Two-stage Total Knee Arthroplasty Research Articles

A Systematic Review and Qualitative Analysis of Studies Performing Total Knee Arthroplasty (TKA) in Tuberculosis (TB) of the Knee.

Tuberculosis (TB) is a widespread global disease that significantly impacts daily life. Skeletal TB comprises about 10-35% of all TB cases. Significant research on the spine and hip exists, but due to the rarity of cases, the management of TB is less explored. Furthermore, exercising the option of total knee arthroplasty (TKA) in TB knees is still in its initial stages. This systematic review aims to identify and comprehend the difficulties associated with diagnosing TB-affected knees, their treatment outcomes, and complications related to TKA. A systematic review of existing English literature retrieved from PubMed, Google Scholar, and Web of Science databases was performed using the PRISMA guidelines. A case series of arthroplasty performed on TB knees included a description of the diagnostic approach, clinical outcome, and complication rates. Moreover, studies involving case series with follow-up functional outcomes were included. The Coleman Methodology was used to assess the quality of the studies. A total of six studies (75 knees) were systematically reviewed in this study. The diagnosis of TB knee is multimodal, with MRI being a reliable tool. Administering anti-TB chemotherapy is essential during the perioperative period. Regarding recurrence, a two-stage TKA has a lower risk of recurrence. It is plausible to state that anti-TB chemotherapy needs to be initiated in the perioperative period to prevent the chances of recurrences. Two-stage TKA is reserved for patients who require soft tissue debridement despite adequate chemotherapy.

Repeat two‐stage revision for knee prosthetic joint infection results in very high failure rates

Two stage revision total knee arthroplasty (TKA) is the gold standard for treatment and eradication of knee prosthetic joint infections (PJI), but the literature is limited on the outcomes of repeat two-stage TKA after PJI recurrence. This study presents the outcomes of repeat two-stage revision TKA and investigates potential factors contributing to success or failure, aiming to assist counselling and decision-making. A retrospective study was undertaken investigating all two-stage revision TKA performed at one institution between 2005 and 2020. Twenty cases underwent repeat two-stage revision TKA. Patient outcomes and factors contributing to treatment success or failure were investigated. PJI was diagnosed according to MSIS criteria. Of the 20 cases, 14 were classified as failed treatment (70%) due to a failure to eradicate infection, further surgical intervention or death. In this cohort, there were no statistically significant differences between the groups regarding factors contributing to treatment success or failure. In the success group, patient reported functional outcomes were variable. This study demonstrates that patients undergoing a repeat two-stage TKA have very poor outcomes. This study did not identify any factors that predicted failure. Patients need to be counselled regarding poor outcomes with repeat two-stage TKA, and other treatment options such as early amputation or lifelong suppression should be considered.

Detailed Revision Risk Analysis after Single- vs. Two-Stage Revision Total Knee Arthroplasty in Periprosthetic Joint Infection: A Retrospective Tertiary Center Analysis.

Periprosthetic joint infection (PJI) remains one of the most common causes of revision knee arthroplasty. Controversy continues to surround the proper operative technique of PJI in knee arthroplasty with single- or two-stage replacement. Significant variations are seen in the eradication rates of PJI and in implant survival rates. This detailed retrospective analysis of a single tertiary center is intended to provide further data and insight comparing single- and two-stage revision surgery. A retrospective analysis of all revision total knee arthroplasty (TKA) surgeries from 2013 to 2019 was performed and screened with respect to single- or two-stage TKA revisions. Single- and two-stage revisions were analyzed with regard to implant survival, revision rate, microbiological spectrum, and other typical demographic characteristics. A total of 63 patients were included, with 15 patients undergoing single-stage revision and 48 patients undergoing two-stage revision. The mean follow-up time was 40.7 to 43.7 months. Statistically, no difference was found between both groups in overall survival (54.4% vs. 70.1%, p = 0.68) and implant survival with respect to reinfection (71.4% vs. 82.4%, p = 0.48). Further, high reinfection rates were found for patients with difficult-to-treat organisms and low- to semi-constrained implant types, in comparison to constrained implant types. A statistically comparable revision rate for recurrence of infection could be shown for both groups, although a tendency to higher reinfection rate for single-stage change was evident. The revision rate in this single-center study was comparably high, which could be caused by the high comorbidity and high proportion of difficult-to-treat bacteria in patients at a tertiary center. In this patient population, the expectation of implant survival should be critically discussed with patients.

