two-stage reimplantation forthesalvage of total knee

Copyright 1990 by The Journal of Bone and Joint Surgery. Incorporated

272 THE JOURNAL OF BONE AND JOINT SURGERY

Two-Stage Reimplantation for the Salvage of

Total Knee Arthroplasty Complicated by Infection

FURTHER FOLLOW-UP AND REFINEMENT OF INDICATIONS*t

BY RUSSELL E. WINDSOR, M.D.t, JOHN N. INSALL, M.D4, WALTER K. URS, M.D.1,

DREW V. MILLER, M.D4, AND BARRY D. BRAUSE, M.D4, NEW YORK, N.Y.

From The Hospitalfor Special Surgery. Affiliated with The New York Hospital - Cornell University Medical College, New York City

ABSTRACT: Thirty-eight total knee replacements (inthirty-five patients) that were complicated by infectionwere treated with a two-stage protocol for reimplanta-tion. The clinical results in these knees (nine of whichhave been previously reported on) were evaluated at anaverage follow-up of four years (range, 2.5 to ten years).

There was only one documented recurrence of in-fection with the original organism. Three patients inwhom the immunological system was suppressed had asubsequent hematogenous infection with a different or-ganism.

According to the knee-rating system of The Hospitalfor Special Surgery, there were eleven excellent, thirteengood, six fair, and seven poor results. For one patientwho had severe polyarticular rheumatoid arthritis, the

result could not be rated.The results of this study suggested that the two-

stage protocol for reimplantation, with a six-week in-terval of intravenous antibiotic therapy, is the procedureof choice for the treatment of an infection around a totalknee arthroplasty. A patient who has polyarticular rheu-matoid arthritis and in whom the immunological systemis suppressed may not be an ideal candidate for theprotocol. Gram-negative bacterial infection may betreated with this protocol, provided the organism is sen-sitive to relatively non-toxic antibiotic medication.

In 1977, a prospective study of a method of salvaging

a total knee arthroplasty that was complicated by infection

was begun on the Knee Service at The Hospital for Special

Surgery. The treatment protocol was divided into three

phases: ( 1) d#{233}bridement of the soft tissues and removal of

the prosthesis and all cement; (2) six weeks of parenteral

administration of antibiotic therapy, in the hospital, main-

taming a minimum serum bactericidal titer of 1 :8, under the

supervision of a consultant in the field of infectious disease;

and (3) implantation of a new total knee prosthesis. The

* No benefits in any form have been received or will be received from

a commercial party related directly or indirectly to the subject ofthis article.No funds were received in support of this study.

t Read in part at the Annual Meeting of The American Academy of

Orthopaedic Surgeons, San Francisco, California, January 24, 1987.� The Hospital for Special Surgery, 535 East 70th Street, New York,

N.Y. 1002 1 . Please address requests for reprints to Dr. Windsor, Knee

Service.

early results of this protocol in ten patients (eleven knees)

were reported previously’0. One of those patients (two in-

volved knees) has since died.

The purposes of the present report were to report on

the longer follow-up of nine of the original patients (nine

knees), to assess the outcome for a larger series of twenty-

six patients (twenty-nine knees) who were subsequently

managed with this protocol, and to define the indications

and limitations of the protocol more clearly.

Materials and Methods

Between January 1977 and December 1985, forty-eight

patients in whom fifty-two total knee arthrophasties were

complicated by infection were admitted to the Knee Service

at The Hospital for Special Surgery. Four patients had bi-

lateral infection. Thirty-four patients (thirty-seven knees)

were men and fourteen (fifteen knees) were women. The

preoperative diagnosis had been osteoarthrosis in thirty-one

knees, rheumatoid arthritis in twelve, post-traumatic ar-

thritis in three, osteonecrosis and hemophilic arthropathy in

two knees each, and pigmented villonodular synovitis and

Blount disease in one knee each. Three of the patients had

diabetes melhitus, and eighteen had had at least one operative

procedure on the knee before the index arthroplasty.

