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Can Implant Retention be Recommended for Treatment of Infected TKA?

  • Symposium: Periprosthetic Joint Infection
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Retention treatment is reportedly associated with lower infection control rates than two-stage revision. However, the studies on which this presumption are based depend on comparisons of historical rather than concurrent controls.

Questions/purposes

We (1) asked whether the infection control rates, number of additional procedures, length of hospital stay, and treatment duration differed between implant retention and two-stage revision treatment; and (2) identified risk factors that can contribute to failure of infection control.

Methods

We reviewed the records of 60 patients treated for 64 infected TKA from 2002 to 2007. Twenty-eight patients (32 knees) underwent débridement with retention of component, and 32 patients (32 knees) were treated with component removal and two-stage revision surgery. We determined patients’ demographics, type of infection, causative organisms, and outcome of treatment. Mean followup was 36 months (range, 12–84 months).

Results

Infection control rate was 31% in retention and 59% in the removal group after initial surgical treatment, and 81% and 91% at latest followup, respectively. Treatment duration was shorter in the retention group and there was no difference in number of additional surgeries and length of hospital stay. Type of treatment (retention versus removal) was the only factor associated with infection control; subgroup analysis in the retention group showed Staphylococcus aureus infection and polyethylene nonexchange as contributing factors for failure of infection control.

Conclusions

Although initial infection control rate was substantially lower in the retention group than the removal group, final results were comparable at latest followup. We believe retention treatment can be selectively considered for non-S. aureus infection, and when applied in selected patients, polyethylene exchange should be performed.

Level of Evidence

Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

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References

  1. Altman DG. Practical Statistics for Medical Research. Boca Raton, FL: Chapman & Hall/CRC; 1991:194–214.

    Google Scholar 

  2. Berbari EF, Marculescu C, Sia I, Lahr BD, Hanssen AD, Steckelberg JM, Gullerud R, Osmon DR. Culture-negative prosthetic joint infection. Clin Infect Dis. 2007;45:1113–1119.

    Article  PubMed  Google Scholar 

  3. Blom AW, Brown J, Taylor AH, Pattison G, Whitehouse S, Bannister GC. Infection after total knee arthroplasty. J Bone Joint Surg Br. 2004;86:688–691.

    Article  PubMed  CAS  Google Scholar 

  4. Brandt CM, Sistrunk WW, Duffy MC, Hanssen AD, Steckelberg JM, Ilstrup DM, Osmon DR. Staphylococcus aureus prosthetic joint infection treated with debridement and prosthesis retention. Clin Infect Dis. 1997;24:914–919.

    PubMed  CAS  Google Scholar 

  5. Burger RR, Basch T, Hopson CN. Implant salvage in infected total knee arthroplasty. Clin Orthop Relat Res. 1991;273:105–112.

    PubMed  Google Scholar 

  6. Deirmengian C, Greenbaum J, Lotke PA, Booth RE, Jr., Lonner JH. Limited success with open debridement and retention of components in the treatment of acute Staphylococcus aureus infections after total knee arthroplasty. J Arthroplasty. 2003;18:22–26.

    Article  PubMed  Google Scholar 

  7. Durbhakula SM, Czajka J, Fuchs MD, Uhl RL. Antibiotic-loaded articulating cement spacer in the 2-stage exchange of infected total knee arthroplasty. J Arthroplasty. 2004;19:768–774.

    Article  PubMed  Google Scholar 

  8. Ellingsen DE, Rand JA. Intramedullary arthrodesis of the knee after failed total knee arthroplasty. J Bone Joint Surg Am. 1994;76:870–877.

    PubMed  CAS  Google Scholar 

  9. Falahee MH, Matthews LS, Kaufer H. Resection arthroplasty as a salvage procedure for a knee with infection after a total arthroplasty. J Bone Joint Surg Am. 1987;69:1013–1021.

