**Extensor Mechanism Complications After Patellar Resurfacing in Knee Replacement – Can They Justify Non-Patellar Resurfacing?**

Antonio Silvestre, Raúl Lopez, Fernando Almeida, Pablo Renovell, Francisco Argüelles and Oscar Vaamonde

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/53382

**1. Introduction**

[21] Chonko DJ, Lombardi AV Jr, Berend KR. Patella baja and total knee arthroplasty (TKA): etiology, diagnosis, and management. Surg Technol Int. 2004;12:231-8.

[22] Healy WL, Wasilewski SA, Takei R, Oberlander M. Patellofemoral complications fol‐ lowing total knee arthroplasty. Correlation with implant design and patient risk fac‐

[23] Kyung Ah, Chun Kenjirou, Ohashi D, Lee Bennett, Georges Y, El-Khoury. Patellar Fractures After Total Knee Replacement. AJR AM J Roent. 2005; sept, 185:655–660.

[24] Aglietti P, Baldini A, Buzzi R, Indelli PF. Patella resurfacing in total knee replace‐ ment: functional evaluation and complications. J Bone Joint Surg Am. 2002 Jul;84-

[25] Bourne RB. Fractures of the patella after total knee replacement. Orthop Clin North

[26] Ortiguera CJ, Berry DJ. Patellar fracture after total knee arthroplasty. J Bone Joint

[27] Keating EM, Haas G, Meding JB. Patella fracture after total knee replacements. Clin

[28] Beight JL, Yao B, Hozack WJ, Hearn SL, Booth RE Jr. The patellar "clunk" syndrome after posterior stabilized total knee arthroplasty. Clin Orthop Relat Res. 1994 Feb;

[29] Maeno S, Kondo M, Niki Y, Matsumoto H. Patellar impingement against the tibial component after total knee arthroplasty. Clin Orthop Relat Res. 2006. Nov; 452: 265.

[30] Matthew B. Collier, MS, et al. Osteolysis After Total Knee Arthroplasty: Influence of Tibial Baseplate Surface Finish and Sterilation of Polyethylene Insert. In The Journal

[31] Hernigou P, Deschamps G. Patellar impingement following unicompartmental ar‐

[32] MacCollum MS 3rd, Karpman RR. Complications of the PCA anatomic patella. Or‐

[33] William H Harris. Osteolysis and particle disease in hip replacement. A review. Acta

[34] Rand JA, Morrey BF, Bryan RS. Patellar tendon rupture after total knee arthroplasty.

[35] Dobbs RE, Hanssen AD, Lewallen DG, Pagnano MW. Quadriceps tendon rupture af‐ ter total knee arthroplasty. Prevalence, complications, and outcomes. Bone Joint Surg

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450 Arthroplasty - Update

(299):139-42.

Patellar resurfacing is still nowadays a controversial matter in articles, cross fires and meet‐ ings. We know that this is not a new subject as the issue of whether or not to resurface the patella when performing a TKA has been a debatable topic for more than two decades [1]. We can find three philosophies around what to do with the patella in TKA and there is still no best conclusion about benefits from one or another procedure.

Many randomised trials provide inconclusive evidence in relation to resurface or not the patella after TKA and these trials fail mainly because short sample sizes. Some metaanalysis have been reported last years in order to clarify this issue and though no great differences have been found between both procedures, patellar resurfacing shows better functional results and less anterior knee pain [2-4]. Nevertheless, what is cleared stated in literature is that treatment of the patellofemoral joint in knee replacement and its ulti‐ mate results are multifactorial.

Surgeons around the world can be classified into three groups according to their preference in the topic of resurfacing or not the patella: universal resurfacers, non-resurfacers and selec‐ tive resurfacers. One of the reasons that non-resurfacers use as justification for their per‐ formance is that patellar resurfacing implies complications related to extensor mechanism of the knee. Moreover complications related to extensor mechanism are a common basis for

© 2013 Silvestre et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

TKA revisions and these problems have less favourable outcome than patients who undergo revision for other reasons.

**Sex Female: 536/ Male: 324**

Extensor Mechanism Complications After Patellar Resurfacing in Knee Replacement – Can They Justify...

Left: 368

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453

Side Right: 492/

Age (years) 73.15±6.06 BMI (kg/m2) 27.76±3.12 Previous surgery (%) 38.3% Radiological valgus (%) 9.7%

In our experience it is crucial to be as thorough as possible in patellar resurfacing step to achieve good results and avoid extensor mechanism complications. Most of these problems should be avoid with a more methodical procedure. We employ the instruments provide by the manufacturer to afford patellar resurfacing though we accept they are not always useful. However, more precise instruments in recent systems allow more accuracy placing the pa‐ tella. The Vanguard System Knee® provides specifically devices (cutting guide) to improve the results. It offers a calliper or vernier to estimate patella thickness before and after the cut, a guide with a magnetize gauge to determine the deep of the cut after guide positioning and it is possible to choose single or three-peg configuration at the time of the surgery. Devices availability in theatre make the surgeons more self-assured when dealing with patello-femo‐ ral joint. Albeit these devices can't be employed in 100% of cases as patellar morphology, size or wear difficult its use. The fact that surgical instrumental can't be employed, doesn't

For this series we have used all-polyethylene patellar component design with single or three-peg configuration. The prostheses employed in our cases just provide onlay patellar implants. We usually make peripheral electrocautery around the patella and remove soft-tis‐ sue synovium in the upper part of the patella to avoid patellar clunk syndrome as we per‐

Patients received intravenous antibiotics (cefazolin 1g/8h) for 48 h after surgery according to the protocol of our Institution. Post-operative bandage was removed at the second day after surgery to check incision and vascular condition of the leg. Output drainage was removed 36-48 h after surgery. They started physiotherapy of the operated knee the second day after surgery when drains were removed if proper laboratory values were obtained. Full weight bearing on the operated limb was allowed immediately except in those cases the surgeon contraindicated the pre-established protocol because of surgical difficulties. Physiothera‐

Pre-operative diagnoses Osteoarthritis Osteonecrosis medial condyle Metabolic arthritis RA Fracture sequela

mean patellar resurfacing is a trivial step in knee surgery.

form posterior stabilized designs.

**Table 1.** Demographic data and preoperative parameters

The use of computer-aid navigation systems in knee replacement have allowed to accurate some of the mistakes in coronal, sagittal and axial alignment of femoral and tibial implant that are related to patellar maltracking. In the near future it should be possible to navigate the patellofemoral joint, so problems linked to this compartment will diminish. Until now, there is a report of a surgical navigation system that let to assess intraoperatively patellar tracking, one of the main reasons of TKAs' failure, with the aid of a computer. The system is quite complex and it is not available for all the knee prosthesis designs. However, the meth‐ od could be a valuable support to analyze patellar tracking at the time of the surgery and a real help to decide whether or not patellar replacement [5].

In this study we have reviewed our extensor mechanism complications relate to knee re‐ placement for the last 6 years in order to analyze if they have a high rate that could justify non-patellar resurfacing. We believe that a careful and meticulous technique during patellar resurfacing can avoid most of the problems found after knee replacement. It is not reasona‐ ble that in these days in which many surgeons are worried about accurate alignment of knee components and most of them use computer-aid navigation systems to be more precise in prosthesis placement we are not as careful as in other steps of the procedure when resurfac‐ ing the patella.

### **2. Material and method**

We have retrospectively revised all the TKA's performed in our Institution from January 2005 until December 2011. For this period of time, the two fellowship-trained surgeons (AS and FA) performed 860 TKA using a standard technique for knee replacement and similar rehabilitation protocol. Postero-stabilized cemented total knee arthroplasties were used in all cases (Performance® Biomet Warsaw, IN and Vanguard® Biomet Warsaw, IN). Patella was resurfaced in all cases according to the philosophy of our Department. Demographic data are shown in table I.

A single dose of intravenous antibiotic (cefazolin 2 gr or vancomycin 1gr in allergic patients according to the protocol of our Hospital Infection Control Committee) was given ½ hour before incision. After general o regional anaesthesia depending on patient and physician's preference, tourniquet was routinely applied as proximal as possible in the thigh. Longitudi‐ nal incision along the knee and medial para-patellar arthrotomy were performed to gain ac‐ cess to the joint. Surgery was performed according to the standard procedure and femur and tibial implants were cemented to the bone. Careful alignment of both components was checked before implantation. Posterior-condyle plus 3° of external rotation and trans-epi‐ condylar axis were used without distinction to get an adequate femoral rotation. On the oth‐ er hand tibial component was aligned to the medial third of the tibial tubercle. We don't usually evert the patella during this time of the procedure. Once femoral and tibial trials were in place, we arrange for the patellar resurfacing step.


#### **Table 1.** Demographic data and preoperative parameters

TKA revisions and these problems have less favourable outcome than patients who undergo

The use of computer-aid navigation systems in knee replacement have allowed to accurate some of the mistakes in coronal, sagittal and axial alignment of femoral and tibial implant that are related to patellar maltracking. In the near future it should be possible to navigate the patellofemoral joint, so problems linked to this compartment will diminish. Until now, there is a report of a surgical navigation system that let to assess intraoperatively patellar tracking, one of the main reasons of TKAs' failure, with the aid of a computer. The system is quite complex and it is not available for all the knee prosthesis designs. However, the meth‐ od could be a valuable support to analyze patellar tracking at the time of the surgery and a

In this study we have reviewed our extensor mechanism complications relate to knee re‐ placement for the last 6 years in order to analyze if they have a high rate that could justify non-patellar resurfacing. We believe that a careful and meticulous technique during patellar resurfacing can avoid most of the problems found after knee replacement. It is not reasona‐ ble that in these days in which many surgeons are worried about accurate alignment of knee components and most of them use computer-aid navigation systems to be more precise in prosthesis placement we are not as careful as in other steps of the procedure when resurfac‐

We have retrospectively revised all the TKA's performed in our Institution from January 2005 until December 2011. For this period of time, the two fellowship-trained surgeons (AS and FA) performed 860 TKA using a standard technique for knee replacement and similar rehabilitation protocol. Postero-stabilized cemented total knee arthroplasties were used in all cases (Performance® Biomet Warsaw, IN and Vanguard® Biomet Warsaw, IN). Patella was resurfaced in all cases according to the philosophy of our Department. Demographic

A single dose of intravenous antibiotic (cefazolin 2 gr or vancomycin 1gr in allergic patients according to the protocol of our Hospital Infection Control Committee) was given ½ hour before incision. After general o regional anaesthesia depending on patient and physician's preference, tourniquet was routinely applied as proximal as possible in the thigh. Longitudi‐ nal incision along the knee and medial para-patellar arthrotomy were performed to gain ac‐ cess to the joint. Surgery was performed according to the standard procedure and femur and tibial implants were cemented to the bone. Careful alignment of both components was checked before implantation. Posterior-condyle plus 3° of external rotation and trans-epi‐ condylar axis were used without distinction to get an adequate femoral rotation. On the oth‐ er hand tibial component was aligned to the medial third of the tibial tubercle. We don't usually evert the patella during this time of the procedure. Once femoral and tibial trials

real help to decide whether or not patellar replacement [5].

were in place, we arrange for the patellar resurfacing step.

revision for other reasons.

452 Arthroplasty - Update

ing the patella.

**2. Material and method**

data are shown in table I.

In our experience it is crucial to be as thorough as possible in patellar resurfacing step to achieve good results and avoid extensor mechanism complications. Most of these problems should be avoid with a more methodical procedure. We employ the instruments provide by the manufacturer to afford patellar resurfacing though we accept they are not always useful. However, more precise instruments in recent systems allow more accuracy placing the pa‐ tella. The Vanguard System Knee® provides specifically devices (cutting guide) to improve the results. It offers a calliper or vernier to estimate patella thickness before and after the cut, a guide with a magnetize gauge to determine the deep of the cut after guide positioning and it is possible to choose single or three-peg configuration at the time of the surgery. Devices availability in theatre make the surgeons more self-assured when dealing with patello-femo‐ ral joint. Albeit these devices can't be employed in 100% of cases as patellar morphology, size or wear difficult its use. The fact that surgical instrumental can't be employed, doesn't mean patellar resurfacing is a trivial step in knee surgery.

For this series we have used all-polyethylene patellar component design with single or three-peg configuration. The prostheses employed in our cases just provide onlay patellar implants. We usually make peripheral electrocautery around the patella and remove soft-tis‐ sue synovium in the upper part of the patella to avoid patellar clunk syndrome as we per‐ form posterior stabilized designs.

Patients received intravenous antibiotics (cefazolin 1g/8h) for 48 h after surgery according to the protocol of our Institution. Post-operative bandage was removed at the second day after surgery to check incision and vascular condition of the leg. Output drainage was removed 36-48 h after surgery. They started physiotherapy of the operated knee the second day after surgery when drains were removed if proper laboratory values were obtained. Full weight bearing on the operated limb was allowed immediately except in those cases the surgeon contraindicated the pre-established protocol because of surgical difficulties. Physiothera‐ pists instructed the patients to walk either with walker or crutches depending on their abili‐ ty. They go up stairs with the help of the banister the fourth-fifth day after surgery before leaving the Hospital.

than 90% of cases three months after surgical procedure. This can be judge as a satisfactory

Pain (VAS) <2 (%) 2.39 83.61 92.19 94.49

KSS (knee score) 53.48±6.21 79.437±8.32 89.065±5.87 92.037±7.23

Average ROM -5 /85° 0 /95° 0 / 115° 0 / 115°

Walking support No support (%) 57.05 62.53 86.12 90.55

Stairs Normal (%) 63.03 77.25 85.16 85.52

Mechanical axis (180º±3º) was restored in 95.04% of cases. Alignments of the femoral and ti‐ bial implants in frontal and coronal axes were measured without significant deviation from

Main extensor mechanism complications are shown in table III. The most frequent complica‐ tions were instability of the extensor mechanism and patellar fractures. However, most of the fractures were related to a traumatic event as patients in this series were old people, so this complication cannot be only linked to surgical aggression. Patellar tendon rupture was

mostly related to knees with previous surgery as valgus osteotomy.

Walking capability

**Table 2.** Clinical results

standard values.

2 to <5 (%) 35.52 13.63 5.75 3.96

Extensor Mechanism Complications After Patellar Resurfacing in Knee Replacement – Can They Justify...

5 to <8 (%) 45.09 2.51 1.91 1.31

>8% 17 0.24 0.24 0.24

>2 h (%) 1.91 50.35 60.04 61.96

>1 h (%) 22 27.63 29.06 29.06

>30' (%) 75 31.31 10.43 8.51

Not walk (%) 1.09 0.71 0.47 0.47

1 cane or crutch (%) 42 35.81 12.58 8.27

2 crutches (%) 0.95 0.95 0.83 0.71

Banister (%) 35.88 21.54 14.37 14.01

**Preoperative 6 weeks 12 weeks 1 year**

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455

score as painful knee arthroplasty is a non-desired state after joint reconstruction.

Prophylactic low molecular weight heparin (enoxaparin) was used for the next 28 days after surgery. Patients stay at our Institution depends on his/her ability to keep up with daily ac‐ tivities (range 4-8 days), obviously after their haematological values were as best as possible.

Outpatient follow-up was done at 6, 12 weeks and the annually for clinical and radiological evaluation of the operated knee. We assessed clinical evaluation including gait, need for as‐ sistance devices, ROM, joint stability, knee score (KSS) and visual analog scale (VAS). Rou‐ tine A-P and lateral views were done to evaluate mechanical axis and proper alignment of the implant. In those cases with extensor mechanism complications axial views and other techniques such as US, CT or MR were used to analyze the problem.

Intra-operative and post-operative complications were captured and collected for descrip‐ tive study. Arthroscopic technique was indicated in case internal injuries of the knee (patel‐ lar clunk syndrome); on the other hand open surgery was used for management of instabilities, tendon ruptures, patellar fracture…

### **3. Results**

There were 860 primary total knee arthroplasties performed with the use of the "Perform‐ ance System" (Biomet®, Warsaw, IN) and the "Vanguard System" (Biomet®, Warsaw, IN) in this series, done through a longitudinal incision with medial para-patellar arthrotomy. Underlying diagnosis was osteoarthritis and osteonecrosis of the medial condyle in more than 80% of cases. Mean follow-up was 48 months (ranging from 6 to 78 months).

Thirteen patients (1.51%) showed wound infection and developed an acute infection and eleven cases (1.27%) suffered haematogenous infection more than a year after surgery so these patients were excluded from this series as they required revision surgery (836 patients were included in this series). Co-morbidities in these patients were diabetes mellitus, rheu‐ matoid arthritis and obesity. During follow-up elevated ESR (>20) and CRP (>5) values and clinical signs of infection were detected. Aspiration culture was positive 19 cases (79.16%) and the most frequent microorganisms identified were staphylococcus spp, meticillin-resist‐ ant staphylococcus aureus, streptococcus spp and pseudomona aeuruginosa.

In our series required time to walk by a walker or two crutches was 2.25±1.45 days and pa‐ tients were able to go up and down stairs with the help of the banister at 5.03±2.67 days (range 4-15 days). More than sixty percent of patients were capable to walk without the help of any assistive aids at four weeks postoperatively. However, we advise the use of at least one cane for the first six weeks after the operation, to avoid stumbling as many patients in this series are elderly. Clinical results are shown in table II.

Knee Society Score improved from 53.48±6.21 (range 39-67) to 92.037± 7.23 (range 85-94) a year after surgery. Visual analog pain score after surgery improved to 1.891±0.31 in more


than 90% of cases three months after surgical procedure. This can be judge as a satisfactory score as painful knee arthroplasty is a non-desired state after joint reconstruction.

#### **Table 2.** Clinical results

pists instructed the patients to walk either with walker or crutches depending on their abili‐ ty. They go up stairs with the help of the banister the fourth-fifth day after surgery before

Prophylactic low molecular weight heparin (enoxaparin) was used for the next 28 days after surgery. Patients stay at our Institution depends on his/her ability to keep up with daily ac‐ tivities (range 4-8 days), obviously after their haematological values were as best as possible. Outpatient follow-up was done at 6, 12 weeks and the annually for clinical and radiological evaluation of the operated knee. We assessed clinical evaluation including gait, need for as‐ sistance devices, ROM, joint stability, knee score (KSS) and visual analog scale (VAS). Rou‐ tine A-P and lateral views were done to evaluate mechanical axis and proper alignment of the implant. In those cases with extensor mechanism complications axial views and other

Intra-operative and post-operative complications were captured and collected for descrip‐ tive study. Arthroscopic technique was indicated in case internal injuries of the knee (patel‐ lar clunk syndrome); on the other hand open surgery was used for management of

There were 860 primary total knee arthroplasties performed with the use of the "Perform‐ ance System" (Biomet®, Warsaw, IN) and the "Vanguard System" (Biomet®, Warsaw, IN) in this series, done through a longitudinal incision with medial para-patellar arthrotomy. Underlying diagnosis was osteoarthritis and osteonecrosis of the medial condyle in more

Thirteen patients (1.51%) showed wound infection and developed an acute infection and eleven cases (1.27%) suffered haematogenous infection more than a year after surgery so these patients were excluded from this series as they required revision surgery (836 patients were included in this series). Co-morbidities in these patients were diabetes mellitus, rheu‐ matoid arthritis and obesity. During follow-up elevated ESR (>20) and CRP (>5) values and clinical signs of infection were detected. Aspiration culture was positive 19 cases (79.16%) and the most frequent microorganisms identified were staphylococcus spp, meticillin-resist‐

In our series required time to walk by a walker or two crutches was 2.25±1.45 days and pa‐ tients were able to go up and down stairs with the help of the banister at 5.03±2.67 days (range 4-15 days). More than sixty percent of patients were capable to walk without the help of any assistive aids at four weeks postoperatively. However, we advise the use of at least one cane for the first six weeks after the operation, to avoid stumbling as many patients in

Knee Society Score improved from 53.48±6.21 (range 39-67) to 92.037± 7.23 (range 85-94) a year after surgery. Visual analog pain score after surgery improved to 1.891±0.31 in more

than 80% of cases. Mean follow-up was 48 months (ranging from 6 to 78 months).

ant staphylococcus aureus, streptococcus spp and pseudomona aeuruginosa.

this series are elderly. Clinical results are shown in table II.

techniques such as US, CT or MR were used to analyze the problem.

instabilities, tendon ruptures, patellar fracture…

leaving the Hospital.

454 Arthroplasty - Update

**3. Results**

Mechanical axis (180º±3º) was restored in 95.04% of cases. Alignments of the femoral and ti‐ bial implants in frontal and coronal axes were measured without significant deviation from standard values.

Main extensor mechanism complications are shown in table III. The most frequent complica‐ tions were instability of the extensor mechanism and patellar fractures. However, most of the fractures were related to a traumatic event as patients in this series were old people, so this complication cannot be only linked to surgical aggression. Patellar tendon rupture was mostly related to knees with previous surgery as valgus osteotomy.


Another important fact in this patellar reconstruction is the direction of the osteotomy. Changes in resection angle influence patellar tracking and favour lateral tilt that could re‐ quire a subsequent lateral release. The goal is to get a flat bone cut with a symmetrical resec‐ tion. This step could be done freehand, but we employ the cutting guide provides by the manufacturer to improve our results. Once the cut has been done, medial placement of the polyethylene offers better patellar tracking than if it is placed laterally. It is advisable to as‐ sess patellar tracking with the "no-thumb" rule placing the knee through full ROM. If the patella tracks laterally, lateral release should be taken into account trying to preserve superi‐ or lateral genicular vessels in order to avoid osteonecrosis, patellar fracture or post-opera‐

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457

The fixation of the implant could be done with single or three pegs system depending on surgeon's preference. Today loosening of the patella is a rare complication. As we have said our knee models have only available "onlay" patellar prosthesis, though some authors rec‐ ommend "inlay" inserts which make them more confident, but no significative differences are observed between the two models [12]. It is said that "inlay" implants allow increase the interface bone-cement, preserve more bone stock and are easy to use [13], but survivorship and clinical and radiological results are similar to the "onlay" designs [14]. In our series we have employed all-polyethylene patella without important complications and good func‐

Patellar instability, which may happen after TKA with or without patellar resurfacing, is a major cause of functional restraint that requires revision surgery. The incidence of symptomatic instability leading to revision is around 0.8%, lower than instability of the extensor mechanism in our series, but we want to remark that most of our cases were classified as subluxations (8 cases out of 15), not frank dislocations so revision rate was similar. Conservative methods as quadriceps exercises, braces or avoiding activities that aggravate instability were applied in subluxations and with time scarring of the retinacu‐ lar tissues lead to resolutions of the symptoms. However in cases of frank dislocation re‐ vision surgery was mandatory. In these cases careful analysis of prosthesis sources of instability were cautious checked to avoid failed surgery. If problem was related to soft tissues, realignment of the extensor mechanism should be considered (lateral release plus

We must remember that other issues as design and placement of the implants may predis‐ pose to extensor mechanism complications. Design of the femoral sulcus generated years ago high incidence of patellofemoral complications and led to debate if patella should be re‐ surface and how to do this replacement [16]. Modern knee prostheses have got more ana‐ tomic designs, but even now there is no consensus about the size, shape and position of the femoral trochlea in relation to femorotibial compartment [17]. Furthermore it is important to restore sulcus position (0.7 mm lateral to the midline of the distal femoral cut) during sur‐

As well as properties of the femoral and patellar designs, surgical details of the technique are also valuables. Restoration of the mechanical axis is of great importance in knee surgery, as it is selecting the appropriate size of the femur to avoid overstuffing of the anterior com‐

tive pain [8, 10].

tional outcomes.

proximal or distal realignment) [15].

gery as best as possible [18].

**Table 3.** Extensor mechanism complications

### **4. Discussion**

For many years dealing with the patella in total knee arthroplasties has been a contro‐ versial topic. Most of the non-resurfacers surgeons justify their choice based in the fre‐ quent complications related to surgery around the patella. It is true that surgical gestures used during patellar resurfacing can affect the patello-femoral tracking, weak patellar bone or alter vascularisation around the patella. Besides it has been remarked by many authors that some knee replacements failures are related to disorders in the me‐ chanics of the patellofemoral joint.

Soft-tissue imbalance is shown as the responsible of patellar instability, the most frequent extensor mechanism complication with an incidence as high as 29% in some series after TKAs [6]. Muscle atrophy, weakness, more proximal attachment of the VMO after closure of the arthrotomy and predominance of the VL are considered the main causes of patellofe‐ moral dysfunction [6]. However, forces from the different bellies of the quadriceps can mod‐ ify patellofemoral function [7].

Aside from anatomical aspects of the quadriceps that are non surgical-dependant, some technical aspects on the patellar side should be observed during this step of the surgery. It is of main importance to restore patellar thickness to prevent from high mechanical pressures and increase de risk of patellar fracture [8]. It is recommended to maintain between 13 and 15 mm of patellar bone remained to adapt the all-polyethylene insert which has 8-10 mm thickness. Surgical technique is of crucial importance in patellar alignment. An increase combined thickness of the implant and patellar bone leads to higher forces on patellar side and close follow-up of these patients should be done. Postoperative lateral tilt increased when thickness after patella resurfacing was augment in 1 mm from the preoperative patella [9]. This lateral tilt is usually treated by lateral release that improves patellar alignment, but lateral release is related to complications as patellar fracture, vascular problems and postop‐ erative pain [10].

Patellar fracture is not an exclusive complication of resurfaced patella and can be sustained in non-resurfaced cases but in rates as low as 0.05%. They are usually related to rheumatoid arthritis or advanced degenerative osteoarthritis [11]. Only in cases of a thin patella or scle‐ rotic bone we advise not to resurface the patella.

Another important fact in this patellar reconstruction is the direction of the osteotomy. Changes in resection angle influence patellar tracking and favour lateral tilt that could re‐ quire a subsequent lateral release. The goal is to get a flat bone cut with a symmetrical resec‐ tion. This step could be done freehand, but we employ the cutting guide provides by the manufacturer to improve our results. Once the cut has been done, medial placement of the polyethylene offers better patellar tracking than if it is placed laterally. It is advisable to as‐ sess patellar tracking with the "no-thumb" rule placing the knee through full ROM. If the patella tracks laterally, lateral release should be taken into account trying to preserve superi‐ or lateral genicular vessels in order to avoid osteonecrosis, patellar fracture or post-opera‐ tive pain [8, 10].

**Instability of the extensor mechanism (patellar dislocation or**

**Table 3.** Extensor mechanism complications

chanics of the patellofemoral joint.

ify patellofemoral function [7].

erative pain [10].

rotic bone we advise not to resurface the patella.

**4. Discussion**

456 Arthroplasty - Update

**subluxation) 1.79% (15 cases)**

Patellar fracture 1.43% (12 cases) Patellar tendon rupture 0.47% (4 cases) Patella loosening 0.95% (8 cases) Clunk syndrome 0.71 (6 cases)

For many years dealing with the patella in total knee arthroplasties has been a contro‐ versial topic. Most of the non-resurfacers surgeons justify their choice based in the fre‐ quent complications related to surgery around the patella. It is true that surgical gestures used during patellar resurfacing can affect the patello-femoral tracking, weak patellar bone or alter vascularisation around the patella. Besides it has been remarked by many authors that some knee replacements failures are related to disorders in the me‐

Soft-tissue imbalance is shown as the responsible of patellar instability, the most frequent extensor mechanism complication with an incidence as high as 29% in some series after TKAs [6]. Muscle atrophy, weakness, more proximal attachment of the VMO after closure of the arthrotomy and predominance of the VL are considered the main causes of patellofe‐ moral dysfunction [6]. However, forces from the different bellies of the quadriceps can mod‐

Aside from anatomical aspects of the quadriceps that are non surgical-dependant, some technical aspects on the patellar side should be observed during this step of the surgery. It is of main importance to restore patellar thickness to prevent from high mechanical pressures and increase de risk of patellar fracture [8]. It is recommended to maintain between 13 and 15 mm of patellar bone remained to adapt the all-polyethylene insert which has 8-10 mm thickness. Surgical technique is of crucial importance in patellar alignment. An increase combined thickness of the implant and patellar bone leads to higher forces on patellar side and close follow-up of these patients should be done. Postoperative lateral tilt increased when thickness after patella resurfacing was augment in 1 mm from the preoperative patella [9]. This lateral tilt is usually treated by lateral release that improves patellar alignment, but lateral release is related to complications as patellar fracture, vascular problems and postop‐

Patellar fracture is not an exclusive complication of resurfaced patella and can be sustained in non-resurfaced cases but in rates as low as 0.05%. They are usually related to rheumatoid arthritis or advanced degenerative osteoarthritis [11]. Only in cases of a thin patella or scle‐ The fixation of the implant could be done with single or three pegs system depending on surgeon's preference. Today loosening of the patella is a rare complication. As we have said our knee models have only available "onlay" patellar prosthesis, though some authors rec‐ ommend "inlay" inserts which make them more confident, but no significative differences are observed between the two models [12]. It is said that "inlay" implants allow increase the interface bone-cement, preserve more bone stock and are easy to use [13], but survivorship and clinical and radiological results are similar to the "onlay" designs [14]. In our series we have employed all-polyethylene patella without important complications and good func‐ tional outcomes.

Patellar instability, which may happen after TKA with or without patellar resurfacing, is a major cause of functional restraint that requires revision surgery. The incidence of symptomatic instability leading to revision is around 0.8%, lower than instability of the extensor mechanism in our series, but we want to remark that most of our cases were classified as subluxations (8 cases out of 15), not frank dislocations so revision rate was similar. Conservative methods as quadriceps exercises, braces or avoiding activities that aggravate instability were applied in subluxations and with time scarring of the retinacu‐ lar tissues lead to resolutions of the symptoms. However in cases of frank dislocation re‐ vision surgery was mandatory. In these cases careful analysis of prosthesis sources of instability were cautious checked to avoid failed surgery. If problem was related to soft tissues, realignment of the extensor mechanism should be considered (lateral release plus proximal or distal realignment) [15].

We must remember that other issues as design and placement of the implants may predis‐ pose to extensor mechanism complications. Design of the femoral sulcus generated years ago high incidence of patellofemoral complications and led to debate if patella should be re‐ surface and how to do this replacement [16]. Modern knee prostheses have got more ana‐ tomic designs, but even now there is no consensus about the size, shape and position of the femoral trochlea in relation to femorotibial compartment [17]. Furthermore it is important to restore sulcus position (0.7 mm lateral to the midline of the distal femoral cut) during sur‐ gery as best as possible [18].

As well as properties of the femoral and patellar designs, surgical details of the technique are also valuables. Restoration of the mechanical axis is of great importance in knee surgery, as it is selecting the appropriate size of the femur to avoid overstuffing of the anterior com‐ partment [19] and placing the femoral implant lateralized. Femorotibial alignment influen‐ ces patellar tracking in native knees as does after knee replacement. Navigation systems that allow surgeons to be more precise in coronal and sagittal planes alignment avoid problems in patellofemoral joints [10].

suppose a different pattern of contact at the patellofemoral joint. To assess intraoperatively patellar tracking a surgical navigation system with the aid of a computer have been de‐ signed but until now it is not routinely used. However, the system could be a valuable sup‐

Extensor Mechanism Complications After Patellar Resurfacing in Knee Replacement – Can They Justify...

http://dx.doi.org/10.5772/53382

459

Until recent days it couldn't have been established a correlation between anterior knee pain and weight [24]. However there is some evidence of a relationship between knee pain and patella tilt. [25]. So "inlay" implants have been criticized for leaving a portion of the lateral facet uncovered by the implant that could be considered a source of pain as it articulates with the femoral component. This liaison may be linked to increase anterior knee pain or worse Knee Society Score. Though we have checked few problems with "onlay" insert in our series, some authors prefer the inset technique of patella resurfacing which for them is simple and safe [1]. We have no experience with the inset patella design proposed by Free‐ man in 1989 and improved over the years. It looks as this design would have less patellar tracking problems, would need less lateral releases and show less signs of instability in the axial X-rays. On the other hand the technique is more demanding and sacrifices more bone,

Many extensor mechanism complications can be evaluated through simple X-ray (patellofe‐ moral instability, patellar fracture, loosening of the patellar insert, complete patellar o quad‐ ricipital tendon rupture...). US images and IRM help us in diagnosis of partial ruptures of the extensor mechanism, synovial effusions... and TC is of great aid in analyzing rotational position of the components. But what can we do in front of a painful total knee arthroplasty without positive results in conventional diagnostic techniques. The easiest decision is to re‐ surface the patella in case it wasn't but if it was? Careful analysis of the different diagnostic tools is essential (X-ray, evaluation of patellar tracking, CT imaging to check components ro‐ tation...). Recently SPECT/CT imaging looks very helpful in establishing the diagnosis of painful knees after TKA, mainly when we are in front of patellofemoral problems without components malposition or loosening. A significantly higher tracer uptake in the patella is shown with this SPECT/CT technique in patients with painful knee due to patellofemoral

Patella resurfacing is related to good clinical results but is also linked to some extensor mechanism complications and a possible need for revision surgery in the future [25]. On the other hand, non-resurfacing could avoid complications of the extensor mechanism but a high rate of anterior knee pain is perceived. This situation drives the surgeon to a predicta‐ ble reoperation as patients increase their retrieval of pain relief. For this reason we consider the decision to resurface the patella as a subjective question [25]. Current literature on patel‐ lar resurfacing after TKA has not shown a clear advantage of patellar resurfacing if we ana‐ lyzed clinical scores, though for many authors patellar replacement looks a better strategy in order to avoid reoperation and anterior knee pain. As the average reoperation rate for nonresurfaced cases was 7.2% compared to 2.8% for the resurfaced, resurfacing the patella would prevent one revision surgery for every 23 patella resurfaced. Knowing the cost of a revision surgery and taking into account that less than 50% of patients would benefit from a

port to analyze one of the main reasons of failure in TKAs [5].

but allow us to be more precise in restoring patellar thickness [1].

problems [26].

In our opinion getting the proper rotation for the femoral and tibial components is the main goal to avoid complications of the extensor mechanism [19, 20]. There are four ways for de‐ termining the rotational alignment of the femur, however we have only used in this series the trans-epicondylar axis and 3° of external rotation based on the posterior condyles. Rota‐ tional alignment of the tibia is as important as femoral placement, so neutral or external ro‐ tation of the tibial component in relation to the tibia decreases the Q angle and helps patellar tracking [20, 21]. Usually more attention is paid to rotational position of the femoral compo‐ nent than to the tibial baseplate and the goal to get proper coverage and good cortical sup‐ port for the tibial implant could led to a wrong rotational tibial alignment. External rotation of the tibial component moves the tibial tubercle internally so less patellofemoral complica‐ tions are detected in this situation [22]. Precise rotational tibial alignment can be obtained from a line perpendicular to the epicondylar axis of the femur [22].

Significance of implant position is crucial in order to avoid extensor mechanism problems, so navigation or personal guides system should offer some advantages at the time of pros‐ theses placement. However many authors believe that proper accuracy can be obtain with traditional guides. X-ray allow to evaluate alignment of the components in the coronal and sagittal plane as well as patellar tracking in the axial view, but rotational position of the im‐ plants can't be assess by simple radiographies. In these cases we must employ CT to get a more precise image of the situation of the components that can justify extensor mechanism complications.

It is important to remark the importance of being careful with this resurfacing step as we are with the other ones. It's surprising as some surgeons are extremely cautious with bone cuts, implant alignment and gaps balancing, but not so watchful with patellar re‐ surfacing. After patella evertion they made a non-controlled cut and leave the PE com‐ ponent on it, without taking into account cut direction, bone width or thickness and medialization of the PE implant.

Preoperative patellar tracking can be a measurement of great value in order to analyze pa‐ tellar position after TKA. Lateral displacement of 3 mm is predictive of patellar maltracking when the knee is placed in full ROM after surgery. This is an evidence of the issue that pa‐ tellar tracking is related to soft-tissue tension [23]. Lateral shift of the patella implies a con‐ tracture of the lateral tissues and this event can be detected in standard preoperative radiographic images. This can be help to identify patients at a higher likehood of experienc‐ ing maltracking after TKA [23]. Of course a valgus knee deformity is related to problems with patellar tracking, but a more careful analysis of the preoperative X-ray may help us in patellar replacement decision.

Resurfacing the patella by all-polyethylene implant can be questioned as this surgical ges‐ ture obviously affects patellar tracking, but on the other hand non-resurfacing the patella suppose a different pattern of contact at the patellofemoral joint. To assess intraoperatively patellar tracking a surgical navigation system with the aid of a computer have been de‐ signed but until now it is not routinely used. However, the system could be a valuable sup‐ port to analyze one of the main reasons of failure in TKAs [5].

partment [19] and placing the femoral implant lateralized. Femorotibial alignment influen‐ ces patellar tracking in native knees as does after knee replacement. Navigation systems that allow surgeons to be more precise in coronal and sagittal planes alignment avoid problems

In our opinion getting the proper rotation for the femoral and tibial components is the main goal to avoid complications of the extensor mechanism [19, 20]. There are four ways for de‐ termining the rotational alignment of the femur, however we have only used in this series the trans-epicondylar axis and 3° of external rotation based on the posterior condyles. Rota‐ tional alignment of the tibia is as important as femoral placement, so neutral or external ro‐ tation of the tibial component in relation to the tibia decreases the Q angle and helps patellar tracking [20, 21]. Usually more attention is paid to rotational position of the femoral compo‐ nent than to the tibial baseplate and the goal to get proper coverage and good cortical sup‐ port for the tibial implant could led to a wrong rotational tibial alignment. External rotation of the tibial component moves the tibial tubercle internally so less patellofemoral complica‐ tions are detected in this situation [22]. Precise rotational tibial alignment can be obtained

Significance of implant position is crucial in order to avoid extensor mechanism problems, so navigation or personal guides system should offer some advantages at the time of pros‐ theses placement. However many authors believe that proper accuracy can be obtain with traditional guides. X-ray allow to evaluate alignment of the components in the coronal and sagittal plane as well as patellar tracking in the axial view, but rotational position of the im‐ plants can't be assess by simple radiographies. In these cases we must employ CT to get a more precise image of the situation of the components that can justify extensor mechanism

It is important to remark the importance of being careful with this resurfacing step as we are with the other ones. It's surprising as some surgeons are extremely cautious with bone cuts, implant alignment and gaps balancing, but not so watchful with patellar re‐ surfacing. After patella evertion they made a non-controlled cut and leave the PE com‐ ponent on it, without taking into account cut direction, bone width or thickness and

Preoperative patellar tracking can be a measurement of great value in order to analyze pa‐ tellar position after TKA. Lateral displacement of 3 mm is predictive of patellar maltracking when the knee is placed in full ROM after surgery. This is an evidence of the issue that pa‐ tellar tracking is related to soft-tissue tension [23]. Lateral shift of the patella implies a con‐ tracture of the lateral tissues and this event can be detected in standard preoperative radiographic images. This can be help to identify patients at a higher likehood of experienc‐ ing maltracking after TKA [23]. Of course a valgus knee deformity is related to problems with patellar tracking, but a more careful analysis of the preoperative X-ray may help us in

Resurfacing the patella by all-polyethylene implant can be questioned as this surgical ges‐ ture obviously affects patellar tracking, but on the other hand non-resurfacing the patella

from a line perpendicular to the epicondylar axis of the femur [22].

in patellofemoral joints [10].

458 Arthroplasty - Update

complications.

medialization of the PE implant.

patellar replacement decision.

Until recent days it couldn't have been established a correlation between anterior knee pain and weight [24]. However there is some evidence of a relationship between knee pain and patella tilt. [25]. So "inlay" implants have been criticized for leaving a portion of the lateral facet uncovered by the implant that could be considered a source of pain as it articulates with the femoral component. This liaison may be linked to increase anterior knee pain or worse Knee Society Score. Though we have checked few problems with "onlay" insert in our series, some authors prefer the inset technique of patella resurfacing which for them is simple and safe [1]. We have no experience with the inset patella design proposed by Free‐ man in 1989 and improved over the years. It looks as this design would have less patellar tracking problems, would need less lateral releases and show less signs of instability in the axial X-rays. On the other hand the technique is more demanding and sacrifices more bone, but allow us to be more precise in restoring patellar thickness [1].

Many extensor mechanism complications can be evaluated through simple X-ray (patellofe‐ moral instability, patellar fracture, loosening of the patellar insert, complete patellar o quad‐ ricipital tendon rupture...). US images and IRM help us in diagnosis of partial ruptures of the extensor mechanism, synovial effusions... and TC is of great aid in analyzing rotational position of the components. But what can we do in front of a painful total knee arthroplasty without positive results in conventional diagnostic techniques. The easiest decision is to re‐ surface the patella in case it wasn't but if it was? Careful analysis of the different diagnostic tools is essential (X-ray, evaluation of patellar tracking, CT imaging to check components ro‐ tation...). Recently SPECT/CT imaging looks very helpful in establishing the diagnosis of painful knees after TKA, mainly when we are in front of patellofemoral problems without components malposition or loosening. A significantly higher tracer uptake in the patella is shown with this SPECT/CT technique in patients with painful knee due to patellofemoral problems [26].

Patella resurfacing is related to good clinical results but is also linked to some extensor mechanism complications and a possible need for revision surgery in the future [25]. On the other hand, non-resurfacing could avoid complications of the extensor mechanism but a high rate of anterior knee pain is perceived. This situation drives the surgeon to a predicta‐ ble reoperation as patients increase their retrieval of pain relief. For this reason we consider the decision to resurface the patella as a subjective question [25]. Current literature on patel‐ lar resurfacing after TKA has not shown a clear advantage of patellar resurfacing if we ana‐ lyzed clinical scores, though for many authors patellar replacement looks a better strategy in order to avoid reoperation and anterior knee pain. As the average reoperation rate for nonresurfaced cases was 7.2% compared to 2.8% for the resurfaced, resurfacing the patella would prevent one revision surgery for every 23 patella resurfaced. Knowing the cost of a revision surgery and taking into account that less than 50% of patients would benefit from a secondary resurfacing, primary replacement of the patella offers economic and clinical ad‐ vantages [25].

The great majority of evidences and experiences are in favour of patellar resurfacing, so we also recommend substituting the patella [36]. This surgical detail only add a short time (less

Extensor Mechanism Complications After Patellar Resurfacing in Knee Replacement – Can They Justify...

http://dx.doi.org/10.5772/53382

461

However patellar resurfacing no longer should be considered a mandatory step in TKAs. We must consider femoral and patellar design before resurfacing patella as several authors have reported nice results with patella non-resurfacing [37]. The importance of the femoral design (patella-friendly component) is of maximum significance as coupling patella design provides better anterior knee pain results and improved knee functions. Routine patellar re‐ placement in TKA cannot be defended when a coupling femoral component is available [37]. However, proper femoral component design is necessary in order to compare patellar resur‐

As we can see many features influence patellofemoral function after TKAs but surgical tech‐ nique is one the primary factors affecting patellar alignment [10], so we can conclude that surgical technique and accurate placement of the implants are of crucial importance in patel‐

**Figure 1.** Advanced-age patient suffered subluxation of the extensor mechanism due to a patella infera, after total knee replacement. It was well tolerated; orthopedics measures were employed (a brace and avoiding activities that

The determination whether to resurface the patella or not is still nowadays controversial [25]. Some trials have concluded there are no advantages in routine patellar resurfacing [38, 39] meanwhile other reports [40] and some meta-analyses [2-4] show less anterior knee pain,

better functional outcomes and lower rates of revision after patella resurfacing.

than 8 minutes) to the surgery and warrant less complains of anterior knee pain [35].

facing and non-resurfacing.

aggravate instability)

la resurfacing and a careful procedure improves outcomes.

The Swedish Knee Arthroplasty Registry shows statistically significant patient satisfaction in cases of patella resurfacing in 98% of about 27000 knees follow-up at 14 years. The Regis‐ try also shows that there is 1.27 risk ratio for unresurfaced patella to be revised. The Austral‐ ian National Joint Registry reveals the same risk ratio (1.25). We must be careful with these numbers about unresurfaced patella being revised because our first option in front of a pa‐ tient with anterior knee pain an unresurfaced patella is to resurface it. However, more than 50% of patients are dissatisfied with revision for only patella component [27, 28]. What looks evident from the different meta-analysis is that anterior knee pain is greater after non-resur‐ facing the patella, as well as patient dissatisfaction and increase revision rate. It looks posi‐ tive resurfacing the patella at primary surgery based on functional results [27]. Some authors do not agree with this assertion and after an observational study from the Norwe‐ gian Arthroplasty Register they conclude that patella resurfacing has no clinical effect on function or anterior knee pain, which is debatable [29]. The Norwegian Register finds a low‐ er risk of revision when the patella is resurfaced after a TKA although differences in rates of revision surgery are not significant. But improvement in new prosthesis designs that have substituted the older ones has been related to an increase in the survivorship of the knee prosthesis in Norway [30].

In a prospective cohort study that compares resurfaced vs. non-resurfaced patella in 65 pa‐ tients that received bilateral total knee replacement, significant better scores were achieved on the resurfaced side at final follow-up. Anterior knee pain was a complaint in 4 patients on the non-resurfaced side and revision surgery was required in these patients. On the other hand no revision was performed in the resurfaced side. The author concluded that better pa‐ tellofemoral functional outcomes, less anterior knee pain and lower rates of revision surgery could be obtained after patella resurfacing [31].

Nowadays, it looks as two great groups of surgeons are completely established and divided by a huge lake: the North American resurfacers and the European non-resurfacers, however it is not possible to reach a conclusion about which alternative is better. But we can add an‐ other group whose select when to resurface the patella. Which are their criteria? How can they determine which patients would need or not patellar resurfacing? The quality of the cartilage and joint congruence can be parameters that aid in the determination of selective patellar resurfacing [32, 33]. When could we advise not to resurface the patella? Park et al remark that non-resurfaced patella is possible if the patient is a young one, the patella is small and its cartilage is almost normal, the patient has no preoperative anterior pain and bone quality is good [34]. If some surgeon decides not to resurface the patella it looks advis‐ able to remove osteophytes of the patella and carry a marginal electrocauterization. Selective resurfacing of patellar bone with specific criteria and the used a patella-friendly implant can be associated with satisfactory outcomes [34].

Reasons for resurfacing the patella are avoiding anterior knee pain, so reoperation rate can be reduced, improve results in some patients with RA and improve functional outcomes as going up stairs [35].

The great majority of evidences and experiences are in favour of patellar resurfacing, so we also recommend substituting the patella [36]. This surgical detail only add a short time (less than 8 minutes) to the surgery and warrant less complains of anterior knee pain [35].

secondary resurfacing, primary replacement of the patella offers economic and clinical ad‐

The Swedish Knee Arthroplasty Registry shows statistically significant patient satisfaction in cases of patella resurfacing in 98% of about 27000 knees follow-up at 14 years. The Regis‐ try also shows that there is 1.27 risk ratio for unresurfaced patella to be revised. The Austral‐ ian National Joint Registry reveals the same risk ratio (1.25). We must be careful with these numbers about unresurfaced patella being revised because our first option in front of a pa‐ tient with anterior knee pain an unresurfaced patella is to resurface it. However, more than 50% of patients are dissatisfied with revision for only patella component [27, 28]. What looks evident from the different meta-analysis is that anterior knee pain is greater after non-resur‐ facing the patella, as well as patient dissatisfaction and increase revision rate. It looks posi‐ tive resurfacing the patella at primary surgery based on functional results [27]. Some authors do not agree with this assertion and after an observational study from the Norwe‐ gian Arthroplasty Register they conclude that patella resurfacing has no clinical effect on function or anterior knee pain, which is debatable [29]. The Norwegian Register finds a low‐ er risk of revision when the patella is resurfaced after a TKA although differences in rates of revision surgery are not significant. But improvement in new prosthesis designs that have substituted the older ones has been related to an increase in the survivorship of the knee

In a prospective cohort study that compares resurfaced vs. non-resurfaced patella in 65 pa‐ tients that received bilateral total knee replacement, significant better scores were achieved on the resurfaced side at final follow-up. Anterior knee pain was a complaint in 4 patients on the non-resurfaced side and revision surgery was required in these patients. On the other hand no revision was performed in the resurfaced side. The author concluded that better pa‐ tellofemoral functional outcomes, less anterior knee pain and lower rates of revision surgery

Nowadays, it looks as two great groups of surgeons are completely established and divided by a huge lake: the North American resurfacers and the European non-resurfacers, however it is not possible to reach a conclusion about which alternative is better. But we can add an‐ other group whose select when to resurface the patella. Which are their criteria? How can they determine which patients would need or not patellar resurfacing? The quality of the cartilage and joint congruence can be parameters that aid in the determination of selective patellar resurfacing [32, 33]. When could we advise not to resurface the patella? Park et al remark that non-resurfaced patella is possible if the patient is a young one, the patella is small and its cartilage is almost normal, the patient has no preoperative anterior pain and bone quality is good [34]. If some surgeon decides not to resurface the patella it looks advis‐ able to remove osteophytes of the patella and carry a marginal electrocauterization. Selective resurfacing of patellar bone with specific criteria and the used a patella-friendly implant can

Reasons for resurfacing the patella are avoiding anterior knee pain, so reoperation rate can be reduced, improve results in some patients with RA and improve functional outcomes as

vantages [25].

460 Arthroplasty - Update

prosthesis in Norway [30].

could be obtained after patella resurfacing [31].

be associated with satisfactory outcomes [34].

going up stairs [35].

However patellar resurfacing no longer should be considered a mandatory step in TKAs. We must consider femoral and patellar design before resurfacing patella as several authors have reported nice results with patella non-resurfacing [37]. The importance of the femoral design (patella-friendly component) is of maximum significance as coupling patella design provides better anterior knee pain results and improved knee functions. Routine patellar re‐ placement in TKA cannot be defended when a coupling femoral component is available [37]. However, proper femoral component design is necessary in order to compare patellar resur‐ facing and non-resurfacing.

As we can see many features influence patellofemoral function after TKAs but surgical tech‐ nique is one the primary factors affecting patellar alignment [10], so we can conclude that surgical technique and accurate placement of the implants are of crucial importance in patel‐ la resurfacing and a careful procedure improves outcomes.

**Figure 1.** Advanced-age patient suffered subluxation of the extensor mechanism due to a patella infera, after total knee replacement. It was well tolerated; orthopedics measures were employed (a brace and avoiding activities that aggravate instability)

The determination whether to resurface the patella or not is still nowadays controversial [25]. Some trials have concluded there are no advantages in routine patellar resurfacing [38, 39] meanwhile other reports [40] and some meta-analyses [2-4] show less anterior knee pain, better functional outcomes and lower rates of revision after patella resurfacing.

We believe the ultimate result of the patella treatment in total knee replacement is multifac‐ torial and depend on patient factors (illness, previous pain, age, weight, BMI...), surgical technique (features shown before), implant design (trochlear groove, tibial implant, patella size and thickness) and above all a proper placement of the components.

However pain is the main reason why the patients seek for a TKA. They accept undergo this procedure to alleviate pain and to restore as best function as possible. Literature reports bet‐ ter functional results and less pain after patellar resurfacing. It seems not fair to avoid patel‐ lar resurfacing for financial criterion or because longer surgical times. If extensor mechanical problems are not as frequent as our series shows and look like these complications could be an acceptable risk, why not to resurface the patella?

**Figure 3.** Loosening of the patellar insert that required removing of the polyethylene. As quality of remaining bone

Extensor Mechanism Complications After Patellar Resurfacing in Knee Replacement – Can They Justify...

http://dx.doi.org/10.5772/53382

463

**Figure 4.** Two examples of fracture of the patella with loosening of the patella. The patients referred a previous trau‐

ma in both cases and revision surgery with extensor mechanism reconstruction was done.

wasn't good, no other all-polyethylene implant was placed

**Figure 2.** Frank dislocation of the patella who required revision surgery. Internal rotational alignment of the femoral component made us to revise it, getting good functional outcome after surgery.

We believe the ultimate result of the patella treatment in total knee replacement is multifac‐ torial and depend on patient factors (illness, previous pain, age, weight, BMI...), surgical technique (features shown before), implant design (trochlear groove, tibial implant, patella

However pain is the main reason why the patients seek for a TKA. They accept undergo this procedure to alleviate pain and to restore as best function as possible. Literature reports bet‐ ter functional results and less pain after patellar resurfacing. It seems not fair to avoid patel‐ lar resurfacing for financial criterion or because longer surgical times. If extensor mechanical problems are not as frequent as our series shows and look like these complications could be

**Figure 2.** Frank dislocation of the patella who required revision surgery. Internal rotational alignment of the femoral

component made us to revise it, getting good functional outcome after surgery.

size and thickness) and above all a proper placement of the components.

an acceptable risk, why not to resurface the patella?

462 Arthroplasty - Update

**Figure 3.** Loosening of the patellar insert that required removing of the polyethylene. As quality of remaining bone wasn't good, no other all-polyethylene implant was placed

**Figure 4.** Two examples of fracture of the patella with loosening of the patella. The patients referred a previous trau‐ ma in both cases and revision surgery with extensor mechanism reconstruction was done.

### **Author details**

Antonio Silvestre1,2, Raúl Lopez1 , Fernando Almeida1 , Pablo Renovell1 , Francisco Argüelles1 and Oscar Vaamonde1


#### **References**

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**Author details**

464 Arthroplasty - Update

Francisco Argüelles1

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923-7

2011; 19: 99-104

Antonio Silvestre1,2, Raúl Lopez1

1 Clinic Hospital of Valencia, Spain

, Fernando Almeida1

[1] Hurson C, Kashir A, Flavin R, Kelly I. Routine patellar resurfacing using an inset pa‐

[2] Parvizi J, Rapuri VR, Saleh KJ, Kuskowski MA, Sharkey PF, Mont MA. Failure to re‐ surface the patella during total knee arthroplasty may result in more knee pain and

[3] Pakos EE, Ntzani EE, Trikalinos TA. Patellar resurfacing in total knee arthroplasty. A

[4] Nizard R S, Biau D, Porcher R, Ravaud P, Bizot P, Hannouche D, Sedel L. A metaanalysis of patellar replacement in total knee arthroplasty. Clin Orthop 2005; 432:

[5] Belvedere C, Catani F, Ensini A, Moctezuma de la Barrera JL, Leardini A. Paellar Trucking Turing total knee arthroplasty: an in Vitro feasibility stydu. Knee Surg

[6] Walligora AC. Johanson NA, Hirsch BE. Clinical Anatomy of the quadriceps femoris

[7] Amis AA. Current concepts on anatomy and biomechanics of patellar stability.

[8] Levai JP. Technical aspects: The patellar side. Knee Surg Sports Traumatol Arthrosc.

[9] Youm YS, Cho WS, Woo JH, Kim BK. The effect of patellar thickness changes on pa‐ tellar tilt in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2010; 18:

[10] Fukagawa S, Matsuda S, Mizu-uchi H, Miura H, Okazaki K, Iwamoto Y. Cjanges in patellar alignment alter total knee arthroplasty. Knee Surg Sports Traumtol Arthrosc.

