Salvage Algorithm for Deep Surgical Site Infections after HTO with Unstable Bone Situation Using a Hexapod System – Primary Results

Abstract

Introduction

The incidence of deep surgical site infections following high tibial osteotomy (HTO) ranges between 0.4 to 4.7%. It is a severe complication with a high risk for poor clinical outcome. The aim of this study was to proof that a salvage algorithm for infected HTO with unstable bone situation leads to an infection-free status and bone union of the osteotomy and that correct limb alignment can be restored with good knee function.

Materials and Methods

The study included seven patients with peri-implant infections following HTO. Infections occurred 83 ± 58.9 days (range: 24–191) after HTO. All patients underwent the “RESTORE” algorithm: patients received (1) REmoval of the HTO hardware and extensive debridement; (2) the osteotomy was STabilized with a hexapod external fixator (Taylor Spatial Frame, TSF); (3) the osteotomy gap was Opened; and (4) the alignment was REconstructed using the TSF, aiming for the intended limb alignment of the initial HTO. Patient-reported outcomes were assessed 22–36 months after removal of the TSF.

Results

After 24 weeks (range: 11–35), an infection-free status and bone healing were achieved. In all cases, the limb was saved, and the previously targeted mechanical axis of the lower limb was restored. All patients reached full extension of the knee joint and at least 110° of flexion. For KOOS: Symptoms 67.86 ± 18.1, Pain 73.41 ± 16.58, ADL 78.99 ± 21.32, Sports 52.14 ± 25.96, and QoL 41.96 ± 24.66. OKS 35.71 ± 8.8, SF-12 Physical Health 38.89 ± 10.3, and SF-12 Mental Health 46.86 ± 13.76.

Conclusions

The “RESTORE” algorithm is a safe and effective salvage procedure. The concept allows for saving the limb and obtaining the previously planned limb alignment. Patient-reported outcome measures showed slightly lowered values than healthy samples, but substantially better values than patients awaiting HTO. Due to the possibility of initial full weight-bearing, the risk of higher morbidity caused by immobilization is minimized.

Zusammenfassung

Einleitung

Die Inzidenz von tiefen Wundinfektionen nach hoher Tibiakopf Osteotomie (HTO) variiert zwischen 0,4 und 4,7%. Tiefreichende Wundinfektionen stellen eine schwere Komplikation mit hohem Risiko für ein schlechtes klinisches Outcome dar. Ziel dieser Studie war es zu zeigen, dass ein Rettungsalgorithmus für Infektsituationen nach HTO mit instabiler knöcherner Situation, zur Infektfreiheit und knöchernen Konsolidierung der Osteotomie führt und eine korrekte Beinachse mit guter Funktionalität des Kniegelenks wiederhergestellt werden kann.

Methoden und Material

Die Studie umfasst 7 Patienten mit periimplantären Infektionen nach HTO. Infektionen traten 83 ± 58.9 Tage (Range: 24–191) nach HTO auf. Alle Patienten wurden entsprechend des „RESTORE“-Algorithmus behandelt: (1) Entfernung („Removal“) der Implantate und ausgiebiges Débridement; (2) Stabilisierung („Stabilization“) der Osteotomie mit einem Hexapod Fixateur externe (TSF); (3) Öffnen („Opening“) des Osteotomiespalts und (4) Rekonstruktion („Reconstruction“) der initial durch die HTO angestrebten Beinachse mit Hilfe des TSF. Patient-reported Outcomes wurden 22–36 Monate nach Entfernung des TSF erhoben.

Ergebnisse

Nach 24 Wochen (Range: 11–35) wurde ein infektfreier Zustand und eine knöcherne Konsolidierung erreicht. In allen Fällen konnte die Extremität erhalten werden und die ursprünglich vorgesehene mechanische Beinachse wiederhergestellt werden. Alle Patienten erreichten eine Kniebeweglichkeit mit voller Extension und mindestens 110° Flexion. KOOS-Werte: Symptome 67,86 ± 18,1, Schmerz 73,41 ± 16,58, ATL 78,99 ± 21,32, Sport 52,14 ± 25,96, Lebensqualität 41,96 ± 24,66, OKS 35,71 ± 8,8 und SF-12 körperliche Gesundheit 38,89 ± 10,3 und SF-12 psychische Gesundheit 46,86 ± 13,76.

