Minimum Two-year Results Of Revision Total Knee .

Knee Surg Relat Res, Vol. 24, No. 4, Dec. 2012Fig. 1. Radiographs showing mobile cement spacer.infection is diagnosed, debridement and lavage were thoroughlyperformed. The type of antibiotics used for the cement spacerin the first-stage procedure was determined as those sensitiveto cultured organisms. In the cases with negative culture results,2 g of vancomycin and 2.25 g of tazocin were mixed with 40g bone cement containing 1 g erythromycin. The spacer wascreated using each package of bone cement for the tibial areaand femoral area. In cases with suspected fungal infection, 50mg of amphotericin was added to the mixture. In the adjacentsoft tissues, 60-90 beads that are 5 mm in diameter and made ofthe same proportion of antibiotics to cement were implanted.If the preoperative culture was positive, sensitive antibioticswere intravenously injected and if negative, 1 g of cetrazole wasadministered. The type of antibiotics was changed accordingto the intraoperative culture results and the intravenousadministration was continued for 6 weeks. The second-stagereimplantation was planned if systemic symptoms accompanyingknee pain, suppuration, open wounds, and fistulas disappearedand blood parameters such as WBC, ESR, and CRP werenormal in more than two consecutive assessments performedwith an interval of 1 month. The final revision procedure wasperformed if 5 polymorphonuclear leukocytes were observedon the intraoperative frozen section biopsy of specimens from 3 areas with a magnification of 400 and there was no signof infection observable with the naked eye. In cases with 5-10polymorphonuclear leukocytes, revision was determined ifinfection was considered resolved based on the assessment ofclinical symptoms, postoperative condition, blood test results,and intraoperative naked-eye inspection.229In the non-infected group, the causes of revision werecomponent loosening in 4, polyethylene wear and breakdown in4, instability in 2, periprosthetic fracture in 3, and polyethylenedislocation in 2 patients, on all of which one-stage revisionwas performed. In 2 patients, periprosthetic fracture wasaccompanied by component loosening.In the revision TKA, rectus snip was performed in 11 patientsin the infected group and 15 patients in the non-infected group,whereas tibial tubercle osteotomy was done in 8 patients inthe infected group and in none of the non-infected group. V-YQuadricepsplasty was not used in both groups. The LCCKsystem (Zimmer, Warsaw, IN, USA) and Scorpio system (StrykerHowmedica Osteonics, Mahway, NJ, USA) were used in 12 and9 patients, respectively, in the infected group (n 21) and in 8patients and 1 patient, respectively, in the non-infected group(n 15). In the remaining patients of the non-infected group,revision surgery was performed using the PFC Sigma kneesystem (Johnson & Johnson, Warsaw, IN, USA) in 2 patients,the rotating Hinge system (Stryker Howmedica Osteonics) in 1patient with severe instability, and the NexGen system (Zimmer)and stems in 3 patients with relatively little bone loss. Both thefemoral and tibial stems were used in all of the patients in theinfected group and in 5 patients in the non-infected group. Inthe remaining patients of the non-infected group, a femoralstem was used in 2 patients and a tibial stem in 2 patients. Metalaugmentation for bone defect was used in 20 patients for thefemur and 14 patients for the tibia in the infected group andin 5 patients for the femur and 3 patients for the tibia in thenon-infected group. Structural bone graft reconstruction wasperformed in 1 patient in the infected group and in 2 patientswith severe periprosthetic fracture in the non-infected group(Table 1).The postoperative rehabilitation protocol was the same inboth groups. Continuous passive motion was initiated from the1st postoperative day. Active motion exercises and quadricepsfemoris strengthening exercises were started from the 2ndpostoperative day. Once normal quadriceps femoris strengthwas achieved, partial weight bearing with crutch assistance wasinitiated. Weigh bearing was not permitted until radiographicevidence of union was achieved in patients with tibial tubercleosteotomy or struactural bone allograft reconstruction. Thepatients were educated to continue with the rehabilitationprogram after hospital discharge and asked for regular follow-upat 3, 6, 9, 12 months after surgery and once a year thereafter.Clinical and radiographic assessments were performed in allthe patients preoperatively and at the last follow-up. The clinical

