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Researchers recommend knee fusion to treat infection after first failed TKA two-stage exchange

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PHILADELPHIA – Researchers from the University of Pennsylvania created a decision tree of treatment options following a failed two-stage exchange in total knee arthroplasty and found knee arthrodesis was most effective in the treatment of infection and preservation of knee function.

“Fusion became the dominant treatment strategy in almost every iteration of the decision tree,” Chancellor F. Gray, MD, stated in his presentation at the Musculoskeletal Infection Society Annual Meeting, here. “As a reference, even if the utility of a revision is set in equivalence to a primary knee – in other words, if you said all your two-stage revisions did as well as all your primary knee patients – and you set the probability of success to a commonly quoted 90%, which is substantially higher than we found in our study, fusion is still clearly the dominant choice in the tree.”

Gray and colleagues performed a meta-analysis of 18 different studies analyzing two-stage exchanges in total knee arthroplasty (TKA) found on PubMed. The decision tree they used calculated the best treatment after a failed two-stage exchange by using game theory, taking into account factors such as the probability of advancing from one branch to another, the utility values of each outcome, and the cost of treatment. Other possible treatment methods examined in the study were chronic suppression, repeat revision or two-stage exchange, and amputation.

“Our review of the literature revealed, surprisingly, that only 80% of first time two-stage revisions actually succeed,” Gray said, which comprised 391 of 494 patients analyzed in the review. “Of the group who failed their first revision, most undergo a repeat revision. This is followed by fusion, ... chronic suppression, and finally amputation.”

Reference:

Gray CF. Knee arthrodesis is most likely to control infection and preserve function followed failed 2 stage procedure for treatment of infected TKA. Presented at: Musculoskeletal Infection Society Annual Meeting. Aug. 2-3, 2013; Philadelphia.

Disclosure: Gray has no relevant financial disclosures.