Translate this page into:
Treatment patterns and failure rates associated with prosthetic joint infection in unicompartmental knee arthroplasty: A systematic review
, Ryan C. Xiao, Christine S. Williams, Jashvant Poeran, Calin S. Moucha, Darwin D. Chen, Brett L. Hayden
∗Corresponding author: Joseph P. Barbera. joseph.barbera@mountsinai.org
-
Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Prosthetic joint infection (PJI) following unicompartmental knee arthroplasty (UKA) is a rare but challenging complication. A paucity of literature exists regarding the management of PJI in UKA. This systematic review aims to assess current treatment patterns in UKA PJI and analyze the failure rates associated with treatment.
PubMed, Scopus, and EMBASE were systematically searched for studies that presented cases of PJI following UKA. Data regarding study design, country of publication, index procedure type, diagnosis of PJI, number and incidence of PJI, timing of PJI (acute versus chronic), treatment, and outcomes were recorded. Failure rates in acute and chronic PJI as well as total failure rates were analyzed.
Sixteen articles were identified that met inclusion criteria. These included 97 PJI cases (37 acute, 58 chronic, 2 unknown timing); incidence across all studies of 0.80%. The most common treatment for all PJI cases was debridement, antibiotics, and implant retention (DAIR) (40.2%), followed by two-stage conversion to total knee arthroplasty (TKA) (33.0%), one-stage conversion to TKA (23.7%), and one-stage exchange UKA (3.1%). There were no significant differences in failure rates across procedures for acute, chronic or overall PJI management (p > 0.05 for all)
This systematic review found relatively few studies reporting on PJI after UKA compared to the available TKA evidence. Further research is warranted to better elucidate the most appropriate treatment of PJI after UKA in both the acute and chronic setting along with risk factors for failure.
Keywords
Prosthetic joint infection
Unicompartmental knee arthroplasty
Revision knee arthroplasty
1 Introduction
The advent of improved implant manufacturing, implant design, and surgical technique has increased the longevity and incidence of unicompartmental knee arthroplasty (UKA), with long-term survival rates upwards of 90% in contemporary series.1–4 Complications of UKA include loosening of the prosthesis, periprosthetic fracture, bearing dislocation, polyethylene wear, progression of arthritis, stiffness, unexplained pain, and prosthetic joint infection (PJI). PJI is a rare but potentially debilitating complication after UKA with incidence rates varying from 0.32% to 1.55% in the literature.1,2,4–8
PJI in the setting of UKA presents a unique challenge in that there is involvement of the native cartilage in addition to the prosthesis. Consequently, PJI can result in the progression of arthritis in the preserved compartments as well as biofilm deposition on the prosthetic components with late mechanical complications if untreated. Although attempts to treat these cases without removing the prosthesis have been successful in eradicating the infection, conversion to TKA may still be necessary for these complications.9,10
Though treatment options for PJI after total knee arthroplasty (TKA) have been widely investigated, ambiguity persists regarding the appropriate management in the setting of UKA. Multiple treatment modalities have been described including debridement, antibiotics, and implant retention (DAIR), one-stage conversion to TKA, and two-stage conversion to TKA. However, there is limited literature evaluating the indications and outcomes for these procedures in the setting of UKA. Such data will be useful to determine the optimal treatment of PJI after UKA, especially given the increasing demand for these surgeries.11,12 Therefore, the objective of this study was to perform a systematic review of the management of UKA PJI in an attempt to 1) determine current treatment patterns in UKA PJI, 2) identify how these patterns differ in the acute versus chronic PJI setting, and 3) analyze the failure rates associated with varying treatment modalities. DAIR was hypothesized to be the most frequently utilized procedure in the setting of acute PJI with two-stage revision to TKA the most common procedure in the management of chronic PJI.
