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In the name of God How to deal with Infected Total Knee Arthroplasty M ohsen M ardani -Ki vi Assistant Professor, Orthopedic Department, Guilan University of Medical Sciences Background • Total joint replacement is one of the most commonly performed and successful operations in Orthopaedics as defined by clinical outcomes and implant survivorship* * Incidence • Infection has occurred in 1% to 2% of primary TKA surgeries and has been the leading cause of failure following TKA. • The rate of peri-prosthetic infection has been declining over the last two to three decades, mostly due to operating room environments and operative techniques Risk Factors for Infected Arthroplasty • • • • • • • Prior surgery Surgery time > 2.5 hours Compromised immune status Poor nutrition Diabetes mellitus Obesity Smoking Risk Factors for Infected Arthroplasty • • • • • • • • Chronic renal insufficiency Diabetes Neoplasm requiring chemo Tooth extraction Skin ulcerations / necrosis Rheumatoid Arthritis Recurrent UTI Oral corticosteroids Surgical Techniques l Hemostasis l Prolonged operating time Surgical Techniques l Avoid skin bridges l Avoid creation of skin flaps Clinical Course l l l l Pain #1 Swelling Fever Wound breakdown drainage Windsor et al JBJS; 1990 Work-Up • • • • Wound History Physical Exam Serial Radiographs Lab/sed rate/CRP (returns to normal level 3 wk post op.) • Bone scan / Indium scan • Serum interlukine-6 (100%sensitivity & 95%specifity) Arthrocentesis • Gold standard for infection diagnosis: WBC Cell count more than 2500 cells/mm3 & 60% PMN Protein high Glucose low Arthrocentesis •direct smear •gram strain •Aerobic •Anaerobic •acid fast •fungi Microbacterial • Majority of infections : Staphylococci • Acute hematogenous infections: – Staphylococcus aureus – Beta-hemolytic streptococci – Enterococcus species • Gram-negative bacilli and anaerobes are also seen in chronic infections but uncommon... Staphylococcus aureus Common cause of musculoskeletal infections: • Early postoperative infection • Late chronic infection • Acute hematogenous infection at the site of a prosthetic joint Staphylococcus aureus Susceptibility to methicillin treated most effectively with • Antistaphylococcal penicillin (e.g., nafcillinor oxacillin) • First-generation cephalosporin. MRSA: Methicillin-resistant Staphylococcus aureus • first described in 1961 • Extra penicillin-binding protein (PBP2a) which results in a low affinity for beta-lactam antibiotics such as the penicillins and cephalosporins MRSA • poor clinical outcome because of the limited effectiveness of antibiotics. • Increase cost for treatment. MRSA • Increasing trend in MRSA infection • Staphylococcus aureus (MRSA) from the nosocomial setting and its emergence as a cause of community-acquired infection. Infection TKR Organism Staphylococcus S. aureus, penicillin sensitive S. aureus, penicillin resistant S. epidermis Gram negative Pseudomonas Escherichia coli Anærobic Other Percent 64 14 28 22 12 7 5 6 17 Treatment of prosthetic infection • Long-term antibiotic suppression • Surgical débridement with retention of the prosthesis • Resection arthroplasty • Arthrodesis • One-stage re-implantation procedure • Two-stage re-implantation procedures • Amputation Treatment of prosthetic infection • Two-stage reconstruction is the standard practice for treating patients with infected total joint arthroplasty. • The success rate of two-stage reimplantation has ranged from 80-100% Treatment Options – Long-term antibiotic suppression – Surgical débridement with retention of the prosthesis – Resection arthroplasty – Arthrodesis – One-stage re-implantation procedure – Two-stage re-implantation procedures – Amputation Antibiotic suppression Indicated in: – – – med compromised patients that prosthesis removal is not feasible The prosthesis is not loose Low virulence micro-organism Duration: life long Treatment Options – Long-term antibiotic suppression – Surgical débridement with retention of the prosthesis – Resection arthroplasty – Arthrodesis – One-stage re-implantation procedure – Two-stage re-implantation procedures – Amputation Surgical Debridement • Debridement with antibiotic suppression therapy – Limited success and Arthroscopic irrigation is not effective – < 3 weeks Surgical Debridement • Debridement with antibiotic suppression therapy – – – – – – Strep/staphepi -- best Avoid repeated attempts Frozen tissue section Suction drains 6 week antibiotic-therapy Polyethylene exchange Treatment Options – Long-term antibiotic suppression – Surgical débridement with retention of the prosthesis – Resection arthroplasty – Arthrodesis – One-stage re-implantation procedure – Two-stage re-implantation procedures – Amputation Two-stage Re-implantation Most successful treatment • Procedure of choice Two-Stage Re-implantation Stage I Complete debridement Stage II 6 weeks IV antibiotics Stage III Reimplantation Two-Stage Reimplantation