Long-term result of a second or third two-stage revision total knee arthroplasty for infected total knee arthroplasty

BackgroundPersistent or recurrent infection after two-stage revision total knee arthroplasty (TKA) for the treatment of an infected TKA is a dreaded complication. The purpose of the current study was to determine the ability of a second or third two-stage revision TKA to control infection, evaluate the long-term survivorship of the TKA prosthesis, and measure the functional outcome after a second or third two-stage revision TKA for reinfection.MethodsWe evaluated 63 patients (65 knees) with failed two-stage TKA treated with a second or a third two-stage revision TKA. There were 25 men and 38 women (mean age, 67 ± 10.2 years). The mean follow-up from the time of a second two-stage TKA revision was 15.1 years (range, 10 to 19 years) and the mean follow-up from the time of a third two-stage TKA revision was 7 years (range, 5 to 10 years).ResultsOverall, infection was successfully controlled in 49 (78%) of 65 knees after a second two-stage revision TKA was performed. In the remaining 16 knees, recurrent infection was successfully controlled in 12 knees (75%) after a third two-stage revision TKA. Survivorship, free of implant removal for recurrent infection, was 94% at 15.1 years (95% CI, 91 to 100%). Survival free of revision TKA for mechanical failure was 95% (95% CI, 92 to 100%).ConclusionsThe results of the current study suggest that a second or a third two-stage revision TKA is a reasonable option for controlling infection, relieving pain, and achieving a satisfactory level of function for patients with infected TKAs.

Two-stage Total Knee Arthroplasty for Treatment of Surgical Failure of Septic Arthritis in Degenerative Knee Joints.

The ultimate goal of the treatment of infectious knee arthritis is to protect the articular cartilage from adverse effects of infection. Treatment, however, is not always hundred percent successful and has a 12% failure rate. Persistent infection is more likely to happen in elderly patients and those with underlying joint diseases, particularly osteoarthritis. Eradication of infection and restoration of function in the involved joint usually are not possible by conventional treatment strategies. There are few case series reporting two-stage primary knee arthroplasty as the salvage treatment of the septic degenerative knee joint; however, the treatment protocol remains to be elucidated. Based on a proposed approach, patients with failure of common interventions for treatment of septic knee arthritis and underlying joint degeneration were treated by two-stage TKA and intervening antibiotic loaded static cement spacer. Suppressive antibiotic therapy was not prescribed after the second stage. Complete infection eradication was achieved with mean follow up of 26 months. All cases were balanced with primary total knee prosthesis. The knee scores and final range of motions were comparable to other studies. The two-stage total knee replacement technique is a good option for management of failure of previous surgical treatment in patients with septic arthritis and concomitant joint degeneration. Our proposed approach enabled us to use primary prosthesis in all of our patients with no need for suppressive antibiotic therapy.

Clinical outcomes of two-stage total knee arthroplasty using articulating cement spacer in patients with infected arthritic knee: A comparison with arthroscopic surgery

