SYMPOSIUM: PAPERS PRESENTED AT THE ANNUAL MEETINGS OF THE KNEE SOCIETY
Reinfected Revised TKA Resolves With an Aggressive Protocol
and Antibiotic Infusion
Leo A. Whiteside MD, Tariq A. Nayfeh MD, PhD,
Renee LaZear RN, Marcel E. Roy PhD
Published online: 27 September 2011
? The Association of Bone and Joint Surgeons1 2011
for infection is challenging, and amputation often is the
We asked whether reinfection after
two-stage revision for infection could be controlled with an
aggressive revision protocol and intraarticular antibiotic
(12 women, six men) who underwent revision for failed
reimplantation between January 1999 and January 2008.
Revision of failed two-stage revision TKA
Mean time from revision for infection to rerevision for
reinfection was 5 months (range, 1–18 months). All knees
were treated with an individualized protocol that included
aggressive exposure, extensive de ´bridement, uncemented
components, closure with muscle flaps (seven knees) and
other plastic surgery procedures (three knees), and direct
antibiotic infusion through Hickman catheters for 6 weeks.
Ten knees had one-stage revision; five had de ´bridement,
cement spacer, and revision surgery 3 to 4 months later;
and three had extensive soft tissue reconstruction before
revision surgery. The minimum followup was 2.3 years
(mean, 6.1 years; range, 2.3–12.0 years).
The mean Knee Society scores improved from 33
preoperatively to 76. Seventeen of the 18 had control of
infection and achieved durable fixation and a closed wound.
and the patient required amputation.
Extensile exposure, de ´bridement, and soft
tissue flaps for closure combined with uncemented fixation
of revision implants and antibiotic infusion into the knee
controlled reinfection after revision TKA.
Level of Evidence
Level III, therapeutic study. See
Guidelines for Authors for a complete description of levels
Revision of total joint arthroplasty for infection is difficult
surgery, and recurrent infection, loosening, and pain con-
are especially difficult to treat in TKA infection, resulting in
Each author certifies that he or she, or a member of their immediate
family, has no commercial associations (eg, consultancies, stock
ownership, equity interest, patent/licensing arrangements, etc) that
might pose a conflict of interest in connection with the submitted
All ICMJE Conflict of Interest Forms for authors and Clinical
Orthopaedics and Related Research editors and board members are
on file with the publication and can be viewed on request.
Each author certifies that his or her institution approved the human
protocol for this investigation, that all investigations were conducted
in conformity with ethical principles of research, and that informed
consent for participation in the study was obtained.
This work was performed at the Missouri Bone and Joint Center,
Missouri Bone and Joint Research Foundation, St Louis, MO, USA.
L. A. Whiteside, R. LaZear
Missouri Bone and Joint Center,
St Louis, MO, USA
T. A. Nayfeh
Johns Hopkins College of Medicine,
Baltimore, MD, USA
L. A. Whiteside (&), M. E. Roy
Missouri Bone and Joint Research Foundation,
1000 Des Peres Road, Suite 150, St Louis,
MO 63131, USA
e-mail: firstname.lastname@example.org; email@example.com
Clin Orthop Relat Res (2012) 470:236–243
and Related Research®
A Publication of The Association of Bone and Joint Surgeons®
failure rates ranging from 24% to 82% [10, 18, 25, 33].
Revision for infection after previous revision for infection
challenging cases. Studies indicate management of reinfec-
tion after at least one revision for infection is attended by a
high incidence of succeeding infection as well as loosening,
instability, and pain [6, 30, 34].
Although it would be difficult to document, it generally
is accepted by practitioners in this field that adequate
exposure and complete de ´bridement are major factors in
the management of multiply failed TKA. If cement has
been pressure-injected into the medullary canals of the
femur and tibia, direct visualization by means of bivalve
osteotomy or endoscopic instruments often is required for
exposure and direct access to the inner surfaces of the
bone. Adequate exposure of the synovial cavity and its
extensions in the form of popliteal cysts and abscesses
often requires extensile exposure such as tibial tubercle
osteotomy or extensive soft-tissue stripping and extension
of the incision proximally between the vastus medialis and
rectus femoris muscles .
Although cemented fixation of revision TKA can
achieve durable fixation , fixation of revision implants
can be a problem in both hip and knee arthroplasty [5, 28].
However, in revision THA, fixation of implants with a
cementless technique has been an important factor in
improving mechanical success . Similarly, cementless
fixation in revision TKA has achieved stable fixation of
both implants in 94% to 97% of cases [37, 40, 41].
