Arthrodesis of the knee joint is a mainly a salvage surgical procedure performed in cases of

infected total knee arthroplasty, tumor, failed kneearthroplasty or posttraumatic complication.

The authors report 9 cases of KAM with flap

Knee arthrodesis is an established procedure for limb salvage after failed

total knee arthroplasty (TKA) in cases of recurrent infection, soft tissue
damage, reduced bone stock or with a deficient extensor mechanism.
Walking with an arthrodesis is more efficient and less costly in terms of
energy expenditure than above-knee amputation. Surgical options include
an arthrodesis nail, external fixator or compression plate. We present our
results of knee arthrodesis using the modular Wichita Fusion Nail in
patients after infected TKA.
Methods

Fifteen patients with irretrievably failed TKA, due to infection, who underwent
arthrodesis with the Wichita Fusion Nail from 2004 to 2012 were retrospectively
reviewed to assess fusion rate, time to fusion, complication rate, including new
infections, and ambulatory status.

Conclusion
Arthrodesis with the Wichita Fusion Nail provides satisfactory results in patients with
failure after infected TKA, with 75 % primary union rate and no new or persistent
infection at last follow-up visit. Although burdened with a high complication rate, it
represents an acceptable option for limb salvage in this particular pathology.

OBJECTIVE:
To evaluate the outcome of knee fixation without bone fusion using an intramedullary modular
nail and interposed cement.
MATERIAL AND METHODS:
Retrospective study of 29 infected total knee arthroplasties with prospective data collection and
a mean follow-up of 4.2 years (3-5).
RESULTS:
Complications included 2 recurrent infections, 1 peri-implant fracture, and 1 cortical erosion due
to the tip of the femoral component. All of these were revised with successful results. The mean
limb length discrepancy was 0.8 cm, with 24<1cm. Twenty-five patients reported no pain. The
mean WOMAC-pain was 86.9, WOMAC-function 56.4, SF12-physical 45.1, and SF12-mental
53.7. Four patients needed a walking frame, and only two were dependent for daily activities.
CONCLUSIONS:
The Endo-Model Link nail is an effective method for knee fixation that restores the anatomical
alignment of the limb with adequate leg length.
Copyright 2014 SECOT. Published by Elsevier Espana. All rights reserved.

Evaluar los resultados de la fijacin de rodilla sin fusin sea, con clavo intramedular e
interposicin de cemento.
Material y mtodos
Estudio retrospectivo de 29 prtesis total de rodilla infectadas con datos recogidos
prospectivamente y seguimiento medio de 4,2 aos (3-5).
Resultados
Las complicaciones fueron 2 infecciones recurrentes, una fractura periimplante y una
erosin cortical en la punta del componente femoral, siendo todas revisadas con buen
resultado. La dismetra media fue 0,8 cm, con 24 < 1 cm. Veinticinco pacientes no
referan dolor. El valor medio de WOMAC-dolor fue 86,9, WOMAC-funcin 56,4,
SF12-fsico 45,1, y SF12-mental 53,7. Cuatro pacientes precisaron andador y solo 2
eran dependientes para actividades diarias.
Conclusiones
El clavo Endo-Model Link es un efectivo mtodo de fijacin de rodilla, restaurando la
alineacin del miembro y adecuada longitud del mismo.

Abstract
Multiple total knee arthroplasty revisions pose significant surgical challenges, such as
bone loss and soft tissue compromise. For patients with bone loss and extensor
mechanism insufficiency after total knee arthroplasty, arthrodesis is a treatment option
for the avoidance of amputation. However, arthrodesis is both difficult to achieve in
situations with massive bone loss and potentially undesirable due to the dramatic
shortening that follows. Although intramedullary nailing for knee arthrodesis has been
widely reported, this technique has traditionally relied on the achievement of bony
union. We report a case of a patient with massive segmental bone loss in which a
modular intercalary prosthesis was used for arthrodesis to preserve limb length without
bony union.

Keywords

knee;

revision;

arthrodesis;

infection;

intramedullary

As the mean age of patients undergoing primary total knee arthroplasty (TKA)
continues to decrease 1 and 2, more solutions for revision TKA will be necessary to
meet patients' long-term functional expectations. Active patients undergoing primary
TKA at relatively young ages may require multiple revisions, with subsequent
procedures presenting such technical challenges as increasing bone loss and
compromise of the soft tissue envelope.
For those patients with massive segmental defects and concomitant extensor mechanism
impairment, therapeutic options are limited chiefly to knee arthrodesis or transfemoral
amputation. Although the choice is highly patient specific, arthrodesis confers the
potential benefits of limb preservation and improved biomechanical efficiency when
compared with transfemoral amputation with the use of a prosthesis 3 and 4. However,
these benefits may be obviated if excessive limb shortening is required to achieve bony
union [5]. As a result, there are situations in which it might be preferable to use an
implant that does not require bony union across the knee for stability. We present one
such case of a patient: status-post multiple TKA revisions with massive femoral and
tibial bone loss and extensor mechanism impairment. The patient provided written
informed consent for print and electronic publication of this report.

