Knee arthrodesis – ultima ratio for the treatment of the infected knee

iprs000027 10.3205/iprs000027 urn:nbn:de:0183-iprs0000279 Research Article Knee arthrodesis – ultima ratio for the treatment of the infected knee Kniearthrodese – Ultima Ratio bei der Behandlung des infizierten Kniegelenkes Tiemann Tiemann Andreas H. H. AH Prof. Dr. med.

Department for Septic and Reconstructive Surgery, Clinic for Trauma- and Reconstructive Surgery, BG-Kliniken Bergmannstrost, Merseburgerstr. 165, 06112 Halle, Germany, Phone: +49/(0)345-1326632Department for Septic and Reconstructive Surgery, Clinic for Trauma- and Reconstructive Surgery, BG-Kliniken Bergmannstrost, Halle, Germany

andreas.tiemann@bergmannstrost.com author German Medical Science GMS Publishing House

Düsseldorf

610 infected knee knee arthrodesis indications technique infiziertes Knie Kniearthrodese Indikationen Techniken 20130425 engl 2193-8091 2 GMS Interdisciplinary Plastic and Reconstructive Surgery DGPW GMS Interdiscip Plast Reconstr Surg DGPW 07 Die unwiderrufliche Zerstörung des Kniegelenkes durch Trauma, Tumor oder Infektion stellt die Indikation zur Kniearthrodese dar. Die Hautpindikation zur Kniearthrodese besteht im Zusammenhang mit irreversibel zerstörten Knieendoprothesen.Zentrales Problem bei der Indikationsstetllung ist der Begriff "unwiederbringliche Zerstörung". Die Einschätzung einer derartigen Situation basiert auf dem subjektiven Empfinden des behandelnden Arztes und seiner Erfahrung auf diesem Gebiet.Dieser Artikel zeigt die typischen Indikationen und Kontraindikationen zur Kniearthrodese nach infektbedingter Zerstörung des Kniegelenkes auf. Zusätzlich werden biomechanische und operationstechnische Aspekte beleuchtet. Abschließend werden die postoperative Nachbehandlung und die Ergebnisse unterschiedlicher Methoden beschrieben. The irretrievable destruction of the knee due to trauma, tumor or infection is the indication for knee arthrodesis. The main reason for knee arthrodesis in terms of infection ist the infected total knee arthroplasty. Central problem is the definition of the term “irretrievable”. It is based on the subjective opinion of the attending physician and depends on his expert knowledge of this specific entity. The preservation of a functioning extremity is the main goal.This article shows the typical indications and contraindications for knee arthrodesis following septic knee diseases. In addition it gives insight into the biomechanical and technical considerations to be kept in mind. Finally the postoperative care and outcome of different techniques are analysed. Introduction“Although the surgeon may consider an arthrodesis of the knee to be a poor outcome, a limb with a fusion is more efficient and functional than is one with an above-the-knee amputation” .Despite the loss of a functioning joint knee fusion can provide a functional symptom-free extremity . In certain situations it may be the only alternative to amputation , .Today manifest irreparable destruction of the knee without any chance of reconstruction or (re)arthroplasty is the indication for knee arthrodesis .These irreversible condition may be caused by:TraumaTumorJoint infection. IndicationsThe indication for knee arthrodesis underwent a constant modification during the decades. In the beginning, based on the lack of sophisticated other options, it was performed in cases of septic arthritis, articular tuberculosis and poliomyelitis as well as in cases of osteoarthritis and rheumatoid arthritis , , , , . Based on the developement of new and efficient therapeutical approaches in many of the above mentioned diseases nowadays the main indication for knee arthrodesis is an irreparable knee destruction based on an infected total knee replacement , , , . According to statistical analyses infections of that type appear in 1 to 4% after primary total knee replacement . Due to the rising number of patients who undergo these procedures the problem becomes more and more immanent , , . After “changing procedures” the infection