Management of infected total knee replacement
Vineet Sharma MS*, Amar S Ranawat MD**, CS Ranawat MD**
*Advanced Hip and Knee Clinic, **Ranawat Orthopaedics Center
ABSTRACT
Infection after a total knee replacement is an uncommon but disastrous complication. The diagnosis and
treatment of an infected total knee has become quite standardized over the last few years. With an increasing
number of total knee replacements being performed, the absolute number of patients with this complication
is going to increase over time. The article presents an overview of the extent of problems, the predisposing
factors, classification and diagnosis and treatment guidelines. With two-stage reimplantation emerging as
the gold standard for treatment of infected total knees, the method is described in detail along with the
various types of spacer options available and the long-term results.
Keywords : Infected knee replacement, two stage reimplantation, articulating spacer.
Infection is a disastrous complication after Total knee
replacement (TKR). The reported incidence in literature varies
between 0.3- 12.4% for primary TKR and between 1-15% for
revision TKR1-8. Fortunately, the treatment of peri-prosthetic
knee infection has become very standardized and outcome more
predictable over the last decade. Around one third of infections
occur in the 1st three months after surgery and the other twothird after 3 months. Various factors contribute to the
pathogenesis of infection after TKR.
Table 1
Risk factors for infection after TKR9-18
1.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
Host Factors
Poor immune status
Diabetes
Rheumatoid arthritis
Urinary tract infection
Kidney or liver transplant
Skin ulceration
Steroid intake
HIV infection
Malignancy
Obesity
Revision surgery
1. Intraoperative factors
a. Surgical time > 2.5 hours
b. Operation theatre environment
c. Human traffic in theatre
d. Sterility
Corresponding Author:
Dr. Vineet Sharma
Advanced Hip and Knee Clinic.
H.No.3, Sector 19A, Chandigarh. Phone: 097813 98114
Email: [email protected]
Pb Journal of Orthopaedics Vol-XI, No.1, 2009
Fig. 1. Patient with draining wound at the lower end of incision.
One of the most important factors to prevent infection
after TKR is administration of pre-operative antibiotic within
30-45 minutes of skin incision19,20. Surgical closure of the wound
especially at the lower third of incision close to the patellar
tendon is very important. Most patients who develop infection
later start with serous discharge from the lower part of the
wound in early post-op period (Fig. 1).
Routine use of antibiotic impregnated cement has been
shown to reduce the incidence of infection in the Norwegian
joint registry but indiscriminate usage in all cases needs to be
weighed against potential development of resistant
organisms.21-24
A few factors of doubtful efficacy in prevention of infection
are the use of laminar airflow, body exhaust suits and hoods.
There is conflicting data on the effect of these factors on the
incidence of infection25-27.
60
Management of infected total knee replacement
DIAGNOSIS
Early diagnosis of deep infection is imperative to salvage
the prosthesis with debridement and retention, otherwise
prosthesis removal is required28. Diagnosing an infected TKR
can in some cases be quite challenging. Most infected knees
present with pain. The chronology of pain and its association
is important. Also the onset of pain after surgery helps in
deciding between early and delayed infection. A review of the
post-op notes regarding delayed wound healing and serous
discharge from wound beyond 48 hours is also important. Plain
radiographs are most often normal but in late stages with chronic
infection, sequential X-rays may show progressive
radiolucencies, focal osteopenia or osteolysis of subchondral
bone and periosteal new bone formation29. Imaging studies,
like the indium-labeled scans are non-specific and rarely
indicated for diagnosis.30,31
diagnose and the delay in most cases, makes prosthesis
retention impossible.
Type 4 infections occur from hematogenous spread of
bacteria in a previously asymptomatic and well functioning
prosthesis. The common primary sites of infection are urinary
tract, dental infections and pneumonia. IV drug abusers and
immunocompromised patients are also pre-disposed to these
infections.
The latest addition to this classification is type 1 infection.