[11] Seijas R, Orduña JM, Castro MC, Granados N, baliarda J, Alcantara E. Journal of Or‐

and extensor apparatus of the knee. Clin Orthop. 2009 (467: 3297-306

2 Orthopedic Department, School of Medicine, University of Valencia, Spain

tellar technique. International Orthopaedics, 2010; 34: 955-58

secondary surgery. Clin Orthop, 2005; 438:191–96

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throplasty – a new dimension of diagnostics? BMC Musculoskeletal disorders, 2011; 12: 36-46

[39] Maculé F, castillo F, Llopis-Miró R, Nogales J, Budeus Gonzalez-Solis JM, Lozano LM, Segur JM, Suso S. Sustitución patelar en artroplastia total de rodilla. Estudio prospectivo multicéntrico: resultados preliminares. Avances Traum, 2008; 38 (1): 30-4

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[40] Waters TS, Bentley G. Patellar resurfacing in total knee arthroplasty. A prospective

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[39] Maculé F, castillo F, Llopis-Miró R, Nogales J, Budeus Gonzalez-Solis JM, Lozano LM, Segur JM, Suso S. Sustitución patelar en artroplastia total de rodilla. Estudio prospectivo multicéntrico: resultados preliminares. Avances Traum, 2008; 38 (1): 30-4

throplasty – a new dimension of diagnostics? BMC Musculoskeletal disorders, 2011;

[27] Clements WJ, Miller S, Whitehouse SL, Graves SE, Ryan P, Crawford RW. Early out‐ comes of patella resurfacing in total knee arthroplasty. A report from the Australian Orthopaedic Association National Joint Replacement Registry. Acta Orthopaedica

[28] Parvizi J, Mortazavi SM, Devulapalli C, Hozack WJ, Sharkey PF, Tithman RH. Secon‐ dary resurfacing of the patella after primary total knee arthroplasty does the anterior

[29] Lygre SHL, Espehaug B, Havelin LI, Vollset SE, Furnes O. Does patella resurfacing really matter? Pain and function in 972 patients alter primary total knee arthroplasty. An observational study from the Norwegian Arthroplasty Register. Acta Orttho‐

[30] Lygre SHL, Espehaug B, Havelin LI, Vollset SE, Furnes O. Failure of total knee ar‐ throplasty with or withpout patella resurfacing. A study from the Norwegian Ar‐ throplasty Register with 0-15 of follow-up. Acta Orthopaedica 2011; 82 (2): 282-92

[31] Patel K, Raut V. Patella in total knee arthroplasty: to resurface or not to – a cohorte study of staged bilateral total knee arthroplasty. International Orthopaedics, 2011; 35:

[32] Atik OS. Is Soutine patellar resurfacing in total knee arthroplasty necessary?. Eklem

[33] Sanchez-Marquez JM, Rodriguez-Merchan EC. Implantación del componente rotulia‐ no en la artroplastia total de rodilla: situación actual. Rev esp cir ortop traumatol

[34] Se-Jin P, Young-Bok J, Hwa –Jae J, Hun-Kyu S, Ho-Joong J, Jong.Jum L, Ji-Woong Y, Kim E. Long-term results of primary total knee arthroplasty with and without patel‐

[35] Ghasemzadeh F, Mateescu C. Resurfacing patella in 140 TKA patients. Letter to the

[36] Li S, Chen Y, Su W, Zhao J, He S, Luo X. Systematic review of patellar resurfacing in

[37] Whitesides LA. Patella resurfacing no longer considered routine in TKA. Orhtopae‐

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[40] Waters TS, Bentley G. Patellar resurfacing in total knee arthroplasty. A prospective randomized study. J Bone Jt Surg Am. 2003 85 (2); 212-7

**Chapter 21**

**Glenoid Loosening in**

Doron Norman

**1. Introduction**

noid component [6].

http://dx.doi.org/10.5772/53438

with a 0.01-6% rate of loosening [2, 3, 4].

all the successive prosthetic designs are compared.

**Total Shoulder Arthroplasty**

Nahum Rosenberg, Maruan Haddad and

Additional information is available at the end of the chapter

Inflammatory or degenerative processes in glenohumeral joint lead to pain and restriction of movements of the shoulder. Prosthetic replacement of the glenohumeral joint has gained in popularity because of its efficacy in relieving pain. The pioneering successful prostheses for total shoulder arthroplasty (TSA) have been based on an unconstrained de‐ sign, i.e. a metal spherical head component fixed to a metal intramedullary stem articulat‐ ing with a high-density polyethylene socket. These components are stabilized in the adjacent bone using polymethylmethacrylate (PMMA) bone cement [1]. The most impor‐ tant cause for failure of the cemented prostheses is related to the glenoid component,

The long term survivorship data of the prosthesis developed by C. Neer for the cemented total shoulder arthroplasty (TSA) show 87% fifteen year survivorship rate for Neer I & II ce‐ mented shoulder prostheses [5]. This implant has become the gold standard, against which

Further developments of TSA implants have been aimed at enhancing longevity by address‐ ing the following most critical issues: (1) Improving the incorporation of the glenoid compo‐ nent using a more "biological" type of fixation in order to reduce the rate of mechanical loosening; (2) Designing a better glenoid component to achieve the lowest possible rate of wear. But still the main cause of TSA failure has remained the aseptic loosening of the gle‐

and reproduction in any medium, provided the original work is properly cited.

© 2013 Rosenberg et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

### **Chapter 21**

## **Glenoid Loosening in Total Shoulder Arthroplasty**

Nahum Rosenberg, Maruan Haddad and Doron Norman

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/53438

### **1. Introduction**

Inflammatory or degenerative processes in glenohumeral joint lead to pain and restriction of movements of the shoulder. Prosthetic replacement of the glenohumeral joint has gained in popularity because of its efficacy in relieving pain. The pioneering successful prostheses for total shoulder arthroplasty (TSA) have been based on an unconstrained de‐ sign, i.e. a metal spherical head component fixed to a metal intramedullary stem articulat‐ ing with a high-density polyethylene socket. These components are stabilized in the adjacent bone using polymethylmethacrylate (PMMA) bone cement [1]. The most impor‐ tant cause for failure of the cemented prostheses is related to the glenoid component, with a 0.01-6% rate of loosening [2, 3, 4].

The long term survivorship data of the prosthesis developed by C. Neer for the cemented total shoulder arthroplasty (TSA) show 87% fifteen year survivorship rate for Neer I & II ce‐ mented shoulder prostheses [5]. This implant has become the gold standard, against which all the successive prosthetic designs are compared.

Further developments of TSA implants have been aimed at enhancing longevity by address‐ ing the following most critical issues: (1) Improving the incorporation of the glenoid compo‐ nent using a more "biological" type of fixation in order to reduce the rate of mechanical loosening; (2) Designing a better glenoid component to achieve the lowest possible rate of wear. But still the main cause of TSA failure has remained the aseptic loosening of the gle‐ noid component [6].

© 2013 Rosenberg et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **2. Aseptic loosening**

Aseptic loosening of endoprostheses occurs as a result of immune rejection response to an implanted foreign material. This response is enhanced when particles of polyethylene (from the glenoid insert), metal (from the glenoid metal backplate and/or from humeral compo‐ nent) or from fixating PMMA are released due to a mechanically abnormal gliding of the prosthesis. These particles, below 10µ in size, usually in 0.5-1.0µ range [7], induce local and systemic recruitment of macrophages and osteoclasts [8], with subsequential generation of reactive pseudomembrane and local lysis of the prosthesis-bone interface [9] (Figure 1). The lysis of the fixation interface of the prosthesis causes its eventual loosening. Since in the TSA prosthesis the glenoid component is exposed to the higher stresses and usually constructed, at least partly, from polyethylene, it's loaded surface is prone to wear and its surrounding is exposed to the wear particles' seeding. For this reason the immune rejection response is con‐ centrated mainly around the glenoid component.

glenoid. Therefore care should be taken to reshape the glenoid towards an anteverted sur‐

Glenoid Loosening in Total Shoulder Arthroplasty

http://dx.doi.org/10.5772/53438

471

In the longitudinal axis the excessive eccentric forces are generated when the superior stabi‐ lization of the humeral head is insufficient, therefore in patients with massive tears of the

The full conformity between the TSA prosthesis components may also lead to an enhanced stress on the globoid rim due to the loss of the humeral head translation, which is possible in the normal shoulder joint, and as a consequence there is a higher risk for prosthetic loos‐ ening. [13,14]. The exact degree of optimal mismatch of the glenoid and the humeral head radii is not known. Furthermore the suboptimal mismatch of the glenoid and humeral com‐ ponent curvature can lead to a considerable rate of polyethylene wear due to an uneven force distribution between the components and a point loading and a point wear of the

There are several unique issues in TSA that should be addressed in the prosthesis design. First is a limited space and a limited bone stock for the glenoid component implantation.

**1.** The fixation area of the glenoid component is limited, either for cemented or cementless fixation. In order to increase fixation interface the glenoid components bear keels (cen‐ tral or in offset position), pegs (straight or tapered) and/or curved backsurface of the in‐ sert. It is not clear what type of fixation design is optimal for the cemented fixation [11]. There is some clinical evidence that a central tapered peg on a metal back-plate, covered by hydroxyapatite for enhanced ossiointegration, and initially fixed by two screws, might reduce loosening rate of glenoid component in cementless press fit fixation [15]

**2.** The polyethylene gliding surface is essential in most designs of the glenoid component. The polyethylene surface should be at least 3 mm thick, preferably 4-6 mm thick, in or‐ der to diminish its wear following interaction with metal head of the humeral compo‐ nent [16]. This requirement prevents the versatile use of the cementless designs of a glenoid component, because they require the use of a metal back-plate under the poly‐ ethylene insert, with essential limitation of the later thickness in order to prevent the joint overstuffing. For this reason there is a high preference for use of all polyethylene made glenoid components for cemented implantation. This type of design allows the use of more thick polyethylene component, with lower wear rate. But the cemented fix‐ ation of this type of glenoid component might produce thermal mediated, adjacent to the implant, bone necrosis while PMMA polymerization and therefore eventually an enhanced loosening. Currently there is no clear information which of the fixation meth‐

ods of the glenoid component is clinically advantageous.

face, in the physiological range, prior to implantation of the glenoid component [12].

rotator cuff muscles an implantation of the glenoid component is contraindicated.

polyethylene [14].

(Figure 2).

**4. Material considerations**

Two main difficulties arise due to this limitation:

**Figure 1.** Micrograph (scale 200μ, HE staining) of pseodocapsule retrieved from the surface of a failed prosthesis. Characteristic foreign body reaction [10] is evident around areas of debris (\*).

#### **3. Mechanical considerations**

The main cause of the wear of the glenoid component is its high loading by the eccentric forces. The excessive eccentric forces are generated when the transverse axis of the implant‐ ed glenoid is situated in a position which is incompatible with normal anatomical version of glenoid, e. g. between 20 of anteversion and 130 of retroversion [11]. This might happen when the prosthesis is implanted in an arthritic joint with advanced erosion of the posterior glenoid. Therefore care should be taken to reshape the glenoid towards an anteverted sur‐ face, in the physiological range, prior to implantation of the glenoid component [12].

In the longitudinal axis the excessive eccentric forces are generated when the superior stabi‐ lization of the humeral head is insufficient, therefore in patients with massive tears of the rotator cuff muscles an implantation of the glenoid component is contraindicated.

The full conformity between the TSA prosthesis components may also lead to an enhanced stress on the globoid rim due to the loss of the humeral head translation, which is possible in the normal shoulder joint, and as a consequence there is a higher risk for prosthetic loos‐ ening. [13,14]. The exact degree of optimal mismatch of the glenoid and the humeral head radii is not known. Furthermore the suboptimal mismatch of the glenoid and humeral com‐ ponent curvature can lead to a considerable rate of polyethylene wear due to an uneven force distribution between the components and a point loading and a point wear of the polyethylene [14].

### **4. Material considerations**

**2. Aseptic loosening**

470 Arthroplasty - Update

centrated mainly around the glenoid component.

Aseptic loosening of endoprostheses occurs as a result of immune rejection response to an implanted foreign material. This response is enhanced when particles of polyethylene (from the glenoid insert), metal (from the glenoid metal backplate and/or from humeral compo‐ nent) or from fixating PMMA are released due to a mechanically abnormal gliding of the prosthesis. These particles, below 10µ in size, usually in 0.5-1.0µ range [7], induce local and systemic recruitment of macrophages and osteoclasts [8], with subsequential generation of reactive pseudomembrane and local lysis of the prosthesis-bone interface [9] (Figure 1). The lysis of the fixation interface of the prosthesis causes its eventual loosening. Since in the TSA prosthesis the glenoid component is exposed to the higher stresses and usually constructed, at least partly, from polyethylene, it's loaded surface is prone to wear and its surrounding is exposed to the wear particles' seeding. For this reason the immune rejection response is con‐

**Figure 1.** Micrograph (scale 200μ, HE staining) of pseodocapsule retrieved from the surface of a failed prosthesis.

The main cause of the wear of the glenoid component is its high loading by the eccentric forces. The excessive eccentric forces are generated when the transverse axis of the implant‐ ed glenoid is situated in a position which is incompatible with normal anatomical version of

when the prosthesis is implanted in an arthritic joint with advanced erosion of the posterior

of retroversion [11]. This might happen

of anteversion and 130

Characteristic foreign body reaction [10] is evident around areas of debris (\*).

**3. Mechanical considerations**

glenoid, e. g. between 20

There are several unique issues in TSA that should be addressed in the prosthesis design. First is a limited space and a limited bone stock for the glenoid component implantation. Two main difficulties arise due to this limitation:


should be undertaken carefully in order to avoid unnecessary revision surgery. In all the cases of suspected TSA prosthesis loosening a standard workup for possible periprosthetic infection should be done in order to avoid a devastating misdiagnosis [18] (the discussion of

Glenoid Loosening in Total Shoulder Arthroplasty

http://dx.doi.org/10.5772/53438

473

**Figure 3.** A shoulder radiograph (anterior-posterior view) of 60 years old male patient, three years after cemented TSA. Lucency is evident in the direct proximity to the glenoid component, but the patient is pain free and has good range of movements of the operated shoulder, without any laboratory evidence of infection and is satisfied from the

function of the operated shoulder.

this topic is out of the scope of the present chapter).

**Figure 2.** An example of glenoid component for cementless implantation: a polyethylene insert mounted on a metal back-plate with tapered peg covered by hydroxyapatite. The initial press fit fixation is enhanced by two screws. This design showed improved survivorship rates.

### **5. Clinical signs of the glenoid component loosening**

The clinical signs of the TSA prosthesis failure include an increased level of pain during fol‐ low-up, that appeared to be related to the implant, with restriction of external rotation to under 20o and abduction to under 60o and/or newly developed radiolucency at the glenoid component interface with the underlying bone, more than 2mm in width [17]. The recogni‐ tion of coexistence of both physical and radiographic signs is essential, since the isolated finding of periprosthetic radiolucency, without pain or significant restriction of movements of the shoulder, might not be of a high clinical importance (Figure 3). This consideration should be undertaken carefully in order to avoid unnecessary revision surgery. In all the cases of suspected TSA prosthesis loosening a standard workup for possible periprosthetic infection should be done in order to avoid a devastating misdiagnosis [18] (the discussion of this topic is out of the scope of the present chapter).

**Figure 2.** An example of glenoid component for cementless implantation: a polyethylene insert mounted on a metal back-plate with tapered peg covered by hydroxyapatite. The initial press fit fixation is enhanced by two screws. This

The clinical signs of the TSA prosthesis failure include an increased level of pain during fol‐ low-up, that appeared to be related to the implant, with restriction of external rotation to

component interface with the underlying bone, more than 2mm in width [17]. The recogni‐ tion of coexistence of both physical and radiographic signs is essential, since the isolated finding of periprosthetic radiolucency, without pain or significant restriction of movements of the shoulder, might not be of a high clinical importance (Figure 3). This consideration

and abduction to under 60o and/or newly developed radiolucency at the glenoid

**5. Clinical signs of the glenoid component loosening**

design showed improved survivorship rates.

under 20o

472 Arthroplasty - Update

**Figure 3.** A shoulder radiograph (anterior-posterior view) of 60 years old male patient, three years after cemented TSA. Lucency is evident in the direct proximity to the glenoid component, but the patient is pain free and has good range of movements of the operated shoulder, without any laboratory evidence of infection and is satisfied from the function of the operated shoulder.

## **6. Survivorship data of TSA prostheses with special emphasis on glenoid loosening**

**7. Treatment of loose glenoid**

cause a considerably favorable clinical outcome [24].

the surgeon's experience and methodical preferences.

more widespread use in the future.

**design**

Surgical revision of failed glenoid should address several crucial factors. One of the main factors for consideration is the preservation of an adequate bone stock following the compo‐ nent removal. This is essential if replantation is considered, otherwise the component resec‐ tion will be the definite procedure. Interestingly several authors reported that a resection of the failed glenoid component without subsequential replantation of a new component might

Glenoid Loosening in Total Shoulder Arthroplasty

http://dx.doi.org/10.5772/53438

475

The second crucial factor is the preservation of adequate version of the remained glenoid in

These two factors can be achieved by bone grafting, autologous or by allograft, with addi‐ tional controlled reaming of the remained glenoid surface. The surgeon's arsenal of glenoid components for replantation includes parts for either cemented or cementless fixation, and biological soft tissue allografts for biological resurfacing. Several reports support the use of soft tissue allograft material, e.g. Achilles tendon, meniscus etc., for glenoid resurfacing in revision surgery [25]. Finally the replantation of the glenoid component might be immedi‐ ate, during the revision surgery, or late, following initial bone grafting of cavitations and/ or bone deficiencies in the treated glenoid. Since this type of surgery has no standard guide‐ lines because of the different patterns of the bone loss of the treated glenoids, a precise sur‐ gical protocol does not exist for this purpose and a lot of the decision making depends on

In order to avoid an extensive tissue damage during the glenoid revision surgery an arthro‐ scopic approach has been suggested and reported in a small number of published reports. This method was popularized by O'Driscoll SW et al [26]. The authors used an arthroscopic approach through the standard anterior and posterior portals, with addition of another ex‐ tended portal for the glenoid component remnants' retrieval. This method is suitable only for all-polyethylene components, because they should be cut in situ to at least 3 parts (by diagonal cuts using an inserted through the portal osteotom) in order to retrieve pieces in sizes which are compatible with the retrieval portal diameter. This method allows also a subsequential bone grafting of the exposed glenoid undersurface by using metal impactors which are inserted through the created portals [27]. This is a technically demanding techni‐ que, especially due to the optical interference, e.g. "mirror effect", that is caused by the met‐ al humeral component head and due to the difficulty to control bleeding from the exposed glenoid surface. But because of the appealing tissue preservation this method might gain

**8. Prospective on the future improvement of the glenoid component**

Two main issues should be considered when seeking the improvement of the TSA survivor‐ ship. First of all the currently used TSA methods have already reached a high, above 90%,

order to avoid future eccentric loads on the replanted glenoid component.

In order to get a meaningful evaluation of the implanted prostheses longevity a powerful statistical tool of survivorship analysis is used [19]. Because the relative complicity in this method implementation, especially in defining the criteria for the "failure" of the implanted prostheses, only few reports on survivorship data of TSA exist, mainly with the parameter of a revision surgery as the indication of the failed prosthesis.

From the few reported survivorship data a short-term glenoid failure, requiring implant re‐ moval, reaches the rate of around 6% for cemented designs and 3% for cementless designs. Overall the glenoid component failure is the cause of between 20% - 60% of all failed TSAs, cemented or cementless (Table 1). Survivorship of TSA is the highest in patients with rheu‐ matoid arthritis and the lowest in patients implanted following trauma and fracture. The reason is probably a lower demand for shoulder activity in the former group and expecta‐ tions for nearly normal function in the latter group of patients [20, 21, 22, 23].


**Table 1.** Long term survivorship data on cemented and the outcome of a large series of a cementless total shoulder replacement prostheses.

### **7. Treatment of loose glenoid**

**6. Survivorship data of TSA prostheses with special emphasis on glenoid**

In order to get a meaningful evaluation of the implanted prostheses longevity a powerful statistical tool of survivorship analysis is used [19]. Because the relative complicity in this method implementation, especially in defining the criteria for the "failure" of the implanted prostheses, only few reports on survivorship data of TSA exist, mainly with the parameter

From the few reported survivorship data a short-term glenoid failure, requiring implant re‐ moval, reaches the rate of around 6% for cemented designs and 3% for cementless designs. Overall the glenoid component failure is the cause of between 20% - 60% of all failed TSAs, cemented or cementless (Table 1). Survivorship of TSA is the highest in patients with rheu‐ matoid arthritis and the lowest in patients implanted following trauma and fracture. The reason is probably a lower demand for shoulder activity in the former group and expecta‐

**No. of Patients Survivorship End point**

10years= 93% 15years= 87%

11years= 75%

**Table 1.** Long term survivorship data on cemented and the outcome of a large series of a cementless total shoulder

**criteria**

Revision – severe pain, abd<90o, ext rot<20o

> Severe pain, radiographic evidence of component loosening

Not calculated Revision 5/180 12/180

Not calculated Revision 9/705 43/705

**Glenoid failure rate**

**Overall failure rate**

7/113 14/113

3/51 6/51

tions for nearly normal function in the latter group of patients [20, 21, 22, 23].

113 [31=OA, 36=RA 12=2ary OA]

> 51 [37=OA 14=RA]

180 [110=OA 28=RA 30=2ary OA 12=revisions]

705 [418=OA 107=RA 180=2ary OA]

of a revision surgery as the indication of the failed prosthesis.

**loosening**

474 Arthroplasty - Update

**Reference Type of**

Tarchia et al [21]

Brenner et al [23]

Cofield [22]

Pfahler et al [20]

replacement prostheses.

**prosthesis**

Neer I & II cemented

Neer II & Gristina cemented

Cofield cementless

Aequalis cemented

OA = osteoarthritis, RA = rheumatoid arthritis

Surgical revision of failed glenoid should address several crucial factors. One of the main factors for consideration is the preservation of an adequate bone stock following the compo‐ nent removal. This is essential if replantation is considered, otherwise the component resec‐ tion will be the definite procedure. Interestingly several authors reported that a resection of the failed glenoid component without subsequential replantation of a new component might cause a considerably favorable clinical outcome [24].

The second crucial factor is the preservation of adequate version of the remained glenoid in order to avoid future eccentric loads on the replanted glenoid component.

These two factors can be achieved by bone grafting, autologous or by allograft, with addi‐ tional controlled reaming of the remained glenoid surface. The surgeon's arsenal of glenoid components for replantation includes parts for either cemented or cementless fixation, and biological soft tissue allografts for biological resurfacing. Several reports support the use of soft tissue allograft material, e.g. Achilles tendon, meniscus etc., for glenoid resurfacing in revision surgery [25]. Finally the replantation of the glenoid component might be immedi‐ ate, during the revision surgery, or late, following initial bone grafting of cavitations and/ or bone deficiencies in the treated glenoid. Since this type of surgery has no standard guide‐ lines because of the different patterns of the bone loss of the treated glenoids, a precise sur‐ gical protocol does not exist for this purpose and a lot of the decision making depends on the surgeon's experience and methodical preferences.

In order to avoid an extensive tissue damage during the glenoid revision surgery an arthro‐ scopic approach has been suggested and reported in a small number of published reports. This method was popularized by O'Driscoll SW et al [26]. The authors used an arthroscopic approach through the standard anterior and posterior portals, with addition of another ex‐ tended portal for the glenoid component remnants' retrieval. This method is suitable only for all-polyethylene components, because they should be cut in situ to at least 3 parts (by diagonal cuts using an inserted through the portal osteotom) in order to retrieve pieces in sizes which are compatible with the retrieval portal diameter. This method allows also a subsequential bone grafting of the exposed glenoid undersurface by using metal impactors which are inserted through the created portals [27]. This is a technically demanding techni‐ que, especially due to the optical interference, e.g. "mirror effect", that is caused by the met‐ al humeral component head and due to the difficulty to control bleeding from the exposed glenoid surface. But because of the appealing tissue preservation this method might gain more widespread use in the future.

### **8. Prospective on the future improvement of the glenoid component design**

Two main issues should be considered when seeking the improvement of the TSA survivor‐ ship. First of all the currently used TSA methods have already reached a high, above 90%, middle and long term survivorship rate, leaving a small, but important margin for improve‐ ment [21]. Secondary it is clear that this margin for improvement is related to the glenoid component design, since most of the failed TSAs are due to glenoid component failure. There is an example supporting this claim, when following a change of the design of the gle‐ noid component a 10% increase in a short term survivorship of cementless TSA prosthesis has been achieved [15].

[5] Tarchia ME, Cofield RH, Settergren CR . Total Shoulder Arthroplasty with the Neer

Glenoid Loosening in Total Shoulder Arthroplasty

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477

[6] Hasan SS, Leith JM, Campbell B, Kapil R, Smith KL, Matsen FA. Characteristics of Unsatisfactory Shoulder Arthroplasties. J Shoulder Elbow Surg 2002; 11 431-41.

[7] Hallab NJ, Jacobs JJ. Biologic Effects of Implant Debris. Bul NYU Hosp Joint Dis

[8] Ren PG, Irani A, Huang Z, Ma T, Biswal S, Goodman SB. Continuous Infusion of UNMWPE Particles Induces Increased Bone Macrophages and Osteolysis. Clin Or‐

[9] Purdue PE, Koulouvaris P, Nestor BJ, Sculco TP. The Central Role of Wear Debris In

[10] Pandey R, Drakoulakis E, Athanasou NA. An Assessment of The Histological Crite‐ ria Used to Diagnose Infection in Hip Revision Artroplasty Tissue. J Clin Pathol 1999;

[11] Strauss EJ, Roche C, Flurin PH, Wright T, Zuckerman JD. The Glenoid In Shoulder

[12] Farron A, Terrier A, Buchler P. Risks Of Loosening of a Prosthetic Glenoid Implanted

[13] Harryman DT, Sidles JA, Harris SL, Lippitt SB, Matsen FA. The Effect of Articular Conformity and the Size of the Humeral Head Component on Laxity and Motion af‐

[14] Walch G, Edwards TB, Boulahia A, Boileau P, Mole D, Adeleine P. The Influence of Glenohumeral Prosthetic Mismatch on Glenoid Radiolucent Lines. Results of a multi‐

[15] Rosenberg N, Neumann L Modi A, Mersich IJ, Wallace AW. Improvements In Sur‐ vival of the Uncemented Nottingham Total Shoulder Prosthesis: A Prospective Com‐

[16] Brems J: The Glenoid Component In Total Shoulder Arthroplasty. J Shoulder Elbow

[17] Wallace AL, Walsh WR, Sonnabend DH: Dissociation of The Glenoid Component In Cementless Total Shoulder Arthroplasty. J Shoulder Elbow Surg 1999; 8 81-84

[18] Zimmerli W., Trampuz A., Ochsner PE. Prosthetic-joint Infections. N Engl J Med

[19] Rosenberg N, Soudry M. Survivorship Analysis of Orthopaedc Procedures – Practi‐

ter Glenohumeral Arthroplasty. J Bone Joint Surg Am 1995; 77-A 555-563

Prosthesis: Long-Term Results. J Shoulder Elbow Surg 1997, 6:495-505.

2009;67(2) 182-188

52 118-123

Surg 1993; 2 47-54.

2004; 351(16) 1645-1654

thop Relat Res 2011; 469 113-122

Periprosthetic Osteolysis. HSSJ 2006; 2 102-113

Arthroplasty. J Shoulder Elbow Surg 2009; 18 819-833

In Retroversion. J Shoulder Elbow Surg 2006; 15 521-526

center study. J Bone Joint Surg Am 2002; 84-A 2186-2191.

cal Approach. Arthroscopy 2011; 27(suppl 4) 16-24

parative Study. BMC Musculoskeletal Disorders 2007; 8 76 - 87

Clearly the main changes in the glenoid component design should address the rate of wear of this component and the efficiency of the component fixation. Therefore it is logical that the prospective for improvement of these issues will be related to finding the articulating surfaces generating less wear particles, even when subjected to excessive eccentric loading. Probably improving the biological osseous integration into the glenoid component will solve the complications of the current fixation either by the PMME or by the mechanical press fit fixation techniques. Some indications of the efficiency of biological fixation of the glenoid component have been already revealed in the devices coated by osteoconductive material, such as hydroxyapatite.

### **Author details**

Nahum Rosenberg1\*, Maruan Haddad2 and Doron Norman2

\*Address all correspondence to: nahumrosenberg@Hotmail.Com

1 Rambam – Health Care Campus, Laboratory of Musculoskeletal Research, Department of Orthopaedic Surgery, Haifa, Israel

2 Rambam – Health Care Campus, Department of Orthopaedic Surgery. Haifa, Israel

### **References**


[5] Tarchia ME, Cofield RH, Settergren CR . Total Shoulder Arthroplasty with the Neer Prosthesis: Long-Term Results. J Shoulder Elbow Surg 1997, 6:495-505.

middle and long term survivorship rate, leaving a small, but important margin for improve‐ ment [21]. Secondary it is clear that this margin for improvement is related to the glenoid component design, since most of the failed TSAs are due to glenoid component failure. There is an example supporting this claim, when following a change of the design of the gle‐ noid component a 10% increase in a short term survivorship of cementless TSA prosthesis

Clearly the main changes in the glenoid component design should address the rate of wear of this component and the efficiency of the component fixation. Therefore it is logical that the prospective for improvement of these issues will be related to finding the articulating surfaces generating less wear particles, even when subjected to excessive eccentric loading. Probably improving the biological osseous integration into the glenoid component will solve the complications of the current fixation either by the PMME or by the mechanical press fit fixation techniques. Some indications of the efficiency of biological fixation of the glenoid component have been already revealed in the devices coated by osteoconductive

and Doron Norman2

1 Rambam – Health Care Campus, Laboratory of Musculoskeletal Research, Department of

[1] Neer CS: Replacement Arthroplasty for Glenohumeral Arthritis. J Bone Joint Surg

[2] Brems J: The Glenoid Component in Total Shoulder Arthroplasty. J Shoulder Elbow

[3] Crites BM, Berend ME, Ritter MA. Technical Considerations of Cemented Acetabular

[4] Pfahler M, Jena F, Neyton L, Sirveaux F, Mole D, Cedex N: Hemiarthroplasty Versus Total Shoulder Prosthesis: Results of Cemented Glenoid Components. J Shoulder El‐

Components: a 30-year Evaluation. Clin Orthop 2000; 382 114-119

2 Rambam – Health Care Campus, Department of Orthopaedic Surgery. Haifa, Israel

has been achieved [15].

476 Arthroplasty - Update

material, such as hydroxyapatite.

Nahum Rosenberg1\*, Maruan Haddad2

Orthopaedic Surgery, Haifa, Israel

Am 1974; 56-A113

Surg 1993; 2 47-54

bow Surg 2006; 15 154-163.

\*Address all correspondence to: nahumrosenberg@Hotmail.Com

**Author details**

**References**


[20] Pfahler M, Jena F, Neyton L, Sirveaux F, Mole D, Cedex N. Hemiarthroplasty Versus Total Shoulder Prosthesis: Results of Cemented Glenoid Components. J Shoulder El‐ bow Surg 2006; 15 154-163

**Section 6**

**Periprosthetic Infection**


## **Periprosthetic Infection**

[20] Pfahler M, Jena F, Neyton L, Sirveaux F, Mole D, Cedex N. Hemiarthroplasty Versus Total Shoulder Prosthesis: Results of Cemented Glenoid Components. J Shoulder El‐

[21] Tarchia ME, Cofield RH, Settergren CR . Total Shoulder Arthroplasty with the Neer

[22] Cofield RH: Uncemented Total Shoulder Arthroplasty. Clin Orthop 1994; 307 86-93

[23] Brenner BC, Ferlic DC, Clayton ML, Dennis DA. Survivorship of Unconstrained To‐

[24] Raphael BS, Dines JS, Warren RF , Figgie M, Craig EV. Symptomatic Glenoid Loosen‐

[25] Namdari S, Gel DP, Wrner JJ. Managing Glenoid Bone Loss In Revision Total

[26] O'Driscoll SW, Petrie RS, Torchia ME. Arthroscopic Removal of the Glenoid Compo‐ nent for Failed Total Shoulder Arthroplasty. A Report of Five Cases. J Bone Joint

[27] Namdari S, Glaser D. Arthroscopically Assisted Conversion of Total Shoulder Ar‐ throplasty to Hemiarthroplasty with Glenoid Bone Grafting. Orthopedics 2011;34(11)

Prosthesis: Long-Term Results. J Shoulder Elbow Surg 1997; 6 495-505

tal Shoulder Arthroplasty. J Bone Joint Surg Am 1989; 71-A 1289-1296

ing Complicating Total Shoulder Arthroplasty. HSSJ 2010; 6 52 -56

Shoulder Arthroplasty: A Review. UPOJ 2010; 20 44-49

bow Surg 2006; 15 154-163

478 Arthroplasty - Update

Surg Am 2005; 87-A 858-863

862-865

**Chapter 22**

**Peri-Prosthetic Joint Infection:**

Adrian J. Cassar Gheiti and Kevin J. Mulhall

Additional information is available at the end of the chapter

the wound and the overall health of the patient.

**2. Pathophysiology**

venting, diagnosis and managing peri-prosthetic joint infection.

http://dx.doi.org/10.5772/53247

**1. Introduction**

**Prevention, Diagnosis and Management**

Total Joint Arthroplasty (TJA) is a safe and effective procedure that improves the quality of life and restores function in most patients suffering from joint arthritis. Post-operative peri-prosthet‐ ic joint infections (PJI) are an uncommon and difficult complication of joint replacement surgery. PJI affects 1-3% total joint replacements and is the most common indication for revision in total knee arthroplasty (TKA) and third most common indication for revision total hip arthroplasty (THA)[1-4]. PJI can be difficult to diagnose and can present at any time from the primary proce‐ dure[5, 6]. PJI is painful, disabling, costly and often requires multiple procedures[7], prolonged periods of rehabilitation, antibiotic treatment and poor functional outcome. It places a considera‐ ble burden on hospital and surgeon resources with an estimated annual cost of infected revisions in US hospitals increasing from \$320 million in 2001 to \$566 million in 2009, with a projected cost exceeding \$1.62 billion by 2020[8]. Consistent efforts at prevention are mandatory, and treatment of infection requires appropriate assessment of its chronicity and causative factors, the status of

We will first provide an overview on peri-prosthetic joint infection and the possible risk fac‐ tors involved. Finally, we will provide an overview of the current evidence available in pre‐

Peri-prosthetic joint infections are a result of an intricate interaction between the host, the pathogen and the implant[9-11]. There is a multitude of host factors, ranging from medical

and reproduction in any medium, provided the original work is properly cited.

© 2013 Gheiti and Mulhall; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

comorbidities to social economic status, which increase the risk of PJI[9, 10, 12-15].

**Chapter 22**

## **Peri-Prosthetic Joint Infection: Prevention, Diagnosis and Management**

Adrian J. Cassar Gheiti and Kevin J. Mulhall

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/53247

### **1. Introduction**

Total Joint Arthroplasty (TJA) is a safe and effective procedure that improves the quality of life and restores function in most patients suffering from joint arthritis. Post-operative peri-prosthet‐ ic joint infections (PJI) are an uncommon and difficult complication of joint replacement surgery.

PJI affects 1-3% total joint replacements and is the most common indication for revision in total knee arthroplasty (TKA) and third most common indication for revision total hip arthroplasty (THA)[1-4]. PJI can be difficult to diagnose and can present at any time from the primary proce‐ dure[5, 6]. PJI is painful, disabling, costly and often requires multiple procedures[7], prolonged periods of rehabilitation, antibiotic treatment and poor functional outcome. It places a considera‐ ble burden on hospital and surgeon resources with an estimated annual cost of infected revisions in US hospitals increasing from \$320 million in 2001 to \$566 million in 2009, with a projected cost exceeding \$1.62 billion by 2020[8]. Consistent efforts at prevention are mandatory, and treatment of infection requires appropriate assessment of its chronicity and causative factors, the status of the wound and the overall health of the patient.

We will first provide an overview on peri-prosthetic joint infection and the possible risk fac‐ tors involved. Finally, we will provide an overview of the current evidence available in pre‐ venting, diagnosis and managing peri-prosthetic joint infection.

## **2. Pathophysiology**

Peri-prosthetic joint infections are a result of an intricate interaction between the host, the pathogen and the implant[9-11]. There is a multitude of host factors, ranging from medical comorbidities to social economic status, which increase the risk of PJI[9, 10, 12-15].

© 2013 Gheiti and Mulhall; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **2.1. Host and environmental factors**

Predisposing factors for PJI can be sub classified into preoperative, intraoperative and post‐ operative factors (Table 1). Preoperative predisposing factors include medical conditions such as diabetes, inflammatory arthropathies, preoperative anemia, congestive heart disease and chronic pulmonary disease to mention few[9, 10, 12, 14]. Intraoperative predisposing factors include simultaneous bilateral joint arthroplasty, longer operative time, knee arthro‐ plasty, increased operating room traffic and contamination by the surgical team during preparation and draping[12, 16-19].

**Predisposing Factors Studies**

Poor Nutrition Berbari et al.[22]

Simultaneous bilateral Pulido et al.[12]

Operating Room Traffic Panahi et al.[18]

Myocardial Infarction Pulido et al.[12]

Higher BMI Pulido et al.[12], Bozic et al.[9]

History of malignancy/metastasis Bozic et al.[9], Berbari et al.[22]

Knee arthroplasty Pulido et al.[12], Buller et al.[20]

Cement with no antibiotics Hanssen AD.[32], Jämsen et al.[21] Skin Preparation and Draping Johnson et al.[33], Katthagen et al.[16]

Renal impairment Pulido et al.[12], Saleh et al.[23], Bozic et al.[9] Allogenic blood transfusion Pulido et al.[12], Berbari et al.[22], Saleh et al.[23]

Urinary tract infection Pulido et al.[12], Wilson et al.[10], Poss et al.[25]

Continuous wound discharge Pulido et al.[12], Jämsen et al.[21], Berbari et al.[22]

Haematoma Pulido et al.[12], Jämsen et al.[21], Berbari et al.[22], Saleh et al.[23]

Contamination by operating room personnel Ayers et al.[34], Rao et al.[35]

Atrial fibrillation Pulido et al.[12], Berbari et al.[22]

Prolonged Hospital stay Pulido et al,[12]. Berbari et al.[22]

Male sex Buller et al.[20], Jämsen et al.[21] Socioeconomic status Pulido et al.[12], Berbari et al.[22]

ASA > 2 Pulido et al.[12], Buller et al.[20], Bozic et al.[9], Saleh et al.[23], Diabetes and elevated blood sugars Buller et al.[20], Bozic et al.[9], Jämsen et al.[24], Berbari et al[22]., Saleh et al.[23] Inflammatory Arthropathy Pulido et al.[12], Bozic et al.[9], Wilson et al.[10], Jämsen et al.[21] , Berbari et al.[22]

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Immunosuppressant medication Wilson et al.[10], Berbari et al.[22], Saleh et al.[23] Preoperative Anaemia Pulido et al.[12], Greenky et al.[14], Bozic et al.[9]

Other infected Joint Arthroplasty Buller et al.[20], Jafari et al.[15], Berbari et al.[22]

Skin ulcers/PVD Bozic et al.[9], Wilson et al.[10], Berbari et al.[22], Poss et al.[25]

Longer operative time Pulido et al.[12], Muilwijk et al.[26], Ong et al.[27], Berbari et al.[22], Saleh et al.[23] No prophylactic antibiotic Fogelberg et al.[28], Pavel et al.[29], Meehan et al.[30], Al-Maiyah et

al.[31]

**Preoperative**

**Intraoperative**

**Postoperative**

**Table 1.** Predisposing factors to PJI

Post-operative predisposing factors to PJI include immunosuppressive medications, allogen‐ ic blood transfusion, post-operative atrial fibrillation, myocardial infarction, urinary tract in‐ fection and longer hospital stay[9, 10, 12].

Peri-prosthetic joint infections are typically caused by microorganisms that grow in bio‐ films[36]. Within biofilms, microorganisms in a polymetric matrix and develop into or‐ ganized complex communities resembling a multicellular organism[37]. In a biofilm, microbes are protected from antimicrobial agents and host immune responses. This may be related to the reduced growth rate of biofilm microorganisms, which enter a station‐ ary phase of growth[38]. Different microbes have different interactions with the host and the prosthetic. Some have specific adhesion molecules which help them adhere to the im‐ plant until a biofilm is formed, which is mediated in part by intracellular adhesion mole‐ cules[39]. Initially, adherent microorganisms and early biofilms are relatively unstable and still susceptible to host defense and antimicrobial agents. In contrast, mature bio‐ films are more stable and resist to elimination[40]. Furthermore, implants are devoid of microcirculation, which is crucial for the immune system and antibiotics to interact with microbes. Implants also tend to activate neutrophils which release peptides that deacti‐ vate granulocytes, impairing the removal of microbes[41]. This effect on granulocytes re‐ duces the minimal amount of microbes that are required to cause an infection[41]. Inoculation of implants, not only occurs during the time of surgery, but can occur in the presence of a bacteremia from any source in the human body during the entire lifetime of the implant[42].

#### **2.2. Microbial profile in PJI**

A multitude of organisms mostly bacteria and fungi are reported to cause PJI (Table.2). The most reported organisms responsible for PJI are Gram positive *cocci*, most commonly *Staphy‐ lococcus Aureus* and *Staphylococcus Epidermidis* as reported by various authors[12, 20, 22, 31, 43-45]. On certain occasions, Gram negative bacteria and Fungi can also be responsible for periprosthetic joint infections[46, 47]. In a recent study published by Buller et al., Methicillin Resistant *Staph. Aureus* (MRSA) and Methicillin Resistant *Staph. Epidermidis* (MRSE) account for about 15.5% of all PJIs[20] and according to other studies up to 19% of PJIs can be poly microbial[12, 22, 48]. These microorganisms can all be part of normal skin flora; hence, direct inoculation at the time of the operation as well as airborne contamination are the most likely causes of these infections.


**Table 1.** Predisposing factors to PJI

**2.1. Host and environmental factors**

482 Arthroplasty - Update

preparation and draping[12, 16-19].

of the implant[42].

**2.2. Microbial profile in PJI**

causes of these infections.

fection and longer hospital stay[9, 10, 12].

Predisposing factors for PJI can be sub classified into preoperative, intraoperative and post‐ operative factors (Table 1). Preoperative predisposing factors include medical conditions such as diabetes, inflammatory arthropathies, preoperative anemia, congestive heart disease and chronic pulmonary disease to mention few[9, 10, 12, 14]. Intraoperative predisposing factors include simultaneous bilateral joint arthroplasty, longer operative time, knee arthro‐ plasty, increased operating room traffic and contamination by the surgical team during

Post-operative predisposing factors to PJI include immunosuppressive medications, allogen‐ ic blood transfusion, post-operative atrial fibrillation, myocardial infarction, urinary tract in‐

Peri-prosthetic joint infections are typically caused by microorganisms that grow in bio‐ films[36]. Within biofilms, microorganisms in a polymetric matrix and develop into or‐ ganized complex communities resembling a multicellular organism[37]. In a biofilm, microbes are protected from antimicrobial agents and host immune responses. This may be related to the reduced growth rate of biofilm microorganisms, which enter a station‐ ary phase of growth[38]. Different microbes have different interactions with the host and the prosthetic. Some have specific adhesion molecules which help them adhere to the im‐ plant until a biofilm is formed, which is mediated in part by intracellular adhesion mole‐ cules[39]. Initially, adherent microorganisms and early biofilms are relatively unstable and still susceptible to host defense and antimicrobial agents. In contrast, mature bio‐ films are more stable and resist to elimination[40]. Furthermore, implants are devoid of microcirculation, which is crucial for the immune system and antibiotics to interact with microbes. Implants also tend to activate neutrophils which release peptides that deacti‐ vate granulocytes, impairing the removal of microbes[41]. This effect on granulocytes re‐ duces the minimal amount of microbes that are required to cause an infection[41]. Inoculation of implants, not only occurs during the time of surgery, but can occur in the presence of a bacteremia from any source in the human body during the entire lifetime

A multitude of organisms mostly bacteria and fungi are reported to cause PJI (Table.2). The most reported organisms responsible for PJI are Gram positive *cocci*, most commonly *Staphy‐ lococcus Aureus* and *Staphylococcus Epidermidis* as reported by various authors[12, 20, 22, 31, 43-45]. On certain occasions, Gram negative bacteria and Fungi can also be responsible for periprosthetic joint infections[46, 47]. In a recent study published by Buller et al., Methicillin Resistant *Staph. Aureus* (MRSA) and Methicillin Resistant *Staph. Epidermidis* (MRSE) account for about 15.5% of all PJIs[20] and according to other studies up to 19% of PJIs can be poly microbial[12, 22, 48]. These microorganisms can all be part of normal skin flora; hence, direct inoculation at the time of the operation as well as airborne contamination are the most likely


While, the patient's endogenous flora is largely held accountable for surgical site infections, the surgical team personnel and operating room environment may also contribute to dis‐ perse organisms[49] and increase the bacterial count[18, 50]. Members of the surgical team who have direct contact with sterile field have been linked to outbreaks of unusual organ‐ ism such as *Serratia Marcescens*[51]. Even though anesthesiologists, are not directly involved in the operative field, they perform a variety of procedures related to the operation and have been associated with outbreaks of bloodstream and surgical site infections linked to the re‐

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485

The classification of PJI is based on, either the type of pathogenesis or the time of clinical manifestation. When PJI are classified according to the pathogenesis, inoculation of the sur‐ gical site occurs either exogenously or haematogenously[11]. Exogenous infection, are infec‐ tions that occur during surgery or in the early post-operative period, usually in the presence of large hematomas. Haematogenous infections are acquired through the bloodstream at any time after surgery. As discussed in section 2.1, it has been reported that implants impair the immune defenses and decrease the minimal abscess-forming dose of *Staph. aureus* at least 10 000 fold both in an animal and human model[53, 54]. Patients with prosthetic joints have a reported risk of 30 - 40% for haematogenous device–associated infection during *Staph. aureus* sepsis[13, 42]. Even though patients, are mostly susceptible to PJI early after

More commonly, PJI is classified according to the time of clinical manifestation after total

**•** Stage I or Early post-operative infection, which present acutely within the first 4 to 8

**•** Stage II or Delayed onset PJI and occurs between the 3rd month up to 24 months after surgery

**•** Stage III or Late onset PJI usually occur after 2 years from the procedure, the presentation

**•** Stage IV or Silent infection when a positive culture is found at time of revision without

Early (Stage I), delayed (Stage II) and silent (Stage IV) infections are commonly exogenous, while stage I infections are probably caused by virulent microorganisms such as *Staph. aur‐ eus* and *Escherichia coli*, Stage II and Stage IV are typically caused by low virulent bacteria such as coagulase negative staphylococci and *Propionbacterium acnes[56, 57]*. Stage III or Late onset PJI occur acutely in a well-functioning joint and are caused by haematogenous spread. The most common primary focus of infection is from skin and soft tissue infections, but seeding from urinary, respiratory, gastrointestinal tract and dental infections are also report‐ ed[58]. In a recent report by Sendi et al., 57.5% of cases with haematogenous PJI had no source identified either because of primary bacteremia, or because the primary infection has

use of propofol vials and other deviations from acceptable protocols[52].

implantation, haematogenous infection can occur at any time after surgery.

is usually sudden in an otherwise well-functioning joint.

already healed by the time signs and symptoms of PJI present[13].

joint replacement. This classification is divided into 4 stages or groups[11, 55, 56]:

**2.3. Classification of PJI**

weeks after the operation

any previous evidence of infection.

MRSA: Methicillin Resistant *Staph. aureus*, MSSA: Methicillin Sensitive *Staph. aureus,* MRSE: Methicillin Resistant *Staph. epidermis.* MSSE: Methicillin Sensitive *Staph. epidermis.*

**Table 2.** Percentage of microbes in PJI [12, 20, 22, 31, 43-45, 48]

While, the patient's endogenous flora is largely held accountable for surgical site infections, the surgical team personnel and operating room environment may also contribute to dis‐ perse organisms[49] and increase the bacterial count[18, 50]. Members of the surgical team who have direct contact with sterile field have been linked to outbreaks of unusual organ‐ ism such as *Serratia Marcescens*[51]. Even though anesthesiologists, are not directly involved in the operative field, they perform a variety of procedures related to the operation and have been associated with outbreaks of bloodstream and surgical site infections linked to the re‐ use of propofol vials and other deviations from acceptable protocols[52].

#### **2.3. Classification of PJI**

**Organism Study (number of cases)**

Mahmud et al [250]

MSSA 19.6% 16% 21.1% 19% 25%

Romano et al [71] Pulido et al [63]

2.8% 5.6% 12.7% 9% 7%

β-Hemolytic Streptococcus 6.1% 7.2% γ-Hemolytic Streptococcus 4.1% 5.6% Enterococcus 2.9% 5.6% 1.6% 1.2% 9% 4.5%

Corynebacterium 0.3% 1.4% 1.6% 0.6% 3.2% Enterobacter 4.1% 1.6% 1% Propionibacterium 2.9% 0.8% 2.8% 1% 1.7%

Escherichia coli 3.2% 1.2% 3.2% 4% 0.9% 5.5%

Citrobacter koseri 0.3% 0.1% Klebsiella 1.2% 3.2% 3% 1.3% Proteus mirabilis 2.0% 1.6% 3.1% Pseudomonas 3.2% 0.8% 5.6% 1.6% 4% 1.9% 5.6% Salmonella 0.9% 1% 0.3% Serratia marcescens 0.3% 1.2% 1.4% 1.6% 0.3% Bacteroides fragilis 0.3% 0.4% 0.5%

Candida 0.3% 0.2% 0.3% **Diphteroids** 1% 9.4% 0.9%

MRSA: Methicillin Resistant *Staph. aureus*, MSSA: Methicillin Sensitive *Staph. aureus,* MRSE: Methicillin Resistant *Staph.*

**Polymicrobial** 0.02% 6.3% 19% **Culture negative** 8.8% 27.2% 9.5% 12%

Peptostreptococcus 2.4% 2.8% 12.3%

Berbari et al [462]

22%

21.2% 22.5% 11% 19% 36% 68.9% 27.8%

Phillips et al [75]

4%

Al-Maiyah et al [106] Salvati et al [2330]

0.7%

6.6% 27.3%

Buller et al [342]

MRSA 13.5% 3.2% 31% 19%

**Staphylococcus**

484 Arthroplasty - Update

MRSE 2%

MSSE 19.9% α-Hemolytic Streptococcus 3.8%

VRE 0.6% Streptococcus milleri 0.6%

Haemophilus 0.3%

**No Results** 22.4%

*epidermis.* MSSE: Methicillin Sensitive *Staph. epidermis.*

**Table 2.** Percentage of microbes in PJI [12, 20, 22, 31, 43-45, 48]

**Gram-positive rods**

**Gram negative**

**Yeasts**

The classification of PJI is based on, either the type of pathogenesis or the time of clinical manifestation. When PJI are classified according to the pathogenesis, inoculation of the sur‐ gical site occurs either exogenously or haematogenously[11]. Exogenous infection, are infec‐ tions that occur during surgery or in the early post-operative period, usually in the presence of large hematomas. Haematogenous infections are acquired through the bloodstream at any time after surgery. As discussed in section 2.1, it has been reported that implants impair the immune defenses and decrease the minimal abscess-forming dose of *Staph. aureus* at least 10 000 fold both in an animal and human model[53, 54]. Patients with prosthetic joints have a reported risk of 30 - 40% for haematogenous device–associated infection during *Staph. aureus* sepsis[13, 42]. Even though patients, are mostly susceptible to PJI early after implantation, haematogenous infection can occur at any time after surgery.

More commonly, PJI is classified according to the time of clinical manifestation after total joint replacement. This classification is divided into 4 stages or groups[11, 55, 56]:


Early (Stage I), delayed (Stage II) and silent (Stage IV) infections are commonly exogenous, while stage I infections are probably caused by virulent microorganisms such as *Staph. aur‐ eus* and *Escherichia coli*, Stage II and Stage IV are typically caused by low virulent bacteria such as coagulase negative staphylococci and *Propionbacterium acnes[56, 57]*. Stage III or Late onset PJI occur acutely in a well-functioning joint and are caused by haematogenous spread. The most common primary focus of infection is from skin and soft tissue infections, but seeding from urinary, respiratory, gastrointestinal tract and dental infections are also report‐ ed[58]. In a recent report by Sendi et al., 57.5% of cases with haematogenous PJI had no source identified either because of primary bacteremia, or because the primary infection has already healed by the time signs and symptoms of PJI present[13].

#### **2.4. Definition of PJI**

The Musculoskeletal Infection Society (MSIS) have recently analyzed the available evi‐ denced and proposed a set of criteria to define peri-prosthetic joint infection.

**Time Strategy**

Improve Diabetic control

Pre – operative anaemia

Smoke Cessation MRSA screening

Surgical Site Shaving

Prophylactic antibiotics

Skin Preparation

Bleeding Control

Skin Closure

Wound Dressing

Double Gloving

Laminar Airflow

CHG: Chlorhexadine Gluconate, OR: Operating Room, PPS: Personal Protection System, MRSA: Methicillin Resistant Staph. aureus Adopted from Matar et al. Preventing infection in total joint arthroplasty. J Bone Joint Surg Am. 2010;92

Impermeable Gowns/PPS

Operating Room Traffic

Antibiotics for 24 hours Wound management

Antibiotic impregnated cement

Decolonization: Surgical scrubbing/rubbing

Blood Transfusion only where indicated Management of medical complications

Late Antibiotic prophylaxis before invasive procedures

Draping

Treat possible site of infections

Improve possible Medical Comorbidities Obesity + Improve Nutritional Status

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Skin decolonisation (CHG wipes/showers)

Host optimization

Surgical Site Optimization

Surgical factors

Surgical team

OR environment

Immediate

**Table 3.** Preoperative, Intraoperative and Post-operative Strategies in preventing PJI

Early

Day of Surgery

**Preoperative**

**Intraoperative**

**Post-operative**

Suppl 2:36-46. Epub 2010/12/09.

Based on these criteria[59], a definite PJI exists when:

	- **a.** elevated serum erythrocyte sedimentation rate and serum C-reactive protein (CRP) concentration,
	- **b.** elevated synovial white blood cell count,
	- **c.** elevated synovial polymorphonuclear percentage(PMN%),
	- **d.** presence of purulence in the affected joint
	- **e.** isolation of a microorganism in one culture of periprosthetic tissue or fluid, or
	- **f.** greater than 5 neutrophils per high-power field in 5 high-power fields ob‐ served from histologic analysis of periprosthetic tissue at ×400magnification.

PJI may be present if less than 4 of these criteria re not met and that in certain infections with low virulent organisms such as *Propionibacetium acnes,* several of these criteria may not be routinely met despite the presence of PJI.

### **3. Prevention of PJI**

Both the host and environmental factors described previously (Table. 1) can affect the risk for developing PJI. An effective strategy in preventing PJI is to improve both host and envi‐ ronmental factors during the pre, intra and post-operative period (Table. 3).

There are a number of host factors that increase the risk of PJI including conditions such as diabetes, inflammatory arthropathy, preoperative anaemia, poor nutrition and obesity to mention a few(Table. 1). Patients who present for elective orthopaedics procedures are in suboptimal health. Furthermore, the impact of various risk factors appears to be accumula‐ tive, such that each factor has an individual affect to increase the risk of infection and has a synergistic potential on the risk conferred by other factors[60, 61]. Thus, identifying such risk factors and addressing them in the preoperative setting is critical in reducing PJI and other postoperative complication.


**2.4. Definition of PJI**

486 Arthroplasty - Update

The Musculoskeletal Infection Society (MSIS) have recently analyzed the available evi‐

**ii.** a pathogen is isolated by culture from 2 or more separate tissue or fluid samples

**a.** elevated serum erythrocyte sedimentation rate and serum C-reactive protein

**e.** isolation of a microorganism in one culture of periprosthetic tissue or fluid, or

**f.** greater than 5 neutrophils per high-power field in 5 high-power fields ob‐ served from histologic analysis of periprosthetic tissue at ×400magnification.