Soft tissue damage caused by repeated surgical expo-
sure, draining sinuses, and subcutaneous abscesses causes
especially difficult problems in closure and sealing of the
joint. Muscle pedicle and subfascial skin flaps often are
necessary to achieve watertight closure in these complex
cases that involve recurrent failure and infection.
One reason for the high failure rate is the difficulty in
delivering antibiotics in high enough concentrations and
for the proper duration to control infection in the joint.
Intravenous antibiotics achieve adequate joint levels only
briefly [13, 17, 22, 23, 26, 35]; and antibiotic-loaded
cement spacers are depleted of available antibiotics after 3
to 7 days and thereafter become a potential nidus for
growth of infecting organisms [2, 26, 32].
In veterinary practice, direct intraarticular injection of
antibiotics has been used for decades, and the reported
intraarticular concentration is many orders of magnitude
higher than that achieved by intravenous administration of
a much higher dose . Direct infusion of antibiotics also
has been used in humans to salvage acutely and chronically
infected TKA and has had a high rate of infection control
(95%) in knees infected with resistant bacteria , a
category of infection that ordinarily has a high failure rate
For treating reinfection after two-stage revision TKA for
infection, the senior author (LAW) developed a surgical
protocol that included tibial tubercle osteotomy for expo-
sure when necessary in stiff knees to avoid extensive soft
tissue stripping, bivalve osteotomy of the femur and tibia to
extirpate extensive cement mantles, cementless fixation,
closure with muscle flaps and subfascial skin flaps in cases
with deficient capsule and skin, and direct infusion of
antibiotics with sealed indwelling catheters. The purpose of
this study was to determine the success rate of this
aggressive approach to infection in a group of knees that
clearly were failures of previous two-stage revision for
We therefore sought to determine (1) the rate of success
in controlling the infection; (2) the safety of the method of
antibiotic delivery by determining complications of using
the catheters and by observing the serum vancomycin
concentration; and (3) the rate of success using a cement-
less fixation technique for the revision arthroplasty.
Patients and Methods
We retrospectively reviewed all 18 patients (18 knees)
treated for reinfection after previous two-stage revision of
infected TKA between January 1999 and January 2008.
Twelve patients were women and six patients were men.
Mean time from the original TKA until the initial revision
was 7 months (range, 1.5–13 months) and from revision to
rerevisionwas 5 months
knees were reinfected with the original organism(s). The
infecting organisms included methicillin-resistant Staphy-
lococcus aureus (11 patients, 11 knees), methicillin-
resistant Staphylococcus epidermidis (two patients, two
knees), methicillin-sensitive S aureus (two patients, two
knees), and mixed Proteus mirabilis and Escherichia coli
(three patients, three knees). All of the Staphylococcus
organisms were sensitive to vancomycin in concentrations
of 2 to 5 lg/mL, and the three E coli and P mirabilis
organisms were sensitive to gentamicin in concentrations
of 2 lg/mL. The minimum followup was 2.3 years (mean,
6.1 years; range, 2.3–12.0 years). No patients were lost to
followup. No patients were recalled specifically for this
study; all data were obtained from medical records.
We treated all knees with the same protocol that
included extensive de ´bridement, revision TKA with
uncemented components, and direct antibiotic infusion.