230 Lee et al. Results of Revision TKA Following Infectious or Non-infectious Causesassessment was based on the range of motion (ROM), Hospitalfor Special Surgery (HSS) score, Knee Society score (KSS),and Western Ontario and McMaster Universities (WOMAC)score. The ROM was measured using a goniometer by the samesurgeon. In the infected group, the ROM measured before thefirst-stage procedure was used as the preoperative ROM. On theradiographic assessment, the Knee Society roentgenographicevaluation system was used to assess the femorotibial angle,radiolucency around the femur and tibia on the anteroposteriorand lateral radiographs18). Changes in the joint line heightwere also included in the assessment. The joint line heightin the unoperated contralateral knee was compared with thepostoperative height in the operated knee. If the contralateralknee had been operated, the measurement obtained beforeprimary TKA was used for the assessment. The joint line heightwas measured as the perpendicular distance between a lineconnecting the most distal points of the medial and lateralfemoral condyles and a parallel line extending to the fibularhead on the anteroposterior radiographs. The distance betweenthe medial and lateral condyles of the femur was measured onthe contralateral knee and the operated knee to avoid errorscaused by radiographic image magnification (Fig. 2). Statisticalanalysis was done using the SPSS ver. 14.0 software (SPSS Inc.,Chicago, IL, USA). According to the normality test, intergroupcomparisons were made using the parametric Student’s t-test andthe nonparametric Mann-Whitney test.Results1. Clinical ResultsThe mean ROM was improved in both groups from 65.2o (range,0o-125o) preoperatively to 101.7o (range, 90o-130o) postoperativelyin the infected group and from 99.9 o (range, 0 o -140 o )preoperatively to 117.8o (range, 85o-140o) postoperatively in thenon-infected group. The increase in the ROM was significantlyhigh in the infected group compared to the non-infected group.The pre- and postoperative ROM values were significantly greaterin the non-infected group (p 0.004, p 0.008) (Table 2).The HSS score was significantly improved postoperatively inboth groups (p 0.001). There was no statistically significantintergroup difference in the mean preoperative HSS score, butthe mean postoperative HSS score was remarkably greater in thenon-infected group (p 0.039) (Table 2).The mean Knee Society Knee Score (KSKS) and Knee SocietyTable 2. Clinical and Radiologic Outcome of the Infected and Noninfected Revision Total Knee .8 8.94.8 6.60.135Further Flexion ( )74.0 37.6104.7 34.80.004Mean ROM (o)65.2 42.099.9 38.00.004HSS score47.4 14.256.5 18.40.238KSKS44.1 17.944.6 14.90.885KSFS28.1 16.233.7 21.10.61960.8 13.560.9 14.10.4684.1 5.84.7 4.40.3122.5 2.31.2 0.90.348Further flexion ( )104.2 14.4119.0 20.70.008Mean ROM (o)101.7 17.2117.8 20.90.008HSS score79.2 9.885.5 10.20.039KSKS75.5 11.986.6 9.60.017KSFS76.9 12.085.5 10.60.016WOMAC30.3 13.921.2 11.50.005-3.8 3.5-5.7 3.60.506PreoperativeROMExtension (o)oWOMACoFT angle ( )PostoperativeExtension (o)oFig. 2. Measurement of the joint line position change on the APradiograph. (A) a: preoperative joint line height, b: preoperative distancebetween the medial and lateral femoral epicondyles, (B) c: postoperativejoint line height, d: postoperative distance between the medial andlateral femoral epicondyles. The difference (D) between preoperative andpostoperative joint line was calculated as: D (b/d)c-a.oFT angle ( )ROM: range of motion, HSS: Hospital for Special Surgery, KSKS: KneeSociety Knee Score, KSFS: Knee Society Function Score, FT angle:femoro-tibial angle (varus: , valgus: -).