PJI may be present if less than 4 of these criteria re not met and that in certain infections with low virulent organisms such as *Propionibacetium acnes,* several of these criteria may not

Both the host and environmental factors described previously (Table. 1) can affect the risk for developing PJI. An effective strategy in preventing PJI is to improve both host and envi‐

There are a number of host factors that increase the risk of PJI including conditions such as diabetes, inflammatory arthropathy, preoperative anaemia, poor nutrition and obesity to mention a few(Table. 1). Patients who present for elective orthopaedics procedures are in suboptimal health. Furthermore, the impact of various risk factors appears to be accumula‐ tive, such that each factor has an individual affect to increase the risk of infection and has a synergistic potential on the risk conferred by other factors[60, 61]. Thus, identifying such risk factors and addressing them in the preoperative setting is critical in reducing PJI and

ronmental factors during the pre, intra and post-operative period (Table. 3).

denced and proposed a set of criteria to define peri-prosthetic joint infection.

**i.** there is a sinus tract communicating with the prosthesis; or

obtained from the affected prosthetic joint; or

**b.** elevated synovial white blood cell count,

**d.** presence of purulence in the affected joint

**c.** elevated synovial polymorphonuclear percentage(PMN%),

Based on these criteria[59], a definite PJI exists when:

**iii.** when 4 of the following 6 criteria exist;

(CRP) concentration,

be routinely met despite the presence of PJI.

**3. Prevention of PJI**

other postoperative complication.

CHG: Chlorhexadine Gluconate, OR: Operating Room, PPS: Personal Protection System, MRSA: Methicillin Resistant Staph. aureus Adopted from Matar et al. Preventing infection in total joint arthroplasty. J Bone Joint Surg Am. 2010;92 Suppl 2:36-46. Epub 2010/12/09.

**Table 3.** Preoperative, Intraoperative and Post-operative Strategies in preventing PJI

#### **3.1. Pre-operative period**

#### *3.1.1. Health optimization*

Pre-operative optimization of health is of crucial importance to ensure a satisfactory out‐ come following total joint arthroplasty. ASA scores >2, diabetes and rheumatoid arthritis among several factors have been associated with increased rates of perioperative complica‐ tions and PJI after total joint arthroplasty[9, 12, 20, 21, 24]. Lei et al. and Malinzak et al. have both reported that diabetes and the total number of comorbidities were associated with a higher risk of infection and that medical conditions have a synergistic effect on the risk of developing a PJI[60, 62].

*3.1.3. Prophylactic antibiotics*

the prevention and treatment of infections.

antibiotic prophylaxis are as follows:

The benefits of prophylactic antibiotics have been widely reported in orthopaedic literature [28-30, 72]. In 1970, Foldberg et al. compared a group treated prophylactically with penicillin given preoperatively, intraoperatively and up to 5 days post operatively, with a control group not treated with antibiotics; both groups underwent a mixture of mold arthroplasties and spinal fusions[28]. The prevalence of infections was 1.7% in the treated group while 8.9% in the control group[28]. Furthermore during the period of the study these authors have noticed an increase in the prevalence of MRSA in all major orthopaedic wound infec‐ tions, which demonstrates a delicate balance between the use and overuse of antibiotics in

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The most common organisms responsible for PJI have been already discussed in section 2.2, and prophylactic antibiotics are targeted to cover this spectrum of organisms. Cefazolin and cefuroxamine are the antibiotics of choice because of their good tissue penetration and excel‐ lent activity against Staphylococci and Streptococci. The American Association of Orthopae‐ dic Surgeons (AAOS) published guidelines regarding prophylactic choice, dosing and optimal postoperative duration[61]. The AAOS recommendations for the use of intravenous

**• Recommendation 1:** The antibiotic used for prophylaxis should be selected carefully, con‐ sistent with current recommendations in the literature, taking into account the issue of re‐ sistance and *patient allergies*. Currently, cefazolin and cefuroxamine are the preferred antibiotics for patients undergoing orthopaedic procedures. Clindamycin and vancomy‐ cin may be used in patients with known β-lactam allergy. Vancomycin may be used in patients with known colonization with MRSA or in facilities with recent MRSA outbreaks. In multiple studies, exposure to vancomycin is reported as a risk in the development of vancomycin resistant enterococcus (VRE) colonization and infection. Vancomycin should be reserved fir the treatment of serious infection with β-lactam resistant organisms or for treatment of infection in patients with life threatening allergy to β-lactam antimicrobials. **• Recommendation 2:** Timing and dosage of antibiotics administration should optimize the *efficiency of the therapy*. Prophylactic antibiotics should be administered within 1 hour be‐ fore skin incision. Owing to an extended infusion time, vancomycin should be started within 2 hours before incision. If a proximal tourniquet is used, the antibiotic must be completely infused before the inflation of the tourniquet. Dose amount should be propor‐ tional to the patients' weight; for patients who weigh more than 80Kg, Cefazolin dose should be doubled. Additional intraoperative doses of antibiotics are advised is [1] the duration of the procedure exceeds one to two tines the antibiotic's half-life or [2] there is significant blood loss during the procedure. The general guidelines for frequency of intra‐ operative antibiotic administration are as follows: cefazolin every 2-5 hours, cefuroxamine

every 2-4 hours, clindamycin every 2-6 hours and vancomycin every 6-12 hours.

when they are continued past the 24 hours.

**• Recommendation 3:** Duration of prophylactic antibiotic administration should not exceed *the 24 hour postoperative period*. Prophylactic antibiotics should be discontinued within 24 hours of the end of surgery. The medical literature does not support the continuation of antibiotics until all drains or catheters are removed and provides no evidence of benefit

Prior to total joint arthroplasty, all patients should be assessed and managed in a multidisci‐ plinary pre-assessment clinic to optimize their general health. These have been shown to significantly reduce both the post-operative mortality and costs per admission in orthopae‐ dic surgery[63]. Pre Assessment Clinics (PAC), focus on optimizing the host health in the preoperative period such as improving nutritional status, optimizing diabetic control, car‐ diac and respiratory comorbidities and screening for possible source of infection and MRSA decolonization. In our institution, all patients are assessed in the pre assessment clinic by a consultant anesthesiologist, specialist nurse, nutritionist and physiotherapist, and if necessa‐ ry further consultation with other medical specialists such as cardiologist, rheumatologist or neurologists is available to optimize the patients' health preoperatively. The anesthetic con‐ sultant also follows the patient during hospitalization and during the post-operative period whenever possible.

#### *3.1.2. Bacterial decolonization*

The Centre for Disease Control (CDC) guidelines for prevention of surgical site infection (SSIs) has strongly recommended that patients require to shower or bathe with an anti‐ septic agent on at least the night before the operative day in order to reduce bacterial load[64]. While whole body bathing with antiseptic has been shown to reduce bacterial load of the skin as well as reducing the risk of infections[35, 65-67], it presents challeng‐ es in achieving entire body coverage and in maintaining sufficiently high concentrations of solution on the skin for effective antisepsis[68]. Further more patient compliance with these protocols is an issue[69]. Recent studies have addressed the effectiveness of preop‐ erative protocols with chlorhexidine gluconate (CHG) applied twice daily by patients at home before their joint replacement[33, 70] and one study reported reduction in SSI in‐ fection from 3.19% to 1.59% after the introduction of 2% CHG in place of povidone io‐ dine antiseptic[71]. Based on the results of these studies, home skin preparation seems to be a simple and cost effective technique in reducing PJI but patient compliance is an is‐ sue and further randomized control trials are required to fully understand the effect on preventing PJI.

#### *3.1.3. Prophylactic antibiotics*

**3.1. Pre-operative period**

488 Arthroplasty - Update

*3.1.1. Health optimization*

developing a PJI[60, 62].

whenever possible.

preventing PJI.

*3.1.2. Bacterial decolonization*

Pre-operative optimization of health is of crucial importance to ensure a satisfactory out‐ come following total joint arthroplasty. ASA scores >2, diabetes and rheumatoid arthritis among several factors have been associated with increased rates of perioperative complica‐ tions and PJI after total joint arthroplasty[9, 12, 20, 21, 24]. Lei et al. and Malinzak et al. have both reported that diabetes and the total number of comorbidities were associated with a higher risk of infection and that medical conditions have a synergistic effect on the risk of

Prior to total joint arthroplasty, all patients should be assessed and managed in a multidisci‐ plinary pre-assessment clinic to optimize their general health. These have been shown to significantly reduce both the post-operative mortality and costs per admission in orthopae‐ dic surgery[63]. Pre Assessment Clinics (PAC), focus on optimizing the host health in the preoperative period such as improving nutritional status, optimizing diabetic control, car‐ diac and respiratory comorbidities and screening for possible source of infection and MRSA decolonization. In our institution, all patients are assessed in the pre assessment clinic by a consultant anesthesiologist, specialist nurse, nutritionist and physiotherapist, and if necessa‐ ry further consultation with other medical specialists such as cardiologist, rheumatologist or neurologists is available to optimize the patients' health preoperatively. The anesthetic con‐ sultant also follows the patient during hospitalization and during the post-operative period

The Centre for Disease Control (CDC) guidelines for prevention of surgical site infection (SSIs) has strongly recommended that patients require to shower or bathe with an anti‐ septic agent on at least the night before the operative day in order to reduce bacterial load[64]. While whole body bathing with antiseptic has been shown to reduce bacterial load of the skin as well as reducing the risk of infections[35, 65-67], it presents challeng‐ es in achieving entire body coverage and in maintaining sufficiently high concentrations of solution on the skin for effective antisepsis[68]. Further more patient compliance with these protocols is an issue[69]. Recent studies have addressed the effectiveness of preop‐ erative protocols with chlorhexidine gluconate (CHG) applied twice daily by patients at home before their joint replacement[33, 70] and one study reported reduction in SSI in‐ fection from 3.19% to 1.59% after the introduction of 2% CHG in place of povidone io‐ dine antiseptic[71]. Based on the results of these studies, home skin preparation seems to be a simple and cost effective technique in reducing PJI but patient compliance is an is‐ sue and further randomized control trials are required to fully understand the effect on The benefits of prophylactic antibiotics have been widely reported in orthopaedic literature [28-30, 72]. In 1970, Foldberg et al. compared a group treated prophylactically with penicillin given preoperatively, intraoperatively and up to 5 days post operatively, with a control group not treated with antibiotics; both groups underwent a mixture of mold arthroplasties and spinal fusions[28]. The prevalence of infections was 1.7% in the treated group while 8.9% in the control group[28]. Furthermore during the period of the study these authors have noticed an increase in the prevalence of MRSA in all major orthopaedic wound infec‐ tions, which demonstrates a delicate balance between the use and overuse of antibiotics in the prevention and treatment of infections.

The most common organisms responsible for PJI have been already discussed in section 2.2, and prophylactic antibiotics are targeted to cover this spectrum of organisms. Cefazolin and cefuroxamine are the antibiotics of choice because of their good tissue penetration and excel‐ lent activity against Staphylococci and Streptococci. The American Association of Orthopae‐ dic Surgeons (AAOS) published guidelines regarding prophylactic choice, dosing and optimal postoperative duration[61]. The AAOS recommendations for the use of intravenous antibiotic prophylaxis are as follows:


#### **3.2. Intra-operative period**

#### *3.2.1. Pre-operative hair removal*

Pre-operative hair removal is of common practice, and a meta-analysis by the Cochrane group showed that the relative risk of surgical site infection following hair removal with a razor was significantly higher than that following hair removal with clippers, but there was no difference reported in the rate of post-operative infections between procedures preceded by hair removal and those performed without hair removal[73]. It is recommended that whenever hair is re‐ moved clippers rather than a razor should be used at the time of surgery[73].

ditional cloth drapes got wet[80]. Iobhan iodophor-impregnated drapes (3M Health Care) have been shown a reduction in wound contamination without any decrease in wound in‐ fection rate after total joint arthroplasty[84]. In their review of 4 000 patients in seven differ‐ ent trials, the Cochrane Wounds Group, found no evidence that adhesive drapes (plain or

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491

Sterile surgical gloves aim to protect the patient from contamination from residual bacteria from members of the surgical team after hand scrubbing and protect the surgical team from the patient's body fluids[86]. Double gloving has been recommended because it has been shown that it reduces perforations in the innermost glove especially in orthopaedic proce‐ dures where sharp surfaces are easily formed[86-88]. Beldame et al. have reported that, 80% of glove perforations occur during surgical incision and changing the outer glove after sur‐ gical incision and before implantation of the prosthesis can reduce the risk of contamination

Operating theatres are designed to reduce bacterial exposure to patients during surgery. Vertical laminar airflow (LAF) provides directional airflow through a higher efficiency par‐ ticulate air (HEPA) filters and positive air pressure within the surgical field. Multiple stud‐ ies have reported reduced PJI rates with LAF[17, 90-92]. Brandt et al. reported no benefit from using LAF, and it was even associated with increased risk of surgical site infection af‐ ter total hip arthroplasty. A recent systematic review on SSI following hip and knee arthro‐ plasty included 8 studies over the past 10 years and showed no improvement on PJI rates and recommends against the installation of LAF systems in new operating theatres[93].

The opening of the operating room door disrupts the laminar airflow, allowing pathogens to enter the space surrounding the site of the operation with increased risk of PJI[17, 94, 95]. Panahi et al. have reported a mean rate of 0.69 door opening per minute for primary and 0.84 openings per minute for revision total joint arthroplasty. Only 8% of the traffic was de‐ termined to be due to scrubbing in and out, demonstrating a high rate of unjustifiable traffic, the authors further advise to implement strategies in reducing operating room traffic in an

The human exhaust system or personal protection system (PPS) was initially introduced by Sir J Charnley in the 1960s and designed to decrease airborne bacteria and intraoperative contamination in total joint arthroplasty[96]. No uniform opinion exists with regard to the use of PPS and the incidence of PJI[97-101]. One of the main issues with PPS is that, they are bulky and tend to get contaminated. In a recent study, Kearns et al. have reported that 53 out of 102 PPS tested were contaminated with staphylococcus and one with MRSA, which means that the PPS does not remain externally sterile in half of the cases[19]. These authors recommend refraining from touching the PPS during surgery and the need to change gloves

impregnated with antimicrobials) reduce surgical site infection rates[85].

and perforation and resulted in a sterile state in 80% of cases[89].

attempt to decrease one etiology of PJI[18].

if hand contact with the PPS occurs[19].

*3.2.5. Laminar flow, operating room traffic and personal protection system*

*3.2.4. Double gloving*

#### *3.2.2. Pre-operative skin preparation*

#### *3.2.2.1. Patients*

Three main types of skin antiseptic agents are used; mainly chlorohexidine gluconate (CHG), alcohol based solutions and povidone-iodine. Chlorohexidine is favored due to its long lasting and cumulative activity against gram-positive and gram negative organisms found on human flora. Povidone iodine it is also effective in reducing skin flora but in becomes ineffective on contact with blood and duration of activity is shorter the CHG. Alcohol is an excellent antimi‐ crobial but its effectiveness is limited by the lack of any residual activity after drying and the risk of flammability. A Cochrane meta-analysis carried out in 2004 showed no difference in ef‐ ficiency among skin antiseptics used in clean surgery[74]. Recent studies strongly suggest that CHG combined with alcohol is superior to povidone-iodine combined with alcohol in antisep‐ sis for patients[75-77]. Ostrander et al. reported reduced bacterial count on feet prepared with Chloraprep (2% CHG and 70% isopropyl alcohol; Medi-Flex, Overland Park, Kansas) than on those prepared with Duraprep (0.7% iodin and 74% isopropyl alcohol; 3M Healthcare, St. Paul, Minnesota) or Techni-Care[3.0% chloroxylenol; Care-Tech Laboratories, St. Louis, Missouri) but there was no difference in infection rates among the 3 groups[77].

#### *3.2.2.2. Surgeon*

Antiseptic agents for surgeons can be classified into hand scrubs agents and hand rub agents. Hand scrubs are typically solutions of CHG or povidone-iodine while hand rubs are typically alcohol based solutions. Most data indicates that povidone–iodine and CHG have equal efficacy in decreasing bacterial colony forming units from the skin of surgeons; fur‐ thermore no difference was found between hand rubs and hand scrub solutions[78, 79]. Some studies report better cost effectiveness of alcoholic hand rub by saving on water con‐ sumption and better physician compliance [78].

#### *3.2.3. Draping*

There is strong evidence in the literature for the use of plastic surgical adhesive tapes and nonpermeable paper drapes for surgical site draping [16, 80-83]. Nonpermeable drapes are used to prevent bacterial penetration during surgery, which was found to increase when tra‐ ditional cloth drapes got wet[80]. Iobhan iodophor-impregnated drapes (3M Health Care) have been shown a reduction in wound contamination without any decrease in wound in‐ fection rate after total joint arthroplasty[84]. In their review of 4 000 patients in seven differ‐ ent trials, the Cochrane Wounds Group, found no evidence that adhesive drapes (plain or impregnated with antimicrobials) reduce surgical site infection rates[85].

#### *3.2.4. Double gloving*

**3.2. Intra-operative period**

490 Arthroplasty - Update

*3.2.1. Pre-operative hair removal*

*3.2.2. Pre-operative skin preparation*

*3.2.2.1. Patients*

*3.2.2.2. Surgeon*

*3.2.3. Draping*

Pre-operative hair removal is of common practice, and a meta-analysis by the Cochrane group showed that the relative risk of surgical site infection following hair removal with a razor was significantly higher than that following hair removal with clippers, but there was no difference reported in the rate of post-operative infections between procedures preceded by hair removal and those performed without hair removal[73]. It is recommended that whenever hair is re‐

Three main types of skin antiseptic agents are used; mainly chlorohexidine gluconate (CHG), alcohol based solutions and povidone-iodine. Chlorohexidine is favored due to its long lasting and cumulative activity against gram-positive and gram negative organisms found on human flora. Povidone iodine it is also effective in reducing skin flora but in becomes ineffective on contact with blood and duration of activity is shorter the CHG. Alcohol is an excellent antimi‐ crobial but its effectiveness is limited by the lack of any residual activity after drying and the risk of flammability. A Cochrane meta-analysis carried out in 2004 showed no difference in ef‐ ficiency among skin antiseptics used in clean surgery[74]. Recent studies strongly suggest that CHG combined with alcohol is superior to povidone-iodine combined with alcohol in antisep‐ sis for patients[75-77]. Ostrander et al. reported reduced bacterial count on feet prepared with Chloraprep (2% CHG and 70% isopropyl alcohol; Medi-Flex, Overland Park, Kansas) than on those prepared with Duraprep (0.7% iodin and 74% isopropyl alcohol; 3M Healthcare, St. Paul, Minnesota) or Techni-Care[3.0% chloroxylenol; Care-Tech Laboratories, St. Louis, Missouri)

Antiseptic agents for surgeons can be classified into hand scrubs agents and hand rub agents. Hand scrubs are typically solutions of CHG or povidone-iodine while hand rubs are typically alcohol based solutions. Most data indicates that povidone–iodine and CHG have equal efficacy in decreasing bacterial colony forming units from the skin of surgeons; fur‐ thermore no difference was found between hand rubs and hand scrub solutions[78, 79]. Some studies report better cost effectiveness of alcoholic hand rub by saving on water con‐

There is strong evidence in the literature for the use of plastic surgical adhesive tapes and nonpermeable paper drapes for surgical site draping [16, 80-83]. Nonpermeable drapes are used to prevent bacterial penetration during surgery, which was found to increase when tra‐

moved clippers rather than a razor should be used at the time of surgery[73].

but there was no difference in infection rates among the 3 groups[77].

sumption and better physician compliance [78].

Sterile surgical gloves aim to protect the patient from contamination from residual bacteria from members of the surgical team after hand scrubbing and protect the surgical team from the patient's body fluids[86]. Double gloving has been recommended because it has been shown that it reduces perforations in the innermost glove especially in orthopaedic proce‐ dures where sharp surfaces are easily formed[86-88]. Beldame et al. have reported that, 80% of glove perforations occur during surgical incision and changing the outer glove after sur‐ gical incision and before implantation of the prosthesis can reduce the risk of contamination and perforation and resulted in a sterile state in 80% of cases[89].

#### *3.2.5. Laminar flow, operating room traffic and personal protection system*

Operating theatres are designed to reduce bacterial exposure to patients during surgery. Vertical laminar airflow (LAF) provides directional airflow through a higher efficiency par‐ ticulate air (HEPA) filters and positive air pressure within the surgical field. Multiple stud‐ ies have reported reduced PJI rates with LAF[17, 90-92]. Brandt et al. reported no benefit from using LAF, and it was even associated with increased risk of surgical site infection af‐ ter total hip arthroplasty. A recent systematic review on SSI following hip and knee arthro‐ plasty included 8 studies over the past 10 years and showed no improvement on PJI rates and recommends against the installation of LAF systems in new operating theatres[93].

The opening of the operating room door disrupts the laminar airflow, allowing pathogens to enter the space surrounding the site of the operation with increased risk of PJI[17, 94, 95]. Panahi et al. have reported a mean rate of 0.69 door opening per minute for primary and 0.84 openings per minute for revision total joint arthroplasty. Only 8% of the traffic was de‐ termined to be due to scrubbing in and out, demonstrating a high rate of unjustifiable traffic, the authors further advise to implement strategies in reducing operating room traffic in an attempt to decrease one etiology of PJI[18].

The human exhaust system or personal protection system (PPS) was initially introduced by Sir J Charnley in the 1960s and designed to decrease airborne bacteria and intraoperative contamination in total joint arthroplasty[96]. No uniform opinion exists with regard to the use of PPS and the incidence of PJI[97-101]. One of the main issues with PPS is that, they are bulky and tend to get contaminated. In a recent study, Kearns et al. have reported that 53 out of 102 PPS tested were contaminated with staphylococcus and one with MRSA, which means that the PPS does not remain externally sterile in half of the cases[19]. These authors recommend refraining from touching the PPS during surgery and the need to change gloves if hand contact with the PPS occurs[19].

#### *3.2.6. Operative time*

Long operative times have been found to increase the risk for PJI after total joint arthroplas‐ ty[27, 102, 103]. From a cohort of 9245 patients undergoing total joint arthroplasty, Pulido et al reported longer operative time as a predisposing factor for PJI, a finding which is also supported Kurtz et al. and Peersman et al[104, 105]. Furthermore, surgeons volume seems to be inversely proportional to the rate of infection, were the higher the surgeon volume the lower the rate of infection, but this was only found to be statistically significant after total knee arthroplasty[26].

dressing assist with healing by acting as a physical barrier to bacteria, splinting the wound to protect it from subsequent injury, helping with haemostasis, reducing dead space and minimizing pain. The use of occlusive dressings is well known to improve re-epithelisation and subsequent collagen synthesis when compared to wound exposed to air[120, 121]. In a recent Cochrane review, Dumville et al. reported no evidence to suggest that one dressing is better than any other in preventing surgical site infection and advised that the choice of dressing should be based on costs and the need for management of specific symptoms[122]. After total joint arthroplasty, a hydrofiber/hydrocolloid dressing using the jubilee method has been shown to reduce the rate of blister formation but no significant reduction in surgi‐ cal site infection[118]. Burke et al. have carried out a prospective randomized study compar‐ ing the jubilee dressing method with standard adhesive dressing after total joint arthroplasty and reported a significant reduction in blister formation, leakage and dressing changes in the group treated with the jubilee method but no significant reduction in SSI. The authors of this study recommend the use of the hydrofiber/hydrocolloid dressing combina‐

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tion after total joint arthroplasty due to the associated lower complication rate[123].

Most medical complications in the post-operative period have been to increased rates of PJI, mainly elevated blood creatinine levels, allogenic blood transfusion, myocardial infarction, atrial fibrillation and urinary tract infections[9, 10, 12, 21, 22, 25]. Adequate hydration is crit‐ ical in post-operative period and allogenic blood transfusion is indicated in the presence of symptomatic anaemia, a haemoglobin level <8g/dL, or when it is medically indicated[124]. Control and monitoring of blood sugar levels is important in diabetic patients and should follow the same principles used in the preoperative period. Persistent wound drainage has been has been found as a contributing factor in the development of PJI[12, 21, 22], however there is little or no supportive evidence for the continues use of antibiotics[61] or antimicro‐ bial impregnated dressings[122]. Furthermore, post-operative complication can result in de‐ layed rehabilitation after a total joint arthroplasty with resultant delay in discharge from hospital, which has been reported by various studies as a risk factor for the development of

Currently there is no diagnostic modality, which is 100% reliable in diagnosis PJI. An assess‐

A careful history and physical examination are crucial in making a diagnosis of PJI. Al‐ though the diagnosis of early postoperative or acute haematogenous infection is not diffi‐ cult, late infections can be challenging to distinguish from other causes of pain in a patient with previous total joint arthroplasty. Clinically, early or acute infections are characterized

ment using a combination of clinical findings and investigations is necessary.

**3.3. Post-operative period**

PJI[12, 22].

**4.1. Clinical**

**4. Diagnosing PJI**

#### *3.2.7. Addition of antibiotics to cement*

In recent years antibiotic impregnated cement has become a standard for use in cemented primary arthroplasty. According to recent studies, the rate of PJI was lower when a combi‐ nation of intravenous antibiotic prophylaxis and antibiotic impregnated cement was used for primary cemented arthroplasty[21, 106]. Antibiotic impregnated cement seems to be of particular use in the revision setting[107-109]. Nevertheless there is strong evidence to sup‐ port the efficiency of combined regime of prophylactic antibiotic and cement impregnated antibiotic when compared to prophylactic antibiotic only in patients with other risk factors for PJI[32, 110, 111].

#### *3.2.8. Wound closure and surgical dressing*

Various methods of skin closure are used in arthroplasty surgery, ranging from skin staples, subcuticular closure with absorbable suture and recently the use of knotless barbed sutures. A recent meta-analysis by Smith et al. reported that closure with skin staples had a signifi‐ cant risk of wound infection when compared to traditional suturing, but out of the six stud‐ ies reviewed only one study had acceptable methodology[112]. Newman et al has reviewed 181 patients after total knee arthroplasty and reported significant fewer complications after closure with skin staples when compared with absorbable subcuticular sutures[113]. A pro‐ spective randomized control trial comparing staples to subcuticular absorbable suture and tissue adhesives after TKA, showed highest superficial infection rate for subcuticular suture (26%) and the lowest for skin staples (5%), although none of them required any treatment with antibiotics[114]. Furthermore, staple based wound closure was fastest and the least ex‐ pensive after TKA but had the longest hospital stay when compared to the other meth‐ ods[114]. Recently there has been increased interest in knotless barbed sutures for wound closure after total joint arthroplasty[115-117]. Most studies reported faster closure times for the barbed sutures when compared to traditional methods[116, 117]. Patell et al. have re‐ ported a significant increase risk of major wound complications especially after TKA, when barbed sutures (4.3%) were used compared to staples 1.1% and standard absorbable subcu‐ ticular closure (4.2%)[115]. However, debate still exists on which is the optimal method of closure.

Surgical technique with careful tissue handling and wound closure is important in wound healing, as well as the type of dressing that is applied postoperatively[118, 119]. Wound dressing assist with healing by acting as a physical barrier to bacteria, splinting the wound to protect it from subsequent injury, helping with haemostasis, reducing dead space and minimizing pain. The use of occlusive dressings is well known to improve re-epithelisation and subsequent collagen synthesis when compared to wound exposed to air[120, 121]. In a recent Cochrane review, Dumville et al. reported no evidence to suggest that one dressing is better than any other in preventing surgical site infection and advised that the choice of dressing should be based on costs and the need for management of specific symptoms[122]. After total joint arthroplasty, a hydrofiber/hydrocolloid dressing using the jubilee method has been shown to reduce the rate of blister formation but no significant reduction in surgi‐ cal site infection[118]. Burke et al. have carried out a prospective randomized study compar‐ ing the jubilee dressing method with standard adhesive dressing after total joint arthroplasty and reported a significant reduction in blister formation, leakage and dressing changes in the group treated with the jubilee method but no significant reduction in SSI. The authors of this study recommend the use of the hydrofiber/hydrocolloid dressing combina‐ tion after total joint arthroplasty due to the associated lower complication rate[123].

#### **3.3. Post-operative period**

*3.2.6. Operative time*

492 Arthroplasty - Update

knee arthroplasty[26].

for PJI[32, 110, 111].

closure.

*3.2.7. Addition of antibiotics to cement*

*3.2.8. Wound closure and surgical dressing*

Long operative times have been found to increase the risk for PJI after total joint arthroplas‐ ty[27, 102, 103]. From a cohort of 9245 patients undergoing total joint arthroplasty, Pulido et al reported longer operative time as a predisposing factor for PJI, a finding which is also supported Kurtz et al. and Peersman et al[104, 105]. Furthermore, surgeons volume seems to be inversely proportional to the rate of infection, were the higher the surgeon volume the lower the rate of infection, but this was only found to be statistically significant after total

In recent years antibiotic impregnated cement has become a standard for use in cemented primary arthroplasty. According to recent studies, the rate of PJI was lower when a combi‐ nation of intravenous antibiotic prophylaxis and antibiotic impregnated cement was used for primary cemented arthroplasty[21, 106]. Antibiotic impregnated cement seems to be of particular use in the revision setting[107-109]. Nevertheless there is strong evidence to sup‐ port the efficiency of combined regime of prophylactic antibiotic and cement impregnated antibiotic when compared to prophylactic antibiotic only in patients with other risk factors

Various methods of skin closure are used in arthroplasty surgery, ranging from skin staples, subcuticular closure with absorbable suture and recently the use of knotless barbed sutures. A recent meta-analysis by Smith et al. reported that closure with skin staples had a signifi‐ cant risk of wound infection when compared to traditional suturing, but out of the six stud‐ ies reviewed only one study had acceptable methodology[112]. Newman et al has reviewed 181 patients after total knee arthroplasty and reported significant fewer complications after closure with skin staples when compared with absorbable subcuticular sutures[113]. A pro‐ spective randomized control trial comparing staples to subcuticular absorbable suture and tissue adhesives after TKA, showed highest superficial infection rate for subcuticular suture (26%) and the lowest for skin staples (5%), although none of them required any treatment with antibiotics[114]. Furthermore, staple based wound closure was fastest and the least ex‐ pensive after TKA but had the longest hospital stay when compared to the other meth‐ ods[114]. Recently there has been increased interest in knotless barbed sutures for wound closure after total joint arthroplasty[115-117]. Most studies reported faster closure times for the barbed sutures when compared to traditional methods[116, 117]. Patell et al. have re‐ ported a significant increase risk of major wound complications especially after TKA, when barbed sutures (4.3%) were used compared to staples 1.1% and standard absorbable subcu‐ ticular closure (4.2%)[115]. However, debate still exists on which is the optimal method of

Surgical technique with careful tissue handling and wound closure is important in wound healing, as well as the type of dressing that is applied postoperatively[118, 119]. Wound Most medical complications in the post-operative period have been to increased rates of PJI, mainly elevated blood creatinine levels, allogenic blood transfusion, myocardial infarction, atrial fibrillation and urinary tract infections[9, 10, 12, 21, 22, 25]. Adequate hydration is crit‐ ical in post-operative period and allogenic blood transfusion is indicated in the presence of symptomatic anaemia, a haemoglobin level <8g/dL, or when it is medically indicated[124]. Control and monitoring of blood sugar levels is important in diabetic patients and should follow the same principles used in the preoperative period. Persistent wound drainage has been has been found as a contributing factor in the development of PJI[12, 21, 22], however there is little or no supportive evidence for the continues use of antibiotics[61] or antimicro‐ bial impregnated dressings[122]. Furthermore, post-operative complication can result in de‐ layed rehabilitation after a total joint arthroplasty with resultant delay in discharge from hospital, which has been reported by various studies as a risk factor for the development of PJI[12, 22].

### **4. Diagnosing PJI**

Currently there is no diagnostic modality, which is 100% reliable in diagnosis PJI. An assess‐ ment using a combination of clinical findings and investigations is necessary.

#### **4.1. Clinical**

A careful history and physical examination are crucial in making a diagnosis of PJI. Al‐ though the diagnosis of early postoperative or acute haematogenous infection is not diffi‐ cult, late infections can be challenging to distinguish from other causes of pain in a patient with previous total joint arthroplasty. Clinically, early or acute infections are characterized by pain, fever, wound drainage or erythema. While the only feature of chronic infection, can be pain unrelieved by a seemingly well-functioning arthroplasty. Loosening during the first year post implantation or a consistently painful arthroplasty should be considered infected until proven otherwise.

Love et al. reported increased sensitivity (96%), specificity (87%) and accuracy (91%) when a leukocyte/marrow scintigraphy was used to identify PJI. The test was significantly more ac‐ curate than bone (50%), bone/gallium (66%) and leuckocyte/bone (70%) scintigraphy in diag‐ nosing PJI[133]. It seems that a Leukocyte/marrow scintigraphy will remain the procedure of choice in diagnosing PJI until agents capable of differentiating infection from aseptic inflam‐

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**Figure 1.** Plain AnteroPosterior and Lateral Radiographs showing focal areas of osteolysis, suspicious of PJI.

Various techniques can be used intraoperatively during revision arthroplasty to diagnose in‐ fection. These techniques include synovial fluid biomarkers, cultures and frozen sections.

Cultures of periprosthetic tissues provide the most reliable means of detecting that pathogen and are often used as a reference standard in diagnosing PJI. Multiple samples should be taken at the time of the procedure from various regions, at least 3 samples for culture are recommended[134-136]. Cultures may be negative because prior antibiotic exposure, low number of organisms, an inappropriate culture medium, fastidious organisms or prolonged

mation are developed[133].

*4.2.4. Intraoperative techniques*

*4.2.4.1. Cultures and Gram stain*

#### **4.2. Diagnostic investigations**

#### *4.2.1. Serology*

Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) are baseline screening tests for any patient planned for revision arthroplasty regardless of the cause of failure[5]. Diagnostic value of ESR and CRP has been widely reported, and their combined use is a very good 'rule out' test [125, 126]. When both ESR and CRP are negative, periprosthetic in‐ fection is unlikely, however when both tests are positive PJI must be considered, and this warrants further investigations [5]. Ghanem et al. have reported that values higher than an ESR of 30 mm/h and CRP 10 mg/l combined to gather had 97.6% sensitivity for a positive diagnosis of PJI[127].

A full blood count including a white blood cell (WBC) count is part of the routine workout for patients with suspected PJI, however recent evidence suggests that serum WBC and dif‐ ferential carries a very low sensitivity (55% and 52% respectively) and specificity (66% and 75% respectively)[128]. Accordingly, routine serum WBC count and differential have no role in the diagnosis of PJI..

#### *4.2.2. Joint aspiration*

Joint aspiration is recommended as part of the work up in diagnosing PJI in patients with combined elevation of ESR and CRP levels in the hip and elevation of ESR and/or CRP levels in the knee joint[5]. Joint aspiration is usually carried out under sterile condi‐ tions, and synovial fluid should be for culture and sensitivity, WBC count and neutro‐ phil percentage. Some patients with abnormal ESR and CRP may require more than one aspiration. A WBC count higher than 1700 cell/µl or a neutrophil percentage greater than 65% is highly suggestive of chronic PJI, however these values are not applicable when diagnosis acute PJI[129, 130]

#### *4.2.3. Imaging studies*

Imaging studies such as plain radiographs, computed tomography (CT) or magnetic reso‐ nance imaging (MRI) scans are useful in sub classifying patient into high and low probabili‐ ty of PJI. Radiolucent lines, focal osteolysis, periosteal bone formation or early loosening may all suggest PJI[131], however differentiating between PJI and aseptic loosening may not be possible using imaging modalities on their own. Nuclear scintigraphy detects inflamma‐ tion in peri-prosthetic tissue, and although technetium-99m bone scintigraphy has very high sensitivity, it lacks specificity for infection[132]. A technetium bone scan can remain positive more than a year after implantation because of increased periprosthetic bone remodelling. Love et al. reported increased sensitivity (96%), specificity (87%) and accuracy (91%) when a leukocyte/marrow scintigraphy was used to identify PJI. The test was significantly more ac‐ curate than bone (50%), bone/gallium (66%) and leuckocyte/bone (70%) scintigraphy in diag‐ nosing PJI[133]. It seems that a Leukocyte/marrow scintigraphy will remain the procedure of choice in diagnosing PJI until agents capable of differentiating infection from aseptic inflam‐ mation are developed[133].

**Figure 1.** Plain AnteroPosterior and Lateral Radiographs showing focal areas of osteolysis, suspicious of PJI.

#### *4.2.4. Intraoperative techniques*

by pain, fever, wound drainage or erythema. While the only feature of chronic infection, can be pain unrelieved by a seemingly well-functioning arthroplasty. Loosening during the first year post implantation or a consistently painful arthroplasty should be considered infected

Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) are baseline screening tests for any patient planned for revision arthroplasty regardless of the cause of failure[5]. Diagnostic value of ESR and CRP has been widely reported, and their combined use is a very good 'rule out' test [125, 126]. When both ESR and CRP are negative, periprosthetic in‐ fection is unlikely, however when both tests are positive PJI must be considered, and this warrants further investigations [5]. Ghanem et al. have reported that values higher than an ESR of 30 mm/h and CRP 10 mg/l combined to gather had 97.6% sensitivity for a positive

A full blood count including a white blood cell (WBC) count is part of the routine workout for patients with suspected PJI, however recent evidence suggests that serum WBC and dif‐ ferential carries a very low sensitivity (55% and 52% respectively) and specificity (66% and 75% respectively)[128]. Accordingly, routine serum WBC count and differential have no role

Joint aspiration is recommended as part of the work up in diagnosing PJI in patients with combined elevation of ESR and CRP levels in the hip and elevation of ESR and/or CRP levels in the knee joint[5]. Joint aspiration is usually carried out under sterile condi‐ tions, and synovial fluid should be for culture and sensitivity, WBC count and neutro‐ phil percentage. Some patients with abnormal ESR and CRP may require more than one aspiration. A WBC count higher than 1700 cell/µl or a neutrophil percentage greater than 65% is highly suggestive of chronic PJI, however these values are not applicable when

Imaging studies such as plain radiographs, computed tomography (CT) or magnetic reso‐ nance imaging (MRI) scans are useful in sub classifying patient into high and low probabili‐ ty of PJI. Radiolucent lines, focal osteolysis, periosteal bone formation or early loosening may all suggest PJI[131], however differentiating between PJI and aseptic loosening may not be possible using imaging modalities on their own. Nuclear scintigraphy detects inflamma‐ tion in peri-prosthetic tissue, and although technetium-99m bone scintigraphy has very high sensitivity, it lacks specificity for infection[132]. A technetium bone scan can remain positive more than a year after implantation because of increased periprosthetic bone remodelling.

until proven otherwise.

diagnosis of PJI[127].

in the diagnosis of PJI..

diagnosis acute PJI[129, 130]

*4.2.3. Imaging studies*

*4.2.2. Joint aspiration*

*4.2.1. Serology*

494 Arthroplasty - Update

**4.2. Diagnostic investigations**

Various techniques can be used intraoperatively during revision arthroplasty to diagnose in‐ fection. These techniques include synovial fluid biomarkers, cultures and frozen sections.

#### *4.2.4.1. Cultures and Gram stain*

Cultures of periprosthetic tissues provide the most reliable means of detecting that pathogen and are often used as a reference standard in diagnosing PJI. Multiple samples should be taken at the time of the procedure from various regions, at least 3 samples for culture are recommended[134-136]. Cultures may be negative because prior antibiotic exposure, low number of organisms, an inappropriate culture medium, fastidious organisms or prolonged transport time to the laboratory[11]. Grams stains have high specificity (97%) but extreme low sensitivity (less than 26%)[137, 138]. The AAOS guidelines recommend against the rou‐ tine use of intraoperative gram stain for the diagnosis of PJI[5].

gorithmic approach to the diagnosis of PJI, beginning with baseline investigations such the Erythrocyte Sedimentation Rate (ESR) and the C Reactive Protein (CRP) that carry high sen‐

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One or more symptoms, AND at least one or more:

• early implant loosening/osteolysis (as detected by x-ray)

• early implant loosening/osteolysis (as detected by x-ray)

\*risk factor supported by evidence or expert opinion. Adopted from the AAOS clinical practice guidelines for the diag‐

Further investigations, such as joint aspiration, are recommended in a stepwise manner de‐ pending on the ESR and CRP levels. The AAOS clinical guidelines and algorithms for the diagnosis peri-prosthetic infections, are available free to download from http://

The management of total joint arthroplasty consists of one or more of the following techni‐

**ii.** Debridement and Irrigation of the joint with component retention or linear ex‐

Management decisions are made on severity, chronicity of the infection, virulence of the in‐ fecting organism, status of surrounding soft tissue and physiological status of the patient.

Pain or joint stiffness only and none of the following:

sitivity and specificity when combined together[125, 126].

• physical exam finding; OR

• physical exam findings; OR

**Table 4.** Stratification of patients into High or low probability of infection[144]

• risk factor\* OR

• risk factors;\* OR

www.aaos.org/research/guidelines/guide.asp.

**iii.** Single Stage Revision Arthroplasty (SSRA)

**iv.** Two Stage Revision Arthroplasty (TSRA)

Higher Probability of Infection

Lower Probability of Infection

nosis of periprosthetic infections[144]

**5. Management of PJI**

**i.** Antibiotic therapy

change

**v.** Arthrodesis

**vi.** Amputation

ques:

#### *4.2.4.2. Frozen sections*

A meta-analysis by Della Valle et al reported that frozen sections are very good in ruling in but have low value in ruling out and infection[5]. These studies have more than 80% sensi‐ tivity and more than 90% specificity, but they also have high interobserver variability. The degree of inflammatory cells infiltrations varies among specimens from the same patient, sometimes even within individual tissue samples[11].

#### *4.2.4.3. Synovial fluid biomarkers*

Synovial fluid can used to analyse for various biomarkers such as leukocyte esterase, syno‐ vial CRP and white blood cell count, interleukin 6 (IL-6) and interleukin 8 (IL-8). Leukocyte esterase is an enzyme secreted by activated neutrophils that migrate at the site of infections. This enzyme is usually found on colorimetric dipsticks to diagnose urinary tract infections. Potential advantages of this diagnostic tool include wide availability, low cost and potential of an accurate diagnosis within minutes. Parvizi et al. have initially reported preliminary da‐ ta on using leukocyte esterase as a diagnostic tool. These authors reported 80.6% sensitivity and 100% specificity in diagnosing PJI, with 100% positive predictive value and 93.3% nega‐ tive predictive value[139]. Wetters et al also reported similar results when they used leuko‐ cyte esterase for diagnosis PJI[140]. In both studies, the leukocyte esterase strip was unreadable in on third off cases due to synovial blood or debris. Even though, these results are promising, both of these studies have their limitations in the methodology used, and fur‐ ther on, none of studies identifies whether the leukocyte esterase strip is able to differentiate between inflammation and infection.

Measurement of synovial CRP has been shown to be a sensitive (85%) and specific (95%) marker in diagnosis PJI[141, 142]. Recent studies report IL-6 levels to be more accurate in diagnosis PJI than ESR, CRP level, or synovial fluid WBC count and can be useful in diagno‐ sis of PJI in patients with confounding systemic variables. Jacovides et al. have also reported higher specificity and sensitivity for both IL-6 (100% and 87.1%) and IL-8 (97.7% and 90.3%) when compared to synovial CRP (97.7% and 87.1%)[143]. Based on these studies synovial fluid biomarkers could provide an additional valuable resource for the diagnosis of PJI, but further studies are required.

#### **4.3. AAOS guidelines**

The American Academy of Orthopaedic Surgeons (AAOS), based on the current clinical evi‐ dence, has proposed clinical guidelines in the diagnosis of peri-prosthetic joint infec‐ tion[144]. On the bases of the clinical features, the patients are classified into those who have a high or low probability of PJI (Table 4). The guidelines consist of 15 recommendations, with the majority being supported strongly in the literature. The guidelines advocate an al‐ gorithmic approach to the diagnosis of PJI, beginning with baseline investigations such the Erythrocyte Sedimentation Rate (ESR) and the C Reactive Protein (CRP) that carry high sen‐ sitivity and specificity when combined together[125, 126].


\*risk factor supported by evidence or expert opinion. Adopted from the AAOS clinical practice guidelines for the diag‐ nosis of periprosthetic infections[144]

**Table 4.** Stratification of patients into High or low probability of infection[144]

Further investigations, such as joint aspiration, are recommended in a stepwise manner de‐ pending on the ESR and CRP levels. The AAOS clinical guidelines and algorithms for the diagnosis peri-prosthetic infections, are available free to download from http:// www.aaos.org/research/guidelines/guide.asp.

#### **5. Management of PJI**

transport time to the laboratory[11]. Grams stains have high specificity (97%) but extreme low sensitivity (less than 26%)[137, 138]. The AAOS guidelines recommend against the rou‐

A meta-analysis by Della Valle et al reported that frozen sections are very good in ruling in but have low value in ruling out and infection[5]. These studies have more than 80% sensi‐ tivity and more than 90% specificity, but they also have high interobserver variability. The degree of inflammatory cells infiltrations varies among specimens from the same patient,

Synovial fluid can used to analyse for various biomarkers such as leukocyte esterase, syno‐ vial CRP and white blood cell count, interleukin 6 (IL-6) and interleukin 8 (IL-8). Leukocyte esterase is an enzyme secreted by activated neutrophils that migrate at the site of infections. This enzyme is usually found on colorimetric dipsticks to diagnose urinary tract infections. Potential advantages of this diagnostic tool include wide availability, low cost and potential of an accurate diagnosis within minutes. Parvizi et al. have initially reported preliminary da‐ ta on using leukocyte esterase as a diagnostic tool. These authors reported 80.6% sensitivity and 100% specificity in diagnosing PJI, with 100% positive predictive value and 93.3% nega‐ tive predictive value[139]. Wetters et al also reported similar results when they used leuko‐ cyte esterase for diagnosis PJI[140]. In both studies, the leukocyte esterase strip was unreadable in on third off cases due to synovial blood or debris. Even though, these results are promising, both of these studies have their limitations in the methodology used, and fur‐ ther on, none of studies identifies whether the leukocyte esterase strip is able to differentiate

Measurement of synovial CRP has been shown to be a sensitive (85%) and specific (95%) marker in diagnosis PJI[141, 142]. Recent studies report IL-6 levels to be more accurate in diagnosis PJI than ESR, CRP level, or synovial fluid WBC count and can be useful in diagno‐ sis of PJI in patients with confounding systemic variables. Jacovides et al. have also reported higher specificity and sensitivity for both IL-6 (100% and 87.1%) and IL-8 (97.7% and 90.3%) when compared to synovial CRP (97.7% and 87.1%)[143]. Based on these studies synovial fluid biomarkers could provide an additional valuable resource for the diagnosis of PJI, but

The American Academy of Orthopaedic Surgeons (AAOS), based on the current clinical evi‐ dence, has proposed clinical guidelines in the diagnosis of peri-prosthetic joint infec‐ tion[144]. On the bases of the clinical features, the patients are classified into those who have a high or low probability of PJI (Table 4). The guidelines consist of 15 recommendations, with the majority being supported strongly in the literature. The guidelines advocate an al‐

tine use of intraoperative gram stain for the diagnosis of PJI[5].

sometimes even within individual tissue samples[11].

*4.2.4.2. Frozen sections*

496 Arthroplasty - Update

*4.2.4.3. Synovial fluid biomarkers*

between inflammation and infection.

further studies are required.

**4.3. AAOS guidelines**

The management of total joint arthroplasty consists of one or more of the following techni‐ ques:


Management decisions are made on severity, chronicity of the infection, virulence of the in‐ fecting organism, status of surrounding soft tissue and physiological status of the patient.

#### **5.1. Unexpected positive intraoperative cultures**

Unexpected positive intraoperative cultures are found in cases where pre-operative assess‐ ment fails to show infection, these cases usually undergo revision for aseptic loosening. Tsu‐ kayama eta al. reported up to 11% of cases were infection was diagnosed with positive intraoperative cultures and were all treated with 6 weeks of antibiotics without additional operation. Antibiotic therapy failed in 3 of these cases, and the patients required further sur‐ gical treatment with 2 patient showing evidence of recurrent infection at 2 year follow up[56]. In another study, 15 patients with positive intraoperative cultures were not treated with antibiotics, recurrence of infection was reported in 6 patients[145]. Based on these stud‐ ies, patients with unexpected positive cultures should be treated with antibiotics for 6 weeks while monitoring their ESR and CRP values to assess response to treatment under the super‐ vision of a specialist microbiologist[146].

**5.4. Single stage revision arthroplasty**

**5.5. Two stage revision arthroplasty**

The advantages of TSRA[166] include:

matogenous spread

of a new prosthesis

Single stage revision with removal of components, debridement, irrigation and reimplantation of new components provides removal of infected prosthesis while limiting the number of sur‐ geries, recovery time and costs. Callaghan et al. reports 8.3% rate of recurrence after single stage revision arthroplasty with a minimum follow up of 10 years[153]. The local therapy, is achieved by adding antibiotics to the cement used for fixation of the implant, this is followed by a minimum of 6 weeks antibiotic therapy. Two studies comparing one-stage to two stage revi‐ sion arthroplasty favoured the two stage technique[154, 155]. Failure rates in SSRA ranged from 10.1% to 12.4%, compared to 3.5% to 5.6% in TSRA. A recent meta-analysis comparing SSRA to TSRA reported the presence of nearly three additional reinfections per 100 revisions when performing a one stage compared to a two stage procedure[156]. However, not enough

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evidence is available to demonstrate that one technique is superior to the other[156].

derwent aspiration compared with 14% in those who did not[165].

stage and during the second stage before reimplantation

Two stage revision arthroplasty (TSRA) is currently the gold standard technique for the treatment of infected joint arthroplasty[107, 157-159]. TSRA involves initial removal of the infected components and all foreign material including cement, cement restrictors and cables or wires whenever possible with meticulous debridement and irrigation. All necrotic tissue is excised, and sinus tracts are debrided. After irrigation the joint should be inspected for any remaining debris. A cement spacer loaded with antibiotics is used, this is either pre-manufactured or constructed at the time of surgery[160, 161]. Various techniques described in the construction of a cement loaded spacer, the technique used depends on the joint involved and the level of bone loss encountered during the first stage[109, 161-164]. These custom spacers allow antibiotic elution locally to eradicate the infective organism and maintain soft tissue balance to accommodate the definitive im‐ plant during the second stage. A minimum course of six weeks of antibiotics is usually required, and resolution of infection is confirmed through serial ESR and CRP and re‐ peated aspiration of the joint. A further aspiration of the joint before the second stage is recommended in one study, which reported recurrence rate of 3% among those who un‐

**i.** meticulous debridement of soft tissue, necrotic bone and cement during the first

**ii.** identification of offending organism, sensitivities are determined and appropriate antibiotic therapy is given for a prolonged period before reimplantation **iii.** evaluation of distant foci of infection and eradication of sites responsible for hae‐

**iv.** informed decision can be made as to whether the degree of disability from resec‐

tion arthroplasty or arthrodesis would justify the risks involved in the implantation

#### **5.2. Antibiotic suppression**

When patients have poor state of health, have a high risk of complications after surgery and the infective organism is of low virulence and susceptible to antibiotic therapy, sup‐ pression by antibiotic alone may be the best option. Rao et al. investigated the rates of eradication of antibiotic resistant organisms with suppression therapy and noted eradica‐ tion in 86% at mean follow up of five years, with five recurrent infections all within the first 3 years[147]. Antibiotic suppression is also indicated in patient with persistent PJI following surgical intervention if they decline or cannot tolerate further surgery[6, 11, 148, 149]. The literature on antibiotic suppressive therapy without any surgical interven‐ tion is poor; despite this, patients who cannot tolerate surgery have no other option than suppressive therapy.

#### **5.3. Debridement and Irrigation with component retention or linear exchange**

Operative debridement and irrigation with component retention should be reserved of acute infections (Stage II and occasionally stage III). Early infections may range in severi‐ ty from superficial cellulitis to deep infections. Superficial infections associated with wound dehiscence or purulent drainage and infections with wound necrosis or infected haematomas often require surgical debridement. Reported eradication rate has been be‐ tween 24% to 71 % following open debridement and irrigation[56, 150, 151]. Even though, some case reports show excellent results from irrigation and debridement[152], a recent multicentre retrospective study showed that irrigation and debridement with com‐ ponent retention is not affected by organism type and that this technique had a failure rate as high as 70%, with the authors questioning the actual role of irrigation and de‐ bridement in the treatment of PJI[151]. Prostheses retention is also contraindicated in those with multiple joint arthroplasty or when the duration of symptoms is more than 1 month[7, 15].

#### **5.4. Single stage revision arthroplasty**

**5.1. Unexpected positive intraoperative cultures**

vision of a specialist microbiologist[146].

**5.2. Antibiotic suppression**

498 Arthroplasty - Update

suppressive therapy.

month[7, 15].

Unexpected positive intraoperative cultures are found in cases where pre-operative assess‐ ment fails to show infection, these cases usually undergo revision for aseptic loosening. Tsu‐ kayama eta al. reported up to 11% of cases were infection was diagnosed with positive intraoperative cultures and were all treated with 6 weeks of antibiotics without additional operation. Antibiotic therapy failed in 3 of these cases, and the patients required further sur‐ gical treatment with 2 patient showing evidence of recurrent infection at 2 year follow up[56]. In another study, 15 patients with positive intraoperative cultures were not treated with antibiotics, recurrence of infection was reported in 6 patients[145]. Based on these stud‐ ies, patients with unexpected positive cultures should be treated with antibiotics for 6 weeks while monitoring their ESR and CRP values to assess response to treatment under the super‐

When patients have poor state of health, have a high risk of complications after surgery and the infective organism is of low virulence and susceptible to antibiotic therapy, sup‐ pression by antibiotic alone may be the best option. Rao et al. investigated the rates of eradication of antibiotic resistant organisms with suppression therapy and noted eradica‐ tion in 86% at mean follow up of five years, with five recurrent infections all within the first 3 years[147]. Antibiotic suppression is also indicated in patient with persistent PJI following surgical intervention if they decline or cannot tolerate further surgery[6, 11, 148, 149]. The literature on antibiotic suppressive therapy without any surgical interven‐ tion is poor; despite this, patients who cannot tolerate surgery have no other option than

**5.3. Debridement and Irrigation with component retention or linear exchange**

Operative debridement and irrigation with component retention should be reserved of acute infections (Stage II and occasionally stage III). Early infections may range in severi‐ ty from superficial cellulitis to deep infections. Superficial infections associated with wound dehiscence or purulent drainage and infections with wound necrosis or infected haematomas often require surgical debridement. Reported eradication rate has been be‐ tween 24% to 71 % following open debridement and irrigation[56, 150, 151]. Even though, some case reports show excellent results from irrigation and debridement[152], a recent multicentre retrospective study showed that irrigation and debridement with com‐ ponent retention is not affected by organism type and that this technique had a failure rate as high as 70%, with the authors questioning the actual role of irrigation and de‐ bridement in the treatment of PJI[151]. Prostheses retention is also contraindicated in those with multiple joint arthroplasty or when the duration of symptoms is more than 1 Single stage revision with removal of components, debridement, irrigation and reimplantation of new components provides removal of infected prosthesis while limiting the number of sur‐ geries, recovery time and costs. Callaghan et al. reports 8.3% rate of recurrence after single stage revision arthroplasty with a minimum follow up of 10 years[153]. The local therapy, is achieved by adding antibiotics to the cement used for fixation of the implant, this is followed by a minimum of 6 weeks antibiotic therapy. Two studies comparing one-stage to two stage revi‐ sion arthroplasty favoured the two stage technique[154, 155]. Failure rates in SSRA ranged from 10.1% to 12.4%, compared to 3.5% to 5.6% in TSRA. A recent meta-analysis comparing SSRA to TSRA reported the presence of nearly three additional reinfections per 100 revisions when performing a one stage compared to a two stage procedure[156]. However, not enough evidence is available to demonstrate that one technique is superior to the other[156].

