Application of structural allogenous bone graft in two-stage exchange arthroplasty for knee periprosthetic joint infection: a case control study

Application of structural allogenous bone graft in two-stage exchange arthroplasty for knee periprosthetic joint infection: a case control study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Application of structural allogenous bone graft in two-stage exchange arthroplasty for knee periprosthetic joint infection: a case control study ChiehAn Chuang, Sheng-Hsun Lee, Chih-Hsiang Chang, Chih-Chien Hu, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-779204/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Apr, 2022 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted You are reading this latest preprint version Abstract Background: Knee prosthetic joint infection (PJI) is a common but devastating complication after knee arthroplasty. The revision surgeries for knee PJI may become more challenging when it is associated with large bone defects. The application of structural bone allograft in knee revision surgeries with large bone defects is not a new technique. However, there is a lack of literature reporting its efficacy in PJI cases. This study aimed to investigate the outcome of structural fresh frozen allogenous bone grafts in treating patients in knee PJI with large bone defects. Methods: We performed a retrospective cohort analysis of knee PJI cases treated with two-stage exchange arthroplasty at our institution from 2010 to 2016. 12 patients with structural allogenous bone graft reconstructions were identified as the study group. 24 patients without structural allograft reconstructions matched with the study group by age, gender, and Charlson comorbidity index were enrolled as the control group. The functional outcome of the study group was evaluated with the Knee Society Score (KSS). Treatment success was assessed according to the Delphi-based consensus definition. The infection relapse rate and implant survivorship were compared between groups. Results: Revision knees with structural allograft presented excellent improvement in the KSS (33.1 to 75.4). There was no significant difference between infection relapse-free survival rate and prosthesis survival rate in two groups. The 8-year prosthesis survival rate was 90.9% in the study group and 91% in the control group (p = 0.913). The 8-year infection relapse-free survival rate was 80% and 83.3% in the study group and control group, respectively (p = 0.377). Conclusion: The structural fresh frozen allogenous bone graft provided an effective way for bone defect reconstruction in knee PJI with accountable survival rate. Meanwhile, using structural allografts did not increase the relapse rate of infection. Orthopedics Orthopedic Surgery Revision knee arthroplasty periprosthetic joint infection bone defect structural allogenous bone graft Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Periprosthetic joint infection (PJI) is a devastating complication after total knee arthroplasty (TKA). The incidence of knee PJI is about 2% in primary TKA( 1 ) and accounts for nearly 20% in revision cases( 2 ). Two-stage exchange arthroplasty, which provides an 85–95% of infection eradication rate with an improved functional score, has been recognized as the treatment of choice for PJI ( 3 , 4 ). The bone defect is a challenging problem in revision TKA, which may result from osteolysis, stress shielding, infection, or multiple revisions( 5 ). Managing this problem can vary widely depending on the defect size, patient condition, and surgeon experience ( 6 , 7 ). Allogenous bone graft is a common resolution for reconstructing bone defects in revision TKA that can fill bone defects and provide mechanical support ( 5 – 7 ). The fresh-frozen allogenous bone graft can provide better biological and mechanical results than irradiated allogenous bone graft ( 8 ). However, there are several concerns of using allogeneous bone grafts, including potential risks of infection, aseptic loosening, disease transmission, nonunion, and bone resorption( 9 , 10 ). Hsieh et al. had conducted a study on using bone allografts to treat hip PJI with massive bone loss, showing positive results with no further infection( 11 ). However, limited literature is available on structural allogenous bone grafts in revision knee PJI with bone defects. Previous literature had reported the risk of infection by using allograft in revision knees( 9 ). Therefore, using structural allograft in knee revision PJI is still a controversial issue. The purpose of our study was to examine the clinical and functional outcomes of knee PJIs by using structural allografts to reconstruct bone defects in a two-stage revision procedure. Methods We retrospectively reviewed the joint arthroplasty databases to identify patients diagnosed with knee PJI and treated with two-stage exchange arthroplasty at our institution between January 2010 and December 2016. The study was approved by the Institutional Review Board of our institution according to the applicable laws and regulations. PJI was defined by fulfilling one of the following criteria: ( 1 ) a sinus tract communicating with the prosthesis; ( 2 ) isolated pathogens in two or more samples obtained from the infected prosthetic joint; ( 3 ) Presence of purulence in the affected joint with elevated synovial white blood cell count and synovial polymorphonuclear percentage (PMN%) combined with serum erythrocyte sedimentation rate(ESR) and serum C-reactive protein(CRP) concentration elevation ( 12 ). All the enrolled patients were treated with two-stage exchange arthroplasty. In brief, resection arthroplasty included radical debridement, removal of the prosthesis, antibiotic-loaded bone cement implantation, and administration of systemic antimicrobial agents for controlling the joint infection. Delayed reimplantation of the prosthesis was performed after successful antimicrobial therapy, which was defined by the absence of signs of infection with ESR and CRP resumed to normal levels( 13 ). The bone defects were evaluated during the second stage revision surgery according to the Anderson Orthopedic Research Institute (AORI) bone defect classification ( 14 ). The allografts were shaped into appropriate sizes then attached to the host bone defect site. We then filled the morselized allograft to residual space between the host bone and the structural allograft. After reconstruction of the bone defect, the prosthesis was implanted fully cemented. Figure 1 showed an example treatment case. Control group We randomly matched two patients without structural bone allograft reconstruction as the control group (non-allograft group) to each patient from the study group (allograft group) based on age, gender, and Charlson comorbidity index (CCI). The paired patients were from the knee joint PJI data in our institute. Bone graft The source of allografts was from the bone bank in our institute. We used deep freezing to sterilize the allograft bone and eliminate antigen-antibody reactions between the allograft and the hosts. The protocol of allograft bone-retrieving was the same as described by Wu et al. in our institute ( 15 ). Outcome assessment The function of the involved knees was assessed before operation and at OPD follow-up according to Knee Society Score (KSS) ( 16 ). Treatment success was assessed according to the Delphi-based consensus definition, including ( 1 ) infection eradication, characterized by a healed wound without fistula, drainage or pain, and no infection recurrence caused by the same organism strain; ( 2 ) no post-operative infection after reimplantation surgery; and ( 3 ) no occurrence of PJI-related mortality with an at least 2-year follow-up. The radiographs were examined regularly for evidence of allograft resorption, migration, or loosening of the allograft-prosthesis composite. The incorporation of the allograft was determined by the appearance of trabecular remodeling within the grafted area and the disappearance of the gap between the host and the allograft. The Log-rank test was performed for Kaplan-Meier survival curve analysis. Statistical analysis was conducted by an independent statistician blinded to surgical outcomes. Statistical analysis was performed with SPSS software version 23.0. Results Between January 2010 and December 2016, we identified 157 consecutive patients with knee PJI treated by a 2-stage exchange arthroplasty protocol at our institute. Patients who did not meet the minimal 2-year-follow up were excluded. At last, 135 patients were enrolled. Among 135 patients, 12 patients with massive bone loss treated with fresh frozen structural bone allograft during 2nd stage reconstruction were enrolled as our study group. There were ten right knees and two left knees. Their mean age at revision was 68.1 years old (from 45.7 to 81.1), and the mean follow-up time was 62.5 months (from 25.7 to 95.0). Details of the 12 allograft-treated patients were shown in Table 1 . The mean age of the 24 patients in the control group was 68.1 years old (from 32.9 to 82.7), the mean follow-up time was 58.4 months (from 24.7 to 129.4). Details of the control group were shown in Table 2 . Table 1 The characteristics of patients in the allograft group (Study group) No. Gen Age Status before Infection Comorbidities CCI Defect site /type (AORI) Prosthesis Antibiotics in bone cement spacer 1st stage culture Antibiotics in interim period 1 F 64.5 Revision TKA DM 3 Femur:III Tibia:I United, U2 PSA Vancomycin + ceftazidime Steph.epidermidis Cotrimoxazole 2 M 67.3 Revision TKA DM, HTN, CKD 5 Femur:IIB United, U2 PSA Vancomycin + ceftazidime Staphylococcus aureus (OSSA) Clindamycin 3 F 79.0 Revision TKA DM, HTN, CAD 5 Femur:IIB United, U2 PSA Vancomycin + ceftazidime Staphylococcus aureus(OSSA) Dicloxacillin 4 M 65.9 Primary TKA DM, HTN 3 Femur:III Zimmer, LCCK Vancomycin + ceftazidime Staphylococcus aureus(OSSA) Dicloxacillin 5 F 79.0 Primary TKA HTN 3 Femur:III United, U2 PSA Vancomycin + ceftazidime Enterococcus faecalis Ampicillin 6 M 78.2 Revision TKA HTN 3 Femur:I Tibia:III Zimmer, LCCK Vancomycin + ceftazidime Enterococcus faecalis Sodium fusidate 