Surgical treatment included thorough removal of non-
absorbable sutures, complete synovectomy, and de ´bridement
of abscesses and popliteal cysts. Vascularized osteoperio-
steal flap osteotomy was used to expose diaphyseal cement
mantles that extended into the diaphysis and could not be
removed from the open end of the bone, leaving the cement
(range, 1–18 months).All
Volume 470, Number 1, January 2012Revision of Reinfected TKA237
bed directly and completely visible for inspection. We
meticulously removed cement using three-phase de ´bride-
ment of the bone surfaces starting with rongeurs followed
by curettes and finishing with a high-torque reamer to burr
away all surfaces exposed to cement. During de ´bridement,
hand-pump irrigation with a saline solution of vancomycin
(1 g/L), polymyxin(30,000
(50,000 U/L) was performed repeatedly. After the de ´bri-
dement was completed, the area was redraped, the surgical
team regowned and gloved, and the instruments were
washed and soaked in the same type of antibiotic solution
used for irrigation. Tibial tubercle osteotomy was used for
exposure in 13 knees. Seventeen knees required bivalve
osteotomy of the femur, tibia, or both to expose the cement
mantle and de ´bride the endosteal surfaces. Five knees had
necrosis of the quadriceps tendon, patella, and patellar
tendon and had de ´bridement and removal of a portion of
the quadriceps tendon, the entire patella, and the patellar
tendon. Seven knees, including all the knees that had
patella and patellar tendon resection, had muscle flaps for
closure of capsular and soft tissue defects. Novel muscle
flaps, including lateral transfer of the vastus medialis and
medial transfer of the vastus lateralis, were necessary in
seven knees. In two knees, a medial gastrocnemius flap was
sutured to the transferred vastus medialis muscle to achieve
extensor continuity through the knee. Ten knees (56%) had
one-stage revision (Fig. 1). Five knees (28%) had de ´bri-
dement, cement spacer, and definitive revision arthroplasty
3 to 4 months later; and three knees (16%) had multiple
extensive soft tissue reconstruction including tissue
expanders to produce enough skin for closure and external
fixators to achieve adequate limb length before their
definitive revision arthroplasty. Two of the patients (two
knees) required de ´bridement of the edge of a muscle flap
and repeat closure within the first week postoperatively.
Three patients (three knees) had open drainage of
hematoma and reclosure during the first 2 weeks postop-
eratively. If the bone and soft tissue quality had adequate
circulation to sustain healing, and adequate soft tissue was
available for closure, then we performed revision TKA
using nonporous, fluted, diaphyseal-engaging titanium
stems and porous-coated implants applied directly to
available bone. No cement was used to fix the implants to
bone, and no bone graft was used to fill bone defects. In
cases in which bone stock and soft tissue were not deemed
adequate for stable fixation of the implants and secure
closure of the joint, implants were not inserted, Hickman
catheters were inserted for delivery of antibiotics, and
closure completed using available skin and muscle flaps,
allowing the extremity to shorten if necessary. These
patients were managed postoperatively to achieve bone
healing of the osteotomies, restore leg length, and gain skin
for closure. Three patients (three knees) underwent external
fixation for gradual lengthening to regain limb length, and
three patients (three knees) had subfascial soft tissue
expanders to provide skin for closure. We used a Constavac
(Stryker Corp., Kalamazoo, MI, USA) drain for 24 to
48 hours postoperatively, but the blood was not reinfused.
To improve the chances of maintaining intraarticular
access for 6 weeks, we inserted two Hickman catheters
(CR Bard Inc, Salt Lake City, UT, USA) in all patients.
These catheters are silicone tubes with a fibrous cuff that
allows fibrous tissue ingrowth to seal the entry point and
prevent ingress and egress of fluid around the catheter. The
catheters were inserted through the lateral thigh, penetrat-
ing the vastus lateralis
suprapatellar area of the knee (Fig. 2). The fibrous cuff was
placed approximately 5 mm deep to the dermis. We
sutured each catheter to the skin surface with silk sutures
on two sides, and the injection portals were taped to the
surface of the skin. The external portals each were fitted
with a Luer lock module and cap to allow injection with a
syringe. The junctions were sealed with Betadine ointment.
Postoperatively the patients received 1 g vancomycin or
80 mg gentamicin intravenously every 12 hours for at least
48 hours postoperatively. The intravenous antibiotics were
discontinued after 48 hours if intraarticular administration
was established. Intraarticular infusion of antibiotics began
in the evening of the first day after surgery. We adminis-
tered 100 mg vancomycin or 20 mg gentamicin in 3 mL
saline daily as a test dose, and the concentration and vol-
ume were increased daily if the wound remained sealed and
quiescent. When the wound was stable and dry, the dosage
was increased to 500 mg vancomycin or 80 mg gentamy-
cin in 8 mL saline. The dose was given every 12 or
24 hours depending on the patient’s ability to tolerate the
Fig. 1 Lateral radiograph performed at 6 weeks after revision with
uncemented implants and Hickman catheters for antibiotic infusion.
The infection resolved, and the patient has progressed to full
238 Whiteside et al. Clinical Orthopaedics and Related Research1
antibiotic in the knee. If irritation and redness occurred, we
decreased the volume and concentration. The injection was
alternated between the two catheters to keep them open.