#### **5.5. Two stage revision arthroplasty**

Two stage revision arthroplasty (TSRA) is currently the gold standard technique for the treatment of infected joint arthroplasty[107, 157-159]. TSRA involves initial removal of the infected components and all foreign material including cement, cement restrictors and cables or wires whenever possible with meticulous debridement and irrigation. All necrotic tissue is excised, and sinus tracts are debrided. After irrigation the joint should be inspected for any remaining debris. A cement spacer loaded with antibiotics is used, this is either pre-manufactured or constructed at the time of surgery[160, 161]. Various techniques described in the construction of a cement loaded spacer, the technique used depends on the joint involved and the level of bone loss encountered during the first stage[109, 161-164]. These custom spacers allow antibiotic elution locally to eradicate the infective organism and maintain soft tissue balance to accommodate the definitive im‐ plant during the second stage. A minimum course of six weeks of antibiotics is usually required, and resolution of infection is confirmed through serial ESR and CRP and re‐ peated aspiration of the joint. A further aspiration of the joint before the second stage is recommended in one study, which reported recurrence rate of 3% among those who un‐ derwent aspiration compared with 14% in those who did not[165].

The advantages of TSRA[166] include:


The disadvantages[166] include:


thesis, especially in patients who cannot tolerate multiple procedures. Arthrodesis allows the patient to retain the extremity at the cost of reducing ambulation especially in patients

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Infection of a total Joint arthroplasty is considered a major complication in orthopaedic sur‐ gery with significant morbidity and places a considerable burden on hospitals and surgeons. Prevention is better than treatment and improving the patients' health prior to surgery is important in reducing the risk of infection. Furthermore, prompt diagnosis, permits early treatment that is important in acute infections. In the absence of a perfect test, the evidence based algorithmic approach brought forward by the AAOS guidelines should enable diag‐ nosis of infection to be made with a high degree of confidence. There is clearly a role for sur‐ gical intervention, and so far a two-stage revision arthroplasty demonstrates the lowest rates

[1] Bozic KJ, Kurtz SM, Lau E, Ong K, Chiu V, Vail TP, et al. The epidemiology of revi‐ sion total knee arthroplasty in the United States. Clin Orthop Relat Res. 2010;468[1]:

[2] Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am. 2009;91[1]:128-33.

[3] Clohisy JC, Calvert G, Tull F, McDonald D, Maloney WJ. Reasons for revision hip surgery: a retrospective review. Clin Orthop Relat Res. 2004[429]:188-92. Epub

[4] Vessely MB, Whaley AL, Harmsen WS, Schleck CD, Berry DJ. The Chitranjan Rana‐ wat Award: Long-term survivorship and failure modes of 1000 cemented condylar total knee arthroplasties. Clin Orthop Relat Res. 2006;452:28-34. Epub 2006/08/29.

of recurrent infection and as such is regarded as the 'gold standard'.

Orthopaedic Research and Innovation Foundation, Republic of Ireland

with a fused knee.

**6. Conclusion**

**Author details**

**References**

Adrian J. Cassar Gheiti and Kevin J. Mulhall

45-51. Epub 2009/06/26.

Epub 2009/01/06.

2004/12/04.

TSRA has been associated with lower rates of recurrent infections in most studies[6, 167, 168]. The duration of antibiotics between the two stages has not been determined, but a min‐ imum of 6 weeks is usually standard and is guided by serial ESR and CRP levels. Manage‐ ment of bone stock deficiency at the time of revision is a problem. Impaction bone grafting with cemented prosthesis has been used for reconstruction during the second stage with good results. English et al. reported eradication in 49 out of 53 cases treated with impaction bone grafting during the second stage with a minimum follow up of 2 years[169] and a re‐ currence rate up to 7.5%[169, 170]. Use of antibiotic loaded cement for fixation of the implant during the second stage has been shown to reduce rates of reinfection. Garvin et al. reported eradication in 95% of patients at 5 year interval when gentamicin loaded cement was utilis‐ ed during the second stage[171]. Highest success rates for TSRA were found for patients treated with antibiotics-eluting spacer or beads between the first and second stage, followed by a second reconstruction with an antibiotic loaded cemented reconstruction[55, 167, 172].

Data on uncemented implants has generally been less positive, with early studies reporting rates of infection as high as 18% and additional cases of loosening[43, 173]. Studies that are more recent have reported reinfection rates between 6% and 11%[174]. The decision regard‐ ing cemented or uncemented reimplantation is guided by the available bone stock, physio‐ logical age and expected longevity of the patient. To minimize loss of bone stock during the first stage, the Exeter group adopted a cement in cement revision technique for hip arthro‐ plasty, where an excision arthroplasty with antibiotic impregnated cement beads is carried out during the first stage. In this technique if the cement mantle from the previous arthro‐ plasty is well fixed, is left alone. During the second stage, the cement beads are removed, and the existing cement mantle is reamed to remove any membrane or microfilm and to cre‐ ate space for the new antibiotic augmented cement and the new implant. Sixteen patients with at least three years follow up underwent this procedure with one patient requiring re‐ vision due to recurrent infection[175].

#### **5.6. Arthrodesis and amputation**

Salvage procedures are reserved for patients whose medical condition such as immunocom‐ promised patients or in patients where successful reconstruction is impossible. Successful reconstruction is limited those patients with insufficient bone stock, inadequate muscle function and poor soft tissue coverage. Eradication of infection after salvage procedures is reported between 86% to 96% although they are usually associated with poor functional out‐ comes[176-178]. Above knee amputation provides good return to function with a fitted pros‐

thesis, especially in patients who cannot tolerate multiple procedures. Arthrodesis allows the patient to retain the extremity at the cost of reducing ambulation especially in patients with a fused knee.

### **6. Conclusion**

The disadvantages[166] include:

**iii.** delayed rehabilitation

vision due to recurrent infection[175].

**5.6. Arthrodesis and amputation**

**ii.** increased costs

500 Arthroplasty - Update

**i.** prolonged period of disability and hospital stay

stock shortening and scarring

**iv.** technically difficult second procedure due to loss soft tissue balance, loss of bone

TSRA has been associated with lower rates of recurrent infections in most studies[6, 167, 168]. The duration of antibiotics between the two stages has not been determined, but a min‐ imum of 6 weeks is usually standard and is guided by serial ESR and CRP levels. Manage‐ ment of bone stock deficiency at the time of revision is a problem. Impaction bone grafting with cemented prosthesis has been used for reconstruction during the second stage with good results. English et al. reported eradication in 49 out of 53 cases treated with impaction bone grafting during the second stage with a minimum follow up of 2 years[169] and a re‐ currence rate up to 7.5%[169, 170]. Use of antibiotic loaded cement for fixation of the implant during the second stage has been shown to reduce rates of reinfection. Garvin et al. reported eradication in 95% of patients at 5 year interval when gentamicin loaded cement was utilis‐ ed during the second stage[171]. Highest success rates for TSRA were found for patients treated with antibiotics-eluting spacer or beads between the first and second stage, followed by a second reconstruction with an antibiotic loaded cemented reconstruction[55, 167, 172].

Data on uncemented implants has generally been less positive, with early studies reporting rates of infection as high as 18% and additional cases of loosening[43, 173]. Studies that are more recent have reported reinfection rates between 6% and 11%[174]. The decision regard‐ ing cemented or uncemented reimplantation is guided by the available bone stock, physio‐ logical age and expected longevity of the patient. To minimize loss of bone stock during the first stage, the Exeter group adopted a cement in cement revision technique for hip arthro‐ plasty, where an excision arthroplasty with antibiotic impregnated cement beads is carried out during the first stage. In this technique if the cement mantle from the previous arthro‐ plasty is well fixed, is left alone. During the second stage, the cement beads are removed, and the existing cement mantle is reamed to remove any membrane or microfilm and to cre‐ ate space for the new antibiotic augmented cement and the new implant. Sixteen patients with at least three years follow up underwent this procedure with one patient requiring re‐

Salvage procedures are reserved for patients whose medical condition such as immunocom‐ promised patients or in patients where successful reconstruction is impossible. Successful reconstruction is limited those patients with insufficient bone stock, inadequate muscle function and poor soft tissue coverage. Eradication of infection after salvage procedures is reported between 86% to 96% although they are usually associated with poor functional out‐ comes[176-178]. Above knee amputation provides good return to function with a fitted pros‐

Infection of a total Joint arthroplasty is considered a major complication in orthopaedic sur‐ gery with significant morbidity and places a considerable burden on hospitals and surgeons. Prevention is better than treatment and improving the patients' health prior to surgery is important in reducing the risk of infection. Furthermore, prompt diagnosis, permits early treatment that is important in acute infections. In the absence of a perfect test, the evidence based algorithmic approach brought forward by the AAOS guidelines should enable diag‐ nosis of infection to be made with a high degree of confidence. There is clearly a role for sur‐ gical intervention, and so far a two-stage revision arthroplasty demonstrates the lowest rates of recurrent infection and as such is regarded as the 'gold standard'.

### **Author details**

Adrian J. Cassar Gheiti and Kevin J. Mulhall

Orthopaedic Research and Innovation Foundation, Republic of Ireland

### **References**


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**Chapter 23**

**Management of Prosthetic**

Peter Choong

**1. Introduction**

http://dx.doi.org/10.5772/53244

**Infection According to Organism**

Trisha Peel, Kirsty Buising, Michelle Dowsey and

Since the advent of prosthetic joint replacement surgery, patients with arthritis have had significant improvement in pain-relief, mobility and quality of life. Approximately 90,000 Australians undergo joint replacement surgery each year [1]. With an ageing population, this number will increase (figure 1). Similar data from USA predicts that by 2030 the number of procedures per year will increase to 4.05 million [2]. Despite the overall suc‐ cess of this surgery, infection of the prosthesis remains a devastating complication [3]. Of concern, the incidence of prosthetic joint infection is increasing, in proportion to the num‐ ber of procedures being performed [4]. Significant patient morbidity is associated with prosthetic joint infections, including the need for further operative procedures, long-term antibiotic therapy with associated toxicity, and prolonged hospitalisation [3]. In addition, the cost to the health system is substantial. The cost of treating infection is 3-5 times the cost of primary arthroplasty [5, 6]. In Australia, the annual additional expenditure incur‐ red as a result of this devastating complication is estimated at AUD \$90 million per year [6]. In the United States, the annual cost of treatment of prosthetic joint infection is pro‐

The incidence of prosthetic joint infection is estimated at 1-3% of all prosthetic joint replace‐ ments [3]. In prosthetic hip replacement, the rate of infection is estimated at 0.88% and in knee replacement at 0.92%[4]. The incidence of prosthetic joint infections is higher for upper limb arthroplasty; in shoulders the incidence of infection is 1.8-4% and in elbow replace‐

> © 2013 Peel et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

Additional information is available at the end of the chapter

jected to exceed US\$1.6 billion dollars by 2020[7].

ments the incidence of infection is 3-7.5% of patients [8-10].

### **Chapter 23**

## **Management of Prosthetic Infection According to Organism**

Trisha Peel, Kirsty Buising, Michelle Dowsey and Peter Choong

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/53244

### **1. Introduction**

Since the advent of prosthetic joint replacement surgery, patients with arthritis have had significant improvement in pain-relief, mobility and quality of life. Approximately 90,000 Australians undergo joint replacement surgery each year [1]. With an ageing population, this number will increase (figure 1). Similar data from USA predicts that by 2030 the number of procedures per year will increase to 4.05 million [2]. Despite the overall suc‐ cess of this surgery, infection of the prosthesis remains a devastating complication [3]. Of concern, the incidence of prosthetic joint infection is increasing, in proportion to the num‐ ber of procedures being performed [4]. Significant patient morbidity is associated with prosthetic joint infections, including the need for further operative procedures, long-term antibiotic therapy with associated toxicity, and prolonged hospitalisation [3]. In addition, the cost to the health system is substantial. The cost of treating infection is 3-5 times the cost of primary arthroplasty [5, 6]. In Australia, the annual additional expenditure incur‐ red as a result of this devastating complication is estimated at AUD \$90 million per year [6]. In the United States, the annual cost of treatment of prosthetic joint infection is pro‐ jected to exceed US\$1.6 billion dollars by 2020[7].

The incidence of prosthetic joint infection is estimated at 1-3% of all prosthetic joint replace‐ ments [3]. In prosthetic hip replacement, the rate of infection is estimated at 0.88% and in knee replacement at 0.92%[4]. The incidence of prosthetic joint infections is higher for upper limb arthroplasty; in shoulders the incidence of infection is 1.8-4% and in elbow replace‐ ments the incidence of infection is 3-7.5% of patients [8-10].

© 2013 Peel et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

infections such as prosthetic joint infections[21]. In medical device associated infections, the planktonic bacteria seed the device and undergo a phenotypic change transforming into the sessile bacteria. The biofilm is comprised of the sessile bacteria and the extracel‐ lular matrix they secrete[21]. This matrix protects the microorganisms from antibiotics and the host immune response and is thought to be the underlying reason for persis‐

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519

*Staphylococcus aureus* and coagulase negative Staphylococcus species are the most com‐ mon aetiological agents of prosthetic joint infections. The incidence of methicillin resist‐ ant strains such as methicillin resistant *Staphylococcus aureus* (MRSA) differ globally; the rate of MRSA prosthetic joint infections across Europe and the Americans MRSA ranges from 8% to 30%[22-24]. In Australia, 26% of prosthetic joint infections are due to MRSA. In addition, methicillin resistant coagulase negative Staphylococci account for a further

Gram negative bacilli such as *Escherichia coli* and *Pseudomonas aeruginosa* are the next most common isolates[3, 26]. Other microorganisms such as enterococci, streptococci, corynebac‐ terium, fungal species and mycobacterial species are reported less commonly [3, 27]. Of note, the microbiology of prosthetic joint infection differs between upper limb and lower limb arthroplasty: *Propionibacterium acnes* is one of the most common microorganisms en‐ countered in shoulder prosthetic joint infection, occurring in up to 40% of shoulder arthro‐ plasty infections [16, 28, 29]. This association may be due to the increased occurrence of *Propionibacterium acnes* around the head and neck, in particular in the sebaceous glands and

From a review of 6,282 prosthetic hip and knee replacements performed at St Vincent's Hos‐ pital Melbourne (SVHM) between 2000 and 2012, there were 138 definite infections (table 1). Prosthetic joint infection was defined by the typical diagnostic criteria which include those discussed further in table 2. Microorganisms were defined as the causative pathogen/s if iso‐

The microbiology of hip and knee prosthetic joint infection was similar, except for an in‐ creased number of culture negative infections in prosthetic knee joints and increased isola‐ tion of *Enterococcus faecalis* from prosthetic hip infections. From SVHM data there was an increased rate of incisional surgical site infections in knee arthroplasties that later developed prosthetic joint infections compared to hip arthroplasty (28% versus 12%)[17, 30]. Therefore it is postulated that the increased number of culture negative infections in the knee replace‐ ment patients may reflect increased antibiotic exposure for superficial wound complications

tence of infections[21].

**3. Microbiology**

22% of isolates [25, 26].

hair bulbs [12].

lated on two or more intra-operative specimens.

or for unrecognised prosthetic joint infection.

**Figure 1.** Prosthetic Joint Replacement Surgery in Australia *(adapted from AOA National Joint Replacement Registry[1]*)

A number of pre-operative factors have been implicated in the development of prosthetic joint infection, including revision arthroplasty, diabetes mellitus and rheumatoid arthritis [11-16]. The risk factors for prosthetic joint infection differ according to the joint replaced. Obesity plays a greater role in the evolution of prosthetic joint infection in lower limb ar‐ throplasty [17-19]. The presence of post-operative wound complications, including high drain tube losses, wound discharge and superficial surgical site infection have been impli‐ cated as risk factors for development of prosthetic joint infection in hip and knee arthroplas‐ ty[11, 20]. In addition the presence of a drain tube appears to be protective for prosthetic knee infections [17, 18]. Underlying inflammatory arthritis and concomitant steroid use in‐ creases the risk of infections in all arthroplasty surgery but the association is particularly marked in the upper limb [16, 17]. In addition male gender has been identified as a risk fac‐ tor in shoulder arthroplasty infection, potentially through the interaction with *Propionibacte‐ rium acnes* (see below)[12].

### **2. Pathogenesis**

There are two main mechanisms of acquisition of prosthetic joint infection; (i) direct inoc‐ ulation of the prosthesis at the time of surgery or with manipulation of the joint and (ii) seeding from the blood stream at a later time[3]. The pathogenesis of prosthetic joint in‐ fections differs to that of many other bacterial infections through the property of microor‐ ganisms to form biofilms[3]. Microorganisms can exist in two phenotypic forms: the planktonic form which is encountered in the majority of acute bacterial infections such as bacterial septicaemia or pneumonia, and the sessile form associated with medical device infections such as prosthetic joint infections[21]. In medical device associated infections, the planktonic bacteria seed the device and undergo a phenotypic change transforming into the sessile bacteria. The biofilm is comprised of the sessile bacteria and the extracel‐ lular matrix they secrete[21]. This matrix protects the microorganisms from antibiotics and the host immune response and is thought to be the underlying reason for persis‐ tence of infections[21].

### **3. Microbiology**

**Figure 1.** Prosthetic Joint Replacement Surgery in Australia *(adapted from AOA National Joint Replacement Registry[1]*)

A number of pre-operative factors have been implicated in the development of prosthetic joint infection, including revision arthroplasty, diabetes mellitus and rheumatoid arthritis [11-16]. The risk factors for prosthetic joint infection differ according to the joint replaced. Obesity plays a greater role in the evolution of prosthetic joint infection in lower limb ar‐ throplasty [17-19]. The presence of post-operative wound complications, including high drain tube losses, wound discharge and superficial surgical site infection have been impli‐ cated as risk factors for development of prosthetic joint infection in hip and knee arthroplas‐ ty[11, 20]. In addition the presence of a drain tube appears to be protective for prosthetic knee infections [17, 18]. Underlying inflammatory arthritis and concomitant steroid use in‐ creases the risk of infections in all arthroplasty surgery but the association is particularly marked in the upper limb [16, 17]. In addition male gender has been identified as a risk fac‐ tor in shoulder arthroplasty infection, potentially through the interaction with *Propionibacte‐*

There are two main mechanisms of acquisition of prosthetic joint infection; (i) direct inoc‐ ulation of the prosthesis at the time of surgery or with manipulation of the joint and (ii) seeding from the blood stream at a later time[3]. The pathogenesis of prosthetic joint in‐ fections differs to that of many other bacterial infections through the property of microor‐ ganisms to form biofilms[3]. Microorganisms can exist in two phenotypic forms: the planktonic form which is encountered in the majority of acute bacterial infections such as bacterial septicaemia or pneumonia, and the sessile form associated with medical device

*rium acnes* (see below)[12].

**2. Pathogenesis**

518 Arthroplasty - Update

*Staphylococcus aureus* and coagulase negative Staphylococcus species are the most com‐ mon aetiological agents of prosthetic joint infections. The incidence of methicillin resist‐ ant strains such as methicillin resistant *Staphylococcus aureus* (MRSA) differ globally; the rate of MRSA prosthetic joint infections across Europe and the Americans MRSA ranges from 8% to 30%[22-24]. In Australia, 26% of prosthetic joint infections are due to MRSA. In addition, methicillin resistant coagulase negative Staphylococci account for a further 22% of isolates [25, 26].

Gram negative bacilli such as *Escherichia coli* and *Pseudomonas aeruginosa* are the next most common isolates[3, 26]. Other microorganisms such as enterococci, streptococci, corynebac‐ terium, fungal species and mycobacterial species are reported less commonly [3, 27]. Of note, the microbiology of prosthetic joint infection differs between upper limb and lower limb arthroplasty: *Propionibacterium acnes* is one of the most common microorganisms en‐ countered in shoulder prosthetic joint infection, occurring in up to 40% of shoulder arthro‐ plasty infections [16, 28, 29]. This association may be due to the increased occurrence of *Propionibacterium acnes* around the head and neck, in particular in the sebaceous glands and hair bulbs [12].

From a review of 6,282 prosthetic hip and knee replacements performed at St Vincent's Hos‐ pital Melbourne (SVHM) between 2000 and 2012, there were 138 definite infections (table 1). Prosthetic joint infection was defined by the typical diagnostic criteria which include those discussed further in table 2. Microorganisms were defined as the causative pathogen/s if iso‐ lated on two or more intra-operative specimens.

The microbiology of hip and knee prosthetic joint infection was similar, except for an in‐ creased number of culture negative infections in prosthetic knee joints and increased isola‐ tion of *Enterococcus faecalis* from prosthetic hip infections. From SVHM data there was an increased rate of incisional surgical site infections in knee arthroplasties that later developed prosthetic joint infections compared to hip arthroplasty (28% versus 12%)[17, 30]. Therefore it is postulated that the increased number of culture negative infections in the knee replace‐ ment patients may reflect increased antibiotic exposure for superficial wound complications or for unrecognised prosthetic joint infection.


The clinical manifestation differs according to time of presentation. In early prosthetic joint infection, patients typically present with surgical wound complications such as purulent dis‐ charge, erythema and swelling of the affected joint (Figure 2) [3, 32]. In delayed and late in‐ fections, pain is the predominant feature with patients reporting a history of slowly increasing pain involving the prosthetic joint [32]. Haematogenous infections in contrast, typically are associated with a history of a joint that was free of any problems for several months to years before an acute onset of fever, erythema around the surgical wound and

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pain in the affected joint[33].

infection [34].

A

B

**5. Diagnosis of prosthetic joint infections**

**Figure 2.** Early Prosthetic Hip Joint Infection (A) at presentation with infection showing wound erythema, swelling and purulent discharge and (B) intra-operative appearance showing purulence surrounding the prosthetic joint.

The presentation of shoulder arthroplasty infection due to *Propionibacterium* acnes is general‐ ly delayed or late[12]. The classic features of infection are frequently absent with pain and stiffness of the joint the predominant symptoms [12, 34]. Bruising along the surgical wound has been described as a pathognomonic sign of *Propionibacterium acnes* shoulder arthroplasty

The diagnosis of infections is challenging due to the absence of an internationally accepted gold standard for defining arthroplasty infection. Current definitions rely on a number of pa‐ rameters including clinical, microbiological and histopathological features (Table 2) [3, 35-39].

CNS = Coagulase negative Staphylococcus species

\* Other gram positive isolates included 1 Peptostreptococcus species, 1 Bacillus cereus and 2 Corynebacterium species

**Table 1.** Microbiology of 138 prosthetic hip and knee joint infections seen at SVHM between 2000 and 2012

### **4. Clinical classification and presentation**

Prosthetic joint infections are classified as (i) early (developing in the first three months after implantation), (ii) delayed (occurring 3 to 24 months after surgery) and (iii) late (greater than 24 months) or (iv) haematagenous [3]. Haematogenous seeding of the prosthesis typically occur late (after 24 months) but can occur at any time point following implantation [3, 31].

The clinical manifestation differs according to time of presentation. In early prosthetic joint infection, patients typically present with surgical wound complications such as purulent dis‐ charge, erythema and swelling of the affected joint (Figure 2) [3, 32]. In delayed and late in‐ fections, pain is the predominant feature with patients reporting a history of slowly increasing pain involving the prosthetic joint [32]. Haematogenous infections in contrast, typically are associated with a history of a joint that was free of any problems for several months to years before an acute onset of fever, erythema around the surgical wound and pain in the affected joint[33].

**Number (%) of Prosthetic Knee Infections (n=66)**

Gram positive organisms 48 (73%) 60 (83%) 108 (78%) *Staphylococcus aureus* 25 (38%) 35 (49%) 60 (43%) Methicillin sensitive 16 (24%) 17 (24%) 33 (24%) Methicillin resistant 9 (14%) 18 (25%) 27 (20%) CNS 14 (21%) 13 (18%) 26 (19%) Methicillin sensitive 1 (2%) 0 1 (1%) Methicillin resistant 13 (20%) 13 (18%) 26 (19%)

Streptococcus species 4 (6%) 2 (3%) 6 (4%) *Enterococcus faecalis* 4 (6%) 10 (14%) 14 (10%) Other gram positive organisms\* 3 (5%) 1 (1%) 4 (3%) Gram negative organisms 9 (14%) 14 (19%) 23 (17%) *Escherichia coli* 1 (2%) 3 (4%) 4 (3%) *Morganella morganii* 4 (6%) 0 4 (3%) *Klebsiella pneumoniae* 0 1 (1%) 1 (1%) *Serratia marcescens* 2 (3%) 0 2 (1%) *Pseudomonas aeruginosa* 0 1 (1%) 1 (1%) *Citrobacter koseri* 0 1 (1%) 1 (1%) *Enterobacter cloacae* 0 3 (4%) 3 (2%) *Proteus mirabilis* 2 (3%) 4 (6%) 6 (4%) *Bacteroides fragilis* 0 1 (1%) 1 (1%) Culture negative 17 (26%) 11 (15%) 28 (20%)

\* Other gram positive isolates included 1 Peptostreptococcus species, 1 Bacillus cereus and 2 Corynebacterium species

Prosthetic joint infections are classified as (i) early (developing in the first three months after implantation), (ii) delayed (occurring 3 to 24 months after surgery) and (iii) late (greater than 24 months) or (iv) haematagenous [3]. Haematogenous seeding of the prosthesis typically occur late (after 24 months) but can occur at any time point following implantation [3, 31].

**Table 1.** Microbiology of 138 prosthetic hip and knee joint infections seen at SVHM between 2000 and 2012

CNS = Coagulase negative Staphylococcus species

520 Arthroplasty - Update

**4. Clinical classification and presentation**

**Number (%) of Prosthetic Hip Infections (n=72)**

**Number (%) of All Prosthetic Joint Infections (n=138)**

**Figure 2.** Early Prosthetic Hip Joint Infection (A) at presentation with infection showing wound erythema, swelling and purulent discharge and (B) intra-operative appearance showing purulence surrounding the prosthetic joint.

The presentation of shoulder arthroplasty infection due to *Propionibacterium* acnes is general‐ ly delayed or late[12]. The classic features of infection are frequently absent with pain and stiffness of the joint the predominant symptoms [12, 34]. Bruising along the surgical wound has been described as a pathognomonic sign of *Propionibacterium acnes* shoulder arthroplasty infection [34].

### **5. Diagnosis of prosthetic joint infections**

B

The diagnosis of infections is challenging due to the absence of an internationally accepted gold standard for defining arthroplasty infection. Current definitions rely on a number of pa‐ rameters including clinical, microbiological and histopathological features (Table 2) [3, 35-39]. Prompt recognition and diagnosis of prosthetic joint infection is imperative to minimize pa‐ tient suffering and to improve patient outcomes [40]. Isolation of the causative microorganism is the most important diagnostic test as it allows confirmation of diagnosis and assessment of antimicrobial susceptibilities. Infection of the prosthesis is suggested by the isolation of the same microorganism from 2 or more intra-operative specimens [3, 35, 36] To increase the likeli‐ hood of diagnosis, ≥5 peri-prosthetic tissue specimens should be obtained intra-operatively with each specimen placed in separate sterile containers [35, 36]. This is of particular impor‐ tance for skin commensals such as *Propionibacterium acnes* and coagulase negative Staphylococ‐ cus species to aid in distinguishing true infection from specimen contamination.

ment of mobility. Chronic suppression is association with a high rate of recurrence of infection. Therefore these strategies are reserved for patients with significant co-morbidities or in patients with recalcitrant infection [3, 33]. Exchange procedures and debridement and

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retention are the two strategies that best meet the goals of treatment [3, 33].

**Figure 3.** SVHM Protocol Algorithm for Management of Prosthetic Joint Infection

Given the heterogeneous nature of prosthetic joint infections there are no large randomized control trials to guide recommendations. Surgical strategies differ significantly worldwide; ex‐

The diagnosis of prosthetic joint infection should be considered in patients with any of the following [3, 36-39]: Presence of peri-prosthetic purulence observed intra-operatively; OR

Isolation of indistinguishable micro-organism/s on ≥2 intra-operative specimens (tissue or joint aspirate cultures); OR Presence of a sinus tract in communication with the prosthetic joint; OR

Histopathological features of acute infections with ≥5 neutrophils per-high power field (x 500 magnifications) in 5 different microscopic fields.

**Table 2.** Diagnosis of Prosthetic Joint Infection

Prior exposure to antibiotic therapy increases the risk of culture negative prosthetic joint in‐ fection [30, 37, 41]. Therefore antibiotic therapy should not be commenced until after obtain‐ ing multiple intra-operative specimens, except in the case of the septic patient in whom commencement of antibiotic therapy should not be delayed. In patients with delayed and late infections, who have received antibiotic therapy prior to obtainment of intra-operative cultures, definitive surgery may be delayed for 2-4 weeks after cessation of antibiotics to in‐ crease the intra-operative yield[30, 37, 41].

Sonication of the explanted prosthesis disrupts the biofilm and may increase the diagnostic yield of microbiological culture. Sonication is particularly useful in patients who have re‐ ceived antibiotics in 14 days preceding surgery [37]. Prolongation of microbiological cul‐ tures from 3 to 14 days also increases the diagnostic yield, particularly of more fastidious organisms such as *Propionibacterium acnes* [42].

### **6. Management of prosthetic joint infection**

The goal of treatment of prosthetic joint infection is to eradicate the biofilm dwelling micro‐ organisms, whilst maintaining function of the joint and patient quality of life[3].

The surgical strategies to manage prosthetic joint infection include: (i) one-stage or twostage exchange procedures, (ii) debridement and retention of the prosthesis in conjunction with biofilm active antibiotics, (iii) removal of the prosthesis +/- arthrodesis, (iv) amputation of the affected limb and (v) chronic suppression without surgical debridement of the infect‐ ed joint. Removal of the prosthesis and amputation are associated with significant impair‐ ment of mobility. Chronic suppression is association with a high rate of recurrence of infection. Therefore these strategies are reserved for patients with significant co-morbidities or in patients with recalcitrant infection [3, 33]. Exchange procedures and debridement and retention are the two strategies that best meet the goals of treatment [3, 33].

Prompt recognition and diagnosis of prosthetic joint infection is imperative to minimize pa‐ tient suffering and to improve patient outcomes [40]. Isolation of the causative microorganism is the most important diagnostic test as it allows confirmation of diagnosis and assessment of antimicrobial susceptibilities. Infection of the prosthesis is suggested by the isolation of the same microorganism from 2 or more intra-operative specimens [3, 35, 36] To increase the likeli‐ hood of diagnosis, ≥5 peri-prosthetic tissue specimens should be obtained intra-operatively with each specimen placed in separate sterile containers [35, 36]. This is of particular impor‐ tance for skin commensals such as *Propionibacterium acnes* and coagulase negative Staphylococ‐

cus species to aid in distinguishing true infection from specimen contamination.

Presence of peri-prosthetic purulence observed intra-operatively; OR

Presence of a sinus tract in communication with the prosthetic joint; OR

different microscopic fields.

522 Arthroplasty - Update

**Table 2.** Diagnosis of Prosthetic Joint Infection

crease the intra-operative yield[30, 37, 41].

organisms such as *Propionibacterium acnes* [42].

**6. Management of prosthetic joint infection**

The diagnosis of prosthetic joint infection should be considered in patients with any of the following [3, 36-39]:

Isolation of indistinguishable micro-organism/s on ≥2 intra-operative specimens (tissue or joint aspirate cultures); OR

Histopathological features of acute infections with ≥5 neutrophils per-high power field (x 500 magnifications) in 5

Prior exposure to antibiotic therapy increases the risk of culture negative prosthetic joint in‐ fection [30, 37, 41]. Therefore antibiotic therapy should not be commenced until after obtain‐ ing multiple intra-operative specimens, except in the case of the septic patient in whom commencement of antibiotic therapy should not be delayed. In patients with delayed and late infections, who have received antibiotic therapy prior to obtainment of intra-operative cultures, definitive surgery may be delayed for 2-4 weeks after cessation of antibiotics to in‐

Sonication of the explanted prosthesis disrupts the biofilm and may increase the diagnostic yield of microbiological culture. Sonication is particularly useful in patients who have re‐ ceived antibiotics in 14 days preceding surgery [37]. Prolongation of microbiological cul‐ tures from 3 to 14 days also increases the diagnostic yield, particularly of more fastidious

The goal of treatment of prosthetic joint infection is to eradicate the biofilm dwelling micro‐

The surgical strategies to manage prosthetic joint infection include: (i) one-stage or twostage exchange procedures, (ii) debridement and retention of the prosthesis in conjunction with biofilm active antibiotics, (iii) removal of the prosthesis +/- arthrodesis, (iv) amputation of the affected limb and (v) chronic suppression without surgical debridement of the infect‐ ed joint. Removal of the prosthesis and amputation are associated with significant impair‐

organisms, whilst maintaining function of the joint and patient quality of life[3].

**Figure 3.** SVHM Protocol Algorithm for Management of Prosthetic Joint Infection

Given the heterogeneous nature of prosthetic joint infections there are no large randomized control trials to guide recommendations. Surgical strategies differ significantly worldwide; ex‐ change procedures are the favoured treatment modality in Northern America, whereas de‐ bridement and retention is more commonly performed in Australia and parts of Europe [3, 26, 33]. A number of treatment algorithms exist to guide management decisions and these are based on factors such as duration of symptoms, the stability of implant, patient co-morbidities and the type of infecting microorganism[3, 33]. Compared to the exchange procedures, pa‐ tients managed with debridement and retention of the implant undergo fewer and less exten‐ sive surgical procedures and have shorter duration of hospitalisation and immobilisation [3, 33, 43]. Therefore early and haematogenous infections can be managed by debridement and re‐ tention. However, if the implant is loose, if the duration of symptoms prior to presentation ex‐ ceed 21 days or if the isolated pathogen is resistant to biofilm-active antibiotics, the likelihood of treatment success for debridement and retention is markedly reduced[3, 33]. Therefore if the patient has any of the above features, expert opinion recommends patients undergo prosthesis exchange (either as a one-stage or two-stage procedure). Delayed or late prosthetic joint infec‐ tions should be managed by one- or two-stage exchange; debridement and retention of the prosthesis in this setting is associated with a high failure rate[3, 33].

as the patient can reliably take oral diet after completion of surgical debridements. For those few patients who are bacteraemic, however, more prolonged intravenous therapy may be required along with appropriate investigation to exclude other foci of infection,

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In patients with MRSA infections managed with two-stage exchange; the insertion of a spacer should be avoided as there is an increased rate of treatment failure [3, 33, 53]. In addi‐ tion, an association between the presence of a spacer and the development of rifampicin re‐

Streptococcus are the causative agent in 8% of prosthetic joint infections[26]. In general the treatment outcomes are excellent for all surgical strategies for Streptococcal arthroplasty in‐ fection [54-58]. However, the outcomes with group B streptococcal infections are mixed with some studies reporting poorer outcomes with these isolates [58-60]. In general intravenous benzylpenicillin or ceftriaxone can be used (often for 2 weeks) before a shift to high dose or‐ al amoxicillin. In some circumstances, with typable streptococci where susceptibility to ri‐ fampicin is expected, rifampicin can be added to the amoxicillin as part of the oral regimen

Enterococcus is an uncommon cause of prosthetic joint infection however, the incidence of these infections is increasing[61]. At our institution, *Enterococcus faecalis* was isolated in 10% of all infections. It is a common isolate in polymicrobial infections of the prosthetic hip joint. There are little published data to guide treatment of enterococcal prosthetic joint infection. Some experts recommend treatment strategies extrapolated from other enterococcal infec‐ tions, in particular enterococcal endocarditis [61]. Beta-lactam antibiotics, such as penicillin are bacteriostatic against enterococci, therefore combination therapy with aminoglycosides such as gentamicin, is recommended for management of enterococcal endocarditis[62]. However data from retrospective studies suggest there is no additional benefit with combi‐ nation therapy with aminoglycosides in enterococcal prosthetic joint infections and, of great concern, there was significant nephrotoxicity and ototoxicity associated with aminoglyco‐ side therapy[61]. Euba et al examined the role of ampicillin-ceftriaxone combination thera‐ py, however, only 3 patients with enterococcal prosthetic joint infection were included in this study and 2 of those patients had late infections[63]. Therefore the role of this combina‐ tion therapy remains unclear and further studies are required. Recent in-vitro models have suggested rifampicin in combination either with ciprofloxacin or linezolid are the most effi‐ cacious antibiotic combinations against biofilm dwelling Enterococcus faecalis, although

there are no reports at present of the use of these combinations in patients[64].

such as endocarditis.

**8. Streptococcus**

**9. Enterococcus**

sistance in MRSA strains has been reported [53].

although the evidence for this practice is still not clear.

At SVHM, a management protocol was established through collaboration between the Ortho‐ paedic and Infectious Diseases Departments. The abbreviated algorithm is shown in Figure 3. The antibiotic regimens for different pathogens are detailed in Table 3. At SVHM patients man‐ aged by debridement and retention of the prosthesis undergo 3 debridements of the infected joint. The liner is changed, where feasible, but other mobile parts are not routinely changed. This differs from other protocols for debridement and retention, in which patients undergo a single debridement with exchange of all mobile parts and liners [33]. Regardless of technique, the aim of the debridement/s is to reduce the microbial burden prior to instigation of antibiotic therapy with activity against the biofilm-dwelling microorganisms.

### **7. Staphylococcus aureus and coagulase negative Staphylococcus species**

Rifampicin has excellent activity against Staphylococcal biofilms and is the mainstay of treatment in these infections, particularly with debridement and retention [3, 33, 44-46]. Older treatment algorithms recommended against debridement and retention for MRSA however, emerging evidence suggests that this is a suitable strategy in carefully selected patients [33, 46, 47].

Staphylococcus becomes rapidly resistant to rifampicin if this antibiotic is used alone, therefore rifampicin must always be administered with a second agent (companion drug) [48]. Fluoroquinolones, such as ciprofloxacin, are frequently used as companion drugs however fluoroquinolone resistance is increasing thus limiting the utility of this combina‐ tion[25]. Alternate companion drugs for rifampicin include fusidic acid, trimethoprim-sul‐ famethoxazole, minocycline, daptomycin and linezolid [33, 47-52]. There are no clinical studies comparing the efficacy of different drugs used in combination with rifampicin. In Australia including SVHM, fusidic acid is commonly prescribed as a companion drug for rifampicin [47] [26].

Rifampicin based regimens are recommended even for methicillin sensitive isolates. Giv‐ en the high oral bioavailability of rifampicin, a move to oral therapy is suggested as soon as the patient can reliably take oral diet after completion of surgical debridements. For those few patients who are bacteraemic, however, more prolonged intravenous therapy may be required along with appropriate investigation to exclude other foci of infection, such as endocarditis.

In patients with MRSA infections managed with two-stage exchange; the insertion of a spacer should be avoided as there is an increased rate of treatment failure [3, 33, 53]. In addi‐ tion, an association between the presence of a spacer and the development of rifampicin re‐ sistance in MRSA strains has been reported [53].

### **8. Streptococcus**

change procedures are the favoured treatment modality in Northern America, whereas de‐ bridement and retention is more commonly performed in Australia and parts of Europe [3, 26, 33]. A number of treatment algorithms exist to guide management decisions and these are based on factors such as duration of symptoms, the stability of implant, patient co-morbidities and the type of infecting microorganism[3, 33]. Compared to the exchange procedures, pa‐ tients managed with debridement and retention of the implant undergo fewer and less exten‐ sive surgical procedures and have shorter duration of hospitalisation and immobilisation [3, 33, 43]. Therefore early and haematogenous infections can be managed by debridement and re‐ tention. However, if the implant is loose, if the duration of symptoms prior to presentation ex‐ ceed 21 days or if the isolated pathogen is resistant to biofilm-active antibiotics, the likelihood of treatment success for debridement and retention is markedly reduced[3, 33]. Therefore if the patient has any of the above features, expert opinion recommends patients undergo prosthesis exchange (either as a one-stage or two-stage procedure). Delayed or late prosthetic joint infec‐ tions should be managed by one- or two-stage exchange; debridement and retention of the

At SVHM, a management protocol was established through collaboration between the Ortho‐ paedic and Infectious Diseases Departments. The abbreviated algorithm is shown in Figure 3. The antibiotic regimens for different pathogens are detailed in Table 3. At SVHM patients man‐ aged by debridement and retention of the prosthesis undergo 3 debridements of the infected joint. The liner is changed, where feasible, but other mobile parts are not routinely changed. This differs from other protocols for debridement and retention, in which patients undergo a single debridement with exchange of all mobile parts and liners [33]. Regardless of technique, the aim of the debridement/s is to reduce the microbial burden prior to instigation of antibiotic

**7. Staphylococcus aureus and coagulase negative Staphylococcus species**

Rifampicin has excellent activity against Staphylococcal biofilms and is the mainstay of treatment in these infections, particularly with debridement and retention [3, 33, 44-46]. Older treatment algorithms recommended against debridement and retention for MRSA however, emerging evidence suggests that this is a suitable strategy in carefully selected

Staphylococcus becomes rapidly resistant to rifampicin if this antibiotic is used alone, therefore rifampicin must always be administered with a second agent (companion drug) [48]. Fluoroquinolones, such as ciprofloxacin, are frequently used as companion drugs however fluoroquinolone resistance is increasing thus limiting the utility of this combina‐ tion[25]. Alternate companion drugs for rifampicin include fusidic acid, trimethoprim-sul‐ famethoxazole, minocycline, daptomycin and linezolid [33, 47-52]. There are no clinical studies comparing the efficacy of different drugs used in combination with rifampicin. In Australia including SVHM, fusidic acid is commonly prescribed as a companion drug for

Rifampicin based regimens are recommended even for methicillin sensitive isolates. Giv‐ en the high oral bioavailability of rifampicin, a move to oral therapy is suggested as soon

prosthesis in this setting is associated with a high failure rate[3, 33].

therapy with activity against the biofilm-dwelling microorganisms.

patients [33, 46, 47].

524 Arthroplasty - Update

rifampicin [47] [26].

Streptococcus are the causative agent in 8% of prosthetic joint infections[26]. In general the treatment outcomes are excellent for all surgical strategies for Streptococcal arthroplasty in‐ fection [54-58]. However, the outcomes with group B streptococcal infections are mixed with some studies reporting poorer outcomes with these isolates [58-60]. In general intravenous benzylpenicillin or ceftriaxone can be used (often for 2 weeks) before a shift to high dose or‐ al amoxicillin. In some circumstances, with typable streptococci where susceptibility to ri‐ fampicin is expected, rifampicin can be added to the amoxicillin as part of the oral regimen although the evidence for this practice is still not clear.

#### **9. Enterococcus**

Enterococcus is an uncommon cause of prosthetic joint infection however, the incidence of these infections is increasing[61]. At our institution, *Enterococcus faecalis* was isolated in 10% of all infections. It is a common isolate in polymicrobial infections of the prosthetic hip joint. There are little published data to guide treatment of enterococcal prosthetic joint infection. Some experts recommend treatment strategies extrapolated from other enterococcal infec‐ tions, in particular enterococcal endocarditis [61]. Beta-lactam antibiotics, such as penicillin are bacteriostatic against enterococci, therefore combination therapy with aminoglycosides such as gentamicin, is recommended for management of enterococcal endocarditis[62]. However data from retrospective studies suggest there is no additional benefit with combi‐ nation therapy with aminoglycosides in enterococcal prosthetic joint infections and, of great concern, there was significant nephrotoxicity and ototoxicity associated with aminoglyco‐ side therapy[61]. Euba et al examined the role of ampicillin-ceftriaxone combination thera‐ py, however, only 3 patients with enterococcal prosthetic joint infection were included in this study and 2 of those patients had late infections[63]. Therefore the role of this combina‐ tion therapy remains unclear and further studies are required. Recent in-vitro models have suggested rifampicin in combination either with ciprofloxacin or linezolid are the most effi‐ cacious antibiotic combinations against biofilm dwelling Enterococcus faecalis, although there are no reports at present of the use of these combinations in patients[64].

*Enterococcus faecium* is infrequently involved in prosthetic joint infections; however, it presents significant treatment challenges, owing to increased resistance when compared to *Enterococcus* faecalis. In particular, *Enterococcus faecium* is increasingly resistant to benzylpe‐ nicillin and amoxicillin[62]. There is little clinical data outlining management approaches for *Enterococcus faecium*, however, exchange procedures are likely to be the optimal strategy in these infections. Other resistant enterococcal prosthetic joint infection including vancomycin resistant enterococcus (VRE), also are very uncommon. In a statewide review of 163 pros‐ thetic joint infections, VRE was isolated once (0.6%). Two-stage exchange of the prosthesis is recommended for VRE arthroplasty infections in conjunction with agents such as daptomy‐ cin, linezolid or pristinamycin. In all enterococcal infections, including VRE, the use of spacers in two-stage exchange procedures is not recommended due to the increased risk of treatment failure [3, 33].

The antibiotic regimens reported to treat patients with *Propionibacterium acnes* prosthetic joint infection are diverse and include: penicillin, amoxicillin, ceftriaxone, clindamycin and rifampicin-fluoroquinolone or rifampicin-clindamycin combination therapy [73, 74]. In gen‐ eral, we recommend IV benzylpenicillin followed by high dose oral amoxicillin combined

Fungal prosthetic joint infections are rare. The majority of fungal prosthetic joint infections are due to Candida species however, other fungal species have been reported including As‐ pergillus species, *Cryptococcus neoformans*, Zygomycetes, *Histoplasma capsulatum, Rhodotorula*

The results for debridement and retention and exchange procedures for management of fun‐ gal prosthetic joint are poor. In treatment guidelines from the Infectious Diseases Society of America, resection arthroplasty is recommended for prosthetic joint infection due to candi‐ dal species[79]. In addition, the use of a spacer following resection of the prosthesis is associ‐ ated with a high rate of failure and should be avoided [75, 80]. If reimplantation is considered following prosthesis resection, a prolonged period (3-6 months) prior to reinser‐ tion is recommended [81]. Finally, in candidal prosthetic joint infections, there is emerging evidence that the activity of caspofungin is better preserved in the presence of biofilm, com‐ pared to fluconazole [80, 82]. For other non candidal fungi, individualized expert advice

**Figure 4.** Rhizopus species cultured from an infected prosthetic hip joint. Photo courtesy of Dr Harsha Sheorey, Micro‐

*These microbiological cultures were obtained from a patient with disseminated Rhizopus infection including prosthetic hip joint involvement. The patient had significant comorbidities and was managed with debridement and retention of the prosthesis and long-term posaconazole therapy[76].* 

Management of Prosthetic Infection According to Organism

http://dx.doi.org/10.5772/53244

527

with rifampicin.

*minuta* [75-78] (figure 4).

should be sought to guide antimicrobial choice.

biology Department, St Vincent's Hospital Melbourne.

**12. Fungi**

### **10. Gram negative bacilli**

For gram-negative bacilli infections, ciprofloxacin has been shown to be effective in guinea pig tissue cage models[65]. There is conflicting data on the clinical outcomes of gram-nega‐ tive bacilli infections, particularly with debridement and retention. The reported success rate for debridement and retention ranges from 27%-94% with a similar range reported for ex‐ change procedures [66-70]. The likelihood of success may relate to the quality of the de‐ bridement and meticulous care should be taken to ensure removal of all dead and devitalised tissue and removal of all cement in the exchange procedures [69]. In addition, gram-negative bacteria, particularly *Pseudomonas aeruginosa*, have a propensity to develop resistance to fluoroquinolones in-vivo[62]. In light of this, many experts recommend a 2-4 week course of beta-lactam antibiotic prior to commencement of ciprofloxacin to reduce the bacterial load and thus reduce the likelihood of generation of in-vivo resistance [33].

### **11. Propionibacterium**

As with all other infections, the duration of symptoms dictates the most appropriate surgical strategy for *Propionibacterium acnes* prosthetic joint infection. In *Propionibacterium* arthroplas‐ ty infection, the majority of cases are delayed or late presentations, with a long duration of symptoms[12]. Therefore prosthesis exchange is the surgical modality of choice.

Evidence of the ability of *Propionibacterium acnes* to form biofilms is emerging. A number of in-vitro models have been developed to assess the activity of antibiotics against biofilm-as‐ sociated *Propionibacterium*. As with staphylococcal biofilm models, the activity of rifampicin is preserved with *Propionibacterium* biofilms[71]. The emergence of rifampicin resistance with monotherapy has not been demonstrated[71]. In one study combination therapy with daptomycin and rifampicin was the most effective treatment regimen[71]. Other studies have demonstrated penicillin alone or combination therapy with rifampicin and linezolid are also effective against *Propionibacterium* biofilms[72].

The antibiotic regimens reported to treat patients with *Propionibacterium acnes* prosthetic joint infection are diverse and include: penicillin, amoxicillin, ceftriaxone, clindamycin and rifampicin-fluoroquinolone or rifampicin-clindamycin combination therapy [73, 74]. In gen‐ eral, we recommend IV benzylpenicillin followed by high dose oral amoxicillin combined with rifampicin.

### **12. Fungi**

*Enterococcus faecium* is infrequently involved in prosthetic joint infections; however, it presents significant treatment challenges, owing to increased resistance when compared to *Enterococcus* faecalis. In particular, *Enterococcus faecium* is increasingly resistant to benzylpe‐ nicillin and amoxicillin[62]. There is little clinical data outlining management approaches for *Enterococcus faecium*, however, exchange procedures are likely to be the optimal strategy in these infections. Other resistant enterococcal prosthetic joint infection including vancomycin resistant enterococcus (VRE), also are very uncommon. In a statewide review of 163 pros‐ thetic joint infections, VRE was isolated once (0.6%). Two-stage exchange of the prosthesis is recommended for VRE arthroplasty infections in conjunction with agents such as daptomy‐ cin, linezolid or pristinamycin. In all enterococcal infections, including VRE, the use of spacers in two-stage exchange procedures is not recommended due to the increased risk of

For gram-negative bacilli infections, ciprofloxacin has been shown to be effective in guinea pig tissue cage models[65]. There is conflicting data on the clinical outcomes of gram-nega‐ tive bacilli infections, particularly with debridement and retention. The reported success rate for debridement and retention ranges from 27%-94% with a similar range reported for ex‐ change procedures [66-70]. The likelihood of success may relate to the quality of the de‐ bridement and meticulous care should be taken to ensure removal of all dead and devitalised tissue and removal of all cement in the exchange procedures [69]. In addition, gram-negative bacteria, particularly *Pseudomonas aeruginosa*, have a propensity to develop resistance to fluoroquinolones in-vivo[62]. In light of this, many experts recommend a 2-4 week course of beta-lactam antibiotic prior to commencement of ciprofloxacin to reduce the

bacterial load and thus reduce the likelihood of generation of in-vivo resistance [33].

symptoms[12]. Therefore prosthesis exchange is the surgical modality of choice.

are also effective against *Propionibacterium* biofilms[72].

As with all other infections, the duration of symptoms dictates the most appropriate surgical strategy for *Propionibacterium acnes* prosthetic joint infection. In *Propionibacterium* arthroplas‐ ty infection, the majority of cases are delayed or late presentations, with a long duration of

Evidence of the ability of *Propionibacterium acnes* to form biofilms is emerging. A number of in-vitro models have been developed to assess the activity of antibiotics against biofilm-as‐ sociated *Propionibacterium*. As with staphylococcal biofilm models, the activity of rifampicin is preserved with *Propionibacterium* biofilms[71]. The emergence of rifampicin resistance with monotherapy has not been demonstrated[71]. In one study combination therapy with daptomycin and rifampicin was the most effective treatment regimen[71]. Other studies have demonstrated penicillin alone or combination therapy with rifampicin and linezolid

treatment failure [3, 33].

526 Arthroplasty - Update

**10. Gram negative bacilli**

**11. Propionibacterium**

Fungal prosthetic joint infections are rare. The majority of fungal prosthetic joint infections are due to Candida species however, other fungal species have been reported including As‐ pergillus species, *Cryptococcus neoformans*, Zygomycetes, *Histoplasma capsulatum, Rhodotorula minuta* [75-78] (figure 4).

The results for debridement and retention and exchange procedures for management of fun‐ gal prosthetic joint are poor. In treatment guidelines from the Infectious Diseases Society of America, resection arthroplasty is recommended for prosthetic joint infection due to candi‐ dal species[79]. In addition, the use of a spacer following resection of the prosthesis is associ‐ ated with a high rate of failure and should be avoided [75, 80]. If reimplantation is considered following prosthesis resection, a prolonged period (3-6 months) prior to reinser‐ tion is recommended [81]. Finally, in candidal prosthetic joint infections, there is emerging evidence that the activity of caspofungin is better preserved in the presence of biofilm, com‐ pared to fluconazole [80, 82]. For other non candidal fungi, individualized expert advice should be sought to guide antimicrobial choice.

**Figure 4.** Rhizopus species cultured from an infected prosthetic hip joint. Photo courtesy of Dr Harsha Sheorey, Micro‐ biology Department, St Vincent's Hospital Melbourne.

#### **13. Culture negative**

One of the greatest challenges in management is the 'culture negative' prosthetic joint in‐ fection. In published case series, the reported rate of culture-negative prosthetic joint in‐ fection ranges from 5-41% [3, 27, 83]. A number of factors contribute to the failure of microbiological cultures to isolate a pathogen including poor culture technique (including obtaining fewer than 5 intra-operative specimens), fastidious organisms that are difficult to culture and prior antibiotic exposure that impedes bacterial growth. Of these mecha‐ nisms, prior antibiotic exposure is the most common reason for failing to isolate a causa‐ tive pathogen. In some studies, 44% of patients with culture negative prosthetic joint infection were receiving antibiotic therapy at the time of obtainment of microbiological specimens[30]. Indeed, the receipt of antibiotics in the 3 months prior to presentation with prosthetic joint infection, lead to a 5-fold increased chance of culture-negative prosthetic joint infection [41].

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The choice of antibiotic treatment in culture negative prosthetic joint infection should be guided by local ecology. In addition, if patients had prior exposure to antibiotic therapy, the spectrum of these antibiotics may also influence subsequent antibiotic selection. The results for culture negative prosthetic joint infection are generally similar to culture positive pros‐ thetic joint infection [41].

#### **14. Conclusion**

With an ageing population and the increasing popularity of arthroplasty, prosthetic joint in‐ fection will continue to present a diagnostic and management challenge to clinicians. Treat‐ ment approaches for arthroplasty infection are still under debate, in particular, optimal treatment strategy for different microorganisms. Increasing understanding of the role of bio‐ film in the pathogenesis of prosthetic joint infections and investigation of the activity of dif‐ ferent antimicrobial agents against biofilm associated microorganisms will provide important information to guide therapy. In addition, multicentre studies and collaborative research groups are key to providing more detailed treatment particularly for less common‐ ly encountered pathogens.

### **Author details**

Trisha Peel, Kirsty Buising, Michelle Dowsey and Peter Choong

University of Melbourne, St. Vincent's Hospital Melbourne, Australia

### **References**

**13. Culture negative**

528 Arthroplasty - Update

joint infection [41].

thetic joint infection [41].

ly encountered pathogens.

