed with a lymphoma and was managed with chemotherapy and radiation therapy. This patient died eighteen months after the arthrodesis from causes that were not related to the index procedure.
In one patient, who was morbidly obese, the knee was assessed as being clinically and radiographically fused at 5.5 months. The patient was able to walk without pain at the time of the sixteen-month follow-up visit. Three years after the index procedure, the patient was readmitted because of the sudden onset of knee pain and breakage of a nail at the arthrodesis site. There was no evidence of recurrent infection. The patient refused additional surgical intervention and was walking with a walker and an extension brace at the time of the latest follow-up.
In one patient, the nail was removed because of a suspected low-grade infection at one year. Reaming and irrigation was carried out. Reinsertion of the nail was not necessary because a solid fusion had already been achieved. There were no other complications or reoperations in the present series.
The average time to union was 5.5 months (range, 3.5 to 12.4 months). The average time to union for the seven patients who underwent preparation of the bone ends with convex-to-concave reamers was shorter than that for the remaining five patients (4.3 compared with 7.4 months).
The mean WOMAC score improved from 41 points (range, 34 to 47 points) before removal of the prostheses to 64 points (range, 40 to 72 points) two years postoperatively.
The average postoperative limb-length discrepancy was 5.5 cm (range, 3.1 to 8.0 cm). Two patients walked with an insole, whereas the rest of the patients required external shoe-lifts. Of the ten patients with a successful arthrodesis, one used a walker, seven used a cane (five on a regular basis and two on an occasional basis), and two walked without any aid at the time of the latest follow-up. The times to union, WOMAC scores, and limb-length discrepancies are shown in Table II.
The indications for the conversion of a total knee arthroplasty to an arthrodesis because of infection are not clear, and the decision-making process is difficult. The surgeon must keep in mind that the functional results after multiple total knee arthroplasty revisions are often poor4,5.
Patients with compromised general health or comorbidities such as diabetes mellitus, smoking, obesity, poor local wound conditions, failure of the extensor mechanism, and/or infection with virulent, antibiotic-resistant bacteria are at a higher risk for the recurrence of infection and failure after reimplantation of a total knee replacement2,18,19. For instance, successful treatment of an infection at the site of a total knee arthroplasty in the presence of methicillin-resistant Staphylococcus aureus is known to be very difficult20. Both of the treatment failures in the present series occurred in patients who had a history of either immunosuppression or diabetes and obesity and the presence of methicillin-resistant Staphylococcus aureus.
In patients with a failed total knee arthroplasty, external fixation with a variety of devices and intramedullary nailing have both been employed21-23. Damron and McBeath, in a review of fifty-six knees, reported a fusion rate of 94% in patients managed with intramedullary rods compared with a 64% rate in patients managed with external fixators24. In general, fusion rates in studies in which external fixators were used were inferior to rates in studies in which intramedullary nails were used3,7,11,21,24-30. In a review of the literature, Wiedel10 reported that external fixation devices were associated with fusion rates ranging from 43% to 71% in five series ranging in size from seven to seventy-one patients9,13,31-33 and that intramedullary nailing was associated with success rates of 83% to 100% in nine series ranging in size from nine to twenty-one 3,11,28-30,33-37.
Intramedullary nails provide greater stability38, avoid pin-track infection, allow faster weight-bearing, and generally are better tolerated than external fixators are3,4,39,40. Several authors have reported good results in association with the use of intramedullary nailing after staged eradication of infection7,35.
One-stage procedures have been used for the treatment of infection in knees with prostheses29,30,41, but the results of two-stage procedures have been reported to be better in terms of both union rate and healing time11,42.
In the present series, union was achieved in ten of twelve patients. We believe that two factors contributed substantially to these favorable results. First, every effort was made to ensure that the infection was eradicated by the time of the arthrodesis. Second, maximum contact and compression of viable cancellous bone ends was the ultimate intraoperative goal. Rigid fixation, compression, and an adequate biologic environment are known to be key elements for bone-healing12,13,21,32,40. Charnley believed that the high success rate that he achieved in association with knee arthrodeses (99%; 169 of 171) was due to two well-coapted surfaces of cancellous bone with intact circulation12.
In seven of our patients, a pair of matched convex-to-concave reamers were used to provide bone-contact areas with a ball-and-socket configuration. Large, bleeding surfaces were prepared in this manner (Figs. 1-A and 1-B). The convex-to-concave configuration allowed maximum contact even in knees in which nail insertion necessitated alterations of the knee alignment. Although our numbers are too small to allow us to draw solid conclusions, none of these seven patients had a complication and the mean time to fusion was shorter than that for the first five patients in the present series, who did not have this treatment (4.3 compared with 7.4 months).
We believe that a staged procedure provides a better environment for bone-healing because eradication of infection allows the bone and soft tissue to revascularize. We recommend the use of a curved nail with an 18° radius of curvature in the sagittal plane and aggressive bone resection in order to achieve maximum contact and stability of fixation. Substantial shortening of the affected extremity following knee fusion has been reported in the literature8,25,30,43,44. In our series, the average limb-length discrepancy was 5.5 cm (range, 3.1 to 8.0 cm).
Most of our patients were able to walk with an aid and were using shoe-lifts at the time of the last follow-up. The mean postoperative WOMAC score was 64 points (range, 40 to 72 points), and the patients with a solid fusion reported a stable, painless extremity with difficulty climbing stairs and when sitting in cars and airplanes.
We believe that arthrodesis can provide a painless, functional limb in patients who are physically and psychologically compromised following multiple failed surgical interventions. We agree with Conway et al., who stated that the overall outcome of a successful arthrodesis is better than the outcome of an amputation or a poor revision2. In the present series, the eradication of infection before nail insertion and the preparation of large congruent contact surfaces of viable bleeding cancellous bone resulted in a high success rate and favorable functional results. We believe that conversion of a total knee arthroplasty to an arthrodesis should be considered for the treatment of infection, particularly in patients who have had multiple operations and in those who are medically compromised. ▪
A video supplement to this article will be available from the Video Journal of Orthopaedics. A video clip will be available at the JBJS web site, . The Video Journal of Orthopaedics can be contacted at (805) 962-3410, web site: .
The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Orthopaedics, Allegheny General Hospital, Pittsburgh, Pennsylvania
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