BackgroundThe aim of this study was to compare the functional outcomes and recurrence rate of infection between patients who underwent arthroscopic surgery and two-stage total knee arthroplasty (TKA) for infected arthritic knees. MethodsA retrospective analysis was conducted on 52 patients (52 knees) with advanced knee joint arthritis who underwent arthroscopic surgery or two-stage TKA using articulating cement spacer (ACS) for knee joint infection between January 2009 and November 2013. Of the 52 patients (52 knees), 38 and 14 patients underwent arthroscopic surgery (AS group) and two-stage TKA using ACS (ACS-TKA group), respectively. Patient-reported outcomes (Knee Injury and Osteoarthritis Outcome Score (KOOS) and EuroQol-Visual Analog Scales (EQ-VAS)); range of motion; and recurrence rate of infection were evaluated. ResultsRecurrence of infection was observed in 7/38 patients who underwent arthroscopic surgery, all of whom received two-stage TKA using ACS. Regarding the functional outcomes of the ACS-TKA group obtained before conversion to TKA and those of the AS group obtained six months after arthroscopic surgery, the former group had better outcomes for KOOS pain, KOOS activities of daily living, KOOS quality of life, and EQ-VAS. Regarding the functional outcomes of the ACS-TKA group obtained during the last follow-up and after conversion to TKA and those of the AS group who underwent TKA after arthroscopic surgery, no significant between-group differences were observed. The infection recurrence rate was higher in the AS than in the ACS-TKA group. ConclusionsConsidering infection control and functional outcomes, two-stage TKA using ACS can be an effective alternative treatment for patients with infected arthritic knees.

Cement Pedestal Spacer Technique for Infected Two-stage Revision Knee Arthroplasty: Description and Comparison of Complications.

Background:Infection following total knee arthroplasty (TKA) is a significant complication, with an incidence of up to 2% in primary TKA and 4%–8% in revision cases. Two-stage revision is the gold standard treatment for long-lasting infections of TKA. The purpose of this study was to describe the cement pedestal spacer technique used in infected two-stage revision knee arthroplasty and compare complications against conventional fixed and mobile cement spacers.Patients and Methods:A retrospective review was conducted in all cases who underwent two-stage TKA revision for infection between 2009 and 2015. These cases were separated into groups depending on the cement spacer utilized (fixed, mobile nonpedestal, and mobile spacers with cement pedestal). The cement pedestal technique involves press fitting a cement cylinder into the femur before definitive spacer insertion.Results:Forty four patients underwent two-stage revision TKA. Fewest complications were observed in the pedestal group, with no spacers having subluxed/tilted. The longest followup was also observed in the pedestal group (mean 52.5 months). Mobile spacers with no cement pedestal displayed the highest reinfection rate (16.7%) and the greatest number of cases with complications (malalignment, subluxation, tilting, and spacer fracture). All patients in the pedestal group were ambulatory after the first-stage revision.Conclusions:The cement pedestal technique minimizes complications by optimizing component positioning and balancing. It also safely extends the indication for an articulated spacer into a set of cases with more extensive bone loss and allows for extended monitoring of inflammatory markers.

Same-stage total knee arthroplasty and osteotomy for osteoarthritis with extra-articular deformity. Part II: Femoral osteotomy, prospective study of 6 cases

BackgroundSame-stage (1S) total knee arthroplasty (TKA) and femoral osteotomy (FO) may deserve consideration in patients with both knee osteoarthritis and severe extra-articular knee deformity (EKD). The objective of this study was to assess clinical and radiological outcomes and morbidity (complications and revisions) in 6 patients managed with S1-TKA-FO. Hypothesis1S-TKA-FO produces satisfactory outcomes and is not associated with higher morbidity rates compared to two-stage TKA-TO or TKA with intra-articular EKD correction, while also significantly shortening total treatment duration. Material and methodsA prospective study was performed in 6 patients managed with 1S-TKA-FO between 1999 and 2011; mean age was 64 years (range, 59–72 years) and mean body mass index was 29.5 (range, 26–35). The EKD was consistently greater than 10°. The cause was post-traumatic mal-union in 4 patients, constitutional EKD in 1 patient, and FO in 1 patient. In each patient, the clinical International Knee Society (IKS) score and the hip-knee-ankle angle (HKA), femoral mechanical angle (FMA) and tibial mechanical angle (TMA), were recorded prospectively before and after surgery. ResultsA long uncemented extension stem was used in all 6 patients and a posterior-stabilised implant in 5 patients. No hinged implants were used. In 4 patients, internal fixation of the FO was performed. Mean follow-up was 10 years (range, 4–15 years). From baseline to last follow-up, the mean IKS score increased from 46 to 161 and mean flexion from 95° (range, 70–110°) to 107° (range, 90–120°). The HKA measured radiographically was between 178° and 182° in all 6 patients. The complications consisted of deep vein thrombosis in 1 patient and knee stiffness requiring manipulation under general anaesthesia in 1 patient. No patient experienced mal-union or required revision surgery. DiscussionApart from a case-series study of 11 patients, very few data are available on 1S-TKA-FO. In our small population, no major complications were recorded. The encouraging long-term outcomes warrant a recommendation to perform 1S-TKA-FO in patients with knee osteoarthritis and an intra-femoral deformity greater than 10°. Level of evidenceIV, prospective observational cohort study.

