Infected arthroplasty of knee: avaliation in arthrodesis with semi rings

Schueda, Marco Antonio; Menegazzo, Cristiano Grimm; Gambeta, Claudecir Evandro; Farias, Ítalo Pires; Heinig Neto, Walter Max

doi:10.1590/S1413-78522011000600010

Abstracts

There were eight knee arthrodesis in infected total knee arthroplasties between January, 2006 and July, 2008. The mean age was 66,3 years old (63-80), three patients were male and five female. The method of choice was external fixation with semi rings and the mean follow up was 21 months (12 - 40 months). This is a multicentric prospective study with patients answering the Nottingham Health Profile, an objective questionnaire which evaluates quality of life. We observed an improvement of 49% in the levels of preoperatory quality of life compared to postoperatively, as well as 100% of radiographic union. These are facts that confirm the safe use of this technique to the treatment of infected total knee arthroplasty. Level of Evidence IV, Case series.

Arthrodesis; Infection; Arthroplasty, Replacement, Knee; Quality of life

Realizaram-se no período de Janeiro de 2006 até Julho de 2008, em pacientes portadores de artroplastia total de joelho infectada oito artrodeses. Com idade média de 66,3 anos (63-80 anos), três pacientes eram do sexo masculino e cinco feminino. Utilizou-se o método de fixador externo com semi-anéis, com acompanhamento pós-operatório médio de 21 meses (12-40 meses). Trabalho multicêntrico, com pacientes respondendo prospectivamente, pré e pós-operatório, questões objetivas, através do questionário Nottingham Health Profile , que avalia qualidade de vida. Foi observado melhora de 49% nos níveis de qualidade de vida pós-operatórios em relação aos pré-operatórios, assim como consolidação clínica radiográfica em todos pacientes. Tais fatos que avalizam a realização desta técnica, para tratamento da artroplastia total de joelho infectada. Nível de Evidência IV, Série de casos.

Artrodese; Infecção; Artroplastia do joelho; Qualidade de vida

UPDATING ARTICLE

^IHospital e Maternidade Marieta Konder Bornhausen - Itajaí - SC, Hospital Dona Helena - Joinville - SC, Instituto de Ortopedia e Traumatologia - IOT - Joinville, SC, Brazil

^IIInstituto de Ortopedia e Traumatologia - IOT - Joinville, SC, Brazil

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ABSTRACT

There were eight knee arthrodeses in infected total knee arthroplasties between January, 2006 and July, 2008. The mean age was 66.3 years old (63-80), three patients were male and five female. The method of choice was external fixation with semi-rings and the mean follow up was 21 months (12 - 40 months). This is a multicentric prospective study with patients answering the Nottingham Health Profile, an objective questionnaire which evaluates quality of life. We observed an improvement of 49% in the levels of preoperative quality of life compared to postoperatively, as well as 100% of radiographic union. These are facts that confirm the safe use of this technique to the treatment of infected total knee arthroplasty. Level of Evidence IV, Case series.

Keywords: Arthrodesis. Infection. Arthroplasty, Replacement, Knee. Quality of life.

INTRODUCTION

Infections in total knee arthroplasties represent a serious problem for the orthopedist, with incidence of approximately 1% to 2% of prosthetic surgeries.^1-5

In some patients, the situation is more complicated due to loss of bone stock, deficiency of the extensor mechanism, instability, important pain and functional impotence, and its revision (change of prosthesis) is not always possible. In select patients arthrodesis or fusion is the salvation procedure that would practically solve the problem.^2,6-8 According to Smille "the need for arthrodesis is the last correction of the fault".

