Infection In Total Knee Replacement Research Articles

MEDIUM-TERM OUTCOMES OF TRANSTIBIAL OSSEOINTEGRATION IN ASSOCIATION WITH TOTAL KNEE ARTHROPLASTY

IntroductionTranstibial osseointegration (TFOI) for amputees has limited but clear literature identifying superior quality of life and mobility versus a socketed prosthesis. Some amputees have knee arthritis that would be relieved by a total knee replacement (TKR). No other group has reported performing a TKR in association with TTOI (TKR+TTOI). We report the outcomes of nine patients who had TKR+TTOI, followed for an average 6.5 years.Materials & MethodsOur osseointegration registry was retrospectively reviewed to identify all patients who had TTOI and who also had TKR, performed at least two years prior. Four patients had TKR first the TTOI, four patients had simultaneous TKR+TTOI, and one patient had 1 OI first then TKR. All constructs were in continuity from hinged TKR to the prosthetic limb. Outcomes were: complications prompting surgical intervention, and changes in daily prosthesis wear hours, Questionnaire for Persons with a Transfemoral Amputation (QTFA), and Short Form 36 (SF36). All patients had clinical follow-up, but two patients did not have complete survey and mobility tests at both time periods.ResultsSix (67%) were male, average age 51.2±14.7 years. All primary amputations were performed to manage traumatic injury or its sequelae. No patients died. Five patients (56%) developed infection leading to eventual transfemoral amputation 36.0±15.3 months later, and 1 patient had a single debridement six years after TTOI with no additional surgery in the subsequent two years. All patients who had transfemoral amputation elected for and received transfemoral osseointegration, and no infections occurred, although one patient sustained a periprosthetic fracture which was managed with internal fixation and implant retention and walks independently. The proportion of patients who wore their prosthesis at least 8 hours daily was 5/9=56%, versus 7/9=78% (p=.620). Even after proximal level amputation, the QTFA scores improved versus prior to TKR+TTOI, although not significantly: Global (45.2±20.3 vs 66.7±27.6, p=.179), Problem (39.8±19.8 vs 21.5±16.8, p=.205), Mobility (54.8±28.1 vs 67.7±25.0, p=.356). SF36 changes were also non-significant: Mental (58.6±7.0 vs 46.1±11.0, p=.068), Physical (34.3±6.1 vs 35.2±13.7, p=.904).ConclusionsTKR+TTOI presents a high risk for eventual infection prompting subsequent transfemoral amputation. Although none of these patients died, in general, TKR infection can lead to patient mortality. Given the exceptional benefit to preserving the knee joint to preserve amputee mobility and quality of life, it would be devastating to flatly force transtibial amputees with severe degenerative knee joint pain and unable to use a socket prosthesis to choose between TTOI but a painful knee, or preemptive transfemoral amputation for transfemoral osseointegration. Therefore, TTOI for patients who also request TKR must be considered cautiously. Given that this frequency of infection does not occur in patients who have total hip replacement in association with transfemoral osseointegration, the underlying issue may not be that linked joint replacement with osseointegrated limb replacement is incompatible, but may require further consideration of biological barriers to ascending infection and/or significant changes to implant design, surgical technique, or other yet-uncertain factors.

Unusual Listeria monocytogenes hematogenous infection in total knee replacement treated with one-stage revision surgery

Septic arthritis due to Listeria monocytogenes (LM) is extremely rare and most infections due to this organism are seen in immunocompromised patients. We describe a patient without immunological compromise, with a late total knee arthroplasty infection caused by LM treated with one-stage revision surgery. She had an elevated erythrocyte sedimentation rate (79 mm/h) and C-reactive protein (13 mg/dL). Aspiration of the knee joint yielded purulent fluid; cultures showed LM. The patient was given 6 weeks of intravenous ampicillin, followed by trimethoprim/sulfamethoxazole, and finally amoxicillin orally for 7 months. Two years after revision surgery, radiographs showed no evidence of implant loosening. This is a single case and although one-stage approach seemed to have worked, it should not be recommended on the basis of a single report.

The Effect of Prosthetic Design and Polyethylene Type on the Risk of Revision for Infection in Total Knee Replacement: An Analysis of 336,997 Prostheses from the Australian Orthopaedic Association National Joint Replacement Registry.

