Intramedullary Arthrodesis of the Knee In the Treatment of Sepsis Following TKR

Richard S. Laskin, MD
Hospital for Special Surgery

Mark P. Figgie, MD
Mark P. Figgie, MD

Chief of the Surgical Arthritis Service, Hospital for Special Surgery
Associate Attending Orthopaedic Surgeon, Hospital for Special Surgery

Thomas P. Sculco, MD
Thomas P. Sculco, MD

Director, Complex Joint Reconstruction Center
Surgeon-in-Chief Emeritus, Hospital for Special Surgery

Russell E. Windsor, MD, PC
Russell E. Windsor, MD, PC
Attending Orthopaedic Surgeon, Hospital for Special Surgery
Professor of Surgery (Orthopaedics), Weill Cornell Medical College

Carl T. Talmo, MD
New England Baptist Hospital, Boston, MA

James V. Bono
New England Baptist Hospital, Boston, MA

Infection is a devastating complication following total knee replacement (TKR).  In the majority of cases, single or two-stage revision has excellent results in eradicating infection and restoring function.  Rarely, recurrent infection requires alternative treatments such as resection, amputation or arthrodesis.
A review of infections following TKR treated at two joint replacement centers identified 29 cases of resistant knee sepsis treated with a long intramedullary fusion nail.  Clinical outcome and radiographs were reviewed at an average follow-up of 48 months (13-114).

Following the initial intramedullary arthrodesis union occurred in 24 of 29 patients (83%).  The average time to fusion was 6 months (3-18 months).  Failures included two cases of nail breakage, one of which subsequently achieved fusion following revision nailing, and 3 cases of recurrent infection requiring nail removal and permanent resection.  At minimum two year follow-up, of the patients that achieved fusion, 28% complained of pain in the fused knee, 28% complained of ipsilateral hip pain and 2 patients complained of contralateral knee pain.  Four of the 25 fused patients (16%) remained nonambulatory following fusion, 17 required walking aids (68%) and only 4 ambulated unassisted.  There was no association between age, number of previous procedures, the use of two-stage versus single stage technique or infecting organism and failure of arthrodesis.

Intramedullary arthrodesis is a viable treatment for refractory infection following TKR.  Patients undergoing fusion should be informed of the potential for nonunion, recurrence of infection, pain in the ipsilateral extremity and the long term need for walking aids.

This article appears in HSS Journal: Volume 3, Number 1.
View the full article at

About the HSS Journal
HSS Journal, an academic peer-reviewed journal, is published twice a year, February and September, and features articles by internal faculty and HSS alumni that present current research and clinical work in the field of musculoskeletal medicine performed at HSS, including research articles, surgical procedures, and case reports.


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