The methods used for this purpose are apparently the internal fixators (intramedullary nails, screws and plates) or external fixators. External fixation offers potential advantages allowing manipulation for angular correction, focal compression and reduction of the risk of systemic infection.^8-10

The objectives of this study are to evaluate consolidation time and to compare the pre- and postoperative quality of life indexes in patients with infected knee arthroplasty, discussing the changes brought about by the arthrodesis technique with compressive semi-ring fixator.¹¹

MATERIAL AND METHODS

Eight (8) arthrodeses were performed in the period from January 2006 to July 2008 due to infected total knee arthroplasties on three (3) male and five (5) female patients with mean age of 66.3 years (63 - 80 years), using the external fixator method with semi-rings. (Figures 1 A and ^B)

Inclusion criteria were patients with infected unilateral knee arthroplasty, treated by the method described here, with minimum postoperative follow-up of 12 months and consent form signed by the patients and their families.

They were monitored in the pre- and postoperative periods in outpatient regime until radiographic consolidation, removal of the external fixator and return to daily life activities. To perform this multicentric study, the patients prospectively answered objective questions pre- and postoperatively through the Nottingham Health Profile¹² questionnaire, evaluating quality of life. (^{Appendix 1} Appendix 1 ).

RESULTS

Analyzed in the period from January 2006 to July 2008, eight patients, with mean follow-up time of 21 months (12 - 40 months) with infected knee arthroplasty, with mean evolution of 5.4 months (3 - 13 months), three of whom were male sex and five female, with mean age of 66.3 years (63 to 80 years), where the predominant etiological agent was Staphylococcus aureus. (Table 1) They were operated by the compression technique with semi-rings (Figure 1), with radiographic consolidation occurring on average at 4.6 months (3 - 6 months). (Table 1) At this time, the external fixators were removed. Data were gathered according to the Nottingham Health Profile quality of life questionnaire, preoperatively and postoperatively, at least 12 months (10-16 months) after surgery. (Table 2)

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The results were analyzed by simple arithmetic mean, which confirmed significant statistical difference among the mean values for quality of life of the patients submitted to the technique. The lowest number of incapacities (No) was qualified as better quality of life. (Table 2)

The mean percentage of differences for improvement of quality of life was 49% (37% - 60%).

DISCUSSION

Demographically, world literature reports the incidence of total knee arthroplasty infection as being around 2%.^13,14 Various techniques are described for revision or arthrodesis in the treatments of this complication.¹⁵

There are descriptions of several arthrodeses with external fixation that can be performed in a uniplanar or modified biplanar manner, as well as categories with transfixing pins and circular molds.^16-20

Patients with described prosthesis infection complications have their activities of daily living (ADLs) compromised and consequently their quality of life seriously affected.

Objective measures that evaluate the improvement of quality of life indexes will be able to validate or not validate a technique that minimizes the complications determined by infection in arthroplasty. The surgical technique used for arthrodesis that was described previously has stabilization with concomitant compression and the possibility of correcting alignments over the course of the postoperative period as advantages, as described by literature when using circular fixators.

Partial weight bearing with crutches was allowed in our cases until radiographic consolidation, when full weight bearing was authorized with removal of the fixator after 30 days.

We opted for the Nottingham Health Profile questionnaire for evaluation of the quality of life index, as it is practical and objective in its questions and values everyday aspects of the patients.¹²

The results were consistent with literature as concerns age, sex, etiology and duration of the infection (under specific antibiotic therapy) without its remission.¹⁹

Our consolidation rate was 100% with a mean 4.6 months, consistent with literature that has its mean time ranging from 4.5 to 6.8 months when using an external fixator.^11,16 Oostenbroek et al.⁶ described a mean time of 10.3 months for consolidation, reporting complications such as infection of the pins, pseudarthrosis and fractures of the femur and/or tibia in their cases, not present in our casuistry, except for superficial infections on the path of the femoral cross pin observed in three cases.

CONCLUSION

The results showed that there was consolidation in all cases and a statistically significant positive difference in the pre and postoperative answers to the quality of life questionnaire. This study endorses the performance of this procedure as being reproducible and applicable for the resolution of total knee arthroplasty infection.

