Treatment and influencing factors of infection after limb salvage surgery for malignant tumor around knee joint_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

SHEN Rongkai ¹ , SU Jie ² , ZHENG Zhihua ² , WU Chaoyang ¹ , LIN Jianhua ¹ ,  ZHU Xia ¹

1. Department of Bone Oncology, the First Affiliated Hospital of Fujian Medical University, Fuzhou Fujian, 350004, P.R.China;
2. The First Clinical College of Fujian Medical University, Fuzhou Fujian, 350004, P.R.China;

Corresponding author：

ZHU Xia, Email: zhuxia-tg@163.com

Keywords：

Knee joint; malignant tumor; limb salvage surgery; periprosthetic infection; complication

DOI：

10.7507/1002-1892.201912021

Video：

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Objective To summarize the experience in the treatment of infection after limb salvage surgery for malignant tumor around knee joint, and explore the risk factor related to infection after limb salvage surgery.Methods A clinical data of 212 patients with malignant tumor around the knee joint underwent limb salvage surgery between January 2008 and December 2017 were retrospectively analyzed. Among them, 14 cases had infection after limb salvage surgery. Two cases of acute infection were treated with sensitive antibiotics; 12 cases of chronic infection were treated with debridement and antibiotic bone cement occupying device implantation in the first stage, and prosthesis revision (8 cases), knee joint fusion (2 cases), or amputation (2 cases) in the second stage after infection control. The age, gender, preoperative chemotherapy cycle, bone marrow suppression, serum albumin, hemoglobin, operation time, postoperative drainage time, and blood transfusion volume were analyzed to screen the risk factors related to infection after limb salvage surgery. The infection and tumor recurrence were observed, and the limb function was evaluated by Enneking scoring system.Results The univariate analysis showed that the preoperative chemotherapy cycle, bone marrow suppression, operation time, and postoperative drainage time were the influencing factors of postoperative infection (P<0.05). Multivariate analysis showed that the operation time, preoperative chemotherapy cycle, and postoperative drainage time were risk factors of postoperative infection (P<0.05). Among the 14 patients, 1 patient died of traffic accident at 6 months after the second stage operation, and 13 patients were followed up 12.2-48.0 months (mean, 19.9 months). Two cases of acute infection cured. Among the 11 patients with chronic infection, 2 cases of subluxation of the antibiotic bone cement occupying device after the first stage operation occurred; 9 cases of infection cured and 2 cases recurred. At 12 months after operation, except 1 case died by accident, the Enneking scores of the other 13 patients were 12-26, with an average of 20. At last follow-up, 1 case of lung metastasis was still alive, and no tumor metastasis or recurrence was found in the rest.Conclusion The time of limb salvage surgery, preoperative chemotherapy cycle, and drainage time after limb salvage surgery are the risk factors of infection after limb salvage surgery. Early etiological examination and drug sensitivity test is the key to the treatment of infection. One-stage debridement combined with antibiotic bone cement occupying device can effectively cure infection and save patients’ limbs.

Citation： SHEN Rongkai, SU Jie, ZHENG Zhihua, WU Chaoyang, LIN Jianhua, ZHU Xia. Treatment and influencing factors of infection after limb salvage surgery for malignant tumor around knee joint. Chinese Journal of Reparative and Reconstructive Surgery, 2020, 34(10): 1226-1232. doi: 10.7507/1002-1892.201912021 Copy

1.	Pala E, Trovarelli G, Angelini A, et al. Megaprosthesis of the knee in tumor and revision surgery. Acta Biomed, 2017, 88(2S): 129-138.
2.	Noia G, Meluzio MC, Sircana G, et al. The use of custom-made antibiotic-loaded spacer in periprosthetic knee infection caused by XDR organism: case report and review of literature. Eur Rev Med Pharmacol Sci, 2019, 23(2 Suppl): 19-25.
3.	Srivastava K, Bozic KJ, Silverton C, et al. Reconsidering strategies for managing chronic periprosthetic joint infection in total knee arthroplasty: using decision analytics to find the optimal strategy between one-stage and two-stage total knee revision. J Bone Joint Surg (Am), 2019, 101(1): 14-24.
4.	Henderson ER, O’Connor MI, Ruggieri P, et al. Classification of failure of limb salvage after reconstructive surgery for bone tumours: a modified system Including biological and expandable reconstructions. Bone Joint J, 2014, 96-B(11): 1436-1440.
5.	Pala E, Trovarelli G, Calabrò T, et al. Survival of modern knee tumor megaprostheses: failures, functional results, and a comparative statistical analysis. Clin Orthop Relat Res, 2015, 473(3): 891-899.
6.	王冀川, 杨毅, 汤小东, 等. 股骨远端肿瘤型膝关节假体中长期假体存留及失败类型分析. 中国骨与关节杂志, 2018, 7(7): 535-541.
7.	Parvizi J, Zmistowski B, Berbari EF, et al. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res, 2011, 469(11): 2992-2994.
8.	Izakovicova P, Borens O, Trampuz A. Periprosthetic joint infection: current concepts and outlook. EFORT Open Rev, 2019, 4(7): 482-494.
9.	姬涛, 郭卫, 杨荣利, 等. 二期翻修治疗膝关节肿瘤型人工关节感染. 中国修复重建外科杂志, 2012, 26(1): 21-25.
10.	Fillingham YA, Della Valle CJ, Suleiman LI, et al. Definition of successful infection management and guidelines for reporting of outcomes after surgical treatment of periprosthetic joint infection: from the workgroup of the Musculoskeletal Infection Society (MSIS). J Bone Joint Surg (Am), 2019, 101(14): e69.
11.	Ruder JA, Springer BD. Treatment of periprosthetic joint infection using antimicrobials: dilute povidone-iodine lavage. J Bone Jt Infect, 2017, 2(1): 10-14.
12.	Teo BJX, Yeo W, Chong HC, et al. Surgical site infection after primary total knee arthroplasty is associated with a longer duration of surgery. J Orthop Surg (Hong Kong), 2018, 26(2): 2309499018785647.
13.	Rhee C, Lethbridge L, Richardson G, et al. Risk factors for infection, revision, death, blood transfusion and longer hospital stay 3 months and 1 year after primary total hip or knee arthroplasty. Can J Surg, 2018, 61(3): 165-176.
14.	Blanco JF, Díaz A, Melchor FR, et al. Risk factors for periprosthetic joint infection after total knee arthroplasty. Arch Orthop Trauma Surg, 2020, 140(2): 239-245.
15.	Petretta R, Phillips J, Toms A. Management of acute periprosthetic joint infection of the knee—Algorithms for the on call surgeon. Surgeon, 2017, 15(2): 83-92.
16.	Parvizi J, Fassihi SC, Enayatollahi MA. Diagnosis of periprosthetic joint infection following hip and knee arthroplasty. Orthop Clin North Am, 2016, 47(3): 505-515.
17.	Zimmerli W. Clinical presentation and treatment of orthopaedic implant-associated infection. J Intern Med, 2014, 276(2): 111-119.
18.	宋兴桂, 李昕, 宋俊雷, 等. 保留假体清创术治疗人工关节置换术后假体周围感染的临床研究. 中国修复重建外科杂志, 2018, 32(6): 685-693.