Discussion

Because TKA aims to relieve pain and restore near-physiologic motion, knee arthrodesis
represents a suboptimal solution to the problem of a knee that is no longer amenable to
revision arthroplasty. Despite this apparent compromise, results achieved with knee
arthrodesis after failed TKA are encouraging when considered relative to those of
transfemoral amputation. In one series of patients with tumors about the knee, Renard et
al reported that functional scores were significantly higher in patients undergoing knee
arthrodesis as opposed to amputation, but that rates of complications and revision
procedures were more common with attempts at limb salvage [6]. For the patient not
prepared to accept the functional limitations imposed by transfemoral amputation,
arthrodesis remains an option for the relative preservation of function. Barton et al [7]
reported that clinical outcome scores in patients after arthrodesis for failed primary
TKA have even proven comparable with those of revision TKA. Despite these reported
successful outcomes, arthrodesis is difficult to achieve after substantial bone loss and
results in considerable limb length discrepancy that can severely limit function. Patients
are often required to use extremely large shoe lifts that can be both heavy and awkward
to use.
We are aware of only one prior reported case of the use of the DePuy LPS implant for
arthrodesis after failed TKA. Rao et al [8] reported comprehensively on 7 patients who
had significant bone loss and extensor mechanism insufficiency after infected and
multiply-revised TKA. Initial arthrodesis was attempted in all patients with the EndoModel Knee Fusion Nail (Newsplint, UK/Waldemar-Link; GmbH & Co. KG, Hamburg,
Germany). Two patients required revision of the fusion nail, one of whom underwent
implantation of the DePuy LPS for limb preservation. In addition to a modular
intercalary prosthesis, we used impaction bone grafting, a technique that has
demonstrated successful results in revision TKA with bone loss 9, 10, 11, 12 and 13. We
used this technique as a means of accounting for the capacious femoral and tibial canals
resulting from multiple reamings and to increase surface area for cement grip. Though
this prosthesis was specifically designed for tumor patients, many cases of bone loss are
found in younger, more active individuals who may have a relatively long life
expectancy. As a result, the durability of this method of limb preservation remains
undetermined. It is evident that fixation is limited to short segments within the femur
and tibia, and the stress concentration at the tips of these implants may lead to pain,
loosening, or fracture.
Although there are numerous reports of intramedullary nailing for arthrodesis after TKA
14, 15, 16, 17, 18, 19, 20 and 21, they have focused primarily on the achievement of
bony union for long-term stability. Indeed, patients with persistent nonunion despite
intramedullary nailing often proceed to transfemoral amputation 15 and 21. The use of a
modular intercalary prosthesis allows for arthrodesis and preservation of limb length
despite massive bone loss. Additional long-term follow-up data are necessary, however,
before any definitive conclusions can be drawn regarding the theoretical benefits of this
strategy.

Conclusion
For patients with massive bone loss and extensor mechanism insufficiency after TKA,
knee arthrodesis is a suboptimal treatment option for the avoidance of amputation. The
use of a modular intercalary prosthesis may allow for the preservation of limb length
and good functional outcome without reliance on bony union for long-term stability.

Further experience with such implants is necessary before conclusions may be drawn
about their long-term efficacy.

Mltiples revisiones de artroplastia total de rodilla plantean desafos

quirrgicos significativos, tales como prdida de masa sea y el compromiso
de los tejidos blandos. Para los pacientes con prdida de masa sea y la
insuficiencia del mecanismo extensor despus de artroplastia total de
rodilla, artrodesis es una opcin de tratamiento para evitar la amputacin.
Sin embargo, la artrodesis es tanto difcil de lograr en situaciones con la
prdida de hueso masiva y potencialmente indeseable debido al
acortamiento dramtico que sigue. A pesar de que el enclavado
intramedular para la artrodesis de rodilla se ha informado ampliamente,
esta tcnica se ha basado tradicionalmente en la realizacin de la unin
sea. Se presenta un caso de un paciente con prdida sea segmentaria
masivo en el que se utiliz una prtesis modular para intercalar artrodesis
para preservar la longitud del miembro sin unin sea.
Palabras clave
rodilla;
revisin;
artrodesis;
infeccin;
intramedular
A medida que la edad media de los pacientes sometidos a artroplastia total
de rodilla primaria (ATR) contina disminuyendo 1 y 2, sern necesarios ms
soluciones para ATR de revisin para satisfacer las expectativas funcionales
a largo plazo de los pacientes. Los pacientes activos sometidos a ATR
primaria a edades relativamente jvenes pueden requerir mltiples
revisiones, con procedimientos posteriores que presentan desafos tcnicos
tales como el aumento de la prdida de hueso y el compromiso de la
envoltura de tejido blando.
Para aquellos pacientes con defectos segmentarios masivos y extensor
concomitante mecanismo de deterioro, las opciones teraputicas son
limitadas principalmente a la artrodesis de rodilla o la amputacin
transfemoral. Aunque la eleccin es altamente especfica del paciente, la
artrodesis confiere los beneficios potenciales de la preservacin del
miembro y la mejora de la eficacia biomecnica en comparacin con
amputacin transfemoral con el uso de una prtesis 3 y 4. Sin embargo,
estos beneficios se puede evitar si se requiere el acortamiento del miembro
excesiva para lograr unin sea [5]. Como resultado, hay situaciones en las

que podra ser preferible usar un implante que no requiere la unin sea a
travs de la rodilla para la estabilidad. Presentamos un caso de un paciente:
estado post mltiples revisiones con TKA femoral masiva y la prdida sea
de la tibia y el deterioro del mecanismo extensor. El paciente proporcionado
consentimiento informado por escrito para la impresin y publicacin
electrnica de este informe.