Periprosthetic infection following total knee replacement remains alarmingly frequent, is devastating for patients, and is an increasingly substantial public health burden. While both the prosthetic design elements and type of polyethylene used in total knee replacement can independently affect survivorship of the prosthesis, their influence on the risk of revision for infection is unknown. Therefore, we examined the effects of total knee prosthetic design and type of polyethylene bearing on the long-term revision risk for nonacute infection following total knee replacement by comparing 4 different cohorts: patients who had minimally stabilized total knee prostheses with crosslinked polyethylene (XLPE) bearing surfaces, minimally stabilized total knee prostheses with noncrosslinked polyethylene (NXLPE), posterior stabilized total knee prostheses with XLPE, and posterior stabilized total knee prostheses with NXLPE. National registry data on revision procedures for surgeon-reported infection following primary total knee replacement for osteoarthritis from September 1999 through December 2015 were obtained for 4 patient cohorts. The cohorts were defined by the total knee prosthetic design and polyethylene type used. Revisions at ≤6 months were censored to reduce confounding bias. Hazard ratios (HRs) were adjusted for age, sex, and antibiotic cement usage. A total of 336,997 primary total knee prostheses were included, 1,651 (0.49%) of which underwent revision for periprosthetic infection. Compared with minimally stabilized total knee prostheses that had XLPE bearing surfaces, the revision risk for infection, adjusted for age, sex, and antibiotic cement usage, was 25% higher for minimally stabilized total knee prostheses with NXLPE bearing surfaces (HR = 1.25 [95% confidence interval (CI), 1.07 to 1.45]; p = 0.003), 89% higher for posterior stabilized total knee prostheses with XLPE (HR = 1.89 [95% CI, 1.52 to 2.35]; p < 0.001), and 102% higher for posterior stabilized total knee prostheses with NXLPE (HR = 2.02 [95% CI, 1.72 to 2.37]; p < 0.001). Posterior stabilized total knee prostheses with NXLPE had a 61% higher risk of infection compared with minimally stabilized total knee prostheses with NXLPE (HR = 1.61 [95% CI, 1.43 to 1.83]; p < 0.001). The revision risk for infection for posterior stabilized total knee prostheses with NXLPE was the same as that for posterior stabilized total knee prostheses with XLPE (HR = 1.08 [95% CI, 0.88 to 1.32]; p = 0.481). Minimally stabilized total knee prostheses with NXLPE bearing surfaces and posterior stabilized total knee prostheses, irrespective of bearing type, had a greater long-term revision risk for periprosthetic infection when compared with the revision risk for minimally stabilized total knee prostheses with XLPE bearing surfaces. Therapeutic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

The Seasonal Variation of TKR Infection Rates

Introduction:A seasonal variation in the incidence of surgical site infections has been described following a number of common surgical procedures. However in the setting of elective Total Knee Replacement (TKR), the role of environmental factors is an area of research that is currently lacking from the literature. Data recently presented from our institution demonstrates a possible trend toward higher infection rates during periods of increased temperature and humidity. The aim of this study was to investigate if seasonal and geographical factors influence the rate of TKR infection within Australia.Methods:Data from the AOA National Joint Registry for all primary TKRs performed within the last 5 years was analysed to determine the revision rates for early (<12 months) post-operative infection. The infection rates for tropical regions (Darwin, Cairns, Townsville, Mackay) were compared to the remainder of the country. A month-by-month analysis was performed to determine if there was a seasonal variation within the 2 study groups.Results:During the study period a total of 207,540 primary TKRs were performed (6,514 tropical vs 201,026 non-tropical regions). Overall, the rate of revision for infection was significantly higher for the tropical regions of Australia (0.80% vs 0.39%). In non-tropical regions, there was no observed seasonal variation of infection rates. In tropical regions, there was a clear seasonal variation found, with the winter months being associated with a significantly lower rate of infection than the remainder of the year (0.37% vs 0.94%). The infection rates were not significantly different between tropical (0.37%) and non- tropical (0.38%) regions during the winter period.Conclusion:To the best of our knowledge, this is the first study to investigate and demonstrate a significant influence from seasonal variation on primary TKR infection rates. This phenomenon is evident only within tropical regions, with the periods of warmer and humid weather resulting in a significantly increased risk of primary TKR infection. These findings require further investigation and research.

