Trends and Outcomes in the Treatment of Failed Septic Total Knee Arthroplasty: Comparing Arthrodesis and Above-Knee Amputation

doi:10.1016/j.arth.2016.01.010

The Journal of Arthroplasty

Volume 31, Issue 7, July 2016, Pages 1574-1577

https://doi.org/10.1016/j.arth.2016.01.010 Get rights and content

Abstract

Background

Options for treatment of a failed septic total knee arthroplasty (TKA) include arthrodesis and above-knee amputation (AKA). Little comparative data exist to help clinicians when considering these alternatives.

Methods

A national database was queried for patients who underwent either knee arthrodesis or AKA for an infected TKA between 2005 and 2012. Procedure volumes, postoperative complications, hospital charges, length of stay, and 90-day readmission rates were evaluated.

Results

A total of 2634 patients underwent arthrodesis and 5001 patients underwent AKA for septic TKA. The percentage of total patients who underwent AKA increased significantly throughout the study period compared to knee arthrodesis. Patients who underwent AKA tended to be older and have more medical comorbidities. Arthrodesis patients had a significantly higher rate of postoperative infection (14.5% vs 8.3%, P < .0001) and transfusion (55.1% vs 46.8%, P < .0001), whereas AKA patients had a higher rate of systemic complications (31.5% vs 25.9%, P < .0001) and in-hospital mortality (3.7% vs 2.1%, P < .0001). The AKA cohort had lower hospital charges ($79,686 vs $84,747, P = .004), longer length of stay (11 vs 7 days, P < .0001), and higher 90-day readmission rate (19.4% vs 16.9%).

Conclusion

Our data suggest that there is an increasing trend toward AKA for the treatment of a failed infected TKA when compared to arthrodesis. Comparative analysis of the outcomes of these procedures should help the clinician when weighing these alternatives.

Section snippets

Materials and Methods

All data for this study were retrieved from the PearlDiver Patient Records Database (www.pearldiverinc.com; PearlDiver Inc, Fort Wayne, IN), a publicly available, for-fee database of patients. The database contains demographics, procedure volumes, and average charge and reimbursement information for patients with International Classification of Diseases, 9th Revision (ICD-9) diagnoses and procedures or Current Procedural Terminology (CPT) codes. Data for the present study were derived from a

Results

A total of 7635 patients were identified in the database search over the 8-year study period from 2005 to 2012. A total of 2634 patients underwent a knee arthrodesis and 5001 patients underwent an AKA for septic TKA. The percentage of total patients who underwent AKA increased significantly throughout the study period compared to knee arthrodesis (P < .0001; Fig. 1).

A larger percentage of patients in the AKA group were above the age of 80 (24.9%) compared to the arthrodesis group (16.2%). The

Discussion

Deep periprosthetic infection remains a particularly devastating complication after TKA. Although 2-stage revision protocols have a high success rate, a percentage of infections cannot be eradicated and reimplantation of components is not possible. In these situations, the surgeon must often choose between a knee arthrodesis or AKA to effectively eradicate the infection. In the studied population, AKA was performed more frequently than knee arthrodesis for septic failure of TKA from 2005 to

Conclusion

In the present study, AKA appears to be performed more frequently than knee arthrodesis for septic failure of TKA from 2005 to 2012. AKA was performed more frequently in older patients and in patients with a higher incidence of certain medical comorbidities. Arthrodesis for septic TKA is associated with significantly higher rates of postoperative infection and blood transfusion compared to AKA, whereas systemic complications and in-hospital mortality were more common after AKA. Arthrodesis had

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Cited by (35)