Knee Surg Relat Res, Vol. 24, No. 4, Dec. 2012231Fig. 3. (A) A 74-year-old woman visited ourclinic with an infection of the left followingtotal knee arthroplasty that had been donein another hospital 13 months ago. (B) Weperformed the first stage reimplantationwith an articulating cement spacer andbeads. (C) The radiograph at 3 years afterthe revision shows satisfactory results.Table 3. Difference in the Average Joint Line Elevation between the TwoGroupsMeanRangeStandarddeviationOutlier( 8 mm)Infective group0.5-8.7–9.54.62 casesNon-infective group2.1-6.9–17.05.21 casesDifference (D, mm)p-value 0.236.Fig. 4. (A) A 60-year-old man visited our clinic for left knee pain andthe radiograph shows femoral component aseptic loosening. (B) Theradiograph at 2 years after the revision shows satisfactory results.Function Score (KSFS) were improved postoperatively in bothgroups (p 0.001). There was no notable intergroup differencein the mean preoperative KSKS and KSFS, but the meanpostoperative values were significantly greater in the non-infectedgroup (p 0.017, p 016) (Table 2).The mean WOMAC score was 60.8 preoperatively and 30.3postoperatively in the infected group and 60.9 preoperativelyand 21.2 postoperatively in the non-infected group. The meanpreoperative WOMAC score was not significantly differentbetween the groups (p 0.468), but the mean postoperative valuewas notably higher in the non-infected group (p 0.005) (Table 2).2. Radiographic ResultsThe mean femorotibial angle was corrected from 4.1o varuspreoperatively to 3.8o valgus postoperatively in the infected groupand from 4.7o varus preoperatively to 5.7o valgus postoperativelyin the non-infected group and there was no significant differentbetween the groups in the pre-and postoperative values (p 0.468,p 0.056) (Table 2). A radiolucent zone of 2 mm was notobserved in all patients during the follow-up, whereas 2 mmradiolucent lines were observed in 3 patients (2 in the infectedgroup and 1 in the non-infected group). All the radiolucent linesdid not progress during the follow-up period (Figs. 3, 4). Themean increase in the joint line height was 0.5 mm in the infectedgroup and 2.1 mm in the non-infected group. More than 8 mmchange in the joint line height was observed in 2 patients in theinfected group and in 1 patient in the non-infected group (Table3).3. ComplicationsDeep infection occurred in 3 patients in the infected groupand in 1 patient in the non-infected group. The patients hadno reinfection at one year after two-stage reimplantation andobtained good ROM (5 o-100 o). During the postoperativerehabilitation period, a patellar tendon rupture in and aperiprosthetic fracture were observed in 1 patient each in thenon-infected group. The ruptured patellar tendon was treatedwith patellar tendon suture and quadriceps femoris turndowntechnique and the fracture with fixation using a metal plate.DiscussionOn the clinical outcome of revision TKA, Insall10) reported

232 Lee et al. Results of Revision TKA Following Infectious or Non-infectious Causesthat good or excellent results were obtained in 89% of patients,whereas satisfying results were achieved in 46% in the study byGoldberg et al.4) and in only 30% in the study by Cameron etal.2). Direct comparison of these studies is difficult due to thedifferences in the follow-up period and criteria of success andfailure. However, the general consensus is that the results ofrevision TKA is less satisfactory than those of primary TKA dueto a variety of factors including the soft tissue weakness, bonedeficiency, limited ROM before revision.Many studies have shown that the results of revision TKAincluding the postoperative ROM are inferior in patientswith infection than those without infection1,4,11-13). This can beattributed to restriction on the ROM, preoperative joint functionimpairment, and soft tissue fibrosis due to repeated operations inpatients with an infection8,11). However, some recent studies havesuggested that revision TKA for infection can be as successfulas that for non-infectious causes with use of mobile antibioticimpregnated cement spacers to compensate for bone loss andsoft tissue fibrosis19,20). On the other hand, Wang et al.21) reportedthat the non-infected group obtained higher knee score andgreater ROM than the infected group, whereas the functionscore and patient satisfaction were identical in both groups. And,Patil et al.16) reported that the SF-36 score, a quality of life