31 Management of TKA Infection –
One-stage Exchange
T. Gehrke1, S.J. Breusch2
1
2
Depatment of Orthopaedics, ENDO-Clinic, Hamburg, Germany
Depatment of Orthopaedics, University of Edinburgh, United Kingdom
Introduction
The management of periprosthetic infection remains a challenge to any arthroplasty
surgeon. Several treatment options are available depending on the clinical situation,
the local set-up, the surgeon’s preference and expertise. In the most frequent scenario, where revision surgery with prosthesis exchange is necessary, controversy still
exists between single and two-stage approach to the problem. With the introduction
of articulating spacers, the functional outcome of two-stage exchange has significantly improved [8, 19, 26, 36]. However, one-stage exchange offers certain advantages including the need for only one operation (if no recurrence), shorter hospitalisation, lower overall cost and high patient satisfaction [3, 10, 11]. In this review the
authors will describe their management strategy and experience with direct
exchange. Particular emphasis is given to the requirements that provide the basis for
success. Furthermore, 8 year outcome data of 100 consecutive patients following onestage revision TKA for infection with no lost to follow-up are provided and discussed.
Pathophysiology and Etiology
Periprosthetic infection is a foreign body associated infection. It must be clearly differentiated from other bone infections, like osteomyelitis. Not only bacteria are recognized by the host defense as “enemies”, but also foreign bodies. Both, micro-organisms and foreign materials induce inflammation as a reaction to tissue injury and are
handled in the same manner by the human body. More than 90 % of infections during
the first year after implantation are due to bacterial contamination during surgery
[30]. Hematogenous infections and infections which reach the site of infection from
other sources are less frequent. In the presence of foreign bodies, a contamination as
low as 100 colony-forming units (CFU) is sufficient to induce an infection in contrast
to 10,000 cfu without foreign material [6, 31]. This effect is due to the diminished
clearing capacity of phagocytosis by leukocytes in the presence of foreign material
[44]. Macrophages as the first line of defence try to degrade these materials by enzymatic digestion. But if the foreign body is too large for our little macrophage, fibroblasts are stimulated to form granulation tissue around the foreign body. Just like
fibroblasts, a number of bacteria, in particular staphylococci are able to colonize the
surface of the foreign body. The competition between the fibroblasts, activated by the
31 Management of TKA Infection – One-stage Exchange
macrophages, and the bacteria to colonize the foreign body has been given a very
descriptive term by Gristina: “The race for the surface”. The bacteria are anchored to
the surface by forming a biofilm. This biofilm protects from the host’s defence mechanisms and these sessile bacteria are also highly resistant to antimicrobial agents [5,
18, 44]. But colonization and formation of slime alone do not cause an infection or an
infectious disease. Periprosthetic infection begins when some of the sessile bacteria
switch back to planktonic forms and induce infection in the adjacent tissue – periprosthetic osteomyelitis [11]. The period between colonization and clinically detectable infection may last for months, even up to about three years. Signs of infection
may occur very late when the bacteria leave the interface, invade surrounding tissue
and induce a secondary osteomyelitis. It is important to realise that periprosthetic
infection is not only an infection of the prosthetic interface, but also an infection of
bone and surrounding soft tissues. This understanding is of utmost importance for
the surgical management.
Diagnosis
The diagnosis of periprosthetic infection can be simple, but occasionally most difficult to establish. In the case of immediate postoperative infection the first symptoms
can be seen around day 4 to 8 after TKA. If purulent secretion is present the diagnosis
is obvious. However, prolonged wound discharge ( 8 7 – 10 days), continued soft tissue swelling and induration, or wound dehiscence should be taken seriously, considered as infection until proven otherwise and managed with a pro-active and aggressive attitude. If an early infection (within 3 weeks) occurs after patient discharge from
hospital, often superficial wound healing problems, hematomas and seromas are evident. However, this is not always obvious and the clinical signs can be more subtle.
Monitoring of C-reactive protein (CRP) is probably the most useful parameter in this
scenario. CRP values are highest with a peak on day 2 – 3 postop, and should return to
normal, preoperative values within 3 weeks. In some patients CRP normalisation can
take up to 6 weeks and there is no reason for concern or panic, as long as CRP values
show a continuing decline. Failure to do so should result in prompt action. In our
experience patients with good (non-indurated) soft tissues, dry wounds and CRP levels below 60 to 90 mg/dl on day 5 – 6 can be considered “safe”, but all others (or if in
doubt) warrant early follow-up in order not to miss the window of opportunity for
early aggressive debridement and suction/irrigation [38].
