Showing papers by "Arlen D. Hanssen published in 2009"
TL;DR: A systematic review of the literature revealed failure to eradicate infection in 10 of 13 patients managed with a similar protocol, and the total success rate of ODCR in acute periprosthetic MRSA knee infection was 18%.
Abstract: The success of open irrigation and debridement with component retention (ODCR) for acute periprosthetic knee joint infection varies widely. The species and virulence of the infecting organism have been shown to influence outcome. This multicenter, retrospective study identified 19 cases of acute periprosthetic methicillin-resistant Staphylococcus aureus (MRSA) knee infections managed by ODCR and at least 4 weeks of postoperative intravenous vancomycin therapy. At minimum follow-up of 2 years, the treatment failed to eradicate the infection in 16 cases (84% failure rate). Of those 16 failures, 13 patients required a 2-stage exchange arthroplasty, 2 patients required repeat incision and debridement with antibiotic suppression, and 1 patient died of MRSA sepsis. In addition, a systematic review of the literature revealed failure to eradicate infection in 10 of 13 patients managed with a similar protocol. The total success rate of ODCR in acute periprosthetic MRSA knee infection was 18%.
212 citations
TL;DR: Patients requiring early surgical treatment for wound-healing problems after primary total knee arthroplasty are at significantly increased risk for further complications, including deep infection and/or major subsequent surgery, specifically, resection arthroPLasty, amputation, or muscle flap coverage.
Abstract: Background: Wound-healing problems are a known complication after primary total knee arthroplasty. However, little is known about the clinical outcomes for patients who require surgical treatment of these early wound-healing problems. The purpose of the present study was to determine the incidence, risk factors, and long-term sequelae of early wound complications requiring surgical treatment.
Methods: The total joint registry at our institution was reviewed for the period from 1981 to 2004. All knees with early wound complications necessitating surgical treatment within thirty days after the index total knee arthroplasty were identified. The cumulative probabilities for the later development of deep infection and major subsequent surgery were determined. A case-control study in which these patients were matched with an equal number of controls was performed to attempt to identify risk factors for the development of early superficial wound complications requiring surgical intervention.
Results: From 1981 to 2004, 17,784 primary total knee arthroplasties were performed at our institution. Fifty-nine knees were identified as having early wound complications necessitating surgical treatment within thirty days after the index arthroplasty, for a rate of return to surgery of 0.33%. For knees with early surgical treatment of wound complications, the two-year cumulative probabilities of major subsequent surgery (component resection, muscle flap coverage, or amputation) and deep infection were 5.3% and 6.0%, respectively. In contrast, for knees without early surgical intervention for the treatment of wound complications, the two-year cumulative probabilities were 0.6% and 0.8%, respectively (p < 0.001 for both comparisons). A history of diabetes mellitus was identified as being significantly associated with the development of early wound complications requiring surgical intervention.
Conclusions: Patients requiring early surgical treatment for wound-healing problems after primary total knee arthroplasty are at significantly increased risk for further complications, including deep infection and/or major subsequent surgery, specifically, resection arthroplasty, amputation, or muscle flap coverage. These results emphasize the importance of obtaining primary wound-healing after total knee arthroplasty.
Level of Evidence: Prognostic Level III. See Instructions to Authors for a complete description of levels of evidence.
203 citations
TL;DR: Two-stage exchange arthroplasty is the most common mode of surgical treatment in North America and relies on removal of all foreign material and insertion of an antibiotic-impregnated cement spacer for the purpose of delivering high doses of antibiotics locally in the interval of time between the resection arthroPLasty and subsequent reimplantation.
Abstract: Periprosthetic joint infection is one of the most dreaded and complex complications of total joint arthroplasty. Periprosthetic joint infection is now the major cause of failure following total knee arthroplasty1 and the third most common cause of failure following total hip arthroplasty2. It is estimated that the prevalence of periprosthetic joint infection may be on the rise3. A wide variety of pathogens are known to cause periprosthetic joint infection, with the majority of infections being caused by gram-positive bacteria, especially staphylococcal species4,5. The treatment of a confirmed periprosthetic joint infection often includes the need for surgical intervention, and two-stage exchange arthroplasty is the most common mode of surgical treatment in North America. Two-stage exchange arthroplasty relies on removal of all foreign material and insertion of an antibiotic-impregnated cement spacer for the purpose of delivering high doses of antibiotics locally in the interval of time between the resection arthroplasty and subsequent reimplantation.