    PubMed  CAS  Google Scholar 

  10. Garvin KL, Cordero GX. Infected total knee arthroplasty: diagnosis and treatment. Instr Course Lect. 2008;57:305–315.

    PubMed  Google Scholar 

  11. Haddad FS, Adejuwon A. The management of infected total knee arthroplasty. Orthopedics. 2007;30:779–780.

    PubMed  Google Scholar 

  12. Haddad FS, Masri BA, Campbell D, McGraw RW, Beauchamp CP, Duncan CP. The PROSTALAC functional spacer in two-stage revision for infected knee replacements. Prosthesis of antibiotic-loaded acrylic cement. J Bone Joint Surg Br. 2000;82:807–812.

    Article  PubMed  CAS  Google Scholar 

  13. Hanssen AD, Rand JA. Evaluation and treatment of infection at the site of a total hip or knee arthroplasty. Instr Course Lect. 1999;48:111–122.

    PubMed  CAS  Google Scholar 

  14. Hartman MB, Fehring TK, Jordan L, Norton HJ. Periprosthetic knee sepsis. The role of irrigation and debridement. Clin Orthop Relat Res. 1991;273:113–118.

    PubMed  Google Scholar 

  15. Isiklar ZU, Landon GC, Tullos HS. Amputation after failed total knee arthroplasty. Clin Orthop Relat Res. 1994;299:173–178.

    PubMed  Google Scholar 

  16. Katz MH. Multivariable Analysis: A Practical Guide for Clinicians. 2nd ed. New York, NY: Cambridge University Press; 2006:117–136.

    Google Scholar 

  17. Laffer RR, Graber P, Ochsner PE, Zimmerli W. Outcome of prosthetic knee-associated infection: evaluation of 40 consecutive episodes at a single centre. Clin Microbiol Infect. 2006;12:433–439.

    Article  PubMed  CAS  Google Scholar 

  18. Leone JM, Hanssen AD. Management of infection at the site of a total knee arthroplasty. J Bone Joint Surg Am. 2005;87:2335–2348.

    PubMed  Google Scholar 

  19. Marculescu CE, Berbari EF, Hanssen AD, Steckelberg JM, Harmsen SW, Mandrekar JN, Osmon DR. Outcome of prosthetic joint infections treated with debridement and retention of components. Clin Infect Dis. 2006;42:471–478.

    Article  PubMed  CAS  Google Scholar 

  20. McPherson EJ, Tontz W, Jr., Patzakis M, Woodsome C, Holtom P, Norris L, Shufelt C. Outcome of infected total knee utilizing a staging system for prosthetic joint infection. Am J Orthop (Belle Mead NJ). 1999;28:161–165.

    CAS  Google Scholar 

  21. McPherson EJ, Woodson C, Holtom P, Roidis N, Shufelt C, Patzakis M. Periprosthetic total hip infection: outcomes using a staging system. Clin Orthop Relat Res. 2002;403:8–15.

    Article  PubMed  Google Scholar 

  22. Mont MA, Waldman B, Banerjee C, Pacheco IH, Hungerford DS. Multiple irrigation, debridement, and retention of components in infected total knee arthroplasty. J Arthroplasty. 1997;12:426–433.

    Article  PubMed  CAS  Google Scholar 

  23. Moyad TF, Thornhill T, Estok D. Evaluation and management of the infected total hip and knee. Orthopedics. 2008;31:581–588; quiz 589–590.

    Article  PubMed  Google Scholar 

  24. Pitto RP, Castelli CC, Ferrari R, Munro J. Pre-formed articulating knee spacer in two-stage revision for the infected total knee arthroplasty. Int Orthop. 2005;29:305–308.

    Article  PubMed  CAS  Google Scholar 

  25. Pulido L, Ghanem E, Joshi A, Purtill JJ, Parvizi J. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res. 2008;466:1710–1715.

    Article  PubMed  Google Scholar 

  26. Schoifet SD, Morrey BF. Treatment of infection after total knee arthroplasty by debridement with retention of the components. J Bone Joint Surg Am. 1990;72:1383–1390.