La Torsion épiphysaire distale du fémur est-elle identique sur les deux genoux d’un même patient ? Étude morphométrique scannographique

IntroductionAppropriate rotational positioning of the femoral component is known to be a key factor of success after total knee replacement. However, distal femoral torsion (DFT) varies among individuals. Preoperative CT-measurement of the DFT associated with computer-assisted surgery improves significantly rotational positioning of the femoral implant. Preoperative CT-imaging is costly and exposes to radiations especially in case of bilateral arthroplasty. The goal of our study was to evaluate DFT of both knees of the same patient undergoing bilateral total knee arthroplasty (TKA). We hypothesized that DFT is symmetrical in patients regardless of the frontal deformity. MaterialsIn this retrospective study between December 2008 and March 2015, 82 patients (mean age: 73 years) who had undergone two-stage bilateral TKA (164 knee) were included. DFT was systematically measured on preoperative CT-scans using the posterior condylar angle as described by Yoshioka et al. Two independent observers performed each measurement twice. The intra- and inter- observer reproducibility was evaluated by the Pearson coefficient (r) and the intra-class correlation coefficient (ρ, ICC). ResultsIn the global series, the mean posterior condylar angle was 5.4° (±1.48°) for the right knee and 5.4° (±1.45°) for the left knee. The difference between both knees varied between 0 and 2.2° (p=0.8). 84.6% of the patients (global series) had a right/left difference inferior to 1°. There was no significant difference between both knees regardless of whether there was an important frontal deviation or not (frontal deviation<10°, p=0,7; frontal deviation>10°, p=0.5) and regardless of whether the knee was in varus or valgus (p=0.9 The intra-observer reproducibility was excellent (94%), le The inter-observer reproducibility was moderate to good (60% for left knees, 53% for right knees). DiscussionPreoperative CT-measurement of the DFT on the two arthritic knees of a same patient is comparable and this measurement is reproducible. A single unilateral CT-scan is therefore enough to preoperatively plan appropriately bilateral TKAs. Level of evidenceRetrospective cobort study, level IV.

Middle term result of two-stage total knee arthroplasty for prosthetic knee joint infection

Introduction: The treatment of periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is a challengeable task. Two-stage exchange arthroplasty is a commonly used treatment for chronic PJI. Purpose: The aim of this study was to investigate the successful rate and possible failure risk factors in patients undergoing a planned two-stage exchange arthroplasty for treatment of knee PJI. Methods: From March 2004 to February 2015, we retrospectively reviewed 35 patients have more than 36 months clinical follow-up with periprosthetic knee joint infections. The clinical outcomes were recorded to define the successful or fail treatment for the periprosthetic knee joint infections. Multiple factors such as obesity, comorbidities, diabetes, were recorded and analyzed to evaluate the risk factors of poor outcome. Results: Five patients were unable to receive second stage surgery with cement spacer retained due to variable reasons. Three patients ended with amputation due to uncontrolled infectious process. Overall 27 patients received two-stage exchange arthroplasty to treat knee PJI were analyzed in this study. However, two patients were loss follow-up during the period between 1st and 2nd time surgery. Two patients were treated with static cement spacer due to poor soft tissue condition. These 4 patients were excluded and overall 23 patients were included and analyzed. Overall success rate is 78.26%. 4 patients with recurrent infection were treated with additional surgical debridement. One patient with recurrent infection was treated with the second time two-stage arthroplasty. All of these patients were successful treated without further recurrent infection. Conclusion: We found that failure rate is increasing when considerate the failure between first stage and second stage surgery. In addition, patients without more than 36 months follow-up may have infection free due to honeymoon period but still in risk of reinfection.