Whereas clinical symptoms are the main parameters for diagnosing periprosthetic
infection in its early stages, laboratory and radiological investigations become more
important in late infection. Erythrocyte sedimentation rate has a longer lag time than
CRP and is probably only a useful additional tool in the management of patients with
rheumatoid arthritis with chronically raised CRP (and ESR) levels. ESR and CRP have
a specificity and sensitivity of about 90 %. In contrast, leukocytosis is unspecific and
rarely present. Other more sophisticated parameters like Interleukin 6, Procalcitonin
or the Interleukin 2 receptor are expensive and generally give us no additional clinically relevant information.
The most important clinical parameter in late infection is the presence (or recurrence !) of pain. Although rarely described in the literature local skin and deep soft
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Clinical Applications: Knee
tissue induration are poor prognostic indicators in our experience. A “woody” leg
should raise the level of suspicion ! Serial radiographic comparison can be of value
and bone scans are non-specific although highly sensitive. Bone scans can stay hot for
several years following arthroplasty, can represent bone remodeling and may be misleading. Recently, antigranulocyte scintigraphy was reported with a sensitivity of 1.0,
a specificity of 0.83, a positive prediction value of 0.83 and a negative prediction value
of 1.0. In contrast, preoperative joint aspiration and culture, was less sensitive, but
showed a specificity and positive prediction value of 1.0 [28].
In our own practice joint aspiration with prolonged culture time of at least 10 – 14
days is considered mandatory and gold standard. This must be done under strictly
sterile conditions without the use of local anaesthetic and saline, which both can
exhibit bactericidal effects. The accuracy of aspiration in the Endoclinic in Hamburg
has been higher than 95 % [40] in more than 7500 periprosthetic infections treated.
However, some special aspects in the investigation of the aspirated fluid have to be
considered. The number of bacteria is very small so culture must last for a minimum
of 10 – 14 days and not only 3 days as is usual for blood cultures. Fast transport of the
aspirated fluid in a sterile container – swabs are inadequate – to the laboratory, rapid
processing and an experienced microbiologist with an interest in this demanding
problem are important pre-requisites and of utmost importance for success. In some
cases repeated aspiration can increase the capture rate, particularly if the patients
have been treated with antibiotics previously. A minimum period of 14 days off any
antibiotics is required before aspiration in this instance.
Management Strategy – One Stage Exchange
Only in the presence of a positive culture and with the respective antibiogram at hand
should a one-stage procedure be considered and offered to the patient. A cemented
fixation using antibiotic loaded acrylic cement (ALAC) is considered treatment of
choice to achieve high local therapeutic levels of antibiotic elution from ALAC [12].
The secret of success not only depends on complete removal of all foreign material
(including intramedullary cement and restrictors) and the use of ALAC, but in particular on the aggressive and complete debridement of the soft tissues and bone. A full
synovectomy also in the posterior aspects of the knee is considered of importance
and performed routinely. To gain access this invariably means sacrificing the posterior cruciate ligament, if still existing, and not infrequently the collateral ligaments,
which will result in the need for hinged implants (see below).
The ALAC should be regarded as a means to prevent re-colonization of the new
implants and not seen as the “killer” and cure for infection. It is the surgeon’s knife
above all, which will determine success. Surgery in periprosthetic infection should be
carried out as a tumor procedure and no comprise should be made during debridement: if in doubt cut it out !
31 Management of TKA Infection – One-stage Exchange
General Pre-Operative Planning
Anaesthesia:
) Clinical and anaesthesiological assessment of operative risk
) Adequate quantity of additional donor blood
) In case of long exchange operations preoperative administration of fibrinolysis
inhibitors (e.g. Trasilol®) is recommended. Cave: risk of anaphylactic shock!
Radiological Preparation
) Conventional x-rays in two or three planes (patella skyline) in a standardized
position are usually adequate. Imaging of hips and entire femur if ipsilateral hip
replacement. Long leg alignment films are recommended.
) In some cases calibrated x-rays may have to be taken with a radiopaque scale,
especially when special, extra small, custom-made implants or megaprostheses
(e.g. total femoral replacement) are required.
Patient Information – Specific Risks
) Risk of recurrent or new infection – about 10 – 15 %
) Re-operation for haematoma, wound debridement or persistent infection
) Damage to peroneal nerve or main vessels
) Postoperative stiffness and loss of function (extensor mechanism)
) Risk of intra- and postoperative fracture
) Increased risk of aseptic loosening
Surgeon’s Planning and Preparation
Choice of Implants and Cement:
) The surgeon should have knowledge of the implant in situ and be familiar with
its removal and disassembly (e.g. hinge mechanism). Occasionally it is useful to
order and use the implant-specific instrumentation, if available for the particular implant
) A variety of implants must be at hand, ranging from primary total condylar to
stemmed hinges, depending on the requirements for reconstruction.