Thirty-two of the index arthroplasties had been done

at our institution and twenty had been done elsewhere. Six

patients had an infection around a revised arthroplasty that

had been done after a total knee prosthesis had failed. Nine-

teen knees were considered to have an early infection (di-

agnosed within three months after the arthroplasty) and

thirty-three knees, a late infection (diagnosed four to sev-

enty-two months after the arthroplasty).

Thirteen patients (fourteen knees) were excluded from

the present study, for a variety ofreasons (Table I). Twenty-

six patients (twenty-nine knees) of the remaining thirty-five

who had the two-stage protocol for reimplantation and nine

patients (nine knees) of the ten whose two-year results were

published previously’0 composed the study group. Only the

long-term results will be given for the nine patients who

were the subject of a previous report. The tenth patient from

that study had an excellent result when she died of a my-

ocardial infarction two years after reimplantation.

Nine of the twenty-six patients whose cases are being

presented for the first time had had an unsuccessful attempt

TWO-STAGE REIMPLANTATION FOR THE SALVAGE OF TOTAL KNEE ARTHROPLASTY 273

VOL. 72-A, NO. 2, FEBRUARY 1990

TABLE I

EXCL UDED PATIENTS

No. of

Case Knees Organism Reason for Exclusion Treatment

I 2 Strep.

pneumoniae

Metastatic adenocarcinoma

of the breast

Incision, drainage,

antibiotic

suppression

2 1 Staph. aureus Concurrent meningitis and

pneumonitis

Incision, drainage,

antibiotic

suppression

3 1 Staph. epidermidis Coronary artery disease; chronic

lung disease; seizures

Excisional

arthroplasty

4 1 Staph. aureus Patient refused

operation

Antibiotic

suppression

5 1 Enterococcus Risk of antibiotic toxicity Arthrodesis

6 1 Staph. aureus,

E. coli

Risk of antibiotic toxicity Arthrodesis

7 1 Past. multocida Risk of antibiotic toxicity Arthrodesis

8 1 Pseud. aeruginosa Risk of antibiotic toxicity Arthrodesis

9 1 Staph. aureus Fulminant systemic

infection; inadequate

viability of skin

Above-the-knee

amputation

10 1 Enterococcus Fulminant systemic

infection; inadequate

viability of skin

Arthrodesis

1 1 1 Beta-hemolytic

Strep.

Extensive necrosis of

quadriceps; inadequate

skin coverage; hemophilia

Excisional

arthroplasty

12 1 Staph. aureus Hemophilia; antibiotic-

induced neutropenia

Excisional

arthroplasty

I 3 1 Staph.

epidermidis

Patient refused

operation

Antibiotic

suppression

at eradication of the infection at another hospital. In five of

the patients, the administration of antibiotics alone had

failed. In four patients, the infection had persisted despite

incision, drainage, and antibiotic suppression, but the pros-

thetic components had been retained.

Diagnosis of Infection

When first seen, all of the twenty-six patients of the

recently treated group complained of pain, twenty (77 per

cent) had swelling of the knee, seven (27 per cent) were

febrile, and seven (27 per cent) had active drainage. At the

time of admission, the average erythrocyte sedimentation

rate was sixty-three millimeters per hour (range, four to 125

millimeters per hour). The average leukocyte count was

8300 per cubic milliliter (8.3 x l0� per liter) and the range

was 5800 to 14,000 per cubic milliliter (5.8 to 14 X l0�

per liter). Infection was identified by culture of a specimen

of fluid that was obtained by aspiration in twenty knees (69

per cent) and by culture of a specimen of drainage from the

wound in eight knees (28 per cent). In one patient, the

infection was not recognized until a gram stain and a culture

were done at the time of a revision that was planned for

aseptic loosening.

Predisposing Factors

Potentially predisposing factors that may have contrib-

uted to infection were persistent postoperative drainage (fif-

teen knees), necrosis of the skin (three knees), urinary tract

infection (four knees), and a positive culture of material

taken during the index arthrophasty (two knees) (Table II).