Total knee arthroplasty in advanced tuberculous arthritis of the knee.

Controversies regarding the treatment of advanced tuberculosis of the knee still exist. We retrospectively investigated protocols of total knee arthroplasty (TKA) and their efficacy in patients with advanced tuberculosis. Nine TKAs associated with advanced tuberculosis were performed at our institution between 2008 and 2013, with a mean follow-up of 4.4years (range 2-7 years). In four cases with elevated inflammatory biomarkers, patients received three months of antitubercular drug treatment followed by two-stage TKA. In the remaining five cases with normal biomarkers, patients received one-stage TKA with no pre-operative drug therapy. All patients received antitubercular therapy for oneyear post-operatively. Clinical and radiological data during follow-up were gathered to evaluate the effects of treatment. There was no tuberculosis reactivation and all cases demonstrated marked improvement in function and favorable states of prostheses. Specifically, the mean Hospital for Special Surgery (HSS) knee score increased from 44.8 (range 30-60) preoperatively to 82.7 (range 64-92) at last follow-up (P < 0.05). The average range of motion was 56° (range 10° to 90°) before surgery and 94° (range 80-110) at final follow-up (P < 0.05). Elevated erythrocyte sedimentation rates (ESR) and C-reactive protein (CRP) levels returned to normal in a mean of 4.0months (range 3-5 months) and 3.9months (range 3-6 months) post-operatively, respectively. Although a consensus of views regarding surgical timing, prosthesis selection, and peri-operative antitubercular therapy has not been reached, our results suggest that TKA can be performed for advanced tuberculous arthritis.

Knee Fusion or Above-The-Knee Amputation after Failed Two-Stage Reimplantation Total Knee Arthroplasty.

Prosthetic joint infection (PJI) is a serious complication of total knee arthroplasty (TKA). Control of infection after a failed two-stage TKA is not always possible, and the resolution of infection may require an above-knee amputation (AKA) or a the-knee (KF). The purpose of this review is to determine which treatment method (AKA or KF) yields better function and ambulatory status for patients after a failed two-stage reimplantation. A PubMed search related to the resolution of infection by means of an above-the-knee amputation (AKA) or a knee fusion was performed until 10 January 2015. The key words were: infected TKA and above-the-knee amputation. Five hundred and sixty-six papers were found, of which ten were reviewed because they were focused on the topic of the article. KF should be strongly considered as the treatment of choice for patients who have persistent infected TKA after a failed two-stage revision arthroplasty. Patients can walk at least inside the house, and activity of daily living independence is achieved by the patients with successful KF, although walking aids, including a shoe lift, are required. An intramedullary nail leads to better functional results than an external fixator. The functional outcome after AKA performed after TKA is poor. A substantial percentage of the patients never fit with a prosthesis, and those who are seldom obtain functional independence. Only 50% of patients are able to walk after AKA. Patients receiving KF for treating recurrent PJI after TKA have better function and ambulatory status compared to patients receiving AKA. KF must be recommended as the treatment of choice for patients who have persistent infected TKA after a failed two-stage reimplantation procedure.

Two-Stage Primary Total Knee Arthroplasty with Well-Designed Antibiotic-Laden Cement Spacer Block for Infected Osteoarthritic Knees: The First Case Series from China.