1. Pala E, Trovarelli G, Angelini A, et al. Megaprosthesis of the knee in tumor and revision surgery. Acta Biomed, 2017, 88(2S): 129-138.
2. Noia G, Meluzio MC, Sircana G, et al. The use of custom-made antibiotic-loaded spacer in periprosthetic knee infection caused by XDR organism: case report and review of literature. Eur Rev Med Pharmacol Sci, 2019, 23(2 Suppl): 19-25.
3. Srivastava K, Bozic KJ, Silverton C, et al. Reconsidering strategies for managing chronic periprosthetic joint infection in total knee arthroplasty: using decision analytics to find the optimal strategy between one-stage and two-stage total knee revision. J Bone Joint Surg (Am), 2019, 101(1): 14-24.
4. Henderson ER, O’Connor MI, Ruggieri P, et al. Classification of failure of limb salvage after reconstructive surgery for bone tumours: a modified system Including biological and expandable reconstructions. Bone Joint J, 2014, 96-B(11): 1436-1440.
5. Pala E, Trovarelli G, Calabrò T, et al. Survival of modern knee tumor megaprostheses: failures, functional results, and a comparative statistical analysis. Clin Orthop Relat Res, 2015, 473(3): 891-899.
6. 王冀川, 杨毅, 汤小东, 等. 股骨远端肿瘤型膝关节假体中长期假体存留及失败类型分析. 中国骨与关节杂志, 2018, 7(7): 535-541.
7. Parvizi J, Zmistowski B, Berbari EF, et al. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res, 2011, 469(11): 2992-2994.
8. Izakovicova P, Borens O, Trampuz A. Periprosthetic joint infection: current concepts and outlook. EFORT Open Rev, 2019, 4(7): 482-494.
9. 姬涛, 郭卫, 杨荣利, 等. 二期翻修治疗膝关节肿瘤型人工关节感染. 中国修复重建外科杂志, 2012, 26(1): 21-25.
10. Fillingham YA, Della Valle CJ, Suleiman LI, et al. Definition of successful infection management and guidelines for reporting of outcomes after surgical treatment of periprosthetic joint infection: from the workgroup of the Musculoskeletal Infection Society (MSIS). J Bone Joint Surg (Am), 2019, 101(14): e69.
11. Ruder JA, Springer BD. Treatment of periprosthetic joint infection using antimicrobials: dilute povidone-iodine lavage. J Bone Jt Infect, 2017, 2(1): 10-14.
12. Teo BJX, Yeo W, Chong HC, et al. Surgical site infection after primary total knee arthroplasty is associated with a longer duration of surgery. J Orthop Surg (Hong Kong), 2018, 26(2): 2309499018785647.
13. Rhee C, Lethbridge L, Richardson G, et al. Risk factors for infection, revision, death, blood transfusion and longer hospital stay 3 months and 1 year after primary total hip or knee arthroplasty. Can J Surg, 2018, 61(3): 165-176.
14. Blanco JF, Díaz A, Melchor FR, et al. Risk factors for periprosthetic joint infection after total knee arthroplasty. Arch Orthop Trauma Surg, 2020, 140(2): 239-245.
15. Petretta R, Phillips J, Toms A. Management of acute periprosthetic joint infection of the knee—Algorithms for the on call surgeon. Surgeon, 2017, 15(2): 83-92.
16. Parvizi J, Fassihi SC, Enayatollahi MA. Diagnosis of periprosthetic joint infection following hip and knee arthroplasty. Orthop Clin North Am, 2016, 47(3): 505-515.
17. Zimmerli W. Clinical presentation and treatment of orthopaedic implant-associated infection. J Intern Med, 2014, 276(2): 111-119.
18. 宋兴桂, 李昕, 宋俊雷, 等. 保留假体清创术治疗人工关节置换术后假体周围感染的临床研究. 中国修复重建外科杂志, 2018, 32(6): 685-693.

Chinese Journal of Reparative and Reconstructive Surgery

Treatment and influencing factors of infection after limb salvage surgery for malignant tumor around knee joint

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