Trisha Peel, Kirsty Buising, Michelle Dowsey and Peter Choong

University of Melbourne, St. Vincent's Hospital Melbourne, Australia

**Author details**

**14. Conclusion**

One of the greatest challenges in management is the 'culture negative' prosthetic joint in‐ fection. In published case series, the reported rate of culture-negative prosthetic joint in‐ fection ranges from 5-41% [3, 27, 83]. A number of factors contribute to the failure of microbiological cultures to isolate a pathogen including poor culture technique (including obtaining fewer than 5 intra-operative specimens), fastidious organisms that are difficult to culture and prior antibiotic exposure that impedes bacterial growth. Of these mecha‐ nisms, prior antibiotic exposure is the most common reason for failing to isolate a causa‐ tive pathogen. In some studies, 44% of patients with culture negative prosthetic joint infection were receiving antibiotic therapy at the time of obtainment of microbiological specimens[30]. Indeed, the receipt of antibiotics in the 3 months prior to presentation with prosthetic joint infection, lead to a 5-fold increased chance of culture-negative prosthetic

The choice of antibiotic treatment in culture negative prosthetic joint infection should be guided by local ecology. In addition, if patients had prior exposure to antibiotic therapy, the spectrum of these antibiotics may also influence subsequent antibiotic selection. The results for culture negative prosthetic joint infection are generally similar to culture positive pros‐

With an ageing population and the increasing popularity of arthroplasty, prosthetic joint in‐ fection will continue to present a diagnostic and management challenge to clinicians. Treat‐ ment approaches for arthroplasty infection are still under debate, in particular, optimal treatment strategy for different microorganisms. Increasing understanding of the role of bio‐ film in the pathogenesis of prosthetic joint infections and investigation of the activity of dif‐ ferent antimicrobial agents against biofilm associated microorganisms will provide important information to guide therapy. In addition, multicentre studies and collaborative research groups are key to providing more detailed treatment particularly for less common‐


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[66] Hsieh P-H, Lee MS, Hsu K-Y, Chang Y-H, Shih H-N, Ueng SW. Gram-negative pros‐ thetic joint infections: risk factors and outcome of treatment. Clinical Infectious Dis‐

[67] Aboltins CA, Dowsey MM, Buising KL, Peel TN, Daffy JR, Choong PF, et al. Gramnegative prosthetic joint infection treated with debridement, prosthesis retention and antibiotic regimens including a fluoroquinolone. Clinical Microbiology and Infection.

[68] Legout L, Senneville E, Stern R, Yazdanpanah Y, Savage C, Roussel-Delvalez M, et al. Treatment of bone and joint infections caused by gram-negative bacilli with a cefe‐ pime-fluoroquinolone combination. Clinical Microbiology and Infection. 2006;12(10):

[69] McDonald DJ, Fitzgerald RH, Ilstrup DM. Two-stage reconstruction of a total hip ar‐ throplasty because of infection. Journal of Bone and Joint Surgery. 1989;71(6):828-34.

[70] Salvati EA, Chekofsky KM, Brause BD, Wilson PD. Reimplantation in infection. Clin‐

[71] Tafin UF, Corvec S, Betrisey B, Zimmerli W, Trampuz A. Role of rifampin against Propionibacterium acnes biofilm in vitro and in an experimental foreign-body infec‐

[72] Bayston R, Nuradeen B, Ashraf W, Freeman BJ. Antibiotics for the eradication of Pro‐ pionibacterium acnes biofilms in surgical infection. Journal of Antimicrobial Chemo‐

[73] Lutz MF, Berthelot P, Fresard A, Cazorla C, Carricajo A, Vautrin AC, et al. Arthro‐ plastic and osteosynthetic infections due to Propionibacterium acnes: a retrospective study of 52 cases, 1995-2002. European Journal of Clinical Microbiology and Infec‐

[74] Zeller V, Ghorbani A, Strady C, Leonard P, Mamoudy P, Desplaces N. Propionibacte‐ rium acnes: an agent of prosthetic joint infection and colonization. Journal of Infec‐

[75] Azzam K, Parvizi J, Jungkind D, Hanssen A, Fehring T, Springer B, et al. Microbio‐ logical, clinical, and surgical features of fungal prosthetic joint infections: a multi-in‐ stitutional experience. Journal of Bone and Joint Surgery. 2009;91-A Suppl 6:142-9. [76] Peel T, Daffy J, Thursky K, Stanley P, Buising K. Posaconazole as first line treatment

[77] Johannsson B, Callaghan JJ. Prosthetic hip infection due to Cryptococcus neofor‐ mans: case report. Diagnostic Microbiology and Infectious Disease. 2009;64(1):76-9.

tion model. Antimicrobial Agents and Chemotherapy 2012;56(4):1885-91.

ical Orthopaedics and Related Research. 1982;170:62-75.

for disseminated zygomycosis. Mycoses. 2008;51(6):542-5.

Agents and Chemotherapy. 1991;35(4):741-6.

eases. 2009;49(7):1036-43.

therapy 2007;60(6):1298-301.

tious Diseases 2005;24(11):739-44.

tion. 2007;55(2):119-24.

2011;17(6):862-7.

1030-3.

534 Arthroplasty - Update


**Chapter 24**

**Periprosthetic Infection**

Michael Soudry, Arnan Greental,

Nahum Rosenberg

**1. Introduction**

http://dx.doi.org/10.5772/53250

Gabriel Nierenberg, Mazen Falah and

Additional information is available at the end of the chapter

future improvement of the treatment modalities.

**2. Pathology and microbiology**

One of the most devastating complications of prosthetic knee arthroplasty is a periprosthetic infection. This complication occurs in 1-2% of knee arthroplasties [1,2] and can exceed 4% in immunocompromized individuals [3] and 7% after revision surgery [4]. Prosthetic infection leads to loosening of the implant, [5,6]. In this circumstances revision surgery is required. Because of the diversity of the clinical presentation, i.e. early, intermediate or late infection [1], different surgical methods to treat infected knee prostheses were developed [5,6]. Sever‐ al treatment methods became well accepted but others are still controversial. In the present review we intend to describe mainly the diagnostic tools for detection of infection and com‐ monly used treatment methods in failed total knee arthroplasty due to infection, with spe‐ cial emphasis on the surgical techniques. Additionally we will describe some trends for the

The main infecting pathogens, around 50%, of knee prostheses, are the different strains of *Staph‐ ylococci*, e.g. coagulase negative *Staphylococci* cause around 27% of knee prostheses infections and *Staphylococcus aureus* is responsible for 23% of infections, according to pooled data from nine different studies [7]. Most of the clinically significant infections are caused by biofilm producing microorganisms. The role of biofilms in pathogenesis of periprosthetic infection is the masking of the pathogens from bodily immune response and antibiotic access. Biofilm is a biological

> © 2013 Soudry et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

**Following Total Knee Arthroplasty**

### **Chapter 24**

## **Periprosthetic Infection Following Total Knee Arthroplasty**

Michael Soudry, Arnan Greental, Gabriel Nierenberg, Mazen Falah and Nahum Rosenberg

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/53250

### **1. Introduction**

One of the most devastating complications of prosthetic knee arthroplasty is a periprosthetic infection. This complication occurs in 1-2% of knee arthroplasties [1,2] and can exceed 4% in immunocompromized individuals [3] and 7% after revision surgery [4]. Prosthetic infection leads to loosening of the implant, [5,6]. In this circumstances revision surgery is required. Because of the diversity of the clinical presentation, i.e. early, intermediate or late infection [1], different surgical methods to treat infected knee prostheses were developed [5,6]. Sever‐ al treatment methods became well accepted but others are still controversial. In the present review we intend to describe mainly the diagnostic tools for detection of infection and com‐ monly used treatment methods in failed total knee arthroplasty due to infection, with spe‐ cial emphasis on the surgical techniques. Additionally we will describe some trends for the future improvement of the treatment modalities.

### **2. Pathology and microbiology**

The main infecting pathogens, around 50%, of knee prostheses, are the different strains of *Staph‐ ylococci*, e.g. coagulase negative *Staphylococci* cause around 27% of knee prostheses infections and *Staphylococcus aureus* is responsible for 23% of infections, according to pooled data from nine different studies [7]. Most of the clinically significant infections are caused by biofilm producing microorganisms. The role of biofilms in pathogenesis of periprosthetic infection is the masking of the pathogens from bodily immune response and antibiotic access. Biofilm is a biological

© 2013 Soudry et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

structure containing bacteria in a planktonic form imbedded in extracellular matrix made of dif‐ ferent polysaccharide molecules, proteins and extracellular DNA (Figure 1). Biofilm generation goes through four consecutive steps: adherence of the pathogens to the surface of prosthesis, ac‐ cumulation of the biofilm components, maturation of the biofilm and finally its detachment and spread of the microorganisms [8]. The ability of the microorganism to produce masking biofilm defines its virulence in prosthetic infection. Commensal bacteria, such as coagulase negative *Staphylococci* are more frequent in immediate and early prosthetic infections, when spread from the surgical wound edges and in late low grade infections. In late infections by hematogeous spread the *Staphylococcus aureus* is the most important causative factor [9].

*Plain films:* The appearance of rapidly progressive radiolucent lines surrounding an implant may be present during an infection. The resorption of subchondral bone and patchy osteo‐

Periprosthetic Infection Following Total Knee Arthroplasty

http://dx.doi.org/10.5772/53250

539

**Figure 2.** Radiograph of right knee (anterior-posterior view) showing radiolucency under the tibial component indi‐

*Bone scan*: bone scan can help confirm a diagnosis. However its high cost and its inability to provide acceptable levels of sensitivity and specificity have restricted its use. Although bone scintigraphy with technetium 99 m – labeled methylene diphosphonate has a high sensitivi‐ ty, it lacks specificity for infection [13]. A technetium bone scan remains positive more than one year after implantation because of increased periprosthetic bone remodeling. Bone scan alone without labeling of the white cell has been found to have no role in diagnosing pros‐ thetic joint infection. However, the use of indium 111 labeled leucocyte is time consuming

*Laboratory tests*: There is no evidence supporting the role of WBC and/or white cell blood dif‐ ferential in diagnosis of presence or absence of infection. ESR and CRP are valuable markers for both diagnosing and monitoring periprosthetic infection. After surgery the C Reactive protein level is elevated and return to normal within weeks. Serial postoperative measure‐

Elevated serum interleukin-6 level correlated positively with the presence of periprosthetic infection in patients undergoing a reoperation at the site of a total hip or knee arthroplasty.

porosis are strong elements of suspicion (Figure 2).

cating periprosthetic infection.

and requires specialized labelling facility [14].

ments are more informative than single values [15].

**Figure 1.** Microscopic image (H&E staining, scale 100μ) of biofilm found at the edge of retrieved tibial component of infected knee prosthesis. Amorphous fibrin-like substance, mostly acellular, is evident

### **3. Timing of occurence**

Infections associated with prosthetic joints are classified according to time at detection as: early (develop less than 3 months after surgery), delayed [3 to 24 months after surgery) or late (more than 24 months after surgery) [10]. Clinical manifestations are in relation with timing [11]. In early cases clinical manifestations are joint pain, effusion, erythema and warmth of the joint. In delayed cases there are subtle signs such as implant loosening, per‐ sistent joint pain. Infection is generally provoked by less virulent microorganism. Late are acquired during hematogenous seeding. In a study of infection with THA during a 16 years period, 29 % of cases were early infections, 41 % delayed and 30% late infections [12]*.*

### **4. Diagnosis**

Accurate and early diagnosis is the first step in effectively managing patients with prosthetic joint infection. Clinical history, physical examination, laboratory data and imaging studies are all taken into consideration. In addition to cultures, the most commonly used laboratory tests include serum inflammatory markers and synovial fluid cytology.

*Plain films:* The appearance of rapidly progressive radiolucent lines surrounding an implant may be present during an infection. The resorption of subchondral bone and patchy osteo‐ porosis are strong elements of suspicion (Figure 2).

structure containing bacteria in a planktonic form imbedded in extracellular matrix made of dif‐ ferent polysaccharide molecules, proteins and extracellular DNA (Figure 1). Biofilm generation goes through four consecutive steps: adherence of the pathogens to the surface of prosthesis, ac‐ cumulation of the biofilm components, maturation of the biofilm and finally its detachment and spread of the microorganisms [8]. The ability of the microorganism to produce masking biofilm defines its virulence in prosthetic infection. Commensal bacteria, such as coagulase negative *Staphylococci* are more frequent in immediate and early prosthetic infections, when spread from the surgical wound edges and in late low grade infections. In late infections by hematogeous

**Figure 1.** Microscopic image (H&E staining, scale 100μ) of biofilm found at the edge of retrieved tibial component of

Infections associated with prosthetic joints are classified according to time at detection as: early (develop less than 3 months after surgery), delayed [3 to 24 months after surgery) or late (more than 24 months after surgery) [10]. Clinical manifestations are in relation with timing [11]. In early cases clinical manifestations are joint pain, effusion, erythema and warmth of the joint. In delayed cases there are subtle signs such as implant loosening, per‐ sistent joint pain. Infection is generally provoked by less virulent microorganism. Late are acquired during hematogenous seeding. In a study of infection with THA during a 16 years

period, 29 % of cases were early infections, 41 % delayed and 30% late infections [12]*.*

tests include serum inflammatory markers and synovial fluid cytology.

Accurate and early diagnosis is the first step in effectively managing patients with prosthetic joint infection. Clinical history, physical examination, laboratory data and imaging studies are all taken into consideration. In addition to cultures, the most commonly used laboratory

spread the *Staphylococcus aureus* is the most important causative factor [9].

infected knee prosthesis. Amorphous fibrin-like substance, mostly acellular, is evident

**3. Timing of occurence**

538 Arthroplasty - Update

**4. Diagnosis**

**Figure 2.** Radiograph of right knee (anterior-posterior view) showing radiolucency under the tibial component indi‐ cating periprosthetic infection.

*Bone scan*: bone scan can help confirm a diagnosis. However its high cost and its inability to provide acceptable levels of sensitivity and specificity have restricted its use. Although bone scintigraphy with technetium 99 m – labeled methylene diphosphonate has a high sensitivi‐ ty, it lacks specificity for infection [13]. A technetium bone scan remains positive more than one year after implantation because of increased periprosthetic bone remodeling. Bone scan alone without labeling of the white cell has been found to have no role in diagnosing pros‐ thetic joint infection. However, the use of indium 111 labeled leucocyte is time consuming and requires specialized labelling facility [14].

*Laboratory tests*: There is no evidence supporting the role of WBC and/or white cell blood dif‐ ferential in diagnosis of presence or absence of infection. ESR and CRP are valuable markers for both diagnosing and monitoring periprosthetic infection. After surgery the C Reactive protein level is elevated and return to normal within weeks. Serial postoperative measure‐ ments are more informative than single values [15].

Elevated serum interleukin-6 level correlated positively with the presence of periprosthetic infection in patients undergoing a reoperation at the site of a total hip or knee arthroplasty. In a prospective, case-control study of 58 patients undergoing revision surgery of total hip and knee arthroplasties, serum Interleukin-6 values >10 pg/mL was reported to have a sensi‐ tivity of 100%, specificity of 95%, positive predictive value of 89%, negative predictive value of 100% and accuracy of 97% [16].

Physical examination should provide information about the patient's neurovascular situa‐ tion, articular mobility, the condition of their extensor mechanism and their soft tissues as well as about any previous incisions or the need of skin coverage by a plastic surgeon. Pre‐ operative planning is important. The final goal of treatment is to eradicate infection, ease the

Periprosthetic Infection Following Total Knee Arthroplasty

http://dx.doi.org/10.5772/53250

541

Efficiency of infection eradication with antibiotic therapy only is limited mainly due to the presence of foreign bodies, as implant and acrylic cement, and bacterial biofilm, therefore its

Indications for this type of treatment are as follows: 1) High operative risk due to medical co-morbidities; 2) Presence of low-virulence micro-organisms susceptible oral antibiotics

Antibiotic treatment should follow 3 basic principles: 1) Use of antibiotics of proven intracel‐ lular efficacy such as rifampicin, and new anti-staphylococcal agents. 2) Antibiotics should be combined, using a minimum of two to enhance the possibility of therapeutic success. 3)

The use of new antibiotics could improve results for resistant bacteria. The oxazolidinone linezolid is a new wide-spectrum antibiotic with very attractive pharmacokinetic and activi‐ ty profiles. It is an antibiotic that acts against methicillin-resistant staphylococci and vanco‐

In early infection debridement and irrigation, without removing the implant, are usually

The approach is through the previous surgical wound. Following division the subcutaneous

Beforehand, the surgeon should carefully evaluate the knee radiographs for any sign of loos‐ ening, slight change in the components position, heterotrophic bone formation. All these may indicate chronic situation. Following the surgical exposure the stability of the implant should be evaluated. If reactive tissue found to sprout at the edge of the implant, it also

Extensive debridement should be performed followed with vigorous irrigation. The debrid‐ ed tissue is sent for cultures and pathology while the implant preserved. When no reactive tissue left, last survey should include the gutters, the patellar tracking and the back fold of

Closure of the knee might need multi layers sutures, using non absorbable materials over heavy drain, which could be left in place for several days to the discharge to stop. Most sur‐ geons allow regular rehabilitation and long term IV antibiotics. Some surgeons leave antibi‐

otic beads and perform recurrent debridement prior to knee rehabilitation [23]

Long-standing administration, i.e. treatment should last a minimum of 6 months.

pain and preserve the limb's function.

**5.1. Antibiotic suppressive therapy**

mycin-resistant enterococci.

chosen for surgical treatment.

tissue the knee is aspirated again.

might indicate on chronicity of the infection.[23, 24, 25]

**5.2. Surgical treatment**

the knee.

use should be restricted to specific circumstances [21,22].

that can be tolerated by the patient; 3) Mechanically stable prosthesis.

*Knee aspirate cell count and differential*: Synovial fluid cell count and differential is a very useful diagnostic test. Antibiotics should be suspended, if possible, for 10 to 14 days before carrying out the aspiration. Traumatic aspirations will result in falsely elevated leukocyte counts.

*Polymerase chain reaction (PCR)*: This method is used to detect and amplify the presence of bacterial DNA. It is thought to be a quick method since it is not affected by whether the pa‐ tient takes antibiotics or not. However, a high percentage of false negative test results has been detected [17]. Therefore currently this technique can be used as a complementary diag‐ nostic tool to the methods described above.

*Sonication:* Organisms associated with prosthetic-joint infection are found attached to the prosthesis, where they often form biofilms. This suggests that obtaining a sample from the implant might improve the diagnosis of prosthetic joint infection by unmasking adherent bacteria from explanted prosthesis by sonication. It was found that culture of samples ob‐ tained by sonication of prostheses were more sensitive than conventional periprosthetic-tis‐ sue culture for the microbiologic diagnosis of prosthetic joint infection, especially in patients who had received antimicrobial therapy within 14 days before surgery [18].

*Intraoperative Frozen Section:* The analysis of frozen histological sections is a valuable tool for diagnosing infection. It most often used to assist decision-making in cases with equivocal se‐ rum inflammatory makers and aspirate cytology. The cutoff value of >5 neutrophils per high power field at a magnification of 400 is most commonly used for the diagnosis of infection. The sensitivity is more than 80 percent and a specificity of of more than 80 percent [19].

*Intraoperative Gram Stain:* This modality is unreliable (sensitivity = 27%) and should not be used routinely. The AAOS guideline recommends against the use of intraoperative gram stain to rule out periprosthetic infection [20].

### **5. Management of total knee arthroplasty infection**

There are several options when it comes to managing an infected TKA. But before we select any of these, we must take into consideration a series of factors. These factors include the amount of time elapsed from infection, host-related factors, condition of the soft tissues, condition of the implant, virulence of microorganism present and its degree of sensitivity and, last but not least, the patient's expectations and functional needs.

Planning for any one option requires having detailed clinical records, cultures, x-rays and information of previously received treatment. It is important to identify high-risk patients, i.e. those receiving immunosuppressive treatment or suffering from malnutrition or system‐ ic disease, trying to improve their general condition as much as possible before surgery. Physical examination should provide information about the patient's neurovascular situa‐ tion, articular mobility, the condition of their extensor mechanism and their soft tissues as well as about any previous incisions or the need of skin coverage by a plastic surgeon. Pre‐ operative planning is important. The final goal of treatment is to eradicate infection, ease the pain and preserve the limb's function.

#### **5.1. Antibiotic suppressive therapy**

In a prospective, case-control study of 58 patients undergoing revision surgery of total hip and knee arthroplasties, serum Interleukin-6 values >10 pg/mL was reported to have a sensi‐ tivity of 100%, specificity of 95%, positive predictive value of 89%, negative predictive value

*Knee aspirate cell count and differential*: Synovial fluid cell count and differential is a very useful diagnostic test. Antibiotics should be suspended, if possible, for 10 to 14 days before carrying out the aspiration. Traumatic aspirations will result in falsely elevated leukocyte counts.

*Polymerase chain reaction (PCR)*: This method is used to detect and amplify the presence of bacterial DNA. It is thought to be a quick method since it is not affected by whether the pa‐ tient takes antibiotics or not. However, a high percentage of false negative test results has been detected [17]. Therefore currently this technique can be used as a complementary diag‐

*Sonication:* Organisms associated with prosthetic-joint infection are found attached to the prosthesis, where they often form biofilms. This suggests that obtaining a sample from the implant might improve the diagnosis of prosthetic joint infection by unmasking adherent bacteria from explanted prosthesis by sonication. It was found that culture of samples ob‐ tained by sonication of prostheses were more sensitive than conventional periprosthetic-tis‐ sue culture for the microbiologic diagnosis of prosthetic joint infection, especially in patients

*Intraoperative Frozen Section:* The analysis of frozen histological sections is a valuable tool for diagnosing infection. It most often used to assist decision-making in cases with equivocal se‐ rum inflammatory makers and aspirate cytology. The cutoff value of >5 neutrophils per high power field at a magnification of 400 is most commonly used for the diagnosis of infection. The sensitivity is more than 80 percent and a specificity of of more than 80 percent [19].

*Intraoperative Gram Stain:* This modality is unreliable (sensitivity = 27%) and should not be used routinely. The AAOS guideline recommends against the use of intraoperative gram

There are several options when it comes to managing an infected TKA. But before we select any of these, we must take into consideration a series of factors. These factors include the amount of time elapsed from infection, host-related factors, condition of the soft tissues, condition of the implant, virulence of microorganism present and its degree of sensitivity

Planning for any one option requires having detailed clinical records, cultures, x-rays and information of previously received treatment. It is important to identify high-risk patients, i.e. those receiving immunosuppressive treatment or suffering from malnutrition or system‐ ic disease, trying to improve their general condition as much as possible before surgery.

who had received antimicrobial therapy within 14 days before surgery [18].

of 100% and accuracy of 97% [16].

540 Arthroplasty - Update

nostic tool to the methods described above.

stain to rule out periprosthetic infection [20].

**5. Management of total knee arthroplasty infection**

and, last but not least, the patient's expectations and functional needs.

Efficiency of infection eradication with antibiotic therapy only is limited mainly due to the presence of foreign bodies, as implant and acrylic cement, and bacterial biofilm, therefore its use should be restricted to specific circumstances [21,22].

Indications for this type of treatment are as follows: 1) High operative risk due to medical co-morbidities; 2) Presence of low-virulence micro-organisms susceptible oral antibiotics that can be tolerated by the patient; 3) Mechanically stable prosthesis.

Antibiotic treatment should follow 3 basic principles: 1) Use of antibiotics of proven intracel‐ lular efficacy such as rifampicin, and new anti-staphylococcal agents. 2) Antibiotics should be combined, using a minimum of two to enhance the possibility of therapeutic success. 3) Long-standing administration, i.e. treatment should last a minimum of 6 months.

The use of new antibiotics could improve results for resistant bacteria. The oxazolidinone linezolid is a new wide-spectrum antibiotic with very attractive pharmacokinetic and activi‐ ty profiles. It is an antibiotic that acts against methicillin-resistant staphylococci and vanco‐ mycin-resistant enterococci.

#### **5.2. Surgical treatment**

In early infection debridement and irrigation, without removing the implant, are usually chosen for surgical treatment.

The approach is through the previous surgical wound. Following division the subcutaneous tissue the knee is aspirated again.

Beforehand, the surgeon should carefully evaluate the knee radiographs for any sign of loos‐ ening, slight change in the components position, heterotrophic bone formation. All these may indicate chronic situation. Following the surgical exposure the stability of the implant should be evaluated. If reactive tissue found to sprout at the edge of the implant, it also might indicate on chronicity of the infection.[23, 24, 25]

Extensive debridement should be performed followed with vigorous irrigation. The debrid‐ ed tissue is sent for cultures and pathology while the implant preserved. When no reactive tissue left, last survey should include the gutters, the patellar tracking and the back fold of the knee.

Closure of the knee might need multi layers sutures, using non absorbable materials over heavy drain, which could be left in place for several days to the discharge to stop. Most sur‐ geons allow regular rehabilitation and long term IV antibiotics. Some surgeons leave antibi‐ otic beads and perform recurrent debridement prior to knee rehabilitation [23]

#### **5.3. Delayed or late infections**

With delayed or late infection the orthopedic surgeon might face various clinical uncertain‐ ties with regard of decision making. The following are the most common clinical situations that are usually encountered:

The use of tourniquet without Esmarch bandage is advisable. Careful marking of the scars allows excision of the scars with old suture material. The arthrotomy should follow the orig‐ inal cut with extended lengths if necessary. Careful dissection is utilized in order to protect the vulnerable subcutaneous flaps. If open sinuses exist they should be debrided through the track. Pus and soft tissue are sent to culture with long incubation [28]. Extensive meticu‐ lous debridement is performed to the level of natural tissue, removing all synovial necrotic and non viable tissue. [27,29]. All prosthetic components and acrylic cement are removed.

Periprosthetic Infection Following Total Knee Arthroplasty

http://dx.doi.org/10.5772/53250

543

After the implants are exposed from all soft tissue, the anterior surface of the femoral com‐ ponent is gently released as with Gigli saw, the distal part of it is detached by thin osteo‐ tome and gentle mallet percussions saving the bone stock, without leaning on the soft infected bone. Following removal of the femoral component the undersurface of the tibial tray is released with a saw and osteotomes which are inserted medially and laterally. Then hammering of the tray away from the tibia is performed. Meticulous removal of **all** pieces of cement **is a must** and,although can be technically demanding, should be accomplished. Thorough debridement is performed again with excision and removal of all remnants of in‐ fected tissue. Then the dressing is changed and the knee is draped again. Irrigation should follow with 3 to 4 liters of saline. Five minutes of betadine soaking of the wound should be

A cement spacer impregnated with eluting antimicrobial drugs, according the sensitivity of the infective microorganism, is then interposed between distal femur and proximal tibia. This keeps the limb at its correct length and allows partial joint mobility Non-articulating, or articulated, spacers, can be used according to preference. Few spacer types are used: antibi‐ otic cemented beads, antibiotic cement block, articulating spacer etc [30, 31, 32] (Figure 4).

The non articulated spacer is a fixed one, with inherited stability that allows post op full weight bearing but no knee movement. Sometimes an intramedullary nail (abut 30-36 cm long) used to bridge the knee with cement for the enhanced stability. Care should be taken

to prevent thermal injuries by the inserted cement at its' extension under the patella.

followed by insertion of antibiotic-impregnated spacers.

**Figure 4.** Knee radiographs showing different types of cement spacers

Suppurating knee with positive cultures

Clinically infected knee with positive laboratory data but negative cultures

Clinically suspected infected knee without support of laboratory data

Clinically not infected knee with positive cultures

#### *5.3.1. Suppurating knee with positive cultures*

Identification of the infective germ prior to surgery allows preparation of appropriate antibi‐ otics use within the operation. In some centers single stage revision preferred in cases of low virulence germ, effective antibiotics available both for embedding in the cement and the pa‐ renteral line.

Most surgeons favor a two-stage revision instead of a one-stage procedure [26, 27]

#### *5.3.1.1. The two stage procedure*

The two-stage procedure is indicated particularly to treat overt infections with an active dis‐ charge and virulent organism on culture such as *Staphylococus aureus* and mainly in methicil‐ lin-resistant staphylococcus (MRSA). Removal of the implant is done in first stage and implantation of the new prosthesis is performed later and delayed for a variable period of time until all parameters of inflammation disappear (Figure 3).

**Figure 3.** Intraoperative image of the grossly infected knee prosthesis before retrieval

The use of tourniquet without Esmarch bandage is advisable. Careful marking of the scars allows excision of the scars with old suture material. The arthrotomy should follow the orig‐ inal cut with extended lengths if necessary. Careful dissection is utilized in order to protect the vulnerable subcutaneous flaps. If open sinuses exist they should be debrided through the track. Pus and soft tissue are sent to culture with long incubation [28]. Extensive meticu‐ lous debridement is performed to the level of natural tissue, removing all synovial necrotic and non viable tissue. [27,29]. All prosthetic components and acrylic cement are removed.

**5.3. Delayed or late infections**

542 Arthroplasty - Update

that are usually encountered:

*5.3.1.1. The two stage procedure*

renteral line.

Suppurating knee with positive cultures

Clinically not infected knee with positive cultures

*5.3.1. Suppurating knee with positive cultures*

With delayed or late infection the orthopedic surgeon might face various clinical uncertain‐ ties with regard of decision making. The following are the most common clinical situations

Identification of the infective germ prior to surgery allows preparation of appropriate antibi‐ otics use within the operation. In some centers single stage revision preferred in cases of low virulence germ, effective antibiotics available both for embedding in the cement and the pa‐

The two-stage procedure is indicated particularly to treat overt infections with an active dis‐ charge and virulent organism on culture such as *Staphylococus aureus* and mainly in methicil‐ lin-resistant staphylococcus (MRSA). Removal of the implant is done in first stage and implantation of the new prosthesis is performed later and delayed for a variable period of

Most surgeons favor a two-stage revision instead of a one-stage procedure [26, 27]

Clinically infected knee with positive laboratory data but negative cultures

Clinically suspected infected knee without support of laboratory data

time until all parameters of inflammation disappear (Figure 3).

**Figure 3.** Intraoperative image of the grossly infected knee prosthesis before retrieval

After the implants are exposed from all soft tissue, the anterior surface of the femoral com‐ ponent is gently released as with Gigli saw, the distal part of it is detached by thin osteo‐ tome and gentle mallet percussions saving the bone stock, without leaning on the soft infected bone. Following removal of the femoral component the undersurface of the tibial tray is released with a saw and osteotomes which are inserted medially and laterally. Then hammering of the tray away from the tibia is performed. Meticulous removal of **all** pieces of cement **is a must** and,although can be technically demanding, should be accomplished. Thorough debridement is performed again with excision and removal of all remnants of in‐ fected tissue. Then the dressing is changed and the knee is draped again. Irrigation should follow with 3 to 4 liters of saline. Five minutes of betadine soaking of the wound should be followed by insertion of antibiotic-impregnated spacers.

A cement spacer impregnated with eluting antimicrobial drugs, according the sensitivity of the infective microorganism, is then interposed between distal femur and proximal tibia. This keeps the limb at its correct length and allows partial joint mobility Non-articulating, or articulated, spacers, can be used according to preference. Few spacer types are used: antibi‐ otic cemented beads, antibiotic cement block, articulating spacer etc [30, 31, 32] (Figure 4).

**Figure 4.** Knee radiographs showing different types of cement spacers

The non articulated spacer is a fixed one, with inherited stability that allows post op full weight bearing but no knee movement. Sometimes an intramedullary nail (abut 30-36 cm long) used to bridge the knee with cement for the enhanced stability. Care should be taken to prevent thermal injuries by the inserted cement at its' extension under the patella.

A divided or articulated spacer contains two parts: one piece should be attached to the prox‐ imal tibia and the other to the distal femur. The articulating cement spacer allows the patient to bend his knee, to exercise for range of movement, thus preventing joint contractures and keeping the extensor mechanism integrity.

the common bacteria. Post operative intravenous antibiotics should be administered for six

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The one-stage type of revision can also be considered in presence of low grade clinical ex‐ pression, such as long relentless pain, local heat, tenderness and slow rehabilitation mile‐ stones, negative preoperative aspiration cultures and intraoperative gram stains, as well as frozen section demonstrating less than 5 polymorphonuclears per high power field. Aged patients with positive cultures for low virulence strains, such as *Staphylococcus epidermidis*

This group of patients is presented with swollen painful knee, sometimes with synovitis and loosening. Usually not long from the primary surgery, with no sign of polyethylene wear, normal laboratory tests as CRP or ESR, normal blood leukocytes count and negative leuko‐ cytes bone scan. Knee aspiration could reveal not clear fluid but with negative culture. In such circumstances repeated aspiration performed and the workup should be extended for material allergy such as nickel and chrome. If the clinical suspicion for infection is signifi‐ cant the surgeon might take steps as for fully infected case, performing two or single stage revision. The decision making in these circumstances lacks a high level of evidence support.

Bone and soft tissue cultures are part of all knee revision as well as routine sonication of the retrieved implants. Sometimes a positive culture might be discovered in routine, not infect‐ ed, with normal blood tests, negative leukocyte bone scan and without gross intraoperative signs of infected knee prosthesis. The finding should be carefully evaluated for contamina‐ tion. If high suspicion for masked infection exists, six weeks of parenteral antibiotic should

As a rule, revision Total Knee Arthroplasty offers inferior results and higher complication

According to the published data the successful functional results following the treatment of late infection of a total knee arthroplasty by a two-stage re-implantation of a new prosthesis

In spite of its high personal and financial burden the two-stage re-implantation is recog‐ nized as the most reliable method for eradicating infection [38]. Although one-stage revision is appealing and less technically demanding, the risk of re-infection is a deterring factor.

Two-stage revision procedures may encounter bone loss, obscure landmarks, structural weakness and soft tissue deficiency, which may result in continued pain, decreased mobility

weeks. The 2nd stage is similar to those performed for the positive culture group.

and *Streptococcus type* A, are sometimes allocated for revision in a single stage.

*5.3.3. Clinically suspected infected knee without support of laboratory data*

*5.3.4. Clinically not infected knee with positive cultures*

**6. Outcome of treatment with surgical revision**

should be expected in about 90% of patients [34, 35, 36, 37].

rates compared to primary arthroplasty [33].

be administered.

Adequate hemostasis should follow tourniquet release, irrigation and closure of the wound over a large bore drain.

Antibiotics are administered intravenously according to microbial sensitivity for an average of six weeks. The interval can vary between the two stages, e.g. between six weeks to three months, when the clinical condition is settled. During this period, the clinical recovery is care‐ fully evaluated by the laboratory tests for infection control (ESR and CRP). If there is no clear evidence of clinical improvement, re-arthrotomy and debridement should be considered.

The second stage requires re-arthrotomy through the old scar, tissue is sent for cultures, for pathologic examination, including high power field microscopic examination. The cement spacer is removed; the surgeon should patiently repeat the meticulous debridement. Intense irrigation and change of knee dressing followed by bone preparation and revision implant cementing are performed. A constrained rotating knee prosthesis is generally the most suita‐ ble implant particularly in cases of bone loss.

#### *5.3.1.2. The one stage procedure*

The use of a single-stage revision is advocated by some in certain patients with known caus‐ ative organism, when no discharging sinuses are present, the patient is not immuno‐ compromized, and there is no radiological evidence of component loosening or osteitis.

This type of revision is considered when pathogen germ has been definitely identified with appropriate sensitive antibiotic. The cement should contain suitable antibiotics according the sensitivity of the infective pathogen, if it is known; antimicrobial treatment is given 2-3 weeks before prosthesis exchange.

Technically one stage revision procedure includes removal of all foreign material, implant components and cement, thorough the same steps of meticulous debridement, as stated above, and re-implantation of a new prosthesis at the same surgical session.

#### *5.3.2. Clinically infected knee with positive laboratory data but negative cultures*

Clinical infection with negative cultures is not rare. A patient may present painful and swol‐ len knee, with synovitis and intraarticular fluid, elevated ESR and CRP, with positive leuko‐ cyte bone scan, while aspirated fluid reveal negative cultures. In such a case the aspiration should be repeated, and microbiological studies for rare microorganisms, including PCR should be performed.

The clinical suspicion mandates the type of surgery: The surgical process should be identical to 1st stage revision with extensive debridement and removal of the implant. Multiple bone and soft tissue cultures and pathology should be obtained intraoperatively. Sonication of the prosthesis might be indicated. The cement spacer should contain antibiotics relevant against the common bacteria. Post operative intravenous antibiotics should be administered for six weeks. The 2nd stage is similar to those performed for the positive culture group.

The one-stage type of revision can also be considered in presence of low grade clinical ex‐ pression, such as long relentless pain, local heat, tenderness and slow rehabilitation mile‐ stones, negative preoperative aspiration cultures and intraoperative gram stains, as well as frozen section demonstrating less than 5 polymorphonuclears per high power field. Aged patients with positive cultures for low virulence strains, such as *Staphylococcus epidermidis* and *Streptococcus type* A, are sometimes allocated for revision in a single stage.

#### *5.3.3. Clinically suspected infected knee without support of laboratory data*

This group of patients is presented with swollen painful knee, sometimes with synovitis and loosening. Usually not long from the primary surgery, with no sign of polyethylene wear, normal laboratory tests as CRP or ESR, normal blood leukocytes count and negative leuko‐ cytes bone scan. Knee aspiration could reveal not clear fluid but with negative culture. In such circumstances repeated aspiration performed and the workup should be extended for material allergy such as nickel and chrome. If the clinical suspicion for infection is signifi‐ cant the surgeon might take steps as for fully infected case, performing two or single stage revision. The decision making in these circumstances lacks a high level of evidence support.

#### *5.3.4. Clinically not infected knee with positive cultures*

A divided or articulated spacer contains two parts: one piece should be attached to the prox‐ imal tibia and the other to the distal femur. The articulating cement spacer allows the patient to bend his knee, to exercise for range of movement, thus preventing joint contractures and

Adequate hemostasis should follow tourniquet release, irrigation and closure of the wound

Antibiotics are administered intravenously according to microbial sensitivity for an average of six weeks. The interval can vary between the two stages, e.g. between six weeks to three months, when the clinical condition is settled. During this period, the clinical recovery is care‐ fully evaluated by the laboratory tests for infection control (ESR and CRP). If there is no clear evidence of clinical improvement, re-arthrotomy and debridement should be considered.

The second stage requires re-arthrotomy through the old scar, tissue is sent for cultures, for pathologic examination, including high power field microscopic examination. The cement spacer is removed; the surgeon should patiently repeat the meticulous debridement. Intense irrigation and change of knee dressing followed by bone preparation and revision implant cementing are performed. A constrained rotating knee prosthesis is generally the most suita‐

The use of a single-stage revision is advocated by some in certain patients with known caus‐ ative organism, when no discharging sinuses are present, the patient is not immuno‐ compromized, and there is no radiological evidence of component loosening or osteitis.

This type of revision is considered when pathogen germ has been definitely identified with appropriate sensitive antibiotic. The cement should contain suitable antibiotics according the sensitivity of the infective pathogen, if it is known; antimicrobial treatment is given 2-3

Technically one stage revision procedure includes removal of all foreign material, implant components and cement, thorough the same steps of meticulous debridement, as stated

Clinical infection with negative cultures is not rare. A patient may present painful and swol‐ len knee, with synovitis and intraarticular fluid, elevated ESR and CRP, with positive leuko‐ cyte bone scan, while aspirated fluid reveal negative cultures. In such a case the aspiration should be repeated, and microbiological studies for rare microorganisms, including PCR

The clinical suspicion mandates the type of surgery: The surgical process should be identical to 1st stage revision with extensive debridement and removal of the implant. Multiple bone and soft tissue cultures and pathology should be obtained intraoperatively. Sonication of the prosthesis might be indicated. The cement spacer should contain antibiotics relevant against

above, and re-implantation of a new prosthesis at the same surgical session.

*5.3.2. Clinically infected knee with positive laboratory data but negative cultures*

keeping the extensor mechanism integrity.

ble implant particularly in cases of bone loss.

*5.3.1.2. The one stage procedure*

weeks before prosthesis exchange.

should be performed.

over a large bore drain.

544 Arthroplasty - Update

Bone and soft tissue cultures are part of all knee revision as well as routine sonication of the retrieved implants. Sometimes a positive culture might be discovered in routine, not infect‐ ed, with normal blood tests, negative leukocyte bone scan and without gross intraoperative signs of infected knee prosthesis. The finding should be carefully evaluated for contamina‐ tion. If high suspicion for masked infection exists, six weeks of parenteral antibiotic should be administered.

### **6. Outcome of treatment with surgical revision**

As a rule, revision Total Knee Arthroplasty offers inferior results and higher complication rates compared to primary arthroplasty [33].

According to the published data the successful functional results following the treatment of late infection of a total knee arthroplasty by a two-stage re-implantation of a new prosthesis should be expected in about 90% of patients [34, 35, 36, 37].

In spite of its high personal and financial burden the two-stage re-implantation is recog‐ nized as the most reliable method for eradicating infection [38]. Although one-stage revision is appealing and less technically demanding, the risk of re-infection is a deterring factor.

Two-stage revision procedures may encounter bone loss, obscure landmarks, structural weakness and soft tissue deficiency, which may result in continued pain, decreased mobility and rarely fractures. Nevertheless, the success rate of this method was found to be in the range of 82-93%, whereas the success rate of the one-stage procedure was of 71-81% [34]. Therefore two-stage re-implantation technique represents the procedure of choice for defini‐ tive eradication of infection and preservation of knee function.

In our series of 43 patients with infected TKA, with characteristic 50% rate of infection with Staphylococcal strains [7], twenty patients underwent a one-stage procedure and 21 patients underwent a two-stage procedure. Our overall data indicate 83% postoperative satisfaction with 87% good and excellent results after revision [41,42]. After an average follow-up of 8 years, subjective satisfaction was reported by 80% of patients without any evidence of reinfection in the whole group of these patients. However in one-stage group a recurrent in‐ fection was noted in 20% of cases. We use a constrained design of revision prosthesis in order to overcome the expected soft tissue insufficiency in the revised knee (Figure 5).

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**Figure 5.** A : Knee radiographs ( Anterior-Posterior and Lateral views). Radiolucency is evident around the tibial com‐ ponent indicating septic loosening. B: Knee radiographs (Anterior-Posterior and Lateral views) following revision with

In failed treatment of revision TKA or in case of a multioperated knee and a debilitated pa‐

tient another surgical procedure might be required for limb salvage.

A: A:

B:

a constrained type prosthesis (CCK).

**7. Salvage surgical procedures**

According to the published data on one-stage revisions (Table 1) in the large series of pa‐ tients, with mid-term follow up, around 80% success rate in eradication of infection should be expected.


\* Rates of infection eradication

**Table 1.** Results of one-stage knee revision arthroplasty

As early as 1983, Windsor and Insall reported a success rate of 97.4% in two-stage revision surgery in 38 patients, with four years of follow-up, but other reports had slightly lower suc‐ cess rates, around 90% (Table 2).


\* Rates of infection eradication

**Table 2.** Results of two-stage knee revision arthroplasty

In our series of 43 patients with infected TKA, with characteristic 50% rate of infection with Staphylococcal strains [7], twenty patients underwent a one-stage procedure and 21 patients underwent a two-stage procedure. Our overall data indicate 83% postoperative satisfaction with 87% good and excellent results after revision [41,42]. After an average follow-up of 8 years, subjective satisfaction was reported by 80% of patients without any evidence of reinfection in the whole group of these patients. However in one-stage group a recurrent in‐ fection was noted in 20% of cases. We use a constrained design of revision prosthesis in order to overcome the expected soft tissue insufficiency in the revised knee (Figure 5).

**Figure 5.** A : Knee radiographs ( Anterior-Posterior and Lateral views). Radiolucency is evident around the tibial com‐ ponent indicating septic loosening. B: Knee radiographs (Anterior-Posterior and Lateral views) following revision with a constrained type prosthesis (CCK).

### **7. Salvage surgical procedures**

and rarely fractures. Nevertheless, the success rate of this method was found to be in the range of 82-93%, whereas the success rate of the one-stage procedure was of 71-81% [34]. Therefore two-stage re-implantation technique represents the procedure of choice for defini‐

According to the published data on one-stage revisions (Table 1) in the large series of pa‐ tients, with mid-term follow up, around 80% success rate in eradication of infection should

**Author Year No. of patients Follow-up duration Success rate\***

Foerster et al39 1991 104 5-15 years 80% Lu et al49 1997 8 20.1 months 100% Siegel et al50 2000 31 2-15 years 71% (22/31) Buechel et al27 2004 22 10.2 years 90.9% Soudry et al42 2009 20 8 years 80% (16/20)

As early as 1983, Windsor and Insall reported a success rate of 97.4% in two-stage revision surgery in 38 patients, with four years of follow-up, but other reports had slightly lower suc‐

Windsor & Insall 40 1983 384 4 years 97.4% Hannsen et al 51 1994 36 52 months 89% Goldman et al 52 1996 64 7.5 years 97% Gacon et al 53 1997 29 3.5 years 82.7% Hirakawa et al 53 1998 55 61.9 months 87.2% Siebel et al 55 2002 10 13.5 months 100% Pietsch et al 56 2003 24 14.8 months 95.8% Haleem et al 37 2004 96 7.2 years 91% Soudry et al 42 2009 21 8 years 100%

**Author Year No. of patients Average follow-up Success rate\***

tive eradication of infection and preservation of knee function.

be expected.

546 Arthroplasty - Update

\* Rates of infection eradication

\* Rates of infection eradication

**Table 2.** Results of two-stage knee revision arthroplasty

cess rates, around 90% (Table 2).

**Table 1.** Results of one-stage knee revision arthroplasty

In failed treatment of revision TKA or in case of a multioperated knee and a debilitated pa‐ tient another surgical procedure might be required for limb salvage.

#### **7.1. Knee arthrodesis**

Knee arthrodesis should be considered as a therapeutic option when other described above techniques have failed, especially in young patients with high functional demands or in pa‐ tients with extensive deformities, advanced alterations of the extensor mechanism, deficient soft tissues, immunosuppression or infections by highly virulent bacteria. Arthrodesis pro‐ vides a stable and pain-free limb. However, there is no flexion and the function of the knee is sacrificed, causing an advanced functional impairment. This is generally an irreversible situation. The procedure can be performed with intramedullary nail, metallic plate or exter‐ nal fixation [43, 44] (Figure 6). We have a good clinical experience using the Ilizarov external fixator for this purpose. We used this method in twelve consecutive patients following failed revision TKA surgery performed as treatment for infected initial knee prosthesis. Solid fu‐ sion was achieved in all patients within an average healing time of 27.6 weeks. Average shortening of the affected lib was 3.7 cm. We concluded that the Ilizarov fixator for knee ar‐ throdesis after failed TKR produced favorable results and should be considered for the use by surgeons who are familiar with this technique [44]. The success is dependent on the pro‐ ficiency of the surgeons in Ilizarov method and patient cooperation*.*

for movement with a certain degree of stability. Candidates for this type of treatment are pa‐

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This technique should be considered the last resort when dealing with salvage of a prosthet‐ ic infection. Its indications are as follows: an uncontrolled infection that threatens the pa‐ tient's life, large bone loss and severe soft tissue defects [46]. Functional results tend to be extremely poor and patients often end up in a wheelchair. However a successful above knee amputation may provide the best function for patients who otherwise would have a func‐ tionless knee joint. In the past limb amputation was required most frequently in infected

**8. Future: Prosthetic design "tuned" to prevention of periprosthetic**

ieved following they usual oral or parenteral administration.

method is still has not reached a proved clinical use [48].

The best solution is to prevent infection rather than treat it. Nowadays the trend is to design an implant that is less susceptible to infection by using surfaces that will be resistant to bac‐ terial adhesion and generation of biofilm. These designs will be appropriate to prevent in‐ fection originating via hematogeous spread. Another approach is to use local slowly released antibacterial agents, such as antibiotics or chemical free radicals, that will keep an efficient periprosthetic high concentration antimicrobial milieu in order to prevent biofilm bacterial masking [47]. This is a very important factor since the effective concentration of an‐ tibiotics for penetration of biofilm masking should be 1000 times higher than can be ach‐

Most of the efforts for generation of anti-biofilm surfaces of the prostheses are still in devel‐ opment stage and still have not gain wide clinical use. Currently three main directions are utilized for this purpose. The most common method is to use titanium surfaces that release bactericidal superoxide radicals [48]. This method is especially appealing since TiO2 is has no significant cytotoxic effect on mammalian cells. We observed that human osteoblast-like cells in culture remain viable after exposure to high concentration of TiO2 0.1 mm granules in culture media (10% v:v). Another metal that has bactericidal properties is silver. There are a lot of efforts in designing prosthetic surfaces containing silver [48]. We found that it has a bactericidal effect on different *Staphylococci* strains, but *Pseudomonas aeruginosa* remained re‐ sistant to its high concentration (10% v:v). The main problem with the use of silver for pros‐ thetic coating is its toxicity to the host cells. We observed a profound cytotoxic effect in cultures of human osteoblast-like cells exposed to 0.1 mm granules of silver in culture media in bactericidal concentration. For this reason the surfaces coated by TiO2 have a better bac‐

There is also a possibility to use immobilized antibiotic coverage for prosthetic surfaces. This

tients with low functional demands [45].

TKA with cemented stem hinges.

tericidal potential for clinical use.

**7.3. Limb amputation**

**infection**

**Figure 6.** Radiographs of fused knees, following failed revision of TKA, by: A: Intramedullary nail, B: Tubular external fixator. C: Internal fixation by plate and screws, D: Ilizarov external fixator.

#### **7.2. Resection arthroplasty**

By this salvage method a permanent removal of the implant and cement with local debride‐ ment, without re-implantation, are performed. The purpose of this technique is to create a false joint that may allow a certain range of motion. The leg is immobilized for a period be‐ tween 3 and 6 months in order to allow the soft tissues retraction with creation of free area for movement with a certain degree of stability. Candidates for this type of treatment are pa‐ tients with low functional demands [45].

#### **7.3. Limb amputation**

**7.1. Knee arthrodesis**

548 Arthroplasty - Update

Knee arthrodesis should be considered as a therapeutic option when other described above techniques have failed, especially in young patients with high functional demands or in pa‐ tients with extensive deformities, advanced alterations of the extensor mechanism, deficient soft tissues, immunosuppression or infections by highly virulent bacteria. Arthrodesis pro‐ vides a stable and pain-free limb. However, there is no flexion and the function of the knee is sacrificed, causing an advanced functional impairment. This is generally an irreversible situation. The procedure can be performed with intramedullary nail, metallic plate or exter‐ nal fixation [43, 44] (Figure 6). We have a good clinical experience using the Ilizarov external fixator for this purpose. We used this method in twelve consecutive patients following failed revision TKA surgery performed as treatment for infected initial knee prosthesis. Solid fu‐ sion was achieved in all patients within an average healing time of 27.6 weeks. Average shortening of the affected lib was 3.7 cm. We concluded that the Ilizarov fixator for knee ar‐ throdesis after failed TKR produced favorable results and should be considered for the use by surgeons who are familiar with this technique [44]. The success is dependent on the pro‐

A: B: C: D:

**Figure 6.** Radiographs of fused knees, following failed revision of TKA, by: A: Intramedullary nail, B: Tubular external

By this salvage method a permanent removal of the implant and cement with local debride‐ ment, without re-implantation, are performed. The purpose of this technique is to create a false joint that may allow a certain range of motion. The leg is immobilized for a period be‐ tween 3 and 6 months in order to allow the soft tissues retraction with creation of free area

ficiency of the surgeons in Ilizarov method and patient cooperation*.*

fixator. C: Internal fixation by plate and screws, D: Ilizarov external fixator.

**7.2. Resection arthroplasty**

This technique should be considered the last resort when dealing with salvage of a prosthet‐ ic infection. Its indications are as follows: an uncontrolled infection that threatens the pa‐ tient's life, large bone loss and severe soft tissue defects [46]. Functional results tend to be extremely poor and patients often end up in a wheelchair. However a successful above knee amputation may provide the best function for patients who otherwise would have a func‐ tionless knee joint. In the past limb amputation was required most frequently in infected TKA with cemented stem hinges.

## **8. Future: Prosthetic design "tuned" to prevention of periprosthetic infection**

The best solution is to prevent infection rather than treat it. Nowadays the trend is to design an implant that is less susceptible to infection by using surfaces that will be resistant to bac‐ terial adhesion and generation of biofilm. These designs will be appropriate to prevent in‐ fection originating via hematogeous spread. Another approach is to use local slowly released antibacterial agents, such as antibiotics or chemical free radicals, that will keep an efficient periprosthetic high concentration antimicrobial milieu in order to prevent biofilm bacterial masking [47]. This is a very important factor since the effective concentration of an‐ tibiotics for penetration of biofilm masking should be 1000 times higher than can be ach‐ ieved following they usual oral or parenteral administration.

Most of the efforts for generation of anti-biofilm surfaces of the prostheses are still in devel‐ opment stage and still have not gain wide clinical use. Currently three main directions are utilized for this purpose. The most common method is to use titanium surfaces that release bactericidal superoxide radicals [48]. This method is especially appealing since TiO2 is has no significant cytotoxic effect on mammalian cells. We observed that human osteoblast-like cells in culture remain viable after exposure to high concentration of TiO2 0.1 mm granules in culture media (10% v:v). Another metal that has bactericidal properties is silver. There are a lot of efforts in designing prosthetic surfaces containing silver [48]. We found that it has a bactericidal effect on different *Staphylococci* strains, but *Pseudomonas aeruginosa* remained re‐ sistant to its high concentration (10% v:v). The main problem with the use of silver for pros‐ thetic coating is its toxicity to the host cells. We observed a profound cytotoxic effect in cultures of human osteoblast-like cells exposed to 0.1 mm granules of silver in culture media in bactericidal concentration. For this reason the surfaces coated by TiO2 have a better bac‐ tericidal potential for clinical use.

There is also a possibility to use immobilized antibiotic coverage for prosthetic surfaces. This method is still has not reached a proved clinical use [48].

Currently the widespread method of prosthetic fixation with methyl methacrylate bone ce‐ ment, containing broad spectrum antibiotics, is the only proven way to create an antimicro‐ bial periprosthetic surrounding. The uncontrolled release of the antibiotics and potential reduced fixation characteristics of the cement containing antibiotics are the main disadvant‐ age of this method, but it is no clinical evidence that might support these concerns.

**References**

460-64.

2004;351(16):1645-54.

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midis. Future Microbiol 2010 5(6): 917-933.

J. Bone Joint Surg Br. 2002; 84:315-21.

Clinic Orthop 1987:225:238-46.

gans 2011; 34(9):947-956.

2004;351(16):1645-54.

221-4.

hip and knee arthroplasry. Instr Course Lect 1999;48:111-122.

[1] Zimmerli W., Trampuz A., Ochsner PE. Prosthetic-joint infections. N Engl J Med

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[2] Kurtz SM., Ong KL., Lau E., Bozic KJ., Berry D., Parvizi J. Prosthetic joint infection risk after TKA in the Medicare population. Clin Orthop Relate Res 2010: 468(1):52-56.

[3] Bengtson S., Knutson K. The infected knee arthroplasty. A 6-year follow-up of 357

[4] Hansen AD., Rand JA. Evaluation and treatment of the infection at the site of a total

[5] Ellenrieder et al. Two-stage revision of implant-associated infections after total hip and knee arthroplasty. GMS Krankenhaushygiene Interdisziplinar 2011;6(1):1-8.

[6] Chiang ER et al. Comparison of articulating and static spacers regarding infection with resistant organisms in total knee arthroplasty .Acta Orthopaedica 2011; 82(4):

[7] Peel TN., Buising KL., Choong PFM. Prosthetic joint infection: challenges of diagno‐

[8] Fey PD., Olson ME. Current concepts in biofilm formation of Staphylococcus epider‐

[9] Sendi P., Zimmerli W. Challenges in periprosthetic knee-joint infection. Int J Artif Or‐

[10] Schafroth M., Zimmerli W., Brunazzi M., Ochsner PE. Infections. In: Ochsner PE ed.

[11] Zimmerli W., Trampuz A., Ochsner PE. Prosthetic-joint infections. N Engl J Med

[12] Giuleri SG., Graber P., Ochsner PE., Zimmerli W. Management of infection associat‐ ed with THA according to a treatment algorithm. Infection; 2004; 32(4):222-8.

[13] Smith SL., Wastle ML., Forster I. Radiolonuclide bone scintigraphy in the detection of significant complications after total knee joint replacement. Clin Radiol; 2001: 56:

[14] Hain SF., O'Doherty MJ., Smith MA. Functional imaging and the orthopedic surgeon.

[15] Shih LY., Wu JJ., Yang DJ. Erythrocyte sedimentation rate and CRP values with THA.

Total hip replacement . Berlin: Springer Verlag; 2003. p65-90.

