Effectiveness of one-stage total knee arthroplasty in treatment of advanced active knee tuberculosis_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

HUO Shoujie ¹ , CHEN Quan ¹ , LI Yicheng ¹ , GUO Xiaobin ¹ , ZHANG Xiaogang ¹ ,  CAO Li ^1,2,3

1. Department of Joint Surgery, the First Affiliated Hospital of Xinjiang Medical University, Urumqi Xinjiang, 830054, P. R. China;
2. Key Laboratory of High Incidence Diseases Research in Xinjiang Ministry of Education (Xinjiang Medical University), Urumqi Xinjiang, 830054, P. R. China;
3. Xinjiang Clinical Research Center for Orthopedics, Urumqi Xinjiang, 830011, P. R. China;

Corresponding author：

CAO Li, Email: xjbone@sina.com

Keywords：

Knee tuberculosis; total knee arthroplasty; antitubercular therapy

DOI：

10.7507/1002-1892.202305027

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Objective To investigate the effectiveness of one-stage total knee arthroplasty (TKA) in the treatment of advanced active knee tuberculosis. Methods The clinical data of 38 patients with advanced active knee tuberculosis who received one-stage TKA between January 2011 and December 2020 were retrospectively analyzed. There were 20 males and 18 females. The age ranged from 20 to 84 years, with an average of 52.8 years. The body mass index ranged from 17 to 36 kg/m², with an average of 23.05 kg/m². The preoperative C reactive protein (CRP) was (23.49±4.72) mg/L, erythrocyte sedimentation rate (ESR) was (45.95±8.82) mm/1 h. The Hospital for Special Surgery (HSS) score was 48.8±9.1. During the operation, the infected lesions of the knee joint were completely removed, and the operative area was repeatedly soaked with 3% hydrogen peroxide solution and 0.5% povidone iodine solution. The intraoperative pathological examination confirmed the tuberculosis of the knee joint, and systemic anti-tuberculosis treatment was performed. The operation time, postoperative hospitalization stay, postoperative anti-tuberculosis chemotherapy time, and complications were recorded. CRP and ESR were recorded and compared before and after operation. Anteroposterior and lateral X-ray films of the knee joint were taken to evaluate whether the prosthesis had signs of loosening and sinking, and to determine whether there was recurrence of tuberculosis. The knee joint function was evaluated by HSS score. With treatment failure due to any reason as the end event, the survival time of prosthesis was analyzed by Kaplan-Meier survival curve. Results All operations were successfully completed without fracture, vascular and nerve injury, deep vein thrombosis, and other complications. All incisions healed by first intention after operation. The operation time ranged from 80 to 135 minutes, with an average of 102.76 minutes; postoperative hospitalization stay was 5-16 days, with an average of 9.7 days; the duration of postoperative anti-tuberculosis chemotherapy ranged from 1 to 18 months, and the median duration was 12 months. All 38 cases were followed up 3-133 months (mean, 63.7 months). At last follow-up, CRP was (4.88±1.24) mg/L and ESR was (13.00±2.97) mm/1 h, both of which were significantly lower than those before operation (t=20.647, P<0.001; t=20.886, P<0.001). During the follow-up, 3 patients (7.89%) had tuberculosis recurrence. Two patients had tuberculosis recurrence due to withdrawal of anti-tuberculosis chemotherapy at 1 and 2 months after operation, respectively. One patient was cured after debridement, preservation of prosthesis and anti-tuberculosis chemotherapy for 12 months, and 1 patient was cured after oral administration of anti-tuberculosis drugs for 12 months. Another 1 patient had recurrent tuberculosis and mixed infection (Corynebacterium gehreni) at 2 months after operation, and the infection was not controlled after debridement, and finally the thigh was amputated. Except for the patients with recurrent infection, no complications such as prosthesis loosening, periprosthetic fracture, and periprosthetic infection were found. At last follow-up, the HSS score of the knee joint was 86.8±4.8, and the knee joint function significantly improved when compared with that before operation (t=−31.198, P<0.001). Prosthesis survival time was (122.57±5.77) months [95%CI (111.25, 133.88) months], and the 10-year survival rate was 92.1%. Conclusion One-stage TKA combined with postoperative antituberculous chemotherapy in the treatment of advanced active knee tuberculosis can achieve satisfactory infection control and joint function.

