Clinical Images  |   March 2020
Chronically Exposed Knee Hardware
Author Notes
  • From Main Line Health at Bryn Mawr Hospital in Pennsylvania.  
  • Financial Disclosures: None reported.  
  • Support: None reported.  
  •  *Address correspondence to Alyson Dobracki, DO, Main Line Health, Bryn Mawr Hospital, 130 S Bryn Mawr Ave, Bryn Mawr, PA, 19010-3121. Email:
Article Information
Imaging / Neuromusculoskeletal Disorders / Clinical Images
Clinical Images   |   March 2020
Chronically Exposed Knee Hardware
The Journal of the American Osteopathic Association, March 2020, Vol. 120, 209. doi:
The Journal of the American Osteopathic Association, March 2020, Vol. 120, 209. doi:
A 66-year-old man who did not routinely seek medical care presented to the hospital with generalized weakness for 4 days. He described chronic right knee pain. Medical history included untreated rheumatoid arthritis and bilateral knee replacement 16 years prior. On examination, his right knee was fixed at 45-degree flexion. Femoral hardware and pus protruded through hyperemic skin (image A). He and his family claimed the hardware had been exposed for “years,” beginning with a small skin opening. Accumulation of detritus material is shown in image B. 
The clinical findings met the Infectious Disease Society of America's definition of prosthetic joint infection by virtue of the persisting sinus tract.1 Plain radiographs were concerning for tibial and femoral osteomyelitis, and there was distal- to mid-femoral osteolysis with complete destruction of the femoral metaphysis. Because of the extent of proximal bone involvement and concern for noncompliance if multiphase intervention were pursued, above-the-knee amputation was deemed the most viable option. Although nonsurgical, palliative measures for exposed hardware have been accomplished,2 the patient's age and ability to rehabilitate led to this approach. Patients with rheumatoid arthritis have a higher risk of prosthetic joint infection.3 Treatment should take into account patient preferences and rehabilitation potential. 
Osmon DR, Berbari EF, Berendt AR, et al. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. . 2013;56(1):e1-e25. doi: 10.1093/cid/cis803 [CrossRef] [PubMed]
Zamani N, Barshes NR. Long-term wound palliation to manage exposed hardware in the setting of peripheral arterial disease. Plast Reconstr Surg Glob Open. 2019;7(2):e2058. doi: 10.1097/GOX.0000000000002058 [CrossRef] [PubMed]
Lenguerrand E, Whitehouse MR, Beswick AD, et al. Risk factors associated with revision for prosthetic joint infection following knee replacement: an observational cohort study from England and Wales. Lancet Infect Dis. . 2019;19(6):589-600. doi: 10.1016/S1473-3099(18)30755-2 [CrossRef] [PubMed]