Management of infected TKR (total knee replacement) and results of two stage surgery for infected TKR

Background: Total knee Replacement is one of the common surgery for knee Osteoarthritis. Infection after total knee replacement is uncommon but disastrous complication. Purpose: Main purpose of study is to determine functional results of two stage surgery in infected TKR, compare the results of two stage surgery with other modalities of treatment, risk factors for infections, role of laboratory and clinical markers for early diagnosis of infection in TKR. Methods: This is retrospective study of 40 patients who operated for infected TKR through two stage revision arthroplasty. Inclusion criteria: All patients operated for infected TKR by two stage revision arthroplasty. Exclusion criteria: · Less than 12 months follow up · Expired patients Results: The average age of patients was 62.1 years. With youngest patient were being 40 years old and the oldest being 82. Average BMI in our series was 27.07. It varied with a range from 19.9 to 38.67. 15 patients had diabetes mellitus (DM), 7 patients had hypertension and 1 patient had hypothyroidism. The average WOMAC score improved from 37.525 to 56.3 with a minimum pre op score of 30 and maximum of 45. The mean clinical knee society score (KSS score) improved from from 50.1 to 69.325. 97% of patients showed improvement in their preoperative pain. The mean range of movement improved from 53.75 to 90.375. Pre op minimum ROM was 30 and maximum was 100. The average extensor lag preoperatively was 6.65 degrees with a range of 0-15 degrees. Patients showed improvement with average extensor lag reducing to 2.75 degree, with range of 0-10 degrees. The failure rate of our study was 8% with persistent infection after treatment. Conclusion: ·

The Clinical Outcome of Management of Periprosthetic Infection in Total Knee Replacement: 治療全膝關節置換術假體周圍感染的臨床結果

Background/PurposeInfection is a severe complication after total knee replacement (TKR) and creates great disability. We reviewed our 11-year experience in the management of TKR infection and its outcome. MethodsPatients who had TKR infection from 2001 to 2011 in our hospital were reviewed retrospectively. ResultsA total of 727 TKRs were performed from 2001 to 2011 and 12 cases of post-TKR infection were identified (1.65%). In the acute group, two patients had debridement with exchange of liner and four patients had a two-stage operation. No re-infection was noted. For the chronic presentation group, four out of six patients had a two-stage operation and none of them suffered from re-infection. The remaining two patients had debridement and exchange of liner and both had re-infection with a two-stage operation performed afterwards. One patient had no re-infection thereafter. Another patient was on long-term suppressive antibiotics because of the failure to eradicate the infection. ConclusionThe incidence of TKR infection in our hospital is comparable to the reported incidence in the literature. This study also showed that a two-stage operation has a higher success rate in the management of chronic TKR infection.

Preventing Deep Infection in Total Knee Replacement

BACKGROUND: The rate of infection following primary total knee replacement (TKR) ranges between 1 and 2%. The medical community has implemented many practices with the intention of preventing infection after TKR. QUESTION: What are the prevention measures to reduce infection risk after TKR? METHODS: A PubMed (MEDLINE) search and a Cochrane Library search were performed until 31 March 2014. Six hundred and fifty-seven articles were found but only 42 were finally analysed. The main criteria for selection were that the articles addressed the aforementioned question. RESULTS: Rheumatoid arthritis, diabetes mellitus, immunosuppression treatment, psoriasis, and previous infections in the knee are the risk factors most clearly related with TKR infection. Appropriate patient selection is fundamental. Staphylococcus Aureus is the most common organism in infected TKRs. Systematic preoperative screening by swab is very important. Prevention of MRSA-positive cases by means of nasal decontamination (mupirocin 3 days) is advisable. Preoperative antibiotic prophylaxis has shown to be an efficient method to lower infection rates. Appropriate surgeon´s preparation and clean air in the operating room (OR) also seem to be important. Many authors have used ORs equipped with laminar air flow (LAF) although some authors have recently found that the incidence of infection decreased after abandoning the LAF in ORs. Adequate skin preparation and dressings also appear to be very important. Prolonged operative time seems to correlate with increased infection rate after TKR. The correlation between antibiotic-loaded cement and the risk of infection is still controversial. CONCLUSIONS: Prevention measures could help diminish the infection rate in patients undergoing TKR but the efficacy of some preventive practices is still controversial.

Paper 109: One Stage Revision for Infected Total Knee Replacement

Infection in total knee replacement is a devastating complication. Current literature supports two-stage revision as the gold standard. The alternative single stage procedure has been reported to have favourable results. We assessed the early clinical results of single stage revision for infected total knee replacement. Between February 2005 and August 2007, 12 patients had revision total knee replacement for infection by the senior authors at two centres. In the majority of the patients, the infective organism was isolated by either arthroscopic synovial biopsy prior to revision. Standard single stage procedure included the explantation, debridement and re-implantation of the prosthesis. All the patients received intravenous antibiotics for a minimum period of six weeks and oral antibiotics were continued for further 6 weeks. All the patients had the inflammatory markers monitored during their follow-up at 6 weeks, 3, 6, 12 and 24 months. Significant improvement was noted in the SF-12 PCS, WOMAC pain and stiffness scores at the latest follow-up. None of these patients required re-revision. Radiological evaluation was done using the Knee Society system. None of the knees showed evidence of progressive loosening. Radio-opaque lines were found around the stems and were present on immediate post-operative radiographs; this did not indicate loosening or infection at a mean follow-up of two years. Early clinical and radiological results of the single stage revision for infected total knee replacement appear to be promising. One operation, one anaesthetic and quicker recovery are the advantages for the patient and with the reduced hospital stay it is cost-effective. The problems of stiffness in the knee and muscle wasting with cement spacer are avoided.

