RESUMO
BACKGROUND: Periprosthetic infection (PJI) with concomitant extensor mechanism disruption (EMD) and soft-tissue defect-hereinafter termed the "Terrible Triad"-is a devastating complication following total knee arthroplasty. The purpose of this study was to define the surgical and clinical outcomes following management of a cohort of patients who have the Terrible Triad. METHODS: From 2000 to 2022, 127 patients underwent operative management for PJI alone, 25 for PJI with soft-tissue defects (defined as defects requiring flap reconstruction or being a factor contributing to the decision of performing above-knee amputation or arthrodesis), 14 for PJI with EMD, and 22 for the Terrible Triad. A composite outcome of infection status, range of motion, extensor lag, and ambulatory status at final follow-up was used to compare the proportion of patients in each group with a favorable overall knee outcome. Differences between groups were determined using one-way analyses of variance with post hoc Tukey's tests and Pearson's Chi-square tests or Fisher's exact tests with post hoc Bonferroni adjustments, where applicable. Odds ratios (OR) were calculated for comparison of the overall knee outcome between groups. A Kaplan-Meier survival analysis for patient mortality was performed. RESULTS: The mean follow-up was 8.4 years and similar between groups (P = .064). Patients who had the Terrible Triad had a 45.5% incidence of above-knee amputation, or arthrodesis, and an 86.4% incidence of an unfavorable outcome. Compared to patients in the PJI group, patients in the PJI who had a soft-tissue defect (OR = 5.8, 95% CI [confidence interval] 2.2 to 15.7), PJI with EMD (OR = 3.7, 95%CI 1.0 to 12.9), and Terrible Triad groups (OR = 11.6, 95% CI 3.3 to 41.5) showed higher odds of an unfavorable knee outcome. CONCLUSIONS: This study demonstrates that the total knee arthroplasty Terrible Triad is a dreaded diagnosis with poor outcomes. Clinicians and patients might consider early treatment with amputation or arthrodesis. LEVEL OF EVIDENCE: III.
RESUMO
BACKGROUND: Extended trochanteric osteotomy (ETO) has long been used in 2-stage revision surgeries of the hip, for both aseptic and septic indications. The purpose of this systematic review is to summarize the cumulative occurrence rates of the clinical and functional outcomes associated with the use of ETO in 2-stage revision total hip arthroplasty for periprosthetic joint infection. METHODS: PubMed/MEDLINE and the Cochrane Database of Systematic Reviews databases were searched for articles published from January 1980 to January 2022 using the following keywords: "extended" AND "trochanteric" AND "osteotomy" AND "infection." Cumulative occurrence rates of outcomes and complications were calculated. A fixed-effects model and a 95% CI were applied. A P value of .05 was considered the significance threshold. RESULTS: Nine studies were in full compliance with the inclusion criteria, with a total population size across all studies of 378. Union and infection eradication rates among studies were 95.1% (95% CI, 92.7-97.1, P = .018) and 94.0% (95% CI, 91.1-96.4, P = .089), respectively. Postoperation complications occurred in 15.34% of patients (95% CI, 10.34-21.22, P = .066). Occurrence rates for stem subsidence, dislocation, and femoral fractures were 6.2% (95% CI, 3.3-9.9, P = .187), 7.6% (95% CI, 4.8-10.9, P = .075), and 9.1% (95% CI, 5.8-13, P = .106), respectively. CONCLUSION: With high rates of union and infection eradication, and low rates of postoperation complications, this study concludes the use of ETO in performing 2-stage revision total hip arthroplasty for the septic hip to be effective and safe.