Successful treatment of active septic knee arthritis with severe chondrolysis or end stage OA with a two stage TKA concept

Background: Native septic arthritis of the knee is a complex surgical challenge, with up to 50% of cases involving this joint. Traditional treatments such as lavage and debridement fail in approximately 10% of patients, often leading to progressive chondrolysis and secondary osteoarthritis. While primary total knee arthroplasty (TKA) was historically contraindicated in the presence of active infection, recent evidence suggests that a staged approach may provide a viable alternative to arthrodesis or resection arthroplasty.

Objective: This article describes a standardized two-stage TKA protocol for treating active septic knee arthritis characterized by severe chondrolysis or advanced degenerative changes.

Key Points: The procedure involves radical synovectomy, debridement of the posterior capsule, and the removal of cruciate ligaments to ensure infection eradication. A temporary articulating spacer is constructed using a metal femoral component and a modified all-polyethylene tibial insert, fixed with high-dose antibiotic-loaded bone cement (3–4 g per 40 g of powder). Systemic antibiotic therapy is administered for six weeks based on culture results. Clinical data from 16 patients demonstrated a 100% infection eradication rate and significant functional improvement, with mean Knee Society Scores increasing from 58/17 preoperatively to 96/86 at a mean 6.1-year follow-up.

Conclusion: A two-stage TKA protocol utilizing an articulating antibiotic-loaded spacer is an effective strategy for managing active septic arthritis in the degenerate knee. This approach achieves high rates of infection clearance while restoring joint function and improving quality of life compared to salvage procedures.