Amputation after Multiple Times Failed Total Knee Arthroplasties: The Last Resort

Document Type : RESEARCH PAPER

Authors

1 Consultant Joint Replacement and Sports Medicine, Indus International Hospital, Derrabassi, Panjab, India

2 Government Medical College and Hospital, Chandigarh, India

3 Vice Chairman and Head of Department Orthopaedics, Max Superspeciality Hospital, Patparganj, New Delhi, India

10.22038/abjs.2024.80181.3659

Abstract

Objectives: The study assessed the clinical and functional outcomes of transfemoral amputations 
following TKA complications, shedding light on a procedure often considered in extreme cases.
Methods: In this retrospective study, six patients undergoing above-knee amputation due to TKA complications 
were analysed. Diagnosis of periprosthetic joint infection relied on clinical presentation and the Musculoskeletal 
Infection Society Definition (2011). Patient demographics, comorbidities, and surgical interventions were 
meticulously recorded. The study aimed to contribute valuable insights into the intricacies of managing complications 
post-TKA.
Results: The study cohort, constituting 0.002% of total TKA cases, exhibited a mean age of 78.8 years. 
Comorbidities, predominantly diabetes, were prevalent. The duration between TKA and amputation averaged 6.3 
years. Surgical interventions, including revisions, debridements, and aspirations, were numerous, reflecting the 
complexity of managing complications. All patients underwent above-knee amputation using a single-stage 
approach, with careful consideration of the surgical site's condition. Post-amputation care, including stump care and 
prosthetic leg options, was tailored to individual patients' needs. Patients were diligently followed for a minimum of 
12 months. Stump wounds healed without requiring revisions, and prosthetic limbs were successfully applied to 
three patients. Mobility status and disability scores, evaluated through the Sickness Impact Profile (SIP), showed 
significant improvement.
Conclusion: The study highlights periprosthetic joint infection as the primary cause of multiple failed procedures 
leading to amputation. Microbiological findings identified common pathogens, including Staphylococcus aureus and 
Pseudomonas aeruginosa. Challenges posed by biofilm formation underscored the complexities of antibiotic 
treatment. Transfemoral amputation emerges as a feasible option for patients with multiple failed TKAs, particularly 
in cases of persistent infection. The decision-making process should encompass a thorough consideration of the 
number of failed procedures, cost-benefit analysis, and various psychosocial and economic factors. Further 
research and extensive multicentric studies are imperative to validate and expand upon these findings.
 Level of evidence: IV

