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More than ¾ patients → good results with
arthrotomy debridement treatment.
→ Open debridement is obviously better
than arthroscopy.
We consider open debridement (Vs arthrosco-
py) in early of hematogenous infection within
the first 2 weeks following clinical symptoms
[3, 4, 5].
Our indications:
acute infection, stable
implant, no radiological evidence of osteitis,
intact soft tissue (open wound: arthroscopy
contraindicated), no bacterial growth or sus-
ceptibility to antibiotics.
We usually use specific and long term antibio-
therapy as soon as sensitivities are known
(6 weeks).
In case of failure with conservative treatment,
we consider to exchange the implant.
25 knees were treated with debridement, com-
ponent removal and insertion of articulating
spacer followed by second stage TK revision
[6, 7].
Our indication :
failure of conservative treat-
ment, sub acute infections (more than
2 weeks), chronic infections, instable ligaments
situation, radiological evidence of loosening,
damaged soft tissue (abscess…), difficulties to
treat microorganisms (multiresistant…)
•
19 Staphylococcus Aureus
→ 15 revisions
• 5 Staphylococcus Epidermidis
→ 1 revision
• 11 Streptococcus
→ 3 revisions
• 4 Enterococcus
→ 3 revisions
In our experience, two-stage revision is more
frequent in the presence of
Staphylococcus
Aureus
and
Enterococcus
[8].
The formation of a biofilm (picture 1) with the
attachment between the uncoated plastic mate-
rial and the bacterial surface is an important
reason of failure if we choose the conservative
treatment in presence of
Staphylococcus
Aureus
for example.
Excisions of the infected tissues, component
removal, AB spacer and IV ABtherapy (about
6 weeks) are essential. There is a wide variabi-
lity in the duration of parenteral ABtherapy
and its oral replacement is also very depending
on the patient and the surgical team.
AB spacer will usually be articulating and
home made, sometimes, monobloc.
One team used the Cuckler technique [9, 10].
For the second time of the procedure, the choi-
ce between the massive prosthetic or a bone
reconstruction depends on the age and the
amount of bone loss (picture 2). If a flap is
necessary, it will be introduced during the
second step (picture 3).
The other option will be discussed after exclu-
sion of all other treatment option.
• Arthrodesis:
insufficience of extension
mechanism,
• Amputation:
salvage procedure,
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288
Picture 1 : Biofilm: the white circles are germs
(with authorization from Prof. J.-L. Gala
from UCL).
Picture 2 : The importance of the osseous
loss determines the choice between osseous
reconstruction or massive prosthesis.