2 Methods
A search of PubMed, Scopus, and Excerpta Medica Database (EMBASE) was performed in July of 2021 utilizing a combination of the following search terms: (“arthroplasty” or “replacement”) and (“unicompartmental” or “unicondylar”) and “infection” and “knee”. Articles published between the date range of 1980–2021 were included. No language restriction was implemented. Reporting guidelines by the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) methodology were followed. After initial exclusion by relevance of title, articles were reviewed by abstract. For relevant abstracts, as well as studies which could not be conclusively excluded based on title and abstract review, full text was obtained and assessed. Articles that presented cases of UKA PJI and discussed the treatment of these cases were included. Articles were excluded if management of PJI was not mentioned. Case reports, reviews, cadaver and technique studies were also excluded. References from included articles were reviewed for additional studies not identified in our initial database search.
Two of the authors (JB and RX) independently reviewed all articles for data extraction. Information regarding study design, country of publication, index UKA procedure (medial, lateral, or patellofemoral) number and incidence of UKA PJI cases, timing of PJI (acute versus chronic), diagnosis of PJI, culture results, treatment (DAIR, one-stage exchange UKA [1SE], one-stage conversion to TKA [1SC], or two-stage conversion to TKA [2SC]), operative details (technique, antibiotic cement utilization), type of prosthesis (constrained versus non-constrained), postoperative antibiotics, outcomes, and follow up was recorded. In patients who underwent DAIR, we also noted whether a modular component exchange was performed. If this was not explicitly reported, it was assumed that a modular component exchange was performed. 1SE refers to patients who underwent a single operation in which all components were removed and new UKA components were placed.
PJI was considered acute if it occurred within six weeks of index UKA procedure or was reported as an acute hematogenous infection. Chronic PJI was defined as infection occurring greater than six weeks after index procedure and was not hematogenous in nature. If the distinction between acute or chronic PJI was not clear, timing of infection was considered unknown and the case was grouped into overall analysis. Failure, defined as recurrent or persistent PJI, was the main outcome of interest. Failure rates were analyzed in the acute and chronic PJI setting as well as total failure rates. Aggregated data were analyzed and statistics were descriptive in nature. A fisher exact test was performed to detect differences in failure rates between treatment modalities. A p-value of <0.05 was considered statistically significant.
3 Result
A total of 1145 articles resulted from our initial search; 16 studies met final inclusion criteria (Fig. 1). There were 15 retrospective cohorts and one prospective cohort (Table 1). The United States (n = 5) was the most common country of publication followed by the United Kingdom (n = 3). France and Germany had two publications each. Austria, Belgium, and Korea were each responsible for one publication. The majority of index procedures were medial compartment UKAs.
| Author | Country | Study Design | Index UKA | PJI Diagnosis | Cultures |
| Chalmers et al. 10 | USA | Retrospective cohort | 19 medial2 lateral | MSIS Definition | 1 MRSA, 8 MSSA, 5 CoNS, 1 MRSE, 3 Streptococcal, 1 Pseudomonas, 1 Polymicrobial, 1 No growth |
| Hernandez et al. 9 | USA | Retrospective cohort | – | MSIS Definition | 7 MSSA, 2 CoNS, 3, Polymicrobial, 3 No growth |
