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1ST ANNUAL SPRING MEETING March 31 – April 2, 2016 | AAHKS Grand Hyatt Washington | Washington, DC Thank you to the AAHKS Spring Meeting Program Committee Craig J. Della Valle, MD Bryan D. Springer, MD Thank you to the AAHKS Spring Meeting Faculty Matthew P. Abdel, MD William P. Barrett, MD Daniel J. Berry, MD Michael P. Bolognesi, MD Kevin J. Bozic, MD, MBA John J. Callaghan, MD John C. Clohisy, MD David F. Dalury, MD Craig J. Della Valle, MD Stephen T. Duncan, MD Thomas K. Fehring, MD Mark I. Froimson, MD, MBA William L. Griffin, MD William A. Jiranek, MD Jay R. Lieberman, MD Adolph V. Lombardi Jr, MD, FACS Steven J. MacDonald, MD R. Michael Meneghini, MD Mark W. Pagnano, MD Brian S. Parsley, MD Javad Parvizi, MD, FRCS Gregory G. Polkowski II, MD, MSc Bryan D. Springer, MD We Need Your Help! Would you like to volunteer for the 26th AAHKS Annual Meeting? We are seeking abstract, poster and surgical technique video reviewers. If you are interested, please contact Sigita Wolfe, AAHKS Director of Education, at [email protected]. Course Description The First Annual AAHKS Spring Meeting is intended to equip practicing orthopaedic surgeons with state-of-the art information and cutting-edge strategies aimed at enhancing the care of patients with arthritis and degenerative disease. It combines general and break-out sessions, emphasizing case-based learning in small group setting for most effective results. Objectives • Analyze total hip and knee arthroplasty cases • Investigate the patterns contributing to effective total hip and knee arthroplasty and revision • Determine the strategies contributing to optimal perioperative and post-operative care, including complication management • Consider effective practice management tips and related healthcare policy • Report the highlights of the 2015 Annual Meeting CME Accreditation and Credit Designation The American Association of Hip and Knee Surgeons (AAHKS) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The American Association of Hip and Knee Surgeons (AAHKS) designates this live activity for a maximum of 15.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. First Annual AAHKS Spring Meeting | 1 Spring Meeting Program Schedule Times and topics are subject to change. Thursday, March 31, 2016 Time Session Room Faculty 7:00 – 9:00 p.m. Registration Declaration Level 7:00 – 9:00 p.m. Opening Reception Cabinet Meeting Room Time Session Room 7:00 – 7:50 a.m. Breakfast and Case Discussions with Faculty Constitution Foyer and Constitution A / B 7:50 – 8:00 a.m. Welcome and Introduction Constitution A / B Jay R. Lieberman, MD 8:00 – 8:30 a.m. Highlights of the 25th AAHKS Annual Meeting Constitution A / B Moderator: Gregory G. Polkowski II, MD, MSc Panelists: Brian S. Parsley, MD, William L. Griffin, MD, Stephen Duncan, MD, William P. Barrett, MD 8:30 – 9:50 a.m. Breakout 1: Primary Total Hip Arthroplasty (THA), Simple to Complex Constitution C / D / E, John Cabin / Arlington or Wilson / Roosevelt 9:50 – 10:00 a.m. Break 10:00 – 11:00 a.m. Symposium I – Perioperative Optimization Friday, April 1, 2016 11:00 a.m. – 12:20 p.m. Breakout 2: Primary Total Knee Arthroplasty (TKA), Simple to Complex Constitution A / B Faculty Moderator: William A. Jiranek, MD Panelists: Michael P. Bolognesi, MD, Steven J. MacDonald, MD, R. Michael Meneghini, MD Constitution C / D / E, John Cabin / Arlington or Wilson / Roosevelt 12:20 – 1:00 p.m. Lunch and Advocacy Update Constitution Foyer and Constitution A / B Speaker: Lynn Shapiro Snyder, JD 1:00 – 2:00 p.m. Symposium II – Periprosthetic