We aimed to assess the efficacy of applying a two-stage primary total knee arthroplasty (TKA) with an antibiotic-laden cement spacer block to treat infected osteoarthritic knees. This retrospective study included 17 cases of severely infected osteoarthritic knees treated with two-stage primary TKA. Open debridement and irrigation with insertion of a well-designed antibiotic cement spacer was performed as the first stage. Systemic antibiotics were used in the interval period. Two-stage TKAs were performed after elimination of infection. The pre- and post-operative Hospital for Special Surgery Knee (HSS) score as well as range of motion (ROM) were assessed. Elimination of infection was achieved in 16 patients. C-reactive protein returned to normal levels in an average of 3.4 wks (range, 1-7 wks), whereas erythrocyte sedimentation rate (ESR) recovered in an average of 11.4 wks (range, 6-19 wks). The average interval between the two-stage operations was 16.8 wks (range, 10-27 wks). Compared with the pre-operative level, the mean HSS score had a substantial increase after the first-stage and second-stage surgery (p<0.05). The post-operative maximum extension degree was smaller and the maximum flexion and ROM degree were larger than the pre-operative degree (all p<0.05). There were no recurrent infections and no patients lost to follow-up. One patient chose to receive arthrodesis because of uncontrolled infection after numerous operations and treatments. Two-stage TKA with open debridement, irrigation, and insertion of a well-designed antibiotic-laden cement spacer at the first stage could provide effective pain relief and function restoration as well as infection control in the interval. This treatment protocol provided an encouraging final clinical outcome, which could be a reliable alternative for patients with infected osteoarthritic knees.

The outcome of infected total knee arthroplasty: culture-positive versus culture-negative.

We studied the outcome in culture-positive and culture-negative infected total knee arthroplasty (TKA). We retrospectively reviewed 140 patients with culture-positive and 102 patients with culture-negative infected TKAs. We determined the infection control rate and clinical outcome after repeated debridement, and repeated 2-stage TKA in the culture-positive and culture-negative groups. The mean follow-up was 9.3years (range 5-14years) in the culture-positive group and 10.6years (5-22) in the culture-negative group. The overall infection control rate was 56% in both groups after the first treatment. The overall infection control rate was 90% in the culture-positive group and 95% in the culture-negative group. A functional knee was obtained in 90% in the culture-positive group and 95% in the culture-negative group. The data suggest that treatment according to the types of infection in both culture-positive and culture-negative groups after TKA controlled infection and maintained functional TKA with a firm level of fixation for most patients. Repeated debridement and repeated two-stage exchange TKA further improved infection control rates after the initial treatment and increased the likelihood of maintaining a functional TKA.

Two-Stage Total Knee Arthroplasty for Prosthetic Joint Infection

PurposeThis retrospective review was conducted to identify prognostic factors for two-stage reimplantation for infected total knee arthroplasty (TKA) and the rate of reinfection following revision TKA.Materials and MethodsOut of 88 patients diagnosed with post-TKA infection between 1998 and 2011, 76 underwent two-stage reimplantation and were reviewed in this study. The 76 patients were divided into two groups-those who experienced reinfection and those who did not. Comorbidities, culture results, and inflammation indices were analyzed and compared between the two groups.ResultsOf the 76 patients who underwent a two-stage reimplantation, 18 (23.7%) experienced reinfection. Patients with more than three comorbidities had significantly higher reinfection rates than those with less than three comorbidities (47.1% vs. 4.8%, p=0.032). The reinfection rate between the culture positive prosthetic joint infection group and the culture negative prosthetic joint infection group was not significantly different (p=0.056). Inflammation indices (erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP]) showed a statistically significant difference between patients with reinfection and those without reinfection at 4 weeks after the first-stage surgery.ConclusionsReimplantation must be carefully performed when the risk of reinfection is high, particularly in patients with more than three systemic or local comorbidities and higher inflammation indices (ESR and CRP) prior to revision TKA.

