|Year : 2020 | Volume
| Issue : 1 | Page : 77-80
Knee Arthrodesis Using Ilizarov Method with Autogenous Bone Graft Application in a Second-Stage Surgery: A Case Report of a Morbidly Obese and Diabetic Patient with a Septic Failure of Total Knee Arthroplasty
Ricardo Marta1, Luís Maia1, Carlos Vilela2, João Carvalho3
1 Department of Orthopaedic Surgery, Hospital da Senhora da Oliveira, Guimarães, Portugal
2 Department of Orthopaedic Surgery, Hospital da Senhora da Oliveira, Guimarães; School of Medicine; Life and Health Sciences Research Institute and 3B's Research Group, University of Minho, Portugal
3 Department of Orthopaedic Surgery, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
|Date of Submission||29-Feb-2020|
|Date of Decision||20-Mar-2020|
|Date of Acceptance||31-Mar-2020|
|Date of Web Publication||30-Jun-2020|
Dr. Ricardo Marta
Department of Orthopaedic Surgery, Hospital da Senhora da Oliveira, Guimarães
Source of Support: None, Conflict of Interest: None
Currently, the main indication for knee arthrodesis is septic failure of a total knee arthroplasty (TKA). Circular external fixation has shown good results, and it is a good option to treat these cases. We present a case of a morbidly obese female, 55 years old, with a chronic septic failure of TKA, submitted to a knee arthrodesis using the Ilizarov technique. In a second-stage surgery, the remaining bone defect was filled with autogenous iliac crest graft. A radiographic and clinical fusion was verified 3 and 5 months, respectively, after the primary surgery. Twelve months later, she is very satisfied with the surgery results, presenting a Visual Analog Scale score 1 and a stable and pain-free lower limb. The residual limb length discrepancy was 3 cm, and she walks with a shoe lift without external support. Our case emphasizes the importance of autogenous bone graft application in a second-stage surgery to a successful and fast knee arthrodesis using the Ilizarov method in patients with chronic septic failure of TKA and severe comorbidities.
Keywords: Autogenous graft, Ilizarov method, knee arthrodesis, morbid obesity, periprosthetic infection, total knee arthroplasty
|How to cite this article:|
Marta R, Maia L, Vilela C, Carvalho J. Knee Arthrodesis Using Ilizarov Method with Autogenous Bone Graft Application in a Second-Stage Surgery: A Case Report of a Morbidly Obese and Diabetic Patient with a Septic Failure of Total Knee Arthroplasty. J Limb Lengthen Reconstr 2020;6:77-80
|How to cite this URL:|
Marta R, Maia L, Vilela C, Carvalho J. Knee Arthrodesis Using Ilizarov Method with Autogenous Bone Graft Application in a Second-Stage Surgery: A Case Report of a Morbidly Obese and Diabetic Patient with a Septic Failure of Total Knee Arthroplasty. J Limb Lengthen Reconstr [serial online] 2020 [cited 2020 Sep 21];6:77-80. Available from: http://www.jlimblengthrecon.org/text.asp?2020/6/1/77/288570
| Introduction|| |
Patients with multiple septic failures of total knee arthroplasty (TKA) are the main indication to knee arthrodesis, which is the best choice for those patients with extensive bone loss, extensor apparatus deficit, and recurring knee infections. Ilizarov external fixator has showed good results, and it is a good option to treat these cases.,,,
| Case Report|| |
A 55-year-old female, with hypertension, uncontrolled diabetes mellitus, and morbid obesity (body mass index: 43), underwent 12 surgeries in the past 6 years due to chronic septic failure of TKA. The microbiological culture examination was positive for Methicillin-resistant Staphylococcus aureus, Morganella morganii, and Citrobacter koseri, and the antibiotic sensitivity was tested, but without success in infection eradication. She had a high bone stock deficiency-type III Anderson Orthopaedic Research Institute bone classification [Table 1] and [Figure 1]. She was informed about the advantages and disadvantages of a knee arthrodesis using the Ilizarov technique, which promptly agreed. Surgery was performed through the previous surgical scar, with an excision of sinus and scar margin. Thorough debridement and wash