Schlussfolgerung

Der „RESTORE“-Algorithmus ist eine sichere und effektive Rettungsprozedur. Das Konzept ermöglicht den Erhalt der Extremität und das Erreichen der initial geplanten Beinachse. Patient-reported Outcome Messungen zeigten leicht erniedrigte Werte im Vergleich zu gesunden Probanden, jedoch deutlich bessere Werte als bei Patienten vor HTO. Durch die Möglichkeit der unmittelbaren Vollbelastung ist das Risiko erhöhter Morbidität durch Immobilisation minimiert.

Keywords

HTO - infection - hexapod - Taylor spatial frame - limb alignment

Schlüsselwörter

HTO - Infektion - Hexapod - Taylor Spatial Frame - Beinachse

Publication History

Received: 06 September 2023

Accepted after revision: 17 January 2024

Article published online:
06 March 2024

• References

• 1 Hoell S, Suttmoeller J, Stoll V. et al. The high tibial osteotomy, open versus closed wedge, a comparison of methods in 108 patients. Arch Orthop Trauma Surg 2005; 125: 638-643 DOI: 10.1007/s00402-005-0004-6. (PMID: 16133475)
• 2 Capella M, Gennari E, Dolfin M. et al. Indications and results of high tibial osteotomy. Ann Joint 2017; 2: 33 DOI: 10.21037/aoj.2017.06.06.
• 3 Anagnostakos K, Mosser P, Kohn D. Infections after high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 2013; 21: 161-169 DOI: 10.1007/s00167-012-2084-5. (PMID: 22729805)
• 4 Ferner F, Lutter C, Schubert I. et al. Perioperative complications in osteotomies around the knee: a study in 858 cases. Arch Orthop Trauma Surg 2022; 142: 769-775 DOI: 10.1007/s00402-020-03696-w. (PMID: 33417020)
• 5 Schenke M, Dickschas J, Simon M. et al. Corrective osteotomies of the lower limb show a low intra- and perioperative complication rate-an analysis of 1003 patients. Knee Surg Sports Traumatol Arthrosc 2018; 26: 1867-1872 DOI: 10.1007/s00167-017-4566-y.
• 6 Waterman BR, Hoffmann JD, Laughlin MD. et al. Success of High Tibial Osteotomy in the United States Military. Orthop J Sports Med 2015; 3: 2325967115574670 DOI: 10.1177/2325967115574670. (PMID: 26665031)
• 7 Reischl N, Wahl P, Jacobi M. et al. Infections after high tibial open wedge osteotomy: a case control study. Arch Orthop Trauma Surg 2009; 129: 1483-1487 DOI: 10.1007/s00402-008-0773-9. (PMID: 19005658)
• 8 Martin R, Birmingham TB, Willits K. et al. Adverse event rates and classifications in medial opening wedge high tibial osteotomy. Am J Sports Med 2014; 42: 1118-1126 DOI: 10.1177/0363546514525929. (PMID: 24634450)
• 9 Kawata M, Jo T, Taketomi S. et al. Type of bone graft and primary diagnosis were associated with nosocomial surgical site infection after high tibial osteotomy: analysis of a national database. Knee Surg Sports Traumatol Arthrosc 2021; 29: 429-436 DOI: 10.1007/s00167-020-05943-4.
• 10 Miltenberg B, Puzzitiello RN, Ruelos VCB. et al. Incidence of Complications and Revision Surgery After High Tibial Osteotomy: A Systematic Review. Am J Sports Med 2024; 52: 258-268 DOI: 10.1177/03635465221142868. (PMID: 36779579)
• 11 Meidinger G, Imhoff AB, Paul J. et al. May smokers and overweight patients be treated with a medial open-wedge HTO? Risk factors for non-union. Knee Surg Sports Traumatol Arthrosc 2011; 19: 333-339 DOI: 10.1007/s00167-010-1335-6.