Ergebnisse einzeitiger vs. zweizeitiger bilateraler Knietotalendoprothetik

The total knee arthroplasty (TKA) is a successful procedure. In cases of bilateral knee osteoarthritis, advantages of single stage TKA vs. two-stage TKA as well as the gap between the procedures in case of two-stage TKA are discussed controversially. The aim of the present study is to compare the clinical and radiographic results of single stage bilateral TKA and two-stage bilateral TKA. In cases of two-stage TKA the dependency on the gap between surgeries was determined. In this retrospective study 43 patients with single stage TKA and 35 patients after two-stage TKA with a maximum of 12 months between surgeries were included. Follow-up was in mean 31 ± 15 months. For clinical and radiological evaluation the Knee Society score (KSS) and Stolzalpen knee score were used. Quality of life was measured by the SF-36 score. The pain was determined using a visual analogue scale (VAS). Radiological evaluation was done by use of Knee Society roentgenographic evaluation and scoring system. The overall hospital stay for patients with two-stage TKA (26 ± 5 days) was twice as long as for patients with single stage TKA (14 ± 4 days). Patients with single stage bilateral TKA had a significantly higher KSS level (186 ± 19 points) than patients after two-stage bilateral TKA (179 ± 22 points). Within the two-stage group the best range of motion was achieved by patients with a gap of 4 to 6 months between surgeries and a decreased point value was measured in patients with a gap of 10 to 12 months between TKAs. Using the VAS patients with simultaneous bilateral TKA had significantly increased pain levels during passive motion. Within the two-stage group there were no differences in VAS. The results of Stolzalpen knee score were comparable in both groups. The analysis of radiological measurements showed a significantly higher number of radiolucent lines (1 mm) in patients with single stage TKA without any clinical relevance or progress in follow-up. Patients with single stage bilateral TKA had a higher complication rate than patients with a two-stage procedure. In the single stage group 6 patients had to be revised because of fracture, dislocation, peroneal nerve palsy, patella lateralisation or loosening. In the two-stage group only one patient had to be revised due to a quadriceps tendon rupture caused by a fall at day one after surgery. Analysis of clinical and radiological results shows only marginal differences between the two groups. In two-stage procedures functional results were best when the second surgery was done 4 to 6 months after the first procedure. Single stage TKA had a significantly higher complication rate. However, patient and surgeon should make the decision for single or two-stage bilateral TKA individually.

Outcome of a Second Two-stage Reimplantation for Periprosthetic Knee Infection

Recurrent or persistent infection after two-stage exchange arthroplasty for previously infected total knee replacement is a challenging clinical situation. We asked whether a second two-stage procedure could eradicate the infection and preserve knee function. We evaluated 18 selected patients with failed two-stage total knee arthroplasty implantation treated with a second two-stage reimplantation between 1999 and 2005. Failure of treatment was defined as recurrence or persistence of infection. The minimum followup was 24 months (mean, 40 months; range, 24-83 months). Recurrent or persistent infection was diagnosed in four of 18 patients, two of whom were successfully treated with a third two-stage exchange arthroplasty. Knee Society score questionnaires administered at the last followup showed an average Knee Society knee score of 73 points (range, 24-100 points) and an average functional score of 49 points (range, 20-90 points). The data suggest repeat two-stage exchange arthroplasty is a reasonable option for eradicating periprosthetic infection, relieving pain, and achieving a satisfactory level of function for some patients. Level IV, therapeutic study.