rate rises up to 20% .Further indications for knee arthrodesis today are , : Methaphyseal bone lossLigamentous instabilityMultiple failed revisionsLoss of extensor mechanismInfection with highly virulent organismsInadequate soft tissue coverageA patient unwilling to consider a revision arthroplasty.According to Vlasak 1995 and Windsor 1993 in 2006 MacDonald pointed out, that knee arthrodesis might be usefull in young patients with unilateral posttraumatic joint destruction in jobs that require heavy manual labour , , . As early as 1993 Isklar et al. demanded knee arthrodesis to be proceeded as early as possible in order to shorten the course of the disease, calm the infection, lower the use of analgetics and preserve bone and soft tissue [. With regard to the patient’s individual “ultima ratio situation” Bierwagen mentioned, that knee arthrodesis in general is the final method in order to preserve the extremity. Failure due to insufficient planning or technique will lead to amputation and subsequently to care dependency . ContraindicationsContraindications for knee arthrodesis include various situations such as , , :Infected contralateral knee arthroplastyInfected ipsilateral hip or ankle arthroplastyExtended bone defect Contralateral leg amputationContralateral hip or knee arthrodesisIpsilateral hip or ankle arthrosis. Indication and contraindication for knee arthrodesis always have to be individualized to the patient’s specific situation in terms of :Individual clinical situationIndividual expectationsIndividual work area situationIndividual social situationIndividual mental situation. Biomechanical considerationsKnee arthrodesis leads to significant functional changings in the lower extremity. Thus they also lead to significant biomechanical changings of the lower extremity, the pelvis and even the whole body. According to Conway et al. and Sandrone et al. the following may be detectable :Increased pelvic inclinationIncreased ipsilateral coxal abductionIncreased ipsilateral dorsalflection of the ankleIncreased energy required for walking (plus 25 to 30%) . Thus knee arthrodesis is contraindicated when contralateral above-knee amputation was proceeded earlier (above-knee amputation increases the strain for walking by 25%). In addition the use of oxygen in patients with knee arthrodesis is 0.16 mL/kg/min compared to 0.20 mL/kg/min following above-knee amputation , .Depending on the technique and the local situation knee arthrodesis leads to a leg shortening. If the estimated reduction is more than 5 cm (secondary) leg lengthening may be considered . General principlesDepending on the chosen technique, the local situation and the estimated bone loss one has to differentiate between two general principles of knee arthrodeses (Figure 1 ):Tibio-femoral contact arthrodesis (“tibio-femoral kissing”)</PlainText></TextGroup> <LineBreak></LineBreak>This concept implicates the direct contact between femur and tibia. Thus bone fusion is possible and the main goal of this procedure.</ListItem><ListItem level="1">Tibio-femoral non-contact arthrodesis <LineBreak></LineBreak>This concept is chosen, if the loss of bone stock is this significant, that direct contact between femur and tibia is impossible or does not make sense. In these cases bone fusion is impossible.</ListItem></UnorderedList></Pgraph><Pgraph>Various techniques have been described in the last decades <TextLink reference="22"></TextLink>:</Pgraph><Pgraph><UnorderedList><ListItem level="1">Long nail </ListItem><UnorderedList><ListItem level="2">Modular nail</ListItem></UnorderedList><UnorderedList><ListItem level="2">Non-modular nail</ListItem></UnorderedList><ListItem level="1">External fixation</ListItem><UnorderedList><ListItem level="2">Monoplanar fixators</ListItem></UnorderedList><UnorderedList><ListItem level="2">Biplanar fixators</ListItem></UnorderedList><UnorderedList><ListItem level="2">Circular frames</ListItem></UnorderedList><ListItem level="1">Hybrid systems</ListItem><UnorderedList><ListItem level="2">Combination of intramedular and external techniques</ListItem></UnorderedList><UnorderedList><ListItem level="2">Compression plating</ListItem></UnorderedList><UnorderedList><ListItem level="2">Vascularized fibular graft.