Periprosthetic infection with fungi, although rare, represents a diagnostic and therapeutic challenge to which clear guidelines have not yet been established. It is not known if the protocol for treatment of a bacterial periprosthetic joint infection can also be applied in the same manner to fungal infections. Patients with fungal periprosthetic joint infection are believed to be a different type of host with decreased cellular immunity, mostly due to an underlying cause of immunosuppression, such as malignant disease, drug therapies (antineoplastic agents, corticosteroids, or immunosuppressive drugs), overuse or inappropriate use of antibiotics, and indwelling catheters (urinary or parenteral hyperalimentation). Other factors, such as diabetes, tuberculosis, intravenous drug use, and acquired immunosuppressive disease, are associated with an increased frequency of mycotic infection6. The lack of reliable antifungal medications for systemic and, in particular, local delivery poses a real challenge …
166 citations
TL;DR: The data support the selective use of structural allograft for large cavitary defects encountered during TKA, however, the rates of complications and reoperations suggest efforts to improve results or develop more durable alternative methods are warranted for these challenging reconstructions.
Abstract: Management of large bone defects in total knee arthroplasty (TKA) usually has involved modular prostheses with metal augments, structural allografts, and megaprostheses. We retrospectively reviewed the outcome of treatment of major bone defects for 74 patients (79 knees) who had revision TKAs with structural allografts; nine patients were lost to followup before 5 years, leaving 65 patients (70 knees, or 88%) followed for a minimum of 5 years or until revision or death. Medical records, radiographs, patient surveys, and correspondence were used for all data. Sixteen patients (22.8%) had failed reconstructions and underwent additional revision surgery; eight of the 16 were secondary to allograft failure, three were secondary to failure of a component not supported by allograft, and five were secondary to infection. In patients not requiring revision surgery, the Knee Society score improved from 49 preoperatively to 87 postoperatively. We observed revision-free survival of 80.7% (95% confidence interval, 71.7–90.8) at 5 years and 75.9% (95% confidence interval, 65.6–87.8) at 10 years. Our data support the selective use of structural allograft for large cavitary defects encountered during TKA. However, the rates of complications and reoperations suggest efforts to improve results or develop more durable alternative methods are warranted for these challenging reconstructions. Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
124 citations
TL;DR: Based on results, the method of fixation used for the femoral component during two-stage reimplantation surgery should be based on the surgeon’s preference for fixation combined with the assessment of femoral bone stock.
Abstract: Most reports on two-stage reimplantation have focused on the short-term cure rate of infection, but little is known about long-term reinfection-free survival or mechanical durability. We retrospectively reviewed 168 patients (169 hips) with infected arthroplasty, all of whom had two-stage reimplantation for the treatment of an infected total hip arthroplasty between 1988 and 1998. In the second stage, the femoral component was fixed with antibiotic-loaded bone cement in 121 hips; the remaining femoral components and all acetabular components were uncemented. The minimum followup time was 2 years (mean, 7 years; range, 2–16 years). At most recent followup, 12 hips (7.1%) were reoperated on for reinfection and 13 hips (7.7%) were revised for aseptic loosening or osteolysis. Apparently aseptic loosening occurred on one or both sides of the joint in 24 hips (14.2%). The 10-year survivals free of reinfection and mechanical failure were 87.5% and 75.2% respectively. Nineteen hips dislocated and eight underwent revision surgery for instability. The method of femoral component fixation, either with or without cement, did not correlate with risk of infection, loosening, or mechanical failure. Based on these results, the method of fixation used for the femoral component during two-stage reimplantation surgery should be based on the surgeon’s preference for fixation combined with the assessment of femoral bone stock.
113 citations
TL;DR: Two patients with failure of metal-on-metal implants who presented with signs that mimicked a deep-seated hip infection are described, which has not been reported previously.
Abstract: New-generation metal-on-metal bearings made from cobalt-chromium alloys for use in total hip arthroplasty are now being utilized worldwide. A hypersensitivity reaction to a metal-on-metal bearing is a rare but reported complication and is thought to be a novel mode of failure of these implants1,2. These reactions were initially observed in patients with first-generation bearings and are now being reported in association with the second-generation metal-on-metal bearings currently in use3-5. Characteristic histological changes in the periprosthetic tissues obtained during revision surgical procedures in these patients have suggested the development of an immunological response2,6.
Reports have suggested that the possibility of such a reaction should be considered when a patient presents with persistent, or the early reappearance of, preoperative pain symptoms, including a marked joint effusion, and the development of early osteolysis or radiolucent lines in the absence of infection2,7. Fever and elevated serum levels of inflammatory markers have routinely been reported to not occur in these patients.
We describe two patients with failure of metal-on-metal implants who presented with signs that mimicked a deep-seated hip infection. To our knowledge, this has not been reported previously. Although the two cases were similar in terms of the clinical presentation, each ultimately represented a different pathological condition and etiology.
The patients were informed that data concerning the case would be submitted for publication, and they consented.
