Both Knee Re-revision Operations with Different Types of Endoprosthesis after Septic Complications

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1 DOI: /v ACTA CHIRURGICA LATVIENSIS 2011 (11) CASE REPORT Both Knee Re-revision Operations with Different Types of Endoprosthesis after Septic Complications Silvestris Zebolds*/***, Valdis Goncars*, Ints Zommers**, Konstantins Kalnberzs*/**. * Hospital of Traumatology and Orthopaedics, Riga, Latvia ** University of Latvia, Riga, Latvia *** Riga Stradins University, Riga, Latvia Summary We report about the patient who underwent seven replacement operations in both knees during twelve years period. Different types of implants were used due to clinical situation and septic complications. Key words: knee joint osteoarthritis, total knee joint replacement, re-revision, septic loosening, rotating-hinge. AIM OF THE DEMONSTRATION The aim of the article is to demonstrate severe knee joint osteoarthritis patient s treatment possibilities with different types of knee endoprotheses. CASE REPORT Seventy-six years old male patient with severe osteoarthritis suffered from pain in both knees from In 1990 pain in the right knee became permanent. Patient complained about limping and increasing deformity. Preoperative treatment included nonsteroidal antiinflammatory drugs, physiotherapy, intraarticular injections of dexamethason. When conservative treatment became non-effective we decided to perform total knee replacement (TKR) of right knee joint. During first TKR in November 21, 1995 we applied posterior cruciate ligament retaining knee resurfacing prosthesis (SKI Waldemar Link GmbH Hamburg) (Fig. Nr.1). 14 months later (January 21, 1997) patient underwent TKR of the left knee joint with cruciate ligaments sacrificing knee resurfacing prosthesis (SKI Waldemar Link GmbH Hamburg) due to clinical signs of the damage of both cruciate ligaments (Fig. Nr.2). Both endoprothesis were fixed with bone cement. In post operative period patient was free of pain and his activity level was pretty high (patient took part in a different kind of sport activities like volleyball and swimming). In the beginning of 2001 patient started to complain about pain, swelling and also some limitation of movements in the left knee. Radiographs showed asymmetry of joint space and radiolucent line between the implant and bone (Fig. Nr.3). 4 years and 10 month after primary TKR of left knee revision operation was performed (Fig. Nr.4). To gain stable and painless knee we used femoral and tibial components of revision endoprosthesis with prolonged polished stems and joint surfaces with stabilized tibial insert with posterior peg (Johnson&Johnson TC3). The bone defects were filled with bone allografts. We used bone cement with antibiotic (Gentamicin) for fixation of femoral and tibial metaphyseal parts. There was found Staphylococcus xylosus in the microbiological samples taken during operation. Despite that the wound healed primarily. Postoperatively the patient got parenteral antibiotics for 3 weeks and then oral antibiotics for 1 month. From 2004 pain and swelling appeared in the right knee. 8 years and 2 months after primary operation, the revision TKR was performed with similar implants as in the left knee (Johnson&Johnson TC3) (Fig. Nr.5,6). The allografting and bone cement with antibiotic (Gentamicin) were used. Both of removed implants were with massive polyethylene wear on the joint surfaces. From 2007 patient had complaints about pain, swelling and limitation of movements in the left knee again, but no microbes were found in the joint fluid sample before the operation. The re-revision operation of left knee joint was done with rotating-hinge endoprosthesis (Waldemar Link company s Endo-model) (Fig. Nr.7,8) 11 years after primary TKR. Both femoral and tibial components (including stems) of endoprosthesis were fixed with antibiotic (Gentamicin) loaded bone cement. During operation no microbes from tissue samples were found. (Fig. Nr.11,12). Half a year after last operation patient had no pain and satisfactory range of movements (flexion 95 degrees, full extension) in both knees. Patient could walk without walking aids and any limp. DISCUSSION TKR have had excellent results, with multiple studies showing survival rates greater than 90% at followup times of 10 to 20 years. 1-6 Development of the knee replacement operations with different types of endoprosthesis still continues. Numerous prostheses have been developed to improve the durability and function of these procedures. However, there has been controversy regarding whether the posterior cruciate ligament (PCL) should be retained or removed during procedure