• 12 Karatosun V, Demir T, Unver B. et al. A brief report on managing infected nonunion of a high tibial osteotomy in two stages: a case series involving seven knees. J Bone Joint Surg Br 2011; 93: 904-906 DOI: 10.1302/0301-620X.93B7.25833. (PMID: 21705561)
• 13 Mariaux S, Borens O. Management of an Infected Nonunion of an Opening-Wedge High Tibial Osteotomy with 2-Stage Implantation of Rotating Hinge Knee Prosthesis. Case Rep Orthop 2018; 2018: 2493095 DOI: 10.1155/2018/2493095. (PMID: 29785313)
• 14 Seki K, Sakka A, Tokushige A. et al. Treatment forStaphylococcus aureus infection following open wedge high tibial osteotomy using antibiotic-impregnated calcium phosphate cement. Knee Surg Sports Traumatol Arthrosc 2014; 22: 2614-2617 DOI: 10.1007/s00167-013-2460-9. (PMID: 23462956)
• 15 Adili A, Bhandari M, Giffin R. et al. Valgus high tibial osteotomy. Comparison between an Ilizarov and a Coventry wedge technique for the treatment of medial compartment osteoarthritis of the knee. Knee Surg Sports Traumatol Arthrosc 2002; 10: 169-176 DOI: 10.1007/s00167-001-0250-2.
• 16 Catagni MA, Guerreschi F, Ahmad TS. et al. Treatment of genu varum in medial compartment osteoarthritis of the knee using the Ilizarov method. Orthop Clin North Am 1994; 25: 509-514 (PMID: 8028891)
• 17 Fowler J, Gie G, MacEachern A. Upper tibial valgus osteotomy using a dynamic external fixator. J Bone Joint Surg Br 1991; 73: 690-691 DOI: 10.1302/0301-620X.73B4.2071665. (PMID: 2071665)
• 18 Kitson J, Weale A, Lee A. et al. Patellar tendon length following opening wedge high tibial osteotomy using an external fixator with particular reference to later total knee replacement. Injury 2001; 32 (Suppl. 4) SD140-SD143 DOI: 10.1016/s0020-1383(01)00167-x.
• 19 Schwartsman V. Circular external fixation in high tibial osteotomy. Instr Course Lect 1995; 44: 469-474 (PMID: 7797884)
• 20 Weale A, Lee A, MacEachern A. High tibial osteotomy using a dynamic axial external fixator. Clin Orthop Relat Res 2001; 382: 154-167 DOI: 10.1097/00003086-200101000-00022. (PMID: 11153983)
• 21 Sen C, Kocaoglu M, Eralp L. The advantages of circular external fixation used in high tibial osteotomy (average 6 years follow-up). Knee Surg Sports Traumatol Arthrosc 2003; 11: 139-144 DOI: 10.1007/s00167-003-0344-0. (PMID: 12669193)
• 22 Robinson PM, Papanna MC, Somanchi BV. et al. High tibial osteotomy in medial compartment osteoarthritis and varus deformity using the Taylor spatial frame: early results. Strategies Trauma Limb Reconstr 2011; 6: 137-145 DOI: 10.1007/s11751-011-0123-2. (PMID: 22072322)
• 23 Gillooly JJ, Tilkeridis K, Simonis RB. et al. The treatment of high tibial osteotomy non-union with the Ilizarov external fixator. Strategies Trauma Limb Reconstr 2012; 7: 93-97 DOI: 10.1007/s11751-012-0138-3.
• 24 Rozbruch SR, Segal K, Ilizarov S. et al. Does the Taylor Spatial Frame accurately correct tibial deformities?. Clin Orthop Relat Res 2010; 468: 1352-1361 DOI: 10.1007/s11999-009-1161-7.
• 25 Ruedi T, Buckley R, Moran C. AO Principles of Fracture Management. 2. Thieme and AO Publishing; Stuttgart: 2007
• 26 Paley D, Herzenberg JE, Tetsworth K. et al. Deformity planning for frontal and sagittal plane corrective osteotomies. Orthop Clin North Am 1994; 25: 425-465 (PMID: 8028886)