Citation： HUO Shoujie, CHEN Quan, LI Yicheng, GUO Xiaobin, ZHANG Xiaogang, CAO Li. Effectiveness of one-stage total knee arthroplasty in treatment of advanced active knee tuberculosis. Chinese Journal of Reparative and Reconstructive Surgery, 2023, 37(9): 1068-1074. doi: 10.7507/1002-1892.202305027 Copy

1.	张军. 膝关节结核诊断与治疗. 中国骨与关节损伤杂志, 2015, 30(12): 1342-1344.
2.	庞波涛, 曹力. 活动期髋、膝关节结核: 可行一期人工关节置换? 中国组织工程研究, 2013, 17(26): 4880-4887.
3.	Öztürkmen Y, Üzümcügil O, Karamehmetoğlu M, et al. Total knee arthroplasty for the management of joint destruction in tuberculous arthritis. Knee Surg Sports Traumatol Arthroscy, 2014, 22(5): 1076-1083.
4.	Zeng M, Xie J, Wang L, et al. Total knee arthroplasty in advanced tuberculous arthritis of the knee. Int Orthop, 2016, 40(7): 1433-1439.
5.	张志昌, 黄媛霞, 耿晓林, 等. 一期全膝关节置换术治疗晚期活动性膝关节结核. 中国骨与关节损伤杂志, 2022, 37(4): 407-410.
6.	Su JY, Huang TL, Lin SY. Total knee arthroplasty in tuberculous arthritis. Clin Orthop Relat Res, 1996, (323): 181-187.
7.	Ha KY, Chung YG, Ryoo SJ. Adherence and biofilm formation of Staphylococcus epidermidis and Mycobacterium tuberculosis on various spinal implants. Spine (Phila Pa 1976), 2005, 30(1): 38-43.
8.	Oga M, Arizono T, Takasita M, et al. Evaluation of the risk of instrumentation as a foreign body in spinal tuberculosis. Clinical and biologic study. Spine (Phila Pa 1976), 1993, 18(13): 1890-1894.
9.	Neogi DS, Yadav CS, Kumar A, et al. Total hip arthroplasty in patients with active tuberculosis of the hip with advanced arthritis. Clin Orthop Relat Res, 2010, 468(2): 605-612.
10.	Lim HC, Bae JH, Hur CR, et al. Arthrodesis of the knee using cannulated screws. J Bone Joint Surg (Br), 2009, 91(2): 180-184.
11.	Bae DK, Yoon KH, Kim HS, et al. Total knee arthroplasty in stiff knees after previous infection Patients and Methods. J Bone Joint Surg (Br), 2005, 87(3): 333-336.
12.	Tuli SM. Tuberculosis of the skeletal system (bones, joints, spine and bursal sheaths). 2nd ed. New Delhi, India: Jaypee Brothers Medical Publishers, 1997: 112-130..Tuli SM. Tuberculosis of the skeletal system (bones, joints, spine and bursal sheaths). 2nd ed. New Delhi, India: Jaypee Brothers Medical Publishers, 1997: 112-130.
13.	Yoon TR, Rowe SM, Santosa SB, et al. Immediate cementless total hip arthroplasty for the treatment of active tuberculosis. J Arthroplasty, 2005, 20(7): 923-926.
14.	张晓岗, 任姜栋, 曹力, 等. 一期全髋关节置换术治疗晚期活动性髋关节结核. 中华骨科杂志, 2013, 33(1): 8-13.
15.	Eskola A, Santavirta S, Konttinen YT, et al. Arthroplasty for old tuberculosis of the knee. J Bone Joint Surg (Br), 1988, 70(5): 767-769.
