Re-infection rates and clinical outcomes following arthrodesis with intramedullary nail and external fixator for infected knee prosthesis: a systematic review and meta-analysis.

Abstract

BackgroundKnee arthrodesis with intramedullary (IM) nail or external fixator (EF) is the most reliable therapeutic option to achieve definitive infection control in patients with septic failure of total knee arthroplasty (TKA). The first aim of this study was to compare re-infection rates following knee arthrodesis for periprosthetic joint infection (PJI) with IM nail or EF. The second aim was to compare rates of radiographic union, complication, and re-operation as well as clinical outcomes.MethodsA systematic search was performed in electronic databases for longitudinal studies of PJIs (minimum ten patients; minimum follow-up = 1 year) treated by knee arthrodesis with IM nail or EF. Studies were also required to report the rate of re-infection as an outcome measure. Eligible studies were meta-analyzed using random-effect models.ResultsThe rate (95% confidence intervals) of re-infection was 10.6% (95% CI 7.3 to 14.0) in IM nail arthrodesis studies. The corresponding re-infection rate for EF was 5.4% (95% CI 1.7 to 9.1). This difference was significant (p = 0.009). The use of IM nail resulted in more advantages than EF for frequency of major complications and limb shortening. Other postoperative clinical and radiographic outcomes were similar for both surgical strategies.ConclusionsThe available evidence from the aggregate published data suggests that knee arthrodesis with EF in the specific context of PJI has a reduced risk of re-infection in comparison with the IM nail strategy. The use of IM nail is more effective for the complication rate and shortening of the affected limb.

Knee arthrodesis as last resort for persistent knee joint infections

“…In 2018 Balato et al were able to show in a systematic review and metaanalysis of 26 publications that in IMA the rate of reinfection and persistence of infection was 13.3% (422 cases studied), while other studies reported rates between 0% (19 investigated cases in Letartre et al 2009) and 50% (26 cases studied byRöhneretal. 2015) [32][33][34]. In contrast, our study showed a proven rate of persistent infections or reinfections of 33% (18 cases studied).…”

“…Persistent infections of the knee joint represents a major therapeutic challenge, in which, after the failure of joint-preserving therapeutic attempts, an arthrodesis of the affected joint has proven to be one of the most reliable surgical treatments for definitive healing of infection while preserving the extremity [15]. The procedures frequently described and compared in the literature are intramedullary nail arthrodesis and EMA using an external fixator [28,29].…”

“…For many years, scientists agreed on the superiority of IMA in terms of better bone consolidation and fusion in the area around the arthrodesis; however, Balato et al came to the conclusion in their major review that there was no significant difference in bone consolidation and/or bone fusion [32]. In our patient population, safe bony consolidation of the EMA was also demonstrated in all cases with a sufficiently long time before the followup examination, which also largely corresponds with the results of Nichols et al and Robinson et al [35,38].…”

“…Examples are septic arthritis, osteomyelitis and an insufficiency of the stretching apparatus with accompanying joint infection [27]. Knee joint arthrodesis can be performed with an intramedullary nail, a tibiofemoral plate osteosynthesis or an external fixator [14][15][16]. The selection of the appropriate procedure depends on various factors.…”

Two-Stage Exchange Using a Short Intramedullary Nail for Treatment of Periprosthetic Knee Infections: A Technique Worth Questioning

“…As an alternative to conventional static immobilization, intramedullary (IM) nails have been increasingly utilized to treat infections of the knee. [18][19][20] Purported benefits of IM nails include the delivery of high concentrations of antibiotics, improved stability, and prevention of further bone loss. 21,22 Additionally, this procedure helps preserve the limb, allowing patients to be functionally independent while maintaining a normally aligned knee that patients can ambulate on soon after surgery.…”