This 1983 prospective study from HSS evaluated a three-phase two-stage reimplantation protocol for salvaging infected total knee arthroplasties. Insall and colleagues report outcomes in 11 knees across 10 patients treated between 1977 and 1979, with minimum 2-year follow-up. The protocol asks: can complete hardware removal, six weeks of monitored parenteral antibiotics, and staged reimplantation reliably eradicate prosthetic knee infection?
Before this paper, deep infection after TKA was widely considered a catastrophic failure with no reliable salvage — the prevailing alternatives were antibiotic suppression, arthrodesis, or amputation, each with poor long-term results. Insall's series provided the first prospective data showing that a disciplined staged approach could reliably eradicate infection and restore acceptable knee function.
When you see a painful TKA without mechanical explanation, treat it as infected until proven otherwise. Aspirate first, and if cultures are negative but suspicion remains, the authors recommend explantation with operative cultures rather than watchful waiting. When infection is confirmed and the patient is medically fit, two-stage reimplantation is the procedure of choice: remove everything (all hardware and all cement), achieve a serum bactericidal titer of at least 1:8 with parenteral antibiotics for six weeks, then reimplant once the wound appears benign with no pain, edema, or inflammation.
Counsel patients preoperatively about extensor mechanism risk. Extension lag and the possibility of patellectomy are not rare exceptions but anticipated complications of this operation. This paper is why modern periprosthetic infection guidelines require hardware removal and why infectious disease co-management with serum bactericidal titer monitoring became standard practice.
This 1983 prospective study from HSS evaluated a three-phase two-stage reimplantation protocol for salvaging infected total knee arthroplasties. Insall and colleagues report outcomes in 11 knees across 10 patients treated between 1977 and 1979, with minimum 2-year follow-up. The protocol asks: can complete hardware removal, six weeks of monitored parenteral antibiotics, and staged reimplantation reliably eradicate prosthetic knee infection?
Before this paper, deep infection after TKA was widely considered a catastrophic failure with no reliable salvage — the prevailing alternatives were antibiotic suppression, arthrodesis, or amputation, each with poor long-term results. Insall's series provided the first prospective data showing that a disciplined staged approach could reliably eradicate infection and restore acceptable knee function.
When you see a painful TKA without mechanical explanation, treat it as infected until proven otherwise. Aspirate first, and if cultures are negative but suspicion remains, the authors recommend explantation with operative cultures rather than watchful waiting. When infection is confirmed and the patient is medically fit, two-stage reimplantation is the procedure of choice: remove everything (all hardware and all cement), achieve a serum bactericidal titer of at least 1:8 with parenteral antibiotics for six weeks, then reimplant once the wound appears benign with no pain, edema, or inflammation.
Counsel patients preoperatively about extensor mechanism risk. Extension lag and the possibility of patellectomy are not rare exceptions but anticipated complications of this operation. This paper is why modern periprosthetic infection guidelines require hardware removal and why infectious disease co-management with serum bactericidal titer monitoring became standard practice.