Hypoalbuminemia Predicts Failure of Two-Stage Exchange for Chronic Periprosthetic Joint Infection of the Hip and Knee.

BACKGROUND: Nutritionally compromized patients, with preoperative serum albumin (SAB) < 3.5g/dL, are at higher risk for periprosthetic joint infection (PJI) in total joint arthroplasty. The relationship between nutritional and PJI treatment success is unknown. The purpose of this study was to examine the relationship between preresection nutrition and success after first-stage resection in planned two-stage exchange for PJI. METHODS: A retrospective review was performed on 418 patients who had first-stage resection of a planned two-stage exchange for chronic hip or knee PJI between 2014 and 2018. A total of 157 patients (58 hips and 99 knees) were included who completed first stage, had available preop SAB and had a 2-year follow-up. Failure was defined as persistent infection or repeat surgery for infection after resection. Demographic and surgical data were abstracted and analyzed. RESULTS: Among knee patients with preop SAB >3.5 g/dL, the failure rate was 32% (15 of 47) versus a 48% (25 of 40) failure rate when SAB <3.5 g/dL (P = .10). Similarly, the failure rate among hip patients with preop SAB >3.5 g/dL versus 12.5% (3 of 24) versus 44% (15 of 34) for hip patients with SAB <3.5 g/dL (P = .01). Multivariable regression results indicated that patients with SAB< 3.5 g/dL (P = .0143) and Musculoskeletal Infection Society host type C (P = .0316) were at an increased risk of failure. CONCLUSION: Low preoperative SAB and Musculoskeletal Infection Societyhost type-C are independent risk factors for failure following first-stage resection in planned two-stage exchange for PJI. Efforts to nutritionally optimize PJI patients, when possible, may improve the outcome of two-stage exchange.

Varus Collapse in Total Knee Arthroplasty: Does Fixation or Bone Fail First?

INTRODUCTION: Aseptic tibial loosening is now considered the most common reason that total knee arthroplasties (TKA) fail long term. There are unique subsets of patients that fail into varus alignment of the tibial tray with collapse of the medial proximal tibia. It is currently unknown if the implant fixation fails first or if the proximal medial tibia collapses first. MATERIALS: We performed a retrospective analysis of 88 patients that were revised at our institution secondary to aseptic varus collapse of the proximal tibia. Two fellowship-trained arthroplasty surgeons performed a retrospective analysis on sequential precollapse radiographs in each patient to determine which failed first: the implant fixation (implant-cement or cement-bone interface) or the medial proximal tibia. DISCUSSION: 36/88 (40.9%) patients had a series of precollapse radiographs that could be reviewed. Failure at the implant-cement interface before varus collapse in 23 vs 22 patients, failure at the implant-cement and cement-bone interface before varus collapse in two patients, and contemporaneous failure at the implant-cement interface and varus collapse in 11 vs 12 patients were identified by reviewers one and two, respectively. CONCLUSION: The most frequent mechanism of failure identified was failure of the implant-cement interface followed by subsequent medial tibial varus collapse. Improving implant fixation may decrease the incidence of this unique failure mechanism. We advocate the use of supplemental stem fixation in high-risk patients and optimal cement techniques for all patients as methods of potentially avoiding tibial varus collapse, one of the most frequent modes of long-term failure.

Isolated Polyethylene Insert Exchange for Flexion Instability After Primary Total Knee Arthroplasty Demonstrated Excellent Results in Properly Selected Patients.

BACKGROUND: Historically, isolated polyethylene exchange (IPE) for flexion instability after total knee arthroplasty (TKA) has demonstrated generally poor and unpredictable results. The purpose of this study is to evaluate the results of a single surgeon's strict indications and protocol for IPE for flexion instability after primary TKA. METHODS: Between 2009 and 2016, 418 revision TKAs were performed by the senior author. Patients were considered for IPE if they demonstrated excellent radiographic alignment and component positioning preoperatively. Intraoperatively, if component rotation, sizing, and fixation were all excellent and the flexion and extension gaps could be balanced, then IPE was performed. We retrospectively reviewed 31 knees in 30 patients who were treated with IPE specifically for flexion instability after primary TKA. The mean follow-up was 41 months (range, 24-85 months). Nineteen knees were cruciate-retaining TKAs revised to a more constrained "deep-dish" ultracongruent insert, and 12 posterior-stabilized TKAs were revised to thicker posterior-stabilized insert. RESULTS: At a mean follow-up of 41 months, only 2 of 31 knees (6.5%) required subsequent component revision surgery for recurrent instability. Knee Society pain scores improved from 70 preoperatively to 86 postoperatively (P < .0001), and function scores improved from 39 points preoperatively to 44 points postoperatively (P = .015). CONCLUSION: IPE for flexion instability in carefully selected patients was successful in over 90% of patients for a mean follow-up of 41 months. Pain and function scores significantly improved. Longer-term follow-up is necessary to determine whether these results are durable over time.

