Results of Using a “2-in-1” Single-Stage Revision Total Knee Arthroplasty for Infection with Associated Bone Loss: Prospective 2-Year Follow-Up

Abstract

Prosthetic joint infections provide a complex challenge for management, owing to their often difficult diagnoses, need for multiple surgeries, and increased technical and financial requirements. The ‘2 in 1’ single-stage approaches have been recently advocated in the field of arthroplasty on account of their reduction in risks, costs, and complications. The aim of our study was to investigate the outcomes of this variant of single-stage revision, which is used in the setting of infection following primary total knee replacement (TKR) and associated bone loss. Prospective data were collected from all patients presenting with an infection following primary TKR over an 8-year period (2009–2017). We examined revision procedures that were undertaken as a single-stage procedure and had bone loss present. Patients were followed-up for evidence of recurrent infection. Functional assessments were conducted using range of motion, Oxford Knee Score (OKS), American Knee Society Score (AKSS), and Short Form-12 (SF-12) survey. Twenty-six patients were included in the analysis, two of whom had previously failed 2 stage revision; another three among them had failed debridement, antibiotics, irrigation, and implant retention procedures. The mean age was 72.5 years, mean body mass index was 33.4, and median American Society of Anesthesiologists (ASA) physical status classification was 2. The mean time to revision was 3.5 years (3 months to 12 years). Six patients had actively been discharging sinuses at the time of surgery. Only 4/26 patients possessed no positive microbiological cultures from deep tissue samples or joint aspirates. One patient was afflicted with a recurrence of infection. This patient did not require further surgery and was successfully treated with the help of long-term antibiotic suppression. There were statistically significant improvements in both the pain component of AKSS scores (preoperative 4.3 to postoperative 32.4) and the functional component of AKSS scores (preoperative 10.7 to postoperative 15.7). There was no significant improvement in flexion; however, mean extension (increased from 18.5 to 6.9 postoperative) and total range of motion (increased from 69.2 preoperative to 90.3 postoperative) both showed statistically significant improvements. The use of “2-in-1” single-stage revision can be considered as an effective option for treating infection following TKR and associated bone loss.