16.	Kim YH. Total knee arthroplasty for tuberculous arthritis. J Bone Joint Surg (Am), 1988, 70(9): 1322-1330.
17.	Habaxi KK, Wang L, Miao XG, et al. Total knee arthroplasty treatment of active tuberculosis of the knee: a review of 10 cases. Eur Rev Med Pharmacol Sci, 2014, 18(23): 3587-3592.
18.	米尔阿地力·麦麦提依明, 赵巍, 阿布都艾尼·热吾提, 等. 一期人工关节置换治疗晚期活动性膝关节结核. 骨科, 2020, 11(3): 192-198.
19.	黄迅悟, 冯会成, 孙继桐, 等. 活动性髋关节结核一期病灶清除全髋关节置换28例报告. 中华骨科杂志, 2013, 33(5): 495-500.
20.	Hernandez P, Sager B, Fa A, et al. Bactericidal efficacy of hydrogen peroxide on Cutibacterium acnes. Bone Joint Res, 2019, 8(1): 3-10.
21.	van Meurs SJ, Gawlitta D, Heemstra KA, et al. Selection of an optimal antiseptic solution for intraoperative irrigation: An in vitro study. J Bone Joint Surg (Am), 2014, 96(4): 285-291.
22.	Siddiqi A, Abdo ZE, Springer BD, et al. Pursuit of the ideal antiseptic irrigation solution in the management of periprosthetic joint infections. J Bone Jt Infect, 2021, 6(6): 189-198.
23.	Lu M, Hansen EN. Hydrogen peroxide wound irrigation in orthopaedic surgery. J Bone Jt Infect, 2017, 2(1): 3-9.
24.	Presterl E, Suchomel M, Eder M, et al. Effects of alcohols, povidone-iodine and hydrogen peroxide on biofilms of Staphylococcus epidermidis. J Antimicrob Chemother, 2007, 60(2): 417-420.
25.	Glynn AA, O’Donnell ST, Molony DC, et al. Hydrogen peroxide induced repression of icaADBC transcription and biofilm development in Staphylococcus epidermidis. J Orthop Res, 2009, 27(5): 627-630.
26.	Siddiqi A, Abdo ZE, Rossman SR, et al. What is the optimal irrigation solution in the management of periprosthetic hip and knee joint infections? J Arthroplasty, 2021, 36(10): 3570-3583.
27.	Brown NM, Cipriano CA, Moric M, et al. Dilute betadine lavage before closure for the prevention of acute postoperative deep periprosthetic joint infection. J Arthroplasty, 2012, 27(1): 27-30.
28.	Chundamala J, Wright JG. The efficacy and risks of using povidone-iodine irrigation to prevent surgical site infection: an evidence-based review. Can J Surg, 2007, 50(6): 473-481.
29.	Rikimaru T, Kondo M, Kondo S, et al. Efficacy of common antiseptics against mycobacteria. Int J Tuberc Lung Dis, 2000, 4(6): 570-576.
30.	Rikimaru T, Kondo M, Kajimura K, et al. Bactericidal activities of commonly used antiseptics against multidrug-resistant mycobacterium tuberculosis. Dermatology, 2002, 204 Suppl 1: 15-20.
31.	Wang Q, Shen H, Jiang Y, et al. Cementless total hip arthroplasty for the treatment of advanced tuberculosis of the hip. Orthopedics, 2011, 34(2): 90.

