Developing a strategy to treat established infection in total knee replacement

Abstract

This review summarises the opinions and conclusions reached from a symposium on infected total knee replacement (TKR) held at the British Association of Surgery of the Knee (BASK) annual meeting in 2011. The National Joint Registry for England and Wales reported 5082 revision TKRs in 2010, of which 1157 (23%) were caused by infection. The diagnosis of infection beyond the acute post-operative stage relies on the identification of the causative organism by aspiration and analysis of material obtained at arthroscopy. Ideal treatment then involves a two-stage surgical procedure with extensive debridement and washout, followed by antibiotics. An articulating or non-articulating drug-eluting cement spacer is used prior to implantation of the revision prosthesis, guided by the serum level of inflammatory markers. The use of a single-stage revision is gaining popularity and we would advocate its use in certain patients where the causative organism is known, no sinuses are present, the patient is not immunocompromised, and there is no radiological evidence of component loosening or osteitis. It is our opinion that single-stage revision produces high-quality reproducible results and will soon achieve the same widespread acceptance as it does in infected hip arthroplasty.

Can Good Infection Control Be Obtained in One-stage Exchange of the Infected TKA to a Rotating Hinge Design? 10-year Results

“…Our results in terms of survivorship free from infection with the single-stage approach appear comparable to those offered by a systematic review of the results of septic TKA revision, which reported mean eradication rates of 90.6% for two-stage and 89.2% for one-stage surgery [32] as well as with other recent studies on the subject of one-stage exchange [36,39,40]. The higher eradication rate after the two-stage revision, especially in combination with a mobile spacer, was based on numerous publications with shortterm followup and/or a low number of study patients with an eradication rate of up to 100%.…”

“…Our definition was based on clinical signs of PJI and not on aspiration or serologic testing at the time of latest followup, which was judged to be unreasonable in asymptomatic patients. Infection control after TKA is influenced by several risk factors, including patient comorbidities, sex, and the causative microorganism [14,40]. A powerful statistical analysis of these factors was not possible as a result of the low number of patients in each group with risk factors.…”

“…Some studies have shown possible advantages of one-stage exchange for the infected TKA in selected patients [14], including the need for only one surgical procedure, shorter hospitalization time, reduced time on antibiotic therapy, reduced overall costs, and improved patient satisfaction [16,29,39,40]. In addition, an increasing number of publications have reported on one-stage exchange in TKA and THA within the last few years, showing high success rates [14,20,36,39,40]. However, these publications share certain limitations: small numbers of patients (\ 20); short followup (\5 years); and strict exclusion criteria such as multiresistant organism-based infections, reinfection, significant bone loss, relevant comorbidities, sinus tract, and other relevant soft tissue complications [26].…”

Tibial Tubercle Osteotomy or Quadriceps Snip in Two-stage Revision for Prosthetic Knee Infection? A Randomized Prospective Study

“…Studies have shown that 6.6% to 38% of RTKAs are attributable to prosthetic knee infections [5,11,23,24,31,41,43,55,58,76,95,96]. Although some [56,63] prefer it, a two-stage procedure for chronic prosthetic knee infection requires temporary cement spacers to preserve limb length and reduce soft tissue retraction.…”

The burden of bone, native joint and soft tissue infections on orthopaedic emergency referrals in a city hospital

“…1 The prevention, diagnosis and treatment of periprosthetic joint infections along with their impact on orthopaedic resources and society remain some of the most closely studied subjects for the orthopaedic community worldwide. [2][3][4] The focus of study tends to be pathogen, site or risk factor specific, such as the use of intravenous drugs. [5][6][7] Such infections can be a regular source of emergency referral or admission to specialist units and may require a variety of interventions ranging from the administration of antibiotics to extensive surgical procedures.…”