The catheters were not flushed but were capped and
clamped to maintain a reliable seal. Vancomycin is
unstable in solution and must not be injected in the knee in
concentrations greater than 100 mg/mL. To avoid precip-
itation of the concentration used in the knees, the dosage
was limited to 50 mg/mL. Eight milliliters of the solution
(500 mg vancomycin or 80 mg gentamicin) was injected
once or twice daily for 6 weeks, and the serum peak and
trough levels were measured twice weekly. We modified
the frequency and dosage to maintain the serum trough
levels between 3 and 10 lg/mL for vancomycin and 1 and
2 lg/mL for gentamicin.
After 6 weeks of treatment, the Hickman catheters were
removed surgically. Six of the 18 knees lost one of the
catheters because of occlusion during the 6-week infusion
interval. Two patients had removal of one of the two
catheters for leakage. One knee had traumatic avulsion of
both catheters 8 days after surgery and required general
anesthesia to insert new catheters. None of the patients had
breakage of the catheters, secondary infection, or chronic
drainage or fistula formation from the catheters.
All knees were allowed full weightbearing after their
final implants were inserted but were supported with a
walker for 4 to 6 weeks. Supervised physical therapy was
started the first day after surgery and continued through
6 weeks. Gentle active and passive ROM exercises and
quadriceps strengthening were begun and progressed as
soon as the patient could cooperate.
The patients were seen at 2 weeks for suture removal, at
6 weeks for removal of the Hickman catheters, and again
2 weeks later for suture removal from the tube site. They
returned at 3 months for physical evaluation and radio-
graphs and then at yearly intervals for physical evaluation
and radiographs. We evaluated all knees for tenderness,
erythema, and induration at 3 months postoperatively.
Serum C-reactive protein (CRP) concentration and sedi-
mentation rate were evaluated at 3 months. Because the
patients were only 3 months postoperative from their
revision surgery and had recently had catheter removal, we
considered CRP level less than 25% above normal and
sedimentation rate less than 50% elevated signs of resolved
infection. Other signs of resolved infection included
absence of erythema and tenderness and absence of
radiographic signs of bone absorption. After 3 months, no
additional laboratory tests were obtained by our office and
the patients were followed with CRP and sedimentation
rates by their infectious disease consultants. Knee scores
were determined using the Knee Society Clinical Rating
To evaluate the quality of the de ´bridement postopera-
tively, one of us (LAW) evaluated AP, lateral, and skyline
patellar radiographs immediately postoperatively and at
1-month and 3-month followup intervals. None had retained
cement or debris on their followup radiographs. The same
radiographs were scrutinized for evidence of migration or
displacement of the bivalve osteotomies and tibial tubercle
osteotomy, and fixation was evaluated by appearance of
radiolucent lines at every followup visit. We identified and
measured radiolucent lines with a ruler accurate to 0.5 mm.
The tibial tubercle and fibular head were chosen as land-
marks to measure tibial component migration, and the
distances from the undersurface of the tibial baseplate to
the top of the fibular head and to the tibial tubercle were
measured on each radiographic examination. We chose the
medial and lateral epicondyles as the femoral bone land-
marks forfemoral component
component position was measured relative to the femoral
bone landmarks by drawing a line that joined the distal
Fig. 2 Illustration of the infusion system using Hickman catheters.
This drawing illustrates the injection portals (a) that are outside the
skin, the fibrous cuffs that are approximately 5 mm deep to the dermis
(b), the catheters inside the synovial cavity of the knee (c), and
outflow of the antibiotic through the synovial membrane and into the
regional veins (d). The fibrous cuffs seal the catheters so that
contaminants do not enter the knee and joint fluid does not leak out.
Reprinted with permission from Whiteside LA, Peppers M, Nayfeh
TA, Roy ME. Methicillin-resistant Staphylococcus aureus in TKA
treated with revision and direct intraarticular antibiotic infusion. Clin
Orthop Relat Res. 2011;469:26–33.
Volume 470, Number 1, January 2012 Revision of Reinfected TKA239
surface of the implant and measuring the distance between
this line and the medial and lateral epicondyles. We defined
radiographic signs of migration as a radiolucent line that
increased by more than 1 mm on one side of a diaphyseal
stem or greater than 1-mm change in distance relative to
one of the bone landmarks on two successive radiographic
examinations. We defined a stable arthroplasty as a total
knee with no sign of migration of either the femoral or
tibial implant over a period of 2 years.