These patients present with a positive intra-operative culture
or frozen section at the time of revision for aseptic reasons. At
least 2 of the 5 cultures have to be positive for a diagnosis to
be made. Treatment in these cases is decided taking into
consideration the pre-operative clinical picture and lab. results
and the overall clinical picture.
The gold standard for diagnosis is the triple test. Knee
joint aspiration, ESR and CRP are done routinely in all suspected
cases of infected TKR32. An abnormal finding in 2 out of these
3 is quite suspicious for infection. Knee joint aspiration should
be done with patient off antibiotics for atleast 7-10 days
otherwise false-negative results are common. Knowledge of
the return of ESR and CRP to normal after surgery is quite
helpful. CRP usually returns to normal within 3 weeks of surgery
and ESR can take up to 3-6 months to come back to normal33.
Serial trend in these lab tests over a period of time is more
helpful than a single raised value.
MANAGEMENT OF INFECTED TKR.
CLASSIFICATION
These patients are best managed with open
debridement, synovectomy and polyethylene exchange. It is
recommended to change the polyethylene spacer in all cases.
This enables a more thorough synovectomy especially from
the posterior capsule and also cleans the interface between the
tibial base plate and the polyethylene liner. In case of all-poly
tibial design, it is recommended to change the polyethylene
tibial component. Results of debridement without poly
exchange are far inferior to when the polyethylene is changed.
Surgeon should be prepared to increase the thickness of
polyethylene by 1 size in many cases. This is due to the fact
that after synovectomy, the knee may not be as stable with the
same size of polyethylene.
Classification of peri-prosthetic infection is done in relation
to onset of symptoms following the index surgical
procedure34. In the latest classification system, infection
occurring in the immediate post-operative period (4-6 weeks
after surgery) is classified as type 2 infection. These patients
usually present with wound drainage or cellulites around
wound edges along with pain. Patients will usually have a
history of prolonged wound drainage, prolonged antibiotic
usage etc. The etiology in these cases is mostly colonization
at the time of surgery, infected hematomas or spread of
superficial infection.
Type 3 infections also occur due to colonization at the
time of surgery. But either the inoculum is small or the
organism is of low virulence, and thus these patients
present with chronic symptoms. Gradually worsening pain or
stiffness and deterioration in function slowly over a period of
time is the usual presentation. There are usually no systemic
or local signs and a high index of suspicion is needed for
diagnosis. These infections are often the most difficult to
Pb Journal of Orthopaedics Vol-XI, No.1, 2009
Type 2 and 4 infections
Most acute infections, either in the early post-operative period
or late hematogenous infections can be managed with
prosthesis retention. The time from onset of symptoms to the
initiation of treatment is important. There is a much higher
likelihood of prosthesis retention in the 1st week of onset on
infection and the chances decrease over time. The chances of
eradication of infection are much higher with a sensitive grampositive organism than with a gram negative bacteria or fungal
infection.
These patients are given IV antibiotics for 2-4 weeks after
surgery and followed by oral antibiotics for another 4 weeks
depending on the organism and sensitivity. ESR and CRP are
monitored weekly at first and then at monthly interval till they
return to normal.
If infection recurs even after debridement, polyethylene
exchange and prolonged antibiotics, removal of prosthesis and
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Sharma et al
2-stage reimplantation should be considered.
Chronic infection
The Gold standard for chronic infection in TKR is
2-stage reimplantation. One stage reimplantation is more or
less out of favor by most surgeons and has limited
indications.
Description of surgical technique for 2-stage reimplantation.
Stage 1: Removal of old prosthesis, synovectomy and insertion
of antibiotic cement spacer
After a diagnosis has been made, the 1st step is the removal of
old prosthesis, synovectomy and debridement and insertion
of an antibiotic cement spacer. The old prosthesis is removed
with special effort made to prevent further bone loss. The ease
of removal will depend on how long the infection has been
present. Not uncommonly, the prosthesis is very well fixed to
bone and removal can be quite challenging. The various
techniques described for removal of prosthesis include the
use of reciprocating saw; giggle saw and stacked osteotome
technique. All residual cement is also removed.
