Download Infections About TKR

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
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Prior surgery
Surgery time > 2.5 hours
Compromised immune status
Poor nutrition
Diabetes mellitus
Obesity
Smoking
Risk Factors for Infected
Arthroplasty
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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
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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
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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
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Microbial Sensitivity
Bactericidal
Heat stable
Powder form
Antibiotic for cement spacer
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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
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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
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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
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Prevension
Adequate surgical debridement
Staged revision
Adequate &Susceptibility
antibiotic