Infection control and clinical signs of success were
obtained in 17 of 18 knees. One patient had recurrent
infection 13 months after one-stage de ´bridement, revision,
and primary closure of the knee. This knee was de ´brided
again, infused with vancomycin for 6 weeks with no
implant in place, and reimplanted with cementless implants
6 weeks after catheter removal. The CRP and sedimenta-
tion rate were normal at reimplantation with no sign of
infection at 28 months followup. One knee failed to obtain
soft tissue closure, drained continuously, and finally had
above-knee amputation 2 months after beginning treat-
ment. CRP and sedimentation rate were within normal
limits at 2-year followup in 16 of the 17 patients. One
patient, who has chronic gingivitis, stasis dermatitis, and
arteriosclerotic coronary artery disease, had 24% elevation
of CRP and a high normal sedimentation rate at 1-year
followup. His knee was asymptomatic and benign to
examination. Aspiration revealed no white blood cells in
the synovial fluid. No patient required chronic suppressive
antibiotics. Two patients received oral tetracycline for
3 months after surgery as routine management by their
infectious disease consultant.
Serum vancomycin levels within appropriate ranges
indicated the safety and efficacy of intraarticular antibiotic
delivery through a catheter. Mean serum vancomycin peak
level at 1 month postoperatively was 4.1 ± 1.2 lg/mL,
and mean trough level was 3.3 ± 1 lg/mL. Mean serum
peak gentamicin level was 1.1 ± 1 lg/mL and trough level
was 0.2 ± 0.1 lg/mL. Three patients with vancomycin and
one with gentamicin infusion required temporary cessation
of antibiotic infusion and resumption at a lower dosage
because of excessively high serum antibiotic levels or
rising blood urea nitrogen and creatinine levels.
No rerevision was performed for loosening or instability
with cementless fixation technique. The bivalve osteoto-
mies for cement removal did not fracture or displace, and
radiographs revealed no retained cement in any knee. No
complications occurred with tibial tubercle osteotomy. All
patients except the one requiring amputation achieved full
weightbearing by 3 months postoperatively. Knee Society
score was 33 ± 11 preoperatively and 76 ± 10 2 years
postoperatively. Extensor function was compromised
markedly in all knees that required resection of the patella
and patellar tendon with extension lag ranging from 5? to
65?. No radiographic signs of implant migration were
detected in 16 knees, whereas one knee had migration of
the femoral component proximally, a complete radiolucent
line around the femoral stem, and 2? varus angulation
during the first year after surgery. Two subsequent yearly
radiographs revealed no further femoral component
migration. One knee had a complete radiolucent line
around the tibial component on the AP radiograph that was
less than 1 mm and did not widen. All knees had at least
one radiographic view showing a less than 1-mm radiolu-
cent line under the tibial porous surface at 2 years
postoperatively, and all knees had a less than 1-mm
radiolucent line under the nonporous-coated anterior fem-
oral flange. None of these lines widened. Six knees had
anterior gaps of 2 to 5 mm since the time of surgery and
have remained radiographically stable throughout the fol-
This series demonstrates the magnitude of deficiency and
the scope of surgical effort necessary to manage reinfection
after two-stage revision for infected TKA and illustrates
that it can be treated with a high success rate when a well-
planned series of surgical procedures is combined with
intraarticular antibiotic infusion. Direct antibiotic infusion
was developed to channel very high intraarticular antibiotic
concentration into the joint for revision of infected TKA
[20, 23, 29]. However, the types of cases in this series
involve problems that cannot be solved only with high
levels of antibiotics, but also require aggressive exposure
and limb salvage techniques and often multiple procedures
to prepare the extremity for reimplantation of the
arthroplasty components. We therefore determined the
success rate of intraoperative and postoperative protocols
for reinfection in a group of knees with previous two-stage
revision for infection. We evaluated (1) the rate of success
in controlling the infection; (2) any complications of
antibiotic delivery through a catheter by observing the
serum vancomycin concentration; and (3) the rate of suc-
cess using a cementless fixation technique for the revision
Our study is limited by several factors. First, we had a
small number of cases, although they were all prospec-
tively followed with a set protocol and no patients were lost
to followup. Reinfection is relatively uncommon and
therefore even in a referral practice, it is difficult to accu-
mulate a large number of cases. Second, we had no
240Whiteside et al. Clinical Orthopaedics and Related Research1
comparative group using alternate protocols. The complex
and varied nature of the surgical procedures necessarily
required individualized treatments. Third, we had a rela-
tively short minimum followup time of 2 years (mean,
6.1 years) but longer than comparative studies [6, 14]
Clinically the infection appeared controlled in 17 of
18 knees. Extensile exposure using tibial tubercle osteotomy
to open the joint and bivalve osteotomy of the femur and
tibia to access retained cement were successful in all cases.
