Reinfected Revised TKA Resolves With an Aggressive Protocol and Antibiotic Infusion
Purchase on Springer.com
$39.95 / €34.95 / £29.95*
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.
Revision of failed two-stage revision TKA for infection is challenging, and amputation often is the only alternative.
We asked whether reinfection after two-stage revision for infection could be controlled with an aggressive revision protocol and intraarticular antibiotic infusion.
We retrospectively reviewed 18 patients (12 women, six men) who underwent revision for failed reimplantation between January 1999 and January 2008. Mean time from revision for infection to rerevision for reinfection was 5 months (range, 1–18 months). All knees were treated with an individualized protocol that included aggressive exposure, extensive débridement, uncemented components, closure with muscle flaps (seven knees) and other plastic surgery procedures (three knees), and direct antibiotic infusion through Hickman catheters for 6 weeks. Ten knees had one-stage revision; five had débridement, cement spacer, and revision surgery 3 to 4 months later; and three had extensive soft tissue reconstruction before revision surgery. The minimum followup was 2.3 years (mean, 6.1 years; range, 2.3–12.0 years).
The mean Knee Society scores improved from 33 preoperatively to 76. Seventeen of the 18 had control of infection and achieved durable fixation and a closed wound. One patient had recurrent infection 13 months after one-stage revision, was revised, and remained asymptomatic 28 months postoperatively after redébridement and vancomycin infusion for 6 weeks. In one patient, soft tissue closure was not obtained and the patient required amputation.
Extensile exposure, débridement, and soft tissue flaps for closure combined with uncemented fixation of revision implants and antibiotic infusion into the knee controlled reinfection after revision TKA.
Level of Evidence
Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
- Adams SB, Lescun TB. How to treat septic joints with constant intra-articular infusion of gentamicin or amikacin. AAEP Proc. 2000;46:188–192.
- Anguita-Alonso P, Rouse MS, Piper KE, Jacofsky DJ, Osmon DR, Patel R. Comparative study of antimicrobial release kinetics from polymethylmethacrylate. Clin Orthop Relat Res. 2006;445:239–244.
- Backe HA Jr, Wolff DA, Windsor RD. Total knee replacement infection after 2-stage reimplantation: results of subsequent 2-stage reimplantation. Clin Orthop Relat Res. 1996;331:125–131. CrossRef
- Haleem AA, Berry DJ, Hanssen AD. Mid-term to long-term followup of two-stage reimplantation for infected total knee arthroplasty. Clin Orthop Relat Res. 2004;428:35–39. CrossRef
- Hamilton WG, Cashen DV, Ho H, Hopper RH Jr, Engh CA. Extensively porous-coated stems for femoral revision: a choice for all seasons. J Arthroplasty. 2007;22(Suppl 1):106–110. CrossRef
- Hanssen AD, Trousdale RT, Osmon DR. Patient outcome with reinfection following reimplantation for the infected total knee arthroplasty. Clin Orthop Relat Res. 1995;321:55–67.
- Hirakawa K, Stulberg BN, Wilde AH, Bauer TW, Secic M. Results of two-stage reimplantation for infected total knee arthroplasty. J Arthroplasty. 1998;13:22–28. CrossRef
- Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989;248:13–14.
- Insall JN, Thompson FM, Brause BD. Two-stage reimplantation for the salvage of infected total knee arthroplasty. J Bone Joint Surg Am. 1983;65:1087–1098.
- Kilgus DJ, Howe DJ, Strang A. Results of periprosthetic hip and knee infections caused by resistant bacteria. Clin Orthop Relat Res. 2002;404:116–124. CrossRef
- Kuechle DK, Landon GC, Musher DM, Noble PC. Elution of vancomycin, daptomycin, and amikacin from acrylic bone cement. Clin Orthop Relat Res. 1991;264:302–308.
- Kurd MF, Ghanem E, Steinbrecher J, Parvizi J. Two-stage exchange knee arthroplasty: does resistance of the infecting organism influence the outcome? Clin Orthop Relat Res. 2010;468:2060–2066. CrossRef
- Lloyd KC, Stover SM, Pascoe JR, Baggot JD, Kurpershoek C, Hietala S. Plasma and synovial fluid concentrations of gentamicin in horses after intra-articular administration of buffered and unbuffered gentamicin. Am J Vet Res. 1988;49:644–649.
- Maheshwari AV, Gioe TJ, Kalore NV, Cheng EY. Reinfection after prior staged reimplantation for septic total knee arthroplasty: is salvage still possible? J Arthroplasty. 2010;25(Suppl):92–97. CrossRef
- Masri BA, Duncan CP, Beauchamp CP. Long-term elution of antibiotics from bone-cement: an in vivo study using the prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) system. J Arthroplasty. 1998;13:331–338. CrossRef
- McLaren RL, McLaren AC, Vernon BL. Generic tobramycin elutes from bone cement faster than proprietary tobramycin. Clin Orthop Relat Res. 2008;466:1372–1376. CrossRef
- Mills ML, Rush BR, St Jean G, Guaghan EM, Mosier D, Gibson E, Freeman L. Determination of synovial fluid and serum concentrations, and morphologic effects of intraarticular ceftiofur sodium in horses. Vet Surg. 2000;29:398–406. CrossRef
- Mittal Y, Fehring TK, Hanssen A, Marculescu C, Odum S, Osmon D. Two-stage reimplantation for periprosthetic knee infection involving resistant organisms. J Bone Joint Surg Am. 2007;89:1227–1231. CrossRef
- Mortazavi SM, Schwartzenberger J, Austin MS, Purtill JJ, Parvizi J. Revision total knee arthroplasty infection: incidence and predictors. Clin Orthop Relat Res. 2010;468:2052–2059. CrossRef
- Nayfeh TA, Whiteside LA, Hirsch M. Direct exchange treatment of septic total joint arthroplasty with intra-articular infusion of antibiotics: technique and early results. Orthopedics. 2004;27:987–988.