| Labruyere et al. 25 | France | Retrospective cohort | 6 medial2 lateral1 patellofemoral | – | 6 CoNS, 1 Streptococcal, 1 Enterococcus durans, 1 Escherichia coli |
| Kim et al. 5 | Korea | Retrospective cohort | – | – | – |
| Nettrour et al. 23 | USA | Retrospective cohort | Medial | – | – |
| Berend et al. 47 | USA | Retrospective cohort | – | – | – |
| Lecuire et al. 27 | France | Retrospective cohort | Medial | – | 1 CoNS, 1 Streptococcal |
| Chawla et al. 24 | USA | Retrospective cohort | Medial | – | 3 MSSA, 1 MRSE, 1 CoNS 1 P. acne, 1 Polymicrobial |
| Winnock et al. 3 | Belgium | Retrospective cohort | Medial | – | 1 MRSA, 2 MSSA, 1 Streptococcal |
| Middleton et al. 6 | UK | Retrospective cohort | Medial | – | – |
| Singer et al. 26 | Germany | Retrospective cohort | – | Preoperative biopsy | – |
| Bohm et al. 45 | Austria | Retrospective cohort | – | – | – |
| Richards et al. 48 | Canada | Retrospective cohort | Medial | – | – |
| Pandit et al. 21 | UK | Prospective cohort | Medial | – | 2 CoNS, 2 No growth |
| Citak et al. 49 | Germany | Retrospective cohort | Medial | – | – |
| Weston-Simons et al. 50 | UK | Retrospective cohort | Lateral | – | – |
| Author | PJI (n) | PJI (%) | Treatment | Constraint | Postop Antibiotics | Outcomes | Follow-up |
| Chalmers et al. 10 | 17 acute4 chronic | – | 17 acute: 15 DAIR, 2 2SC4 chronic: 1 DAIR, 1 1SC 2 2SC | 0 | IV Abx x6 weeks → chronic PO in select patients (15/21) | DAIR: 25% failure,1SC: no failures, 2SC: 25% failure | Mean 3 years |
| Hernandez et al. 9 | 10 acute5 chronic | 1.16% | 10 acute: 8 DAIR, 2 2SC5 chronic: 3 DAIR, 2 2SC | 0 | IV Abx x4-6 weeks → chronic PO in select patients (7/15) of postop IV. | DAIR: 36.36% failure2SC: no failures | Median 4 years |
| Labruyere et al. 25 | 9 chronic | – | 1SC | 2 required hinged prosthesis | 2 IV Abx x6 weeks → PO x6 weeks | No failures | Median 60 months |
| Kim et al. 5 | 5 chronic | 0.32% | 2SC | – | – | – | – |
| Nettrour et al. 23 | 2 acute1 chronic | 1.58% | DAIR | – | – | No failures | Mean 3.3 years |
| Berend et al. 47 | 5 chronic | – | 2SC | 1 required unspecified constraint | – | – | – |
| Lecuire et al. 27 | 2 chronic | – | 1SE | – | – | No failures | Mean 3.5 years |
| Chawla et al. 24 | 6 acute1 chronic | 0.83% | DAIR | – | IV Abx x6 weeks → PO x6 months | No failures | Unspecified |
| Winnock et al. 3 | 1 acute3 chronic | 0.87% | 2SC | 1 required unspecified constraint | – | – | – |
| Middleton et al. 6 | 2 chronic | 1.55% | 2SC | 2 required hinge prosthesis | – | – | – |
| Singer et al. 26 | 6 chronic | – | 1SC | 0 | IV Abx x2 weeks → PO x4 weeks | No failures | Mean 36 months |
| Bohm et al. 45 | 2 unknown | 0.67% | 1 1SE1 2SC | – | – | No failures | Unspecified |
| Richards et al. 48 | 2 chronic | 1.37% | 2SC | – | – | – | – |
| Pandit et al. 21 | 4 chronic | 0.58% | 2SC | 0 | – | No failures | Mean 3.5 years |
| Citak et al. 49 | 7 chronic | – | 1SC | – | – | – | – |
| Weston-Simons et al. 50 | 1 acute2 chronic | 1.13% | 1 acute: DAIR2 chronic: 1 DAIR, 1 2SC | – | – | – | – |
97 cases of UKA PJI (37 acute, 58 chronic, and 2 unknown timing) were identified; incidence across all studies of 0.80%. Two studies utilized the Musculoskeletal Infection Society (MSIS) definition of PJI to establish diagnosis while another used preoperative tissue biopsy. The remainder of the included articles did not provide diagnostic details. Seven studies discussed culture results. The most common identified organism was methicillin sensitive Staphylococcus aureus (MSSA) (n = 20), followed by Coagulase Negative Staphylococcus (CoNS) (n = 17). Methicillin resistant Staphylococcus aureus (MRSA) and methicillin resistant Staphylococcus epidermidis (MRSE) were identified in two patients each.