7 F 50.4 Revision TKA SLE 2 Tibia:IIB Zimmer, RHK Vancomycin + ceftazidime Pseudomonas aeruginosa Ciprofloxacin 8 M 63.5 Primary TKA DM, RA 4 Femur:III Zimmer, LCCK Vancomycin + ceftazidime Serratia marcescens Ciprofloxacin 9 F 71.8 Primary TKA DM 4 Femur:IIB Tibia:I United, U2 PSA Vancomycin + ceftazidime Mycobacterium tuberculosis Rifampicin + Isoniazid 10 F 81.1 Primary TKA HTN, CVA 5 Femur:I Tibia:III United, U2 PSA Vancomycin + ceftazidime Escherichia coli Ciprofloxacin 11 F 45.7 Primary TKA DM, HB 2 Femur:III United, tumor prosthesis Vancomycin + ceftazidime Staphylococcus aureus Dicloxacillin 12 F 70.2 Primary TKA HTN 3 Tibia:III Zimmer, LCCK Vancomycin + ceftazidime Coagulase(-) staphylococcus Dicloxacillin, cotrimoxazole Gen: Gender; CCI: Charlson comorbidity index; TKA:Total knee arthroplasty; HTN: Hypertension; DM: Diabetes mellitus; CKD: Chronic kidney disease; CAD: coronary artery disease; HB: Hepatitis B; RA: Rheumatic arthritis; SLE: Systemic Lupus Erythematosus OSSA: Oxacillin- susceptible Staphylococcus aureus Zimmer: Zimmer Biomed Institute, USA United: United Orthopedics corporation, Taiwan Table 2 The characteristics of patients in the non-allograft group (Control group) No. Gen Age Status before Infection Comorbidities CCI Antibiotics in bone cement spacer 1-stage culture Antibiotics in interim period 1 F 62.7 Primary TKA Cecal cancer 2 Vancomycin + piperacillin Ps.stutzeri Ciprofloxacin 2 F 62.3 Primary TKA HTN, DM 3 Vancomycin + ceftazidime Staph.aureus (ORSA) Daptomycin, Ciprofloxacin 3 M 65.6 Revision TKA HTN, DM, CKD, HC 5 Vancomycin + ceftazidime nil Vancomycin 4 M 68.2 Primary TKA HTN, DM, PU, CVA, 5 Vancomycin + ceftazidime Serratia marcescens Ciprofloxacin 5 F 77.6 Revision TKA HTN, DM, CKD 6 Vancomycin + ceftazidime nil Vancomycin 6 F 80.1 Primary TKA HTN, DM 5 Vancomycin + ceftazidime nil Dicloxacillin 7 M 63.2 Revision TKA HTN 2 Vancomycin + ceftazidime Ps.aeruginosa Fortum 8 M 65.3 Primary TKA HTN, HB 3 Vancomycin + ceftazidime Staph.epidermidis (ORSE) Vancomycin 9 F 79.1 Revision TKA nil 3 Vancomycin + ceftazidime Staph.aureus(OSSA) Dicloxacillin 10 F 76.0 Primary TKA HTN, DM 4 Vancomycin + ceftazidime Staph.aureus(ORSA) Cotrimoxazole 11 M 77.2 Primary TKA HTN 3 Vancomycin + ceftazidime Staph.aureus(OSSA) Ecoli Dicloxacillin 12 M 80.3 Revision TKA Asthma 4 Vancomycin + ceftazidime B-strepto.Gr.A Gm(-)bacilli-glucose nonfermentin Ampicillin 13 F 59.3 Revision TKA nil 1 Vancomycin + ceftazidime Staph.epidermidis (ORSE) Rifampicin Fusidin 14 F 50.8 s/p ITL nail DM 2 Vancomycin + ceftazidime Staph. epidermidis (ORSE) Rifampicin Fusidin 15 M 62.1 Revision TKA HTN, HB 3 Vancomycin + ceftazidime staph. aureus (OSSA) Dicloxacillin 16 M 60.4 Primary TKA RA 3 Vancomycin + ceftazidime Staph. epidermidis (ORSE) Clindamycin 17 F 74.9 Primary TKA HTN, DM 4 Vancomycin + ceftazidime Nil Teicoplanin, ertapenem 18 F 74.6 Revision TKA HTN, PU, HB 5 Daptomycin + teinem Parvimonas micra Metronidazole 19 F 82.7 Primary TKA HT, DM, CVA 6 Vancomycin + ceftazidime Staph.aureus(OSSA) Rifampicin 20 F 79.8 Primary TKA HT, DM Dementia, CAD 6 Vancomycin + ceftazidime Kleb pneumoniae Ampicillin 21 F 56.8 Revision TKA HB 2 Vancomycin + ceftazidime Ps.aeruginosa Ciprofloxacin 22 F 32.9 Revision TKA Bone tumor s/p 2 Vancomycin + ceftazidime Staph.aureus(ORSA) Teicoplanin 23 F 69.9 Primary TKA HTN 2 Streptomycin mycobacterium tuberculosis complex Rifinah 24 F 71.9 Revision TKA HTN 3 Vancomycin + ceftazidime Staph.aureus(OSSA) Dicloxacillin Gen: Gender; CCI: Charlson comorbidity index; TKA: Total knee arthroplasty; s/p: status post; ITL: Interlocking nail HTN: Hypertension; DM: Diabetes mellitus; HB: Hepatitis B; HC: Hepatitis C; CKD: Chronic kidney disease; CVA: cerebrovascular accident; CAD: coronary artery disease; PU: Peptic ulcer Ps: Pseudomonus; Staph: Staphylococcus OSSA: Oxacillin- susceptible Staphylococcus aureus; ORSA: Oxacillin-resistant Staphylococcus aureus; ORSE: Oxacillin-resistant Staphylococcus epidermidis The micro-organism isolated from the first stage of resection arthroplasty, the impregnated antibiotics in cement spacer and the provided antibiotics in the interim period were shown in Table 1 and Table 2 . Generally, gram-positive bacteria account for the majority of the infection source. The mean KSS improved from 33.1 (16–45) pre-operatively to 75.4 (49–87) postoperatively in the study group. The radiographs showed no nonunion, resorption, or fracture in allografts during follow-up. The treatment example was showed in Fig. 2 . There was one patient who sustained re-infection, and one patient underwent implant revision during the follow-up. The details of the two patients were shown below. One 50-year-old female patient reconstructed with tumor prosthesis at the 2nd stages surgery suffered from recurrent right knee infection at 74 months after 2nd stage reconstruction. Associated findings included urinary tract infection and left foot cellulitis. She was admitted to the infection ward for sepsis control first, and the operation with debridement and irrigation was performed later by us. The intra-operative culture was negative. After debridement surgery, we provided intravenous antibiotics (vancomycin and ceftriaxone) then oral antibiotics (dicloxacillin and clindamycin) for further infection control. Decreased CRP levels with improved clinical conditions were noted afterward. Another 78-years-old male sustained right knee soreness at 32 months after 2nd stage reconstruction. Tibia component breakage was noted from the radiographic follow-up. Revision surgery with TM cone implantation over the tibia side was performed with no infection sign noted intra-operatively. The radiographic image was presented as Fig. 3 . The 8-year infection-free survival rate was 80% in the study group and 83.3% in the control group. There was no significant difference in 8-year infection-free survival between patients with or without allografts (p = 0.377, Fig. 4 ). For prosthesis survivorship, the 8-year prosthesis-retention survival rate was 90.9% in the study group and 91.0% in the control group (Fig. 5 ). There was no significant difference (p = 0.913) between these two groups. Discussion Knee PJI accompanied with bone loss is a challenging problem in knee joint revision. Several studies have reported the outcomes of revision knees with bone defects reconstructed by bone allografts. However, limited literature focuses on the same issue in knee PJI cases. Using allogenous bone graft for bone defect reconstruction remains a controversial issue, especially for knee PJI revision. In this current study, we compared the outcomes of knee PJI with bone defect reconstruction by structural allografts to outcomes of general cases in knee PJI without using structural allografts. There was no significant difference in the relapse rate of infection and implant survival rate between the groups. We believe using structural allogenous bone graft in the second stage of knee PJI reconstruction can be safe and feasible. Two-stage treatment for knee PJI PJI is one of the most common complications that leads to the revision of TKA( 2 ), and two-stage total knee revision is considered as the proper treatment for PJI with a success rate of around 85%-90%( 3 , 17 , 18 ). Bongers et al.( 19 ) reported a 20% re-infection rate at five years in 113 PJI knees with 2-stage revision. We performed a 2-stage revision protocol for all knee PJI patients from our database including knees with bone defects. In our results, both groups presented with around 90% of 8-year prosthesis survival rate and approximately 80% of 8-year infection relapse-free survival rate. The outcome of 2-stage treatment for knee PJI was in line with previous studies. Bone defect management Bone defects reconstruction is challenging in knee revision arthroplasty( 20 ). When it comes to large bone defects, metal augment is feasible in managing AORI type II bone defects, and structural allograft is the treatment option for AORI type IIB to type III( 5 , 7 ). Hockman et al. ( 21 ) compared the efficacy of using metal augment to allograft for bone loss treatments in knee revision. The result revealed a 59% failure rate of using metal augment alone, and 48% of the knees required additional structural allograft. It was believed that metal augment reduced the contact surface between the host bone and the implant, making it relatively more unstable. In addition, augment could not manage bone defects over 20 mm depth, and there were risks of fretting and erosion, as well as limitations on bone stock restoration ( 6 , 22 ). Richards et al.( 23 ) also declared that patients treated with allograft demonstrated better clinical outcomes and lower complication rates than those treated with metal augment. Metal cones were another treatment choice for knee revision with large bone defects as AORI type III. A systematic review had reported a lower loosening rate of the porous metal cones than structural allograft in revision knees ( 24 ). However, the re-infection rate revealed no significant difference between these two methods. In our experiences, it was necessary to remove additional host bones when applying metal cones in particular cases. Besides, metal cones have a limited choice in sizes and are inapplicable to knees with small bone sizes. Furthermore, metal cones may cause an additional financial burden to patients comparing to allograft, which is more cost-effective. All these factors need to be considered when managing large bone defects indicated for both structural allograft and cones systems. Structural allogenous bone graft Structural allograft is known for its capability of incorporating the host bone and stress protection. Literature had reported a prosthesis survival rate between 76% and 93% at a 5-year follow-up, showing the capability of structural allograft in treating knee revision cases with bone loss ( 9 , 10 , 25 ). For mid-term to long-term survivorship, Chun et al.