Fig. 2 : Picture of femoral mould for making an articulating cement
spacer.
A thorough synovectomy is performed next and all infected
soft tissue is removed. Care should be taken to prevent
iatrogenic damage to the collaterals and patellar tendon. Once
a thorough debridement has been performed, an antibiotic
cement spacer is inserted.
The various types of spacers are described below.
Articulating spacers
These spacers are molded in the shape of distal femur and
proximal tibia like knee prosthesis. These spacers allow the
knee to be flexed to a certain degree. This allows the soft tissues
to be supple at revision surgery and the exposure is easy
compared to a static spacer35. Also the final ROM with the use
of these spacers is better than with static spacers. The
articulating spacer can be of several types36-41. The most
commonly used techniques are described here.
Hoffmann Technique
In this method, after standard exposure and removal of infected
prosthesis, the removed femoral prosthesis is autoclaved
again42,43. A new all polyethylene tibial component is opened.
Patella polyethylene button is removed. After synovectomy,
the components are cemented in place. The cementing
technique is quite different here as the aim is not to achieve a
good fixation but to have just enough fixation to enable the
prosthesis to be fixed to bone. Also it should be possible to
remove the prosthesis at 2nd stage with minimal bone loss. Excess
cement at the side of prosthesis is not removed. As the cement
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Fig. 3: Articulating cement spacer in situ.
is setting, the components are gently toggled to prevent rigid
fixation.
Molded cement spacers
The spacer can also be made with commercially available cement
moulds like the prostalac44. These moulds are available in
various sizes and need to be determined after removal of
prosthesis45. Cement mixed with antibiotic is injected into to
moulds and allowed to harden. Once the cement is set, the
moulds are cut with a knife and spacers inserted into the knee
(Fig. 2 & 3). These molds add to the cost of the procedure.
Static cement spacer
This technique is still the gold standard for cement spacers
and is extremely helpful in cases of severe bone loss46. The
cement mixed with antibiotic is put into the knee in extension.
62
Management of infected total knee replacement
quadriceps snip and quadriceps turndown (V-Y Plasty). Also
the final ROM with use of articulating spacer is slightly
better35,47,48,52.
Period between 2 stages
The length of this period can vary from 8-16 weeks and is
individualized. In the early post-operative, period patient’s
knee is kept in extension to allow soft tissue and wound
healing. Intra-venous antibiotics are given for 6 weeks.
Initially, Vancomycin is given till the culture results are
available and then organism-specific antibiotics are
administered. It is recommended to get a central line inserted
to allow for long-term intravenous antibiotic administration.
Fig. 4 a & b- Static cement spacer in a patient with severe bone loss.
In cases of incompetent collaterals, a DCP plate or a Steinmann
pin can be put into the medullary canals embedded in the
cement. This technique requires the knee to be in extension
and in a brace post-operatively. Some authors believe that the
use of these spacers provide adequate rest to infected and
inflamed soft tissues and thus better eradication of infection
(Fig. 4 a & b). But the results with either technique are
comparable as far as eradication of infection is concerned35,47,48.
After the spacer is inserted, the wound is closed.
We recommend using non-braided sutures like PDS
for closure and avoid using vicryl or ethibond in
infected cases. Also usage of drain is avoided after 1st stage,
as the elution of antibiotic is maximum within the 1st 48-72 hours
after spacer.
Patient is allowed to walk with a walker. Weight bearing
varies with the type of spacer inserted. With Hoffmann type
of spacer, patient can weight bear as tolerated and with the
static and articulating cement mould space, only toe-touch
weight bearing is allowed. With the articulating spacer, patient
is allowed and encouraged to do bedside range of motion
exercises. Flexion should be increased gradually and allowed
up to 90 degrees only. Breakage of cement spacer as well as
subluxation/dislocation is known complications (Fig. 5 & 6).
The only objective of allowing ROM exercises is to make the
revision surgery easier in the 2nd stage.