</ListItem></UnorderedList></UnorderedList></Pgraph></TextBlock> <TextBlock linked="yes" name="Strategy"> <MainHeadline>Strategy</MainHeadline><SubHeadline>In general</SubHeadline><Pgraph>Knee arthrodesis needs a proper preoperative planning. The following considerations should be kept in mind:</Pgraph><Pgraph><UnorderedList><ListItem level="1">Correct tibio – femoral alignment</ListItem><ListItem level="1">External rotation tibia vs. femur: 10°</ListItem><ListItem level="1">Genuflection: 10°</ListItem><ListItem level="1">Tibio-femoral contact arthrodesis: Removal of all cartilage (tibial cancellous bone meets femoral cancellous bone)</ListItem><ListItem level="1">Tibio-femoral contact arthrodesis: Fixation under compression in order to increase the bone healing</ListItem><ListItem level="1">Slight shortening of the leg in order to ease the "follow-through" of the leg.</ListItem></UnorderedList></Pgraph><SubHeadline>Timing of the arthrodesis</SubHeadline><Pgraph>According to the literature one may proceed knee arthrodesis in single, two or multi stage strategies <TextLink reference="21"></TextLink>. In terms of knee arthrodeses following knee infection the strategy depends on the extent of the infection, it’s course, previous operations, the patient’s general condition and the type and virulence of the infect causative pathogene (Figure 2 <ImgLink imgNo="2" imgType="figure"/>). This thesis is supported by Waldmann et al. The authors mentioned in 1999 that “following prior surgical procedures resulting in a failed and infected arthroplasty, knee arthrodesis should ideally be attempted as a two stage procedure” <TextLink reference="28"></TextLink>. We perform knee arthrodesis mostly in a multy stage regime due to the fact, that the infect situation after one surgical revision mostly is not sufficient calmed. To achieve this more than one operation is needed.</Pgraph><SubHeadline>Temorary stabilisation of the knee (infect sedation period)</SubHeadline><Pgraph>Analogous to the infect treatment in other sites of the musculo-skeletal system also in infected knees surgical eradication of the infected area and temporary stabilisation are the basic strategy. Thus the way of a temporary knee arthrodesis during the infection treatment has to be defined. The chosen strategy depends on the extent of the infection and the bone stock (Figure 3 <ImgLink imgNo="3" imgType="figure"/>).</Pgraph><SubHeadline>Choice of the correct method</SubHeadline><Pgraph>The choice of the correct method for the definite knee arthrodesis depends on (Figure 4 <ImgLink imgNo="4" imgType="figure"/>):</Pgraph><Pgraph><UnorderedList><ListItem level="1">Loss of bone stock</ListItem><ListItem level="1">Type and virulence of the pathogene that caused the infection</ListItem><ListItem level="1">Patient’s general health.</ListItem></UnorderedList></Pgraph><Pgraph>We perform compression plate tibio-femoral contact arthrodeses as an exception in cases, where internal stabilisation may be particulary promising but the anatomical shape of femur and/or tibia does not allow an intramedullary system. Nevertheless in some cases supplementing the intramedullar stabilisation by plates (and bone grafts) leads to bone fusion even in difficult cases <TextLink reference="20"></TextLink>, <TextLink reference="24"></TextLink>.</Pgraph><Pgraph>As a new method in the last years computer assisted navigation for knee arthrodesis is mentioned in the literature. By analogy with computer assisted implantation of total knee replacements the use of this technique should lead to a perfect three dimensional alignement of tibio-femoral contact arthrodeses. Maniar et al. described the method for the first time in a case of septic arthritis in 2011 <TextLink reference="17"></TextLink>.