DAIR (40.2%, n = 39) was the most frequently performed procedure for all (acute and chronic) PJI cases. 2SC (33.0%, n = 32) was the next most common followed by 1SC (23.7%, n = 23), and 1SE (3.1%, n = 3); Fig. 2. For acute PJI, DAIR was most utilized (86.5%, n = 32) again followed by 2SC (13.5%, n = 5). No 1SE or 1SC were performed for acute PJI. For chronic cases, 2SC was most frequently performed (44.8%, n = 26), followed by 1SC (39.7%, n = 23), DAIR (12.1%, n = 7), and 1SE (3.4%, n = 2).
In patients undergoing DAIR, 92.3% (36/39) had a modular component exchange. Level of constraint used in conversion to TKA, including 1SC and 2SC, was reported in half of the included articles; 15.4% of patients required some level of additional constraint. Of those requiring a constrained prosthesis, 66.7% required a hinged construct while the other 22.2% did not explicitly state the level of constraint utilized. Postoperative antibiotic protocols were only presented in five articles. The course of postoperative intravenous (IV) antibiotics ranged from two to six weeks and were specific to culture results when possible. This was followed by a course of antibiotics by mouth (PO) for an additional four weeks to six months and chronic suppressive antibiotics were used in select patients.
Outcome data were reported in nine articles representing 68 PJI cases. The failure rate of DAIR in the management of acute and chronic UKA PJI was 22.6% and 16.1%, respectively (Table 2). 2SC demonstrated no failures for acute PJI and a failure rate of 12.5% for chronic PJI. There were no failure rates reported for chronic PJI managed by 1SE or 1SC. There were no significant differences across failure rates of DAIR, 1SE, 1SC, or 2SC for acute, chronic or overall PJI management (p > 0.05 for all).When evaluating failure rates by identified organism, polymicrobial infections had the highest total failure rates (40%) followed by MSSA (22.2%); Table 3.
| Treatment | Acute PJI | Chronic PJI | Total PJI | ||||||
| Cases, n | Failure, n (%) | p-value | Cases, n | Failure, n (%) | p-value | Cases, n | Failure, n (%) | p-value | |
| DAIR | 31 | 7 (22.6%) | 0.367 | 6 | 1 (16.1%) | 0.258 | 37 | 8 (21.6%) | 0.155 |
| 1SE | 0 | 0 | 2 | 0 (0%) | 3 | 0 (0%) | |||
| 1SC | 0 | 0 | 16 | 0 (0%) | 16 | 0 (0%) | |||
| 2SC | 4 | 0 (0%) | 8 | 1 (12.5%) | 13 | 1 (8.3%) | |||
| Organism | DAIR | 1SE | 1SC | 2SC | |||||
| Cases, n | Failures, n (%) | Cases, n | Failures, n (%) | Cases, n | Failures, n (%) | Cases, n | Failures, n (%) | ||
| No growth, n = 6 | 3 | 1 (33.3%) | – | – | – | – | 3 | 0 (0%) | |
| MRSA, n = 1 | 1 | 0 (0%) | – | – | – | – | – | – | |
| MSSA, n = 18 | 15 | 4 (26.7%) | – | – | – | – | 3 | 1 (33.3%) | |
| CoNS, n = 17 | 7 | 1 (14.35) | 1 | 0 (0%) | 6 | 0 (0%) | 3 | 0 (0%) | |
| MRSE, n = 2 | 1 | 0 (0%) | 1 | 0 (0%) | |||||
| Streptococcus, n = 4 | 2 | 0 (0%) | 1 | 0 (0%) | 1 | 0 (0%) | 1 | 0 (0%) | |
| Psuedomonas, n = 1 | – | – | – | – | – | – | 1 | 0 (0%) | |
| Polymicrobial, n = 6 | 4 | 2 (50%) | – | – | – | – | 1 | 0 (0%) | |
| Enterococcus, n = 1 | – | – | – | – | 1 | 0 (0%) | – | – | |
| E. coli, n = 1 | – | – | – | – | 1 | 0 (0%) | – | – | |
| P. acne, n = 1 | 1 | 0 (0%) | – | – | – | – | – | – | |
4 Discussion
Despite the plethora of evidence evaluating treatment options for PJI in TKA, management of PJI after UKA lacks consensus due to the scarcity of available literature. This systematic review demonstrates a trend towards DAIR in the management of acute UKA PJI, while chronic PJI is more commonly managed by 1SC or 2SC. Even with the compilation of data from the available literature, there were no statistically significant differences in the effectiveness of these procedures in eradicating infection.