Weekly ESR and CRP are done for 6 weeks. IV antibiotics
are stopped after 6 weeks. Patient is kept off antibiotics for 2
weeks and a repeat ESR and CRP is done. Once the
Antibiotics in cement spacer
There are lots of recommendations on the nature and amount
of antibiotic for cement spacers. Most authors recommend a
combination of Vancomycin and Tobramycin in all cases.
These have a broad-spectrum coverage and resistance to
these antibiotics is not a clinically significant problem at this
time. The dosage as recommended by the surgeons at Mayo
Clinic is gaining widespread acceptance now (personal
communication). They recommend 2-4 gm of Vancomycin
and 2 gm of Tobramycin with each batch of cement. Such
high dose has not been associated with any systemic side
effects on the kidney.
Results of cement spacers
All the 3 techniques mentioned above have an equivalent
success rate of over 90%46,47,49-51. The articulating spacers
have a slightly lower incidence of requiring a special exposure
technique at 2 nd sage stage of revision including the
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Fig. 5 & 6 : Complications of cement spacer, broken spacer in figure
5 and subluxed in figure 6.
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Sharma et al
values are showing a downward trend and are in the normal
range, planning is done for the 2nd stage. Some surgeons
recommend doing a knee aspiration and culture also at this
stage.
2nd stage of revision TKR
The knee is exposed in a standard fashion. Surgeon
should be familiar with and be prepared to use the special
techniques for exposure. These include the rectus snip,
quadriceps turn-down (V-Y Plasty), skeletonisation of distal
femur and in extremely rare instances, tibial tubercle osteotomy
(TTO).
The cement spacer is taken out. Technique for removal
will vary with the type of cement spacer in place. With a
Hoffmann type of spacer, removal is best done with a
reciprocating saw working at the implant-cement interface.
Removal of a static spacer can be challenging at times and it
is not easy to distinguish the cement from the native bone.
For this reason, methylene blue can be added to the cement
spacer at 1st stage and this makes the distinction between
cement and native bone easier.
Some authors recommend sending frozen section of
tissues at 2nd stage to make sure that the infection is eradicated.
A cell count of more than 5 neutrophils / HPF is quite
suspicious of infection. This technique depends a lot on the
experience and expertise of the pathologist. We do not
recommend doing this in most cases as this can confuse the
picture and we depend solely on the intra-operative clinical
picture.
The insertion of revision prosthesis is done paying
special attention to joint line, equal flexion and extension gaps
and soft tissue balancing. As in most revisions, stems are
used for added stability, fixation and alignment. We almost
always used hybrid cement fixation in infected TKR’s. This
technique involves cementing the prosthesis and the proximal
part of stem and press fitting the distal part of stem. This
allows for antibiotic cement to elude the antibiotics and also
in case of further revision for any reason, removal of stems
and cement is relatively easier. We routinely replace the patella
in cases of all primary and revision TKR’s. In case of revision,
if the patellar bone stock is not adequate, trabecular metal
patella can be used. The closure is done in a standard fashion
with or without the use of drain as per surgeon preference.
We do not use drain in most primary and revision cases
(Illustrative case, Figs. 7-14).
Post-operative protocol is similar to primary cases. After
the 2nd stage, IV antibiotics are given for 24-48 hours only.
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Fig. 7 & 8 : Post-operative radiographs of a 62-year-old male.
Fig. 9 & 10 : Radiographs taken 9 months after surgery showing
progressive radiolucencies. Patient never had pain relief after the
index surgery.
Fig. 11 : Hoffman type articulating spacer inserted after confirmation
of diagnosis of infection.
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Management of infected total knee replacement
Arthroscopic lavage
This has a high failure rate as reported in literature with a few
sporadic case reports showing good results59-61. The reasons
for poor results with this technique that are inadequate
debridement and synovectomy and also the inability to change
the polyethylene liner. Also the interface between the tibial
base plate and polyethylene cannot be cleaned. The reported
success rate with this technique is around 20% to 38%62,63.
The only indication might be in patient with fulminant sepsis
and who is on DVT prophylaxis, making open surgery difficult61.