Joint Infection Constitution A / B Moderator: Bryan D. Springer, MD Panelists: Matthew P. Abdel, MD, Javad Parvizi, MD, FRCS, Gregory G. Polkowski II, MD, MSc 2:00 – 2:20 p.m. Break 2:20 – 3:40 p.m. Breakout 3: Non-arthroplasty Hip or UKA Constitution C / D / E, John Cabin / Arlington (Knee) or Wilson / Roosevelt (Hip) 3:50 – 4:50 p.m. Symposium III – Preparing for the Transition to Value Based Healthcare Constitution A / B Moderator: Kevin J. Bozic, MD, MBA Panelist: Mark I. Froimson, MD, MBA 4:50 – 5:00 p.m. Closing Remarks Constitution A / B Brian D. Springer, MD 5:00 – 6:30 p.m. Reception Constitution Foyer First Annual AAHKS Spring Meeting | 2 Saturday, April 2, 2016 Time Session Room 7:00 – 7:50 a.m. Breakfast and Case Discussions with Faculty Constitution Foyer and Constitution A / B 7:50 – 8:00 a.m. Welcome and Introduction Constitution A / B Jay R. Lieberman, MD 8:00 – 8:30 a.m. Highlights of the AAOS, The Hip Society and The Knee Society Closed Meetings Constitution A / B Moderator: Mark W. Pagnano, MD Panelists: Thomas K. Fehring, MD, Daniel J. Berry, MD, Adolph V. Lombardi Jr., MD, FACS, John C. Clohisy, MD 8:30 – 9:50 a.m. Breakout 4: Revision Total Hip Arthroplasty (THA), Simple to Complex Constitution C / D / E, John Cabin / Arlington or Wilson / Roosevelt 9:50 – 10:00 a.m. Break 10:00 – 11:00 a.m. Symposium IV – The Business of Orthopaedics 11:00 a.m. – 12:20 p.m. Breakout 5: Revision Total Knee Arthroplasty (TKA), Simple to Complex Constitution A / B Faculty Moderator: Mark I. Froimson, MD, MBA Panelists: Kevin J. Bozic, MD, MBA, William A. Jiranek, MD, Jay R. Lieberman, MD Constitution C / D / E, John Cabin / Arlington or Wilson / Roosevelt 12:20 – 1:00 p.m. Lunch Constitution Foyer 1:00 – 2:00 p.m. Symposium V – Perioperative Care Constitution A / B 2:00 – 2:20 p.m. Break 2:20 – 3:40 p.m. Breakout 6: Managing Complications in Hip and Knee Arthroplasty Constitution C / D / E, John Cabin / Arlington or Wilson / Roosevelt 3:50 – 4:50 p.m. Symposium VI – Step by Step: Key Choices and Techniques in the Tough Revision Total Hip Arthroplasty (THA) and Revision Total Knee Arthroplasty (TKA) Constitution A / B Moderator: Daniel J. Berry, MD Panelists: John J. Callaghan, MD, Craig J. Della Valle, MD 4:50 – 5:00 p.m. Closing Remarks Constitution A / B Craig J. Della Valle, MD Moderator: Jay R. Lieberman, MD Panelists: David F. Dalury, MD, Mark W. Pagnano, MD You can visit our sponsors in the exhibit area: DePuy Synthes, DJO Global, Medtronic, Pacira Pharmaceuticals, Inc., Smith & Nephew, Stryker and Zimmer Biomet First Annual AAHKS Spring Meeting | 3 First Annual AAHKS Spring Meeting | 4 Session Materials First Annual AAHKS Spring Meeting | 5 3/16/2016 Highlights of the 25th AAHKS Annual Meeting 3/16/2016 3/16/2016 “Best of the AAHKS 2015 Annual Meeting” AAHKS 2016 Spring Meeting “Best of the AAHKS 2015 Annual Meeting” AAHKS 2016 Spring Meeting “Best of the AAHKS 2015 Annual Meeting” Gregory G Polkowski, MD, MSc Assistant Professor of Orthopaedic Surgery Vanderbilt Orthopaedic Institute AAHKS 2016 Spring Meeting Gregory G Polkowski, MD, MSc 2015 AAHKS Annual Meeting Program Chair Assistant Professor of Orthopaedic Surgery Vanderbilt Orthopaedic Institute 2015 AAHKS Annual Meeting Program Chair Gregory G Polkowski, MD, MSc Assistant Professor of Orthopaedic Surgery Vanderbilt Orthopaedic Institute 2015 AAHKS Annual Meeting Program Chair Disclosures Disclosures Disclosures Something Something Something V A N D E R B I L T Orthopaedic Institute V A N D E R B I L T Orthopaedic Institute V A N D E R B I L T Orthopaedic Institute “Best of