REFERENCES

1. Klinger HM, Spahn G, Schultz W, Baums MH. Arthrodesis of the knee after failed infected total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2006;14:447-53.
2. Rand JA, Bryan RS, Morrey BF, Westholm F. Management of infected total knee arthroplasty. Clin Orthop Relat Res. 1986;(205):75-85.
3. Damron TA, McBeath AA. Arthrodesis following failed total knee arthroplasty: comprehensive review and meta-analysis of recent literature. Orthopedics. 1995;18:361-8.
4. Bargiotas K, Wohlrab D, Sewecke JJ, Lavinge G, Demeo PJ, Sotereanos NG. Arthrodesis of the knee with a long intramedullary nail following the failure of a total knee arthroplasty as the result of infection. J Bone Joint Surg Am. 2006;88:553-8.
5. Panagiotopoulos E, Kouzelis A, Matzaroglou Ch, Saridis A, Lambiris E. Intramedullary knee arthrodesis as a salvage procedure after failed total knee replacement. Int Orthop. 2006;30:545-9.
6. Behr JT, Chmell SJ, Schwartz CM. Knee arthrodesis for failed total knee arthroplasty. Arch Surg. 1985;120:350-4.
7. 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;69:1013-21.
8. 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.
9. Smillie I. Fractures of tibia and femur involving the knee joint. Injuries of the knee joint. 4th ed. Edinburgh: Livingstone; 1970. p. 224-67.
10. Bengtson S, Knutson K. The infected knee arthroplasty. A 6-year follow-up of 357 cases. Acta Orthop Scand. 1991;62:301-11.
11. Schueda MA, Menegazzo CG, Daguer MK, Gambeta CE, Comim O. Artrodese de joelho utilizando compressor externo híbrido pós-artroplastia infectada. Tec Ortop. 2008;1:7-12.
12. Herdman M, Fox-Rushby J, Badia X. 'Equivalence and the translation and adaptation of health-related quality of life questionnaires. Qual Life Res. 1997;6:237-47.
13. Peersman G, Laskin R, Davis J, Peterson M. Infection in total knee replacement: a retrospective review of 6489 total knee replacements. Clin Orthop Relat Res. 2001;(392):15-23.
14. Ayers DC, Dennis DA, Johanson NA, Pellegrini VD. Common complications of the total knee arthroplasty. J Bone Joint Surg Am. 1997;79:278-311.
15. Barton TM, White SP, Mintowt-Czyz W, Porteous AJ, Newman JH. A comparison of patient based outcome following knee arthrodesis for failed total knee arthroplasty and revision knee arthroplasty. Knee. 2008;15:98-100.
16. Mabry TM, Jacofsky DJ, Haidukewych GJ, Hanssen AD. Comparison of intramedullary nailing and external fixation knee arthrodesis for the infected knee replacement. Clin Orthop Relat Res. 2007;464:11-5.
17. Salem KH, Keppler P, Kinzl L, Schmelz A. Hybrid external fixation for arthrodesis in knee sepsis. Clin Orthop Relat Res. 2006;451:113-2.
18. McQueen DA, Cooke FW, Hahn DL. Knee arthrodesis with the Wichita Fusion Nail: an outcome comparison. Clin Orthop Relat Res. 2006;446:132-9.
19. Oostenbroek HJ, van Roermund PM. Arthrodesis of the knee after an infected arthroplasty using the Ilizarov method. J Bone Joint Surg Br. 2001;83:50-4.
20. Cunningham JL, Richardson JB, Soriano RM, Kenwright J. A mechanical assessment of applied compression and healing in knee arthrodesis. Clin Orthop Relat Res. 1989;(242):256-64.

Appendix 1

Infected arthroplasty of knee: evaluation in arthrodesis with semi-rings

Marco Antonio Schueda^I; Cristiano Grimm Menegazzo^II; Claudecir Evandro Gambeta^II; Ítalo Pires Farias^II; Walter Max Heinig Neto^II

Publication Dates

Publication in this collection
24 Jan 2012
Date of issue
2011

History

Received
03 Oct 2009
Accepted
26 May 2010

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Klinger HM, Spahn G, Schultz W, Baums MH. Arthrodesis of the knee after failed infected total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2006;14:447-53.