( 26 ) reported the results of 27 patients undergoing revision TKA with severe bone defect using a fresh-frozen femoral head allograft with a minimum of 8-year follow up. They demonstrated an improved Hospital for Special Surgery knee score from 46 to 83, and 26 out of 27 patients presented no complications. Engh et al. reported a 91% survivorship at 10 years for femoral head allograft in tibial defects in 46 patients receiving revision TKA( 27 ). Clatworthy et al. presented a prosthesis survival rate of 92% at 5 years and 72% at 10 years in 52 patients with uncontained bone defect constructed with structural allograft in knee revisions ( 28 ). In this current study, cases enrolled in the study group were all knee PJI cases with bone defects. We demonstrated a 90.9% 8-year implant survival rate in structural allograft reconstruction knees, indicating a similar outcome compared with the previous literatus though our cases were all PJI revision knees. Despite the reliable results of structural allograft in revision knees, some complications were still with concerns. The potential risk of disease transmission remains an unresolved problem of using bone allografts( 29 ). Several studies had reported a higher infection rate of using allograft bone, which led to revision failure. Franke et al. reported a study in which 30 patients were treated with allografts for revision TKA, and the infection rate was 10%( 10 ). Bauman et al. reviewed structural allograft for TKA reconstruction with an infection rate of 7.1% ( 9 ). Backstein et al. used structural allograft in revision TKA and reported a re-operation rate of 4.9% for secondary infection ( 30 ). However, Wang et al. conducted a case series study with revision knee reconstructed with femoral head allograft showed no recurrent infection among PJI cases( 31 ). In this current study, one patient in the study group sustained recurrent infection, while the other 11 patients presented free of infection relapse. The results showed an infection rate of 8.3%, and a 100% 5-year infection-free survival rate and an 80% 8-year infection-free survival rate. Though the infection rate was similar to previous articles, it was acceptable owing to cases in this study were all PJI cases. We supposed the application of structural allograft to knee PJI cases did not increase the infection rate compared to general cases. The outcome can be attributed to the following reasons. First, the bone bank in our institute is under strict regulations which are supervised by the government, and all of the bone grafts were harvested by experienced surgeons ( 15 ). Wu et al. had reported the result of using bone allografts from our bone bank for surgery with a relatively low infection rate of 1.2% ( 15 ). Second, all allografts used in this study were femoral heads harvested from the patients undergoing total hip arthroplasty in our institute. Based on our previous study, administering prophylaxis antibiotics before surgery resulted in their presence in fresh-frozen femoral heads, which exhibited inhibitory effects against bacteria in vitro after two weeks of deep-frozen storage ( 32 ). For other complications, Backstein et al. reported three cases of resorption and one case of nonunion in 58 patients ( 30 ). Franke et al. reported one case of nonunion to the graft and host bone in 30 cases of revision knee using allograft bone ( 10 ). Bauman et al. reported two cases of nonunion and three cases of post-operative fracture in 79 cases of revision knee treated by structural bone allograft ( 9 ). In our study, no graft resorption, nonunion or fracture was reported during our radiographic follow-up concerning structural allograft. One patient suffered from tibial component breakage two and half years after the reconstruction surgery. The structural allograft was applied to the tibia bone defect without nonunion or resorption by x-ray follow-up. By comparing our study group results to the control group (PJI cases without allografts) and previous articles on revision knees managed with structural allograft, the results revealed the capability of allograft to resolve bone defects in knee PJI cases. The outcome showed no additional infection relapse rate and a satisfying prosthesis survival rate. This study validated the efficacy of using allograft in solving PJI with bone loss in the two-stage revision procedure. Limitations The study has several limitations. First, this was a retrospective study with a relatively small sample size. Second, the size of the control group's bone defects was inconsistent with that of the study group. Some of the cases in the control group might be simple revision cases that presented with minimal bone defects. Generally, the bone defect would be more extensive in the study group. The infection rate in complex revisions knees, which require structural bone reconstruction, might be higher than simple revision or small bone defect cases. However, we presented a different point of view according to our results. Third, we did not compare the functional outcome between the study and control groups, which is also essential for comparison. Nevertheless, the overall KSS was good in our study group after the revisions. At last, the implants were not matched between cases in the study group and control group. The different implants might affect the survival rate and complication rate. Conclusion The reconstruction of bone defects in knee PJI with structural allogenous bone graft does not increase the relapse rate of infection and provides a good prosthesis survival rate. The use of structural fresh frozen allogenous bone graft for managing bone defects in the second stage of knee PJI reconstruction is a promising and safe method. Abbreviations Prosthetic joint infection (PJI); Polymorphonuclear percentage (PMN%); Erythrocyte sedimentation rate (ESR); C-reactive protein (CRP); Anderson Orthopedic Research Institute (AORI); Charlson comorbidity index (CCI); Knee Society Score (KSS) Declarations Ethic approval: This retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Human Investigation Committee (IRB) of Chang Gung Memorial hospital approved this study (No. 201701121B0) . Consent for publication Patients signed informed consent regarding publishing their data and photographs. Availability of data and material The datasets generated during or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors have no conflicts of interest to declare that are relevant to the content of this article. Funding No funding was received for conducting this study. Authors’ contributions All authors contributed to the study conception and design. Material preparation, data collection were performed by Sheng-Hsun Lee, Chih-Hsiang Chang, Chih-Chien Hu, Hsin-Nung Shih, Steve W.N. Ueng, and Yuhan Chang. The first draft of the manuscript was written by Chieh An Chuang and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. 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Severe tibial bone loss in revision total knee replacement managed with structural femoral head allograft: a prospective case series from the Royal London Hospital. Knee. 2009;16(5):326–31. Chun CH, Kim JW, Kim SH, Kim BG, Chun KC, Kim KM. Clinical and radiological results of femoral head structural allograft for severe bone defects in revision TKA — A minimum 8-year follow-up. Knee. 2014;21(2):420–3. Engh GA, Ammeen DJ. Use of structural allograft in revision total knee arthroplasty in knees with severe tibial bone loss. J Bone Joint Surg Am. 2007;89(12):2640–7. Clatworthy MG, Ballance J, Brick GW, Chandler HP, Gross AE. The use of structural allograft for uncontained defects in revision total knee arthroplasty. A minimum five-year review. J Bone Joint Surg Am. 2001;83-a(3):404 – 11. Buck BE, Malinin TI, Brown MD. Bone transplantation and human immunodeficiency virus. An estimate of risk of acquired immunodeficiency syndrome (AIDS). Clin Orthop Relat Res. 1989(240):129–36. Backstein D, Safir O, Gross A. Management of bone loss: structural grafts in revision total knee arthroplasty. Clin Orthop Relat Res. 2006;446:104–12. Wang JW, Hsu CH, Huang CC, Lin PC, Chen WS. Reconstruction using femoral head allograft in revision total knee replacement: an experience in Asian patients. The bone joint journal. 2013;95-b(5):643–8. Chang Y, Shih HN, Chen DW, Lee MS, Ueng SW, Hsieh PH. The concentration of antibiotic in fresh-frozen bone graft. The Journal of bone joint surgery British volume. 2010;92(10):1471–4. Cite Share Download PDF Status: Published Journal Publication published 05 Apr, 2022 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-779204","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":44273376,"identity":"3732c335-7b6e-4de6-a614-55ca6adb4af9","order_by":0,"name":"ChiehAn Chuang","email":"","orcid":"https://orcid.org/0000-0003-1099-4814","institution":"Chang Gung Memorial Hospital Linkou Main Branch: Chang Gung Memorial Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"ChiehAn","middleName":"","lastName":"Chuang","suffix":""},{"id":44273377,"identity":"88efd65d-20a3-4eae-9714-d470a7187c71","order_by":1,"name":"Sheng-Hsun Lee","email":"","orcid":"","institution":"Chang Gung Memorial Hospital Linkou Main Branch: Chang Gung Memorial Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sheng-Hsun","middleName":"","lastName":"Lee","suffix":""},{"id":44273378,"identity":"31583549-bfca-42a5-a79d-5ab3e70d07bb","order_by":2,"name":"Chih-Hsiang Chang","email":"","orcid":"","institution":"Chang Gung Memorial Hospital Linkou Main Branch: Chang Gung Memorial Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Chih-Hsiang","middleName":"","lastName":"Chang","suffix":""},{"id":44273379,"identity":"0f2fe831-4abc-4029-9b00-f406cccdf711","order_by":3,"name":"Chih-Chien Hu","email":"","orcid":"","institution":"Chang Gung Memorial Hospital Linkou Main Branch: Chang Gung Memorial Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Chih-Chien","middleName":"","lastName":"Hu","suffix":""},{"id":44273380,"identity":"ab97d276-d7ef-4378-8263-403019b22279","order_by":4,"name":"Hsin-Nung Shih","email":"","orcid":"","institution":"Chang Gung Memorial Hospital Linkou Main Branch: Chang Gung Memorial Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hsin-Nung","middleName":"","lastName":"Shih","suffix":""},{"id":44273381,"identity":"42bae648-3e42-4979-b573-148c30041bb2","order_by":5,"name":"Steve