In four patients, the infection developed around the arthro-

plasty after a subsequent operation. In two of these patients,

necrosis of the skin developed after a patellectomy; in the

third, the infection developed after open reduction and in-

ternal fixation of a supracondylar fracture of the femur; and

in the fourth patient, necrosis of the skin developed after a

patellar realignment.

Bacteriological and Pathological Findings

Twenty-five total condylar-type, two Guepar, one

Shiers, and one stabilocondylar prosthesis were involved.

A single organism was grown on culture of specimens from

twenty-three knees in the recently treated group. There were

seventeen gram-positive infections (eight Staphylococcus

epidermidis, four Staphylococcus aureus, four Streptococ-

cus, and one diphtheroid) and six gram-negative infections

(three Escherichia coli and three Pseudomonas aeruginosa).

In 86 per cent of these patients, culture of a specimen of

the preoperative aspirate revealed the same organism that

grew on cultures of a specimen obtained when the prosthesis

was removed.

The remaining six knees in the recently treated group

had a mixed polymicrobial infection and an actively draining

wound. Four knees were infected with Staphylococcus ep-

idermidis as well as Escherichia coli (one knee), entero-

coccus (one knee), Bacteroides (one knee), or Peptococcus

TABLE II

RISK FACTORS FOR THE GROUP THAT HAD

SHORT-TERM FOLLOW-UP (TWENTY-NINE KNEES)

Persistent postoperative drainage

Necrosis of the skin

Complication after a subsequent operation

Necrosis of the skin after patellectomy

Necrosis of the skin after patellar realignment

Open reduction of a supracondylar fracture with

postoperative infection

Patellectomy with postoperative infection

Urinary tract infection

Escherichia coli

Pseudomonas

Beta-hemolytic Streptococcus

Positive culture at time of index arthroplasty

Diphtheroid

Staphylococcus epidermidis

274 R. E. WINDSOR ET AL.

THE JOURNAL OF BONE AND JOINT SURGERY

and Serratia marcescens (one knee) . One knee was infected

with enterococcus and Enterobacter species and another,

with Klebsiella and Escherichia coli. In only two patients

did culture of the swabs of the drainage reveal all of the

organisms that were grown on culture of specimens taken

during the initial d#{233}bridement. Since the drainage did not

contain all of the organisms that were in the fluid that was

still within the knee joint itself, it was necessary to obtain

fluid from the knee joint for culture before d#{233}bridement.

In 82 per cent of the knees, histopathohogical analysis

of tissue that was obtained during d#{233}bridement revealed a

high polymorphonuclear leukocyte count, consistent with

acute infection. Histiocytic reaction and areas of focal ne-

crosis were present in all of the specimens.

Operative and Medical Management

The previously described method of excision of the

total knee prosthesis and the necrotic tissue’#{176}is still used.

Parenteral antibiotics are chosen on the basis of the sensi-

tivity of the specific organism or organisms that were grown

on culture at the time of operation and on the basis of the

toxicity of the medication. In vitro minimum bactericidal

concentrations of the antibiotic or antibiotics are determined

by serial dilutions of the patient’s serum to find the highest

dilution that will kill 99 per cent of the standard bacterial

inoculum.

Serum bactericidal activity is determined in samples

of blood drawn sixty, ninety, or 120 minutes after admin-

istration of antibiotics every four, six, or eight hours, re-

spectively. Empirically, when this so-called post-peak

serum bactericidal level is 1 :8, antibiotic coverage is con-

sidered to be adequate, and that level has been found to be

effective in the treatment of the form of osteomyelitis under

study2. Often it is necessary to use several antibiotics to

eradicate a polymicrobial infection or to exploit the syn-

ergistic effects of combinations of antibiotics. Serum bac-

tericidal levels and auditory and renal function are closely

monitored to determine if the dosage or type of antibiotic

should be modified.

The antibiotic dosage that maintains a minimum bac-

tericidal level of 1 :8 is administered in the hospital for six

No. of weeks (forty-two days). Any period of time during which

Knees this level is not maintained is not counted toward the total

15 of forty-two days. Thus, in patients in whom a level of 1:83 is difficult to maintain, the time between excision and reim-

4 plantation may be longer than six weeks.The knee is immobilized for six weeks: a bulky Jones

dressing is used for four weeks and a Jordan splint, for two.