4.1 Diagnosis of PJI
The majority of the included studies do not specify the criteria used to diagnosis PJI after UKA. Traditionally, the MSIS criteria is utilized in the diagnosis of PJI after TKA.13 However, an infected UKA presents a unique diagnostic challenge as the presence of native and prosthetic joint surfaces can confound interpretation of laboratory values and theoretically limit the generalizability of the MSIS criteria.14 In 2021, the optimal cutoff values of erythrocyte sedimentation rate (ESR), C reactive protein (CRP), and synovial white blood cell count (WBC) in the diagnosis UKA PJI were found to be comparable to those in TKA: ESR 27 mm/h, CRP 14 mg/L, synovial WBC 6200 μL with 60% polymorphonuclear (PMN) cells.14 However, it is unclear how these lab values differ in the acute versus chronic setting. More research is required to identify the laboratory values which optimize sensitivity and specificity in diagnosing PJI following UKA in both the acute and chronic settings.
4.2 Treatment of PJI
Hernandez et al. and Chalmers et al. conducted retrospective studies evaluating management of acute and chronic UKA PJI.9,10 No specific indications for the selected procedure were presented, however DAIR was generally used in acute PJI while 1SC or 2SC were used in chronic. Both studies demonstrated higher PJI recurrence rates in the DAIR cohort. Additionally, three DAIR patients across both studies required subsequent conversion to TKA for early progression of arthritis. It is suspected that bacterial damage to the preserved cartilage poses a risk for UKA failure via arthritis progression following DAIR even if the infection is eradicated. While these studies did not demonstrate a statistically significant difference in treatment outcomes, they suggest better overall survivorship with 2SC compared to DAIR. Pandit et al. also demonstrated success with 2SC although details surrounding management were limited.15
There was minimal discussion of the type of antibiotic spacer utilized (i.e. UKA spacer, articulating TKA spacer, or static TKA spacer) in 2SC. Only Hernandez et al. and Chalmers et al. discussed their technique9,10 Both authors performed femoral and tibial TKA bone cuts at the time of first stage procedure with placement of a high-dose antibiotic TKA spacer. Hernandez et al. used an articulating spacer, while Chalmers et al. used a static.9,10 A descriptive study by Pandit et al. also recommends placement of a TKA spacer as the native cartilage retained in UKA spacers poses a risk for failure of infection eradication.16
Despite the DAIR findings presented in these studies, others have presented success with DAIR for management of UKA PJI.17,18 Nettrour et al. and Chawla et al. demonstrated no recurrent infections in both acute and chronic PJI.17,18 Unfortunately, neither study provides insight into their indications for DAIR.
Labruyère et al. and Singer et al. performed a retrospective analysis of patients with chronic UKA PJI treated with 1SC.19,20 The indication for 1SC was based on the isolation of a causative organism via preoperative joint aspirate, antibiotic susceptibility of the identified organism, and the integrity of the soft tissue envelope. Singer et al. also excluded patients with MRSA or MRSE.20 Both studies’ operative technique included a total synovectomy followed by a cemented TKA. Singer et al. utilized antibiotic impregnated cement while Labruyère et al. did not. There were no recurrent infections. The authors largely attributed eradication of infection to the feasibility of performing a complete debridement and synovectomy in UKA relative to TKA as well as the identification of a susceptible causal organism.
Lecuire et al. was the only study that discussed 1SE.21 Unfortunately, they did not provide their indications or details regarding diagnosis and treatment. Nonetheless, they reported successful eradication of chronic PJI with 1SE. In their two cases, a synovectomy was performed and one patient underwent UKA reimplantation with antibiotic impregnated cement while the other patient was reimplanted without cement.