Recurrent Periprosthetic Joint Infections: Diagnosis, Management, and Outcomes
2024, Orthopedic Clinics of North America
Socioeconomic Disadvantage Predicts Decreased Likelihood of Maintaining a Functional Knee Arthroplasty Following Treatment for Prosthetic Joint Infection
2024, Journal of Arthroplasty
Prosthetic joint infection (PJI) carries major morbidity and mortality as well as a complicated and lengthy treatment course. In patients who have high degrees of socioeconomic disadvantage, this may be a particularly devastating complication. Our study sought to evaluate the impact of socioeconomic deprivation on outcomes following treatment for PJI of the knee.
We conducted a retrospective review of revision total knee arthroplasty (TKA) procedures performed for the treatment of initial PJI between 2008 and 2020 at a single tertiary care center in the United States. The Area Deprivation Index (ADI) was used to quantify socioeconomic deprivation. The primary outcome measure was presence of a functional knee joint at the time of most recent follow-up defined as TKA components or an articulating spacer. A total of 96 patients were included for analysis. The median follow-up duration was 26.5 months.
There was no significant difference in the rate of treatment failure (P = .63). However, the proportion of patients who had a functional knee arthroplasty (in contrast to having undergone arthrodesis, amputation, or retention of a static spacer) declined significantly with increasing ADI index (81.8% for the least disadvantaged group, 58.7% for the middle group, 42.9% for the most disadvantaged group, P = .021).
Patients who have a higher socioeconomic disadvantage as measured by ADI are less likely to maintain a functional knee arthroplasty following treatment for TKA PJI. These findings support continued efforts to improve access to care and optimize treatment plans for patients who have socioeconomic disadvantage.
Knee arthrodesis using a compression clamp and a single-plane external fixator to treat infection
2022, Orthopaedics and Traumatology: Surgery and Research
In patients with knee infection, arthrodesis by external fixation is a limb-salvage procedure appropriate in highly selected patients. No hardware that might lead to infection is left in situ. However, the fusion rate is limited. Use of a device that applies compression in the coronal plane has been suggested in combination with sagittal external fixation to increase the fusion rate but has not been the focus of published studies. The objectives of this retrospective study were to determine: 1) the fusion rate and, 2) the rate of infection eradication.
Knee arthrodesis using an external fixator and a compression clamp provides higher fusion rates compared to reports of external fixation without compression.
We retrospectively studied 30 patients who underwent knee arthrodesis using external fixation and a compression clamp. The reason for arthrodesis was recurrent infection after total knee arthroplasty in 18 patients and septic arthritis in 12 patients. There were 16 females and 14 males with a mean age of 66.0 ± 11.6 years (range, 30–83 years). Mean follow-up was 42.5 ± 23.6 months (range, 24–106 months).
Fusion was achieved in 25 (83%) patients, after a mean of 7.5 months (range, 6–12 months). Of the 8 patients with severe bone loss (≤ 25% bone contact), 4 experienced non-union, compared to 1 of the 22 patients whose bone loss was moderate or mild (50% and >50% bone contact, respectively) (p = 0.01). After at least 2 years of follow-up, the infection was eradicated in 28 (93%) patients. Complications occurred in 9 patients and consisted of pin-site infection managed by lavage (n = 3), recurrent infection requiring revision surgery for debridement and lavage combined with material exchange and antibiotic therapy (n = 2), and femoral shaft fracture (n = 3) or traumatic fracture of the arthrodesis (n = 1) treated by changing the clamp and fixator assembly.
The fusion rate achieved using this combined technique is high and better than obtained with external fixation alone. Our results confirm that infection eradication is obtained more often than with nailing. This one-stage, simple, reproducible procedure does not leave any foreign material in situ.
IV, retrospective observational cohort study.
Knee arthrodesis using a compression clamp and a single-plane external fixator to treat infection
2022, Revue de Chirurgie Orthopedique et Traumatologique
L’arthrodèse de genou par fixateur externe pour traiter une infection est une opération de sauvetage du membre inférieur dans des indications restreintes. Elle permet de ne pas laisser de matériel, potentielle source de complications infectieuses. L’utilisation d’un compresseur dans le plan frontal a été proposée en association à un fixateur externe sagittal pour augmenter le taux de fusion, faiblesse de cette technique, mais cette modification technique n’a pas encore été étudiée à ce jour. Aussi nous avons mené une étude rétrospective afin de déterminer : 1) le taux de fusion, 2) le taux d’éradication de l’infection.
L’arthrodèse de genou par fixateur externe associé à un compresseur de Charnley a un taux de consolidation supérieur à celui de l’arthrodèse par fixateur externe sans compression en comparaison à la littérature.
Nous avons évalué rétrospectivement trente patients ayant eu une arthrodèse du genou par fixateur externe associé à un compresseur de Charnley. Les 2 indications étaient l’échec infectieux récurrent sur arthroplastie totale de genou (18 cas) et l’arthrite infectieuse (12 cas). Il y avait 16 femmes et 14 hommes dont l’âge moyen était de 66 ans (30–83 ± 11,6). Le suivi moyen était de 42,5 mois (24–106 ± 23,6).