Osteotomy, although tedious and time-consuming, was
essential to exposure and did not result in complications in
this series. Despite all efforts in one knee, soft tissue
coverage failed and amputation was required. Although
knee function was restored with the planned series of
reconstructive procedures, it was compromised in a size-
able proportion of these cases because of loss of the patella
and other elements of the extensor apparatus.
Two-stage revision, using intravenous antibiotics and an
antibiotic-loaded cement spacer to deliver antibiotics into
the joint, is considered the conservative surgical approach
to infected TKA [4, 6, 9, 26], but its clinical results are
disappointing. Reinfection rates varying from 11% to 24%
have been reported in centers that specialize in care of
these difficult cases using two-stage de ´bridement and
reimplantation [7, 10, 12, 18, 19, 33]. Repeat revision for
reinfection adds another dimension of challenge to man-
aging the infected TKA. It has not been reported often, but
the few reported series illustrate the difficulty of this con-
dition. One series had a 31% failure rate after repeat two-
stage revision for recurrent infection . In another series
of 24 reinfected revision TKAs, only one achieved an
uninfected knee prosthesis  (Table 1). Although one
series reported no failures to control the infection in
repeated revision for infection , in that series of 12, only
two were reinfected with the original organism, so 10 cases
were not failures of revision for infection. Our success rate
in this especially challenging condition suggests direct
antibiotic infusion offers a substantial benefit in this
situation when combined with an aggressive regimen of
de ´bridement, soft tissue coverage, and cementless fixation
Previous studies of antibiotic infusion directly into the
joint have reported remarkable success, including revision
for infection with methicillin-resistant S. aureus .
Antibiotics injected into synovial joints are absorbed in a
manner similar to antibiotics injected intramuscularly and
produce similar serum concentration [13, 27], so some
peripheral therapeutic antibiotic effect would be expected.
Antibiotics injected directly into the joint produce con-
centrations substantially higher in the adjacent bone than
can be achieved with intravenous administration [17, 35].
This suggests local antibiotic concentration in the bone and
soft tissue beyond the synovial membrane would more
likely be bactericidal with intraarticular than with intra-
venous administration of antibiotics.
Antibiotic concentrations achieved with antibiotic-
loaded cement spacers can be high early but decrease
substantially after the first 24 hours [2, 16, 26, 31]. Anti-
biotic release is minimal after 5 days , but the levels
remain detectable for as long as 340 days postoperatively
. These levels may be too low to be bactericidal in
resistant bacteria or gram-negative organisms, even in the
first few days, and are likely to be ineffective as time
passes . A low concentration of antibiotics in the
synovial fluid and on the surface of the cement spacer
fosters the development of resistant bacteria . Small
colony variants require sustained, high antibiotic concen-
trations and longer exposure to high antibiotic levels than
can be obtained with intravenous antibiotics and antibiotic-
loaded cement spacers [21, 24].
Fixation of the implants with one-stage revision and
cementless implants was successful in this series. Fixation
of implants to bone consistently has been a problem in
revision TKA, especially in cases of infection with resistant
organisms [10, 18, 25, 33]. Mechanical failure rates of 20%
to 40% are reported in centers with high surgical volume
and recognized expertise in this field [1, 6, 30, 34].
Table 1. Outcomes of treatment for reinfection after previous revision for infected TKA
et al. 
244 103105 1 (4%) 47
et al. 
35520130 24 (69%) 59
18100000 17 (94%)73
Volume 470, Number 1, January 2012Revision of Reinfected TKA241
Cementless fixation with porous devices in revision
arthroplasty has had a high rate of success in both hip and
knee arthroplasty and has become the predominant mode of
fixation in revision THA . Results of the current study
using cementless porous-coated devices in difficult cases of
infected TKA resemble those of revision THA, and this
technique appears to offer an advantage over cemented
fixation [5, 38].
Although the reinfected revision TKA protocol may be
daunting and require months to complete, we anticipate
successful limb salvage and a functioning extremity in the
majority of cases. Good soft tissue coverage and revision
arthroplasty with cementless implants followed by 6 weeks
of antibiotics infused directly into the joint can achieve
stable implants and control infection in most cases.
assistance with the illustration and Diane J. Morton, MS, for assis-
tance with manuscript preparation.
We thank William C. Andrea, MS, FAMI, for
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