Keywords

Main Subjects

References

1. Henderson RA, Austin MS. Management of periprosthetic joint 
infection: the more we learn, the less we know. J Arthroplasty. 
2017; 32(7):2056-9. doi:10.1016/j.arth.2017.02.023.
2. Sierra RJ, Trousdale RT, Pagnano MW. Above-knee amputation 
after a total knee replacement: prevalence, etiology, and 
functional outcome. J Bone Joint Surg Am. 2003; 85(6):1000-4. 
doi:10.2106/00004623-200306000-00003. 
3. Rand JA, Peterson L, Bryan R, Ilstrup D. Revision total knee 
arthroplasty. Instr Course Lect. 1986; 35:305-18.
4. Parvizi J, Tan T.L, Goswami K, et al. The 2018 Definition of 
Periprosthetic Hip and Knee Infection: An Evidence-Based and 
Validated Criteria. J Arthroplasty. 2018, 33, 1309–1314.e2. 
doi:10.1016/j.arth.2018.02.078. 
5. Kahlenberg CA, Nwachukwu BU, McLawhorn AS, Cross MB, 
Cornell CN, Padgett DE. Patient satisfaction after total knee 
replacement: a systematic review. HSS J.2018; 14(2):192-201. 
doi: 10.1007/s11420-018-9614-8.
6. Shahi A, Parvizi J. Prevention of Periprosthetic Joint Infection. 
Arch Bone Jt Surg. 2015; 3(2):72-81. 
7. Thompson O, W-Dahl A, Lindgren V, Gordon M, Robertsson O, 
Stefánsdóttir A. Similar periprosthetic joint infection rates 
after and before a national infection control program: A study 
of 45,438 primary total knee arthroplasties. Acta Orthop. 
2022, 93, 3–10. doi:10.1080/17453674.2021.1977532. 
8. Zmistowski B, Restrepo C, Hess J, Adibi D, Cangoz S, Parvizi J. 
Unplanned readmission after total joint arthroplasty: Rates, 
reasons, and risk factors. J Bone Joint Surg Am. 2013; 
95(20):1869-76. doi:10.2106/jbjs.l.00679. 
9. Sierra RJ, Cooney WP, Pagnano MW, Trousdale RT, Rand JA. 
Reoperations after 3200 revision TKAs: rates, etiology, and 
lessons learned. Clin Orthop Relat Res. 2004; 425:200–206. 
doi:10.1097/01.blo.0000138094.86911.55. 
10. Sheng PY, Jamsen E, Lehto M, Pajamaki J, Halonen P, Konttinen 
YT. Revision total knee arthroplasty with the total condylar III 
system: a comparative analysis of 71 consecutive cases of 
osteoarthritis or inflammatory arthritis. Acta Orthop. 2006; 
77:512–518. doi:10.1080/17453670610012520. 
11. Van Rensch P, Van de Pol G, Goosen J, Wymenga A, De Man F. 
Arthrodesis of the knee following failed arthroplasty. Knee 
Surg Sports Traumatol Arthrosc. 2014; 22(8):1940-8. 
doi:10.1007/s00167-013-2539-3. 
12. Briffa N, Ringrose A, Mitchell P, Bridle S. Salvage revision TKR 
for infection: a 10-year experience of a two-stage reimplantation technique. European Orthopaedics and 
Traumatology. 2013; 4(1):3-8. doi:10.1007/s12570-012-
0142-6. 
13. Bengtson S, Knutson K. The infected knee arthroplasty: a 6-
year follow-up of 357 cases. Acta Orthop Scand. 1991; 
62(4):301-11. doi:10.3109/17453679108994458. 
14. De Paula Mozella A, Da Palma IM, De Souza AF, Gouget GO, De 
Araújo Barros Cobra HA. Amputation after failure or complication of total knee arthroplasty: Prevalence, etiology 
and funcional outcomes. Rev Bras Ortop. 2013; 48(5):406-11. 
doi:10.1016/j.rboe.2012.07.011. 
15. Amouyel T, Brunschweiler B, Freychet B, et al. No 
improvement in the post-TKA infection prognosis when the 
implant is not reimplanted: Retrospective multicentre study of 
72 cases. Orthop Traumatol Surg Res. 2015; 101(6):S251-S5. 
doi:10.1016/j.otsr.2015.06.010. 
16. Son M-S, Lau E, Parvizi J, Mont MA, Bozic KJ, Kurtz S. What Are 
the Frequency, Associated Factors, and Mortality of 
Amputation and Arthrodesis After a Failed Infected TKA? Clin 
Orthop Relat Res.2017; 475(12):2905-13. 
doi:10.1007/s11999-017-5285-x. 
17. Mousavian A, Sabzevari S, Ghiasi S, et al. Amputation as a 
Complication after Total Knee Replacement, is it a Real 
Concern to be Discussed?: A Systematic Review. Arch Bone Jt 
Surg. 2021; 9(1):9. doi:10.22038/abjs.2020.53892.2692.
18. Haggis P, Yates P, Blakeway C, et al. Compartment syndrome 
following total knee arthroplasty: a report of seven cases. J 
Bone Joint Surg Br. 2006; 88(3):331-4. doi:10.1302/0301-
620x.88b3.16919. 
19. Gehrke T, Alijanipour P, Parvizi J. The management of an 
infected total knee arthroplasty. Bone Joint J. 2015; 97-B (10 
Suppl A):20-9. doi:10.1302/0301-620x.97b10.36475. 
20. Kurtz SM, Ong KL, Lau E, Bozic KJ, Berry D, Parvizi J. Prosthetic 
joint infection risk after TKA in the Medicare population. Clin 
Orthop Relat Res. 2010; 468(1):52-6. doi:10.1007/s11999-
009-1013-5. 
21. Joshy S, Gogi N, Thomas B, Mahale A, Singh BK. Delayed onset 
of deep infection after total knee arthroplasty: comparison 
based on the infecting organism. J Orthop Surg (Hong Kong). 
2007; 15(2):154-8. doi:10.1177/230949900701500205. 
22. Friedrich MJ, Schmolders J, Wimmer MD, et al. Two-stage knee 
arthrodesis with a modular intramedullary nail due to septic 
failure of revision total knee arthroplasty with extensor 
mechanism deficiency. Knee. 2017; 24(5):1240-6. 
doi:10.1016/j.knee.2017.05.019. 
23. Goldman AH, Clark NJ, Taunton MJ, Lewallen DG, Berry DJ, 
Abdel MP. Definitive resection arthroplasty of the knee: A 
surprisingly viable treatment to manage intractable infection 
in selected patients. J Arthroplasty. 2020; 35(3):855-8. 
doi:10.1016/j.arth.2019.10.025. 
24. Cahill JL, Shadbolt B, Scarvell JM, Smith PN. Quality of life after 
infection in total joint replacement. J Orthop Surg (Hong Kong) 
2008; 16(1):58-65. doi:10.1177/230949900801600115.
The Archives of Bone and Joint Surgery
Volume 13, Issue 4
April 2025
Pages 188-195

Files

History

  • Receive Date: 11 June 2024
  • Revise Date: 01 November 2024
  • Accept Date: 07 December 2024

Share

How to cite

Statistics