) Ligament deficient knees will require constraint implants, but ligament deficiency may also result during intraoperative debridement – hence the need for
rotating of fixed hinge implants. Due to the aggressive soft tissue debridement
strategy of both authors this is the case in almost all cases of one stage
exchange.
) Loss of bone stock, the possibility of intraoperative complications such as shaft
fractures, perforations of the cortex, windows and tibial/femoral disintegration
must be taken into consideration when choosing the implant. Always have a
second line of defence available!
) Distal femoral or proximal tibial replacement implants may have to be chosen in
patients with significant bone deficiency. Bone loss is always significantly more
extensive than radiographically evident. Custom made implants with extra long
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Clinical Applications: Knee
Bacteria
Antibiotics
Dosage per 40 g
PMMA cement
Gram positive
Staphylococci
Streptococci
Propionibacteria
Lincomycin
Gentamicin
3.0 g
1.0 g
Staphylococci
Streptococci
Propionibacteria
Cefuroxim
Gentamicin
3.0 g
1.0 g
Staphylococci
(highly resistant)
Vancomycin
Ofloxacin
2.0 g
1.0 g
Enterococci
Vancomycin
Ampicillin
2.0 g
1.5 g
Cefotaxim
Gentamicin
3.0 g
1.0 g
Cefoperazon
Amikacin
2.0 g
2.0 g
Streptomycin
2.0 g
Gram negative
Enterobacteriaceae
Pseudomonas aeruginosa
Acid-fast rods
Mycobacteria
Table 1. Combinations
of antibiotics recommended for addition
to PMMA cement.
(Selected according to
the susceptibility of
the pathogen)
or narrow stems may have to be ordered prior to surgery. The potential need for
total femoral replacement implants should also be considered.
) In patients where significant damage to the extensor mechanism is pre-existing
or can be anticipated an arthrodesis nail should be available as a last resort
(patient consent!)
) ALAC with additional antibiotics (AB) in powderform to be added intraoperatively should be available (Table 1). Invariably at least 2 – 3 mixes of cement
(80 – 120 g) per femur and also per tibia are required. Large mixing systems and
appropriate cement guns are required. In patients with a narrow diaphysis extra
narrow nozzles allow for appropriate retrograde cementing technique.
) The surgeon should know which type of ALAC was been used at the index operation, as resistance of the organism to the previously used AB must be expected
[34, 42] and a different ALAC should be chosen. In individual cases an industrially
pre-manufactured ALAC cement may be appropriate. The antibiogram and ideally
a recommendation from the microbiologist should be available (Table 1) including
the AB for cement impregnation and for postoperative i.v. administration.
Operative steps
Skin Incision and Debridement:
) Old scars in the line of the skin incision should be excised (Fig. 1).
) If a prior incision does not lie in this line, keep sufficient distance between it and
the new incision. Use the incision from the last approach if technically feasible.
Avoid raising a subcutaneous flap.
) Crossing the old scar at an acute angle or deviating from it should be avoided.
31 Management of TKA Infection – One-stage Exchange
Fig. 1. Skin incision
and fistulectomy
Fig. 2. Complete synovectomy and debridement
) Fistulae should be integrated into the skin incision if possible and radically
excised all the way to the joint (Fig. 1). If the fistulae lie too far laterally or posteriorly they are handled by means of a separate excision, following down the fistula tract. Methylene blue staining can be helpful in this case.
) If the need for muscular-cutaneous flaps can be anticipated, a plastic surgeon
should be available. However, if the surgeon is familiar with a medial gastrocnemius transfer, most situations can be handled.
) As the operative time commonly exceeds 2 hours an above knee tourniquet is
applied but not inflated. The procedure is started without tourniquet so that all
bleeders can be coagulated on the way in. Furthermore, without tourniquet the
boundary between infected tissue, scar and healthy bleeding soft tissue (and bone)
can be distinguished better during debridement. All non bleeding tissue and bone
should be excised. Particular emphasis should be given to perform a complete synovectomy and debridement in the posterior compartment (Figs 2 and 3).