index,and knee score were higher in the infected group than noninfected group. Likewise, there is diverse comparative reports onresults of the infected and non-infected groups. In the currentstudy, the clinical results based on the HSS score, KSKS, KSFS,and WOMAC score were more satisfying in the non-infectedgroup at statistically significant levels (p 0.05). The pre- andpostoperative ROM were significantly greater in the non-infectedgroup (p 0.05). We attributed these results to the fact that theROM before the primary procedure was smaller in the infectedgroup, repeated operations resulted in more soft tissue and skindamage, and the ROM was limited due to the use of antibioticimpregnated cement spacers in the two-stage reimplantation.However, the clinical and radiographic results were withinthe satisfactory range in the infected group as well. Recurrenceof an infection could be prevented with proper curettage. Jointmobility could be maintained during infection healing withthe use of mobile antibiotic impregnated cement spacers forprevention of soft tissue adhesion. Balanced flexion-extensiongap was achieved and joint line height was restored by using thestemmed prosthesis and metal augmentation to compensate forbone loss. On the clinical results, the mean postoperative ROM(104.2o; range, 90o-130o) in the infected group was satisfactory.Considering that 120o of high flexion is necessary for kneelingand sitting cross-legged on the floor in Korean culture, therefore,the relatively low clinical results in the infected group comparedto those in the non-infected group can be attributed to thelimitations in daily living activities.The non-infectious causes of revision TKA include implantloosening and wear, instability, and malalignment. Bargren etal.22) reported that malalignment is present in most of the TKApatients. In the current study, the degree of malalignment wasgreater in the infected group: the mean preoperative femorotibialangle was 4.1o varus in the infected group, whereas 4.7o varus inthe non-infected group.Bone deficiency is one of the most important factors thatinfluence the success of TKA23). Metal augmentation can beeffective in preventing changes in the joint line height, but maycause corrosion in the long-term and accordingly poor overalllong-term outcome24,25). In this study, the infected group hadmore extensive bone deficiency than the non-infected group.Thus, we used more metal augmentation materials in the infectedgroup during revision surgery, which improved the clinicaloutcome during the short-term follow-up period. In spite of this,we believe the results should be confirmed by a long-term followup.There is controversy regarding the radiolucency after TKA orrevision TKA. Some authors associate radiolucent lines with thelack of firm stabilization between the tibia and bone cement26,27).On the other hand, Reckling et al.28) reported that the presenceof progressive radiolucent lines do not signify looseness of theimplant. In this study, 2 mm radiolucency was not observed inthe tibia and femur in all the patients and the 2 mm radiolucentlines in 3 patients did not progress or result in loosening of theprosthesis.Restoration of the joint line height is crucial to the successof TKA. Figgie et al. 29) reported that joint line height wassignificantly correlated with the functional knee score, ROM,patellofemoral pain, and mechanical symptoms, and 8 mmchange in the joint line height increased the need for revision.Ryu et al.30) reported that the ROM was good in patients with2.1 mm change in the joint line height, whereas the ROM waspoor in patients with approximately 3 times greater changes (5.7mm). In our study, the mean joint line height elevation was notsignificantly different between the groups with 0.5 mm in theinfected group and 2.1 mm in the non-infected group (p 0.236).A 8 mm joint line height change was observed in 2 patients(9.5%) in the infected group and in 1 patient (6.7%) in the noninfected group and they obtained good results at the last followup examination. We believe this was because we used stemmed

