Salvage Algorithm for Deep Surgical Site Infections after HTO with Unstable Bone Situation Using a Hexapod System – Primary Results

Abstract

Introduction

The incidence of deep surgical site infections following high tibial osteotomy (HTO) ranges between 0.4 to 4.7%. It is a severe complication with a high risk for poor clinical outcome. The aim of this study was to proof that a salvage algorithm for infected HTO with unstable bone situation leads to an infection-free status and bone union of the osteotomy and that correct limb alignment can be restored with good knee function.

Materials and Methods

The study included seven patients with peri-implant infections following HTO. Infections occurred 83 ± 58.9 days (range: 24–191) after HTO. All patients underwent the “RESTORE” algorithm: patients received (1) REmoval of the HTO hardware and extensive debridement; (2) the osteotomy was STabilized with a hexapod external fixator (Taylor Spatial Frame, TSF); (3) the osteotomy gap was Opened; and (4) the alignment was REconstructed using the TSF, aiming for the intended limb alignment of the initial HTO. Patient-reported outcomes were assessed 22–36 months after removal of the TSF.

Results

After 24 weeks (range: 11–35), an infection-free status and bone healing were achieved. In all cases, the limb was saved, and the previously targeted mechanical axis of the lower limb was restored. All patients reached full extension of the knee joint and at least 110° of flexion. For KOOS: Symptoms 67.86 ± 18.1, Pain 73.41 ± 16.58, ADL 78.99 ± 21.32, Sports 52.14 ± 25.96, and QoL 41.96 ± 24.66. OKS 35.71 ± 8.8, SF-12 Physical Health 38.89 ± 10.3, and SF-12 Mental Health 46.86 ± 13.76.

Conclusions

The “RESTORE” algorithm is a safe and effective salvage procedure. The concept allows for saving the limb and obtaining the previously planned limb alignment. Patient-reported outcome measures showed slightly lowered values than healthy samples, but substantially better values than patients awaiting HTO. Due to the possibility of initial full weight-bearing, the risk of higher morbidity caused by immobilization is minimized.

Zusammenfassung

Einleitung

Die Inzidenz von tiefen Wundinfektionen nach hoher Tibiakopf Osteotomie (HTO) variiert zwischen 0,4 und 4,7%. Tiefreichende Wundinfektionen stellen eine schwere Komplikation mit hohem Risiko für ein schlechtes klinisches Outcome dar. Ziel dieser Studie war es zu zeigen, dass ein Rettungsalgorithmus für Infektsituationen nach HTO mit instabiler knöcherner Situation, zur Infektfreiheit und knöchernen Konsolidierung der Osteotomie führt und eine korrekte Beinachse mit guter Funktionalität des Kniegelenks wiederhergestellt werden kann.

Methoden und Material

Die Studie umfasst 7 Patienten mit periimplantären Infektionen nach HTO. Infektionen traten 83 ± 58.9 Tage (Range: 24–191) nach HTO auf. Alle Patienten wurden entsprechend des „RESTORE“-Algorithmus behandelt: (1) Entfernung („Removal“) der Implantate und ausgiebiges Débridement; (2) Stabilisierung („Stabilization“) der Osteotomie mit einem Hexapod Fixateur externe (TSF); (3) Öffnen („Opening“) des Osteotomiespalts und (4) Rekonstruktion („Reconstruction“) der initial durch die HTO angestrebten Beinachse mit Hilfe des TSF. Patient-reported Outcomes wurden 22–36 Monate nach Entfernung des TSF erhoben.

Ergebnisse

Nach 24 Wochen (Range: 11–35) wurde ein infektfreier Zustand und eine knöcherne Konsolidierung erreicht. In allen Fällen konnte die Extremität erhalten werden und die ursprünglich vorgesehene mechanische Beinachse wiederhergestellt werden. Alle Patienten erreichten eine Kniebeweglichkeit mit voller Extension und mindestens 110° Flexion. KOOS-Werte: Symptome 67,86 ± 18,1, Schmerz 73,41 ± 16,58, ATL 78,99 ± 21,32, Sport 52,14 ± 25,96, Lebensqualität 41,96 ± 24,66, OKS 35,71 ± 8,8 und SF-12 körperliche Gesundheit 38,89 ± 10,3 und SF-12 psychische Gesundheit 46,86 ± 13,76.

Schlussfolgerung

Der „RESTORE“-Algorithmus ist eine sichere und effektive Rettungsprozedur. Das Konzept ermöglicht den Erhalt der Extremität und das Erreichen der initial geplanten Beinachse. Patient-reported Outcome Messungen zeigten leicht erniedrigte Werte im Vergleich zu gesunden Probanden, jedoch deutlich bessere Werte als bei Patienten vor HTO. Durch die Möglichkeit der unmittelbaren Vollbelastung ist das Risiko erhöhter Morbidität durch Immobilisation minimiert.

Keywords

HTO - infection - hexapod - Taylor spatial frame - limb alignment

Schlüsselwörter

HTO - Infektion - Hexapod - Taylor Spatial Frame - Beinachse

Publikationsverlauf

Eingereicht: 06. September 2023

Angenommen nach Revision: 17. Januar 2024

Artikel online veröffentlicht:
06. März 2024

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