Indications for the varying procedures used in the management of PJI after UKA remain difficult to establish. Similarly, in the TKA literature, there are varying opinions surrounding the indications for DAIR, one-stage exchange arthroplasty, and two-stage exchange arthroplasty. Nonetheless, there is significantly more supporting literature to aid decision making in the treatment algorithm for TKA PJI.
In TKA PJI, DAIR is recommended in acute postoperative or acute hematogenous infections while contraindicated in chronic infections due to higher failure rates as a result of biofilm development.22–26 DAIR has many benefits including preservation of bone stock and knee function, fewer operations, and reduced cost of care.27,28 The preservation of bone stock and knee function is an even bigger consideration in the UKA setting as this coincides with the preservation of native joint articulations, biomechanics, and ligaments that would otherwise be resected in 1SC or 2SC. Additionally, The Kidney, Liver, Index surgery, Cemented prosthesis and CRP (KLIC) and CRIME80 scores assist surgeons in identifying patients who are at higher risk of failure.29,30 Nevertheless, there is no evidence supporting the extrapolation of these scores to the UKA setting.
Similar DAIR utilization trends were observed in UKA PJI. DAIR was largely used for acute infections, however 12.1% of observed chronic PJIs received a DAIR. Given the higher failure rates observed in the chronic setting, we abide by the TKA recommendations that DAIR be reserved for management of acute postoperative and acute hematogenous UKA PJI. Furthermore, it is important to educate patients on the risk of early arthritis progression in the preserved compartments and subsequent need for conversion to TKA as was observed in this study.9,10
One versus two-stage exchange arthroplasty remains a controversial topic in the TKA PJI literature. Interestingly, both UKA studies discussing 1SC were published out of Europe where one-stage exchange arthroplasty is more widely accepted compared to North America.19,20,31 Similar to DAIR, one-stage exchange arthroplasty offers many advantages over a two-stage. Patients are spared from a period of limited knee function following the first stage of a two-stage exchange arthroplasty and avoid the morbidity of multiple surgeries.32,33 Shorter length of stay, reduced cost of care, and earlier functional rehabilitation are other reported advantages.31,34,35
Articles analyzing 1SC noted indications similar to those for one-stage exchange in the TKA PJI literature.31 The UKA studies suggest that if the following criteria are met, a 1SC can be performed: 1) preoperative identification of the causal organism, 2) the organism is susceptible to antibiotics, 3) there is an adequate soft tissue envelope that will allow for primary wound closure.19,20 The TKA literature adds an immunocompetent host as an indication and inability to administer local antibiotics therapy as a relative contraindication.31 Since there is limited literature supporting 1SC or 2SC for the treatment of UKA PJI, we see 1SC as a viable option for PJI management given the success observed in this study and aforementioned advantages of a single stage procedure.
The additional option of 1SE further complicates the decision making algorithm. Only three cases utilizing this procedure were identified and details regarding indications, treatment, and outcomes is minimal.21,36 Consequently, we do not recommend 1SE as an option for UKA PJI management.
To the authors’ knowledge, there are no studies analyzing the association between identified causal organism and failure rates in the management of UKA PJI. Our study observed that polymicrobial and MSSA infections had the highest overall failure rates and failure rates were particularly high for polymicrobial infections managed by DAIR. In the TKA infection literature, it was concluded that causal organism does not impact treatment outcomes in PJI management.37 Nonetheless, more research needs to be conducted analyzing risk factors, including causal organism, for PJI recurrence in patients undergoing DAIR, 1SE, 1SC, or 2SC.
4.3 Limitations
This study is not without limitations. First, this systematic review was limited by the level of evidence of the included articles as they were predominately retrospective cohort designs. Second, the majority of studies did not explicitly state their indications for DAIR versus one-stage revision versus two-stage revision. This precluded us from formulating specific management guidelines, and only generalizations can be made. Third, procedural details were minimally presented in the included articles. This study also does not differentiate between infection rates and outcomes observed in medial, lateral or patellofemoral UKAs.
