Surgical treatments for patients with an infected total knee arthroplasty

ONE-STAGE RESECTION AND REIMPLANTATION

The medical literature suggests that primary exchange revision arthroplasty may be a viable alternative to the two-stage revision procedure. In one-stage surgery, incision and arthrotomy are performed in the usual way; and a thorough irrigation and debridement are done, all infected total knee components are removed, and new total knee components are placed during the same session. In one study, 22 infected total knees were revised using single-stage resection and reimplantation.²¹ The patients were then treated with 4 to 6 weeks of IV antibiotics, followed by 6 to 12 months of oral antibiotics under the guidance of an infectious disease consultant.²¹ One patient expired as a result of overwhelming sepsis, one patient was lost to follow-up, and one infection recurred 6.5 years later (and was successfully treated with one-stage resection/reimplantation).²¹ Nineteen of 21 patients showed no signs of recurrent infection at an average of 10.2 years of follow-up.²¹

IRRIGATION AND DEBRIDEMENT ALONE

In both the one-stage and two-stage procedures, the infected total knee components are removed and replaced with new components. Another surgical alternative is open debridement and irrigation of the infected joint with retention of the primary total knee components. The advantages of component retention include reduced stress for the patient, less bone loss, better function of the knee, and less cost to the health care system. This procedure is not an option, however, if any of the primary components show signs of septic loosening.

The procedure itself involves arthrotomy, obtaining appropriate cultures and Gram's stain specimens, inspecting the components for loosening, and a complete synovectomy and thorough debridement of grossly infected and necrotic tissue. The joint is then copiously irrigated with antibiotic solution. The tibial polyethylene is removed, when possible, to allow for improved exposure and thorough debridement and irrigation of the posterior knee. A new polyethylene liner is inserted and the wound is closed, usually over surgical drains. Patients are placed on IV antibiotics after surgery, and follow-up includes an infectious disease consultant.

Mont and colleagues treated 24 patients with infected total knee arthroplasties who had onset of infection symptoms within 30 days of presentation and no radiographic evidence of loosening.²² Ten of the 10 knees with infections occurring in the early postoperative phases (less than 3 months following initial joint replacement) were retained; and 10 of the 14 late infections (occurring more than 3 months after primary replacement—presumptively, hematogenously-infected knees) were retained.²² Another study used open irrigation and debridement to treat 33 patients with acute gram-positive infected total knee arthroplasties with poor success.⁵ Of the 31 patients who underwent debridement with component retention, 20 (65%) experienced recurrent infection and eventual removal of components.⁵ These studies suggest that both the duration of symptoms and the infecting pathogen must be considered when deciding to proceed with an open irrigation and debridement with retention of the primary total knee components.

ARTHROSCOPIC IRRIGATION AND DEBRIDEMENT

An alternative to open irrigation and debridement is to attempt eradication of infection with arthroscopic surgery and antibiotic therapy. Arthroscopic surgery reduces trauma to the infected joint and soft tissues compared with open surgery. The major drawback of an arthroscopic approach is that the posterior knee cannot be adequately debrided because the polyethylene liner is retained.

With arthroscopic debridement, numerous small portals are made around the infected knee to allow visualization with the arthroscopic camera and to allow for inflow and outflow of antibiotic saline through the joint. Debridement is achieved using a motorized shaver through the various portals. An aggressive, meticulous synovectomy is performed in the various compartments of the knee, including the medial and lateral gutters, anterior knee, suprapatellar pouch, and femoral notch. Again, antibiotic therapy under the guidance of an infectious disease consultant should be instituted postoperatively.

Studies of this approach have had varying results. Five patients with infected total knee arthroplasties and symptoms present for less than 7 days were treated with arthroscopic irrigation and debridement; at an average of 41 months follow-up, none have needed or undergone revision.²³ Other studies have not reported such successful results, however. Waldman and colleagues achieved eradication of infection in 6 of 16 patients treated with arthroscopic irrigation and debridement.²⁴ Dixon and colleagues reported similar findings, successfully retaining the primary total knee components in 9 of 15 patients using arthroscopic irrigation and debridement.²⁵ The use of arthroscopic irrigation and debridement is very controversial, and these studies show that while more research needs to be done on this procedure before it is widely practiced, it may be an option for a patient whose health may not permit open revision or debridement.

CONCLUSION

Two-stage revision arthroplasty is the most commonly used treatment for infected total knee arthroplasty and has thus far had the best treatment results reported in the literature. Even with this procedure, however, patients should expect to lose some function of their prosthesis following two-stage revision arthroplasty. Alternative treatment options have had some documented success at eradicating infection, and some evidence suggests that they may have a role when treating early infections or against certain infecting organisms. Additional research needs to be done, however, to determine their overall effectiveness and appropriateness. Two-stage revision arthroplasty is a long, difficult treatment, and with patients living longer with more health problems, a less traumatic alternative for the infected total knee arthroplasty will need to be developed. If these alternative treatments can approach the success rate of two-stage arthroplasty, they will be viable options. JAAPA

Joseph Kotelnicki and Kevin Mitts practice in the Department of Orthopaedics, Berkshire Medical Center, Pittsfield, Massachusetts. The authors have indicated no relationships to disclose relating to the content of this article.

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