#### **9. Conclusion**

Despite considerable advances in surgical techniques and preoperative care, a 0.5-2% prevalence of infection in total knee arthroplasty (TKA) still poses a great challenge in the treatment of this devastating and costly complication. Current solutions to treat peri‐ prosthetic infection remain imperfect. Treatment strategy varies from conservative lifelong antibiotic suppression therapy in the very high risk patient, arthroscopic or surgical debridement, revision in one or two-stage, arthrodesis or resection arthroplasty as a sal‐ vage procedure, and amputation in life-threatening conditions. The decision on the best method of treatment should be personalized to the patient's general health, the severity of the infection and the complexity of the surgery. Currently most of the surgeons have adopted the two-stage protocol, where prosthetic removal, debridement and culture-spe‐ cific I.V. therapy prior to re-implantation are regarded as standards of care. Although one-stage revision procedure is practiced by some, there is no clear evidence to define when this procedure can be safely applied, because there is no sufficient reliable data on a clinical reliability of this approach. The quest to perform one-stage revision should be continued, as two-stage operations classify the patient in a multiple operations category, with all the resulting potential complications, such as arthrodesis and amputation. Nev‐ ertheless, the threat of re-infection after the one-stage procedure surpasses the potential benefits. Judicious selection of patients is the key for successful mode of treatment. Cur‐ rently the two-stage exchange arthroplasty, with all its inherent problems and draw‐ backs, allows only a partial success in treatment of TKA infection. New modalities or avenues for treatment of prosthetic infection are desirable.

#### **Author details**

Michael Soudry1\*, Arnan Greental2 , Gabriel Nierenberg2 , Mazen Falah2 and Nahum Rosenberg2

\*Address all correspondence to: michael.soudry@gmail.com

1 Department of Orthopaedic Surgery, Hillel Yaffe Medical Center, Hadera, Israel

2 Rambam Health Care Campus, Dept of Orthopaedic Surgery. Haifa, Israel

#### **References**

Currently the widespread method of prosthetic fixation with methyl methacrylate bone ce‐ ment, containing broad spectrum antibiotics, is the only proven way to create an antimicro‐ bial periprosthetic surrounding. The uncontrolled release of the antibiotics and potential reduced fixation characteristics of the cement containing antibiotics are the main disadvant‐

Despite considerable advances in surgical techniques and preoperative care, a 0.5-2% prevalence of infection in total knee arthroplasty (TKA) still poses a great challenge in the treatment of this devastating and costly complication. Current solutions to treat peri‐ prosthetic infection remain imperfect. Treatment strategy varies from conservative lifelong antibiotic suppression therapy in the very high risk patient, arthroscopic or surgical debridement, revision in one or two-stage, arthrodesis or resection arthroplasty as a sal‐ vage procedure, and amputation in life-threatening conditions. The decision on the best method of treatment should be personalized to the patient's general health, the severity of the infection and the complexity of the surgery. Currently most of the surgeons have adopted the two-stage protocol, where prosthetic removal, debridement and culture-spe‐ cific I.V. therapy prior to re-implantation are regarded as standards of care. Although one-stage revision procedure is practiced by some, there is no clear evidence to define when this procedure can be safely applied, because there is no sufficient reliable data on a clinical reliability of this approach. The quest to perform one-stage revision should be continued, as two-stage operations classify the patient in a multiple operations category, with all the resulting potential complications, such as arthrodesis and amputation. Nev‐ ertheless, the threat of re-infection after the one-stage procedure surpasses the potential benefits. Judicious selection of patients is the key for successful mode of treatment. Cur‐ rently the two-stage exchange arthroplasty, with all its inherent problems and draw‐ backs, allows only a partial success in treatment of TKA infection. New modalities or

, Gabriel Nierenberg2

1 Department of Orthopaedic Surgery, Hillel Yaffe Medical Center, Hadera, Israel

2 Rambam Health Care Campus, Dept of Orthopaedic Surgery. Haifa, Israel

, Mazen Falah2

and

age of this method, but it is no clinical evidence that might support these concerns.

avenues for treatment of prosthetic infection are desirable.

\*Address all correspondence to: michael.soudry@gmail.com

**9. Conclusion**

550 Arthroplasty - Update

**Author details**

Nahum Rosenberg2

Michael Soudry1\*, Arnan Greental2


[16] Di Cesare PE., Chang E., Preston CF., Liu CJ. Serum Interleukin-6 as a Marker of Per‐ iprosthetic Infection Following Total Hip and Knee Arthroplasty. J Bone Joint Surg Am 2005; 87(9):1921-1927.

[30] Kohl S., Evangelopoulos DS., Kohlhof H., Krueger A., Hartel M., Roeder C., Eggli S. An intraoperatively moulded PMMA prostheses-like spacer for two-stage revision of

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[31] Choi HR., Malchau H., Bedair H. Are Prosthetic Spacers Safe to Use in 2-Stage Treat‐ ment for Infected Total Knee Arthroplasty? J of Arthroplasty 2012; in press.

[32] Macmull S., Bartlett W., Miles GW., Blunn J., Pollock RC., Carrington RWJ., Skinner JA., Cannon SR., Briggs TWR. Custom-made hinged spacers in revision knee surgery

[33] Joseph TN., Chen AL., Di Cesare PE. Use of antibiotic-impregnated cement in total

[34] Hanssen AD., Rand JA. Evaluation and treatment of infection at the site of a total hip

[35] Hoad-Reddick DA., Evans CR., Norman .P, Stockly I. Is there a role for extended an‐ tibiotic therapy in a two-stage revision of the infected knee arthroplasty?. J Bone Joint

[36] Freeman MA., Sudlow RA., Casewell MW., Radcliff SS. The management of infected

[37] Haleem AA., Berry DJ., Hanssen AD. Mid-term to long-term follow-up of two-stage reimplantation for infected total knee arthroplasty. Clin Orthop. 2004: 428:35-39. [38] Wilde AH., Ruth JT. Two-stage reimplantation in infected total knee arhroplasty.

[39] Von Foerster G., Klüber D., Käbler U. Mid- to long-term results after treatment of 118 cases of periprosthetic infections after knee joint replacement using one-stage ex‐

[40] Windsor R., Insall J. Management of the infected total knee arthroplasty. In: Insall-Scott, eds. Surgery of the Knee. 1st ed. Churchill Livingstone, New York, 1983.

[41] Soudry M., Greental A., Niereberg G., Falah M. One and two-stage revision in infect‐

[42] Soudry M., Nierenberg G., Msika C., Jontschew DA., Falah M. One vs two-stage revi‐ sion of infected knee arthroplasty. Portugese Journal of Orthopaedics. 2009: Vol 17

[43] 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(5):

[44] David R., Shtarker H., Horesh Z., Tsur A., Soudry M. Knee Arthrodesis with the Ili‐

zarov after failed knee arthroplasty. Orthopedics, 2001 Jan: 24(1):33-6.

for patients with infection, bone loss and instability. Knee 2010;17: 403–406.

infected total knee arthroplasty. Knee 2011;18: 464–469.

joint arthroplasty. J Am Acad Orthop Surg 2003;11:38-47.

or knee arthroplasty. J Bone Joint Surg 1998; 80:910-922.

total knee replacements. J Bone Joint Surg Br 1985; 67:764-768.

change surgery]. Orthopade. 1991 Jun;20(3):244-52.

ed TKA. JBJS B. 2005: Vol 87-B. Supp III: 389.

Surg Br 2005; 87-B:171-174.

Clin Orthop 1988; 236:23-35.

959-974.

(4): 1-11.

447-53.


[30] Kohl S., Evangelopoulos DS., Kohlhof H., Krueger A., Hartel M., Roeder C., Eggli S. An intraoperatively moulded PMMA prostheses-like spacer for two-stage revision of infected total knee arthroplasty. Knee 2011;18: 464–469.

[16] Di Cesare PE., Chang E., Preston CF., Liu CJ. Serum Interleukin-6 as a Marker of Per‐ iprosthetic Infection Following Total Hip and Knee Arthroplasty. J Bone Joint Surg

[17] Marian BD., Martin DS., Levine MJ., Booth RE., Tuan RS. Polymerase Chain. Reac‐ tion Detection of Bacterial Infection in Total Knee Arthroplasty. Clinical Orthop 1996;

[18] Trampuz A., Piper K., Jacobson M. et al. Sonication of removed hip and knee pros‐

[19] Tampuz A., Hansen AD., Osmon DR., Mandrekar J., Steckekberg JM., Patel R. Ad‐ vances in the laboratory diagnosis of prosthetic joint infection. Rev Med Microbiol

[20] Parvizi J., Della Valle CJ. In: AAOS Clinical Practice Guideline. Diagnosis and Treat‐ ment of periprosthetic joint infections of the hip and knee. J. Am Acad Orthop Surg

[21] Grogan TJ., Dorey F., Rollins J. et al. Deep sepsis following TKA. JBJS A, 1986:

[22] Johnson DP., Bannister GC. The outcome of infected arthoplasty of the knee. JBJS B

[23] Do CSO., Beauchamp CP., Clarke HD., Spangehl MJ. A Two-stage Retention De‐ bridement Protocol for Acute Periprosthetic joint infection. Clin Orthop Relat Res.

[24] Parvizi J., Ghanem E., Sharkey P. Prosthetic Joint Infections. Clin Orthop Relat Res

[25] Coventry MB., Beckenbaugh RD., Nolan DR., Ilstrup DM. 2,012 total hip arthroplas‐ ties. A study of postoperative course and early complications. J Bone Joint Surg Am.

[26] Parkinson RW., Kay PR., Rawal A. A case for one-stage revision in infected totalknee

[27] Buechel FF. The Infected Total Knee Arthroplasty. Just When You Thought It Was

[28] Fink B., Gebhard A., Fuerst M., Berger I., Schafer P. High Diagnostic Value of Synovi‐ al Biopsy in Periprosthetic Joint Infection of the Hip. Clin Orthop Relat Res. in press.

[29] Nickinson RS.J, Board TN., Gambhir AK., Porter ML., Kay PR. Two stage revision knee arthroplasty for infection with massive bone loss. A technique to achieve spacer

theses for diagnosis of infection. N Engl J Med 2007;357:654-63.

Am 2005; 87(9):1921-1927.

331: 11-22.

552 Arthroplasty - Update

2003; 14:1-14.

2010;18:771-772.

1986:68;289-291.

2007; 461:44-47.

1974;56(2):273-84.

arthroplasty. Knee 2011; 18:1–4.

stability. Knee 2012;19: 24–27.

Over. The Journal of Arthroplasty 2004; Suppl 4: 19.

2010: Aug;468(8):2029-38.

68:226-234.


[45] Falahee MH., Matthews LS., Kaufer H. Resection Arthroplasty as a salvage proce‐ dure for a knee with infection after TKA. JBJS A 1987: 69: 1013-1021.

**Chapter 25**

**Articulating Spacers in Infection of Total Knee**

Infection is one of the most devastating complications of total knee arthroplasty. It is also the leading cause of early revision after knee arthroplasty, ahead of instability and aseptic

Treatment of an infected total knee arthroplasty requires 3 to 6 times more hospital resources than a primary arthroplasty and 2 times more than an aseptic revision [2]. The goal of treatment

Two-stage exchange remains the treatment of choice in cases of late infection, with good or excellent results in 80% to 100% of cases; nevertheless, it is aggressive, costly, and long. It is also considered the treatment of choice in cases of fungal infection, infection by virulent organisms, inflammatory diseases, immunosuppression, and reinfection after reimplantation. Compared with direct replacement, 2-stage revision of infected arthroplasty has several disadvantages: longer hospital stay, higher cost, longer surgical time, tissue retraction, instability, and functional limitation between procedures. From a technical standpoint, surgical reimplantation may be hampered by retraction of soft tissue and loss of tissue planes. Most authors agree that almost all of these problems can be minimized using antibiotic-loaded articulating cement spacers, although 2-stage exchange can be used to eradicate infection both

The most consistent results have been published with 2-stage exchange, regardless of varia‐ tions in the type of spacer, causal microorganism, or duration of infection. In a systematic

and reproduction in any medium, provided the original work is properly cited.

© 2013 Villanueva-Martínez et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

**Arthroplasty — State of the Art**

Antonio Pérez-Caballer

http://dx.doi.org/10.5772/53243

**1. Introduction**

loosening [1].

Manuel Villanueva-Martínez, Antonio Ríos-Luna, Francisco Chana-Rodriguez, Jose A. De Pedro and

Additional information is available at the end of the chapter

is to eradicate infection and maintain joint function.

with and without cement spacers.


## **Articulating Spacers in Infection of Total Knee Arthroplasty — State of the Art**

Manuel Villanueva-Martínez, Antonio Ríos-Luna, Francisco Chana-Rodriguez, Jose A. De Pedro and Antonio Pérez-Caballer

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/53243

### **1. Introduction**

[45] Falahee MH., Matthews LS., Kaufer H. Resection Arthroplasty as a salvage proce‐

[46] Pring DJ., Marks, Angel JC. Mobility after amputation for failed knee replacement.

[47] Vasilev K., Cook .J, Griesser HJ. Antibacterial surfaces for biomedical devices. Expert

[48] Visai L., De Nardo L., Punta C., Melone L., Cigada A., Imbriani M., Arciala CR. Tita‐ nium oxide antibacterial surfaces in biomedical devices. Int J Artif Organs 2011;

[49] Lu H., Kou B., Lin J. One-stage reimplantation for the salvage of total knee arthro‐ plasty complicated by infection. Zhonghua Wai Ke Za Zhi. 1997 Aug;35(8):456-8.

[50] Siegel A., Frommelt L., Runde W. Therapy of bacterial knee joint infection by radical synovectomy and implantation of a cemented stabilized knee joint endoprosthesis.

[51] Hanssen AD., Rand JA., Osmon DR. Treatment of the infected total knee arthroplasty with insertion of another prosthesis. The effect of antibiotic-impregnated bone ce‐

[52] Goldman RT., Scuderi GR., Insall JN. 2-stage reimplantation for infected total knee

[53] Gacon G., Laurencon M., Van de Velde D., Giudicelli DP. Two stages reimplantation for infection after knee arthroplasty. Apropos of a series of 29 cases. Rev Chir Orthop

[54] Hirakawa K., Stulberg BN., Wilde AH., Bauer TW., Secic M. Results of two-stage re‐ implantation for infected total knee arthroplasty. J Arthroplasty. 1998 Jan;13(1):22-8.

[55] Siebel T., Kelm J., Porsch M., Regitz T., Neumann WH. Two-stage exchange of infect‐ ed knee arthroplasty with a prosthesis-like interim cement spacer. Acta Orthop Belg.

[56] Pietsch M., Wenisch C., Traussnig S., Trnoska R., Hofmann S. Temporary articulating spacer with antibiotic-impregnated cement for an infected knee endoprosthesis. Or‐

dure for a knee with infection after TKA. JBJS A 1987: 69: 1013-1021.

JBJS B 1988: 70: 770-771).

34(9):929-946.

554 Arthroplasty - Update

Rev Med Devices 2009; 6(5): 553-567.

Chirurg. 2000 Nov;71(11):1385-91.

ment. Clin Orthop Relat Res. 1994 Dec;(309):44-55.

Reparatrice Appar Mot. 1997;83(4):313-23.

2002 Apr;68(2):150-6.

thopade. 2003 Jun;32(6):490-7.

replacement. Clin Orthop Relat Res. 1996 Oct;(331):118-24.

Infection is one of the most devastating complications of total knee arthroplasty. It is also the leading cause of early revision after knee arthroplasty, ahead of instability and aseptic loosening [1].

Treatment of an infected total knee arthroplasty requires 3 to 6 times more hospital resources than a primary arthroplasty and 2 times more than an aseptic revision [2]. The goal of treatment is to eradicate infection and maintain joint function.

Two-stage exchange remains the treatment of choice in cases of late infection, with good or excellent results in 80% to 100% of cases; nevertheless, it is aggressive, costly, and long. It is also considered the treatment of choice in cases of fungal infection, infection by virulent organisms, inflammatory diseases, immunosuppression, and reinfection after reimplantation.

Compared with direct replacement, 2-stage revision of infected arthroplasty has several disadvantages: longer hospital stay, higher cost, longer surgical time, tissue retraction, instability, and functional limitation between procedures. From a technical standpoint, surgical reimplantation may be hampered by retraction of soft tissue and loss of tissue planes.

Most authors agree that almost all of these problems can be minimized using antibiotic-loaded articulating cement spacers, although 2-stage exchange can be used to eradicate infection both with and without cement spacers.

The most consistent results have been published with 2-stage exchange, regardless of varia‐ tions in the type of spacer, causal microorganism, or duration of infection. In a systematic

© 2013 Villanueva-Martínez et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

review of the literature between 1980 and 2005, Jämsen et al. [3] found 31 original articles describing the results of 154 direct exchanges and 926 2-stage exchanges. Eradication rates were 73%-100% for 1-stage exchange and 82%-100% for 2-stage exchange. Final range of motion and reinfection rates were lower in the series that used antibiotic-loaded articulating spacers. No correlation was observed with the type of spacer or functional outcome between direct revision and 2-stage exchange.

Although this approach remains open to debate, most authors agree that articulating spacers provides better functional results and enable more efficacious eradication of infection than

Articulating Spacers in Infection of Total Knee Arthroplasty — State of the Art

http://dx.doi.org/10.5772/53243

557

The shape and features of articulating spacers vary considerably, from fully manual spacers made in preformed molds to modular spacers, which include plastic and metal surfaces. Spacers differ in price, complexity, and degree of constraint. The advantages of articulating spacers are as follows: retraction of soft tissue and extensor mechanisms is prevented, high doses of antibiotics can be added in the time between operations, bone mass is preserved better than with nonarticulating spacers[9], [16], the need for expanded approaches at reimplantation is reduced, and the success rate is increased. These approaches also enable greater controlled mobility of the joint and application of a partial support brace, thus facilitating acceptable

Use of antibiotic-loaded articulating spacers was first reported by Wilde and Ruth [6] in 1988. This was the first attempt to reduce complications due to functional disability between

Preformed articulating systems (PROSTALAC®) first appeared in 1992. Their main advantage was excellent tolerability and function between procedures, thanks to high joint congruence and reduced friction [17]. Their disadvantages include high cost, presence of metal and plastic surfaces that could facilitate bacterial growth, and size limitations. Preformed articulating systems are not widely used because of their price and the theoretical risk that the presence of metal and plastic components facilitates persistence of infection, although this has not been confirmed in clinical practice. Therefore, other factors (eg, aggressiveness of the microorgan‐ ism, addition of high proportions of cement, and antibiotic treatment) may be more important

Hand-made cement articulating spacers, however, maintain almost all the advantages of

Between these extremes, many authors have developed modifications to minimize the disadvantages of hand-made spacers and PROSTALAC® spacers, by adapting them to their technical and economic possibilities. The real impact of the theoretical advantages of the

**1.** Manual construction of a spacer with cement in the operating room by recreating the normal anatomy of the patient [18], [19] (Figure 1 ) or more congruent systems (ball and

**2.** Construction of customized spacers in the operating room using prefabricated silicone or aluminum molds [21], [22], or using trial components to shape the spacer [23]. Cement

nonarticulating spacers [3], [13-15].

function between procedures.

than the type of spacer used.

different types of spacer is unknown.

The main forms are as follows:

socket) [20] (Figure 2).

**3. Historical development of articulating spacers**

operations, as observed in the initial work by Windsor and Insall [4].

preformed spacers, although they also have a series of drawbacks.

### **2. Spacer types: Nonarticulating and articulating**

The 2-stage exchange protocol was designed by Insall in 1983. Since the first report in 1990, long-term results have shown two-stage exchange to be the treatment of choice for infection after total knee arthroplasty [4]. The outcome of the original procedure was poor to fair in 20% of cases, mainly owing to functional disability and retraction of soft tissue. Atrophy, stiffness, bone loss, and increased extensile exposure were observed at reimplantation.

The use of antibiotic-loaded articulating spacers helped to reduce these complications and improve the possibilities of eradicating infection [5-9]. The choice of spacer depends on many factors, including degree of bone loss, state of the soft tissue, choice of antibiotics, and financial and technical restraints. A benefit that is common to both articulating and nonarticulating antibiotic-loaded spacers is the fact that greater intra-articular levels of antibiotic can be delivered than with parenteral antibiotics [10-11].

The approach aims to be above breakpoint sensitivity (ie, the level of antibiotic that sets the boundary between bacterial susceptibility and the development of resistance) and to eradicate infection.

Nonarticulating spacers enable local administration of a high concentration of antibiotic, improve patient autonomy, facilitate outpatient treatment, and maintain the joint space for future procedures.

Borden and Gearen [5], Booth and Lotke [7], and Cohen et al. [12] reported data for antibioticloaded beads and cement spacers, which are molded to adapt to the defect created by removal of the infected prosthesis. Although in some cases these authors made the spacer in 2 semi‐ blocks, thus forming a partial joint, neither the design of the blocks nor the rehabilitation protocol included controlled mobility. Calton et al. [9] modified this approach, although disadvantages were still observed (eg, bone loss when the spacer sank into the tibia).

Other disadvantages of this system are the minimal range of motion of the joint, which can lead to shortening of the quadriceps, capsule, and ligaments, thus increasing the need for extensile approaches with longer surgical time during reimplantation.

Antibiotic-loaded articulating cement spacers can improve function between operations and facilitate the second stage.

Although this approach remains open to debate, most authors agree that articulating spacers provides better functional results and enable more efficacious eradication of infection than nonarticulating spacers [3], [13-15].

The shape and features of articulating spacers vary considerably, from fully manual spacers made in preformed molds to modular spacers, which include plastic and metal surfaces. Spacers differ in price, complexity, and degree of constraint. The advantages of articulating spacers are as follows: retraction of soft tissue and extensor mechanisms is prevented, high doses of antibiotics can be added in the time between operations, bone mass is preserved better than with nonarticulating spacers[9], [16], the need for expanded approaches at reimplantation is reduced, and the success rate is increased. These approaches also enable greater controlled mobility of the joint and application of a partial support brace, thus facilitating acceptable function between procedures.

### **3. Historical development of articulating spacers**

Use of antibiotic-loaded articulating spacers was first reported by Wilde and Ruth [6] in 1988. This was the first attempt to reduce complications due to functional disability between operations, as observed in the initial work by Windsor and Insall [4].

Preformed articulating systems (PROSTALAC®) first appeared in 1992. Their main advantage was excellent tolerability and function between procedures, thanks to high joint congruence and reduced friction [17]. Their disadvantages include high cost, presence of metal and plastic surfaces that could facilitate bacterial growth, and size limitations. Preformed articulating systems are not widely used because of their price and the theoretical risk that the presence of metal and plastic components facilitates persistence of infection, although this has not been confirmed in clinical practice. Therefore, other factors (eg, aggressiveness of the microorgan‐ ism, addition of high proportions of cement, and antibiotic treatment) may be more important than the type of spacer used.

Hand-made cement articulating spacers, however, maintain almost all the advantages of preformed spacers, although they also have a series of drawbacks.

Between these extremes, many authors have developed modifications to minimize the disadvantages of hand-made spacers and PROSTALAC® spacers, by adapting them to their technical and economic possibilities. The real impact of the theoretical advantages of the different types of spacer is unknown.

The main forms are as follows:

review of the literature between 1980 and 2005, Jämsen et al. [3] found 31 original articles describing the results of 154 direct exchanges and 926 2-stage exchanges. Eradication rates were 73%-100% for 1-stage exchange and 82%-100% for 2-stage exchange. Final range of motion and reinfection rates were lower in the series that used antibiotic-loaded articulating spacers. No correlation was observed with the type of spacer or functional outcome between

The 2-stage exchange protocol was designed by Insall in 1983. Since the first report in 1990, long-term results have shown two-stage exchange to be the treatment of choice for infection after total knee arthroplasty [4]. The outcome of the original procedure was poor to fair in 20% of cases, mainly owing to functional disability and retraction of soft tissue. Atrophy, stiffness,

The use of antibiotic-loaded articulating spacers helped to reduce these complications and improve the possibilities of eradicating infection [5-9]. The choice of spacer depends on many factors, including degree of bone loss, state of the soft tissue, choice of antibiotics, and financial and technical restraints. A benefit that is common to both articulating and nonarticulating antibiotic-loaded spacers is the fact that greater intra-articular levels of antibiotic can be

The approach aims to be above breakpoint sensitivity (ie, the level of antibiotic that sets the boundary between bacterial susceptibility and the development of resistance) and to eradicate

Nonarticulating spacers enable local administration of a high concentration of antibiotic, improve patient autonomy, facilitate outpatient treatment, and maintain the joint space for

Borden and Gearen [5], Booth and Lotke [7], and Cohen et al. [12] reported data for antibioticloaded beads and cement spacers, which are molded to adapt to the defect created by removal of the infected prosthesis. Although in some cases these authors made the spacer in 2 semi‐ blocks, thus forming a partial joint, neither the design of the blocks nor the rehabilitation protocol included controlled mobility. Calton et al. [9] modified this approach, although

Other disadvantages of this system are the minimal range of motion of the joint, which can lead to shortening of the quadriceps, capsule, and ligaments, thus increasing the need for

Antibiotic-loaded articulating cement spacers can improve function between operations and

disadvantages were still observed (eg, bone loss when the spacer sank into the tibia).

extensile approaches with longer surgical time during reimplantation.

bone loss, and increased extensile exposure were observed at reimplantation.

direct revision and 2-stage exchange.

556 Arthroplasty - Update

**2. Spacer types: Nonarticulating and articulating**

delivered than with parenteral antibiotics [10-11].

infection.

future procedures.

facilitate the second stage.


molds can be made during surgery using trial components, and the definitive spacer can be made using these cement molds [24], [25].

reactions as a result of particle generation; however, this has not been considered a real

Articulating Spacers in Infection of Total Knee Arthroplasty — State of the Art

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559

**Figure 3.** Hand-made spacer for a segmental defect. Excellent range of motion. Due to instability or giving way the

problem in published series [18], [21], [24].

**Figure 2.** Ball and socket spacer.

patients usually walks with a brace.


**Figure 1.** Remodeling prominent areas of a hand-made spacer with a high-speed burr.

Favorable results have been reported with each of these types of spacers. The more rudimen‐ tary a spacer is, the lower its congruence and the greater the sensation of popping, giving way, or instability. In contrast, it is cheaper, more widely available, and versatile. The specific advantage of spacers built manually with cement only is that the whole spacer is loaded with antibiotics, and these can be tailored to the causative organism. The spacer does not include plastic, metal, or resterilized parts and can be applied in any operating room with no need for specific instruments. The main disadvantage of cement spacers is the lack of optimal congru‐ ence, instability, and the difficulty in modeling, especially with high antibiotic loads (>10%-15%) (Figure3). In addition, cement-on-cement spacers can cause more inflammatory reactions as a result of particle generation; however, this has not been considered a real problem in published series [18], [21], [24].

**Figure 2.** Ball and socket spacer.

molds can be made during surgery using trial components, and the definitive spacer can

**4.** Cement components in combination with modular components made of plastic and metal

**5.** Resterilization of the prosthesis and insertion of a femoral component and a tibial polyethylene insert with cement or a new prosthesis as a spacer (prosthesis-spacer) with

**6.** Combinations of these approaches for moderate or massive defects [31], [32].

be made using these cement molds [24], [25].

**3.** Prefabricated spacers made of cement only [26].

high antibiotic loads [29], [30].

558 Arthroplasty - Update

(PROSTALAC®, DePuy, Warsaw, Indiana) [27], [28].

**Figure 1.** Remodeling prominent areas of a hand-made spacer with a high-speed burr.

Favorable results have been reported with each of these types of spacers. The more rudimen‐ tary a spacer is, the lower its congruence and the greater the sensation of popping, giving way, or instability. In contrast, it is cheaper, more widely available, and versatile. The specific advantage of spacers built manually with cement only is that the whole spacer is loaded with antibiotics, and these can be tailored to the causative organism. The spacer does not include plastic, metal, or resterilized parts and can be applied in any operating room with no need for specific instruments. The main disadvantage of cement spacers is the lack of optimal congru‐ ence, instability, and the difficulty in modeling, especially with high antibiotic loads (>10%-15%) (Figure3). In addition, cement-on-cement spacers can cause more inflammatory

**Figure 3.** Hand-made spacer for a segmental defect. Excellent range of motion. Due to instability or giving way the patients usually walks with a brace.

Customized spacers constructed completely of cement using prefabricated silicone or alumi‐ num molds are not difficult to shape with greater antibiotic loads.

Vacuum mixing decreases the porosity of the cement and thus potentially decreases the elution rate. However, this is not true for all cements, because other factors, such as hydrophilicity or

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In a recent study, Meyer et al. [34] compared the elution of 6 commercially available vacuummixed and manually mixed antibiotic-loaded cements. All showed detectable antimicrobial activity during the 5 days of the trial, with peak activity on the first day and levels above breakpoint sensitivity. Levels decreased rapidly thereafter. Cumulative antimicrobial activity during the trial was similar with the manually mixed Cemex Genta and the vacuum-mixed Cobalt G-HV and Palacos RG and higher than that of VersaBond AB, Simplex P with Tobra‐ mycin, and SmartSet GMV. The cumulative antimicrobial activity of manually mixed Cemex Genta over 5 days was significantly higher than that of Cobalt G-HV and Palacos RG, which in turn significantly higher cumulative antimicrobial activity than VersaBond AB, Simplex P with Tobramycin, and SmartSet GMV. Vacuum mixing increased the cumulative antimicrobial activity of Cobalt G-HV, Palacos RG, and Simplex P with Tobramycin and decreased the activity of Cemex Genta, SmartSet GMV, and VersaBond AB. The antimicrobial activity was similar for Cobalt G-HV and Palacos RG and significantly higher than that of the other cements. Furthermore, vacuum mixing also increased the number of days of elution above the break‐ point sensitivity necessary to eliminate 99% of methicillin-susceptible *Staphylococcus aureus* (MSSA) and methicillin-resistant *S. aureus* (MRSA) and 85% of coagulase-negative staphylo‐ cocci (CNS) recorded between 2009 and 2010. For Palacos RG, the number of days of elution increased from 2 days for manually mixed cements to 5 days for vacuum-mixed cements. For Cobalt G-HV, this value increased from 2 to 3 days; for Simplex P with Tobramycin it increased from 1 to 2 days. By contrast, vacuum mixing reduced the number of days' elution above this limit for Cemex Genta from 3 days to 1 day. The authors concluded that vacuum mixing had adverse effects on elution with low-viscosity cement (Cemex Genta), positive effects on elution with high-viscosity cements (Cobalt G-HV and Palacos RG), and unpredictable effects on elution with medium-viscosity cements (Simplex P with Tobramycin, SmartSet GMV, and VersaBond AB). Only manually mixed Cemex Genta and vacuum-mixed Palacos RG eluted antibiotics above breakpoint sensitivity on the third day; the remainder did so only on the first day. Although Cobalt G-HV and Palacos RG have a lower gentamicin load, they have greater antimicrobial activity and elution rates than other cements with a higher antibiotic load.

Other studies confirm differences between cements. Stevens et al. [40] studied the *in vitro* elution of antibiotics from Simplex and Palacos cements and noted that Palacos was a more

Antibiotic-loaded cement spacers release high concentrations of drug and enable higher intraarticular concentrations to be reached than parenteral antibiotics alone, with little effect on serum or urine concentrations and therefore with minimal risk of systemic damage [29], [43], [44]. It is essential to achieve local bactericidal concentrations that make it possible to eradicate infection or prevent colonization of the new implant during the reimplantation phase (the "race

effective vehicle for local administration [41], [42].

**4.2. Choice of antibiotic**

for the surface").

viscosity, may be more important than the area of elution.

By contrast, preformed spacers including metal or plastic elements or resterilized prostheses have a limited antibiotic load, which is not tailored to the patient. These spacers involve the insertion of foreign material into a septic environment. In these cases, only the cement fixing the metal components, the prosthesis, or the preformed spacer takes the maximum load of tailored antibiotics.

Also important is the degree of constriction of the spacer. All spacers made intraoperatively with a mold design lack a tibial post and femoral bar; at most, they have a tibial post that gives them some medial-lateral stability. The bar, or lever, which provides anteroposterior stability, is exclusive to PROSTALAC® systems or prosthesis-spacers.

## **4. Characteristics of antibiotic-loaded spacers**

Elution of antibiotics from bone cement depends on several factors: the type of antibiotic, the concentration and combination of antibiotics, the porosity and type of the cement, and the surface of the spacer [33], [34].

#### **4.1. Cement type: Commercially available vs. custom antibiotic-loaded cement**

Most commercially available antibiotic-loaded cements, have a low dose of antibiotic, which can act as prophylaxis in patients at risk (ie, double prophylaxis in combination with parenteral antibiotics), or during reimplantation in a 2-stage revision of an infected total knee arthro‐ plasty, but not for the treatment of infection when it is diagnosed[35].

Therefore, surgeons should add antibiotics to the cement to achieve the appropriate doses needed for the treatment of periprosthetic joint infection and to tailor the drug to the causative microorganism.

In comparison with commercial presentations, manually mixed cement releases less antibiotic [33], [34].

Manual mixing of cement and antibiotics increases the porosity of the cement. In theory, this approach weakens the cement, but increases the elution surface, since the antibiotic is released from the surface of the spacer and from cracks in the surface. On the other hand, distribution is not homogeneous (unlike commercially available preloaded cements), thus decreasing the rate of elution from a given surface [36], [37]. One study showed that increasing the surface area of bone cement by 40% yielded a 20% increase in the elution rate of vancomycin [38].

The addition of dextran increases porosity and elution rates. Kuechle et al. [39] noted that when dextran was added at 25%, the release of antibiotics during the first 48 hours was about 4 times greater, and the duration of elution reached 10 days instead of only 6, compared with the routine preparation. The same effect was observed with the addition of lactose and xylitol (or other sugars), which increase the release of daptomycin, vancomycin, and gentamicin [33].

Vacuum mixing decreases the porosity of the cement and thus potentially decreases the elution rate. However, this is not true for all cements, because other factors, such as hydrophilicity or viscosity, may be more important than the area of elution.

In a recent study, Meyer et al. [34] compared the elution of 6 commercially available vacuummixed and manually mixed antibiotic-loaded cements. All showed detectable antimicrobial activity during the 5 days of the trial, with peak activity on the first day and levels above breakpoint sensitivity. Levels decreased rapidly thereafter. Cumulative antimicrobial activity during the trial was similar with the manually mixed Cemex Genta and the vacuum-mixed Cobalt G-HV and Palacos RG and higher than that of VersaBond AB, Simplex P with Tobra‐ mycin, and SmartSet GMV. The cumulative antimicrobial activity of manually mixed Cemex Genta over 5 days was significantly higher than that of Cobalt G-HV and Palacos RG, which in turn significantly higher cumulative antimicrobial activity than VersaBond AB, Simplex P with Tobramycin, and SmartSet GMV. Vacuum mixing increased the cumulative antimicrobial activity of Cobalt G-HV, Palacos RG, and Simplex P with Tobramycin and decreased the activity of Cemex Genta, SmartSet GMV, and VersaBond AB. The antimicrobial activity was similar for Cobalt G-HV and Palacos RG and significantly higher than that of the other cements. Furthermore, vacuum mixing also increased the number of days of elution above the break‐ point sensitivity necessary to eliminate 99% of methicillin-susceptible *Staphylococcus aureus* (MSSA) and methicillin-resistant *S. aureus* (MRSA) and 85% of coagulase-negative staphylo‐ cocci (CNS) recorded between 2009 and 2010. For Palacos RG, the number of days of elution increased from 2 days for manually mixed cements to 5 days for vacuum-mixed cements. For Cobalt G-HV, this value increased from 2 to 3 days; for Simplex P with Tobramycin it increased from 1 to 2 days. By contrast, vacuum mixing reduced the number of days' elution above this limit for Cemex Genta from 3 days to 1 day. The authors concluded that vacuum mixing had adverse effects on elution with low-viscosity cement (Cemex Genta), positive effects on elution with high-viscosity cements (Cobalt G-HV and Palacos RG), and unpredictable effects on elution with medium-viscosity cements (Simplex P with Tobramycin, SmartSet GMV, and VersaBond AB). Only manually mixed Cemex Genta and vacuum-mixed Palacos RG eluted antibiotics above breakpoint sensitivity on the third day; the remainder did so only on the first day. Although Cobalt G-HV and Palacos RG have a lower gentamicin load, they have greater antimicrobial activity and elution rates than other cements with a higher antibiotic load.

Other studies confirm differences between cements. Stevens et al. [40] studied the *in vitro* elution of antibiotics from Simplex and Palacos cements and noted that Palacos was a more effective vehicle for local administration [41], [42].

#### **4.2. Choice of antibiotic**

Customized spacers constructed completely of cement using prefabricated silicone or alumi‐

By contrast, preformed spacers including metal or plastic elements or resterilized prostheses have a limited antibiotic load, which is not tailored to the patient. These spacers involve the insertion of foreign material into a septic environment. In these cases, only the cement fixing the metal components, the prosthesis, or the preformed spacer takes the maximum load of

Also important is the degree of constriction of the spacer. All spacers made intraoperatively with a mold design lack a tibial post and femoral bar; at most, they have a tibial post that gives them some medial-lateral stability. The bar, or lever, which provides anteroposterior stability,

Elution of antibiotics from bone cement depends on several factors: the type of antibiotic, the concentration and combination of antibiotics, the porosity and type of the cement, and the

Most commercially available antibiotic-loaded cements, have a low dose of antibiotic, which can act as prophylaxis in patients at risk (ie, double prophylaxis in combination with parenteral antibiotics), or during reimplantation in a 2-stage revision of an infected total knee arthro‐

Therefore, surgeons should add antibiotics to the cement to achieve the appropriate doses needed for the treatment of periprosthetic joint infection and to tailor the drug to the causative

In comparison with commercial presentations, manually mixed cement releases less antibiotic

Manual mixing of cement and antibiotics increases the porosity of the cement. In theory, this approach weakens the cement, but increases the elution surface, since the antibiotic is released from the surface of the spacer and from cracks in the surface. On the other hand, distribution is not homogeneous (unlike commercially available preloaded cements), thus decreasing the rate of elution from a given surface [36], [37]. One study showed that increasing the surface area of bone cement by 40% yielded a 20% increase in the elution rate of vancomycin [38].

The addition of dextran increases porosity and elution rates. Kuechle et al. [39] noted that when dextran was added at 25%, the release of antibiotics during the first 48 hours was about 4 times greater, and the duration of elution reached 10 days instead of only 6, compared with the routine preparation. The same effect was observed with the addition of lactose and xylitol (or other sugars), which increase the release of daptomycin, vancomycin, and gentamicin [33].

**4.1. Cement type: Commercially available vs. custom antibiotic-loaded cement**

plasty, but not for the treatment of infection when it is diagnosed[35].

num molds are not difficult to shape with greater antibiotic loads.

is exclusive to PROSTALAC® systems or prosthesis-spacers.

**4. Characteristics of antibiotic-loaded spacers**

tailored antibiotics.

560 Arthroplasty - Update

surface of the spacer [33], [34].

microorganism.

[33], [34].

Antibiotic-loaded cement spacers release high concentrations of drug and enable higher intraarticular concentrations to be reached than parenteral antibiotics alone, with little effect on serum or urine concentrations and therefore with minimal risk of systemic damage [29], [43], [44]. It is essential to achieve local bactericidal concentrations that make it possible to eradicate infection or prevent colonization of the new implant during the reimplantation phase (the "race for the surface").

The antibiotic used must have 2 fundamental properties:

**•** Thermostability: Polymerization of the cement is an exothermic reaction. The cement increases in temperature within 10-13 minutes, and this change may alter the properties of the antibiotic.

bacterial inhibition during the study period. In addition, unlike Copal, Palacos RG was unable to inhibit bacterial growth of gentamicin-resistant CNS. The addition of clindamycin to gentamicin-loaded cement had an additive effect on the inhibition of biofilm. Conversely, although both cements fulfill ISO norms, the mechanical properties of Palacos RG are superior.

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The study by Ensing et al. [46] has several practical implications. Synergy can enable the release of greater amounts of antibiotic, thus making inhibition of bacterial growth more effective and increasing the chances of winning the "race for the surface". By achieving high rates of antibiotic elution, even resistant bacteria can be eradicated when the dose rises sufficiently. Finally, given its worse biomechanical properties, Copal seems ideal for articulating spacers, which are withdrawn after a few weeks, but not as appropriate as Palacos RG for definitive

Effective elution from cement has also been observed with quinolones, daptomycin, and linezolid, although these agents are difficult to obtain in powder form or are too expensive [48]. Anguita-Alonso et al. [48] compared quinolones, cefazolin, and linezolid and found linezolid to be the most stable antibiotic after polymerization of PMMA. It achieved high peak concentrations at 7.5% and 15%. All detectable concentrations of linezolid were always above

Daptomycin has also demonstrated the ability to elute in local bactericidal concentrations for

In the case of fungal infections, the recommended antibiotic is amphotericin B or fluconazole (Figure 4). 5-Flucytosine is not stable and is therefore not valid for use in cement. Amphotericin can cause nephrotoxicity, hepatotoxicity, chills, nausea, and blood disorders, thus necessitat‐ ing lower doses and more prolonged treatment. Fortunately, the incidence of fungal infection is low. Most infections are by *Candida* species, of which *C. albicans* accounts for 60%, *C. parapsilosis* 20%, and *C. tropicalis* 20%. More uncommon species include *Coccidioides immitis*,

*S. aureus* and CNS, with a release profile similar to that of vancomycin [39], [49], [50].

**Figure 4.** Preformed cement spacer with amphotericin B and fluconazole in a prosthesis with fungal infection.

reimplantation once the infection has been cured.

the cutoff sensitivity of *Staphylococcus* spp. (≤4 µg/mL).

*Sporothrix schenckii*, and *Blastomyces dermatitidis*.

**4.3. Fungal infections**

**•** Water solubility: The antibiotic is disseminated in the tissues surrounding the infected joint. By maintaining the spacer in the joint for no less than 8 weeks, the antibiotic is released at a constant rate. However, the bactericidal effect is concentrated in the early days. Subse‐ quently, spacers fulfill mainly a mechanical function.

The most frequently used antibiotics are tobramycin, gentamicin, vancomycin, and cephalo‐ sporins. Antibiotics can be combined to achieve broad-spectrum coverage, depending on the nature of the causative microorganism. Aminoglycoside in powder is recommended, as it does not weaken the cement; however, it is difficult to obtain in some countries. The surgeon's options are therefore limited when combining antibiotics.

Periprosthetic infections are caused mainly by gram-positive microorganisms (*S. aureus* and CNS). When the pathogen and its antibiotic sensitivity profile are clearly identified, a single antibiotic should be administered. When the pathogen is unknown, treatment is more difficult, and a combination of antibiotics can improve the chances of eradicating infection. Vancomycin covers MRSA, gentamicin covers Enterobacteriaceae and *Pseudomonas aeruginosa*, and cefo‐ taxime destroys microorganisms resistant to gentamicin.

In addition to increasing the range of coverage, some combinations of antibiotics have a synergistic effect. Penner et al. [41] observed that the combination of vancomycin and tobra‐ mycin acted synergistically, although they discouraged the use of vancomycin in monother‐ apy. However, other authors have reported excellent results for CNS and MRSA with cement loaded with only 5-7.5% vancomycin (Simplex P, Howmedica, Rutherford, New Jersey, USA: 2-3 g of vancomycin per bag), both in static and in articulating spacers [45].

Synergy between aminoglycosides and vancomycin and, occasionally, a cephalosporin can make it possible to cover a broad spectrum of microorganisms. These antibiotics are usually available in powder form; however, antibiotic-loaded cements are not commercially available. Heraeus are working on a commercial presentation of gentamicin with vancomycin for commercial use in Europe in 2012.

The only commercial presentation with a synergistic effect is Copal, which combines clinda‐ mycin and gentamicin. Copal enables increased release of antibiotic and greater ability to inhibit the formation of biofilm than gentamicin alone. Ensing et al. [46] showed that the elution rate of Copal (clindamycin + gentamicin) is much greater than that of other cements, which are also considered excellent [47]. At 7 days, the elution rate was 65% for clindamycin and 41% for gentamicin; for Palacos RG the value for release was 4% for preloaded gentamicin. This increased release of antibiotic resulted in greater and more prolonged inhibition of bacterial growth on agar plates. Gentamicin-susceptible *S. aureus* strains were "small colony variants" that were resistant to gentamicin in Palacos RG and less so to the gentamicin in Copal. Elution of gentamicin in Palacos RG ceased after 72 hours, in contrast with Copal, which maintained bacterial inhibition during the study period. In addition, unlike Copal, Palacos RG was unable to inhibit bacterial growth of gentamicin-resistant CNS. The addition of clindamycin to gentamicin-loaded cement had an additive effect on the inhibition of biofilm. Conversely, although both cements fulfill ISO norms, the mechanical properties of Palacos RG are superior.

The study by Ensing et al. [46] has several practical implications. Synergy can enable the release of greater amounts of antibiotic, thus making inhibition of bacterial growth more effective and increasing the chances of winning the "race for the surface". By achieving high rates of antibiotic elution, even resistant bacteria can be eradicated when the dose rises sufficiently. Finally, given its worse biomechanical properties, Copal seems ideal for articulating spacers, which are withdrawn after a few weeks, but not as appropriate as Palacos RG for definitive reimplantation once the infection has been cured.

Effective elution from cement has also been observed with quinolones, daptomycin, and linezolid, although these agents are difficult to obtain in powder form or are too expensive [48]. Anguita-Alonso et al. [48] compared quinolones, cefazolin, and linezolid and found linezolid to be the most stable antibiotic after polymerization of PMMA. It achieved high peak concentrations at 7.5% and 15%. All detectable concentrations of linezolid were always above the cutoff sensitivity of *Staphylococcus* spp. (≤4 µg/mL).

Daptomycin has also demonstrated the ability to elute in local bactericidal concentrations for *S. aureus* and CNS, with a release profile similar to that of vancomycin [39], [49], [50].

#### **4.3. Fungal infections**

The antibiotic used must have 2 fundamental properties:

quently, spacers fulfill mainly a mechanical function.

options are therefore limited when combining antibiotics.

taxime destroys microorganisms resistant to gentamicin.

commercial use in Europe in 2012.

the antibiotic.

562 Arthroplasty - Update

**•** Thermostability: Polymerization of the cement is an exothermic reaction. The cement increases in temperature within 10-13 minutes, and this change may alter the properties of

**•** Water solubility: The antibiotic is disseminated in the tissues surrounding the infected joint. By maintaining the spacer in the joint for no less than 8 weeks, the antibiotic is released at a constant rate. However, the bactericidal effect is concentrated in the early days. Subse‐

The most frequently used antibiotics are tobramycin, gentamicin, vancomycin, and cephalo‐ sporins. Antibiotics can be combined to achieve broad-spectrum coverage, depending on the nature of the causative microorganism. Aminoglycoside in powder is recommended, as it does not weaken the cement; however, it is difficult to obtain in some countries. The surgeon's

Periprosthetic infections are caused mainly by gram-positive microorganisms (*S. aureus* and CNS). When the pathogen and its antibiotic sensitivity profile are clearly identified, a single antibiotic should be administered. When the pathogen is unknown, treatment is more difficult, and a combination of antibiotics can improve the chances of eradicating infection. Vancomycin covers MRSA, gentamicin covers Enterobacteriaceae and *Pseudomonas aeruginosa*, and cefo‐

In addition to increasing the range of coverage, some combinations of antibiotics have a synergistic effect. Penner et al. [41] observed that the combination of vancomycin and tobra‐ mycin acted synergistically, although they discouraged the use of vancomycin in monother‐ apy. However, other authors have reported excellent results for CNS and MRSA with cement loaded with only 5-7.5% vancomycin (Simplex P, Howmedica, Rutherford, New Jersey, USA:

Synergy between aminoglycosides and vancomycin and, occasionally, a cephalosporin can make it possible to cover a broad spectrum of microorganisms. These antibiotics are usually available in powder form; however, antibiotic-loaded cements are not commercially available. Heraeus are working on a commercial presentation of gentamicin with vancomycin for

The only commercial presentation with a synergistic effect is Copal, which combines clinda‐ mycin and gentamicin. Copal enables increased release of antibiotic and greater ability to inhibit the formation of biofilm than gentamicin alone. Ensing et al. [46] showed that the elution rate of Copal (clindamycin + gentamicin) is much greater than that of other cements, which are also considered excellent [47]. At 7 days, the elution rate was 65% for clindamycin and 41% for gentamicin; for Palacos RG the value for release was 4% for preloaded gentamicin. This increased release of antibiotic resulted in greater and more prolonged inhibition of bacterial growth on agar plates. Gentamicin-susceptible *S. aureus* strains were "small colony variants" that were resistant to gentamicin in Palacos RG and less so to the gentamicin in Copal. Elution of gentamicin in Palacos RG ceased after 72 hours, in contrast with Copal, which maintained

2-3 g of vancomycin per bag), both in static and in articulating spacers [45].

In the case of fungal infections, the recommended antibiotic is amphotericin B or fluconazole (Figure 4). 5-Flucytosine is not stable and is therefore not valid for use in cement. Amphotericin can cause nephrotoxicity, hepatotoxicity, chills, nausea, and blood disorders, thus necessitat‐ ing lower doses and more prolonged treatment. Fortunately, the incidence of fungal infection is low. Most infections are by *Candida* species, of which *C. albicans* accounts for 60%, *C. parapsilosis* 20%, and *C. tropicalis* 20%. More uncommon species include *Coccidioides immitis*, *Sporothrix schenckii*, and *Blastomyces dermatitidis*.

**Figure 4.** Preformed cement spacer with amphotericin B and fluconazole in a prosthesis with fungal infection.

Immunosuppression, prolonged hospitalization, prolonged intravenous therapy, drug dependence, and inflammatory diseases are risk factors for the development of fungal infections; however, in most published cases the patients did not present these risk factors. A reasonable postulate is that infection is caused by intraoperative inoculation rather than by hematogenous spread. The symptoms are those of a subacute infection, namely, mild to moderate pain or discomfort, effusion, and, occasionally, progressive osteolysis [51]. Publish‐ ed series are very short [52]-[54]. Phelan et al. [55] performed a 2-stage revision procedure with systemic administration of antifungal agents to treat 4 *Candida* infections of total joint arthro‐ plasties. They also identified 6 other cases in the literature that had been treated with the same regimen. In addition to resection arthroplasty, 8 patients received amphotericin B alone or in combination with other antifungal agents, and 1 patient was treated with fluconazole in monotherapy. Eight patients had no recurrence of infection at a mean of 50.7 months after reimplantation.

**4.5. Resistance: Mechanical properties of cement**

effects on the spacers [59], [60].

nonloaded cement.

for some commercial forms, such as Copal.

and lack of impact on the patient.

The factors affecting the mechanical properties of the cement are type of cement, proportion and combination of antibiotics, administration in liquid or powder form, and mixing method (manual or vacuum). Cement mixed with cloxacillin, cefazolin, gentamicin, vancomycin, and tobramycin has been shown to maintain good resistance to tension and compression [57], [58].

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However, adding liquid antibiotic interferes with early polymerization, leading to a sig‐ nificant deterioration in the properties of the cement, because of the effect of the water and not the properties of the antibiotic itself. For example, addition of liquid gentamicin instead of powder can decrease the resistance of the cement to compression by 49% and the tensile strength by 46%. Tobramycin powder, on the other hand, had not detrimental

Manually adding antibiotic also weakens the cement. Vacuum-mixed antibiotic-impregnated cement improves its mechanical properties by reducing porosity by up to 20%. It has been estimated that manual mixing causes a 30-40% reduction in resistance and that vacuum mixing

Commercial antibiotic-loaded cements retain their mechanical properties, although the dose may not be sufficient for the treatment of an infection or for the manufacture of spacers, except

Duncan [17] reported that manual mixing decreased resistance by 36% with respect to commercially available cement, while the resistance of the latter did not differ from that of

Lewis [33] compared several cements and their biomechanical properties after combination with different antibiotics. The composition of the cement was a major factor. The elution rate of vancomycin and tobramycin from Palacos RG is superior to that of Simplex, and the elution rate of Simplex is superior to that of CMW. The combination of antibiotics is also important. Vancomycin combined with tobramycin increases elution with Palacos (the same is true of gentamicin), but with Simplex P, elution of tobramycin decreases, not vice versa. Vacuum mixing also affects elution. CMW variants decrease elution of gentamicin when vacuummixed; however, with Palacos the opposite occurs, as confirmed by a recent study [34]. The concentration of vancomycin did not differ significantly depending on whether the cement was mixed manually or by vacuum. These authors also studied the effect of loading and impact cycles, which can lead to minor porosity and cracks in the spacer, thus increasing the elution rate. Among the cements studied, elution only increased with Palamed G, whose porosity is higher. For the remainder, no statistically significant differences were observed between load

Also important is the way in which the mixture is made. Hanssen and Spangehl [63] proposed a method for adding high doses of antibiotics to bone cement powder. Polymethylmethacrylate monomer and cement powder must first be mixed to form the liquid cement, and the antibiotic is added afterwards. It is important to leave as many large crystals as possible intact in order

to create a more porous mix that increases the elution rate of the antibiotics.

can reduce 10-fold the rate of fracture during cyclic loading with spacers [61], [62].

#### **4.4. Dose of antibiotic**

Lewis [33] studied the properties of antibiotic-loaded cements. Elution typically occurs in 3 phases: an exponential phase (during the first 24 hours), a declining phase, and a final low constant elution phase. The exponential phase depends on the diffusion area of the surface of the spacer, although porosity and hydrophilicity of the cement also play a role. Porosity determines the amount of liquid that comes into contact with the surface of the cement, which in turn determines the elution rate of the antibiotic from the surface or from deeper cracks in the cement.

The addition of high doses of antibiotic to the cement is a key element of treatment when attempting to reach maximum intra-articular concentrations in the exponential phase, although some authors have observed persistent effective levels of antibiotics until 4 months after surgery [56].

The antibiotic should not exceed 20% of the total mass of cement. In addition, it should be in powder form, since liquid forms hinder polymerization. No standard ideal dosage of each drug to be mixed with bone cement has been established. Addition of 2 antibiotics to the cement is superior to the addition of 1. The most frequently used doses vary from 2.4 g of tobramycin with 1 g of vancomycin per 40 g of cement to 4 g of vancomycin with 4.6 g of tobramycin per 40 g of cement. These doses have been associated with success rates of above 90% [41], [56].

As the amount of antibiotic powder increases, the strength of the cement decreases. How‐ ever, antibiotic load seems to be yet another factor within 2-stage exchange, and consis‐ tent results have been obtained using unloaded antibiotic spacers or spacers with only minimal loads. Fehring et al. [15] reported efficacious results with 1.2 g of tobramycin per 40 g of bone cement. Mean follow-up was 36 months for patients who received a nonarti‐ culating spacer (88% eradication) and 27 months for patients treated with an articulating spacer (93% eradication).