5 Conclusion
Compared to the available evidence analyzing PJI after TKA, this systematic review found relatively few studies reporting on PJI after UKA. Similar to TKA, DAIR was generally reserved for the management of acute UKA PJI, while 1SC and 2SC were more commonly performed for chronic PJI. Although no statistically significant difference in failure rates between procedures was observed, we recommend DAIR be reserved for acute PJI, and either 1SC, in select patients, or 2SC for chronic PJI. Further research is warranted to better elucidate the most appropriate treatment of PJI after UKA in both the acute and chronic setting along with risk factors for failure.
Informed consent
N/A.
Institutional ethical committee approval
N/A.
Authors contribution
Barbera: Conceptualization, methodology, validation, investigation, writing, visualization. Xiao: Conceptualization, methodology, validation, investigation, writing, visualization. Williams: Investigation, data curation, formal analysis, writing. Poeran: Software, formal analysis, supervision. Moucha: Conceptualization, supervision, project administration. Chen: Conceptualization, supervision, project administration. Hayden: Conceptualization, methodology, review & editing, supervision, project administration.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
References
- Comparison of long-term survival analysis between open-wedge high tibial osteotomy and unicompartmental knee arthroplasty. J Arthroplasty. 2021;36(5):1562-1567.
- [Google Scholar]
- Results of unicompartmental knee arthroplasty at a minimum of ten years of follow-up. J Bone Joint Surg Am. 2005;87(5):999-1006.
- [Google Scholar]
- Outcomes of a fixed-bearing, medial, cemented unicondylar knee arthroplasty design: survival analysis and functional score of 460 cases. J Arthroplasty. 2018;33(9):2792-2799.
- [Google Scholar]
- Long-term survivorship and failure modes of unicompartmental knee arthroplasty. Clin Orthop Relat Res. 2013;471(1):102-108.
- [Google Scholar]
- Analysis and treatment of complications after unicompartmental knee arthroplasty. Knee Surg Relat Res. 2016;28(1):46-54.
- [Google Scholar]
- The largest survivorship and clinical outcomes study of the fixed bearing Stryker Triathlon Partial Knee Replacement - a multi-surgeon, single centre cohort study with a minimum of two years of follow-up. Knee. 2018;25(4):732-736.
- [Google Scholar]
- Unicondylar knee arthroplasty has fewer complications but higher revision rates than total knee arthroplasty in a study of large United States databases. J Arthroplasty. 2019;34(8):1617-1625.
- [Google Scholar]
- Have the causes of revision for total and unicompartmental knee arthroplasties changed during the past two decades? Clin Orthop Relat Res. 2017;475(7):1874-1886.
- [Google Scholar]
- Infection after unicompartmental knee arthroplasty: a high risk of subsequent complications. Clin Orthop Relat Res. 2019;477(1):70-77.
- [Google Scholar]
- Treatment and outcome of periprosthetic joint infection in unicompartmental knee arthroplasty. J Arthroplasty. 2020;35(7):1917-1923.
- [Google Scholar]
- Unicompartmental knee arthroplasty and total knee arthroplasty among Medicare beneficiaries, 2000 to 2009. J Bone Joint Surg Am. 2013;95(22):e174.
- [Google Scholar]
- Yearly incidence of unicompartmental knee arthroplasty in the United States. J Arthroplasty. 2008;23(3):408-412.
- [Google Scholar]
- The 2018 definition of periprosthetic hip and knee infection: an evidence-based and validated criteria. J Arthroplasty. 2018;33(5):1309-1314.
- [Google Scholar]
- Diagnosis of periprosthetic joint infection after unicompartmental knee arthroplasty. J Arthroplasty. 2012;27(8):46-50.
- [Google Scholar]
- The Oxford medial unicompartmental knee replacement using a minimally-invasive approach. J Bone Joint Surg Br. 2006;88(1):54-60.
