Experience of using neoadjuvant three-componeEvaluation of the effectiveness of revision oncological knee replacement performed for infection

Introduction. With the increase in the number of primary oncological knee joint replacement, the frequency of postoperative complications has also increased, among which infection has become one of the most serious, occurring in 10–25 % of patients. Two-stage revision, including removal of an infected prosthesis and installation of a spacer followed by antibiotic therapy, is considered the gold standard for treating infection. However, removing an infected prosthesis can lead to a number of problems, such as loss of bone mass, cortical defects, muscle atrophy, and impaired joint function, which reduces the effectiveness of the second stage of treatment. These circumstances highlight the need to evaluate the actual effectiveness of two-stage revision interventions, which was the reason for this study.

Aim. To study the results of treatment of patients who underwent two-stage cancer revision arthroplasty of the knee joint.

Materials and methods. In our study, 56 patients were enrolled, who underwent the first stage of revision arthroplasty of the knee joint in our clinic. The inclusion criterion was a follow-up period of at least 36 months after the second stage of surgical treatment. At the first stage, arthrodesis cement spacers were used, installed using titanium lockable intramedullary rods. After a course of antibiotic therapy, further tactics of treatment were chosen, which could include various types of final surgical interventions, such as endoprosthesis, amputation, arthrodesis using an external fixation apparatus or modular oncological structures. The average age of the patients was 52 years, the majority of whom were women (58.9 %). To achieve the goal, the following parameters were analyzed: the presence of infection recurrence, the nature of the final treatment, the duration of use of the spacer, the presence of bone and extensor apparatus defects, functional results, and endoprosthesis survival. Functional results were evaluated 12 months after surgery using the Musculoskeletal Tumor Society Score (MSTS) scale.

Results. In the study, 56 patients participated, with no signs of infection recurrence detected in 43 (76.8 %) of them after installing the spacer. Of these 43 patients, three performed a buried arthrodesis with an oncological modular system, 8 – arthrodesis using AFV, 5 – installation of a spacer with blocking. Endoprosthesis was performed in 27 (48.2 %) patients, of whom 19 had resection of the distal femur, and eight – proximal tibia. After implantation of the endoprosthesis, infection recurred in three patients after 39, 46, and 56 months, respectively. Five-year survival without infection recurrence was 87.5 %. The median time to event-free survival of the structure was 88 months. In the presence of extensive intraosseous defects, the risk of revision surgical intervention increases significantly (p = 0,041). Of the 13 patients diagnosed with infection recurrence after installing the spacer, only eight managed to perform resetting of the spacer, while the remaining five underwent lower limb amputation. Using the MSTS scale, an analysis of the function of the knee joint was performed in patients who underwent knee endoprosthesis. The median was 76.7 %, and in patients with resection of the distal femur, the knee joint function was statistically significantly better (p <0.001).

Conclusion. Our results confirm that two-stage revision oncological arthroplasty of the knee joint is effective in treating infectious complications in patients with oncological lesions of the knee joint. This approach provides control over infection and allows for the reinstallation of the endoprosthesis. To reduce the likelihood of failures and improve the functional outcomes of treatment, it is necessary to take into account the risks associated with extensive intraosseous defects, insufficiency of the extensor apparatus, and the timing between stages of the operation.

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