Total Knee Arthroplasty Infected by Brucella Melitensis: Septic Loosening and Long-Term Results of Two-Stage Revision Knee Arthroplasty

OBJECTIVES: Brucella infection associated with arthroplasty is a rare event. We present the long-term results of two-stage revision knee arthroplasty due to TKA infection by Brucella melitensis. METHODS: A 62-year-old man presented with a 4-month history of night sweats, high body temperature, and right knee pain in 2003. Two years previously, he had undergone a right TKA for treatment of gonarthrosis. Upon examination, the knee appeared swollen, warm, and sore, and a sinus tract formation had developed at the incision area. Bacteriologic cultures taken from the sinus tract discharge revealed B. melitensis. The patient’s erythrocyte sedimentation rate (ESR) was 83 mm/h, C-reactive protein (CRP) level was 12.38 mg/L, and blood leukocyte concentration was 9425/mm3. Plain radiography confirmed septic loosening. A two-stage revision TKA was planned. The first stage involved removal of the infected prosthesis and debridement of the remaining cement and necrotic tissue. Removal of the prosthetic components and cement and application of an antibiotic-loaded spacer (teicoplanin-impregnated) was also performed in the first stage. Oral rifampicin (900 mg) and doxycycline (300 mg) were administered daily for 12 weeks postoperatively. At the end of the antibiotic therapy, the patient was seen as an outpatient, and his ESR, CRP level, and antibody titer had decreased to normal values. Finally, prosthetic revision was performed in the second stage of the TKA. RESULTS: Ten years following surgery, the patient had returned to full activities of daily living, described no knee pain, and was very satisfied with the outcome. No abnormalities associated with the femoral, tibial, or patellar components were observed on plain radiography 10 years following surgery. The results of a Brucella agglutination test at that time were negative. CONCLUSION: Osteoarticular disease related to Brucella remains a problem in endemic regions. Brucellosis should be kept in mind in the differential diagnosis of prosthetic joint infections, especially in patients with a history of brucellosis and exposure to possible sources of the bacteria. We believe that two-stage revision arthroplasty is the first-line treatment of a loose TKA infected with B. melitensis. In addition, if a systemic Brucella infection is identified, the patient should be managed with two-stage revision surgery.