</Pgraph></TextBlock> <TextBlock linked="yes" name="Postoperative care"> <MainHeadline>Postoperative care</MainHeadline><SubHeadline>(Modular) internal stabilisation</SubHeadline><Pgraph><UnorderedList><ListItem level="1">Mobilisation: First postoperative day</ListItem><ListItem level="1">Physiotherapy with full weight-bearing: First postoperative day (intramedular stabilisation). <LineBreak></LineBreak>Tibio-femoral plate arthrodesis: 20 kg for 4 weeks, 1/2 bodyweight till week 8, afterwards gradually rising till full bodyweight (week 12)</ListItem><ListItem level="1">Elasto-compressive wrapping until soft tissue is consolidated </ListItem><ListItem level="1">Low-dose heparin</ListItem><ListItem level="1">Patient visits the outpatient clinic every 2 weeks (month 1–3). Later once a month (month 4–6). Afterwards individual timing.</ListItem><ListItem level="1">X-ray every 4 weeks (month 1–3). Afterwards in month 6. Then individual timing. Additional CT in cases of complicated healing of tibio-femoral contact arthrodeses and in order to prove the bony consolidation of the tibio-femoral contact arthrodesis. </ListItem></UnorderedList></Pgraph><SubHeadline>External stabilisation</SubHeadline><Pgraph><UnorderedList><ListItem level="1">Mobilisation: First postoperative day</ListItem><ListItem level="1">Physiotherapy with full weight-bearing: First postoperative day (tibio-femoral contact arthrodesis)</ListItem><ListItem level="1">Elasto-compressive wrapping until soft tissue is consolidated </ListItem><ListItem level="1">Low-dose heparin</ListItem><ListItem level="1">Patient visits the outpatient clinic every 2 weeks (month 1-3). Later once a month (month 4-6). Afterwards individual timing.</ListItem><ListItem level="1">X-ray every 4 weeks (month 1-3). Afterwards in month 6. Then individual timing. Additional CT in cases of complicated healing of tibio-femoral contact arthrodeses and in order to prove the bony consolidation of the tibio-femoral contact arthrodesis.</ListItem></UnorderedList></Pgraph><Pgraph>External fixator “specialties”:</Pgraph><Pgraph><UnorderedList><ListItem level="1">Patient </ListItem><UnorderedList><ListItem level="2">Practice: Cleaning of the fixator wires and Schanz screws</ListItem></UnorderedList><ListItem level="1">Doc</ListItem><UnorderedList><ListItem level="2">Tension of the wires (100N): Check once per week</ListItem></UnorderedList><UnorderedList><ListItem level="2">Compression of the arthrodesis: Check every 2 weeks</ListItem></UnorderedList></UnorderedList></Pgraph></TextBlock> <TextBlock linked="yes" name="Fusion rates of tibio-femoral contact arthrodeses"> <MainHeadline>Fusion rates of tibio-femoral contact arthrodeses</MainHeadline><Pgraph>The fusion rates depend on the chosen technique. According to the literature the fusion rates of the intramedullar stabilized arthrodeses are approximately 10 to 15% higher than those achieved by external fixation.</Pgraph></TextBlock> <TextBlock linked="yes" name="Complications"> <MainHeadline>Complications</MainHeadline><Pgraph>Due to the fact, that knee arthrodeses are “ultima ratio” procedures, the rate of complications is rather high. According to the literature it ranges between 20 and 84%. Depending on the type of arthrodesis (see below) the following complications may occur <TextLink reference="8"></TextLink>, <TextLink reference="12"></TextLink>, <TextLink reference="19"></TextLink>:</Pgraph><SubHeadline>In general</SubHeadline><Pgraph><UnorderedList><ListItem level="1">Tibio-femoral pseudarthroses</ListItem><ListItem level="1">Tibio-femoral nonunion</ListItem><ListItem level="1">Tibio-femoral malalignment</ListItem><ListItem level="1">Insufficient cancellous bone plastic</ListItem><ListItem level="1">Persistence or recurrence of the infection <LineBreak></LineBreak>Regardless of the chosen method the rate of recurrent infections is mentioned between 0 and approximately 20%.