Case 1. A fifty-three-year-old man presented to our emergency department because of bilateral hip pain and episodes of low-grade fever three years after a bilateral metal-on-metal total hip arthroplasty. A Pinnacle acetabular component with a cobalt-chromium metal bearing surface (DePuy Orthopaedics, Warsaw, Indiana) had been implanted bilaterally. The pain had been present since the surgery, and the patient had never stopped …
108 citations
TL;DR: At the time of short-term follow-up, the porous tantalum metaphyseal tibial cones effectively provided structural support for the tibia implants in this series, and the potential for long-term biologic fixation may provide durability for these tibIAL reconstructions.
Abstract: BACKGROUND: The best treatment method for large tibial bone defects during revision knee replacement has not been established The purpose of this study was to determine the initial results obtained with a unique reconstructive implant, the porous tantalum metaphyseal cone, designed as an alternative treatment for severe tibial bone loss following total knee arthroplasty METHODS: Porous tantalum metaphyseal cones were implanted during fifteen revision total knee replacements in eight women and seven men who had an average age of 681 years at the time of the procedure The patients had had an average of 35 prior total knee replacements According to the Anderson Orthopaedic Research Institute bone defect classification, eight knees had a Type-3 defect and seven knees had a Type-2B bone defect All patients were followed clinically and radiographically RESULTS: The patients were followed for an average of thirty-four months (range, twenty-four to forty-seven months) Overall, the average Knee Society clinical scores improved from 52 points preoperatively to 85 points at the time of the final follow-up At the final follow-up evaluation, all fifteen porous metaphyseal cones showed evidence of osseointegration with reactive osseous trabeculation at points of contact with the tibia There was no evidence of loosening or migration of any of these tibial reconstructions at the time of final follow-up CONCLUSIONS: At the time of short-term follow-up, the porous tantalum metaphyseal tibial cones effectively provided structural support for the tibial implants in this series The potential for long-term biologic fixation may provide durability for these tibial reconstructions Long-term follow-up and comparison with alternative reconstructive techniques will be required to evaluate the true effectiveness of this treatment approach LEVEL OF EVIDENCE: Therapeutic Level IV See Instructions to Authors for a complete description of levels of evidence
84 citations
TL;DR: It is hypothesized TKAs performed after infected tibial plateau fractures would have an even higher complication rate when compared with noninfected tibials, and previously infected knees were 4.1 times more likely to require additional procedures compared with knees with no previous infection.
Abstract: Total knee arthroplasty performed after tibial plateau fracture has a known high rate of complications. We hypothesized TKAs performed after infected tibial plateau fractures would have an even higher complication rate when compared with noninfected tibial plateau fractures. In a matched case-control study, we retrospectively reviewed 19 patients who underwent primary TKAs after infected tibial plateau fractures between 1971 and 2005. The mean time from the most recent infection to arthroplasty was 5.6 years. The minimum clinical followup after TKA was 2 years (mean, 6.4 years; range, 2–15.1 years). Case patients were matched for age, gender, and arthroplasty year with 19 control subjects who underwent TKAs for tibial plateau fractures with no history of infections. After surgery, the Knee Society scores for the study group improved from 45 to 63 for pain and from 37 to 63 for function. Ten case patients (53%) sustained complications, including surgery for wound breakdown (three), manipulation (one), aseptic loosening (two), definitive resection arthroplasty (two), and above-knee amputation (two). Recurrent infections occurred in five patients (26%) at a mean of 1.1 years. Previously infected knees were 4.1 times more likely to require additional procedures compared with knees with no previous infection. Level of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
33 citations
TL;DR: The hypothesis that the two-incision technique for total hipArthroplasty would substantially improve the short-term recovery after total hip arthroplastic surgery compared with the mini-posterior-incison technique was not proved; instead, the patients managed with themini-postior- incision technique had the quicker recovery.
Abstract: BACKGROUND: It has been claimed that the two-incision total hip arthroplasty technique provides quicker recovery than other methods do. To date, however, there have been no studies that have directly compared the two-incision technique with another method in similar groups of patients managed with the same advanced anesthetic and rehabilitation protocol. We posed the hypothesis that patients managed with two-incision total hip arthroplasty would recover faster than those managed with mini-posterior-incision total hip arthroplasty and designed a randomized controlled trial specifically (1) to determine if patients recovered faster after two-incision total hip arthroplasty than after mini-posterior-incision total hip arthroplasty as measured on the basis of the attainment of functional milestones that reflect activities of daily living, (2) to determine if the general health outcome after two-incision total hip arthroplasty was better than that after mini-posterior-incision total hip arthroplasty as measured with Short Form-12 (SF-12) scores, and (3) to evaluate the surgical complexity of the two procedures on the basis of the operative time and the prevalence of early complications.
