Irrigation and Debridement and Re-implantation of Femoral and Tibial Implants in a 65-Year-Old Woman with Chronic PJI

From Grand Rounds from HSS: Management of Complex Cases | Volume 14, Issue 1

Case Report

A 65-year-old woman presented with continuous left knee pain after left primary total knee arthroplasty (TKA) and revision TKA 3 years later, followed 2 months later by irrigation and debridement (I&D). Swelling and pain worsened and led to multiple emergency department visits.

Examination of the knee showed signs of synovitis including effusion but no draining sinus. Range of motion (ROM) was 5° to 40°, and there was a fluctuant mass at the anterolateral region and laxity in the joint with lateral patella tracking. Left knee radiographs showed the revision implants with radiolucency at both the distal femur and the proximal tibia (Figure 1). Laboratory results showed erythrocyte sedimentation rate (ESR) of 49 mm/hr and C-reactive protein level of 1.8 mg/dL. Synovial aspiration was positive for Staphylococcus epidermidis with multiple drug resistance, confirming a chronic periprosthetic joint infection (PJI).

Figure 1: Anteroposterior (A) and lateral (B) radiographs of the left knee; the patient had undergone revision TKA and I&D for PJI.

Surgery involving implant removal and static spacer insertion was planned. A medial sinus tract with purulence required debridement; nonviable tissues were removed, resulting in significant tibial and femoral bone loss. A humeral nail (7 mm × 9.5 mm × 255 mm) was coated with high-dose antibiotic cement and inserted into the canals with the static spacer. The postoperative knee radiograph showed the static spacer in good position (Figure 2) without loosening. The patient was discharged with daptomycin IV via a peripherally inserted central catheter line. At the 3-month follow-up, aspiration showed no sign of infection.

Figure 2: Anteroposterior (A) and lateral (B) radiographs of the left knee after static spacer insertion.

Six months after spacer insertion, the patient underwent re-revision TKA with a cone augment (Figure 3). A month postoperatively, she reported knee pain, and the ESR was 44mm/hr, indicating recurring infection. Examination found severe anterior knee soft-tissue deficits requiring repeat I&D with implant retention; antibiotic cement beads were inserted. The extensor mechanism deficit was repaired with wire fixation and a gastrocnemius muscle flap. Another I&D was performed a week later, which resolved swelling and pain.

Figure 3: Anteroposterior (A) and lateral (B) radiographs of the left knee after reimplantation of femoral and tibial implants using a cone augment.

At 11-month follow-up, the patient walked without a limp, used a cane for long distances, and had a well-healed incision without effusion. The ROM was 0° to 65°, without evidence of loosening.

Discussion

As the gold standard to treat chronic PJI after TKA, 2-stage revision has shown good eradication rates and clinical outcomes [1-3]. Patients with acute infection (symptoms lasting less than 4 weeks) have been treated with I&D and implant retention (DAIR) with mixed results. The 2-stage, double-DAIR approach, in which high-dose beads administer local antibiotics between stages, provides a more “sterile” field at the second stage of the procedure, facilitating consecutive debridement [4].

The aggressive debridement required for revision TKA for PJI involves excision of nonviable tissue, extirpation of fistulous tracts, thorough lavage, and depending on the acute or chronic infection state, explantation of all prosthetic components and hardware [3]. In this case, after initial 2-stage revision, additional double DAIR was performed to maximize infection control.

Static spacers are beneficial for massive soft-tissue deficits requiring a soft-tissue flap and for severe bone loss [5,6]. The infection itself may be responsible for those deficits but so may multiple revisions and debridement. Furthermore, lack of joint fixation can lead to instability and progressive bone loss, impeding the creation of a structurally normal joint after PJI treatment [7]. While the eradication rate is similar for both the static and articulating spacer, the latter has been associated with improved postoperative long-term function and range of motion [1,5]. In this case, a static spacer was chosen due to the severe bone loss and soft-tissue deficits.

Because the risk of PJI increases with the number of revisions [8], TKA patients needing multiple revisions require a patient-specific approach. The failure rate of 2-stage revision is as high as 47%, with a reinfection rate of 29% after 6 years [9]. A recent report on failed 2-stage revision showed reinfection at an average of 21.3 months and a 22% rate of pathogen persistence [2], suggesting the need for close monitoring for 2 years. Nevertheless, as this case suggests, a proactive approach in PJI revision maximizes chances for a complication-free outcome.

Authors

References

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