W.N. Ueng","email":"","orcid":"","institution":"Chang Gung Memorial Hospital Linkou Main Branch: Chang Gung Memorial Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Steve","middleName":"W.N.","lastName":"Ueng","suffix":""},{"id":44273382,"identity":"14a0782d-923c-434e-876b-745a332faf03","order_by":6,"name":"Yuhan Chang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYDACCQY2ECUHxGykaTFGaCGoE6olsYFoLQa3m589+LmjNr2/f3XaA4aKe3YN8j0G+LXcOWZu2HvmeO6MG2+3GzCcKU5uYOMhoOVGDpsEb9ux3A0SZ7dJMLYlJDOw8W4gqEXyb9uxdAOStEjzttUkGPD3grXYEdQieSPNTFq27YDhjBu82yQSziQksLHlf8Crhe9G8jPJt2118vz9QId9qEiw52c+loBXi8IBMHUYGEFAhUCU2IZXPRDIN4CpOgYGfohme0I6RsEoGAWjYOQBAI6ORr1OzvsBAAAAAElFTkSuQmCC","orcid":"","institution":"Chang Gung Memorial Hospital Linkou Main Branch: Chang Gung Memorial Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Yuhan","middleName":"","lastName":"Chang","suffix":""}],"badges":[],"createdAt":"2021-08-04 10:38:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-779204/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-779204/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12891-022-05228-6","type":"published","date":"2022-04-05T12:53:51+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":12256898,"identity":"7caec982-507b-4022-aae3-a9cefc1d9df0","added_by":"auto","created_at":"2021-08-09 17:47:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":636707,"visible":true,"origin":"","legend":"Intraoperative pictures from second-stage reconstruction of a 50 years old female diagnosed with PJI with bone defect showing a) AORI type IIB bone defect over left tibia b) defect reconstructed by structural allogenous bone graft with screws.","description":"","filename":"Fig.1.png","url":"https://assets-eu.researchsquare.com/files/rs-779204/v1/570821dde5c37dc061b88d7f.png"},{"id":12256613,"identity":"f29fd455-a4e4-47ee-8ef2-4e456a5cce9f","added_by":"auto","created_at":"2021-08-09 17:44:44","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":127826,"visible":true,"origin":"","legend":"Radiographs of a 50-year-old female showing a) septic status of a left total knee arthroplasty b) one months after the first-stage operation with large tibia defect and reconstructed with antibiotics cement prosthesis and c) two years after revision with reconstruction of the tibia plateau defect restored by a femoral head allograft in structural type.","description":"","filename":"Fig.2.png","url":"https://assets-eu.researchsquare.com/files/rs-779204/v1/04ce06109e22a2d51472cc81.png"},{"id":12257066,"identity":"ef1e3ccd-4ab2-4246-9805-fe1ff65f20d0","added_by":"auto","created_at":"2021-08-09 17:50:44","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":178720,"visible":true,"origin":"","legend":"Radiographs of a 78-year-old male showing a) septic status of a left total knee arthroplasty b) status after 1st-stage ALBCS implantation and c) status after 2nd stage revision with reconstruction of structural allograft d) tibia component breakage 32 months after revision e) status after revision surgery with TM cone reconstruction.","description":"","filename":"Fig.3.png","url":"https://assets-eu.researchsquare.com/files/rs-779204/v1/5319d7215a3e4f7f7c7b2ec5.png"},{"id":12256616,"identity":"6d8e6b90-17ce-4b98-8b2d-ae4f24391448","added_by":"auto","created_at":"2021-08-09 17:44:44","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":56228,"visible":true,"origin":"","legend":"Kaplan-Meier survival curves show no significant difference in 8-year infection relapse-free survival rate between structural allograft group and non-structural allograft group in knee PJI revisions. (p = 0.377)","description":"","filename":"Fig.4.png","url":"https://assets-eu.researchsquare.com/files/rs-779204/v1/85a31f2a1472c18fcce9541a.png"},{"id":12256896,"identity":"6eb3b277-9b3f-4408-905a-2e3add060473","added_by":"auto","created_at":"2021-08-09 17:47:44","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":56088,"visible":true,"origin":"","legend":"Kaplan-Meier survival curves show no significant difference in 8-year implant survival rate between structural allograft group and non-structural allograft group in knee PJI revisions. (p = 0.913)","description":"","filename":"Fig.5.png","url":"https://assets-eu.researchsquare.com/files/rs-779204/v1/9bba53178e630af44ee749e7.png"},{"id":19971007,"identity":"2c8593c3-623a-4cf0-86ef-d7d1bba3769a","added_by":"auto","created_at":"2022-04-05 12:53:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1720687,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-779204/v1/893d62d9-66be-4fa7-84a5-3f198c65f512.pdf"}],"financialInterests":"","formattedTitle":"Application of structural allogenous bone graft in two-stage exchange arthroplasty for knee periprosthetic joint infection: a case control study","fulltext":[{"header":"Background","content":"\u003cp\u003ePeriprosthetic joint infection (PJI) is a devastating complication after total knee arthroplasty (TKA). The incidence of knee PJI is about 2% in primary TKA(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) and accounts for nearly 20% in revision cases(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Two-stage exchange arthroplasty, which provides an 85\u0026ndash;95% of infection eradication rate with an improved functional score, has been recognized as the treatment of choice for PJI (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe bone defect is a challenging problem in revision TKA, which may result from osteolysis, stress shielding, infection, or multiple revisions(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Managing this problem can vary widely depending on the defect size, patient condition, and surgeon experience (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Allogenous bone graft is a common resolution for reconstructing bone defects in revision TKA that can fill bone defects and provide mechanical support (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The fresh-frozen allogenous bone graft can provide better biological and mechanical results than irradiated allogenous bone graft (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). However, there are several concerns of using allogeneous bone grafts, including potential risks of infection, aseptic loosening, disease transmission, nonunion, and bone resorption(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHsieh et al. had conducted a study on using bone allografts to treat hip PJI with massive bone loss, showing positive results with no further infection(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). However, limited literature is available on structural allogenous bone grafts in revision knee PJI with bone defects. Previous literature had reported the risk of infection by using allograft in revision knees(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Therefore, using structural allograft in knee revision PJI is still a controversial issue.\u003c/p\u003e \u003cp\u003eThe purpose of our study was to examine the clinical and functional outcomes of knee PJIs by using structural allografts to reconstruct bone defects in a two-stage revision procedure.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e We retrospectively reviewed the joint arthroplasty databases to identify patients diagnosed with knee PJI and treated with two-stage exchange arthroplasty at our institution between January 2010 and December 2016. The study was approved by the Institutional Review Board of our institution according to the applicable laws and regulations.\u003c/p\u003e \u003cp\u003ePJI was defined by fulfilling one of the following criteria: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) a sinus tract communicating with the prosthesis; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) isolated pathogens in two or more samples obtained from the infected prosthetic joint; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Presence of purulence in the affected joint with elevated synovial white blood cell count and synovial polymorphonuclear percentage (PMN%) combined with serum erythrocyte sedimentation rate(ESR) and serum C-reactive protein(CRP) concentration elevation (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAll the enrolled patients were treated with two-stage exchange arthroplasty. In brief, resection arthroplasty included radical debridement, removal of the prosthesis, antibiotic-loaded bone cement implantation, and administration of systemic antimicrobial agents for controlling the joint infection. Delayed reimplantation of the prosthesis was performed after successful antimicrobial therapy, which was defined by the absence of signs of infection with ESR and CRP resumed to normal levels(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The bone defects were evaluated during the second stage revision surgery according to the Anderson Orthopedic Research Institute (AORI) bone defect classification (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The allografts were shaped into appropriate sizes then attached to the host bone defect site. We then filled the morselized allograft to residual space between the host bone and the structural allograft. After reconstruction of the bone defect, the prosthesis was implanted fully cemented. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e showed an example treatment case.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eControl group\u003c/h2\u003e \u003cp\u003eWe randomly matched two patients without structural bone allograft reconstruction as the control group (non-allograft group) to each patient from the study group (allograft group) based on age, gender, and Charlson comorbidity index (CCI). The paired patients were from the knee joint PJI data in our institute.