This technique is only of an academic interest now and not
recommended in most cases.
Resection arthroplasty
Fig. 12-14 : Oblique and lateral radiographs (Osteolysis series)
6 months after 2nd stage revision. Patient had good pain relief and
excellent function at this time
OTHER TREATMENT OPTIONS
Antibiotic Suppression
Antibiotic treatment alone is almost never successful in
eradicating deep peri-prosthetic infection and is strongly
discouraged. It has a high failure rate and only complicates
definitive management. The criterion for using this suppressive
therapy are 1) Prosthesis removal is not feasible (medically
unfit patient) 2) Microorganism has low virulence, 3) The
organism is susceptible to an oral antibiotic, 4) The antibiotic
can be tolerated without serious toxicity, 5) The prosthesis is
not loose53. In these cases, antibiotic can help suppress the
infection but development of resistant organisms over time
will make this option non-viable54,55. The presence of other
joint arthroplasty and cardiac valvular prosthesis is a strong
contraindication for use of chronic antibiotic suppression.
This technique might be used in patients with limited
ambulatory needs and who had multiple prior attempts at
eradication of infection. Patients with poor bone quality in
whom arthrodesis might not be successful are also candidates
for resection arthroplasty. Polyarticular RA patients with limited
functional demands and in whom eradication of infection is
likely to be very difficult are also candidates (Fig. 15 & 16).
The functional outcome after resection arthroplasty is poor
but patients are able to sit better than patients with arthrodesis.
Weight bearing and ambulation are usually difficult due to
instability64,65.
Arthrodesis
This is indicated in cases of poor bone stock, poor soft tissue
coverage and after failed 2 stage reimplantation. Indications
include 1) Individuals with high functional demands, 2) single
joint disease, 3) young age, 4) disruption of extensor mechanism,
Debridement with prosthesis retention
Open debridement may be indicated for an acute infection in
early post-op period (Type 2 infection) and for acute
hematogenous infection (type 3) of a securely fixed and
functional prosthesis. This method is more likely to be
successful if 1) less than 2 weeks since the onset of symptoms
of infection, 2) susceptible gram positive organism, 3) absence
of prolonged post-op drainage or a draining sinus tract, 4) no
prosthetic loosening or radiographic signs of infection56. The
success rate with this technique is very variable and depends
on the timing of drainage, duration of symptoms, host immune
status and the nature of the microbe56. Reported success rate
is between 19% to 100%1,29,56-58.
Pb Journal of Orthopaedics Vol-XI, No.1, 2009
Fig. 15 & 16 : Patient with multiple failed attempts for eradication of
infection treated with resection arthroplasty. This patient had renal
transplant and could not tolerate high dose Vancomycin in cement
spacer necessitating removal of spacer.
65
Sharma et al
5) poor soft tissue envelope around the knee, 6) systemic
immunocompromise. Contraindications include 1)
Bilateral knee disease, 2) ipsilateral hip or ankle disease, 3)
severe segmental bone loss, 4) contralateral extremity
amputation.
The best device to achieve arthrodesis after a failed TKR
is an intra-medullary device with a fusion rate between 67% to
100%66. With the availability of newer nails, like the Wichita
nail, the surgery is quite simple and high fusion rate can be
achieved (Figs.17 & 18). Plate fixation and external fixation
devices have a relatively lower success rate in these cases
(Figs. 19 & 20). Fusion rate can be as high as 90% after surface
replacements and good bone stock and as low as 50% for
infected hinged knee replacements2,67,68.
Fig. 17 & 18 : Patient treated with knee arthrodesis with a Wichita
nail.
AMPUTATION
Very rarely, if all other techniques fail, an above knee amputation
is the last resort to manage an infected TKR. Patients with
failed attempts at arthrodesis, lives threatening systemic sepsis,
poor soft tissue coverage are a few examples where amputation
might be considered. The functional outcome after an above
knee amputation in these patients is generally sub-optimal as
many of these patients are never fitted with prostheses69.
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