A The procedure of a TKA replaces the

A total knee
arthroplasty (TKA) is an elective surgical procedure that has had success for
the treatment of arthritis in the knee.1,2 The procedure of a TKA
replaces the components of the tibiofemoral joint, including the femur, tibia,
and patella, with a metal implant.3 The goal of a TKA is for
individuals to experience a reduction in pain and improvement in function.4 There are approximately
700,000 TKA’s that are performed each year in the United States.5 The number of procedures is
expected to increase to 3.48 million procedures per year by the year 2030.5,6 The survivorship of a
TKA has been known to last on average 10 years.4 The success of the TKA is
dependent on patient demographics, technique of the surgeon, and other surgical
factors.1 Patient demographics that
place patient’s at an increased risk for failure include African American race,
males, patients under 50, and comorbid conditions such as chronic obstructive
lung disease, depression, and diabetes.7 The risk of failure for a TKA
requiring a revision surgery within 10 years of the operation is 5%.1

When components of
the TKA have failed, a total knee arthroplasty revision (TKR) is often considered
by the medical team.3 With the continued success of
TKA, there has been growth in the amount of TKA procedures and subsequently,
there has also been an increase in TKR procedures.2,7,8,9,10,11 It has been estimated
that there will be 41,432 revisions procedures performed in the United States
by the year 2030.9 The revision TKA burden is
defined as a percentage and is calculated as the ratio of TKR to TKA and TKR
combined.8,12

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As there are
multiple reasons for failure of a TKA, the most common causes are septic
infection, aseptic loosening, and implant failure.1,2,8,9,11,13 Septic infections may
appear in different fashions depending on when the symptoms arise.14 Sepsis is identified as a
life threatening organ dysfunction that occurs from an extreme and abnormal
response to infection.15 They may present with pain
around the joint, wound drainage, fever, or swelling.14 Early infections occur within
3 months and usually develop during implantation.14 Delayed infections occur from
3 months to a year post surgery and also usually develop during implantation.14 Late infections occur the
earliest a year after the procedure and develop due to an infection at another
site in the body.14 Aseptic loosening is the
loosening of the components and presents with pain in joint movement and weight
bearing.14 Implant failure can be a
result of dislocation, where the prosthetic is forced out of its positioning,
leading to pain and difficulty moving the knee.14 Differential diagnosis of
infection from mechanical or aseptic problems is important because there are
different treatment options depending on the cause of failure.14

            The
surgical procedure of a TKR is to replace the components of the prosthesis with
a new prosthesis.3,14 Dependent on the reason for
failure, the surgeon will decide on the most appropriate approach.14,16,17 The two-stage exchange
arthroplasty has been the most common surgical procedure used to treat septic
infection. 14,16,18The first stage of the surgery
is known as resection arthroplasty and includes the removal of the infected
components and insertion of an antibiotic-impregnated spacer.14, 16 After this first procedure,
the patient is given antibiotics for usually 6 weeks.14,16 After the antibiotic
treatment, the patient is reassessed for any signs of infection and the next
step will be insertion of a new prosthesis.14,16

Functional
recovery of patient’s following both a TKA and TKR is an important measure of
the patient’s ability to return to their prior level of function. Functional
recovery can be measured through selected outcome measures.19 Patient satisfaction
following TKA or TKR is associated with relief of pain, improvement in
function, and the patient’s expectations.20 Dissatisfaction is a result
of unmet expectations.20 The most reported cause of
patient dissatisfaction is pain and limitations in function.20 It is important for the
surgeon to explain the risk and benefits associated with the procedure in an
effort to limit the likelihood of patient dissatisfaction.20 Communication between the
patient and surgeon is an essential component to ensure agreement on the
expected quality of life following the procedure.21

The Knee Society
Score is an outcome measure that has been used worldwide to assess patient
satisfaction, expectation, and physical activities following a TKA or TKR.20,22 The Knee Society Score is
completed by both the patient and the surgeon preoperatively and
postoperatively.22 The patient version asks them
to report their demographic information, pain, expectations, satisfaction, and
functional activities.22 The surgeon is asked to
report range of motion, ligament stability, and assessment of alignment.22 The Knee Society Score has
been a validated and responsive outcome measure for patients undergoing TKA or
TKR.22 Research has shown that there
is no gold standard for patient-reported outcome measures that solely evaluates
patients undergoing TKA or TKR.23 The Knee Society Score has
continued to be the most popular outcome measure used because it looks at
clinical measure as well as patient satisfaction.24

Description of the patient

The patient is an African American male in his 50’s
presenting to Hartford hospital with signs of sepsis, expressive aphasia, and
an altered mental status. The patient has a multitude of comorbidities and
those are listed in appendix 1. When the patient arrived to Hartford Hospital
he was taken for a computed tomography (CT) to rule in a stroke. The initial CT
scan reported a negative finding, but the patient was sent for a repeat CT scan
and was diagnosed with a left middle cerebral artery (MCA) stroke. Blood
cultures determined the cause of the stroke to be endocarditis. The blood
culture also showed the gram-positive bacteria Enterococcus faecalis and sick
sinus syndrome. The patient was taken for more diagnostic tests that showed the
need for open-heart surgery for mitral valve debridement and implantation of a
pacemaker.

The patient was admitted to Hartford Hospital following the
stroke. The patient’s most notable deficits were expressive aphasia,
deconditioning, and coordination deficits. The patient’s treatment included
sessions with the physical therapist, the occupational therapist, and the
speech language pathologist. The patient was initially progressing well with
therapy, however he began to express significant left knee pain. The patient
has a history of a left total knee arthroplasty more than 5 years ago. The
patient was evaluated and revealed decreased range of motion, decreased
strength, and pain in his left knee. The patient’s knee was septic secondary to
the spread of infection from endocarditis. The patient was taken for incision
and drainage with the orthopedic team with considerations for revision in the
future. The patient continued with incision and drainage weekly to biweekly as
needed.

Prior to the stroke, the patient lived alone in his house and was
independent. The main goal of the patient was to return to his baseline of
function. The patient was treated in the acute care setting at Hartford
Hospital with goals to maximize his independence. Recommendations from the
physical therapist, occupational therapist, and speech language pathologist
were made for the patient to continue therapy at an acute rehabilitation
facility.

Clinical question

The patient’s clinical presentation and history provide
information for the need of revision surgery. Understanding the prognosis for
patients following surgery is of important consideration before determining to
continue with the procedure. It is necessary to know the risks and benefits for
all individuals undergoing surgery. The clinical question we were interested in for this patient
was: what is the prognosis for return to function for
an older adult who will be having a total knee arthroplasty revision due to
sepsis? The clinical question aims to understand the risk of a total knee
revision procedure where the joint is infected.