Knee Surg Relat Res, Vol. 24, No. 4, Dec. 2012prostheses and metal augmentation to compensate for bonedeficiency and soft tissue imbalance and took measures to restorethe flexion and extension gap and the joint line height.The limitations of this study include the retrospective studydesign, small number of patients, and short follow-up. Further,it is difficult to generalize our findings due to the small studypopulation. Therefore, we believe the results should be confirmedin further studies with a large number of patients.10.11.12.ConclusionsRevision TKA for non-infectious causes resulted in significantlybetter outcome than revision TKA for infection. However,revision TKA patients with infectious causes could obtain goodresults with the use of mobile antibiotic impregnated cementspacers for mobility maintenance during the healing period andproper implant selection for joint line height restoration.References1.2.3.4.5.6.7.8.9.Bae DK, Yoon KH, Kim HS, Song SJ, Yi JW, Kim YC. Theresults of revision total knee arthroplasty. J Korean OrthopAssoc. 2003;38:689-94.Cameron HU, Hunter GA, Welsh RP, Bailey WH. Revisionof total knee replacement. Can J Surg. 1981;24:418-20.Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M.Prevalence of primary and revision total hip and kneearthroplasty in the United States from 1990 through 2002. JBone Joint Surg Am. 2005;87:1487-97.Goldberg VM, Figgie MP, Figgie HE 3rd, Sobel M. Theresults of revision total knee arthroplasty. Clin Orthop RelatRes. 1988;(226):86-92.Jacofsky DJ, Della Valle CJ, Meneghini RM, Sporer SM,Cercek RM. Revision total knee arthroplasty: what thepracticing orthopaedic surgeon needs to know. J Bone JointSurg Am. 2010;92:1282-92.Mulhall KJ, Ghomrawi HM, Engh GA, Clark CR, Lotke P,Saleh KJ. Radiographic prediction of intraoperative boneloss in knee arthroplasty revision. Clin Orthop Relat Res.2006;446:51-8.Ritter MA, Eizember LE, Fechtman RW, Keating EM, FarisPM. Revision total knee arthroplasty. A survival analysis. JArthroplasty. 1991;6:351-6.Insall JN, Dethmers DA. Revision of total knee arthroplasty.Clin Orthop Relat Res. 1982;(170):123-30.Barrack RL. Early failure of modern cemented stems. J13.14.15.16.17.18.19.20.21.22.233Arthroplasty. 2000;15:1036-50.Insall JN. Revision of total knee replacement. Instr CourseLect. 1986;35:290-6.Windsor RE, Insall JN, Urs WK, Miller DV, Brause BD. Twostage reimplantation for the salvage of total knee arthroplastycomplicated by infection. Further follow-up and refinementof indications. J Bone Joint Surg Am. 1990;72:272-8.Barrack RL, Engh G, Rorabeck C, Sawhney J, Woolfrey M.Patient satisfaction and outcome after septic versus asepticrevision total knee arthroplasty. J Arthroplasty. 2000;15:9903.Hwang SC, Cho SH, Jeong ST, Yune YP, Hwang IH. Clinicaloutcomes of infective and non-infective groups in revisiontotal knee arthroplasty. J Korean Knee Soc. 2005;17:91-8.Bose WJ, Gearen PF, Randall JC, Petty W. Long-termoutcome of 42 knees with chronic infection after total kneearthroplasty. Clin Orthop Relat Res. 1995;(319):285-96.Park SJ, Song EK, Seon JK, Yoon TR, Park GH. Comparisonof static and mobile antibiotic-impregnated cement spacersfor the treatment of infected total knee arthroplasty. IntOrthop. 2010;34:1181-6.Patil N, Lee K, Huddleston JI, Harris AH, Goodman SB.Aseptic versus septic revision total knee arthroplasty: patientsatisfaction, outcome and quality of life improvement. Knee.2010;17:200-3.Hanssen AD, Rand JA, Osmon DR. Treatment of the in fected total knee arthroplasty with insertion of anotherprosthesis. The effect of antibiotic-impregnated bonecement. Clin Orthop Relat Res. 1994;(309):44-55.Ewald FC. The Knee Society total knee arthroplastyroentgenographic evaluation and scoring system. ClinOrthop Relat Res. 1989;(248):9-12.Goldstein WM, Kopplin M, Wall R, Berland K. Temporaryarticulating methylmethacrylate antibiotic spacer (TAMMAS).A new method of intraoperative manufacturing of a customarticulating spacer. J Bone Joint Surg Am. 2001;83 Suppl 2 Pt2:92-7.Hofmann AA, Goldberg T, Tanner AM, Kurtin SM.Treatment of infected total knee arthroplasty using anarticulating spacer: 2- to 12-year experience. Clin OrthopRelat Res. 2005;(430):125-31.Wang CJ, Hsieh MC, Huang TW, Wang JW, Chen HS, LiuCY. Clinical outcome and patient satisfaction in aseptic andseptic revision total knee arthroplasty. Knee. 2004;11:45-9.Bargren JH, Blaha JD, Freeman MA. Alignment in totalknee arthroplasty. Correlated biomechanical and clinical

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Conclusions: Revision TKA is an effective treatment that can provide successful results in the infected as well as non-infected patients. The overall results of non-infected revision were more satisfactory than infected revision. Key words: Infection, Non-infection, Re