This week’s Orthopaedic Crossfire® debate was part of the 34th Annual Current Concepts in Joint Replacement® (CCJR®), Winter meeting, which took place in Orlando. This week’s topic is “The Hinge: Prerequisite Solution for the Infected TKA.” For is Thorsten Gehrke, M.D., ENDO-Klinik, Hamburg, Germany. Opposing is Fares S. Haddad, M.D., F.R.C.S., University College Hospital, London, United Kingdom. Moderating is Jay R. Lieberman, M.D., Keck Medical Center of USC, Los Angeles, California.
Dr. Gehrke: Let’s bring Fares, let’s bring Brexit negotiations to the next and hopefully a better level, a good end and a good result that means that you pay the bill for your crazy decision.
Periprosthetic joint infection (PJI) in total knee arthroplasty [TKA] as we all know is probably the most serious complication and it’s always, almost always associated with really severe soft tissue involvement. To treat this kind of complication, we have to be radical. Radical in our debridement. That’s rule number 1 in septic surgery. We have to be radical, very similar to an oncologic surgeon.
The choice of our implant. The re-implant, it’s all depending on the stabilizing structures—I mean ligaments mainly. According to Adolph Lombardi’s algorithm if the MCL is gone, we should think about a hinge knee. Also, if you have non-correctable varus/valgus instability or flexion/extension gap mismatch, the recommendation is to use a hinge.
In a quite simple 1-stage case. There wasn’t a severe infection…not very viral. Even so, during debridement you have to harm it quite radically and it ends up in a situation with the loss of the medial collateral ligament. You address the infection radically, the collateral ligaments are involved, and when you look at the debridement of the posterior capsule, you see that there is an absolute mismatch between the extension and flexion gaps.
We cannot correct this flexion gap without using a hinge knee.
Even in a 2-stage revision, we have the same situation. There is no difference in the infection and the involvement of the soft tissue. Where are the ligaments that are stabilizing the knee? They are all gone. The solution, in my opinion, is…and we do it at the ENDO-Klinik almost exclusively…. implantation of a hinge knee. Because we have no ability to stabilize the knee otherwise.
Another argument for a hinge knee—a strong argument—is it’s easy. It’s a very simple procedure. You don’t need so many instrument trays as with a CCK design. Just one tray is enough. And with only one tray I can solve with a hinge knee all the infections that I showed you—even the 2-stage. It’s an easy procedure that everybody can perform quite simply.
And to cite only one paper in this talk. And this is Fares’ paper (CORR 2010), where he compared the outcome of revisions using a Posterior Stabilized design, a condylar constrained design, and a rotating hinge design. For me, not surprising, the results were that the rotating hinge group had the highest satisfaction rates. The overall 10-year survivorship was 90.6% with the highest survivorship seen in the rotating hinge group. And then they analyzed the complications. In the hinge group they had much less complications.
I like to implant a hinge if I have an infection. For me it’s logical and the patients are really satisfied with this solution.