Risk Factors for Revision Surgery Following Revision Total Knee Arthroplasty Using a Hinged Knee Prosthesis for Septic and Aseptic Indications.

INTRODUCTION: The use of hinged knee replacements (HKRs) for limb salvage is a popular option for revision total knee arthroplasty (RTKA). Although recent literature focuses on the outcomes of HKR for septic and aseptic RTKAs, little is reported on the risk factors of returning to the operating room. The purpose of this study was to evaluate risk factors of revision surgery and revision after receiving HKR for septic versus aseptic etiology. METHODS: A multicenter, retrospective review was conducted on consecutive patients who received HKR from January 2010 to February 2020 with a minimum follow-up of 2 years. Patients were separated into two groups: septic and aseptic RTKAs. Demographic, comorbidity, perioperative, postoperative, and survivorship data were collected and compared between groups. Cox hazard regression was used to identify risk factors associated with revision surgery and revision. RESULTS: One-hundred fifty patients were included. Eighty-five patients received HKR because of prior infection, and 65 received HKR for aseptic revision. A larger proportion of septic RTKA returned to the OR versus aseptic RTKA (46% vs 25%, P = 0.01). Survival curves revealed superior revision surgery-free survival favoring the aseptic group ( P = 0.002). Regression analysis revealed that HKR with concomitant flap reconstruction was associated with a three-fold increased risk of revision surgery ( P < 0.0001). DISCUSSION: HKR implantation for aseptic revision is more reliable with a lower revision surgery rate. Concomitant flap reconstruction increased the risk of revision surgery, regardless of indication for RTKA using HKR. Although surgeons must educate patients about these risk factors, HKR remains a successful treatment option for RTKA when indicated. LEVEL OF EVIDENCE: prognostic, level III evidence.

Extensor Mechanism Reconstruction After Total Knee Arthroplasty with Allograft Versus Synthetic Mesh: A Multicenter Retrospective Cohort.

INTRODUCTION: Patellar and quadriceps tendon ruptures after total knee arthroplasty (TKA) have historically poor outcomes. To date, there is no consensus for optimal treatment. The purpose of this study is to directly compare clinical outcomes and survivorship between allograft versus synthetic mesh for reconstruction of native extensor mechanism (EM) rupture after TKA. METHODS: A multicenter, retrospective review identifying consecutive TKA patients operated between December 2009 to November 2019 was conducted. Patients aged ≥ 45 years old with native EM disruption treated with either allograft or synthetic mesh with minimum 2 year follow-up were included. Demographic information, injury mechanism, range of motion, surgical time, revision surgeries, and postoperative Knee Injury and Osteoarthritis Outcome Scores (KOOS Jr.) were collected. Student t-tests and Fisher exact tests were used to compare the demographic data between groups. The Kaplan-Meier survival curve method was used to determine the survivorship as treatment failure was defined as postoperative EM lag >30° or revision surgery. Survival curves were compared using the log-rank test. Univariate Cox proportional hazard regression identified risk factors associated with treatment failure. RESULTS: Twenty patients underwent EM reconstruction using allograft versus 35 with synthetic mesh. Both groups had similar demographics and an average follow-up time of 3.5 years (P = 0.98). Patients treated with allograft had significantly greater postoperative flexion than patients treated with mesh (99.4 ± 9.5 allograft versus 92.6 ± 13.6 synthetic mesh, P = 0.04). Otherwise, there was no difference in postoperative outcomes between the two groups in average KOOS Jr. (P = 0.29), extensor lag (P = 0.15), graft failure (P = 0.71), revision surgery rates (P = 0.81), surgical time (P = 0.42), or ambulatory status (P = 0.34) at the most recent follow-up. Survival curve comparison also yielded no difference at up to 5-year follow-up (P = 0.48). DISCUSSION AND CONCLUSION: Our findings suggest that reconstruction with allograft or synthetic mesh leads to similar clinical outcomes with good survivorship. Future studies, including larger randomized control trials, are required to determine the superior reconstruction method for this injury. LEVEL OF EVIDENCE: III.