DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Infected right total knee arthroplasty.
POSTOPERATIVE DIAGNOSIS: Infected right total knee arthroplasty.
PROCEDURE PERFORMED:
1. Removal of right total knee arthroplasty.
2. Implantation of antibiotic spacer. The antibiotic spacer consisted of 3 packages of Simplex cement containing both tobramycin and vancomycin.
SURGEON: John Doe, MD
BLOOD LOSS: 200 mL
CULTURE: Tissue was sent for pathology.
ANESTHESIA: Femoral block and general endotracheal intubation.
Of note, in addition, the department of radiology placed a removable Greenfield filter into the inferior vena cava during the procedure. This will be described separately.
INDICATIONS FOR PROCEDURE: This is a (XX)-year-old female, diabetic, well known to us with history of bilateral knee arthritis. The patient had undergone a left total knee arthroplasty without complication. On MM/DD/YYYY, she underwent a right total knee arthroplasty. This knee was implanted using antibiotic-containing bone cement. Her postoperative course was complicated by an episode of bronchitis and a urinary tract infection. The patient presented to the office later in spring with complaints of pain. She was noted to have some mild warmth. The wound was healed. There was no evidence of drainage. There was mild erythema. The patient did not improve and in fact the pain worsened with time.
The patient underwent a workup, including aspiration under sterile condition. The fluid obtained did appear purulent, but we were unable to identify a bacteria pathogen. The patient was seen in consultation by the infectious disease department. The workup was suggestive of infection, and the decision was made that this was a grossly infected total knee arthroplasty and warranted surgical removal and antibiotic spacer. The patient was scheduled for surgical procedure.
The patient’s examination demonstrates that she has an acutely painful right lower extremity, decreased range of motion, erythema, no active drainage. Radiographs demonstrate what appears to be lucency about the prosthesis, and the lab work was suggestive of infection with elevated white count, sed rate, and C-reactive protein. Our overall impression is that this is a diabetic female with a right total knee arthroplasty that is infected, unknown organism. The plan would be surgical debridement, removal of the implant, implantation of antibiotic spacer, long-term antibiotics, and return in 6 to 8 weeks for a re-exploration debridement. If free of infection, consider reimplantation of total knee arthroplasty.
DESCRIPTION OF PROCEDURE: The patient did not receive antibiotics until specimens were sent for both culture and pathology evaluation. The patient was brought to the operating room and the anesthetic was administered. The right lower extremity had nonsterile tourniquet applied. It was then scrubbed and draped in the usual fashion. We did an anterior skin incision, medial parapatellar arthrotomy, and there was grossly purulent material, marked inflammatory changes to the surrounding soft tissue. The fluid was aspirated and sent for culture. Tissue was sent for pathology and then the vancomycin was ordered to be administered.
We then proceeded to perform a surgical debridement of the joint. The tibial component was noted to be grossly loose. The surrounding bony tissue also did appear to be infected. We removed all of the implant with the use of the TPS, the flexible osteotomes. We then debrided the bone and soft tissue with the use of a knife, curette, and rongeur and then thoroughly irrigated out the joint and surrounding soft tissue.
We obtained intraoperative radiographs to make sure that there was no retained cement. We then irrigated through 6 liters of bacitracin-containing solution. We began mixing 3 packages of tobramycin containing Simplex cement. We added in addition vancomycin, 4 grams, to this mixture. We then prepared, when the cement was doughy, a large antibiotic spacer including an area anterior in the patellofemoral articulation. We then thoroughly irrigated out the area and allowed the cement to harden.
Once the cement was hardened, we closed the extensor mechanism over a large drain with #1 Vicryl, 3 stitches were used. We then did skin stitches, #3-0 nylon, staples and nonadherent dressing, 4 x 4, Webril, Ace wrap, and knee immobilizer was applied. The patient then remained on the operating room table while the interventional radiology team proceeded with the inferior vena cava filter.
POSTOPERATIVE PLAN:
1. This knee was grossly infected and we would, regardless of the culture results, strongly encourage 6 weeks of IV antibiotics.
2. Physical therapy. This patient should not work on range of motion because there is not a working total knee in this patient. We should allow her to ambulate. She can do isometric exercises, work on range of motion of the ankle and hip and she is allowed to be weightbearing as tolerated.
3. Pain medication. This patient has had a history of back pain, had been treated in the past by Dr. Jane Doe and she is consulted regarding pain control.
4. The patient is diabetic. We discussed the situation and came upon the decision to proceed with the inferior vena cava filter and aspirin as our anticoagulation given this patient’s overall immobility, familial history of pulmonary embolism, and current inability to range of motion of the right lower extremity.
5. Discharge planning. Discussed with the patient and family the need for this patient to be independent before she returns to home due to lack of available resources for her care. She has discussed the possibility of acute rehab versus an extended care facility and will get the discharge planners involved.