- Neut D, Hendriks JG, van Horn JR, van der Mei HC, Busscher HJ. Pseudomonas aeruginosa biofilm formation and slime excretion on antibiotic-loaded bone cement. Acta Orthop. 2005;76:109–114. CrossRef
- Perry CR, Hulsey RE, Mann FA, Miller GA, Pearson RL. Treatment of acutely infected arthroplasties with incision, drainage, and local antibiotics delivered via an implantable pump. Clin Orthop Relat Res. 1992;281:216–223.
- Perry CR, Pearson RL. Local antibiotic delivery in the treatment of bone and joint infections. Clin Orthop Relat Res. 1991;263:215–226.
- Rusthoven JJ, Davies TA, Lerner SA. Clinical isolation and characterization of aminoglycoside-resistant small colony variants of Enterobacter aerogenes. Am J Med. 1979;67:702–706. CrossRef
- Salgado CD, Dash S, Cantey JR, Marculescu CE. Higher risk of failure of methicillin-resistant Staphylococcus aureus prosthetic joint infections. Clin Orthop Relat Res. 2007;461:48–53.
- Salvati EA, Callaghan JJ, Brause BD, Klein RF, Small RD. Reimplantation in infection: elution of gentamicin from cement and beads. Clin Orthop Relat Res. 1986;207:83–93.
- Schurman DJ, Hirshman HP, Kajiyama G, Moser K, Burton DS. Cefazolin concentrations in bone and synovial fluid. J Bone Joint Surg Am. 1978;60:359–362.
- Shannon BD, Klassen JF, Rand JA, Berry DJ, Trousdale RT. Revision total knee arthroplasty with cemented components and uncemented intramedullary stems. J Arthroplasty. 2003;18(Suppl 1):27–32. CrossRef
- Shaw JA. The use of long-term indwelling catheters for local antibiotic administration into infected joints: a concept report. J Orthop Tech. 1995;3:181–184.
- Stuart MJ, Larson JE, Morrey BF. Reoperation after condylar revision total knee arthroplasty. Clin Orthop Relat Res. 1993;286:168–173.
- van de Belt H, Neut D, Schenk W, van Horn JR, van der Mei HC, Busscher JH. Gentamicin release from polymethylmethacrylate bone cements and Staphylococcus aureus biofilm formation. Acta Orthop Scand. 2000;71:625–269.
- van de Belt H, Neut D, Uges DR, Schenk W, van Horn JR, van der Mel HC, Busscher HJ. Surface roughness, porosity, wettability of gentamicin-loaded bone cements and their antibiotic release. Biomaterials. 2000;21:1981–1987. CrossRef
- Volin SJ, Hinrichs SH, Garvin KL. Two-stage reimplantation of total joint infections: a comparison of resistant and non-resistant organisms. Clin Orthop Relat Res. 2004;427:94–100. CrossRef
- Wang CJ, Huang TW, Wang JW, Chen HS. The often poor clinical outcome of infected total knee arthroplasty. J Arthroplasty. 2002;17:608–614. CrossRef
- Werner LA, Hardy J, Bertone AL. Bone gentamicin concentration after intra-articular injection or regional intravenous perfusion in the horse. Vet Surg. 2003;32:559–565. CrossRef
- Whaley AL, Trousdale RT, Rand JA, Hanssen AD. Cemented long-stem revision total knee arthroplasty. J Arthroplasty. 2003;18:592–599. CrossRef
- Whiteside LA. Cementless fixation issues in revision total knee arthroplasty. Instr Course Lect. 1999;48:177–182.
- Whiteside LA. Major femoral bone loss in revision total hip arthroplasty treated with tapered, porous-coated stems. Clin Orthop Relat Res. 2004;429:222–226. CrossRef
- Whiteside LA. Surgical exposure in total knee arthroplasty. In: Brown TE, Cui Q, Mihalko WM, Saleh KJ, eds. The Knee. Philadelphia: Elsevier; 2008.
- Whiteside LA. Two-stage exchange for infected TKA—opposes. Semin Arthroplasty. 2008;19:121–125. CrossRef
- Whiteside LA, Bicalho PS. Radiologic and histologic analysis of morselized allograft in revision total knee replacement. Clin Orthop Relat Res. 1998;357:149–156. CrossRef
- Whiteside LA, Peppers M, Nayfeh TA, Roy ME. Methicillin-resistant Staphylococcus aureus in TKA treated with revision and direct intraarticular antibiotic infusion. Clin Orthop Relat Res. 2011;469:26–33. CrossRef
- Reinfected Revised TKA Resolves With an Aggressive Protocol and Antibiotic Infusion
Clinical Orthopaedics and Related Research®
Volume 470, Issue 1 , pp 236-243
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- Industry Sectors
- Author Affiliations
- 1. Missouri Bone and Joint Center, St Louis, MO, USA
- 3. Missouri Bone and Joint Research Foundation, 1000 Des Peres Road, Suite 150, St Louis, MO, 63131, USA
- 2. Johns Hopkins College of Medicine, Baltimore, MD, USA