The sutures are removed when the Jones dressing is dis-continued, and the skin is washed twice daily with soap and

4 water. The patient is permitted to use a wheelchair and to

walk with crutches or a walker without bearing weight on

2 the lower limb.2 Implantation of a new total knee prosthesis is the last

stage in the protocol. Osseous deficits in the distal part of

the femur and the proximal part of the tibia frequently ne-

cessitate use of a custom-designed prosthesis that includes

metal augmentation of the femoral component, metal

wedges on the tibial component, and an intermedullary

stem. Patellar bone stock is often deficient; for this reason,

five of the patellae in this series were not resurfaced. One

patient needed a patellectomy. Six patients needed a mod-

ified V-Y quadricepsplasty to obtain exposure’. The post-

operative management of these patients was unchanged from

that described previously’0.

The time from removal of the prosthesis and d#{233}bride-

ment of the infected tissue to implantation of the second

prosthesis averaged fifty days (range, forty-two to seventy-

four days). The average hospital stay was seventy-seven

days. Approximately 65 per cent of the time in the hospital

was devoted to antibiotic therapy; 15 per cent, to postop-

erative care; and 20 per cent, to physiotherapy.

In one patient, mild acute inflammatory changes were

present in the tissue that had been removed when the second

prosthesis was implanted. In three patients, a few colonies

of Staphylococcus epidermidis were grown on culture ap-proximately forty-eight hours after the second prosthesis had

been implanted, although there was no histological evidence

of an acute infection and gram-staining of intraoperative

cultures had been negative. None of these three patients

have had evidence of reinfection. No patient received an-

tibiotics for more than forty-eight hours postoperatively.

Evaluation

At the most recent follow-up examination, the results

of thirty-seven arthroplasties (including nine of the eleven

reported on previously) were evaluated clinically with the

knee-rating scale of The Hospital for Special Surgery”.

Despite good function ofthe knee, one patient in the recently

treated group was bedridden because of severe polyarticular

rheumatoid arthritis, and the result could not be evaluated

with the clinical system.

Clinical results were also evaluated using the Venn

diagram system that was described by Tj#{246}rnstrand et al.

(Fig. 1 ). This system emphasizes function of the knee itself.

STABILITY

# OF KNEES

LENGTH OF FOLLOW-UP ( YEARS)


VOL. 72-A, NO. 2. FEBRUARY 1990

PAIN

F’u. I

RANGE OF MOTION

6

The Lund system (Venn diagram) for evaluating the function of a knee after total arthroplasty. Three strict criteria must be met.

To use the method, three strictly defined criteria must be

met: the patient must be able to walk at least 100 meters

without pain; the knee, to be considered mobile, must flex

90 degrees, with no more than a 5-degree lack of extension;

and varus-valgus instability must be less than 5 degrees, as

measured by stress-testing, with no medial or lateral thrust.

Results

The average length of follow-up was four years (range,

2.5 to ten years) (Fig. 2) for the total series, eight years

(range, three to ten years) for the nine knees that were

previously reported on, and four years (range, 2.5 to six

years) for the twenty-nine more recently treated knees.

There were eleven excellent, thirteen good, six fair, and

seven poor results. The poor results were subdivided into

two groups: clinical failure (three knees) and subsequent

infection (four knees).

The result in the nine knees in the initial group was

excellent in three, good in four, fair in one, and poor in

one. The results were identical to the ones originally re-

ported for these patients and did not deteriorate over time.

The one poor result was for a knee in which a new infection

developed thirty months after reimplantation.

There were eight excellent, nine good, five fair, and

six poor results in the more recently treated group.

On the basis of the Venn diagram, there were twenty-

two excellent, seven good, three fair, and six poor results.

