Knee replacement: Second-stage revision to distal femoral EPR (Implantcast MUTARS MK) with EPORE collar and tibial cone
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Increasing numbers of primary and revision knee replacements are being performed which inevitably lead to more prosthetic joint infections (PJI) presenting to specialist PJI multi-disciplinary teams. Infection is a devastating complication of total joint arthroplasty and not only the most common cause for early failure of joint replacements but also the most common cause for failure of revision knee replacements at any time.
That PJI is associated with higher mortality than some common malignancies has been widely reported. The five year survival after PJI is 78% compared to 90% in patients undergoing aseptic revision arthroplasty (Matar H, et al. Septic Revision Total Knee Arthroplasty Is Associated With Significantly Higher Mortality Than Aseptic Revisions: Long-Term Single-Center Study (1254 Patients). Journal of Arthroplasty 2021 https://doi.org/10.1016/j.arth.2021.01.068).
The treatment of prosthetic joint infection typically requires surgery involving explant of the infected prosthesis, radical debridement and then either immediate reimplantation or use of an antibiotic loaded cement spacer and delayed reimplantation (a two-stage revision, as in this case). Alternative strategies include debridement and implant retention with modular exchange (indicated in acute PJI) and single-stage revision (considered in infected primary arthroplasty implants, sensitive organisms and without soft-tissue defects requiring plastic surgery). There is endless debate about selecting the correct option for each case, the decision is multi-factorial and probably best decided in specialist PJI multi-disciplinary meetings.
Infected revision knee replacements are increasing in prevalence due to the increasing numbers of revision joint replacements being performed for septic and aseptic indications such that a 7.5-fold increase in re-revision knee replacements due to infection that has been experienced in the UK since 2005 (Lenguerrand et al. Description of the rates, trends and surgical burden associated with revision for prosthetic joint infection following primary and revision knee replacements in England and Wales: an analysis of the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man.
Here I present a challenging case of reconstruction of an infected revision knee replacement, which underwent a two-stage revision using a porous tibial cone for severe bone loss and a silver-coated endoprosthetic replacement to manage segmental bone loss.
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Author:Jonathan Stevenson FRCS (Tr & Orth)
Institution: Royal Orthopaedic Hospital, Birmingham, UK