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eBone graft\u003c/h2\u003e \u003cp\u003eThe source of allografts was from the bone bank in our institute. We used deep freezing to sterilize the allograft bone and eliminate antigen-antibody reactions between the allograft and the hosts. The protocol of allograft bone-retrieving was the same as described by Wu et al. in our institute (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eOutcome assessment\u003c/h2\u003e \u003cp\u003eThe function of the involved knees was assessed before operation and at OPD follow-up according to Knee Society Score (KSS) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Treatment success was assessed according to the Delphi-based consensus definition, including (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) infection eradication, characterized by a healed wound without fistula, drainage or pain, and no infection recurrence caused by the same organism strain; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) no post-operative infection after reimplantation surgery; and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) no occurrence of PJI-related mortality with an at least 2-year follow-up.\u003c/p\u003e \u003cp\u003eThe radiographs were examined regularly for evidence of allograft resorption, migration, or loosening of the allograft-prosthesis composite. The incorporation of the allograft was determined by the appearance of trabecular remodeling within the grafted area and the disappearance of the gap between the host and the allograft.\u003c/p\u003e \u003cp\u003eThe Log-rank test was performed for Kaplan-Meier survival curve analysis. Statistical analysis was conducted by an independent statistician blinded to surgical outcomes. Statistical analysis was performed with SPSS software version 23.0.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBetween January 2010 and December 2016, we identified 157 consecutive patients with knee PJI treated by a 2-stage exchange arthroplasty protocol at our institute. Patients who did not meet the minimal 2-year-follow up were excluded. At last, 135 patients were enrolled. Among 135 patients, 12 patients with massive bone loss treated with fresh frozen structural bone allograft during 2nd stage reconstruction were enrolled as our study group. There were ten right knees and two left knees. Their mean age at revision was 68.1 years old (from 45.7 to 81.1), and the mean follow-up time was 62.5 months (from 25.7 to 95.0). Details of the 12 allograft-treated patients were shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The mean age of the 24 patients in the control group was 68.1 years old (from 32.9 to 82.7), the mean follow-up time was 58.4 months (from 24.7 to 129.4). Details of the control group were shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe characteristics of patients in the allograft group (Study group)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGen\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatus before Infection\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eComorbidities\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCCI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDefect site /type (AORI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eProsthesis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAntibiotics in bone cement spacer\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1st stage culture\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eAntibiotics in interim period\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRevision TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFemur:III\u003c/p\u003e \u003cp\u003eTibia:I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUnited, U2 PSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSteph.epidermidis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eCotrimoxazole\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRevision TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDM, HTN, CKD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFemur:IIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUnited, U2 PSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eStaphylococcus aureus (OSSA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eClindamycin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRevision TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDM, HTN, CAD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFemur:IIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUnited, U2 PSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eStaphylococcus aureus(OSSA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eDicloxacillin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDM, HTN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFemur:III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eZimmer, LCCK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eStaphylococcus aureus(OSSA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eDicloxacillin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHTN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFemur:III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUnited, U2 PSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEnterococcus faecalis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eAmpicillin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRevision TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHTN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFemur:I Tibia:III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eZimmer, LCCK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEnterococcus faecalis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSodium fusidate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRevision TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSLE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTibia:IIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eZimmer, RHK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePseudomonas aeruginosa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eCiprofloxacin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDM, RA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFemur:III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eZimmer, LCCK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSerratia marcescens\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eCiprofloxacin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFemur:IIB Tibia:I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUnited, U2 PSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eMycobacterium tuberculosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eRifampicin\u0026thinsp;+\u0026thinsp;Isoniazid\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHTN, CVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFemur:I Tibia:III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUnited, U2 PSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEscherichia coli\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eCiprofloxacin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDM, HB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFemur:III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUnited,\u003c/p\u003e \u003cp\u003etumor prosthesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eStaphylococcus aureus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eDicloxacillin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHTN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTibia:III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eZimmer, LCCK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCoagulase(-) staphylococcus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eDicloxacillin, cotrimoxazole\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"11\" nameend=\"c11\" namest=\"c1\"\u003e \u003cp\u003eGen: Gender; CCI: Charlson comorbidity index; TKA:Total knee arthroplasty; HTN: Hypertension; DM: Diabetes mellitus; CKD: Chronic kidney disease; CAD: coronary artery disease; HB: Hepatitis B; RA: Rheumatic arthritis; SLE: Systemic Lupus Erythematosus\u003c/p\u003e \u003cp\u003eOSSA: Oxacillin- susceptible Staphylococcus aureus\u003c/p\u003e \u003cp\u003eZimmer: Zimmer Biomed Institute, USA\u003c/p\u003e \u003cp\u003eUnited: United Orthopedics corporation, Taiwan\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe characteristics of patients in the non-allograft group (Control group)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGen\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatus before Infection\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eComorbidities\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCCI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAntibiotics in bone cement spacer\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1-stage culture\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAntibiotics in interim period\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCecal cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;piperacillin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePs.stutzeri\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCiprofloxacin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHTN, DM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eStaph.aureus (ORSA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDaptomycin, Ciprofloxacin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRevision TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHTN, DM, CKD, HC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003enil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eVancomycin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHTN, DM, PU, CVA,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSerratia marcescens\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCiprofloxacin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRevision TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHTN, DM, CKD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003enil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eVancomycin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHTN, DM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003enil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDicloxacillin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRevision TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHTN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePs.aeruginosa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFortum\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHTN, HB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eStaph.epidermidis (ORSE)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eVancomycin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRevision TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003enil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eStaph.aureus(OSSA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDicloxacillin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHTN, DM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eStaph.aureus(ORSA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCotrimoxazole\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHTN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eStaph.aureus(OSSA) Ecoli\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDicloxacillin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRevision TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAsthma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eB-strepto.Gr.A\u003c/p\u003e \u003cp\u003eGm(-)bacilli-glucose nonfermentin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAmpicillin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRevision TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003enil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eStaph.epidermidis (ORSE)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eRifampicin\u003c/p\u003e \u003cp\u003eFusidin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003es/p ITL nail\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eStaph. epidermidis (ORSE)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eRifampicin\u003c/p\u003e \u003cp\u003eFusidin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRevision TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHTN, HB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003estaph. aureus (OSSA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDicloxacillin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eStaph. epidermidis (ORSE)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eClindamycin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHTN, DM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTeicoplanin, ertapenem\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRevision TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHTN, PU, HB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDaptomycin\u0026thinsp;+\u0026thinsp;teinem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eParvimonas micra\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMetronidazole\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHT, DM, CVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eStaph.aureus(OSSA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eRifampicin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHT, DM Dementia, CAD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eKleb pneumoniae\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAmpicillin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRevision TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePs.aeruginosa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCiprofloxacin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRevision TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBone tumor s/p\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eStaph.aureus(ORSA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTeicoplanin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHTN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStreptomycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003emycobacterium tuberculosis complex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eRifinah\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRevision TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHTN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVancomycin\u0026thinsp;+\u0026thinsp;ceftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eStaph.aureus(OSSA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDicloxacillin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003eGen: Gender; CCI: Charlson comorbidity index; TKA: Total knee arthroplasty; s/p: status post; ITL: Interlocking nail\u003c/p\u003e \u003cp\u003eHTN: Hypertension; DM: Diabetes mellitus; HB: Hepatitis B; HC: Hepatitis C; CKD: Chronic kidney disease; CVA: cerebrovascular accident; CAD: coronary artery disease; PU: Peptic ulcer\u003c/p\u003e \u003cp\u003ePs: Pseudomonus; Staph: Staphylococcus\u003c/p\u003e \u003cp\u003eOSSA: Oxacillin- susceptible Staphylococcus aureus; ORSA: Oxacillin-resistant Staphylococcus aureus;\u003c/p\u003e \u003cp\u003eORSE: Oxacillin-resistant Staphylococcus epidermidis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe micro-organism isolated from the first stage of resection arthroplasty, the impregnated antibiotics in cement spacer and the provided antibiotics in the interim period were shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Generally, gram-positive bacteria account for the majority of the infection source.\u003c/p\u003e \u003cp\u003eThe mean KSS improved from 33.1 (16\u0026ndash;45) pre-operatively to 75.4 (49\u0026ndash;87) postoperatively in the study group. The radiographs showed no nonunion, resorption, or fracture in allografts during follow-up. The treatment example was showed in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. There was one patient who sustained re-infection, and one patient underwent implant revision during the follow-up. The details of the two patients were shown below.\u003c/p\u003e \u003cp\u003eOne 50-year-old female patient reconstructed with tumor prosthesis at the 2nd stages surgery suffered from recurrent right knee infection at 74 months after 2nd stage reconstruction. Associated findings included urinary tract infection and left foot cellulitis. She was admitted to the infection ward for sepsis control first, and the operation with debridement and irrigation was performed later by us. The intra-operative culture was negative. After debridement surgery, we provided intravenous antibiotics (vancomycin and ceftriaxone) then oral antibiotics (dicloxacillin and clindamycin) for further infection control. Decreased CRP levels with improved clinical conditions were noted afterward. Another 78-years-old male sustained right knee soreness at 32 months after 2nd stage reconstruction. Tibia component breakage was noted from the radiographic follow-up. Revision surgery with TM cone implantation over the tibia side was performed with no infection sign noted intra-operatively. The radiographic image was presented as Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe 8-year infection-free survival rate was 80% in the study group and 83.3% in the control group. There was no significant difference in 8-year infection-free survival between patients with or without allografts (p\u0026thinsp;=\u0026thinsp;0.377, Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). For prosthesis survivorship, the 8-year prosthesis-retention survival rate was 90.9% in the study group and 91.0% in the control group (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). There was no significant difference (p\u0026thinsp;=\u0026thinsp;0.913) between these two groups.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eKnee PJI accompanied with bone loss is a challenging problem in knee joint revision. Several studies have reported the outcomes of revision knees with bone defects reconstructed by bone allografts. However, limited literature focuses on the same issue in knee PJI cases. Using allogenous bone graft for bone defect reconstruction remains a controversial issue, especially for knee PJI revision. In this current study, we compared the outcomes of knee PJI with bone defect reconstruction by structural allografts to outcomes of general cases in knee PJI without using structural allografts. There was no significant difference in the relapse rate of infection and implant survival rate between the groups. We believe using structural allogenous bone graft in the second stage of knee PJI reconstruction can be safe and feasible.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTwo-stage treatment for knee PJI\u003c/h2\u003e \u003cp\u003ePJI is one of the most common complications that leads to the revision of TKA(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), and two-stage total knee revision is considered as the proper treatment for PJI with a success rate of around 85%-90%(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Bongers et al.(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) reported a 20% re-infection rate at five years in 113 PJI knees with 2-stage revision. We performed a 2-stage revision protocol for all knee PJI patients from our database including knees with bone defects. In our results, both groups presented with around 90% of 8-year prosthesis survival rate and approximately 80% of 8-year infection relapse-free survival rate. The outcome of 2-stage treatment for knee PJI was in line with previous studies.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eBone defect management\u003c/h2\u003e \u003cp\u003eBone defects reconstruction is challenging in knee revision arthroplasty(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). When it comes to large bone defects, metal augment is feasible in managing AORI type II bone defects, and structural allograft is the treatment option for AORI type IIB to type III(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Hockman et al. (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) compared the efficacy of using metal augment to allograft for bone loss treatments in knee revision. The result revealed a 59% failure rate of using metal augment alone, and 48% of the knees required additional structural allograft. It was believed that metal augment reduced the contact surface between the host bone and the implant, making it relatively more unstable. In addition, augment could not manage bone defects over 20 mm depth, and there were risks of fretting and erosion, as well as limitations on bone stock restoration (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Richards et al.