Discusin
Debido TKA pretende aliviar el dolor y restaurar el movimiento casi
fisiolgica, artrodesis de rodilla representa una solucin subptima para el
problema de una rodilla que ya no es susceptible a la artroplastia de
revisin. A pesar de esta aparente compromiso, los resultados obtenidos con
la artrodesis de rodilla, tras fracaso de la ATR son alentadores cuando se
considera en relacin con los de la amputacin transfemoral. En una serie
de pacientes con tumores de la rodilla, Renard et al informaron de que las
puntuaciones funcionales fueron significativamente mayores en los
pacientes sometidos a la artrodesis de la rodilla en lugar de amputacin,
pero que las tasas de complicaciones y procedimientos de revisin fueron
ms comunes con los intentos de recuperacin de la extremidad [6] . Para el
paciente no est dispuesto a aceptar las limitaciones funcionales impuestas
por la amputacin transfemoral, artrodesis sigue siendo una opcin para la
preservacin de la funcin relativa. Barton et al [7] inform que las
puntuaciones de resultados clnicos en los pacientes despus de la
artrodesis fallida TKA primaria incluso han demostrado ser comparables con
los de ATR de revisin. A pesar de estos resultados positivos reportados,
artrodesis es difcil de lograr despus de la prdida sea sustancial y da
como resultado una considerable diferencia de longitud de las extremidades
que puede limitar gravemente la funcin. Los pacientes a menudo estn
obligados a utilizar los ascensores de zapatos muy grandes que pueden ser
tanto pesados y difciles de usar.
Somos conscientes de un solo caso reportado antes del uso del implante
DePuy LPS para artrodesis tras fracaso de la ATR. Rao et al [8] inform de
manera integral en 7 pacientes que tuvieron significativa la prdida sea y
la insuficiencia del mecanismo extensor despus de TKA infectada y se
multiplican revisada. artrodesis inicial se intent en todos los pacientes con
el clavo de Endo-Model Fusin rodilla (Newsplint, Reino Unido / WaldemarLink; GmbH & Co. KG, Hamburgo, Alemania). Dos pacientes requirieron
revisin de la ua de fusin, uno de los cuales se sometieron a la
implantacin de la LPS DePuy para la preservacin del miembro. Adems de
una prtesis modular de intercalado, se utiliz un injerto seo impactado,
una tcnica que ha demostrado resultados exitosos en ATR de revisin con
la prdida de hueso 9, 10, 11, 12 y 13. Se utiliz esta tcnica como un
medio para contabilizar la femoral de gran capacidad y los canales de tibia
resultante de mltiples reamings y para aumentar la superficie de agarre de
cemento. A pesar de esta prtesis se dise especficamente para pacientes

con tumores, muchos casos de prdida sea se encuentran en los individuos

ms jvenes, ms activos que pueden tener una esperanza de vida
relativamente larga. Como resultado, la durabilidad de este mtodo de
preservacin del miembro permanece indeterminado. Es evidente que la
fijacin se limita a segmentos cortos dentro del fmur y la tibia, y la
concentracin de esfuerzos en las puntas de estos implantes puede
conducir a dolor, aflojamiento o fractura.
Aunque existen numerosos informes de clavos intramedulares para la
artrodesis despus de la ATR 14, 15, 16, 17, 18, 19, 20 y 21, se han
centrado principalmente en la realizacin de la unin sea para la
estabilidad a largo plazo. De hecho, los pacientes con falta de unin
persistente a pesar de enclavado intramedular a menudo proceder a la
amputacin transfemoral 15 y 21. El uso de una prtesis de intercalar
modular permite la artrodesis y la conservacin de la longitud del miembro
a pesar de la prdida de hueso masiva. Los datos de seguimiento a largo
plazo adicionales son necesarios, sin embargo, antes de sacar conclusiones
definitivas se pueden extraer con respecto a los beneficios tericos de esta
estrategia.
Conclusin
Para los pacientes con prdida de hueso masiva e insuficiencia mecanismo
extensor despus de TKA, la artrodesis de la rodilla es una opcin de
tratamiento subptimo para evitar la amputacin. El uso de una prtesis
modular intercalado puede permitir la preservacin de la longitud de las
extremidades y el buen resultado funcional sin depender de la unin sea
para la estabilidad a largo plazo. Ms experiencia con este tipo de implantes
es necesario antes de que se pueden extraer conclusiones sobre su eficacia
a largo plazo.
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