Keywords

arthroplasty - revision - infection

Publication History

Received: 23 October 2018

Accepted: 12 August 2019

Article published online:
30 September 2019

• References

• 1 Blom AW, Brown J, Taylor AH, Pattison G, Whitehouse S, Bannister GC. Infection after total knee arthroplasty. J Bone Joint Surg Br 2004; 86 (05) 688-691
• 2 National Joint Registry. NJR Reports: Patient characteristics for knee revision procedures [Internet]. 2017. Accessed March 20, 2018 at: http://www.njrreports.org.uk/knees-revision-procedures-patient-characteristics/K16v1NJR?reportid=AB5D4468-323C-4E54-8737-11C7DAA7B75E&defaults=DC__Reporting_Period__Date_Range=%22MAX%22,J__Filter__Calendar_Year=%22MAX%22,H__Filter__Joint=%22Knee%22
• 3 Green S, Miles R. The Burden of Disease and Illness in the UK: A preliminary assessment to inform the development of UK Health Research and Development Priorities. Oxford: Oxford Health Assoc; 2007
• 4 Lavernia C, Lee DJ, Hernandez VH. The increasing financial burden of knee revision surgery in the United States. Clin Orthop Relat Res 2006; 446 (446) 221-226
• 5 Insall JN, Thompson FM, Brause BD. Two-stage reimplantation for the salvage of infected total knee arthroplasty. J Bone Joint Surg Am 1983; 65 (08) 1087-1098
• 6 Goldman RT, Scuderi GR, Insall JN. 2-stage reimplantation for infected total knee replacement. Clin Orthop Relat Res 1996; (331) 118-124
• 7 Bauer T, Piriou P, Lhotellier L, Leclerc P, Mamoudy P, Lortat-Jacob A. [Results of reimplantation for infected total knee arthroplasty: 107 cases]. Rev Chir Orthop Repar Appar Mot 2006; 92 (07) 692-700
• 8 Macheras GA, Kateros K, Galanakos SP, Koutsostathis SD, Kontou E, Papadakis SA. The long-term results of a two-stage protocol for revision of an infected total knee replacement. J Bone Joint Surg Br 2011; 93 (11) 1487-1492
• 9 Mahmud T, Lyons MC, Naudie DD, Macdonald SJ, McCalden RW. Assessing the gold standard: a review of 253 two-stage revisions for infected TKA. Clin Orthop Relat Res 2012; 470 (10) 2730-2736
• 10 Parkinson RW, Kay PR, Mereddy PKR, Howard K. “2-in-1” Single stage revision for infected TKR: the Wirral and Wrightington experience. In: Presentation at BOA Congress. Liverpool; 2008. Available at: https://online.boneandjoint.org.uk/doi/abs/10.1302/0301-620X.93BSUPP_I.0930015
• 11 Göksan SB, Freeman MAR. One-stage reimplantation total for infected total knee replacement. J Bone Jt Surg 1992; 74: 78-82
• 12 Buechel FF, Femino FP, D'Alessio J. Primary exchange revision arthroplasty for infected total knee replacement: a long-term study. Am J Orthop 2004; 33 (04) 190-198 , discussion 198
• 13 Parkinson RW, Kay PR, Rawal A. A case for one-stage revision in infected total knee arthroplasty?. Knee 2011; 18 (01) 1-4
• 14 Masters et al. A systematic review of the evidence for single stage and two stage revision of infected knee replacement. BMC Musculoskeletal Disorders 2013; 14: 222
• 15 Tibrewal S, Malagelada F, Jeyaseelan L, Posch F, Scott G. Single-stage revision for the infected total knee replacement: results from a single centre. Bone Joint J 2014; 96-B [phone]
• 16 Mereddy PKR, Pydisetty R, Howard K, Kay PR. PRW. ‘2-IN-1’ single stage revision for infected total knee replacement: the Wirral and Wrightington experience. Orthop Proc 2011; 93: 15
• 17 Klim SM, Amerstorfer F, Bernhardt GA. et al. Septic revision total knee arthroplasty: treatment of metaphyseal bone defects using metaphyseal sleeves. J Arthroplasty 2018; 33 (12) 3734-3738
• 18 Alexander GE, Bernasek TL, Crank RL, Haidukewych GJ. Cementless metaphyseal sleeves used for large tibial defects in revision total knee arthroplasty. J Arthroplasty 2013; 28 (04) 604-607
• 19 Agarwal S, Azam A, Morgan-Jones R. Metal metaphyseal sleeves in revision total knee replacement. Bone Joint J 2013; 95-B (12) 1640-1644
• 20 Thorsell M, Hedström M, Wick MC, Weiss RJ. Good clinical and radiographic outcome of cementless metal metaphyseal sleeves in total knee arthroplasty. Acta Orthop 2018; 89 (01) 84-88
• 21 Morgan-Jones R, Oussedik SI, Graichen H, Haddad FS. Zonal fixation in revision total knee arthroplasty. Bone Joint J 2015; 97-B [phone]
• 22 Watters TS, Martin JR, Levy DL, Yang CC, Kim RH, Dennis DA. Porous-coated metaphyseal sleeves for severe femoral and tibial bone loss in revision TKA. J Arthroplasty 2017; 32 (11) 3468-3473
• 23 Chalmers BP, Desy NM, Pagnano MW, Trousdale RT, Taunton MJ. Survivorship of metaphyseal sleeves in revision total knee arthroplasty. J Arthroplasty 2017; 32 (05) 1565-1570
• 24 Dalury DF, Barrett WP. The use of metaphyseal sleeves in revision total knee arthroplasty. Knee 2016; 23 (03) 545-548
• 25 Agarwal S, Neogi DS, Morgan-Jones R. Metaphyseal sleeves in revision total knee arthroplasty: minimum seven-year follow-up study. Knee 2018; 25 (06) 1299-1307
• 26 Kalairajah Y, Azurza K, Hulme C, Molloy S, Drabu KJ. Health outcome measures in the evaluation of total hip arthroplasties--a comparison between the Harris hip score and the Oxford hip score. J Arthroplasty 2005; 20 (08) 1037-1041
• 27 Jones RE, Barrack RL, Skedros J. Modular, mobile-bearing hinge total knee arthroplasty. Clin Orthop Relat Res 2001; (392) 306-314