(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) also declared that patients treated with allograft demonstrated better clinical outcomes and lower complication rates than those treated with metal augment.\u003c/p\u003e \u003cp\u003eMetal cones were another treatment choice for knee revision with large bone defects as AORI type III. A systematic review had reported a lower loosening rate of the porous metal cones than structural allograft in revision knees (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). However, the re-infection rate revealed no significant difference between these two methods. In our experiences, it was necessary to remove additional host bones when applying metal cones in particular cases. Besides, metal cones have a limited choice in sizes and are inapplicable to knees with small bone sizes. Furthermore, metal cones may cause an additional financial burden to patients comparing to allograft, which is more cost-effective. All these factors need to be considered when managing large bone defects indicated for both structural allograft and cones systems.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStructural allogenous bone graft\u003c/h2\u003e \u003cp\u003eStructural allograft is known for its capability of incorporating the host bone and stress protection. Literature had reported a prosthesis survival rate between 76% and 93% at a 5-year follow-up, showing the capability of structural allograft in treating knee revision cases with bone loss (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). For mid-term to long-term survivorship, Chun et al.(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) reported the results of 27 patients undergoing revision TKA with severe bone defect using a fresh-frozen femoral head allograft with a minimum of 8-year follow up. They demonstrated an improved Hospital for Special Surgery knee score from 46 to 83, and 26 out of 27 patients presented no complications. Engh et al. reported a 91% survivorship at 10 years for femoral head allograft in tibial defects in 46 patients receiving revision TKA(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Clatworthy et al. presented a prosthesis survival rate of 92% at 5 years and 72% at 10 years in 52 patients with uncontained bone defect constructed with structural allograft in knee revisions (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). In this current study, cases enrolled in the study group were all knee PJI cases with bone defects. We demonstrated a 90.9% 8-year implant survival rate in structural allograft reconstruction knees, indicating a similar outcome compared with the previous literatus though our cases were all PJI revision knees.\u003c/p\u003e \u003cp\u003eDespite the reliable results of structural allograft in revision knees, some complications were still with concerns. The potential risk of disease transmission remains an unresolved problem of using bone allografts(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Several studies had reported a higher infection rate of using allograft bone, which led to revision failure. Franke et al. reported a study in which 30 patients were treated with allografts for revision TKA, and the infection rate was 10%(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Bauman et al. reviewed structural allograft for TKA reconstruction with an infection rate of 7.1% (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Backstein et al. used structural allograft in revision TKA and reported a re-operation rate of 4.9% for secondary infection (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). However, Wang et al. conducted a case series study with revision knee reconstructed with femoral head allograft showed no recurrent infection among PJI cases(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). In this current study, one patient in the study group sustained recurrent infection, while the other 11 patients presented free of infection relapse. The results showed an infection rate of 8.3%, and a 100% 5-year infection-free survival rate and an 80% 8-year infection-free survival rate. Though the infection rate was similar to previous articles, it was acceptable owing to cases in this study were all PJI cases. We supposed the application of structural allograft to knee PJI cases did not increase the infection rate compared to general cases. The outcome can be attributed to the following reasons. First, the bone bank in our institute is under strict regulations which are supervised by the government, and all of the bone grafts were harvested by experienced surgeons (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Wu et al. had reported the result of using bone allografts from our bone bank for surgery with a relatively low infection rate of 1.2% (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Second, all allografts used in this study were femoral heads harvested from the patients undergoing total hip arthroplasty in our institute. Based on our previous study, administering prophylaxis antibiotics before surgery resulted in their presence in fresh-frozen femoral heads, which exhibited inhibitory effects against bacteria in vitro after two weeks of deep-frozen storage (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor other complications, Backstein et al. reported three cases of resorption and one case of nonunion in 58 patients (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Franke et al. reported one case of nonunion to the graft and host bone in 30 cases of revision knee using allograft bone (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Bauman et al. reported two cases of nonunion and three cases of post-operative fracture in 79 cases of revision knee treated by structural bone allograft (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In our study, no graft resorption, nonunion or fracture was reported during our radiographic follow-up concerning structural allograft. One patient suffered from tibial component breakage two and half years after the reconstruction surgery. The structural allograft was applied to the tibia bone defect without nonunion or resorption by x-ray follow-up.\u003c/p\u003e \u003cp\u003eBy comparing our study group results to the control group (PJI cases without allografts) and previous articles on revision knees managed with structural allograft, the results revealed the capability of allograft to resolve bone defects in knee PJI cases. The outcome showed no additional infection relapse rate and a satisfying prosthesis survival rate. This study validated the efficacy of using allograft in solving PJI with bone loss in the two-stage revision procedure.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe study has several limitations. First, this was a retrospective study with a relatively small sample size. Second, the size of the control group's bone defects was inconsistent with that of the study group. Some of the cases in the control group might be simple revision cases that presented with minimal bone defects. Generally, the bone defect would be more extensive in the study group. The infection rate in complex revisions knees, which require structural bone reconstruction, might be higher than simple revision or small bone defect cases. However, we presented a different point of view according to our results. Third, we did not compare the functional outcome between the study and control groups, which is also essential for comparison. Nevertheless, the overall KSS was good in our study group after the revisions. At last, the implants were not matched between cases in the study group and control group. The different implants might affect the survival rate and complication rate.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe reconstruction of bone defects in knee PJI with structural allogenous bone graft does not increase the relapse rate of infection and provides a good prosthesis survival rate. The use of structural fresh frozen allogenous bone graft for managing bone defects in the second stage of knee PJI reconstruction is a promising and safe method.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eProsthetic joint infection (PJI); Polymorphonuclear percentage (PMN%); Erythrocyte sedimentation rate (ESR); C-reactive protein (CRP); Anderson Orthopedic Research Institute (AORI); Charlson comorbidity index (CCI); Knee Society Score (KSS)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthic approval:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Human Investigation Committee (IRB) of Chang Gung Memorial hospital approved this study (No. 201701121B0) .\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients signed informed consent regarding publishing their data and photographs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare that are relevant to the content of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for conducting this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection were performed by Sheng-Hsun Lee, Chih-Hsiang Chang, Chih-Chien Hu, Hsin-Nung Shih, Steve W.N. Ueng, and Yuhan Chang. The first draft of the manuscript was written by Chieh An Chuang and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to thank the support of the Center for Big Data Analytics and Statistics at Chang Gung Memorial Hospital\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic Burden of Periprosthetic Joint Infection in the United States. The Journal of Arthroplasty. 2012;27(8, Supplement):61 \u0026ndash; 5.e1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDelanois RE, Mistry JB, Gwam CU, Mohamed NS, Choksi US, Mont MA. Current Epidemiology of Revision Total Knee Arthroplasty in the United States. J Arthroplasty. 2017;32(9):2663\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRomano CL, Gala L, Logoluso N, Romano D, Drago L. Two-stage revision of septic knee prosthesis with articulating knee spacers yields better infection eradication rate than one-stage or two-stage revision with static spacers. Knee Surg Sports Traumatol Arthrosc. 