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Clinical Applications: Knee
Fig. 3. Removed sinovia and debrided
tissue
Fig. 4. Prosthesis
removal may require a
dedicated instrumentarium
) Biopsy material, preferably 5 – 6 samples, should be taken as a routine measure
from all relevant areas of the operation site for microbiological and histological
evaluation [1, 39]. Then the chosen i.v. AB are administered. This commonly
comprises a broad spectrum cephalosporin and additionally one or two others
according to the antibiogram.
Implant Removal and Completion of Debridement
) Removing cemented implants stems is generally much easier and less invasive
than removing cementless components, in particular when these are stemmed
and ingrown.
) In cases of well fixed uncemented components with stem, often cortical windows
are required to gain access to the interface. High speed burrs and curved saw
blades aid removal (Fig. 4). Unfortunately even in experienced hands occasionally significant destruction and loss of bone stock will occur.
) Using narrow straight osteotomes with asymmetrically honed blade remove all
31 Management of TKA Infection – One-stage Exchange
Fig. 5. Implant and
cement removal with
osteotomes
)
)
)
)
)
)
)
)
accessible bone cement (if cemented implant), that can be removed without causing further loss of bone stock
A Gigli say can be useful to cut around the femoral shield and the tibial base
plate of the implant. A full range of narrow and wide osteotomes of various
thicknesses (Lambotte osteomes) should be available. By using multiple osteotomes, which are carefully driven between tibial base plate and cement from
medial and lateral the tibial component, even if stemmed, can be gradually
wedged/forced out from its cement mantle (Fig. 5). This is less destructive than
aggressive extraction with hammer blows.
Extract the implant using special or universal extraction instruments, if available. Otherwise punches are required.
Cement removal is completed using special cement chisels, long rongeurs, curretting instruments, long drills and cement taps, as well as ball headed reamers. The
particular technique of cement removal has been described elsewhere [13, 14].
Final debridement of bone and posterior soft tissues must be as radical as
possible. It should include areas of osteolysis and non-viable bone (Fig. 6).
Copious pulsatile lavage should be used throughout the procedure.
After another thorough lavage the intramedullary canals are packed with Chlorhexidine soaked swabs (Lavasept®) and large Chlorhexidine soaked packs are
placed, before the wound is covered with a clean incisional film or closed temporarily.
The entire surgical team should now re-scrub and new instruments are used for
re-implantation after re-draping.
A second dose of i.v. AB is given after 1.5 hrs operating time or if blood loss at
this point exceeds 1 l.
Reimplantation
) After completion of debridement and implant removal, it can be helpful to then
inflate the tourniquet to aid final intramedullary cement removal and in particular for re-cementation and closure. In short legs or if proximal soft tissue expo-
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Clinical Applications: Knee
Fig. 6. Radical soft
tissues and bone
debridement
Fig. 7. Bone defect
reconstruction and
prosthesis fixation
with antibiotic-loaded
acrylic cement
sure is extensive no tourniquet can be used, unless a sterile one can be made available.
) Reconstruction of bone stock may require the use of allograft, although ideally
this should be avoided. We prefer to fill large defects with ALAC if biomechanically acceptable (Fig. 7).
) If morcellized allograft is used, it should be thoroughly lavaged (pulsatile lavage
with hot saline !) and impregnated with antibiotics [22] prior to impaction
grafting
) Antibiotic loaded cement is prepared. It is mandatory to only use suitable antibiotics which need to fulfill the following criteria:
– Appropriate AB, antibiogram, good elution characteristics from cement [43].
– Bactericidal (exception Clindamyin)
– Powder form (never use liquid AB !)
31 Management of TKA Infection – One-stage Exchange
Fig. 8. Post-operative X-rays. One-stage
revision with antibiotic-loaded hinged
prosthesis
– Pharmaceutical admixing of AB powder to PMMA powder using a fine sieve
before mixing
– Maximum addition of 10 %/PMMA powder (e.g. 4 g AB/ 40g PMMA powder
– in MRSA: Vancomycin plus Ofloxacin [29].
Cave: Some antibiotics (e.g. vancomycin) will change the polymerization behavior of the cement causing acceleration of cement curing !
) The principle of modern cementing techniques should be applied. As mentioned
above a better cement bone interface can be achieved if the tourniquet is inflated
prior to cementing (Fig 8).
) Postoperatively, i.v. AB are administered according to the treatment recommendations given by the microbiologist. Commonly not more than 14 days are
required. The value of prolonged AB given orally thereafter is not proven.
) Serial CRP levels are the most important tool for postoperative monitoring.
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Clinical Applications: Knee
Discussion
One stage exchange for infected TKA is less popular than two stage procedures [22].