Stage I l remove prosthesis / cement l thorough debridement Two-Stage Reimplantation Stage I l create antibiotic spacer impregnated with antibiotics lwound closure Two-Stage Re-implantation • Spacer Antibiotic Regimen • Tobramycin 2.4 gm/3.6 gm per 40 gms of PMMA • Vancomycin > 0.5 gm to 1 gm per 40 gms of PMMA Antibiotic Impregnated Spacer l Cidal levels of antibiotic l Spacer to preserve tissue tension l Facilitates re-implant and wound exposure Local Delivery of Antibiotics • Antibiotic cemen bead/spacer • local levels of antibiotics that far exceed those attained with systemic antibiotic therapy. Local Delivery of Antibiotics • Antibiotic bead - difficulty in removing after implantation. • Antibiotic impregnated spacers - minimizes limb-shortening - limits scar formation - facilitates reimplantation Antibiotic for cement spacer • • • • Microbial Sensitivity Bactericidal Heat stable Powder form Antibiotic for cement spacer • • • • Gentamycin Tobramycin Vancomycin Fosfomycin MRSA • Vancomycin is first choice in MRSA • Vancomycin bead/cement space • Intravenous vancomycin Block spacers 1. Simple tibio-femoral block 2. Molded arthrodesis block 3. Articulating mobile spacers (especially in bilateral infected TKAs) Block spacers • Simple tibio-femoral block Block spacers • Molded arthrodesis block Block spacers • Articulating mobile spacers (especially in bilateral infected TKAs) • Multiple Techniques Mobile spacer technique Prosthesis removal Removal of debris and cement Cement spacer molding Insertion with a pack of cement Final implantation Postoperative x- ray PROSTALAC COMPONENTs PROSTALAC COMPONENTs • Haffmann’s Procedure: – Using of the patients own prosthesis Infections About TKR Stage II – Antibiotic Treatment l Hickman catheter l MIC 1:8 / 6 wks l Patient should use knee brace l In mobile articulating spacers patient is allowed up to 50% PWB and is encouraged ROM Stage III – Reimplantation Serial aspirations Pre-op planning Bone scan / Sed rate • Intra-operative Frozen Section l < 5 PMN’s per HPF – no infection l > 10 PMN’s per HPF – infection Treatment Options – Long-term antibiotic suppression – Surgical débridement with retention of the prosthesis – Resection arthroplasty – Arthrodesis – One-stage re-implantation procedure – Two-stage re-implantation procedures – Amputation Resection Arthroplasty l Removal all components l Remove all cement l Effective in medically compromised patient Treatment Options – Long-term antibiotic suppression – Surgical débridement with retention of the prosthesis – Resection arthroplasty – Arthrodesis – One-stage re-implantation procedure – Two-stage re-implantation procedures – Amputation Arthrodesis Indications l l l l l Extensor mechanism disruption Resistant bacteria Inadequate bonestock Inadequate soft tissues Young patient Advantages Definitive treatment Little chance of recurrence Disadvantages Difficulty with transfers / small spaces Increase energy requirements Infections About TKR Algorithm • TKA • Clinical Sepsis < 3 wks Debridement Antibiotics (6 wks) (GRAM + Organism) > 3 wks 2-Stage Replant Infections About TKR Algorithm •Debridement Antibiotics Success No Success 2-stage Replant 2-stage Replant Success No Success Arthrodesis Resection Arthroplasty Result of treatment in MRSA infection • Yogesh Mittal retrospective cohort study • 37 TKA patients with MRSA or MRSE infection • Two stage revision: success rate 76% at median duration of follow-up was 51 months (range, twentyfour to 111 months). MRSA : Antibiotic Alternate antibiotic • Allergy to Vancomycin • Pathogen resistance to Vancomycin increase reports of decreasing susceptibility of S. aureus to vancomycin Juan J. Picazo.Activity of daptomycin against staphylococci collected from bloodstream infections in Spanish medical centers.Diagnostic Microbiology and Infectious Disease.2009;64 ,448–451 MRSA sensitivity Possible alternatives • Teicoplanin • Daptomycin • Leinazolid • Fosfomycin Picazo JJ, Betriu C.Activity of daptomycin against staphylococci collected from bloodstream infections in Spanish medical centers.Diagn Microbiol Infect Dis. 2009 ;64(4):448-51. Schintler MV,High fosfomycin concentrations in bone and peripheral soft tissue in diabetic patients presenting with bacterial foot infection. J Antimicrob Chemother. 2009 Jul 3. Antibiotic cement in MRSA Boonsin Buranapanithit : in vitro study • Gentamycin , Cefalexin bead cannot inhibit MRSA • Vancomycin , Fosfomycin bead effectively inhibit growth of MRSA Boonsin Buranapanitkit.In vitro Elution Characteristics of Antibiotic Cement on MRSA organism.The journal of the asean orthopaedic association.2000, 13.33-36 Fosfomycin • • • • A synthetic broad spectrum antibiotic Bactericidal antibiotic Heat stable High concentration in bone Boselli E, Allaouchiche B.Diffusion in bone tissue of antibiotics. Presse Med 1999; 28(40): 2265-76 Conclusions • • • • Prevension Adequate surgical debridement Staged revision Adequate &Susceptibility antibiotic