The system of The Hospital for Special Surgery and that of

Lund (the Venn diagram) differ in emphasis. The former is

a numerical system that considers all of the patient’s func-

tions, whereas the latter is a non-numerical system that

emphasizes the function of the knee itself. For eight of the

original nine knees, the clinical rating was maintained after

four more years of follow-up, but in the ninth knee a new

FIi. 2

Bar graph showing the lengths of follow-up.



infection developed almost three years after reimplantation.

The range of motion averaged 95 degrees (range, 80

to 120 degrees) for the original group and 87 degrees (range,

60 to 120 degrees) for the recently treated group. In the

recently treated group, two knees had a 10-degree and one

had a 50-degree extension lag. The hatter patient had needed

a quadricepsplasty for exposure during the initial and final

stages of the protocol, and a patehlectomy had been done

during implantation of the new prosthesis. In the original

group, only one knee had a persistent 5-degree extension

lag. In that group, a 5-degree extension lag improved to

full extension in one knee and a 20-degree extension hag

did so in another.

Twenty-three patients, two of whom were in the orig-

inal group, complained of some pain when walking. Fifteen

patients (three from the original group) had mild pain; six

patients (one from the original group), moderate pain; and

two patients, severe pain. Three patients from each group

used a cane; two of them complained of severe pain, and

three patients in the recently treated group needed two

crutches when walking.

Plain anteroposterior and hateral radiographs of each

knee were made with the patient standing. Twenty-seven

(73 per cent) of the knees had a radiohucency, less than two

millimeters wide, about the tibiah component. Six knees in

the original group still had a radiolucency, which had not

progressed, but none had a complete radiolucency. One knee

in the recently treated group had a three-millimeter-wide

radiolucency under the medial and lateral tibial plateaus,

but that knee had no radiohucency around the tibial stem.

Three knees in the original group and four in the recently

treated group had a radiohucency about the femoral com-

ponent. One recent lateral femoral radiograph showed a

complete radiolucency that was more than two millimeters

wide.

Poor Clinical Results

Three patients had a poor chinicah result. Functional

disturbance of the extensor mechanism contributed to the

poor result in all three knees, and severe pain was present

in two knees. All three patients were in the recenthy treated

group.

One of the three patients had had muhtiple previous

procedures and had needed two quadriceps turndowns (a

procedure in which the incision for a medial arthrotomy and

that for a lateral retinacular release are connected at the

proximal portion of the quadriceps tendon, for exposure) as

well as a patellectomy. Three years postoperatively, passive

motion of the knee was 0 to 60 degrees, and there was a

50-degree extension lag.

The second patient, who was followed for four years

after reimplantation, had had an ipsilateral total hip replace-

ment for osteoarthrosis secondary to a previous infection

after open reduction and internal fixation of a fractured hip.

The knee was stable, but the range of motion was only 70

degrees. The patient continued to complain of moderate or

severe pain when walking, but some of the pain may have

been due to the ipsilateral total hip replacement.

The third patient, who was followed for three years

after reimplantation, complained of severe pain when walk-

ing, poor function of the quadriceps (an extension lag of

10 degrees), and medial-lateral instability. She needed two

crutches to walk.

Suspected and Documented Infection

Recurrent Infection

In the recently treated group, a patient who had severe

polyarticular rheumatoid arthritis had the sole documented

reinfection (that is, infection with an organism that was the

same as that grown on culture of specimens from the site

of the initial infection and had identical sensitivities to an-

tibiotics). Three years after the original reimphantation for

failure of the prosthesis due to infection with beta-hemolytic

Streptococcus, the patient had an acute onset of pain and

swelling in the knee. An infection by the same organism

that had initially been grown on culture was demonstrated,

and another two-stage reimplantation was done. The patient

had had an excellent clinical result before the reinfection,

and she had a good result at the time of writing, two years

hater.

New Infections

In the recently treated group, a sixty-eight-year-old

woman who had severe polyarticular rheumatoid arthritis

had a large hemarthrosis after a fall, seven months after

reimplantation because of infection with Pseudomonas

aeruginosa. The knee (which until then had had a fair result)

became painful, and culture of a specimen of aspirate from

the knee revealed Staphylococcus aureus. Two days afterthe subsequent d#{233}bridement, the patient became hypoten-

sive, septic shock with disseminated intravascular coagu-

lation developed, and she died.