1. 张军. 膝关节结核诊断与治疗. 中国骨与关节损伤杂志, 2015, 30(12): 1342-1344.
2. 庞波涛, 曹力. 活动期髋、膝关节结核: 可行一期人工关节置换? 中国组织工程研究, 2013, 17(26): 4880-4887.
3. Öztürkmen Y, Üzümcügil O, Karamehmetoğlu M, et al. Total knee arthroplasty for the management of joint destruction in tuberculous arthritis. Knee Surg Sports Traumatol Arthroscy, 2014, 22(5): 1076-1083.
4. Zeng M, Xie J, Wang L, et al. Total knee arthroplasty in advanced tuberculous arthritis of the knee. Int Orthop, 2016, 40(7): 1433-1439.
5. 张志昌, 黄媛霞, 耿晓林, 等. 一期全膝关节置换术治疗晚期活动性膝关节结核. 中国骨与关节损伤杂志, 2022, 37(4): 407-410.
6. Su JY, Huang TL, Lin SY. Total knee arthroplasty in tuberculous arthritis. Clin Orthop Relat Res, 1996, (323): 181-187.
7. Ha KY, Chung YG, Ryoo SJ. Adherence and biofilm formation of Staphylococcus epidermidis and Mycobacterium tuberculosis on various spinal implants. Spine (Phila Pa 1976), 2005, 30(1): 38-43.
8. Oga M, Arizono T, Takasita M, et al. Evaluation of the risk of instrumentation as a foreign body in spinal tuberculosis. Clinical and biologic study. Spine (Phila Pa 1976), 1993, 18(13): 1890-1894.
9. Neogi DS, Yadav CS, Kumar A, et al. Total hip arthroplasty in patients with active tuberculosis of the hip with advanced arthritis. Clin Orthop Relat Res, 2010, 468(2): 605-612.
10. Lim HC, Bae JH, Hur CR, et al. Arthrodesis of the knee using cannulated screws. J Bone Joint Surg (Br), 2009, 91(2): 180-184.
11. Bae DK, Yoon KH, Kim HS, et al. Total knee arthroplasty in stiff knees after previous infection Patients and Methods. J Bone Joint Surg (Br), 2005, 87(3): 333-336.
12. Tuli SM. Tuberculosis of the skeletal system (bones, joints, spine and bursal sheaths). 2nd ed. New Delhi, India: Jaypee Brothers Medical Publishers, 1997: 112-130..Tuli SM. Tuberculosis of the skeletal system (bones, joints, spine and bursal sheaths). 2nd ed. New Delhi, India: Jaypee Brothers Medical Publishers, 1997: 112-130.
13. Yoon TR, Rowe SM, Santosa SB, et al. Immediate cementless total hip arthroplasty for the treatment of active tuberculosis. J Arthroplasty, 2005, 20(7): 923-926.
14. 张晓岗, 任姜栋, 曹力, 等. 一期全髋关节置换术治疗晚期活动性髋关节结核. 中华骨科杂志, 2013, 33(1): 8-13.
15. Eskola A, Santavirta S, Konttinen YT, et al. Arthroplasty for old tuberculosis of the knee. J Bone Joint Surg (Br), 1988, 70(5): 767-769.
16. Kim YH. Total knee arthroplasty for tuberculous arthritis. J Bone Joint Surg (Am), 1988, 70(9): 1322-1330.
17. Habaxi KK, Wang L, Miao XG, et al. Total knee arthroplasty treatment of active tuberculosis of the knee: a review of 10 cases. Eur Rev Med Pharmacol Sci, 2014, 18(23): 3587-3592.
18. 米尔阿地力·麦麦提依明, 赵巍, 阿布都艾尼·热吾提, 等. 一期人工关节置换治疗晚期活动性膝关节结核. 骨科, 2020, 11(3): 192-198.
19. 黄迅悟, 冯会成, 孙继桐, 等. 活动性髋关节结核一期病灶清除全髋关节置换28例报告. 中华骨科杂志, 2013, 33(5): 495-500.
20. Hernandez P, Sager B, Fa A, et al. Bactericidal efficacy of hydrogen peroxide on Cutibacterium acnes. Bone Joint Res, 2019, 8(1): 3-10.
21. van Meurs SJ, Gawlitta D, Heemstra KA, et al. Selection of an optimal antiseptic solution for intraoperative irrigation: An in vitro study. J Bone Joint Surg (Am), 2014, 96(4): 285-291.
22. Siddiqi A, Abdo ZE, Springer BD, et al. Pursuit of the ideal antiseptic irrigation solution in the management of periprosthetic joint infections. J Bone Jt Infect, 2021, 6(6): 189-198.
23. Lu M, Hansen EN. Hydrogen peroxide wound irrigation in orthopaedic surgery. J Bone Jt Infect, 2017, 2(1): 3-9.
24. Presterl E, Suchomel M, Eder M, et al. Effects of alcohols, povidone-iodine and hydrogen peroxide on biofilms of Staphylococcus epidermidis. J Antimicrob Chemother, 2007, 60(2): 417-420.
25. Glynn AA, O’Donnell ST, Molony DC, et al. Hydrogen peroxide induced repression of icaADBC transcription and biofilm development in Staphylococcus epidermidis. J Orthop Res, 2009, 27(5): 627-630.
26. Siddiqi A, Abdo ZE, Rossman SR, et al. What is the optimal irrigation solution in the management of periprosthetic hip and knee joint infections? J Arthroplasty, 2021, 36(10): 3570-3583.
27. Brown NM, Cipriano CA, Moric M, et al. Dilute betadine lavage before closure for the prevention of acute postoperative deep periprosthetic joint infection. J Arthroplasty, 2012, 27(1): 27-30.
28. Chundamala J, Wright JG. The efficacy and risks of using povidone-iodine irrigation to prevent surgical site infection: an evidence-based review. Can J Surg, 2007, 50(6): 473-481.
29. Rikimaru T, Kondo M, Kondo S, et al. Efficacy of common antiseptics against mycobacteria. Int J Tuberc Lung Dis, 2000, 4(6): 570-576.
30. Rikimaru T, Kondo M, Kajimura K, et al. Bactericidal activities of commonly used antiseptics against multidrug-resistant mycobacterium tuberculosis. Dermatology, 2002, 204 Suppl 1: 15-20.
31. Wang Q, Shen H, Jiang Y, et al. Cementless total hip arthroplasty for the treatment of advanced tuberculosis of the hip. Orthopedics, 2011, 34(2): 90.

Chinese Journal of Reparative and Reconstructive Surgery

Effectiveness of one-stage total knee arthroplasty in treatment of advanced active knee tuberculosis

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