    PubMed  CAS  Google Scholar 

  27. Segawa H, Tsukayama DT, Kyle RF, Becker DA, Gustilo RB. Infection after total knee arthroplasty. A retrospective study of the treatment of eighty-one infections. J Bone Joint Surg Am. 1999;81:1434–1445.

    PubMed  CAS  Google Scholar 

  28. Silva M, Tharani R, Schmalzried TP. Results of direct exchange or debridement of the infected total knee arthroplasty. Clin Orthop Relat Res. 2002;404:125–131.

    Article  PubMed  Google Scholar 

  29. Tattevin P, Cremieux AC, Pottier P, Huten D, Carbon C. Prosthetic joint infection: when can prosthesis salvage be considered? Clin Infect Dis. 1999;29:292–295.

    Article  PubMed  CAS  Google Scholar 

  30. Teeny SM, Dorr L, Murata G, Conaty P. Treatment of infected total knee arthroplasty. Irrigation and debridement versus two-stage reimplantation. J Arthroplasty. 1990;5:35–39.

    Article  PubMed  CAS  Google Scholar 

  31. Trampuz A, Hanssen AD, Osmon DR, Mandrekar J, Steckelberg JM, Patel R. Synovial fluid leukocyte count and differential for the diagnosis of prosthetic knee infection. Am J Med. 2004;117:556–562.

    Article  PubMed  Google Scholar 

  32. Trebse R, Pisot V, Trampuz A. Treatment of infected retained implants. J Bone Joint Surg Br. 2005;87:249–256.

    Article  PubMed  CAS  Google Scholar 

  33. Tsukayama DT, Estrada R, Gustilo RB. Infection after total hip arthroplasty. A study of the treatment of one hundred and six infections. J Bone Joint Surg Am. 1996;78:512–523.

    PubMed  CAS  Google Scholar 

  34. Tsukayama DT, Goldberg VM, Kyle R. Diagnosis and management of infection after total knee arthroplasty. J Bone Joint Surg Am. 2003;85-A Suppl 1:S75–S80.

    PubMed  Google Scholar 

  35. Wiedel JD. Salvage of infected total knee fusion: the last option. Clin Orthop Relat Res. 2002;404:139–142.

    Article  PubMed  Google Scholar 

  36. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. 2004;351:1645–1654.

    Article  PubMed  CAS  Google Scholar 

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Acknowledgments

We thank Dr Andrew Freiberg, Dr Dennis Burke, Dr Joseph McCarthy, and Dr Harry Rubash for their help in preparing this article.

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Authors and Affiliations

  1. Harris Orthopedic Laboratory, Department of Orthopedic Surgery, Massachusetts General Hospital, 55 Fruit Street, GRJ-1126, Boston, MA, 02114, USA

    Ho-Rim Choi MD, Fabian von Knoch MD & Henrik Malchau MD, PhD

  2. Department of Orthopedic Surgery, SoonChunHyang University Hospital, CheonAn, South Korea

    Ho-Rim Choi MD

  3. Departments of Anesthesiology and Surgery, Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA

    David Zurakowski PhD

  4. Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA

    Sandra B. Nelson MD

Authors
  1. Ho-Rim Choi MD
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  2. Fabian von Knoch MD
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  3. David Zurakowski PhD
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  4. Sandra B. Nelson MD
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  5. Henrik Malchau MD, PhD
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Corresponding author

Correspondence to Henrik Malchau MD, PhD.

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Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This work was performed at the Harris Orthopedic Laboratory, Massachusetts General Hospital, Boston, MA

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Choi, HR., von Knoch, F., Zurakowski, D. et al. Can Implant Retention be Recommended for Treatment of Infected TKA?. Clin Orthop Relat Res 469, 961–969 (2011). https://doi.org/10.1007/s11999-010-1679-8

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  • DOI: https://doi.org/10.1007/s11999-010-1679-8

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