<LineBreak></LineBreak>Intramedullar arthrodesis: 0 to 22% <TextLink reference="3"></TextLink>, <TextLink reference="9"></TextLink>, <TextLink reference="18"></TextLink>, <TextLink reference="15"></TextLink><LineBreak></LineBreak>External fixation: 0 to 18% <TextLink reference="9"></TextLink>, <TextLink reference="19"></TextLink>, <TextLink reference="26"></TextLink> </ListItem><ListItem level="1">Pain resulting from pseudarthroses or nonunions <TextLink reference="2"></TextLink>.</ListItem><ListItem level="1">Additional fractures</ListItem></UnorderedList></Pgraph><SubHeadline>Depending on the method chosen</SubHeadline><SubHeadline2>External fixation:</SubHeadline2><Pgraph><UnorderedList><ListItem level="1">Neurovascular lesions</ListItem><ListItem level="1">Failure of the construction (f.e. breakage of Schanz screws or wires etc.)</ListItem><ListItem level="1">Local infection at the entry points of Schanz screws or wires</ListItem><ListItem level="1">Fractures</ListItem></UnorderedList></Pgraph><SubHeadline2>Internal fixation:</SubHeadline2><Pgraph><UnorderedList><ListItem level="1">Breakage of the osteosynthesis material (intramedular nail, plate)</ListItem><ListItem level="1">Dislocation of the osteosynthesis material</ListItem><ListItem level="1">Fractures</ListItem></UnorderedList></Pgraph></TextBlock> <TextBlock linked="yes" name="Résumé"> <MainHeadline>Résumé</MainHeadline><Pgraph>A couple of key-factors may be postulated in order to choose the individual correct technique for knee arthrodesis for each patient:</Pgraph><Pgraph><UnorderedList><ListItem level="1">Key factor I: Profound knowledge of the correct indication for internal or external stabilisation (intramedular nail / plate vs. external fixator). </ListItem><ListItem level="1">Key factor II: Profound knowledge of the advantages and disadvantages of the specific methods. </ListItem><ListItem level="1">Key factor III: Profound knowledge in trouble-shooting.</ListItem><ListItem level="1">Key factor IV: Precise individual planning for every patient.</ListItem></UnorderedList></Pgraph><Pgraph>Additionally one should keep in mind, that:</Pgraph><Pgraph><UnorderedList><ListItem level="1">The risk of recurrent infection is almost similar for internal and fixator based arthrodeses.</ListItem><ListItem level="1">The fusion rate for intramedullar contact arthrodeses is significantly higher than the one found when fixator contact arthrodeses are proceeded.</ListItem></UnorderedList></Pgraph></TextBlock> <TextBlock linked="yes" name="Notes"> <MainHeadline>Notes</MainHeadline><SubHeadline>Competing interests</SubHeadline><Pgraph>The author declares that he has no competing interests.</Pgraph></TextBlock> <References linked="yes"> <Reference refNo="1"> <RefAuthor>Agneskirchner JD</RefAuthor> <RefAuthor>Lobenhoffer P</RefAuthor> <RefTitle>Endoprothetik des Kniegelenks</RefTitle> <RefYear>2004</RefYear> <RefJournal>Unfallchirurg</RefJournal> <RefPage>219-29</RefPage> <RefTotal>Agneskirchner JD, Lobenhoffer P. 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New York: Churchill Livingstone; 1993. p. 1103-16.</RefTotal> </Reference> </References> <Media> <Tables> <NoOfTables>0</NoOfTables> </Tables> <Figures> <Figure format="png" height="522" width="863"> <MediaNo>1</MediaNo> <MediaID>1</MediaID> <Caption><Pgraph><Mark1>Figure 1: Types of knee arthrodeses</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="471" width="648"> <MediaNo>2</MediaNo> <MediaID>2</MediaID> <Caption><Pgraph><Mark1>Figure 2: General algorithm for treatment of joint infection </Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="470" width="654"> <MediaNo>3</MediaNo> <MediaID>3</MediaID> <Caption><Pgraph><Mark1>Figure 3: Considerations concerning the temporary knee stabilisation</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="465" width="633"> <MediaNo>4</MediaNo> <MediaID>4</MediaID> <Caption><Pgraph><Mark1>Figure 4: Choice of the correct implant </Mark1></Pgraph></Caption> </Figure> <NoOfPictures>4</NoOfPictures> </Figures> <InlineFigures> <NoOfPictures>0</NoOfPictures> </InlineFigures> <Attachments> <NoOfAttachments>0</NoOfAttachments> </Attachments> </Media> </OrigData> </GmsArticle>