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Arthrodesis of the Knee with a Long Intramedullary Nail Following the Failure of a Total Knee Arthroplasty as the Result of Infection
Konstantinos Bargiotas, MD1; David Wohlrab, MD1; Jeffrey J. Sewecke, DO1; Gregory Lavinge, MD1; Patrick J. DeMeo, MD1; Nicholas G. Sotereanos, MD1
1 Federal North, 1307 Federal North Street, Pittsburgh, PA 15212. E-mail address for K. Bargiotas: kbargio@yahoo.gr. E-mail address for N.G. Sotereanos: nsotereanos@usa.net
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A video supplement to this article will be available from the Video Journal of Orthopaedics. A video clip will be available at the JBJS web site, www.jbjs.org. The Video Journal of Orthopaedics can be contacted at (805) 962-3410, web site: www.vjortho.com.
The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Orthopaedics, Allegheny General Hospital, Pittsburgh, Pennsylvania

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Mar 01;88(3):553-558. doi: 10.2106/JBJS.E.00575
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Abstract

Background: Knee arthrodesis can be an effective treatment option for relieving pain and restoring some function after the failure of a total knee arthroplasty as the result of infection. The purpose of the present study was to review the outcome of a staged approach for arthrodesis of the knee with a long intramedullary nail after the failure of a total knee arthroplasty as the result of infection.

Methods: We reviewed the results for twelve patients who underwent knee arthrodesis after the removal of a prosthesis because of infection. The study group included seven women and five men who had an average age of sixty-eight years at the time of the arthrodesis. All patients were managed with a staged protocol. Implant removal, débridement, and insertion of antibiotic cement spacers was followed by the administration of systemic antibiotics. Provided that clinical and laboratory data suggested eradication of the infection, arthrodesis of the affected knee with use of a long intramedullary nail was carried out. Clinical and laboratory evaluation and radiographic analysis were performed after an average duration of follow-up of 4.1 years.

Results: Solid union was achieved in ten of the twelve knees. The average time to union was 5.5 months. One patient had an above-the-knee amputation because of recurrence of infection. In another patient, nail breakage occurred three years following implantation. The average limb-length discrepancy was 5.5 cm. The mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score improved from 41 to 64 points. None of the seven patients who underwent arthrodesis with a technique involving convex-to-concave reamers had a complication, and the average time to union for these seven patients was shorter than that for the remaining five patients (4.3 compared with 7.4 months).

Conclusions: We believe that obtaining large surfaces of bleeding contact bone during arthrodesis following staged treatment of an infection at the site of a failed total knee arthroplasty contributes to stability and enhances bone-healing. Staged arthrodesis with use of a long intramedullary nail and convex-to-concave preparation of bone ends provided a painless functional gait with low complication and reoperation rates in this challenging group of patients.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Levent Altinel, M.D.
    Posted on April 22, 2006
    Arthrodesis of the Knee Without Limb Shortening
    Afyon Kocatepe University, Faculty of Medicine, Afyon, TURKEY

    To the Editor:

    I would like to comment on the article by Bargiotas, et al(1). Failure of TKA because of infection is a devastating complication and treatment may require removal of components, thorough debridement, and arthrodesis. In the author’s study, the mean leg length discrepancy following arthrodesis using an intramedullary nail was 5.5 cm.

    In our experience, the resulting intraoperative defect can be even larger than anticipated because of the extensive debridement and shaping of the bone ends so that they are suitable for arthrodesis. In addition, intramedullary nails are not free of complications. Nail breakage, migration, and instability secondary to differences in the intramedullary diameters of the femur and tibia can occur.

    To avoid such shortening, we prefer to perform leg lengthening as part of the arthrodesis for failed infected knee replacements using the Ilizarov fixator. The Ilizarov fixator can be used when other athrodesis techniques fail(2) and even in the presence of active infection, substantial shortening, and bone loss(3). The Ilizarov fixator offers the advantages of early weightbearing, a high union rate, and simultaneous lengthening of the extremity.

    In summary, arthrodesis and restoration of leg length with the Ilizarov fixator is a superior alternative to intramedullary nails when performing arthrodesis in a patient with an infected total knee arthroplasty.

    References:

    1. Bargiotas K, Wohlrab D, Sewecke JJ, Lavinge G, Demeo PJ, Sotereanos NG. Arthrodesis of the knee with a long intramedullary nail following the failure of a total knee arthroplasty as the result of infection. J Bone Joint Surg Am. 2006 Mar;88(3):553-8.

    2. Oostenbroek HJ, van Roermund PM. Arthrodesis of the knee after an infected arthroplasty using the Ilizarov method. J Bone Joint Surg Br. 2001 Jan;83(1):50-4.

    3.Manzotti A, Pullen C, Deromedis B, Catagni MA. Knee arthrodesis after infected total knee arthroplasty using the Ilizarov method. Clin Orthop Relat Res. 2001 Aug;(389):143-9.

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