• 27 Ahrend MD, Finger F, Grunwald L. et al. Improving the accuracy of patient positioning for long-leg radiographs using a Taylor Spatial Frame mounted rotation rod. Arch Orthop Trauma Surg 2021; 141: 55-61 DOI: 10.1007/s00402-020-03460-0. (PMID: 32377844)
• 28 Roos EM, Roos HP, Lohmander LS. et al. Knee Injury and Osteoarthritis Outcome Score (KOOS)—development of a self-administered outcome measure. J Orthop Sports Phys Ther 1998; 28: 88-96 DOI: 10.2519/jospt.1998.28.2.88. (PMID: 9699158)
• 29 Naal FD, Impellizzeri FM, Sieverding M. et al. The 12-item Oxford Knee Score: cross-cultural adaptation into German and assessment of its psychometric properties in patients with osteoarthritis of the knee. Osteoarthritis Cartilage 2009; 17: 49-52 DOI: 10.1016/j.joca.2008.05.017.
• 30 Ware jr J. , Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care 1996; 34: 220-233 DOI: 10.1097/00005650-199603000-00003. (PMID: 8628042)
• 31 Deutsche Rentenversicherung Bund. Sozialmedizinisches Glossar der Deutschen Rentenversicherung. DRV-Schriften; Berlin: 2013
• 32 Schröter S, Mueller J, van Heerwaarden R. et al. Return to work and clinical outcome after open wedge HTO. Knee Surg Sports Traumatol Arthrosc 2013; 21: 213-219 DOI: 10.1007/s00167-012-2129-9. (PMID: 22810885)
• 33 Wang CJ, Hsieh MC, Huang TW. et al. Clinical outcome and patient satisfaction in aseptic and septic revision total knee arthroplasty. Knee 2004; 11: 45-49 DOI: 10.1016/S0968-0160(02)00094-7. (PMID: 14967328)
• 34 Williamson T, Sikka R, Tompkins M. et al. Use of the Knee Injury and Osteoarthritis Outcome Score in a Healthy United States Population. Am J Sports Med 2016; 44: 440-446 DOI: 10.1177/0363546515616812. (PMID: 26657571)
• 35 Grünwald L, Angele P, Schröter S. et al. Patients’ expectations of osteotomies around the knee are high regarding activities of daily living. Knee Surg Sports Traumatol Arthrosc 2019; 27: 3022-3031 DOI: 10.1007/s00167-018-5326-3.
• 36 Hamilton DF, Giesinger JM, Patton JT. et al. Making the Oxford Hip and Knee Scores meaningful at the patient level through normative scoring and registry data. Bone Joint Res 2015; 4: 137-144 DOI: 10.1302/2046-3758.48.2000524.
• 37 Robinson PM, Papanna MC, Somanchi BV. et al. High tibial osteotomy in medial compartment osteoarthritis and varus deformity using the Taylor spatial frame: early results. Strat Traum Limb Recon 2011; 6: 137-145 DOI: 10.1007/s11751-011-0123-2.
• 38 Winkler T, Stuhlert MGW, Lieb E. et al. Outcome of short versus long interval in two-stage exchange for periprosthetic joint infection: a prospective cohort study. Arch Orthop Trauma Surg 2019; 139: 295-303 DOI: 10.1007/s00402-018-3052-4. (PMID: 30443674)
• 39 Berend KR, Lombardi AV jr., Morris MJ. et al. Two-stage treatment of hip periprosthetic joint infection is associated with a high rate of infection control but high mortality. Clin Orthop Relat Res 2013; 471: 510-518 DOI: 10.1007/s11999-012-2595-x.
• 40 Nubling M, Andersen HH, Mühlbacher A. Entwicklung eines Verfahrens zur Berechnung der körperlichen und psychischen Summenskalen auf Basis der SOEP-Version des SF-12 (Algorithmus). DIW; Berlin: 2006. Accessed January 19, 2024 at: https://www.diw.de/documents/publikationen/73/diw_01.c.44987.de/diw_datadoc_2006–016.pdf