In an eighty-year-old woman who had osteoarthrosis,

a hematogenous infection developed in the same knee three

years after reimplantation of a prosthesis because of infec-

tion with Staphylococcus aureus. This occurred after an

ipsilateral bunionectomy became infected. Culture of a spec-

imen of aspirate from the knee revealed Staphylococcus

aureus, but the organism had different sensitivities to an-

tibiotics than those of the organism that had originally in-

fected the knee. However, the sensitivities were the same

as those of the organism infecting the site of the bunionec-

tomy. The components of the knee prosthesis were retained,

as the patient was deemed medically unfit for another reim-

plantation. She had had a fair result before the second in-

fection. She died six months later.

Possible Infection

A seventy-eight-year-old woman who had osteoar-

throsis fell eighteen months after reimplantation of the pros-

thesis. Until then, the knee had had a good clinical result,

but swelling, pain, and erythema developed. Cultures of

specimens that were obtained at the time of the reimphan-

tation had revealed no organisms. Still, it was decided to


VOL. 72-A, NO. 2. FEBRUARY 1990

remove the components because an infection was strongly

suspected, but the patient refused reimplantation and re-

quested an arthrodesis. This was successfully performed

using external fixation356 13.17#{149}

Discussion

The original study of this two-stage protocol included

only eleven knees, which were fohhowed for a relatively

short time (thirty-four months)’#{176}. The present study showed

that, with one exception, the initial success of the protocol

in the remaining nine available knees was maintained over

time. In the more recent series of twenty-nine knees, which

were followed for an average of four years, the protocol

has been equally successful, given that some patients had

very complicated problems with the revision.

The protocol successfully eradicated the original deep

infection in thirty-seven knees (97.4 per cent) in the total

series. Only one knee had a documented recurrence of the

original infection. The other three reinfections (7.9 per cent

of the series) resulted from hematogenous seeding by or-

ganisms that were different from those causing the original

infection. We cannot readily explain the one recurrence of

infection with the same organism. That organism was highly

sensitive to antibiotics and the initial antibiotic treatment

had been adequate.

The three patients who subsequenthy had an infection

by what was most hikely a hematogenous source all were

at high risk for reinfection because of medical reasons. Two

of these patients had polyarticular rheumatoid arthritis and

had had previous total joint arthroplasties. Although we do

not consider that an absolute contraindication to the use of

this protocol, the immunological systems of such patients

are frequently suppressed. This limited ability to combat

infection results in an increased risk of subsequent infection

around the prosthetic joint by means of hematogenous bac-

teriah spread’5’6’9.

It is important to note that, of the total of forty-eight

patients whom we have seen because of infection around a

knee prosthesis, 27 per cent were not candidates for this

protocol (Table I). Incision, drainage, and suppression with

antibiotics may be the only feasible alternative to reim-

plantation in the medically compromised patient’2.

The management of a total knee arthrophasty that is

complicated by infection is the greatest challenge to a sur-

geon performing revision arthroplasty. The soft tissues and

bone are often more necrotic than those found during re-

vision that is being done for aseptic causes. The operative

exposure is more difficult, and there may be mechanical

difficulties due to necrosis of the extensor mechanism of

the knee. Loss of bone is usually severe after the implant

is removed, and custom-designed implants are often needed.

The poor clinical results in our series were mostly related

to mechanical problems that were caused by disruption of

the extensor mechanism.

Our patients had fewer satisfactory (good or excellent)

clinical resuhts (63 per cent) than those obtained after re-

vision for aseptic causes (89 per cent)9. However, the results

in our patients probably constitute an acceptable outcome

if one considers that our patients had two procedures and

six weeks of immobilization of the knee joint. The knees

that subsequently became infected obviously had a poor

result, but before the second infection developed, one chin-

ical result had been considered excellent; one, good; and

two, fair.