La consolidation a été obtenue chez 25/30 patients (83 %), à un délai moyen de 7,5 mois. Une pseudarthrodèse était observée chez 4/8 patients qui avaient une perte osseuse sévère (contact osseux limité à 25 % ou moins) contre 1/22 patients qui avaient une perte osseuse modérée (contact osseux de 50 % de la surface) ou légère (contact > 50 %) (p = 0,01). À 2 ans de recul minimum, 28/30 patients (93 %) étaient guéris de l’infection. Des complications sont survenues chez 9 patients avec 3 infections sur fiche de fixateur traitées par lavage des orifices de fiche, 2 infections itératives ayant nécessité une reprise pour parage et lavage avec changement de matériel et antibiothérapie, 3 fractures fémorales diaphysaires et une fracture sur arthrodèse après traumatisme traitées en modifiant le montage du compresseur et du fixateur.
Cette technique offre un taux de consolidation élevé, supérieur à celui observé dans les autres séries utilisant un simple fixateur externe, et confirme la notion d’un taux de guérison de l’infection plus élevé qu’avec l’enclouage. C’est une intervention en un temps avec une technique simple et reproductible ne laissant pas de matériel en place.
IV, série rétrospective.
Osseointegration Following Transfemoral Amputation After Infected Total Knee Replacement: A Case Series of 10 Patients With a Mean Follow-up of 5 Years
2022, Arthroplasty Today
Citation Excerpt :
KF may be viewed as favorable because patients retain the potential for bipedal ambulation without a prosthetic leg. However, QOL may not be superior [33,34]; 5.9% of patients may remain infected, 14.6% may lose ambulatory capacity, 18.8% of ambulatory patients may require assistive devices, and 50% of patients may have additional unplanned surgeries. Regarding TKR PJI amputees, only 25% may walk at 38.5 months following amputation [6], 55.9% primarily use a wheelchair for mobility, 79.5% have phantom pain, 47.1% require chronic pain medications, and only 52.9% were satisfied with their QOL [35].
Management of total knee replacement (TKR) infection may sometimes prompt knee fusion (KF) or transfemoral amputation (TFA), both associated with low mobility and quality of life (QOL). Transcutaneous osseointegration for amputees provides superior mobility and QOL vs traditional socket prostheses but has not been studied for patients with a history of infected TKR. This study investigates the following hypothesis: Patients who have had TFA or KF following infected TKR achieve better mobility and QOL following transfemoral osseointegration.
A retrospective evaluation of the prospectively maintained registry identified 10 patients who had prior infected TKR. The mobility assessments (patient daily prosthesis wear time, K-level, Timed Up and Go, 6-Minute Walk Test) and QOL surveys (Questionnaire for Persons with a Transfemoral Amputation Global, Mobility, and Problem scores) were compared preoperatively and after at least 2 years. Complications requiring an additional surgery were also evaluated.
Daily wear hours, K-level, and 6-Minute Walk Test and Questionnaire for Persons with a Transfemoral Amputation Global and Problem scores significantly improved (P < .05). Through 1 year, 4 patients (40%) had additional surgeries. After several years, 7 patients (70%) had at least 1 additional surgery, and 5 (50%) had multiple, for an average of 1 debridement and 1.3 soft-tissue refashionings per patient. One patient died of newly diagnosed cancer 1 year after transcutaneous osseointegration for amputees.
Transfemoral osseointegration confers significantly better mobility and QOL vs KF or a TFA with traditional socket prostheses following infected TKR. Technique improvements to prevent subsequent surgeries may provide an increasingly streamlined experience.
Management of Periprosthetic Joint Infection and Extensor Mechanism Disruption With Modular Knee Fusion: Clinical and Biomechanical Outcomes
2021, Arthroplasty Today
Citation Excerpt :
A second 2-stage protocol with extensor mechanism reconstruction necessitates prolonged immobilization and delayed ambulation [4,5], and a recent multicenter study demonstrated a 75% rate of failure, mostly from reinfection [1]. While AKA is an option, results are also not favorable with loss of mobility, prolonged hospital stays, and high readmission rates [6-8]. Hungerer et al. [2] found that no patients who underwent AKA over the age of 60 years were able walk with a prosthesis.
Extensor mechanism disruption (EMD) combined with periprosthetic joint infection (PJI) after total knee arthroplasty are life-changing complications. The literature suggests many eventually receive above-knee amputation and lose ambulatory function. An alternative is modular knee fusion (KF), but little is known about its outcomes and biomechanical function. We report early term results on a case series of patients.
A retrospective review was conducted of patients who underwent 2-stage reconstruction with modular KF for combined EMD and PJI. Patient-reported outcomes at 1 year after arthrodesis and complications of surgery were recorded. Biomechanical analysis was conducted on 6 patients >1 year after surgery to measure gait speed and balance.
Fifteen patients received a modular KF. At the most recent follow-up visit (average 25.7 months), 12 patients had their modular KFs in place and were ambulatory while 2 had died. Six patients used a walker; 4, a cane; and 2, unassisted. Gait analysis of 6 of these patients showed variation in patterns and speed. Balance was better than historical controls treated with above-knee amputation. Average Knee Injury and Osteoarthritis Outcome Score Junior was 76 ± 11.
Modular KF for EMD and PJI can result in successful outcomes in terms of preventing additional operations and maintaining ambulation. While speed is variable, physical testing shows this method for limb salvage may allow patients to ambulate with a gait aid although further studies are needed to evaluate midterm and long-term results.

