Knee arthrodesis in the treatment of failed total knee replacement.

Twenty-six primary arthrodeses and 6 repeat arthrodeses were done for a total of 32 arthrodesis procedures in 26 patients, with followup from 2 to 10 years (mean, 4 years). The indications for arthrodesis were septic failure in 18 patients and aseptic loosening in 8 patients. Thirteen arthrodeses were done using external fixators, and 12 arthrodeses were done using a closed fluted intramedullary nail for fixation (1 arthrodesis was done with a custom proximal and distal interlocked nail). In addition, 6 repeat arthrodeses with intramedullary nail fixation were done for treatment of nonunions after external fixation. Five (38%) of the 13 patients who underwent arthrodesis with an external fixator had clinical and radiographic union at a mean of 5 months. All 13 patients with primary intramedullary nail arthrodesis achieved union. The knees of the 6 patients with nonunions after external fixation that were treated with repeat intramedullary nail arthrodesis achieved union. Patients with septic failure had staged debridements before intramedullary nail arthrodesis. Intramedullary nail arthrodesis can be done safely in patients with sepsis as a staged procedure. Knee arthrodesis using intramedullary nail fixation gives a much higher union rate than does external fixation and is associated with fewer complications.

Long-term outcome of 42 knees with chronic infection after total knee arthroplasty.

The outcome of treatment in 40 patients (42 knees) with chronic infections after total knee arthroplasty was reviewed. Eighteen knees were treated with a 2-stage reimplantation. Sixteen of these 18 knees were treated with antibiotic-containing beads between debridement and reimplantation, and 7 of these were also treated with antibiotics in the cement at reimplantation. Infection did not recur in any of these 18 knees. Clinically, the 2-stage reimplantation group averaged a score of 90 points on the Knee Society Clinical Rating System. Average function score was 86.5 points, with average range of motion from 2 degrees to 109 degrees. Sixteen knees were treated with an arthrodesis: 9 with a 1-stage technique with a uniplanar external fixator and 7 with a 2-stage technique with intramedullary nail internal fixation. Infection did not recur in 6 of 9 knees treated with the 1-stage technique, but only 2 had a solid arthrodesis. All 7 treated with the 2-stage intramedullary nail technique had no recurrence of infection and achieved a solid fusion. Reimplantation or arthrodesis was not attempted in 8 other knees because of recalcitrant infection, vascular complications, or medical infirmity. Of the 42 knees, 11 (26%) had a severely morbid outcome. The infection could not be eradicated in 7 knees: 6 required amputation and 1 had a solid fusion but chronic drainage. In 3 knees, the infection was cured but resection arthroplasties were required, and in 1 patient an amputation was needed as a result of an intraoperative vascular complication.

Structural bone-grafting for early atraumatic avascular necrosis of the femoral head.

Between 1970 and 1987, nineteen patients, thirty-one to fifty-five years old, had twenty core-decompression procedures with corticocancellous bone-grafting for Stage-I or II atraumatic avascular necrosis of the femoral head. A tibial autogenous graft was used in three hips; a fibular autogenous graft, in seven hips; and a fibular allograft, in ten hips. Treatment was considered to have failed when there was clinical or roentgenographic evidence of progression of the necrosis. Eighteen patients who had a minimum follow-up of two years (average, eight years; range, two to nineteen years) were asymptomatic, with no evidence of progression of the necrosis or collapse of the affected segment. In two hips, the necrotic segment of the femoral head collapsed within one year after the operation, and a replacement arthroplasty was carried out.

Infected total knee arthroplasty. A protocol for management.

All cases of deep wound infection following total knee arthroplasty presented to the senior author between April 1977 and February 1984 were reviewed in an attempt to develop a protocol for salvaging a functional, painless knee. Two of 23 knees were eliminated because of extensive soft tissue loss. The remaining 21 infected total knee arthroplasties were analyzed. A determination of the chronicity of the infection and an evaluation of any radiolucencies were essential in determining the type of treatment used. Three distinct methods of surgical management were identified: radical debridement with retention of the initial prosthesis, one-stage reimplantation, and two-stage reimplantation. A functional uninfected total knee arthroplasty was salvaged in 18 of 21 patients, with an average follow-up period of 46 months.

Fibrous dysplasia of the femoral neck. Treatment by cortical bone-grafting.

Fibrous dysplasia of the femoral neck is difficult to treat. In a series of fifteen young patients, ten had a monostotic lesion and five, the polyostotic form of the disease. Twelve patients were first seen with a fatigue fracture. Grafts of cortical bone were used. The objectives of relief of pain, union of the fracture, and prevention of deformity were achieved in all fifteen patients. Two patients required a repeat procedure. None of the patients had important deformity of the femoral neck, and none needed an osteotomy.