- [Google Scholar]
- Converting a unicompartmental knee arthroplasty to a total knee arthroplasty: ensuring primary outcome. Semin Arthroplast JSES. 2011;22(3):143-149.
- [Google Scholar]
- High failure rates for unicompartmental knee arthroplasty in morbidly obese patients: a two-year minimum follow-up study. J Arthroplasty. 2020;35(4):989-996.
- [Google Scholar]
- Barbed suture is associated with increased risk of wound infection after unicompartmental knee arthroplasty. J Arthroplasty. 2016;31(7):1561-1567.
- [Google Scholar]
- Chronic infection of unicompartmental knee arthroplasty: one-stage conversion to total knee arthroplasty. Orthop Traumatol Surg Res. 2015;101(5):553-557.
- [Google Scholar]
- High rate of infection control with one-stage revision of septic knee prostheses excluding MRSA and MRSE. Clin Orthop Relat Res. 2012;470(5):1461-1471.
- [Google Scholar]
- Partial or total replacement of a unicompartmental knee prosthesis by another unicompartmental knee prosthesis: a reasonable option? About 22 cases. Eur J Orthop Surg Traumatol. 2013;23(8):933-938.
- [Google Scholar]
- Hip and knee section, treatment, debridement and retention of implant: proceedings of international consensus on orthopedic infections. J Arthroplasty. 2019;34(2S):S399-S419.
- [Google Scholar]
- Utilization of debridement, antibiotics, and implant retention for infection after total joint arthroplasty over a decade in the United States. J Arthroplasty. 2020;35(8):2210-2216.
- [Google Scholar]
- Success rates of debridement, antibiotics, and implant retention in 230 infected total knee arthroplasties: implications for classification of periprosthetic joint infection. J Arthroplasty. 2021;36(1):305-310.
- [Google Scholar]
- Understanding biofilm resistance to antibacterial agents. Nat Rev Drug Discov. 2003;2(2):114-122.
- [Google Scholar]
- Biofilm-related infections: bridging the gap between clinical management and fundamental aspects of recalcitrance toward antibiotics. Microbiol Mol Biol Rev. 2014;78(3):510-543.
- [Google Scholar]
- The fate of acute methicillin-resistant Staphylococcus aureus periprosthetic knee infections treated by open debridement and retention of components. J Arthroplasty. 2009;24(6 Suppl):101-104.
- [Google Scholar]
- Results of direct exchange or debridement of the infected total knee arthroplasty. Clin Orthop Relat Res. 2002;404:125-131.
- [Google Scholar]
- KLIC-score for predicting early failure in prosthetic joint infections treated with debridement, implant retention and antibiotics. Clin Microbiol Infect Off Publ Eur Soc Clin Microbiol Infect Dis. 2015;21(8)
- [Google Scholar]
- Predicting failure in early acute prosthetic joint infection treated with debridement, antibiotics, and implant retention: external validation of the KLIC score. J Arthroplasty. 2018;33(8):2582-2587.
- [Google Scholar]
- Hip and knee section, treatment, one stage exchange: proceedings of international consensus on orthopedic infections. J Arthroplasty. 2019;34(2):S421-S426.
- [Google Scholar]
- Use of static or articulating spacers for infection following total knee arthroplasty: a systematic literature review. J Bone Joint Surg Am. 2013;95(17):1594-1599.
- [Google Scholar]
- Results of 2-stage reimplantation for infected total knee arthroplasty. J Arthroplasty. 1998;13(1):22-28.
- [Google Scholar]
- One-stage revision for infected total hip arthroplasty. Orthop Clin N Am. 2016;47(1):11-18.
- [Google Scholar]
- Revision surgery after failed unicompartmental knee arthroplasty: a study of 35 cases. J Arthroplasty. 2000;15(8):982-989.
- [Google Scholar]
- Hip and knee section, pathogen factors: proceedings of international consensus on orthopedic infections. J Arthroplasty. 2019;34(2):S381-S386.
- [Google Scholar]