#### **4.5. Resistance: Mechanical properties of cement**

Immunosuppression, prolonged hospitalization, prolonged intravenous therapy, drug dependence, and inflammatory diseases are risk factors for the development of fungal infections; however, in most published cases the patients did not present these risk factors. A reasonable postulate is that infection is caused by intraoperative inoculation rather than by hematogenous spread. The symptoms are those of a subacute infection, namely, mild to moderate pain or discomfort, effusion, and, occasionally, progressive osteolysis [51]. Publish‐ ed series are very short [52]-[54]. Phelan et al. [55] performed a 2-stage revision procedure with systemic administration of antifungal agents to treat 4 *Candida* infections of total joint arthro‐ plasties. They also identified 6 other cases in the literature that had been treated with the same regimen. In addition to resection arthroplasty, 8 patients received amphotericin B alone or in combination with other antifungal agents, and 1 patient was treated with fluconazole in monotherapy. Eight patients had no recurrence of infection at a mean of 50.7 months after

Lewis [33] studied the properties of antibiotic-loaded cements. Elution typically occurs in 3 phases: an exponential phase (during the first 24 hours), a declining phase, and a final low constant elution phase. The exponential phase depends on the diffusion area of the surface of the spacer, although porosity and hydrophilicity of the cement also play a role. Porosity determines the amount of liquid that comes into contact with the surface of the cement, which in turn determines the elution rate of the antibiotic from the surface or from deeper cracks in

The addition of high doses of antibiotic to the cement is a key element of treatment when attempting to reach maximum intra-articular concentrations in the exponential phase, although some authors have observed persistent effective levels of antibiotics until 4 months

The antibiotic should not exceed 20% of the total mass of cement. In addition, it should be in powder form, since liquid forms hinder polymerization. No standard ideal dosage of each drug to be mixed with bone cement has been established. Addition of 2 antibiotics to the cement is superior to the addition of 1. The most frequently used doses vary from 2.4 g of tobramycin with 1 g of vancomycin per 40 g of cement to 4 g of vancomycin with 4.6 g of tobramycin per 40 g of cement. These doses have been associated with success rates of above 90% [41], [56].

As the amount of antibiotic powder increases, the strength of the cement decreases. How‐ ever, antibiotic load seems to be yet another factor within 2-stage exchange, and consis‐ tent results have been obtained using unloaded antibiotic spacers or spacers with only minimal loads. Fehring et al. [15] reported efficacious results with 1.2 g of tobramycin per 40 g of bone cement. Mean follow-up was 36 months for patients who received a nonarti‐ culating spacer (88% eradication) and 27 months for patients treated with an articulating

reimplantation.

564 Arthroplasty - Update

the cement.

after surgery [56].

spacer (93% eradication).

**4.4. Dose of antibiotic**

The factors affecting the mechanical properties of the cement are type of cement, proportion and combination of antibiotics, administration in liquid or powder form, and mixing method (manual or vacuum). Cement mixed with cloxacillin, cefazolin, gentamicin, vancomycin, and tobramycin has been shown to maintain good resistance to tension and compression [57], [58].

However, adding liquid antibiotic interferes with early polymerization, leading to a sig‐ nificant deterioration in the properties of the cement, because of the effect of the water and not the properties of the antibiotic itself. For example, addition of liquid gentamicin instead of powder can decrease the resistance of the cement to compression by 49% and the tensile strength by 46%. Tobramycin powder, on the other hand, had not detrimental effects on the spacers [59], [60].

Manually adding antibiotic also weakens the cement. Vacuum-mixed antibiotic-impregnated cement improves its mechanical properties by reducing porosity by up to 20%. It has been estimated that manual mixing causes a 30-40% reduction in resistance and that vacuum mixing can reduce 10-fold the rate of fracture during cyclic loading with spacers [61], [62].

Commercial antibiotic-loaded cements retain their mechanical properties, although the dose may not be sufficient for the treatment of an infection or for the manufacture of spacers, except for some commercial forms, such as Copal.

Duncan [17] reported that manual mixing decreased resistance by 36% with respect to commercially available cement, while the resistance of the latter did not differ from that of nonloaded cement.

Lewis [33] compared several cements and their biomechanical properties after combination with different antibiotics. The composition of the cement was a major factor. The elution rate of vancomycin and tobramycin from Palacos RG is superior to that of Simplex, and the elution rate of Simplex is superior to that of CMW. The combination of antibiotics is also important. Vancomycin combined with tobramycin increases elution with Palacos (the same is true of gentamicin), but with Simplex P, elution of tobramycin decreases, not vice versa. Vacuum mixing also affects elution. CMW variants decrease elution of gentamicin when vacuummixed; however, with Palacos the opposite occurs, as confirmed by a recent study [34]. The concentration of vancomycin did not differ significantly depending on whether the cement was mixed manually or by vacuum. These authors also studied the effect of loading and impact cycles, which can lead to minor porosity and cracks in the spacer, thus increasing the elution rate. Among the cements studied, elution only increased with Palamed G, whose porosity is higher. For the remainder, no statistically significant differences were observed between load and lack of impact on the patient.

Also important is the way in which the mixture is made. Hanssen and Spangehl [63] proposed a method for adding high doses of antibiotics to bone cement powder. Polymethylmethacrylate monomer and cement powder must first be mixed to form the liquid cement, and the antibiotic is added afterwards. It is important to leave as many large crystals as possible intact in order to create a more porous mix that increases the elution rate of the antibiotics.

This approach is not applicable when using antibiotic-loaded cement prophylactically, as crystals weaken the cement. Moreover, manual mixing decreases the elution rate in some types of cement. Therefore, commercial forms are preferred.

Several studies compare the results of 2-stage exchange with articulating spacers and 28 studies

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Park et al. [68] compared 20 prosthetic knee infections treated with monoblock spacers and 16 treated with articulating spacers. The reinfection rate was 6.3% for the articulating group and 15% for the fixed group. The range of motion with the spacer was 80º and 9º, respectively (final range, 108º and 92º). The clinical and functional score according to the HSS scale was signifi‐ cantly better with the articulating spacer, and the number of extensile exposures was lower. In the static spacer group, 75% of patients (65% of the femurs and 50% of the tibias) had bone

Meek et al. [27] retrospectively analyzed the results of 2-stage exchange with a PROSTALAC articulating spacer in 47 patients with infected knee prosthesis and a mean follow-up of 41 months. The eradication rate was 96%. The Western Ontario and McMaster Universities Osteoarthritis scale and the Oxford-12 and Short Form-12 scales showed better scores for

Calton et al. [9] compared the outcomes of patients treated with articulating spacers and patients treated with nonarticulating spacers. Among the 24 patients with a nonarticulating spacer, 60% had an average bone loss of 6.2 mm in the tibia and 12.8 mm in the femur, often with invagination and migration of the spacer and problems of soft tissue retraction. The authors recommended intramedullary extension of the spacer to prevent migration and obtain the appropriate thickness. They also recommended tightening the collateral ligaments to prevent contracture and a block that is sufficiently wide to rest on the cortical rim and prevent migration to cancellous bone. No differences were observed between the groups in eradication

Fehring et al. [15] studied 25 nonarticulating spacers and 30 articulating spacers and found that articulating spacers facilitated reimplantation and were not associated with bone loss.

Emerson et al. [13] reported that range of motion was greater with articulating knee spacers than with nonarticulating spacers; flexion of the knee averaged 107.8° and 93.7°, respectively,

Therefore, a comprehensive review of the literature provides more arguments for articulating spacers than for static spacers. Articulating spacers seem to be the most widespread form of treatment. The method of making the spacer does not seem to affect eradication rates or

Durbhakula et al. [21] treated 4 patients with antibiotic-loaded articulating spacers made in vacuum-injected silicone molds designed to produce articulating femoral and tibial compo‐ nents. The final average range of motion was 104° and the HSS score was 82. The rate of eradication of infection was 92% after an average of 33 months. A system of this type does not require a metal-polyethylene articulation surface and reduces costs by applying reusable molds that cost about \$300 each. The authors reported no problems of dislocation, retraction,

loss. This complication was not observed for the articulating spacers.

compare the results with a static spacer [3].

rates, time of surgery, or functional outcome.

and no evidence of higher complication rates was found.

bone loss, fracture, or fragmentation of the spacer.

articulating spacers.

functional outcome.

The method of Frommelt and Kühn [64], namely, fractional addition of antibiotic (now generally recommended), involves the gradual addition of cement and antibiotic powder and mixture of the two until the expected load of antibiotic is complete. The mixture can then be made manually or by vacuum, depending on the type of cement and the availability of vacuum systems. Once mixed, the cement has to be applied in the doughy phase or late phase of polymerization to prevent excessive interdigitation with the bone, thus facilitating extraction during surgery and providing the surgeon with a certain degree of freedom to shape the articular surface of the spacer.

#### **4.6. Safety**

As with any treatment, the surgeon must be aware of the possible side effects of the antibiotics used in spacers. Despite the large number of infected arthroplasties treated annually and the widespread use of antibiotic-loaded cement, complications are rare.

Evans [54] used 4 g of vancomycin and 4.6 g of tobramycin in powder per batch of 40 g of polymethylmethacrylate cement in 44 patients with a total of 54 periprosthetic joint infections. Follow-up to a minimum of 2 years showed no renal, vestibular, or auditory effects. Springer et al. [43] studied the systemic safety of cement loaded with high doses of antibiotic over time and reported that an average dose of 10.5 g of vancomycin and 12.5 g of gentamicin was clinically safe, with no signs of acute renal failure or other systemic side effects. In contrast, Van Raaij et al. [65] reported a case of acute renal failure that affected an 83-year-old woman after treatment with 2 g of gentamicin in a 240-g cement block combined with 7 strings of gentamicin-loaded polymethylmethacrylate beads. Serum levels of gentamicin were high, leading to removal of the spacer and eventual recovery of renal function. Ceffa et al. [66] reported 2 cases of mucormycosis after treatment with antibiotic-loaded cement spacers.

The complications reported are rare events in which other factors (eg, blood volume or intravenous antibiotics) could play a role, since the normalization profile of serum antibiotic levels, when using antibiotic-loaded spacers, is exponential and reaches normal values in 24 hours.

### **5. Results**

The use of a polymethylmethacrylate antibiotic-loaded spacer provides not only more effective treatment of periprosthetic infection, with eradication rates ranging from 90% to 100% in the literature, but also improved function, reduced pain, greater patient satisfaction, shorter hospital stay, and lower costs. Few studies analyze developments in the medium-to-long term. Although the results remain more or less stable, up to 30% of patients require revision for loosening, reinfection, or other causes in the medium term [67].

Several studies compare the results of 2-stage exchange with articulating spacers and 28 studies compare the results with a static spacer [3].

This approach is not applicable when using antibiotic-loaded cement prophylactically, as crystals weaken the cement. Moreover, manual mixing decreases the elution rate in some types

The method of Frommelt and Kühn [64], namely, fractional addition of antibiotic (now generally recommended), involves the gradual addition of cement and antibiotic powder and mixture of the two until the expected load of antibiotic is complete. The mixture can then be made manually or by vacuum, depending on the type of cement and the availability of vacuum systems. Once mixed, the cement has to be applied in the doughy phase or late phase of polymerization to prevent excessive interdigitation with the bone, thus facilitating extraction during surgery and providing the surgeon with a certain degree of freedom to shape the

As with any treatment, the surgeon must be aware of the possible side effects of the antibiotics used in spacers. Despite the large number of infected arthroplasties treated annually and the

Evans [54] used 4 g of vancomycin and 4.6 g of tobramycin in powder per batch of 40 g of polymethylmethacrylate cement in 44 patients with a total of 54 periprosthetic joint infections. Follow-up to a minimum of 2 years showed no renal, vestibular, or auditory effects. Springer et al. [43] studied the systemic safety of cement loaded with high doses of antibiotic over time and reported that an average dose of 10.5 g of vancomycin and 12.5 g of gentamicin was clinically safe, with no signs of acute renal failure or other systemic side effects. In contrast, Van Raaij et al. [65] reported a case of acute renal failure that affected an 83-year-old woman after treatment with 2 g of gentamicin in a 240-g cement block combined with 7 strings of gentamicin-loaded polymethylmethacrylate beads. Serum levels of gentamicin were high, leading to removal of the spacer and eventual recovery of renal function. Ceffa et al. [66] reported 2 cases of mucormycosis after treatment with antibiotic-loaded cement spacers.

The complications reported are rare events in which other factors (eg, blood volume or intravenous antibiotics) could play a role, since the normalization profile of serum antibiotic levels, when using antibiotic-loaded spacers, is exponential and reaches normal values in 24

The use of a polymethylmethacrylate antibiotic-loaded spacer provides not only more effective treatment of periprosthetic infection, with eradication rates ranging from 90% to 100% in the literature, but also improved function, reduced pain, greater patient satisfaction, shorter hospital stay, and lower costs. Few studies analyze developments in the medium-to-long term. Although the results remain more or less stable, up to 30% of patients require revision for

loosening, reinfection, or other causes in the medium term [67].

widespread use of antibiotic-loaded cement, complications are rare.

of cement. Therefore, commercial forms are preferred.

articular surface of the spacer.

**4.6. Safety**

566 Arthroplasty - Update

hours.

**5. Results**

Park et al. [68] compared 20 prosthetic knee infections treated with monoblock spacers and 16 treated with articulating spacers. The reinfection rate was 6.3% for the articulating group and 15% for the fixed group. The range of motion with the spacer was 80º and 9º, respectively (final range, 108º and 92º). The clinical and functional score according to the HSS scale was signifi‐ cantly better with the articulating spacer, and the number of extensile exposures was lower. In the static spacer group, 75% of patients (65% of the femurs and 50% of the tibias) had bone loss. This complication was not observed for the articulating spacers.

Meek et al. [27] retrospectively analyzed the results of 2-stage exchange with a PROSTALAC articulating spacer in 47 patients with infected knee prosthesis and a mean follow-up of 41 months. The eradication rate was 96%. The Western Ontario and McMaster Universities Osteoarthritis scale and the Oxford-12 and Short Form-12 scales showed better scores for articulating spacers.

Calton et al. [9] compared the outcomes of patients treated with articulating spacers and patients treated with nonarticulating spacers. Among the 24 patients with a nonarticulating spacer, 60% had an average bone loss of 6.2 mm in the tibia and 12.8 mm in the femur, often with invagination and migration of the spacer and problems of soft tissue retraction. The authors recommended intramedullary extension of the spacer to prevent migration and obtain the appropriate thickness. They also recommended tightening the collateral ligaments to prevent contracture and a block that is sufficiently wide to rest on the cortical rim and prevent migration to cancellous bone. No differences were observed between the groups in eradication rates, time of surgery, or functional outcome.

Fehring et al. [15] studied 25 nonarticulating spacers and 30 articulating spacers and found that articulating spacers facilitated reimplantation and were not associated with bone loss.

Emerson et al. [13] reported that range of motion was greater with articulating knee spacers than with nonarticulating spacers; flexion of the knee averaged 107.8° and 93.7°, respectively, and no evidence of higher complication rates was found.

Therefore, a comprehensive review of the literature provides more arguments for articulating spacers than for static spacers. Articulating spacers seem to be the most widespread form of treatment. The method of making the spacer does not seem to affect eradication rates or functional outcome.

Durbhakula et al. [21] treated 4 patients with antibiotic-loaded articulating spacers made in vacuum-injected silicone molds designed to produce articulating femoral and tibial compo‐ nents. The final average range of motion was 104° and the HSS score was 82. The rate of eradication of infection was 92% after an average of 33 months. A system of this type does not require a metal-polyethylene articulation surface and reduces costs by applying reusable molds that cost about \$300 each. The authors reported no problems of dislocation, retraction, bone loss, fracture, or fragmentation of the spacer.

Goldstein et al. [23] formed spacers intraoperatively using cement and test components on aluminum foil to prevent interdigitation. The femoral condyles were molded with the tibial trial implant, and the tibial implant was used to calculate the size and thickness of the cemented tibial component. The authors reported initial success in 5 patients.

associated with severe bone loss on revision arthroplasty in 11 cases (58%), tumor endopros‐ theses in 4 (21%), primary arthroplasty in 2 (11%), and infection on fracture or osteotomy in 2. The eradication rate at 38 months was 63% (12 cases), Four patients (21%) suffered reinfection and 2 were amputees. Jeys et al. [72] reported an eradication rate of 72% in primary infection

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569

Reinfection after reimplantation has not been adequately studied in the literature, although the high percentage of rescue treatments indicates that reinfection has its own prognostic implications. Therefore, it could be classified as a separate type of infection and independently

Hanssen et al. [73] published a series of 24 reinfections after infected total knee prosthesis. The infection was eradicated in only 1 case. Another patient received suppressive therapy after a

Hart and Jones [74] reported 6 cases of reinfection following 2-stage revision. The infection was eradicated in 2 cases (with another 2-stage revision), 2 patients had bone fusions, and 2

**1.** Two-stage exchange is considered the treatment of choice in the following circumstances: late infection, unidentified causal microorganisms, fungal infections, infections by virulent organisms, underlying inflammatory diseases, immunosuppression, and

**2.** Articulating spacers can minimize complications between procedures, thus enhancing patient autonomy and mobility, preventing retraction of the soft tissues, and facilitating

**3.** In addition, articulating spacers seem to improve eradication rates and functional

**4.** The way the spacer is constructed does not seem to affect eradication rates and functional outcome. The surgeon's choice of spacer will depend on technical and financial restraints. Despite their advantages and disadvantages, all types of spacer have demonstrated

**6.** The antibiotic should be added as powder to avoid weakening the cement. Appropriate use of synergies increases the spectrum of coverage and elution rate of certain antibiotics.

**7.** Once fractionated addition is complete, vacuum mixing increases the elution of the antibiotic from the spacer when high-viscosity cements are used. Manual mixing is

**5.** Not all cements are equally suitable for the prevention and treatment of infection.

of massive tumor prosthesis with a 2-stage protocol.

new reimplantation, and the rest underwent arthrodesis.

studied in the future.

had suppressive treatments.

reinfection after reimplantation.

outcomes and reduce complications.

consistent and reproducible results.

preferred when low-viscosity cements are used.

**6. Conclusions**

reimplantation.

MacAvoy and Ries [20] described an inexpensive mold-based method for manufacturing a spherical articulating spacer (ball and socket). They used this method in cases with severe bone deficiency and damage to the ligaments because of its high congruence. The average load was 3.6 g to 4 g of tobramycin + 1 g of vancomycin per bag of Palacos. For an average of 4 cements, this represents a dose of more than 14 g. In 12 patients with severe comorbidities, infection was eradicated in 9 of 13 knees with a mean follow-up of 28 months. All patients could walk with minimal assistance. The average range of motion of the knee with the spacer was 79°, which increased to 98° at the end of treatment. The authors rarely used hinge models, despite serious injury to the ligaments and bone loss.

Using cement spacer molds created intraoperatively with Palacos RG loaded with 0.5 g of gentamicin plus 3 g of vancomycin, Shen et al. [25] obtained 10 reimplantations in 17 cases followed for 30 months. In 5 cases, the spacer was the definitive treatment, in 1 case the joint merged, and 1 patient required amputation. The average range of motion with the spacer was 82° (97° after reimplantation).

Excellent results have been reported with the Hoffman prosthesis-spacer system. Anderson et al. [30] reported a range of motion of 2° to 115°; Huang et al. [69] reported 97.6°, which was smaller than in previous publications (104º to 115º). As for eradication with this type of spacer, reinfection rates are variable: 4% according to Anderson et al. [30] (25 knees), 0%-12% accord‐ ing to Hofmann et al. [29] (22 and 50 patients; Simplex cement with 4.8 g of vancomycin per bag), 9% according to Emerson et al. [13] (22 patients), and 2% according to Cuckler [70] (44 patients).

Ha [24] reported motion ranging from 2° to 104° with manually modeled cement spacers. The study included 12 cases treated with spacers made using the double mold (a cement negative is made with trial components and the definitive spacer is modeled on the negative) and using doses of 4.8 g of tobramycin and 4 g of vancomycin per cement bag. The antibiotic load accounted for 20% of the cement-antibiotic composite.

In addition to the type of spacer, range of motion is influenced by preoperative mobility, the state of the soft tissues, surgical technique, implant selection, early rehabilitation, and patient cooperation. Our group [18] found the range of motion to be 107° after reimplantation using manual spacers and 7.5% antibiotic load.

Soft tissue damage, severe bone loss or general health status, appear to be more important than the treatment method, and the results of 2-stage exchange, which are generally excellent, are much worse in patients with a less favorable health status.

Macmull et al. [71] published 19 cases with the SMILES spacer, which was based on an antibiotic-loaded hinge coated with antibiotic-loaded cement (Palacos RG, Heraeus Medical GmbH, Wehrheim, Germany). The spacer was used in the early stages of chronic infection associated with severe bone loss on revision arthroplasty in 11 cases (58%), tumor endopros‐ theses in 4 (21%), primary arthroplasty in 2 (11%), and infection on fracture or osteotomy in 2. The eradication rate at 38 months was 63% (12 cases), Four patients (21%) suffered reinfection and 2 were amputees. Jeys et al. [72] reported an eradication rate of 72% in primary infection of massive tumor prosthesis with a 2-stage protocol.

Reinfection after reimplantation has not been adequately studied in the literature, although the high percentage of rescue treatments indicates that reinfection has its own prognostic implications. Therefore, it could be classified as a separate type of infection and independently studied in the future.

Hanssen et al. [73] published a series of 24 reinfections after infected total knee prosthesis. The infection was eradicated in only 1 case. Another patient received suppressive therapy after a new reimplantation, and the rest underwent arthrodesis.

Hart and Jones [74] reported 6 cases of reinfection following 2-stage revision. The infection was eradicated in 2 cases (with another 2-stage revision), 2 patients had bone fusions, and 2 had suppressive treatments.

### **6. Conclusions**

Goldstein et al. [23] formed spacers intraoperatively using cement and test components on aluminum foil to prevent interdigitation. The femoral condyles were molded with the tibial trial implant, and the tibial implant was used to calculate the size and thickness of the cemented

MacAvoy and Ries [20] described an inexpensive mold-based method for manufacturing a spherical articulating spacer (ball and socket). They used this method in cases with severe bone deficiency and damage to the ligaments because of its high congruence. The average load was 3.6 g to 4 g of tobramycin + 1 g of vancomycin per bag of Palacos. For an average of 4 cements, this represents a dose of more than 14 g. In 12 patients with severe comorbidities, infection was eradicated in 9 of 13 knees with a mean follow-up of 28 months. All patients could walk with minimal assistance. The average range of motion of the knee with the spacer was 79°, which increased to 98° at the end of treatment. The authors rarely used hinge models, despite

Using cement spacer molds created intraoperatively with Palacos RG loaded with 0.5 g of gentamicin plus 3 g of vancomycin, Shen et al. [25] obtained 10 reimplantations in 17 cases followed for 30 months. In 5 cases, the spacer was the definitive treatment, in 1 case the joint merged, and 1 patient required amputation. The average range of motion with the spacer was

Excellent results have been reported with the Hoffman prosthesis-spacer system. Anderson et al. [30] reported a range of motion of 2° to 115°; Huang et al. [69] reported 97.6°, which was smaller than in previous publications (104º to 115º). As for eradication with this type of spacer, reinfection rates are variable: 4% according to Anderson et al. [30] (25 knees), 0%-12% accord‐ ing to Hofmann et al. [29] (22 and 50 patients; Simplex cement with 4.8 g of vancomycin per bag), 9% according to Emerson et al. [13] (22 patients), and 2% according to Cuckler [70] (44

Ha [24] reported motion ranging from 2° to 104° with manually modeled cement spacers. The study included 12 cases treated with spacers made using the double mold (a cement negative is made with trial components and the definitive spacer is modeled on the negative) and using doses of 4.8 g of tobramycin and 4 g of vancomycin per cement bag. The antibiotic load

In addition to the type of spacer, range of motion is influenced by preoperative mobility, the state of the soft tissues, surgical technique, implant selection, early rehabilitation, and patient cooperation. Our group [18] found the range of motion to be 107° after reimplantation using

Soft tissue damage, severe bone loss or general health status, appear to be more important than the treatment method, and the results of 2-stage exchange, which are generally excellent, are

Macmull et al. [71] published 19 cases with the SMILES spacer, which was based on an antibiotic-loaded hinge coated with antibiotic-loaded cement (Palacos RG, Heraeus Medical GmbH, Wehrheim, Germany). The spacer was used in the early stages of chronic infection

tibial component. The authors reported initial success in 5 patients.

serious injury to the ligaments and bone loss.

accounted for 20% of the cement-antibiotic composite.

much worse in patients with a less favorable health status.

manual spacers and 7.5% antibiotic load.

82° (97° after reimplantation).

patients).

568 Arthroplasty - Update


### **Author details**

Manuel Villanueva-Martínez1\*, Antonio Ríos-Luna2 , Francisco Chana-Rodriguez1 , Jose A. De Pedro3 and Antonio Pérez-Caballer4

\*Address all correspondence to: mvillanuevam@yahoo.com

1 Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain

[9] Calton, T. F, Fehring, T. K, & Griffin, W. L. Bone loss associated with the use of spacer blocks in infected total knee arthroplasty. Clin Orthop (1997). , 345, 148-54.

Articulating Spacers in Infection of Total Knee Arthroplasty — State of the Art

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571

[10] Jiranek, W. A, Arlen, D, Hanssen, A. D, & Greenwald, A. S. Antibiotic-loaded bone cement for infection prophylaxis in total joint replacement. J Bone Joint Surg Am.

[11] Alt, V, Bechert, T, & Steinrücke, P. In vitro testing of antimicrobial activity of bone

[12] Cohen, J. C, Hozack, W. J, Cucker, J. M, & Booth, R. E. Two stage reimplantation of septic total knee arthroplasty: report of three cases using an antibiotic PMMA spacer

[13] Emerson Jr RHMuncie M, Tarbox TR, Higgins LL. Comparison of a static with a mobile

[14] Cui, Q, Mihalko, W. M, Shields, J. S, Ries, M, & Saleh, K. J. Antibiotic-impregnated cement spacers for the treatment of infection associated with total hip or knee arthro‐

[15] Fehring, T. K, Odum, S, Calton, T. F, & Mason, J. B. Articulating versus static spacers in revision total knee arthroplasty for sepsis. The Ranawat Award. Clin Orthop (2000). ,

[16] Chiang, E. R, Su, Y. P, Chen, T. H, Chiu, F. Y, & Chen, W. M. Comparison of articulating and static spacers regarding infection with resistant organisms in total knee arthro‐

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[18] Villanueva-martínez, M, Ríos-luna, A, Pereiro, J, & Fahandez-saddi, H. Hand-made articulating spacers in two-stage revision for infected total knee arthroplasty: good

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3 Hospital Universitario Salamanca, Salamanca University, Spain

4 Hospital Infanta Elena, Francisco de Vitoria University, Madrid, Spain

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**Author details**

570 Arthroplasty - Update

Jose A. De Pedro3

Madrid, Spain

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2 Orthoindal Center, El Ejido, Almería University, Almería, Spain

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[46] Ensing, G. T, Van Horn, J. R, Van Der Mei, H. C, Busscher, H. J, & Neut, D. Copal Bone Cement Is More Effective in Preventing Biofilm Formation than Palacos R-G. Clin Orthop Relat Res (2008). , 466, 1492-1498.

[58] Klekamp, J, Dawson, J. M, Haas, D. W, Deboer, D, & Christie, M. The use of vancomycin and tobramycin in acrylic bone cement: biomechanical effects and elution kinetics for

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[60] Deluise, M, & Scott, C. P. Addition of hand-blended generic tobramycin in bone cement:

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[65] Van Raaij, T. M, Visser, L. E, Vulto, A. G, & Verhaar, J. A. Acute renal failure after local gentamicin treatment in an infected total knee arthroplasty. J Arthroplasty (2002). , 17,

[66] Ceffa, R, Andreoni, S, Borre, S, Ghisellini, F, Fornara, P, Brugo, G, & Ritter, M. A. Mucoraceae infections of antibiotic-loaded cement spacers in the treatment of bacterial

[67] Haleem, A. A, Berry, D. J, & Hanssen, A. D. Mid-Term to Long-Term Followup of Twostage Reimplantation for Infected Total Knee Arthroplasty. Clin Orthop Relat Research

[68] Park, S. J, Song, E. K, Seon, J. K, Yoon, T. R, & Park, Y. H. Comparison of static and mobile antibiotic-impregnated cement spacers for the treatment of infected total knee

[69] Huang, H, Su, J, & Chen, S. The results of articulating spacer technique for infected

[70] Cuckler, J. M. The infected total knee. Management options. J Arthroplasty (2005). S ,

[71] Macmull, S, Bartlett, W, Miles, W, Blunn, J, Pollock, G. W, Carrington, R. C, Skinner, R. W, Cannon, J. A, Briggs, S. R, & Custom-made, T. W. hinged spacers in revision knee surgery for patients with infection, bone loss and instability. The Knee (2010). , 17,

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[58] Klekamp, J, Dawson, J. M, Haas, D. W, Deboer, D, & Christie, M. The use of vancomycin and tobramycin in acrylic bone cement: biomechanical effects and elution kinetics for use in joint arthroplasty. J Arthroplasty (1999). , 14, 339-46.

[46] Ensing, G. T, Van Horn, J. R, Van Der Mei, H. C, Busscher, H. J, & Neut, D. Copal Bone Cement Is More Effective in Preventing Biofilm Formation than Palacos R-G. Clin

[47] Neut, D, De Groot, E. P, Kowalski, R. S, Van Horn, J. R, Van Der Mei, H. C, & Busscher, H. J. Gentamicin-loaded bone cement with clindamycin or fusidic acid added: biofilm

[48] Anguita-alonso, P, Rouse, M. S, Piper, K. E, Jacofsky, D. J, Osmon, D. R, & Patel, R. Comparative study of antimicrobial release kinetics from polymethylmethacrylate.

[49] Webb, N. D, Mccanless, J. D, Courtney, H. S, Bumgardner, J. D, & Haggard, W. O. Daptomycin Eluted From Calcium Sulfate Appears Effective Against Staphylococcus.

[50] Hall, E. W, Rouse, M. S, Jacofsky, D. J, Osmon, D. R, Hanssen, A. D, Steckelberg, J. M, & Patel, R. Release of daptomycin from polymethylmethacrylate beads in a continuous flow chamber. Diagnostic Microbiology and Infectious Disease (2004). , 50, 261-265.

[51] Wyman, J, Mcgough, R, & Limbird, R. Fungal infection of a total knee prosthesis: Successful treatment using articulating cement spacers and staged reimplantation.

[52] Baumann, P. A, Cunningham, B, Patel, N. S, & Finn, H. A. Aspergillus fumigatus infection in a mega prosthetic total knee arthroplasty: salvage by staged reimplantation

[53] Langer, P, Kassim, R. A, Macari, G. S, & Saleh, K. J. Aspergillus infection after total knee

[54] Evans, R. P. Successful treatment of TH and TK infection with articulating antibiotic components. A modified treatment method. Clin Orthop Relat Research. (2004). , 427,

[55] Phelan, D. M, Osmon, D. R, Keating, M. R, & Hanssen, A. D. Delayed reimplantation arthroplasty for candidal prosthetic joint infection: a report of 4 cases and review of the

[56] Masri, B. A, Duncan, C. P, & Beauchamp, C. P. Long-term elution of antibiotics from bone-cement: an in vivo study using the prosthesis of antibiotic-loaded acrylic cement

[57] Armstrong, M. S, Spencer, R. F, Cunningham, J. L, Gheduzzi, S, Miles, A. W, & Learmonth, I. D. Mechanical characteristics of antibiotic-laden bone cement. Acta

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[72] Jeys, J L. M, Grimer, S. R, & Tillman, R. M. Periprosthetic infection in patients treated for an orthopaedic oncological condition. Bone Jt Surg Am (2005). , 87, 842-9.

**Chapter 26**

**The Role of Knee Arthrodesis After TKA Infection**

Infection after total knee arthroplasty (TKA) is a devastating complication posing substantial clinical and financial burden, which incidence is increasing in line with the rise of the number of TKAs performed worldwide. The incidence of this complication rates from 1% in primary TKAs to 5.8% after TKAs revision in long series [1]. The lowest reinfection rate after a prior

The goals in the treatment of chronic infected TKA are control of the disease and restoring knee function. Alternative techniques in the management of reinfected knee prosthesis are another two-stage prosthesis reimplantation, arthrodesis, resection arthroplasty, and supra‐ condylar amputation [3]. Although two-stage surgery is generally believed as the most

Recurring infection at the site of a total knee arthroplasty should be treated by knee arthrodesis unless control of the disease and good functional recover could be possible [4]. Arthrodesis of the knee can provide a stable painless joint for an independent lifestyle that would not be possible after a failed total knee replacement. Whereas reimplantation of a TKA shows better limb function, arthrodesis achieves better pain relief, not finding significant differences in knee scores between the two procedures (Oxford knee score) [5, 6]. Knee arthrodesis can be achieved with a cemented or uncemented intramedullary nail, inserted from great trochanter or through the knee, with two plates applied in two planes or using an external fixator to produce a joint fusion [4]. Intramedullary nails provide greater stability, avoid pin-track infection, allow faster weight bearing and generally are better accepted by the patients than external fixators [7]. Illizarov method is more desirable when soft tissues conditions are poor or after failing of

> © 2013 Renovell et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

successful decision, chronic infection forces surgeons to look for other alternatives.

Pablo Renovell, Antonio Silvestre and

Additional information is available at the end of the chapter

reimplantation for septic TKA has been reported near 30% [2].

Oscar Vaamonde

**1. Introduction**

intramedullary nail [8, 9].

http://dx.doi.org/10.5772/53690


## **The Role of Knee Arthrodesis After TKA Infection**

Pablo Renovell, Antonio Silvestre and Oscar Vaamonde

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/53690

### **1. Introduction**

[72] Jeys, J L. M, Grimer, S. R, & Tillman, R. M. Periprosthetic infection in patients treated for an orthopaedic oncological condition. Bone Jt Surg Am (2005). , 87, 842-9.

[73] Hanssen, A. D, Trousdale, R. T, & Osmon, D. R. Patient outcome with reinfection following reimplantation for the infected total knee arthroplasty. Clin Orth Relat Res

[74] Hart, W. J, & Jones, R. S. Two-stage revision of infected total knee replacements using articular cement spacers and short-term antibiotic therapy. J Bone J Surg Br (2006). , 88,

(1995). , 321, 55-67.

1011-5.

576 Arthroplasty - Update

Infection after total knee arthroplasty (TKA) is a devastating complication posing substantial clinical and financial burden, which incidence is increasing in line with the rise of the number of TKAs performed worldwide. The incidence of this complication rates from 1% in primary TKAs to 5.8% after TKAs revision in long series [1]. The lowest reinfection rate after a prior reimplantation for septic TKA has been reported near 30% [2].

The goals in the treatment of chronic infected TKA are control of the disease and restoring knee function. Alternative techniques in the management of reinfected knee prosthesis are another two-stage prosthesis reimplantation, arthrodesis, resection arthroplasty, and supra‐ condylar amputation [3]. Although two-stage surgery is generally believed as the most successful decision, chronic infection forces surgeons to look for other alternatives.

Recurring infection at the site of a total knee arthroplasty should be treated by knee arthrodesis unless control of the disease and good functional recover could be possible [4]. Arthrodesis of the knee can provide a stable painless joint for an independent lifestyle that would not be possible after a failed total knee replacement. Whereas reimplantation of a TKA shows better limb function, arthrodesis achieves better pain relief, not finding significant differences in knee scores between the two procedures (Oxford knee score) [5, 6]. Knee arthrodesis can be achieved with a cemented or uncemented intramedullary nail, inserted from great trochanter or through the knee, with two plates applied in two planes or using an external fixator to produce a joint fusion [4]. Intramedullary nails provide greater stability, avoid pin-track infection, allow faster weight bearing and generally are better accepted by the patients than external fixators [7]. Illizarov method is more desirable when soft tissues conditions are poor or after failing of intramedullary nail [8, 9].

© 2013 Renovell et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

There are few and short series of cemented modular nail for knee arthrodesis after TKA infection in literature [10, 11]. The purpose of this study is to report the role of knee arthrodesis after chronic infection of knee prostheses and show our results with the use of a modular cemented nail inserted through the knee.

### **2. Material and methods**

We review retrospectively twenty-one patients who have undergone knee arthrodesis with a cemented modular nail for chronic infection of knee prosthesis, from January 2003 until January 2011 in our Department. Three senior surgeons performed all procedures.

Endo-Model® Knee Fusion Nail (Newsplint, UK/Waldemar Link®, GmbH & Co. KG, Hamburg, Germany) was used in all cases. Twelve of those cases received previous surgery in our Hospital (a reference institution for knee reconstruction) but the other nine cases came from others Hospitals. The decision to undertake knee fusion was arranged after analyzing the different options with the patient.

The first surgical stage was exhaustive debridement and placement of a double antibioticloaded (clindamycin and gentamicin) bone cement as a static spacer (Rofabacin® Revi‐ sion, Biomet®). Systemic antibiotics according to the culture results were given to the patients for at least six weeks. When the patient was recovered from the first-stage surgery, no signs of infection were observed and values of inflammatory markers (PCR and ESR) were decreased, the cemented modular nail was inserted through the knee after reaming tibial and femoral canals. Tibial and femur implants are cemented with antibiotic loaded cement. Nineteen cases were performed according to this two-stage procedure, but two cases were done in just one-stage.

Hospital records and serial radiographies of all patients were reviewed to evaluate patient status and outcomes. We have excluded a patient lost on follow-up.

Number of previous surgeries per patient, comorbidities and microorganisms responsible for the infection were recorded.

In order to assess functional outcome, the Oxford Knee Score (OKS) [12] was checked before removal of the implants and at final follow-up. Successful outcome was defined as not or slight pain on the operated limb and able to walk with or without aids at the time of the last follow-up.

### **3. Results**

Twenty-one patients were treated with cemented modular nail for knee arthrodesis from 2003 to 2011 for chronic infection of the prostheses (Figure 1.). One patient was lost during followup and was excluded from this series. Mean follow-up of patients was 3.2 years (range, six months to eight years).

**Figure 1.** Cemented modular nail for knee arthrodesis.

The Role of Knee Arthrodesis After TKA Infection

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579

**Figure 1.** Cemented modular nail for knee arthrodesis.

There are few and short series of cemented modular nail for knee arthrodesis after TKA infection in literature [10, 11]. The purpose of this study is to report the role of knee arthrodesis after chronic infection of knee prostheses and show our results with the use of a modular

We review retrospectively twenty-one patients who have undergone knee arthrodesis with a cemented modular nail for chronic infection of knee prosthesis, from January 2003 until

Endo-Model® Knee Fusion Nail (Newsplint, UK/Waldemar Link®, GmbH & Co. KG, Hamburg, Germany) was used in all cases. Twelve of those cases received previous surgery in our Hospital (a reference institution for knee reconstruction) but the other nine cases came from others Hospitals. The decision to undertake knee fusion was arranged after analyzing

The first surgical stage was exhaustive debridement and placement of a double antibioticloaded (clindamycin and gentamicin) bone cement as a static spacer (Rofabacin® Revi‐ sion, Biomet®). Systemic antibiotics according to the culture results were given to the patients for at least six weeks. When the patient was recovered from the first-stage surgery, no signs of infection were observed and values of inflammatory markers (PCR and ESR) were decreased, the cemented modular nail was inserted through the knee after reaming tibial and femoral canals. Tibial and femur implants are cemented with antibiotic loaded cement. Nineteen cases were performed according to this two-stage procedure, but two

Hospital records and serial radiographies of all patients were reviewed to evaluate patient

Number of previous surgeries per patient, comorbidities and microorganisms responsible for

In order to assess functional outcome, the Oxford Knee Score (OKS) [12] was checked before removal of the implants and at final follow-up. Successful outcome was defined as not or slight pain on the operated limb and able to walk with or without aids at the time

Twenty-one patients were treated with cemented modular nail for knee arthrodesis from 2003 to 2011 for chronic infection of the prostheses (Figure 1.). One patient was lost during followup and was excluded from this series. Mean follow-up of patients was 3.2 years (range, six

status and outcomes. We have excluded a patient lost on follow-up.

January 2011 in our Department. Three senior surgeons performed all procedures.

cemented nail inserted through the knee.

**2. Material and methods**

578 Arthroplasty - Update

the different options with the patient.

cases were done in just one-stage.

the infection were recorded.

of the last follow-up.

months to eight years).

**3. Results**

Twenty patients were fully recorded. The series includes eleven women and nine men with a mean age of seventy-six years (range 68-86 years) at the time of arthrodesis. Time since primary knee arthroplasty until knee arthrodesis, ranged from eight months to nine years (mean 4.4 years). The number of procedures carried out before definitive arthrodesis ranged from 2 to 7 (mean 3.3 surgeries).

Most frequent comorbidities were hypertension (65%), obesity [BMI>30kg/m2 ] (45%) and Diabetes Mellitus (40%). Demographics of the patients are shown in Table 1.


Intraoperative cultures were positive on 19 cases (95%). In eight of the cases (40%) only one bacteria could be checked, but on the other hand two or more microorganisms yielded on cultures in eleven cases (55%). The predominant microorganisms were *staphylococcus epider‐ midis* in 11 cases (55%) and *staphylococcus aureus* in 7 cases (35%), 10 of which (8 *s. epidermidis* and 2 *s. aureus*) were *methicillin-resistant staphylococcus (MRS),* so we can conclude that 50% of fused knees were positive to MRS. Other microorganism included in this series was *Escherichia coli* in 4 cases (20%).

Fifteen patients (75%) healed without problems and they did not need more surgeries, four (20%) showed inadequate control of infection so required new performances (one case onestage debridement, two arthrodesis with external fixators and one case supracondylar amputation), and two cases (10%) suffered a tibial shaft fracture below the tip of the nail. One of the fractures was resolved changing the nail for a longer one (Figure 2), and the other was treated with immobilization. Two of the four cases (50%) with persistence of of infection were operated in one-stage surgery.

**Figure 2.** Tibia fracture and bone loosening below the nail.

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581

**Figure 2.** Tibia fracture and bone loosening below the nail.

Twenty patients were fully recorded. The series includes eleven women and nine men with a mean age of seventy-six years (range 68-86 years) at the time of arthrodesis. Time since primary knee arthroplasty until knee arthrodesis, ranged from eight months to nine years (mean 4.4 years). The number of procedures carried out before definitive arthrodesis ranged from 2 to 7

] (45%) and

Most frequent comorbidities were hypertension (65%), obesity [BMI>30kg/m2

Diabetes Mellitus (40%). Demographics of the patients are shown in Table 1.

**Number of patients fully recorded** 20

**Age** 76.8±10.2

**Sex (M/F)** 11/9 **Side (R/L)** 12/8

**Body mass index (Kg/m2)** 29.8±1.4

**Mean nº of knee prior surgeries** 3.3(2-7)

**Preoperative OKS** 17.1 (9-32)

Intraoperative cultures were positive on 19 cases (95%). In eight of the cases (40%) only one bacteria could be checked, but on the other hand two or more microorganisms yielded on cultures in eleven cases (55%). The predominant microorganisms were *staphylococcus epider‐ midis* in 11 cases (55%) and *staphylococcus aureus* in 7 cases (35%), 10 of which (8 *s. epidermidis* and 2 *s. aureus*) were *methicillin-resistant staphylococcus (MRS),* so we can conclude that 50% of fused knees were positive to MRS. Other microorganism included in this series was *Escherichia*

Fifteen patients (75%) healed without problems and they did not need more surgeries, four (20%) showed inadequate control of infection so required new performances (one case onestage debridement, two arthrodesis with external fixators and one case supracondylar amputation), and two cases (10%) suffered a tibial shaft fracture below the tip of the nail. One of the fractures was resolved changing the nail for a longer one (Figure 2), and the other was treated with immobilization. Two of the four cases (50%) with persistence of of infection were

HTA 13 (65%) Obesity 9 (45%) DM 8 (40%)

(mean 3.3 surgeries).

580 Arthroplasty - Update

**Comorbidities**

**Table 1.** Demographics of the study population

*coli* in 4 cases (20%).

operated in one-stage surgery.

The mean Oxford knee score improved from 17.1 points (range, 9 to 32 points) before removal of the prosthesis, to 27.4 points (range, 6 to 41 points) postoperatively. Successful outcome was 95% at the time of the last follow-up. Results of the series are shown in Table 2.

The alternative of resection arthroplasty in case of recalcitrant TKA infection is only an option when the patient previously was not able to walk, due to a medical infirmity or other limb pathology. Results on pain and functional scores are always lower than two-stage reimplata‐

The Role of Knee Arthrodesis After TKA Infection

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583

Clinical outcomes of revision TKA after aseptic loosening are better than knee prosthesis revision after chronic infection [17]. Wang et al [5] asserted, comparing clinical outcomes of the different alternatives in the treatment of infected TKA, that Oxford Knee Score after revision TKA is similar to knee arthrodesis. He reported just about mild-to-moderate knee pain on almost 50% of the reimplanted TKAs. Knee arthrodesis shows better pain relief but worse function than revision TKA, whereas reimplanted TKA reveals better function and worse pain relief than knee fusion. Anyway, knee arthrodesis allows the patient an independ‐ ent lifestyle with few complications [18]. And it is important to keep in mind that re-infection rate after TKA revision is 68.6%, lessen to 52.6% in case of resistant microorganisms [2]. The rate can be reduced to only 18% when these microorganisms are identified and properly treated [19]. Maheshwari et al [2] reported that supracondylar amputation was performed on 14.2% of his cases, whereas only on 5.7% of his patients arthrodesis was the final operation. Our results show that infection was controlled in 75% of our patients with a knee arthrodesis done with a cemented modular nail and no more re-operations were needed. In our series, just one case of amputation was performed (5%). We agree with others authors [13, 20] that after a second TKA infection due to high virulence microorganisms or after multiple attempts of failed revision arthroplasty, knee arthrodesis should be the therapeutic choice in most of the cases or at least in those cases with low functional demanding patients in order to avoid a possible

The three most frequent surgical techniques used to achieved knee arthrodesis after failed TKA are internal plate fixation, intramedullary rod fixation and external fixation [4]. Subsequent conversion of a knee arthrodesis to a total knee arthroplasty is not advisable, as almost of the

Internal plate fixation is rarely used to achieve knee fusion due to the requirement of a broad soft tissue exposure, long time weight-bearing and because of the incidence of

External fixation has been the method of choice to attained knee arthrodesis following chronic infected TKA [8, 9, 23-25]. Advantages of external fixation include the fact that produces proper bone compression, the surgical procedure can be performed in one operative stage, and no implants remain inside the body after the external fixator removal. These details presume less recurrent infection rate than other arthrodesis techniques. Problems related to this treatment are carrying the device for long periods of time, usually more than six months, the subsequent shortening of the limb, the pin site infection or the possibility of a fracture through the weakened bone [7]. Nowadays this alternative is used in chronic infected knees after arthrod‐ esis with bad tolerance of the nail. [4]. Two of our patients (10% of cases) needed an external

tion or arthrodesis [16].

supracondylar amputation.

pseudoarthrosis is high.

reimplanted arthroplasties fail [21, 22].

fixator (Illizarov method) to achieve a useful limb.


**Table 2.** Results of knee arthrodesis with cemented modular nail

### **4. Discussion**

The reason to turn a TKA into arthrodesis due to a chronic infection is not clear nowadays, and the decision-making process is sometimes difficult. When a second infection happens, the number of surgeries performed in the knee reaches until 9.3 of average [1], so this detail must be always present on surgeon's mind when re-infection occurs. Infection of primary TKA has been related with hyperglycaemia, prolonged operative time, obesity, rheumatoid arthritis and others [1], however in TKA reinfection, the main factors related to this condition are previous infection with tough microorganisms, poor soft tissue coverage and number of previous surgeries [2].

Although surgeon might consider joint fusion as a poor result, comparing to other choices, knee with a fusion is more efficient and functional [13]. Supracondylar amputation as a consequence of a failed total knee revision arthroplasty is a salvage procedure in front of a severe infection, uncontrolled pain or massive bone loss. This radical surgery should not be related knee prosthesis complications but to peripheral vascular disease or recurrence of a malignant tumor [14]. Functional outcome after supracondylar amputation carried out ought to an infected total knee replacement is poor. Patients with a supracondylar amputation after chronic infection of prosthesis show low functional status. Only 50% of these patients are able to walk after the surgery [15]. The awful OKS of our amputated patients (6 points), confirms this fact.

The alternative of resection arthroplasty in case of recalcitrant TKA infection is only an option when the patient previously was not able to walk, due to a medical infirmity or other limb pathology. Results on pain and functional scores are always lower than two-stage reimplata‐ tion or arthrodesis [16].

The mean Oxford knee score improved from 17.1 points (range, 9 to 32 points) before removal of the prosthesis, to 27.4 points (range, 6 to 41 points) postoperatively. Successful outcome was

95% at the time of the last follow-up. Results of the series are shown in Table 2.

Fracture on tibia below the nail

Arthrodesis with external fixator2 One-stage debridement 1 Supracondylar amputation 1 Change for a longer nail 1 **Postoperative OKS** 27.4 (6-41)

**Causes of reoperations**

**Reoperations**

**Table 2.** Results of knee arthrodesis with cemented modular nail

**4. Discussion**

582 Arthroplasty - Update

previous surgeries [2].

this fact.

**Number of cases infected by MRS** 10 (50%) **Patients healed without problems** 15 (75%)

Persistent infection 4 (20%)

(and bone loosening) 1 (5%)

The reason to turn a TKA into arthrodesis due to a chronic infection is not clear nowadays, and the decision-making process is sometimes difficult. When a second infection happens, the number of surgeries performed in the knee reaches until 9.3 of average [1], so this detail must be always present on surgeon's mind when re-infection occurs. Infection of primary TKA has been related with hyperglycaemia, prolonged operative time, obesity, rheumatoid arthritis and others [1], however in TKA reinfection, the main factors related to this condition are previous infection with tough microorganisms, poor soft tissue coverage and number of

Although surgeon might consider joint fusion as a poor result, comparing to other choices, knee with a fusion is more efficient and functional [13]. Supracondylar amputation as a consequence of a failed total knee revision arthroplasty is a salvage procedure in front of a severe infection, uncontrolled pain or massive bone loss. This radical surgery should not be related knee prosthesis complications but to peripheral vascular disease or recurrence of a malignant tumor [14]. Functional outcome after supracondylar amputation carried out ought to an infected total knee replacement is poor. Patients with a supracondylar amputation after chronic infection of prosthesis show low functional status. Only 50% of these patients are able to walk after the surgery [15]. The awful OKS of our amputated patients (6 points), confirms

Clinical outcomes of revision TKA after aseptic loosening are better than knee prosthesis revision after chronic infection [17]. Wang et al [5] asserted, comparing clinical outcomes of the different alternatives in the treatment of infected TKA, that Oxford Knee Score after revision TKA is similar to knee arthrodesis. He reported just about mild-to-moderate knee pain on almost 50% of the reimplanted TKAs. Knee arthrodesis shows better pain relief but worse function than revision TKA, whereas reimplanted TKA reveals better function and worse pain relief than knee fusion. Anyway, knee arthrodesis allows the patient an independ‐ ent lifestyle with few complications [18]. And it is important to keep in mind that re-infection rate after TKA revision is 68.6%, lessen to 52.6% in case of resistant microorganisms [2]. The rate can be reduced to only 18% when these microorganisms are identified and properly treated [19]. Maheshwari et al [2] reported that supracondylar amputation was performed on 14.2% of his cases, whereas only on 5.7% of his patients arthrodesis was the final operation. Our results show that infection was controlled in 75% of our patients with a knee arthrodesis done with a cemented modular nail and no more re-operations were needed. In our series, just one case of amputation was performed (5%). We agree with others authors [13, 20] that after a second TKA infection due to high virulence microorganisms or after multiple attempts of failed revision arthroplasty, knee arthrodesis should be the therapeutic choice in most of the cases or at least in those cases with low functional demanding patients in order to avoid a possible supracondylar amputation.

The three most frequent surgical techniques used to achieved knee arthrodesis after failed TKA are internal plate fixation, intramedullary rod fixation and external fixation [4]. Subsequent conversion of a knee arthrodesis to a total knee arthroplasty is not advisable, as almost of the reimplanted arthroplasties fail [21, 22].

Internal plate fixation is rarely used to achieve knee fusion due to the requirement of a broad soft tissue exposure, long time weight-bearing and because of the incidence of pseudoarthrosis is high.

External fixation has been the method of choice to attained knee arthrodesis following chronic infected TKA [8, 9, 23-25]. Advantages of external fixation include the fact that produces proper bone compression, the surgical procedure can be performed in one operative stage, and no implants remain inside the body after the external fixator removal. These details presume less recurrent infection rate than other arthrodesis techniques. Problems related to this treatment are carrying the device for long periods of time, usually more than six months, the subsequent shortening of the limb, the pin site infection or the possibility of a fracture through the weakened bone [7]. Nowadays this alternative is used in chronic infected knees after arthrod‐ esis with bad tolerance of the nail. [4]. Two of our patients (10% of cases) needed an external fixator (Illizarov method) to achieve a useful limb.

Intramedullary nail is actually the most widespread option to fuse the knee [4, 20, 26-29]. Rate of fusion near 100% has been well documented in literature, as well as the satisfactory results in case of persistent infection that rarely forces the surgeon to take out the nail [30]. Compli‐ cations of intramedullary nail fixation include periprosthetic fracture, hardware-related pain, bone loosening and persistent infection. Arthrodesis performed with a nail should be done according to a two-staged protocol in order to reduce the incidence of reinfection. Two of our four cases (50%), which showed inadequate infection control, were treated in first instance through a one-stage surgery; this fact supports previous reports and remarks the requirement of two stage-surgery to get a free-infected arthrodesis [4,31,32].

order to avoid this terrible result, knee arthrodesis, preferably in two-stages, could be an option to achieve a useful and stable painless limb. Among the different alternatives to obtain knee arthrodesis, we believe that the best procedure is inserting a cemented modular nail through the knee, which provides a strong fixation, has a low rate of reinfection and allows to restore

The Role of Knee Arthrodesis After TKA Infection

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585

[1] Blom, A. W, Brown, J, Taylor, A. H, Pattison, G, Whitehouse, S, & Bannister, G. C. Infection after total knee arthroplasty. J Bone Joint Surg Br. (2004). Jul;, 86(5), 688-91.

[2] Maheshwari, A. V, Gioe, T. J, Kalore, N. V, & Cheng, E. Y. Reinfection after prior staged reimplantation for septic total knee arthroplasty: is salvage still possible? J Arthroplas‐

[3] Morrey, B. F, Westholm, F, Schoifet, S, Rand, J. A, & Bryan, R. S. Long-term results of various treatment options for infected total knee arthroplasty. Clin Orthop Relat Res.

[4] Conway, J. D, Mont, M. A, & Bezwada, H. P. Arthrodesis of the knee. J Bone Joint Surg

[5] Wang, C. J, Huang, T. W, Wang, J. W, & Chen, H. S. The often poor clinical outcome of infected total knee arthroplasty. J Arthroplasty. (2002). Aug; , 17(5), 608-14.

[6] Husted, H. Toftgaard Jensen T. Clinical outcome after treatment of infected primary

[7] Mabry, T. M, Jacofsky, D. J, Haidukewych, G. J, & Hanssen, A. Comparison of intra‐ medullary nailing and external fixation knee arthrodesis for the infected knee replace‐

[8] Oostenbroek, H. J, & Van Roermund, P. M. Arthrodesis of the knee after an infected arthroplasty using the Ilizarov method. J Bone Joint Surg Br. (2001). Jan;, 83(1), 50-4.

[9] Manzotti, A, Pullen, C, Guerreschi, F, & Catagni, M. A. The Ilizarov method for failed

knee arthrodesis following septic TKR. Knee. (2001). Jun;, 8(2), 135-8.

total knee arthroplasty. Acta Orthop Belg. (2002). , 68, 500-7.

ment. Clin Orthop Relat Res. (2007). Nov; , 464, 11-5.

the length of the limb though significant bone loss due to previous surgeries.

Pablo Renovell, Antonio Silvestre and Oscar Vaamonde

ty. (2010). Sep; 25(6 Suppl): , 92-7.

Am. (2004). Apr;A(4):835-48., 86.

(1989). Nov;(248): 120-8.

Orthopaedic Department. Hospital Clínico of Valencia, Spain

**Author details**

**References**

The preference of achieving knee fusion with an external fixator or with the aid of an intra‐ medullary rod should be based on surgeon's experience and on the review of the advantages and disadvantages of each techniques [7].