2 The main cause for primary implant failure was the wear of polyethylene surface. (Fig. Nr.9.10.). About twenty years ago one of the philosophies was to use cruciate ligaments retaining knee resurfacing prosthesis. We also used this type of prosthesis in the right knee of our patient for primary TKR. This concept is till now very popular for young and high demanding patients 7, however the risk of wear is higher than in cruciate ligaments sacrificing endoprosthesis due to not perfect balanced ligaments. The primary operation of our patient was performed when sophisticated instruments for the alignment of prosthesis components were not available. Now the further development of instruments gives us possibility to avoid alignment failures. The quality of materials for joint surfaces have also improved like in vacuum sterilised polyethylene what we used later. During the second revision of left knee the PCL sacrificing endoprosthesis was used. The concept of knee joint revision with prolonged polished femoral and tibial stems is very popular, but our experience shows also good results with fully cemented long stem implants like rotating-hinge enoprosthesis (Endo-model). This type of prosthesis has advantages for difficult revision operations and re-revision cases with collateral ligament insufficiency and bone loss especially after septic cases. under passive and weight-bearing conditions. J Arthroplasty. 2005;20: Frank R. Kolisek, M.D., Michael S. McGrath, M.D., David R. Marker, B.S., Nenette Jessup, M.P.H., Thorsten M. Seyler, M.D., Michael A. Mont, M.D., and C. Lowry Barnes, M.D. Posterior-stabilizided versus posterior cruciate ligament-retaining total knee arthroplasty. The Iowa Orthopaedic Journal 2009; 29: Address: Konstantins Kalnberzs Hospital of Traumatology and Orthopaedics, Riga, Duntes street 22, LV-1005, Latvia zommers@inbox.lv Conflict of interest: None REFERENCES 1. Attar FG, Khaw FM, Kirk LM, Gregg PJ. Survivorship analysis at 15 years of cemented pressfit condylar total knee arthroplasty. J Arthroplasty. 2008;23: Baker PN, Khaw FM, Kirk LM, Esler CN, Gregg PJ. Arandomised controlled trial of cemented versus cementless press-fit condylar total knee replacement: 15-year survival analysis. J Bone Joint Surg Br. 2007;89: Khaw FM, Kirk LM, Morris RW, Gregg PJ. A randomised, controlled trial of cemented versus cementless press-fit condylar total knee replacement. Ten-year survival analysis. J Bone Joint Surg Br. 2002;84: Langlais F, Belot N, Ropars M, Lambotte JC, Thomazeau H. The long-term results of press-fit cemented stems in total knee prostheses. J Bone Joint Surg Br. 2006;88: Rodricks DJ, Patil S, Pulido P, Colwell CW., Jr Press-fit condylar design total knee arthroplasty. Fourteen to seventeen-year follow-up. J Bone Joint Surg Am. 2007;89: Vessely MB, Whaley AL, Harmsen WS, Schleck CD, Berry DJ. The chitranjan ranawat award: Long-term survivorship and failure modes of 1000 cemented condylar total knee arthroplasties. Clin Orthop Relat Res. 2006;452: Yoshiya S, Matsui N, Komistek RD, Dennis DA, Mahfouz M, Kurosaka M. In vivo kinematic comparison of posterior cruciate-retaining and posterior stabilized total knee arthroplasties Fig 1. Primary TKR in right knee due to knee joint osteoarthritis (1995) with PCL retaining endoprosthesis. Fig 2. Primary TKR in left knee due to knee joint osteoarthritis (1997) with PCL sacrificing endoprosthesis. 168

3 Fig 3. Septic loosening of both components in left knee 4 years and ten months after primary TKR. Fig 4. In revision TKR (J&J) in left knee due to septic loosening of both components. Fig 5. Aseptic loosening of both right knee prosthesis components 8 years after operation. Fig 6. In revision TKR (J&J) in right knee with long stemmed endoprosthesis. 169

4 Fig 8. In re-revision s second step - TKR by rotating-hinge endoprosthesis. Fig. 7. Septic loosening 6 years after the first revision in left knee. Fig 9. Removed endoprosthesis due to polyethilene wear. Fig 10. Removed endoprosthesis due to polyethilene wear. 170

5 Fig 12. Full extension of both knees after last rerevision. Fig 11. Flexion (105 ) of both knees after last rerevision. 171