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: One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2016.01.010.

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Complications - InfectionTrends and Outcomes in the Treatment of Failed Septic Total Knee Arthroplasty: Comparing Arthrodesis and Above-Knee Amputation

Abstract

Background

Methods

Results

Conclusion

Section snippets

Materials and Methods

Results

Discussion

Conclusion

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

Knee

Knee

Clin Orthop Relat Res

J Arthroplasty

Two-stage revision total knee arthroplasty in cases of periprosthetic joint infection: an analysis of 50 cases

Open Orthop J

Assessing the gold standard: a review of 253 two-stage revisions for infected TKA

Clin Orthop Relat Res

Preoperative diagnosis of periprosthetic joint infection: role of aspiration

AJR Am J Roentgenol

Definition of periprosthetic joint infection: is there a consensus?

Clin Orthop Relat Res

Outcomes of revision total knee arthroplasty after methicillin-resistant Staphylococcus aureus infection

Clin Orthop Relat Res

Articulating versus static spacers in revision total knee arthroplasty for sepsis. The Ranawat Award

Clin Orthop Relat Res

2-stage reimplantation for infected total knee replacement

Clin Orthop Relat Res

Mid-term to long-term followup of two-stage reimplantation for infected total knee arthroplasty

Clin Orthop Relat Res

Patient outcome with reinfection following reimplantation for the infected total knee arthroplasty

Clin Orthop Relat Res

Complications - Infection
Trends and Outcomes in the Treatment of Failed Septic Total Knee Arthroplasty: Comparing Arthrodesis and Above-Knee Amputation