[2] 2. Rand JA, Bryan RS, Morrey BF, Westholm F. Management of infected total knee arthroplasty. Clin Orthop Relat Res. 1986;(205):75-85.

[3] 3. Damron TA, McBeath AA. Arthrodesis following failed total knee arthroplasty: comprehensive review and meta-analysis of recent literature. Orthopedics. 1995;18:361-8.

[4] 4. Bargiotas K, Wohlrab D, Sewecke JJ, Lavinge G, Demeo PJ, Sotereanos NG. Arthrodesis of the knee with a long intramedullary nail following the failure of a total knee arthroplasty as the result of infection. J Bone Joint Surg Am. 2006;88:553-8.

[5] 5. Panagiotopoulos E, Kouzelis A, Matzaroglou Ch, Saridis A, Lambiris E. Intramedullary knee arthrodesis as a salvage procedure after failed total knee replacement. Int Orthop. 2006;30:545-9.

[6] 6. Behr JT, Chmell SJ, Schwartz CM. Knee arthrodesis for failed total knee arthroplasty. Arch Surg. 1985;120:350-4.

[7] 7. 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;69:1013-21.

[8] 8. 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.

[9] 9. Smillie I. Fractures of tibia and femur involving the knee joint. Injuries of the knee joint. 4th ed. Edinburgh: Livingstone; 1970. p. 224-67.

[10] 10. Bengtson S, Knutson K. The infected knee arthroplasty. A 6-year follow-up of 357 cases. Acta Orthop Scand. 1991;62:301-11.

[11] 11. Schueda MA, Menegazzo CG, Daguer MK, Gambeta CE, Comim O. Artrodese de joelho utilizando compressor externo híbrido pós-artroplastia infectada. Tec Ortop. 2008;1:7-12.

[12] 12. Herdman M, Fox-Rushby J, Badia X. 'Equivalence and the translation and adaptation of health-related quality of life questionnaires. Qual Life Res. 1997;6:237-47.

[13] 13. Peersman G, Laskin R, Davis J, Peterson M. Infection in total knee replacement: a retrospective review of 6489 total knee replacements. Clin Orthop Relat Res. 2001;(392):15-23.

[14] 14. Ayers DC, Dennis DA, Johanson NA, Pellegrini VD. Common complications of the total knee arthroplasty. J Bone Joint Surg Am. 1997;79:278-311.

[15] 15. Barton TM, White SP, Mintowt-Czyz W, Porteous AJ, Newman JH. A comparison of patient based outcome following knee arthrodesis for failed total knee arthroplasty and revision knee arthroplasty. Knee. 2008;15:98-100.

[16] 16. Mabry TM, Jacofsky DJ, Haidukewych GJ, Hanssen AD. Comparison of intramedullary nailing and external fixation knee arthrodesis for the infected knee replacement. Clin Orthop Relat Res. 2007;464:11-5.

[17] 17. Salem KH, Keppler P, Kinzl L, Schmelz A. Hybrid external fixation for arthrodesis in knee sepsis. Clin Orthop Relat Res. 2006;451:113-2.

[18] 18. McQueen DA, Cooke FW, Hahn DL. Knee arthrodesis with the Wichita Fusion Nail: an outcome comparison. Clin Orthop Relat Res. 2006;446:132-9.

[19] 19. Oostenbroek HJ, van Roermund PM. Arthrodesis of the knee after an infected arthroplasty using the Ilizarov method. J Bone Joint Surg Br. 2001;83:50-4.

[20] 20. Cunningham JL, Richardson JB, Soriano RM, Kenwright J. A mechanical assessment of applied compression and healing in knee arthrodesis. Clin Orthop Relat Res. 1989;(242):256-64.

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