Developing a strategy to treat established infection in total knee replacement

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.

Distraction osteogenesis as a salvage method in infected knee megaprostheses

Infection of total knee replacement represents a severe complication. Especially in cases of infected megaprostheses, treatment options are limited and even amputation may become unavoidable. We present two cases of infected knee hinged megaprostheses. Both were treated by prosthesis removal and debridement of all surrounding infected bone and soft tissue, followed by distraction osteogenesis for the bridging of the large bone defect which had resulted. Implant removal and surgical debridement were combined with Ilizarov frame application and femoral and tibial osteotomies in a one-stage procedure, for commencing distraction osteogenesis. After bone transportation was completed, arthrodesis of the knee in both cases was successful. Two years after completion of the treatment, both patients demonstrate a stable knee arthrodesis and a satisfactory clinical result. The described treatment plan represents an effective salvage method in cases of infected knee megaprostheses that can successfully address both the need for a stable arthrodesis and the avoidance of a severe leg-length discrepancy by bridging the extensive bone defect.

Infection in Total Knee Replacement

Six thousand four hundred eighty-nine knee replacements were done in 6120 patients at the authors' institution between 1993 and 1999. Operations were done in a theater with vertical laminar flow and with the surgical team using body exhaust suits. Of these knee replacements, 116 knees became infected and 113 were available for followup. One hundred of the infections occurred in patients undergoing primary knee replacement, whereas the remaining infections occurred in patients undergoing revision knee replacement. Ninety-seven of these knees (86%) had deep periprosthetic infections and the remaining 16 knees had superficial wound infections. One third of the deep infections occurred within the first 3 months after surgery and the remaining 2/3 occurred after 3 months. The overall early deep infection rate for patients undergoing a primary knee replacement was 0.39%, whereas the rate for patients undergoing a revision knee replacement was 0.97%. A cohort of noninfected knee replacements from patients matched for gender, age, and month of surgery was used as a control group. Those comorbidities that were statistically significant in increasing the risk of infection were prior open surgical procedures, immunosuppressive therapy, poor nutrition, hypokalemia, diabetes mellitus, obesity, and a history of smoking. Patients undergoing revision procedures had a statistically higher risk of infection than did patients undergoing primary surgeries. If the surgery took longer than 2.5 hours, the risk of infection was increased significantly. There was no change in the infection rate when the perioperative antibiotic prophylaxis was decreased from 48 to 24 hours after surgery. The predominant infectious organisms were gram-positive (Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus Group B). Twenty percent of the knees that were infected clinically had no organisms that could be identified. In each case, the patient had been treated empirically at another institution with antibiotics before a culture of the joint was obtained.

原発性悪性骨腫よう長期生存例の人工膝関節置換術後の合併症に対する膝関節再建術

Limb-saving surgery plays an increasingly important role in the treatment of malignant tumors of the extremities.This type of surgery may pose special problems in longterm survivors. The different possibilities of reconstruction after a tumor resection and repercussions in growth are discussed.Case 1. In this ten year old girl with osteosarcoma of the left distal femur, wide excision of the tumor site and a total knee replacement were done in September 1983, Two years postoperatively she presented late hematogenous infection of total knee replacement. Three times of surgery, debridement only, remove of prosthesis and two stage revision, wase done. In September 1989 rotationplasty were done because of uncontrolled infection. Case 2. In this twentytwo year old female with malignant fibrous histiocytoma of the left proximal tibia, wide excision of the tumor site and a total knee replacement were done in December 1983. Four years postoperatively she presented patellar tendon rupture, In July 1988 repair of the tendon with the use dacron ligament prosthesis to reattatch the tendon to the tibial component were done. To date, they had been followed for seven years with good function of limb, but without any indication of either local recurrence or metastases.The role of recostruction by means of a rotation plasty versus other methods of recostruction, and the repair of the tendon using ligament prosthesis and autotendon to reattatch the tendon to the tibial component is specially cosidered.