were done, the bone edges were freshened with a saw or bone file, and approximation of the bone ends was achieved by good bony coaptation and compression. The femoral and tibial frames were applicated and adjusted [Figure 2]. Wounds were closed in 1 layer over a suction drain. Compression was started from day 1 at the rate 0.5 mm/day in one weekly sitting till radiological appearance of complete compression. Weight-bearing was allowed as tolerated. She completed oral antibiotics for 4 weeks based on the previous sensitivity reports. One month later, the remaining bone defect was filled with autogenous iliac crest graft. Radiographic fusion was defined as trabecular bridging along the whole fusion area in both the anteroposterior and lateral planes. Once it was observed, the connecting rods were removed to clinically assess the fusion by varus/valgus stress test. A clinically stable arthrodesis without pain was the criterion for successful fusion. A radiographic and clinical fusion was verified 3 and 5 months, respectively, after the primary surgery. At 5-month follow-up, the fixator was removed and the patient was put on knee brace for 3 weeks [Figure 3]. The residual limb length discrepancy was 3 cm, and she walks with a shoe lift of 1 cm without external support. Twelve months later, she is very satisfied with the surgery results, presenting a Visual Analog Scale score 1 and a stable and pain-free lower limb [Figure 4]. She has no clinical or analytical inflammatory signs.
|Figure 1: Preoperative anteroposterior and lateral radiographs showing knee condition after chronic septic failure of total knee arthroplasty|
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|Figure 2: Postoperative anteroposterior and lateral radiographs showing knee fixation with circular external fixator|
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|Figure 3: Anteroposterior and lateral radiographs after the removal of circular external fixation|
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| Discussion|| |
Reported union rates with circular external fixator ranged from 76.5% to 93.8%, and the mean fusion time ranged from 7.1 to 14.2 months [Table 2].,,, In comparison with other arthrodesis techniques, only the Ilizarov method provides a mechanical stimulus for bone formation and improves the quality of the bone and of the microcirculation, which enhances the host response against infection. Our case shows a completed knee arthrodesis in a morbidly obese and diabetic patient at 5-month follow-up, which is within the time range of knee arthrodesis using the Ilizarov technique reported until now.,,, We believe that the contribution of autogenous bone graft in a second-stage surgery may be crucial for a successful and fast arthrodesis.
| Conclusion|| |
Autogenous bone graft application in a second-stage surgery may increase the success rate of knee arthrodesis using the Ilizarov method in patients with complicated septic failure of TKA and severe comorbidities.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Van Rensch PJ, Van de Pol GJ, Goosen JH, Wymenga AB, De Man FH. Arthrodesis of the knee following failed arthroplasty. Knee Surg Sports Traumatol Arthrosc 2014;22:1940-8.
Spina M, Gualdrini G, Fosco M, Giunti A. Knee arthrodesis with the Ilizarov external fixator as treatment for septic failure of knee arthroplasty. J Orthop Traumatol 2010;11:81-8.
Reddy VG, Kumar RV, Mootha AK, Thayi C, Kantesaria P, Reddy D. Salvage of infected total knee arthroplasty with Ilizarov external fixator. Indian J Orthop 2011;45:541-7.
] [Full text]
Kuchinad R, Fourman MS, Fragomen AT, Rozbruch SR. Knee arthrodesis as limb salvage for complex failures of total knee arthroplasty. J Arthroplasty 2014;29:2150-5.
Bruno AA, Kirienko A, Peccati A, Dupplicato P, De Donato M, Arnaldi E, et al
. Knee arthrodesis by the Ilizarov method in the treatment of total knee arthroplasty failure. Knee 2017;24:91-9.
Engh GA, Ammeen DJ. Classification and preoperative radiographic evaluation: Knee. Orthop Clin North Am 1998;29:205-17.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]