Higher success rates for two stage have been postulated and with articulating spacers
the functional outcome and patient satisfaction [17, 32] have improved significantly
[8, 19, 26, 36]. Furthermore, the operative approach is less demanding due to minimal
contractures [7, 9, 17, 25] and the rate of extensor mechanism complications has been
reduced [19, 27]. Far more studies have been published about two stage revision and
fewer series, usually with small patient numbers treated with one stage exchange are
available.
In the non-English literature, the early Endoclinic experience from 1976 to 1985,
including 118 one stage revision TKAs for infection – followed for 5 – 15 years –
showed a 73 % chance of cure of infection [10]. An English literature review in 2002
of direct exchange [38] revealed that there were only 8 studies on this topic reporting
a total of 37 knees – 32 treated with ALAC -, of which 18 were part of one series [15].
All other quoted studies reported patient numbers below 6 and therefore should be
considered case reports [38]. The overall success rate, i.e. control of infection was calculated as 89.2 %, but no information was provided regarding the respective length of
follow-up. The largest cohort of 69 patients was excluded from the metaanalysis as no
distinction from two stage outcomes was possible [38].
A more recent study [4] of 22 consecutive patients treated with direct exchange,
radical debridement, ALAC, i.v. AB for 4 – 6 weeks followed by 6 – 12 months oral AB
showed a 90.9 % rate free of infection after 1.4 to 19.6 years (mean 10.2 years). The
authors concluded that their results compare favorably with delayed exchange revision TKA.
Apart from use of ALAC [21, 38] aggressive debridement of all infected tissue [3,
15, 38] the absence of sinus formation [38] and Gram-positive organisms [38] are
considered factors associated with success. Our results and experience would support
that Gram-positive organisms are more benign, but fistulae have not been associated
with poorer outcome. On the contrary, if sinus formation is present (i.e. draining
infection) the extent of soft tissue infection is usually less pronounced. Multiple previous surgeries have been reported to adversely affect the chance of success [23]. This,
however, was not the case in our series.
The duration of postoperative intravenous antibiotics ranged from 2 – 4 weeks
(mean 2.4) in the metaanalysis of direct exchange [38]. A prolonged administration
of intravenous AB for 6 weeks is particular common in the interval between first and
second stage [16]. However, the rationale for this has been questioned most recently
[24] and the authors concluded from their experience in 38 patients, that a prolonged
course of AB does not seem to alter the incidence of recurrent or persistent infection
after two stage revision. Interestingly, if patients are re-aspirated prior to re-implantation positive cultures can be found in almost 10 %, thus providing the rationale and
justification for pre-revision cultures [33]. In the Endoclinic protocol of direct
exchange a duration of 10 days is rarely exceeded now.
In our series of 100 consecutive patients with infected TKA, which were treated
with one stage exchange, all required hinge prostheses. This fact both reflects the
degree of aggressive debridement and the patient material. Furthermore, at the time
the use of fixed hinges was policy, but since then the majority of patients are treated
31 Management of TKA Infection – One-stage Exchange
with rotating hinges (ratio 70:30). In a recent report using the same implant for salvage revision TKA, 23 cases were done for infection, which showed encouraging outcome at midterm, however inferior compared to aseptic patients [37]. A similar experience with this implant used for salvage of limb threatening cases has also been
reported [41]. The functional outcome with this design has been encouraging,
although in general stiffer knees have to be expected in septic two stage exchange
compared to aseptic revision TKA [2]. In our series there was a 3 % amputation rate,
this has dropped , however since to 0.5 % in the last 7 years.
The overall rate of patients free of infection at 8.5 years was 90 % in this consecutive Endoclinic series and can be regarded as more than acceptable. If one includes
the 3 patients who required a “second-stage” (further direct exchange) then the success rate is 93 %. Long-term observation is important, as the implant survival rates
can deteriorate significantly over time, for both mechanical failure, but also recurrent
infection requiring re-operation. In a series of 96 knees, followed for a mean of 7.2
years after two stage revision TKA, the survivorship free of implant removal for reinfection was 93.5 % at 5 years, but dropped to 85 % at 10 years [20].
In conclusion, the Endoclinic results presented here further support the philosophy of direct exchange for infected TKA. Patient satisfaction is high as hospitalisation
is rarely over 2 weeks and only one operative procedure is required in 90 % of cases.
Decreased morbidity for the patient by eliminating the need for a second major procedure with high risk of repeated blood transfusion [35] and associated prolonged
inpatient stay are further arguments in favor of a one stage strategy [3]. It remains the
more cost-effective approach [4] and can offer similar if not better cure and survival
rates even in the longer term.
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