Tuberculous Arthritis of the Knee Treated with Two-Stage Total Knee Arthroplasty

It has been estimated that 2 billion people worldwide currently have tuberculosis in its latent form and that the active form of the disease will develop in 8 million people annually1. Tuberculous arthritis of the knee is one of the most common musculoskeletal manifestations2-6. While chemotherapy remains the cornerstone of treatment7, surgery of the knee may also be indicated and has been reported to include debridement and synovectomy8-10, arthrodesis11-14, amputation15-18, resection arthroplasty19-23, and prosthetic joint replacement24. Recently, there have been several reports of successful management of tuberculous arthritis of the knee with primary total knee arthroplasty25-31. Most of the world's experience in managing musculoskeletal tuberculosis is reported from outside of the United States. Yet, the prevalence of this disease in the United States is substantial and, according to recent data, may be on the rise32. To raise awareness and improve management of this disease, we report the case of a patient with advanced, active, and refractory tuberculous arthritis of the knee with extensive joint destruction. Our patient was managed with medical therapy and a two-stage surgical approach that was designed to sterilize the joint and permit successful total knee arthroplasty. The patient was informed that data concerning the case would be submitted for publication, and he consented. A sixty-two-year-old native-born Filipino man, 167 cm tall and weighing 77 kg, presented in January 2004, with symptoms of fever and a productive cough of several weeks' duration. The patient had immigrated to the United States in 1955 and had become a U.S. citizen, but he still frequently visited the Philippines. After a positive Mantoux skin test, further workup included chest …

Use of recombinant human erythropoietin in two-stage total knee arthroplasty for infection.

A multicenter prospective study was conducted to determine whether epoetin alfa could be used to lower transfusion requirements after two-stage exchange arthroplasty for infection. Forty-one consecutive patients undergoing successful two-stage exchange arthroplasty for an infected total knee arthroplasty were enrolled in a prospective study. Epoetin alfa (40,000 units) was administered subcutaneously after prosthesis resection and antibiotic spacer placement. Although there was no difference in the hemoglobin levels before resection arthroplasty or on postoperative Day 3 between the study group and the control group, hemoglobin levels before reimplantation were higher in the patients who received epoetin alfa (12.4 mg/dL; range, 9.3-15.1 mg/dL) compared with the control group (11.3 mg/dL; range, 8.1-14.4 mg/dL). Average increase in hemoglobin level in the interval between stages was higher in the treatment group (3.2 mg/dL; range, -0.7-6.8 mg/dL) than the control group (1.7 mg/dL; range, -1.9-6 mg/dL). The transfusion rate decreased from 83% of patients in the control group to 34% in the study group during reimplantation. In addition, overall incidence of transfusion for either stage improved from 89% in the control group to 44% in the patients treated with epoetin alfa. Perioperative epoetin alfa statistically increased the hemoglobin levels and decreased transfusion rates for patients undergoing two-stage revision for infected total knee arthroplasty.

Blood Management in Two-Stage Revision Knee Arthroplasty for Deep Prosthetic Infection

Treatment of infected total knee arthroplasty requires aggressive management to treat the infection and restore joint function. For patients with infected knee arthroplasties, a two-stage procedure is used that involves resection of the joint and placement of an antibiotic impregnated cement spacer followed by implantation of a new prosthetic 6 weeks later. Patients undergoing the two-stage procedure typically endure high allogeneic blood transfusion rates (82% to 88%) and progressive anemia because the two surgeries are spaced closely and because the infection precludes the use of alternatives to allogeneic blood. Records were reviewed of 75 patients who underwent two-stage total knee arthroplasty to characterize perioperative hemoglobin levels and blood transfusion needs in this patient group. Although transfusions were administered only when warranted by clinical symptoms and were not based on predetermined hematologic values, 62 (82%) patients received a mean of 2.3 units of blood at first-stage surgery, and 60 (80%) patients received a mean of 2.1 units of blood at the second stage. Overall, only 12% of patients did not have allogeneic blood transfusion. At the first stage before resection, mean hemoglobin concentration was 11.6 g/dL and reached a mean nadir of 8.6 g/dL 3 days after surgery. At the second stage before reimplantation, hemoglobin concentration averaged 11.1 g/dL and reached a mean nadir of 8.2 g/dL 3 days after surgery. After the first stage, allogeneic blood transfusion failed to improve postoperative hemoglobin levels enough to prevent transfusions associated with the second-stage. Patients undergoing two-stage total knee arthroplasty have anemia, and a substantial proportion of these patients require allogeneic blood transfusion at both stages. Thus, novel blood management practices are required to improve hemoglobin levels and reduce allogeneic transfusion rates in this patient population.