METHODS: Between November 2004 and January 2006, seventy-two patients undergoing total hip arthroplasty were randomized to two treatment groups: one group was managed with the two-incision technique, and the other group was managed with the mini-posterior-incision technique. The two-incision group comprised thirty-six patients (twenty men and sixteen women) with a mean age of sixty-seven years and a mean body mass index of 28.7. The mini-posterior-incision group comprised thirty-six patients (twenty men and sixteen women) with a mean age of sixty-six years and a mean body mass index of 30.2. All patients received the same design of uncemented acetabular and femoral components and were managed with the same comprehensive perioperative pain management and rapid rehabilitation protocol. Operative times and complications were recorded. At two months and one year, all patients were assessed with regard to functional outcome and general health outcome.
RESULTS: The patients in the two-incision group recovered more slowly than did those in the mini-posterior-incision group as measured on the basis of the mean time to discontinue a walker or crutches, to discontinue all walking aids, and to return to normal daily activities. The clinical outcome as measured on the basis of the SF-12 scores was similar at both two months and one year postoperatively. The two-incision total hip arthroplasty was a more complex surgical procedure, with a mean operative time that was twenty-four minutes longer; however, the rate of complications (2.8%; one of thirty-six) was the same in the two groups.
CONCLUSIONS: Our hypothesis that the two-incision technique for total hip arthroplasty would substantially improve the short-term recovery after total hip arthroplasty compared with the mini-posterior-incision technique was not proved; instead, the patients managed with the mini-posterior-incision technique had the quicker recovery.
LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.
28 citations
TL;DR: A 59-year-old man with Waldenstrom’s macroglobulinemia and active alcohol use who presented with bilateral knee pain 5 years after a bilateral staged TKA is reported, indicating C canimorsus may be an unrecognized cause of culture-negative joint arthroplasty infections.
Abstract: We report the case of a 59-year-old man with Waldenstrom’s macroglobulinemia and active alcohol use who presented with bilateral knee pain 5 years after a bilateral staged TKA. Cultures of synovial fluid and periprosthetic tissue specimens from both knees yielded, after prolonged anaerobic incubation, a catalase- and oxidase-positive gram-negative bacillus, which was identified as Capnocytophaga canimorsus by 16S ribosomal RNA PCR analysis. C canimorsus, an organism that is commonly found in dog and cat saliva, is a rare cause of various infections in immunocompromised and healthy individuals. However, a review of the medical literature indicates C canimorsus has not been reported previously to cause infection after joint arthroplasty. The patient was immunocompromised by cytotoxic chemotherapy, corticosteroids, and alcohol use. The patient was managed successfully with bilateral two-stage exchange and 6 weeks of intravenous ertapenem therapy. Because of its fastidious and slow-growing characteristics, C canimorsus may be an unrecognized cause of culture-negative joint arthroplasty infections, especially in cases when dog and cat exposure is evident in the clinical history.
23 citations
TL;DR: This course will help you to understand the distinction between aseptic and septic failure on the basis of the preoperative evaluation and the etiology of osteolysis in total knee arthroplasty.
Abstract: • Understand the appropriate methods of evaluating the failed total knee arthroplasty • Understand the distinction between aseptic and septic failure on the basis of the preoperative evaluation • Understand the etiology of osteolysis in total knee arthroplasty.
TL;DR: The advantages and disadvantages of the different prophylactic agents that can be used to prevent deep venous thrombosis after total hip and knee arthroplasty are defined.
Abstract: • Understand the similarities and differences between the various guidelines for the prevention of deep venous thrombosis after total joint arthroplasty • Define the advantages and disadvantages of the different prophylactic agents that can be used to prevent deep venous thrombosis after total hip and knee arthroplasty.
TL;DR: This course helps you to understand methods of surgical approach that allow component removal and insertion in revision total hip arthroplasty and to understand implant reinsertion techniques.
Abstract: • Learn methods of surgical approach that allow component removal and insertion in revision total hip arthroplasty • Understand implant reinsertion techniques.
TL;DR: The indications, surgical technique, and available clinical results for this promising reconstructive strategy, which uses the mechanical and biologic benefits of highly porous metal technology, are detailed.
Abstract: Severe bone loss may be encountered in a multitude of scenarios during revision total knee arthroplasty, such as osteolysis and component subsidence, and is a challenge for the joint replacement surgeon. The appropriate reconstructive techniques are dictated by the quantity and location of the tibia
TL;DR: The systematic approach to evaluate extrinsic versus intrinsic factors of a patient with a painful hip after arthroplasty and the evaluation and treatment of the several causes of pain associated with metal-on-metal hip replacements are described.
Abstract: • Describe the systematic approach to evaluate extrinsic versus intrinsic factors of a patient with a painful hip after arthroplasty • Describe the evaluation and treatment of the several causes of pain associated with metal-on-metal hip replacements.
01 Jan 2009