2012;20(12):2445\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKildow BJ, Della-Valle CJ, Springer BD. Single vs 2-Stage Revision for the Treatment of Periprosthetic Joint Infection. J Arthroplasty. 2020;35(3S):24\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLei PF, Hu RY, Hu YH. Bone Defects in Revision Total Knee Arthroplasty and Management. Orthop Surg. 2019;11(1):15\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePanegrossi G, Ceretti M, Papalia M, Casella F, Favetti F, Falez F. Bone loss management in total knee revision surgery. Int Orthop. 2014;38(2):419\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSculco PK, Abdel MP, Hanssen AD, Lewallen DG. The management of bone loss in revision total knee arthroplasty: rebuild, reinforce, and augment. The bone \u0026amp; joint journal. 2016;98-B(1 Suppl A):120\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCostain DJ, Crawford RW. Fresh-frozen vs. irradiated allograft bone in orthopaedic reconstructive surgery. Injury. 2009;40(12):1260\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBauman RD, Lewallen DG, Hanssen AD. Limitations of structural allograft in revision total knee arthroplasty. Clin Orthop Relat Res. 2009;467(3):818\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFranke KF, Nusem I, Gamboa G, Morgan DA. Outcome of revision total knee arthroplasty with bone allograft in 30 cases. Acta Orthop Belg. 2013;79(4):427\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHsieh PH, Shih CH, Chang YH, Lee MS, Yang WE, Shih HN. Treatment of deep infection of the hip associated with massive bone loss: two-stage revision with an antibiotic-loaded interim cement prosthesis followed by reconstruction with allograft. The Journal of bone joint surgery British volume. 2005;87(6):770\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ, et al. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res. 2011;469(11):2992\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWheat LJ, Freifeld AG, Kleiman MB, Baddley JW, McKinsey DS, Loyd JE, et al. Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America. Clin Infect Dis. 2007;45(7):807\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEngh GA, Ammeen DJ. Classification and preoperative radiographic evaluation: knee. The Orthopedic clinics of North America. 1998;29(2):205\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu C, Hsieh P, Fan Jiang J, Shih H, Chen C, Hu C. A positive bacterial culture from allograft bone at implantation does not correlate with subsequent surgical site infection. The bone \u0026amp; joint journal. 2015;97-b(3):427 \u0026ndash; 31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInsall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989(248):13\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParvizi J, Cavanaugh PK, Diaz-Ledezma C. Periprosthetic knee infection: ten strategies that work. Knee Surg Relat Res. 2013;25(4):155\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaddad FS, Sukeik M, Alazzawi S. Is single-stage revision according to a strict protocol effective in treatment of chronic knee arthroplasty infections? Clin Orthop Relat Res. 2015;473(1):8\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBongers J, Jacobs AME, Smulders K, van Hellemondt GG, Goosen JHM. Reinfection and re-revision rates of 113 two-stage revisions in infected TKA. J Bone Jt Infect. 2020;5(3):137\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLombardi AV, Berend KR, Adams JB. Management of bone loss in revision TKA: it's a changing world. Orthopedics. 2010;33(9):662.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHockman DE, Ammeen D, Engh GA. Augments and allografts in revision total knee arthroplasty: usage and outcome using one modular revision prosthesis. J Arthroplasty. 2005;20(1):35\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel JV, Masonis JL, Guerin J, Bourne RB, Rorabeck CH. The fate of augments to treat type-2 bone defects in revision knee arthroplasty. The Journal of bone joint surgery British volume. 2004;86(2):195\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRichards CJ, Garbuz DS, Pugh L, Masri BA. Revision total knee arthroplasty: clinical outcome comparison with and without the use of femoral head structural allograft. J Arthroplasty. 2011;26(8):1299\u0026ndash;304.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeckmann NA, Mueller S, Gondan M, Jaeger S, Reiner T, Bitsch RG. Treatment of severe bone defects during revision total knee arthroplasty with structural allografts and porous metal cones-a systematic review. J Arthroplasty. 2015;30(2):249\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLyall HS, Sanghrajka A, Scott G. Severe tibial bone loss in revision total knee replacement managed with structural femoral head allograft: a prospective case series from the Royal London Hospital. Knee. 2009;16(5):326\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChun CH, Kim JW, Kim SH, Kim BG, Chun KC, Kim KM. Clinical and radiological results of femoral head structural allograft for severe bone defects in revision TKA \u0026mdash; A minimum 8-year follow-up. Knee. 2014;21(2):420\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEngh GA, Ammeen DJ. Use of structural allograft in revision total knee arthroplasty in knees with severe tibial bone loss. J Bone Joint Surg Am. 2007;89(12):2640\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClatworthy MG, Ballance J, Brick GW, Chandler HP, Gross AE. The use of structural allograft for uncontained defects in revision total knee arthroplasty. A minimum five-year review. J Bone Joint Surg Am. 2001;83-a(3):404 \u0026ndash; 11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBuck BE, Malinin TI, Brown MD. Bone transplantation and human immunodeficiency virus. An estimate of risk of acquired immunodeficiency syndrome (AIDS). Clin Orthop Relat Res. 1989(240):129\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBackstein D, Safir O, Gross A. Management of bone loss: structural grafts in revision total knee arthroplasty. Clin Orthop Relat Res. 2006;446:104\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang JW, Hsu CH, Huang CC, Lin PC, Chen WS. Reconstruction using femoral head allograft in revision total knee replacement: an experience in Asian patients. The bone joint journal. 2013;95-b(5):643\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang Y, Shih HN, Chen DW, Lee MS, Ueng SW, Hsieh PH. The concentration of antibiotic in fresh-frozen bone graft. The Journal of bone joint surgery British volume. 2010;92(10):1471\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Revision knee arthroplasty, periprosthetic joint infection, bone defect, structural allogenous bone graft","lastPublishedDoi":"10.21203/rs.3.rs-779204/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-779204/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eKnee prosthetic joint infection (PJI) is a common but devastating complication after knee arthroplasty. The revision surgeries for knee PJI may become more challenging when it is associated with large bone defects. The application of structural bone allograft in knee revision surgeries with large bone defects is not a new technique. However, there is a lack of literature reporting its efficacy in PJI cases. This study aimed to investigate the outcome of structural fresh frozen allogenous bone grafts in treating patients in knee PJI with large bone defects.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eWe performed a retrospective cohort analysis of knee PJI cases treated with two-stage exchange arthroplasty at our institution from 2010 to 2016. 12 patients with structural allogenous bone graft reconstructions were identified as the study group. 24 patients without structural allograft reconstructions matched with the study group by age, gender, and Charlson comorbidity index were enrolled as the control group. The functional outcome of the study group was evaluated with the Knee Society Score (KSS). Treatment success was assessed according to the Delphi-based consensus definition. The infection relapse rate and implant survivorship were compared between groups.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eRevision knees with structural allograft presented excellent improvement in the KSS (33.1 to 75.4). There was no significant difference between infection relapse-free survival rate and prosthesis survival rate in two groups. The 8-year prosthesis survival rate was 90.9% in the study group and 91% in the control group (p\u0026thinsp;=\u0026thinsp;0.913). The 8-year infection relapse-free survival rate was 80% and 83.3% in the study group and control group, respectively (p\u0026thinsp;=\u0026thinsp;0.377).\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eThe structural fresh frozen allogenous bone graft provided an effective way for bone defect reconstruction in knee PJI with accountable survival rate. Meanwhile, using structural allografts did not increase the relapse rate of infection.\u003c/p\u003e","manuscriptTitle":"Application of structural allogenous bone graft in two-stage exchange arthroplasty for knee periprosthetic joint infection: a case control study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-08-09 17:44:42","doi":"10.21203/rs.3.rs-779204/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"be7f747f-5a99-4455-a087-41a94468aac5","owner":[],"postedDate":"August 9th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":6304400,"name":"Orthopedics"},{"id":6304401,"name":"Orthopedic Surgery"}],"tags":[],"updatedAt":"2022-04-05T12:53:51+00:00","versionOfRecord":{"articleIdentity":"rs-779204","link":"https://doi.org/10.1186/s12891-022-05228-6","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2022-04-05 12:53:51","publishedOnDateReadable":"April 5th, 2022"},"versionCreatedAt":"2021-08-09 17:44:42","video":"","vorDoi":"10.1186/s12891-022-05228-6","vorDoiUrl":"https://doi.org/10.1186/s12891-022-05228-6","workflowStages":[]},"version":"v1","identity":"rs-779204","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-779204","identity":"rs-779204","version":["v1"]},"buildId":"rHA-KDH7Qsr4HCuvH75dn","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}