In our patients, pain was the most common symptom

heading to the diagnosis of infection. We consider any pa-

tient who complains of severe pain more than three months

after the arthrophasty to have an infection unless proved

otherwise. The knee joint must be aspirated, since culture

of specimens obtained with swabs from an infected sinus

tract may not reveal all of the organisms that are present in

the knee joint. In 82 per cent of the knees that were infected

with a single organism, culture of a specimen of the pre-

operative aspirate of the knee revealed the same organism

that had been grown on culture when the prosthesis was

removed. Cuhture of a specimen of drainage from the sinus

tract revealed the same organism in only 28 per cent of the

knees.

Although we previously cautioned against using this

protocol for reimplantation in the presence of gram-negative

infection’0, additional experience has led us to believe that

it is feasible if the organism is sensitive to relatively non-

toxic antibiotics. Infections by Escherichia coli and Pseu-

domonas aeruginosa were treated successfully.

Currently, we have attempted to shorten the over-all

stay in the hospital by administering antibiotics parenterally

at home for three or four weeks by means of a Broviac

catheter (Evermed, Kirkland, Washington). It must be em-

phasized, however, that a minimum bactericidal concentra-

tion of h :8 must be maintained for six weeks, counting only

the days on which this concentration is reached.

The six-week two-stage protocol for reimphantation

was apparently successful in eradicating the infection in

thirty-seven of thirty-eight knees. In our opinion, it repre-

sents the most successful method that has been described

to date’7’#{176}’4’9 for managing total knee arthroplasty that is

complicated by infection, and it is the procedure of choice

for handling this difficult problem.

References

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Failed Total Knee Arthroplasty. J. Bone and Joint Surg., 61-A: 181-185, March 1979.4. D’AMBROSIA, R. D. � SHOJI, HIROMU: and HEATER, RICHARD: Secondarily Infected Total Joint Replacements by Hematogenous Spread. J. Bone

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7. HOVELIUS, LENNART, and JOSEFSSON, GORAN: An Alternative Method for Exchange Operation oflnfected Arthroplasty. Acta Orthop. Scandinavica,50: 93-96, 1979.

8. INSALL, J. N. : Surgical Approaches to the Knee. In Surgery of the Knee, p. 47. Edited by J. N. Insall. New York, Churchill Livingstone, 1984.9. INSALL, J. N. , and DETHMERS, D. A.: Revision of Total Knee Arthroplasty. Clin. Orthop. , 170: 123-130, 1982.

10. INSALL, J. N.; THOMPSON, F. M. ; and BRAUSE, B. D.: Two-Stage Reimplantation for the Salvage of Infected Total Knee Arthroplasty. J. Boneand Joint Surg. , 65-A: 1087-1098, Oct. 1983.

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15. SALVATI, E. A.; CHEKOFSKY, K. M.; BRAUSE, B. D.; and WILSON, P. D., JR.: Reimplantation in Infection. A 12-Year Experience. Clin. Orthop.,170: 62-75, 1982.

16. STINCHFIELD, F. E. ; BIGLIANI, L. U. ; NEU, H. C. ; Goss, T. P. ; and FOSTER, C. R. : Late Hematogenous Infection of Total Joint Replacement.J. Bone and Joint Surg., 62-A: 1345-1350, Dec. 1980.

17. STULBERG, S. D.: Arthrodesis in Failed Total Knee Replacements. Orthop. Clin. North America, 13: 213-224, 1982.18. TJORNSTRAND, B. A. E.; EGUND, NIELS; and HAGSTEDT, B. V.: High Tibial Osteotomy. A Seven-Year Clinical and Radiographic Follow-up.

Clin. Orthop., 160: 124-136, 1981.19. WIGREN, ANDERS; KARLSTROM, GORAN; and KAUFER, HERBERT: Hematogenous Infection of Total Joint Implants: A Report of Multiple Joint

Infections in l’hree Patients. Clin. Orthop. , 152: 288-291 , 1980.


two-stage reimplantation forthesalvage of total knee

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