There are different models of knee nails used to achieve arthrodesis. In the beginning long Küntscher nail was introduced through the great trochanter after debridement of the infected joint [33, 34]. This double approach is rarely used nowadays, and is reserved to failures of previous arthrodesis, fractures of the tibia or femur or cases of bone loosening that requires extended fixation [35, 36]. One patient (5%) of our series needed this procedure.

Modular nail can be inserted through the knee and it is at the present time the most frequent surgical technique to achieve a knee fusion; it shows fusion rates of nearly 95% of cases [37-39]. Modular nails could be cemented or uncemented but there is no literature that compares results of these models. When an uncemented nail is used, maximum bone contact is extremely important in order to get knee arthrodesis and usually autologous bone graft is required. After using an uncemented device shortening of the limb is frequent, as occurs with external fixators. Fractures around the tip of the rod or the locked screws are possible [40], as well as loosening of the implant. Few reports and small number of cases with the use of cemented nails have been published, so hardly any conclusions about this procedure can be obtained [10, 11]. The technique of cementing the nail could avoid shortening of the limb, compensate bone loss and provide an artificial joint fusion without employing bone graft. Fractures around the nail are probably less frequent than in uncemented nails, but when cemented nails must be removed surgery is quite tougher and bone loss bone could be a problem for the revision surgeries. Neuerburg et al [11] have published a review with the same number of cases than us, with similar results and conclusions, advising of clinical and radiological follow-up to allow appropriate surgery in case of loosening.

### **5. Conclusion**

Recurrent infection after a previously exchange arthroplasty for chronic infected TKA is a challenging problem. This devastating complication is associated to infection due to high virulence resistant microorganisms, poor soft tissue coverage and a high number of previous surgeries. When this complication occurs, surgeons must always have in mind the possibility of an above knee amputation as a final result if we insist on revising to a knee arthroplasty. In order to avoid this terrible result, knee arthrodesis, preferably in two-stages, could be an option to achieve a useful and stable painless limb. Among the different alternatives to obtain knee arthrodesis, we believe that the best procedure is inserting a cemented modular nail through the knee, which provides a strong fixation, has a low rate of reinfection and allows to restore the length of the limb though significant bone loss due to previous surgeries.

### **Author details**

Intramedullary nail is actually the most widespread option to fuse the knee [4, 20, 26-29]. Rate of fusion near 100% has been well documented in literature, as well as the satisfactory results in case of persistent infection that rarely forces the surgeon to take out the nail [30]. Compli‐ cations of intramedullary nail fixation include periprosthetic fracture, hardware-related pain, bone loosening and persistent infection. Arthrodesis performed with a nail should be done according to a two-staged protocol in order to reduce the incidence of reinfection. Two of our four cases (50%), which showed inadequate infection control, were treated in first instance through a one-stage surgery; this fact supports previous reports and remarks the requirement

The preference of achieving knee fusion with an external fixator or with the aid of an intra‐ medullary rod should be based on surgeon's experience and on the review of the advantages

There are different models of knee nails used to achieve arthrodesis. In the beginning long Küntscher nail was introduced through the great trochanter after debridement of the infected joint [33, 34]. This double approach is rarely used nowadays, and is reserved to failures of previous arthrodesis, fractures of the tibia or femur or cases of bone loosening that requires

Modular nail can be inserted through the knee and it is at the present time the most frequent surgical technique to achieve a knee fusion; it shows fusion rates of nearly 95% of cases [37-39]. Modular nails could be cemented or uncemented but there is no literature that compares results of these models. When an uncemented nail is used, maximum bone contact is extremely important in order to get knee arthrodesis and usually autologous bone graft is required. After using an uncemented device shortening of the limb is frequent, as occurs with external fixators. Fractures around the tip of the rod or the locked screws are possible [40], as well as loosening of the implant. Few reports and small number of cases with the use of cemented nails have been published, so hardly any conclusions about this procedure can be obtained [10, 11]. The technique of cementing the nail could avoid shortening of the limb, compensate bone loss and provide an artificial joint fusion without employing bone graft. Fractures around the nail are probably less frequent than in uncemented nails, but when cemented nails must be removed surgery is quite tougher and bone loss bone could be a problem for the revision surgeries. Neuerburg et al [11] have published a review with the same number of cases than us, with similar results and conclusions, advising of clinical and radiological follow-up to allow

Recurrent infection after a previously exchange arthroplasty for chronic infected TKA is a challenging problem. This devastating complication is associated to infection due to high virulence resistant microorganisms, poor soft tissue coverage and a high number of previous surgeries. When this complication occurs, surgeons must always have in mind the possibility of an above knee amputation as a final result if we insist on revising to a knee arthroplasty. In

extended fixation [35, 36]. One patient (5%) of our series needed this procedure.

of two stage-surgery to get a free-infected arthrodesis [4,31,32].

and disadvantages of each techniques [7].

584 Arthroplasty - Update

appropriate surgery in case of loosening.

**5. Conclusion**

Pablo Renovell, Antonio Silvestre and Oscar Vaamonde

Orthopaedic Department. Hospital Clínico of Valencia, Spain

### **References**


[10] Rao, M. C, Richards, O, Meyer, C, & Jones, R. S. Knee stabilisation following infected knee arthroplasty with bone loss and extensor mechanism impairment using a modular cemented nail. Knee. (2009). Dec; , 16(6), 489-93.

[25] Vanryn, J. S, & Verebelyi, D. M. One-stage débridement and knee fusion for infected total knee arthroplasty using the hybrid frame. J Arthroplasty. (2002). Jan;, 17(1), 129-34.

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[26] Wilde, A. H, & Stearns, K. L. Intramedullary fixation for arthrodesis of the knee after infected total knee arthroplasty. Clin Orthop Relat Res. (1989). Nov;(248):87-92.

[27] Gore, D. R, & Gassner, K. Use of an intramedullary rod in knee arthrodesis following

[28] MacDonald JHAgarwal S, Lorei MP, Johanson NA, Freiberg AA. Knee arthrodesis. J

[29] Talmo, C. T, Bono, J. V, Figgie, M. P, Sculco, T. P, Laskin, R. S, & Windsor, R. E. Intramedullary arthrodesis of the knee in the treatment of sepsis after TKR. HSS J.

[30] Schoifet, S. D, & Morrey, B. Persistent infection after successful arthrodesis for infected total knee arthroplasty. A report of two cases. J Arthroplasty. (1990). Sep;, 5(3), 277-9.

[31] Knutson, K, Hovelius, L, Lindstrand, A, & Lidgren, L. Arthrodesis after failed knee

[32] Elligsen, D. E. Rand, JA Intramedullary arthrodesis of the knee after failed total knee

[33] Mazet R JrUrist MR. Arthrodesis of the knee with intramedullary nail fixation. Clin

[34] Knutson, K, & Lidgren, L. Arthrodesis after infected knee arthroplasty using an intramedullary nail. Reports of four cases. Arch Orthop Trauma Surg. (1982). , 100(1),

[35] Jorgensen, P. S, & Torholm, C. Arthrodesis after infected knee arthroplasty using long

[36] Bargiotas, K, Wohlrab, D, Sewecke, J. J, Lavinge, G, Demeo, P. J, & Sotereanos, N. G. Arthrodesis of the knee with a long intramedullary nail following the failure of a total knee arthroplasty as the result of infection. Surgical technique. J Bone Joint Surg Am.

[37] Waldman, B. J, Mont, M. A, Payman, K. R, Freiberg, A. A, Windsor, R. E, Sculco, T. P, & Hungerford, D. S. Infected total knee arthroplasty treated with arthrodesis using a

[38] Mcqueen, D. A, Cooke, F. W, & Hahn, D. L. Knee arthrodesis with the Wichita Fusion Nail: an outcome comparison. Clin Orthop Relat Res. (2006). May;, 446, 132-9.

[39] Iacono, F, & Bruni, D. Lo Presti M, Raspugli G, Bondi A, Sharma B, Marcacci M. Knee arthrodesis with a press-fit modular intramedullary nail without bone-on-bone fusion after an infected revision TKA. Knee. (2012). Oct;Epub 2012 Feb 15., 19(5), 555-9.

arthrodesis nail. A report of five cases. Am J Knee Surg. (1995). , 8, 110-3.

failed total knee arthroplasty. J Knee Surg. (2003). Jul;, 16(3), 165-7.

Am Acad Orthop Surg. (2006). Mar;, 14(3), 154-63.

arthroplasty. J Bone Joint Surg (1994). A:870-877., 76.

(2007). Feb;, 3(1), 83-8.

arthroplasty. Clin Orthop. (1984).

(2007). Mar;89 Suppl 2 Pt., 1, 103-10.

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Orthop. (1960). , 18, 43-53.

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[25] Vanryn, J. S, & Verebelyi, D. M. One-stage débridement and knee fusion for infected total knee arthroplasty using the hybrid frame. J Arthroplasty. (2002). Jan;, 17(1), 129-34.

[10] Rao, M. C, Richards, O, Meyer, C, & Jones, R. S. Knee stabilisation following infected knee arthroplasty with bone loss and extensor mechanism impairment using a modular

[11] Neuerburg, C, Bieger, R, Jung, S, Kappe, T, Reichel, H, & Decking, R. Bridging knee arthrodesis for limb salvage using an intramedullary cemented nail: a retrospective

[12] Dawson, J, Fitzpatrick, R, Murray, D, & Carr, A. Questionnarie on the perceptions of patients about total knee replacement. J Bone Joint Surg (Br) (1998). B: 63-9., 80. [13] Klinger, H. M, Spahn, G, Schultz, W, & Baums, M. H. Arthrodesis of the knee after failed infected total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. (2006).

[14] Sierra, R. J, Trousdale, R. T, & Pagnano, M. W. Above-the-knee amputation after a total knee replacement: prevalence, etiology, and functional outcome. J Bone Joint Surg Am.

[15] Fedorka, C. J, Chen, A. F, Mcgarry, W. M, & Parvizi, J. Klatt BA Functional ability after above-the-knee amputation for infected total knee arthroplasty. Clin Orthop Relat Res.

[16] Falahee, M. H, Matthews, L. S, & Kaufer, H. Resection arthroplasty as a salvage procedure for a knee with infection after a total arthroplasty. J Bone Joint Surg Am.

[17] Barrack, R. L, Engh, G, Rorabeck, C, et al. Patient satisfaction and outcome after septic versus aseptic revision total knee arthroplasty. J Arthroplasty 15:990, (2000).

[18] Benson, E. R, Resine, S. T, & Lewis, C. G. Functional outcome of arthrodesis for failed

[19] Kilgus, D. J, Howe, D. J, & Strang, A. Results of periprosthetic hip and knee infections caused by resistant bacteria. Clin Orthop Relat Res. (2002). Nov;(404):116-24.

[20] Wiedel, J. D. Salvage of infected total knee fusion: the last option. Clin Orthop Relat

[21] Naranja RJ JrLotke PA, Pagnano MW, Hanssen AD. Total knee arthroplasty in a previously ankylosed or arthrodesed knee. Clin Orthop. (1996). , 331, 234-7.

[22] Clemens, D, Lereim, P, & Holm, I. Reikerås O Conversion of knee fusion to total arthroplasty: complications in 8 patients. Acta Orthop. (2005). Jun;, 76(3), 370-4. [23] Phillips, H. T, & Mears, D. C. Knee fusion with external skeletal fixation after an infected hinge prosthesis: a case report. Clin Orthop Relat Res. (1980). Sep;(151):147-52. [24] Garberina, M. J, Fitch, R. D, Hoffmann, E. D, Hardaker, W. T, Vail, T. P, & Scully, S. P. Knee arthrodesis with circular external fixation. Clin Orthop Relat Res. (2001). Jan;(382):

total knee arthroplasty. Orthopedics. (1998). , 21, 875-9.

outcome analysis of a case series. Arch Orthop Trauma Surg. (2012). May 13.

cemented nail. Knee. (2009). Dec; , 16(6), 489-93.

May;, 14(5), 447-53.

586 Arthroplasty - Update

(2003). Jun; A(6):1000-4., 85.

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[40] Hinarejos, P, Ginés, A, Monllau, J. C, Puig, L, & Cáceres, E. Fractures above and below a modular nail for knee arthrodesis. A case report. Knee. (2005). Jun;, 12(3), 231-3.

**Section 7**

**Alternatives to Arthroplasty**

## **Alternatives to Arthroplasty**

[40] Hinarejos, P, Ginés, A, Monllau, J. C, Puig, L, & Cáceres, E. Fractures above and below a modular nail for knee arthrodesis. A case report. Knee. (2005). Jun;, 12(3), 231-3.

588 Arthroplasty - Update

**Chapter 27**

**Proximal Interphalangeal Joint Arthrodesis with**

**Tendon Transfer of the Flexor Digitorum Brevis**

Hammer toe is a deformity characterized by dorsiflexion of the metatarsophalangeal (MTP) joint, plantarflexion of the proximal interphalangeal (PIP) joint, and dorsiflexion of the distal interphalangeal (DIP) joint. Claw toe is a similar deformity characterized by dorsiflexion of the MTP and plantarflexion of the PIP and DIP joints. These terms are often used interchange‐

The causes of dorsiflexion of the metatarso- and interphalangeal joint have been described by various authors. [3], [4], [5], [6] Sandeman [2] reported that when the proximal phalanx is in the dorsal position at the expense of MTP dorsiflexion, the axis of the intrinsic musculature shifts. This causes a loss of competence of the intrinsic musculature of the foot, and the proximal phalanx can no longer be maintained in a plantar position. In the presence of concurrent flexor digitorum longus (FDL) contraction, the intrinsic musculature loses its ability to plantarflex the MTP joint. In a closed kinetic chain, this causes pathologic dorsiflexion of the MTP joint and places the proximal phalanx in a dorsal position. The result is claw or hammer deformity of the involved digits. Surgical correction of claw and hammer toe deformities utilize the action of the FDL tendon transferred to transform the deforming forces

Correction of this flexible digital deformity by means of tendinous transposition of the flexor musculature to the extensor region of the toes has been described. [7], [8], [9], [10], [11], [12], [13] In each instance two cutaneous incisions have been utilized, one dorsal and another plantar. Only Barbari and Brevig [9] have described FDL tendon transfer to the dorsum of the

and reproduction in any medium, provided the original work is properly cited.

© 2013 de Bengoa Vallejo et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

Ricardo Becerro de Bengoa Vallejo,

Additional information is available at the end of the chapter

ably because both deformities involve the MTP joint. [1]

Marta Elena Losa Iglesias and Miguel Fuentes Rodriguez

http://dx.doi.org/10.5772/52752

**1. Introduction**

into corrective forces.

## **Proximal Interphalangeal Joint Arthrodesis with Tendon Transfer of the Flexor Digitorum Brevis**

Ricardo Becerro de Bengoa Vallejo, Marta Elena Losa Iglesias and Miguel Fuentes Rodriguez

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/52752

### **1. Introduction**

Hammer toe is a deformity characterized by dorsiflexion of the metatarsophalangeal (MTP) joint, plantarflexion of the proximal interphalangeal (PIP) joint, and dorsiflexion of the distal interphalangeal (DIP) joint. Claw toe is a similar deformity characterized by dorsiflexion of the MTP and plantarflexion of the PIP and DIP joints. These terms are often used interchange‐ ably because both deformities involve the MTP joint. [1]

The causes of dorsiflexion of the metatarso- and interphalangeal joint have been described by various authors. [3], [4], [5], [6] Sandeman [2] reported that when the proximal phalanx is in the dorsal position at the expense of MTP dorsiflexion, the axis of the intrinsic musculature shifts. This causes a loss of competence of the intrinsic musculature of the foot, and the proximal phalanx can no longer be maintained in a plantar position. In the presence of concurrent flexor digitorum longus (FDL) contraction, the intrinsic musculature loses its ability to plantarflex the MTP joint. In a closed kinetic chain, this causes pathologic dorsiflexion of the MTP joint and places the proximal phalanx in a dorsal position. The result is claw or hammer deformity of the involved digits. Surgical correction of claw and hammer toe deformities utilize the action of the FDL tendon transferred to transform the deforming forces into corrective forces.

Correction of this flexible digital deformity by means of tendinous transposition of the flexor musculature to the extensor region of the toes has been described. [7], [8], [9], [10], [11], [12], [13] In each instance two cutaneous incisions have been utilized, one dorsal and another plantar. Only Barbari and Brevig [9] have described FDL tendon transfer to the dorsum of the

© 2013 de Bengoa Vallejo et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

extensor digitorum longus (EDL) tendon through a single incision approach. In this approach the dorso-lateral incision over the MTP joint extends about 3 cm distally from the neck of the metatarsal bone when there is only a single involved digit. When the procedure is undertaken in multiple digits, a transverse incision at the level of the digit crease is performed and the FDL tendon is sutured end-to-side to the EDL tendon. The authors stated that care must be taken to avoid injuring the neurovascular axes which are retracted laterally. The authors also advocated, when indicated, performing plantar capsulotomies for the DIP and PIP joints as described by Pyper [12] and Taylor. [13] The additional incision, however, increases the risk for injuring the principal plantar vessels of the involved digits..

of the proximal phalanx to the dorsal aspect of the FDL and FDB tendons were released to further expose the flexor tendon sheath (Fig. 2). The tendon sheath was then incised and split longitudinally to the base of the middle phalanx (Fig. 3A), and the medial and lateral hemi‐ tendons of the FDB were exposed dorsally to the FDL (Fig. 3B). Plantar exposure of the FDB tendon was performed by inserting a curved hemostat by means of a blunt technique to identify and isolate the medial and lateral fascicles (Fig. 4 A, B). If the hemitendons of the FDB were not split adequately to permit passage of the FDL tendon, the FDB was divided longitu‐ dinally and proximally using a #15 blade (Fig. 5). The lateral and medial FDB hemitendons were then retracted to expose the FDL tendon (Fig. 6). Using a curved hemostat the FDL was collected dorsally between the medial and lateral FDB hemitendons (Fig. 7). Using a miniosteotome, the FDL tendon was released from the plantar aspect of the distal middle phalanx to maximize the available tendon length (Fig. 8). This technique maximizes the length of the free distal tendinous stump to facilitate transfer to the dorsal aspect of the proximal phalanx (Fig. 9). The free proximal end of the tendon was clamped for later transfer (Fig 10). Next, using a #15 blade, the long flexor was split longitudinally in two portions, lateral and medial, proximal to distal (Fig. 11). Both free proximal FDL tendons were exposed between the plantar

Proximal Interphalangeal Joint Arthrodesis with Tendon Transfer of the Flexor Digitorum Brevis

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593

aspect of the proximal phalanx and the dorsal aspect of the FDB tendons (Fig 12).

**Figure 1.** Dorsal aspect of the second digit after arthroplasty of the proximal phalanx and release of the metatarso‐ phalangeal joint. The base of the middle phalanx is exposed. The proximal phalanx with the head resected is shown, and plantarly is the digital segment of the distal tendon sheath of the flexor digitorum longus and brevis tendons.

Thus far, it has been recommended that correction of claw and hammer toe deformities be performed by transferring the FDL tendon to the dorsum of the proximal phalanx. Transpo‐ sition of the FDL tendon via the dorsal approach through a unique longitudinal dorsal cutaneous incision without performing plantar incisions for capsulotomies of the DIP and PIP joints has not been previously described. To determine the feasibility of transferring the FDL tendon as an approach to correct claw and hammer toe deformities with this approach, it is necessary to determine whether these fascicles are long enough to transpose to the plantar aspect of the EDL tendon in the dorsal area of the proximal phalanx, and directly to the dorsum of the proximal phalanx of the second and third toes. We hypothesized that the FDL tendon, when incised at the level of the PIP joint, has adequate anatomical length to be transferred to the dorsal aspect of the proximal phalanx via a single longitudinal dorsal cutaneous incision and it would not be necessary to perform plantar capsulotomies at the interphalangeal joints, thus decreasing the risk of injury to the principal plantar vessels of the digits.

### **2. Materials and methods**

Sixty cadaveric foot specimens (Total N, 60; 30 right, 30 left) were used for study procedures, including fourteen fresh and forty-six embalmed specimens. Transfer of the FDL tendon to the dorsum of the proximal phalanx via dorsal approach was attempted in 120 toes (60 each second and third toes).

The surgical technique performed in this study was a modification of a previously described method to transfer the flexor digitorum brevis (FDB) tendon. [14] To perform the FDL transfer a central longitudinal incision was made on the dorsal aspect of the digit, preserving the medial and lateral vessels and nerves. The incision was along the dorsum of the proximal phalanx of the digit from the base to the PIP joint. Once the EDL tendon was exposed, it was tenomiced and released along with the transverse aponeurosis that shapes the digital extensor apparatus. Proximal phalanx arthroplasty and hood ligament and MTP joint release were then performed by means of a dorsal, medial, and lateral capsulotomy. Section of the collateral and suspensory ligaments was performed to reduce the fixed extension deformity of the MTP joint in the specimens with fixed claw or hammer toe deformities.

After arthroplasty of the proximal phalanx was completed the dorsal aspect of the distal tendon sheath of the FDL and FDB tendons was exposed (Fig. 1). The vincula from the plantar aspect

of the proximal phalanx to the dorsal aspect of the FDL and FDB tendons were released to further expose the flexor tendon sheath (Fig. 2). The tendon sheath was then incised and split longitudinally to the base of the middle phalanx (Fig. 3A), and the medial and lateral hemi‐ tendons of the FDB were exposed dorsally to the FDL (Fig. 3B). Plantar exposure of the FDB tendon was performed by inserting a curved hemostat by means of a blunt technique to identify and isolate the medial and lateral fascicles (Fig. 4 A, B). If the hemitendons of the FDB were not split adequately to permit passage of the FDL tendon, the FDB was divided longitu‐ dinally and proximally using a #15 blade (Fig. 5). The lateral and medial FDB hemitendons were then retracted to expose the FDL tendon (Fig. 6). Using a curved hemostat the FDL was collected dorsally between the medial and lateral FDB hemitendons (Fig. 7). Using a miniosteotome, the FDL tendon was released from the plantar aspect of the distal middle phalanx to maximize the available tendon length (Fig. 8). This technique maximizes the length of the free distal tendinous stump to facilitate transfer to the dorsal aspect of the proximal phalanx (Fig. 9). The free proximal end of the tendon was clamped for later transfer (Fig 10). Next, using a #15 blade, the long flexor was split longitudinally in two portions, lateral and medial, proximal to distal (Fig. 11). Both free proximal FDL tendons were exposed between the plantar aspect of the proximal phalanx and the dorsal aspect of the FDB tendons (Fig 12).

extensor digitorum longus (EDL) tendon through a single incision approach. In this approach the dorso-lateral incision over the MTP joint extends about 3 cm distally from the neck of the metatarsal bone when there is only a single involved digit. When the procedure is undertaken in multiple digits, a transverse incision at the level of the digit crease is performed and the FDL tendon is sutured end-to-side to the EDL tendon. The authors stated that care must be taken to avoid injuring the neurovascular axes which are retracted laterally. The authors also advocated, when indicated, performing plantar capsulotomies for the DIP and PIP joints as described by Pyper [12] and Taylor. [13] The additional incision, however, increases the risk

Thus far, it has been recommended that correction of claw and hammer toe deformities be performed by transferring the FDL tendon to the dorsum of the proximal phalanx. Transpo‐ sition of the FDL tendon via the dorsal approach through a unique longitudinal dorsal cutaneous incision without performing plantar incisions for capsulotomies of the DIP and PIP joints has not been previously described. To determine the feasibility of transferring the FDL tendon as an approach to correct claw and hammer toe deformities with this approach, it is necessary to determine whether these fascicles are long enough to transpose to the plantar aspect of the EDL tendon in the dorsal area of the proximal phalanx, and directly to the dorsum of the proximal phalanx of the second and third toes. We hypothesized that the FDL tendon, when incised at the level of the PIP joint, has adequate anatomical length to be transferred to the dorsal aspect of the proximal phalanx via a single longitudinal dorsal cutaneous incision and it would not be necessary to perform plantar capsulotomies at the interphalangeal joints,

Sixty cadaveric foot specimens (Total N, 60; 30 right, 30 left) were used for study procedures, including fourteen fresh and forty-six embalmed specimens. Transfer of the FDL tendon to the dorsum of the proximal phalanx via dorsal approach was attempted in 120 toes (60 each second

The surgical technique performed in this study was a modification of a previously described method to transfer the flexor digitorum brevis (FDB) tendon. [14] To perform the FDL transfer a central longitudinal incision was made on the dorsal aspect of the digit, preserving the medial and lateral vessels and nerves. The incision was along the dorsum of the proximal phalanx of the digit from the base to the PIP joint. Once the EDL tendon was exposed, it was tenomiced and released along with the transverse aponeurosis that shapes the digital extensor apparatus. Proximal phalanx arthroplasty and hood ligament and MTP joint release were then performed by means of a dorsal, medial, and lateral capsulotomy. Section of the collateral and suspensory ligaments was performed to reduce the fixed extension deformity of the MTP joint in the

After arthroplasty of the proximal phalanx was completed the dorsal aspect of the distal tendon sheath of the FDL and FDB tendons was exposed (Fig. 1). The vincula from the plantar aspect

thus decreasing the risk of injury to the principal plantar vessels of the digits.

**2. Materials and methods**

specimens with fixed claw or hammer toe deformities.

and third toes).

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for injuring the principal plantar vessels of the involved digits..

**Figure 1.** Dorsal aspect of the second digit after arthroplasty of the proximal phalanx and release of the metatarso‐ phalangeal joint. The base of the middle phalanx is exposed. The proximal phalanx with the head resected is shown, and plantarly is the digital segment of the distal tendon sheath of the flexor digitorum longus and brevis tendons.

(a)

(b)

with inadequate separation.

flexor digitorum longus tendon.

**Figure 4. (a)** The medial and lateral fascicles of the flexor digitorum brevis tendon are isolated using a curved hemo‐ stat. The flexor digitorum longus is localized plantarly. **(b)** Dorsal view of the hemitendons of flexor digitorum brevis

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**Figure 5.** Flexor digitorum brevis is divided longitudinally and proximally using a blade #15 to permit passage of the

**Figure 2.** The plantar vincula are sectioned to release the flexor tendon sheath at the plantar aspect of the proximal phalanx of the second digit.

**Figure 3. (a)** The tendinous sheath is cut longitudinally, proximally and distally to the base of the middle phalanx. **(b)** The tendinous sheath is opened, and the flexor digitorum brevis hemitendons, lateral and medial, are exposed over the curved hemostat.

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**Figure 2.** The plantar vincula are sectioned to release the flexor tendon sheath at the plantar aspect of the proximal

**Figure 3. (a)** The tendinous sheath is cut longitudinally, proximally and distally to the base of the middle phalanx. **(b)** The tendinous sheath is opened, and the flexor digitorum brevis hemitendons, lateral and medial, are exposed over

phalanx of the second digit.

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(a)

(b)

the curved hemostat.

**Figure 4. (a)** The medial and lateral fascicles of the flexor digitorum brevis tendon are isolated using a curved hemo‐ stat. The flexor digitorum longus is localized plantarly. **(b)** Dorsal view of the hemitendons of flexor digitorum brevis with inadequate separation.

**Figure 5.** Flexor digitorum brevis is divided longitudinally and proximally using a blade #15 to permit passage of the flexor digitorum longus tendon.

**Figure 6.** Medial and lateral hemitendon of the flexor digitorum brevis are retracted for plantar exposure of the flexor digitorum longus tendon.

**Figure 8.** Using a mini-osteotome, the flexor digitorum longus tendon is released from the plantar aspect of the mid‐

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**Figure 9.** Flexor digitorum longus tendon is cut through its insertion point as distally as possible to the middle phalanx

dle phalanx distally to obtain more tendon to facilitate the transfer.

to maximize the length of the free distal tendinous stump.

**Figure 7.** Using a curved hemostat and situating it plantar to the flexor digitorum longus is collocated dorsally be‐ tween the medial and lateral hemitendons of flexor digitorum brevis.

**Figure 8.** Using a mini-osteotome, the flexor digitorum longus tendon is released from the plantar aspect of the mid‐ dle phalanx distally to obtain more tendon to facilitate the transfer.

**Figure 6.** Medial and lateral hemitendon of the flexor digitorum brevis are retracted for plantar exposure of the flexor

**Figure 7.** Using a curved hemostat and situating it plantar to the flexor digitorum longus is collocated dorsally be‐

tween the medial and lateral hemitendons of flexor digitorum brevis.

digitorum longus tendon.

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**Figure 9.** Flexor digitorum longus tendon is cut through its insertion point as distally as possible to the middle phalanx to maximize the length of the free distal tendinous stump.

**Figure 10.** The stump of the proximal flexor digitorum longus tendon is clamped.

**Figure 12.** The flexor digitorum longus tendon has been split longitudinally in two portions, lateral and medial.

of the proximal phalanx (Fig. 13 A,B,C,D).

Once the medial and lateral fascicles of the FDL tendon had been clamped they were trans‐ ferred to the dorsal aspect of the medial and lateral proximal phalanx, respectively. During this procedure the length of the split tendinous fascicles of the FDL tendon were evaluated to ascertain whether the length was sufficient to permit transposition over the dorsal proximal phalanx. If the length was not adequate, a major incision was made in the proximal flexor tendon sheath. The medial and lateral FDL tendon stumps were sutured to itself in the dorsum

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**Figure 11.** The long flexor is split longitudinally using a #15 blade.

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**Figure 10.** The stump of the proximal flexor digitorum longus tendon is clamped.

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**Figure 11.** The long flexor is split longitudinally using a #15 blade.

**Figure 12.** The flexor digitorum longus tendon has been split longitudinally in two portions, lateral and medial.

Once the medial and lateral fascicles of the FDL tendon had been clamped they were trans‐ ferred to the dorsal aspect of the medial and lateral proximal phalanx, respectively. During this procedure the length of the split tendinous fascicles of the FDL tendon were evaluated to ascertain whether the length was sufficient to permit transposition over the dorsal proximal phalanx. If the length was not adequate, a major incision was made in the proximal flexor tendon sheath. The medial and lateral FDL tendon stumps were sutured to itself in the dorsum of the proximal phalanx (Fig. 13 A,B,C,D).

the proximal phalanx, respectively, and clamped with a pick up. The hemostat is showing the flexor digitorum brevis hemitendons intact. **(d)** Dorsal view of the flexor digitorum longus transferred to the dorsal aspect of the proximal

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The toe was pinned using a double-pointed 0.54-mm Kirschner wire in a retrograde manner driven antegrade from the PIP joint, out the tip of the toe, and then retrograde into the proximal phalanx and the metatarsal head. The EDL stumps were sutured over the transferred FDL

**Figure 14.** The extensor digitorum longus tendon stumps are sutured over the transferred flexor digitorum longus

The FDL tendon transfer by the unique longitudinal dorsal approach attempted on 120

The results of this study indicate that transfer of the FDL tendinous fascicles between the FDB hemitendons can be performed on second and third digits via a unique dorsal incision. Success of the procedure is predicated, in part, on an adequate longitudinal incision of the flexor tendon sheath that permits exposure and separation of the FDB hemitendons. We believe the indica‐ tions for FDL tendon transfer between FDB hemitendons are the same as those for the FDL tendon transfer that other authors [28]- [36] are using for the correction of sagittal plane lesser MTP joint instability and loss of digital purchase. We do not, however, advocate this approach

cadaveric toes (60 second toes and 30 third toes) was successful in 100% of the cases.

tendon (Fig. 14), and cutaneous suturing was performed in a usual manner.

phalanx

tendon.

**3. Results**

**4. Discussion**

**Figure 13. (a and b)** The medial and lateral fascicles of the flexor digitorum longus tendon are transferred to the dor‐ sal area of the proximal phalanx. The hemostat is showing the flexor digitorum brevis hemitendons. **(c)** Dorsal view of the medial and lateral stumps of the flexor digitorum longus tendon transferred to the medial and lateral aspects of the proximal phalanx, respectively, and clamped with a pick up. The hemostat is showing the flexor digitorum brevis hemitendons intact. **(d)** Dorsal view of the flexor digitorum longus transferred to the dorsal aspect of the proximal phalanx

The toe was pinned using a double-pointed 0.54-mm Kirschner wire in a retrograde manner driven antegrade from the PIP joint, out the tip of the toe, and then retrograde into the proximal phalanx and the metatarsal head. The EDL stumps were sutured over the transferred FDL tendon (Fig. 14), and cutaneous suturing was performed in a usual manner.

**Figure 14.** The extensor digitorum longus tendon stumps are sutured over the transferred flexor digitorum longus tendon.

### **3. Results**

(a) (a)

600 Arthroplasty - Update

(b) )(b b)

(c)

(d)

**Figure 13. (a and b)** The medial and lateral fascicles of the flexor digitorum longus tendon are transferred to the dor‐ sal area of the proximal phalanx. The hemostat is showing the flexor digitorum brevis hemitendons. **(c)** Dorsal view of the medial and lateral stumps of the flexor digitorum longus tendon transferred to the medial and lateral aspects of The FDL tendon transfer by the unique longitudinal dorsal approach attempted on 120 cadaveric toes (60 second toes and 30 third toes) was successful in 100% of the cases.

### **4. Discussion**

The results of this study indicate that transfer of the FDL tendinous fascicles between the FDB hemitendons can be performed on second and third digits via a unique dorsal incision. Success of the procedure is predicated, in part, on an adequate longitudinal incision of the flexor tendon sheath that permits exposure and separation of the FDB hemitendons. We believe the indica‐ tions for FDL tendon transfer between FDB hemitendons are the same as those for the FDL tendon transfer that other authors [28]- [36] are using for the correction of sagittal plane lesser MTP joint instability and loss of digital purchase. We do not, however, advocate this approach when the fifth digit is involved. In the current investigation, the FDB tendon was absent in 3 cases (7%), thus the dorsal approach was not possible. Any hammer toe or claw toe deformity that is accompanied by a semi-rigid or rigid MTP joint requires accompanying correction. This correction may be accomplished via PIP joint fusion or FDL tendon transfer, which moves the lever arm to the MTP joint and holds the proximal phalanx in a plantarflexed position.

flexor was then isolated, drawn out using a blunt hook, and divided near its distal insertion.

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Coughlin [18], [19] performed an FDL tendon transfer by first making a transverse incision at the MTP joint, and then a second incision at the dorsal aspect of the digit. Kuwada [20] performed 81 procedures to transfer the FDL tendon via a dorsolateral incision along the digit beginning proximally at the MTP joint and extending distally to least the proximal PIP joint. Thompson and Deland [21] performed transfer of the FDL tendon in 13 digits following the indications of Coughlin [18] via the plantar and dorsal approach. Gazdag and Cracchiolo [22] in 11 feet performed an isolating tendon transfer of the FDL through the 2-cm longitudinal midline incision on the plantar side of the base of the proximal phalanx and performed another dorsal incision at the base of the proximal phalanx. Recently, Boyer and DeOrio [23] treated 70 toes with fixed or flexible hammer toes with a flexor-to-extensor tendon transfer making a longitudinal incision on the plantar aspect of the proximal phalanx and at the dorsal aspect of

The literature up to now reveals no attempts to discover why Parrish [11] found FDB tendon transfer to be a non-viable option. His findings, however, have been accepted by the scientific community without confirmation or challenge. Furthermore, many of the authors cited, except Barbari and Brevig, [9] performed the double plantar and dorsal incision approach as described

In a cadaveric study we found [14] that it is possible to correct flexible claw and hammer toe deformity by transposing the FDB tendon to the extensor, or dorsal, area of the base of the proximal phalanx. This is a modification of the procedure used by Parrish [11] using a plantar and dorsal incision approach of the digit. We sought to transfer the FDB tendon to the dorsal aspect of the proximal phalanx via the dorsal approach through a unique incision, as described by Barbari and Brevig. [9]A search of the indexed literature found no previous reports of this

It is possible anatomical variations in the insertion of the FDB tendon may prohibit the popularity of this transfer approach. Three variations have been described: 1) absence of the tendon; 2) absence of the lateral and medial tendinous fascicles but presence of a single tendon running parallel to the FDL tendon; and 3) fusion of the FDB tendon to the FDL tendon. [24]- [27] LeDouble [24] and Nathan and Gloobe [25] found the FDB tendon to be absent in the fifth toe in 21.5% of cases. Testut [27] found the FDB tendon to be absent in the fourth and fifth toes in 3% of the dissections performed. In two separate studies [26], [27] Testut found that the FDB medial and lateral fascicles are not divided. Rather, the fascicles run parallel to the FDL tendon before inserting into a side of the intermediate phalanx of the fifth or fourth toe in 5% of patients. Although Testut [26], [27] did not specify individual percentages for variability in attachment for each of these digits, he established that the FDB tendon of the fifth toe is fused to the FDL tendon in 2% of cases. Thus, the anatomical variations found occur more frequently

Anomalies or variations in the insertion of the FDB tendon in the third and second toes have not, however, been described. We reported [14] on transposition of the FDB tendon via the

It was then sutured end to end to the extensor tendon.

the toe.

procedure.

by Girdlestone in 1947. [13]

in the FDB tendon insertion of the fifth toe.

Based on the results of this investigation, we believe the surgical technique for FDL tendon transfer should utilize a dorsal approach to minimize the risk of compromising the principal blood supply to the involved digits. Chen et al [37] evaluated the vasculature of 20 foot specimens focusing on the second, third, and fourth toes. Findings from the study suggest that plantar circulation is predominant in the second, third, and fourth toes, while dorsal circulation predominated in the first digit. Chen et al [37] further stated that the plantar digital arteries of the lesser toes provide the predominant arterial supply of the PIP joints through a system of transverse and longitudinal arches. Thus, when a claw or hammer toe deformity correction is performed via FDL tendon transfer through a two-incision plantar approach, a decision must be made regarding whether to continue or discontinue surgery when there is a risk of vascular compromise to the digit due to two incisions. Emphasizing the potential deleterious conse‐ quences of multiple incisions, Coughlin [18] recommended that it is far better to offer a 2-stage repair of the deformity than to incur a vascular insult with excessive surgery on a digit.

Surgical correction of hammer and claw toe deformity has been described extensively. Transposition of the flexor tendon to the extensor musculature through a dorso-lateral cut, with FDL tendon transfer to the dorso-lateral area of the proximal phalanx, was originally performed by Girdlestone in 1947 and developed by Taylor. [13] In his study, Taylor included 68 patients with claw or hammer toe deformity treated with this technique and associated procedures, such as dorsal capsulotomy of the MTP joint. Taylor also performed plantar capsulotomy of the interphalangeal joints and stabilization of the proximal phalanx using an external splint. Several modifications of the procedure have subsequently been reported. In 1970, Sgarlato [16] reported 53 cases of FDL tendon transfer through 3 skin incisions. Pyper [12] performed the technique described by Taylor [13] on 45 feet in 23 patients. To correct the digital deformity, he combined it with lengthening of the EDL tendon and dorsal capsulotomy of the MTP joint. Subsequently, Parrish [11] modified this technique by detaching the FDL tendon and dividing the proximal tendinous stump longitudinally and repositioning its medial and lateral aspects in the extensor area. He performed FDL and FDB tendon transfer on the first 5 patients in his series but not on the remaining 18 patients, stating that "the FDB tendon had a smaller calibre and its length was insufficient for the transposition." [11]

Marcinko et al [17] described the FDL tendon transfer using two incisions in the toe, one plantar and another dorsal. Barbari and Brevig [9] performed 39 FDL transpositions to the extensor area in 31 patients; 11 of the 39 procedures were performed in accordance with the technique of Taylor, [13] with the remaining 28 following the modified technique described by Parrish. [11] The approach was through a dorso-lateral incision over the MTP joint extending approx‐ imately 3 cm distally from the neck of the metatarsal bone. Dissection was then performed on each side of the proximal phalanx. The sheath of the flexor tendons was located, and the long flexor was then isolated, drawn out using a blunt hook, and divided near its distal insertion. It was then sutured end to end to the extensor tendon.

when the fifth digit is involved. In the current investigation, the FDB tendon was absent in 3 cases (7%), thus the dorsal approach was not possible. Any hammer toe or claw toe deformity that is accompanied by a semi-rigid or rigid MTP joint requires accompanying correction. This correction may be accomplished via PIP joint fusion or FDL tendon transfer, which moves the lever arm to the MTP joint and holds the proximal phalanx in a plantarflexed position.

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Based on the results of this investigation, we believe the surgical technique for FDL tendon transfer should utilize a dorsal approach to minimize the risk of compromising the principal blood supply to the involved digits. Chen et al [37] evaluated the vasculature of 20 foot specimens focusing on the second, third, and fourth toes. Findings from the study suggest that plantar circulation is predominant in the second, third, and fourth toes, while dorsal circulation predominated in the first digit. Chen et al [37] further stated that the plantar digital arteries of the lesser toes provide the predominant arterial supply of the PIP joints through a system of transverse and longitudinal arches. Thus, when a claw or hammer toe deformity correction is performed via FDL tendon transfer through a two-incision plantar approach, a decision must be made regarding whether to continue or discontinue surgery when there is a risk of vascular compromise to the digit due to two incisions. Emphasizing the potential deleterious conse‐ quences of multiple incisions, Coughlin [18] recommended that it is far better to offer a 2-stage repair of the deformity than to incur a vascular insult with excessive surgery on a digit.

Surgical correction of hammer and claw toe deformity has been described extensively. Transposition of the flexor tendon to the extensor musculature through a dorso-lateral cut, with FDL tendon transfer to the dorso-lateral area of the proximal phalanx, was originally performed by Girdlestone in 1947 and developed by Taylor. [13] In his study, Taylor included 68 patients with claw or hammer toe deformity treated with this technique and associated procedures, such as dorsal capsulotomy of the MTP joint. Taylor also performed plantar capsulotomy of the interphalangeal joints and stabilization of the proximal phalanx using an external splint. Several modifications of the procedure have subsequently been reported. In 1970, Sgarlato [16] reported 53 cases of FDL tendon transfer through 3 skin incisions. Pyper [12] performed the technique described by Taylor [13] on 45 feet in 23 patients. To correct the digital deformity, he combined it with lengthening of the EDL tendon and dorsal capsulotomy of the MTP joint. Subsequently, Parrish [11] modified this technique by detaching the FDL tendon and dividing the proximal tendinous stump longitudinally and repositioning its medial and lateral aspects in the extensor area. He performed FDL and FDB tendon transfer on the first 5 patients in his series but not on the remaining 18 patients, stating that "the FDB tendon had a smaller calibre and its length was insufficient for the transposition." [11]

Marcinko et al [17] described the FDL tendon transfer using two incisions in the toe, one plantar and another dorsal. Barbari and Brevig [9] performed 39 FDL transpositions to the extensor area in 31 patients; 11 of the 39 procedures were performed in accordance with the technique of Taylor, [13] with the remaining 28 following the modified technique described by Parrish. [11] The approach was through a dorso-lateral incision over the MTP joint extending approx‐ imately 3 cm distally from the neck of the metatarsal bone. Dissection was then performed on each side of the proximal phalanx. The sheath of the flexor tendons was located, and the long Coughlin [18], [19] performed an FDL tendon transfer by first making a transverse incision at the MTP joint, and then a second incision at the dorsal aspect of the digit. Kuwada [20] performed 81 procedures to transfer the FDL tendon via a dorsolateral incision along the digit beginning proximally at the MTP joint and extending distally to least the proximal PIP joint. Thompson and Deland [21] performed transfer of the FDL tendon in 13 digits following the indications of Coughlin [18] via the plantar and dorsal approach. Gazdag and Cracchiolo [22] in 11 feet performed an isolating tendon transfer of the FDL through the 2-cm longitudinal midline incision on the plantar side of the base of the proximal phalanx and performed another dorsal incision at the base of the proximal phalanx. Recently, Boyer and DeOrio [23] treated 70 toes with fixed or flexible hammer toes with a flexor-to-extensor tendon transfer making a longitudinal incision on the plantar aspect of the proximal phalanx and at the dorsal aspect of the toe.

The literature up to now reveals no attempts to discover why Parrish [11] found FDB tendon transfer to be a non-viable option. His findings, however, have been accepted by the scientific community without confirmation or challenge. Furthermore, many of the authors cited, except Barbari and Brevig, [9] performed the double plantar and dorsal incision approach as described by Girdlestone in 1947. [13]

In a cadaveric study we found [14] that it is possible to correct flexible claw and hammer toe deformity by transposing the FDB tendon to the extensor, or dorsal, area of the base of the proximal phalanx. This is a modification of the procedure used by Parrish [11] using a plantar and dorsal incision approach of the digit. We sought to transfer the FDB tendon to the dorsal aspect of the proximal phalanx via the dorsal approach through a unique incision, as described by Barbari and Brevig. [9]A search of the indexed literature found no previous reports of this procedure.

It is possible anatomical variations in the insertion of the FDB tendon may prohibit the popularity of this transfer approach. Three variations have been described: 1) absence of the tendon; 2) absence of the lateral and medial tendinous fascicles but presence of a single tendon running parallel to the FDL tendon; and 3) fusion of the FDB tendon to the FDL tendon. [24]- [27] LeDouble [24] and Nathan and Gloobe [25] found the FDB tendon to be absent in the fifth toe in 21.5% of cases. Testut [27] found the FDB tendon to be absent in the fourth and fifth toes in 3% of the dissections performed. In two separate studies [26], [27] Testut found that the FDB medial and lateral fascicles are not divided. Rather, the fascicles run parallel to the FDL tendon before inserting into a side of the intermediate phalanx of the fifth or fourth toe in 5% of patients. Although Testut [26], [27] did not specify individual percentages for variability in attachment for each of these digits, he established that the FDB tendon of the fifth toe is fused to the FDL tendon in 2% of cases. Thus, the anatomical variations found occur more frequently in the FDB tendon insertion of the fifth toe.

Anomalies or variations in the insertion of the FDB tendon in the third and second toes have not, however, been described. We reported [14] on transposition of the FDB tendon via the plantar approach in 180 digits of cadaveric feet, including 45 second digits, 45 third digits, 45 fourth digits, and 45 fifth digits. We found no cases of variation in the insertion of the FDB tendon in the second, third, or fourth digits, and the FDB tendon was present in all 45 cases. There was variability in FDB tendon presentation in the fifth digit, including FDB tendon absence in 3 of 45 digits (7%), which is a recognized anatomical variation. Thus, we performed the dorsal FDL tendon transfer via the dorsal approach between the FDB hemitendons in only the second and third digits.

A final challenge associated with this novel surgical approach is ankle positioning while suturing FDL tendon stumps. If the ankle is in plantarflexion the tendon has adequate length to permit suturing to the dorsal aspect of the proximal phalanx without difficulty. When the patient is weight-bearing or walking, however, the ankle is in dorsiflexion, which shortens the FDL tendon and forces the MTP joint into plantarflexion. The FDL tendon should therefore be sutured in its anatomical position to avoid inappropriate flexion or extension positioning of

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Transfer of the FDL tendon to the dorsum of the proximal phalanx can be performed for the correction of claw and hammer toe deformities in the second and third digits. The meticulous longitudinal incision of the flexor tendon sheath to expose the FDB tendon and its longitudinal incision are essential to the success of the procedure. Furthermore, this approach preserves the

1 Escuela Universitaria de Enfermería, Fisioterapia y Podología, Universidad Complutense

[1] Coughlin, M. J. Lesser-toe abnormalities. J Bone Joint Surg Am (2002). , 84, 1446-1469.

[2] Sandeman, J. C. The role of soft tissue correction of claw toes. Br J Clin Pract (1967). ,

[3] Coughlin, M. J, & Mann, R. A. Lesser Toe Deformities. In: MJ Coughlin, RA Mann

[4] Richardson, E. G. Lesser Toe Abnormalities. In: AH Crenshaw. *Campbell's Operative*

2 Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Madrid, Spain

*Surgery of the Foot and Ankle,* 7th ed. Mosby, St Louis; (1999). , 328.

*Orthopaedics,* 8th ed. Mosby-Year Book, St Louis; (1992). , 99.

and

integrity of the primary plantar blood supply to the digits of interest.

Ricardo Becerro de Bengoa Vallejo1\*, Marta Elena Losa Iglesias2

\*Address all correspondence to: ibebeva@enf.ucm.es

any involved joint.

**5. Conclusions**

**Author details**

Miguel Fuentes Rodriguez1

de Madrid, Madrid, Spain

21, 489-93.

**References**

Another potential factor prohibiting the tendon transfer approach described in this study may be inadequate space for FDL passage through the FDB hemitendons. After arthroplasty the tendon sheath is exposed and opened longitudinally, and the hemitendons of the FDB are identified just over the FDL tendon. Once the hemitendons are identified they are carefully separated (Fig. 4). If there is not adequate room for FDL passage, the FDB hemitendons must be incised longitudinally (Fig. 5). We believe this additional surgical step is the primary challenge associated with this technique, and may potentially explain why this technique has not previously been described.

Available FDL tendon length may also impact the surgical approach. Once the FDL tendon is detached distally from the distal phalange, it must be long enough to be transposed to the dorsal aspect of the proximal phalanx. When the MTP joint is rigidly dorsiflexed, it is necessary to perform a dorsal capsulotomy and MTP joint release as described by Barbari and Brevig, [9] thus relocating the proximal phalanx to its anatomical position. With this approach there is no need for plantar capsulotomies of the interphalangeal joints.

If there is difficulty in transferring the distal stumps of the longitudinally split FDL tendon to the dorsal aspect of the proximal phalanx of any digit, the clinician must cut the proximal flexor tendon sheath longitudinally for better FDL tendon exposure. We were able to transfer the FDL tendon via dorsal approach between the FDB hemitendons in100% of second and third digits via a unique single longitudinal incision. We did find it difficult, however, to transfer the FDL "around" the lateral aspects of the FDB hemitendons. This transfer was unsuccessful in 83 (69,16%; N = 120) digits, including 45 (37,5%) second digits and 38 (31,66%) of the third digits. We believe this was a consequence of inadequate proximal tendon sheath dissection. When attempting transfer of the split FDL tendon lateral to the FDB hemitendons, it is difficult to obtain adequate proximal exposure secondary to the depth of the anatomical structures. A mini-osteotome may be used to release the FDL tendon from the plantar aspect of the distal middle phalanx to obtain more tendon and facilitate the transfer.

While passing the split FDL tendons between the hemitendons of the FDB is necessary to cut the flexor tendon sheath.

We also encountered difficulty in transposing the FDL tendon as a consequence of the transverse aponeurotic fibers originating from the EDL tendon. These fibers surround the MTP joint capsule and join in the plantar area with the glenoid plate, the deep MTP ligament, and the sheath of the flexor tendons to insert distally into the plantar base of the proximal phalanx. These aponeurotic fibers and the sheath of the flexor tendons must be cut to allow the split FDL tendon to be repositioned and sutured to the dorsal aspect of the proximal phalanx.

A final challenge associated with this novel surgical approach is ankle positioning while suturing FDL tendon stumps. If the ankle is in plantarflexion the tendon has adequate length to permit suturing to the dorsal aspect of the proximal phalanx without difficulty. When the patient is weight-bearing or walking, however, the ankle is in dorsiflexion, which shortens the FDL tendon and forces the MTP joint into plantarflexion. The FDL tendon should therefore be sutured in its anatomical position to avoid inappropriate flexion or extension positioning of any involved joint.

### **5. Conclusions**

plantar approach in 180 digits of cadaveric feet, including 45 second digits, 45 third digits, 45 fourth digits, and 45 fifth digits. We found no cases of variation in the insertion of the FDB tendon in the second, third, or fourth digits, and the FDB tendon was present in all 45 cases. There was variability in FDB tendon presentation in the fifth digit, including FDB tendon absence in 3 of 45 digits (7%), which is a recognized anatomical variation. Thus, we performed the dorsal FDL tendon transfer via the dorsal approach between the FDB hemitendons in only

Another potential factor prohibiting the tendon transfer approach described in this study may be inadequate space for FDL passage through the FDB hemitendons. After arthroplasty the tendon sheath is exposed and opened longitudinally, and the hemitendons of the FDB are identified just over the FDL tendon. Once the hemitendons are identified they are carefully separated (Fig. 4). If there is not adequate room for FDL passage, the FDB hemitendons must be incised longitudinally (Fig. 5). We believe this additional surgical step is the primary challenge associated with this technique, and may potentially explain why this technique has

Available FDL tendon length may also impact the surgical approach. Once the FDL tendon is detached distally from the distal phalange, it must be long enough to be transposed to the dorsal aspect of the proximal phalanx. When the MTP joint is rigidly dorsiflexed, it is necessary to perform a dorsal capsulotomy and MTP joint release as described by Barbari and Brevig, [9] thus relocating the proximal phalanx to its anatomical position. With this approach there is no

If there is difficulty in transferring the distal stumps of the longitudinally split FDL tendon to the dorsal aspect of the proximal phalanx of any digit, the clinician must cut the proximal flexor tendon sheath longitudinally for better FDL tendon exposure. We were able to transfer the FDL tendon via dorsal approach between the FDB hemitendons in100% of second and third digits via a unique single longitudinal incision. We did find it difficult, however, to transfer the FDL "around" the lateral aspects of the FDB hemitendons. This transfer was unsuccessful in 83 (69,16%; N = 120) digits, including 45 (37,5%) second digits and 38 (31,66%) of the third digits. We believe this was a consequence of inadequate proximal tendon sheath dissection. When attempting transfer of the split FDL tendon lateral to the FDB hemitendons, it is difficult to obtain adequate proximal exposure secondary to the depth of the anatomical structures. A mini-osteotome may be used to release the FDL tendon from the plantar aspect of the distal

While passing the split FDL tendons between the hemitendons of the FDB is necessary to cut

We also encountered difficulty in transposing the FDL tendon as a consequence of the transverse aponeurotic fibers originating from the EDL tendon. These fibers surround the MTP joint capsule and join in the plantar area with the glenoid plate, the deep MTP ligament, and the sheath of the flexor tendons to insert distally into the plantar base of the proximal phalanx. These aponeurotic fibers and the sheath of the flexor tendons must be cut to allow the split FDL tendon to be repositioned and sutured to the dorsal aspect of the proximal phalanx.

the second and third digits.

604 Arthroplasty - Update

not previously been described.

the flexor tendon sheath.

need for plantar capsulotomies of the interphalangeal joints.

middle phalanx to obtain more tendon and facilitate the transfer.

Transfer of the FDL tendon to the dorsum of the proximal phalanx can be performed for the correction of claw and hammer toe deformities in the second and third digits. The meticulous longitudinal incision of the flexor tendon sheath to expose the FDB tendon and its longitudinal incision are essential to the success of the procedure. Furthermore, this approach preserves the integrity of the primary plantar blood supply to the digits of interest.

### **Author details**

Ricardo Becerro de Bengoa Vallejo1\*, Marta Elena Losa Iglesias2 and Miguel Fuentes Rodriguez1

\*Address all correspondence to: ibebeva@enf.ucm.es

1 Escuela Universitaria de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, Madrid, Spain

2 Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Madrid, Spain

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## *Edited by Plamen Kinov*

New technologies, developments in implant design and advances in surgical technique have improved outcomes after joint replacement and decreased rate of complications. It is not a surprise that the number of arthroplasties increases steadily every year and nowadays more than one million patients undergo the procedure annually worldwide. This book is a sequel of a successful series dedicated to one of the fastest growing fields in orthopedics - arthroplasty. Aiming at dissemination of scientific research this book provides a profound overview of the recent evolution of technology and surgical techniques. New developments of implant design and current treatment strategies have been critically discussed by the contributing authors. The process of improving care for patients and standards of treatment requires straightforward access to upto-date research and knowledge. The format of the publication allows easy and quick reference to shared ideas and concepts. We hope, that the current book will add significant contribution to the success of this endeavor.

Photo by Goettingen / iStock

Arthroplasty - Update

Arthroplasty

Update

*Edited by Plamen Kinov*