Symposium” “Best of Symposium” Gregory G Polkowski, MD, MSc Moderator “Best of Symposium” Gregory G Polkowski, MD, MSc Brian Parsley, MD Moderator William Griffin, MD Brian Parsley, MD William Barret, MD Gregory G Polkowski, MD, MSc Moderator William Griffin, MD Stephen Duncan, MD William Barret, MD Brian Parsley, MD Stephen Duncan, MD William Griffin, MD V A N D E R B I L T Orthopaedic Institute William Barret, MD Stephen Duncan, MD V A N D E R B I L T Orthopaedic Institute V A N D E R B I L T Orthopaedic Institute First Annual AAHKS Spring Meeting | 6 1 1 3/16/2016 Highlights of the 25th AAHKS Annual Meeting 3/16/2016 3/16/2016 2015 AAHKS Annual Meeting • • • • • • • • • • 2015 AAHKS Annual Meeting Year for the record books 25th Anniversary Most abstracts submitted Year for the record books – ~1300 25th Anniversary – 59 papers (4.5% Most abstracts submitted acceptance rate) Year for the record books – th200 posters (15%) ~1300 25 Anniversary – 59 papers (4.5% Record attendance Most abstracts submitted acceptance rate) 2015 AAHKS Annual Meeting – ~2400 total ~1300 – 200 posters (15%) • 1600 clinical – 59 papers (4.5% • Record attendance • 400 more than 2014 acceptance rate) – ~2400 total – 200 posters (15%) • 1600 clinical V A N D E R B I L T Orthopaedic Institute • Record attendance • 400 more than 2014 – ~2400 total V A N D E R• B1600 clinical I L T Orthopaedic Institute • 400 more than 2014 V A N D E R B I L T Orthopaedic Institute Pre‐Meeting Courses • 7th Annual Residents Course Pre‐Meeting Courses – Keith Berend and Matt Austin • 5th Annual Team Member • Course 7th Annual Residents Course Pre‐Meeting Courses Keith Berend and Matt Austin – David Dalury and Chris Peters • • Total Joint Replacement, Course Surviving and Thriving” Keith Berend and Matt Austin – David Dalury and Chris Peters • 5 Annual Team Member 1–stth Lawry Barnes and Annual “The Business of Mark Froimson Course Total Joint Replacement, – David Dalury and Chris Peters • Surviving and Thriving” Industry Symposia Lawry Barnes and • 1–st 15 Total Annual “The Business of Mark Froimson Total Joint Replacement, Surviving and Thriving” V A•N Industry Symposia D E R B I L T Orthopaedic Institute 5stth Annual “The Business of Annual Team Member 1 7th Annual Residents Course – Lawry Barnes and 15 Total Mark Froimson V A•N Industry Symposia D E R B I L T Orthopaedic Institute – 15 Total V A N D E R B I L T Orthopaedic Institute Recognition • Guest NationsRecognition – Chilean Hip Society – Japanese Society for • Guest Nations Recognition • • • • • • Replacement Arthroplasty – Chilean Hip Society AAHKS Humanitarian Award – Japanese Society for Guest Nations Recipient Replacement Arthroplasty – Chilean Hip Society – Dr. Adolph Lombardi AAHKS Humanitarian Award – Japanese Society for AAHKS Presidential Award Recipient Replacement Arthroplasty – Dr. Frank Voss – Dr. Adolph Lombardi AAHKS Humanitarian Award AAHKS Presidential Award Recipient – – Dr. Frank Voss Dr. Adolph Lombardi V A N D E R B I L T Orthopaedic Institute • AAHKS Presidential Award – Dr. Frank Voss V A N D E R B I L T Orthopaedic Institute V A N D E R B I L T Orthopaedic Institute First Annual AAHKS Spring Meeting | 7 2 2 3/16/2016 Highlights of the 25th AAHKS Annual Meeting 3/16/2016 3/16/2016 2015 Fall Meeting Symposia • Clinical Practice Difficult Cases • Outcome • Measures Clinical Practice Difficult Cases • Metal Reactions Outcome • Risk Stratification Clinical Practice Measures •• Outpatient Difficult Cases • Arthroplasty Metal Reactions •• Bundled Payments Outcome Risk Stratification Measures Outpatient • FAI • Arthroplasty Metal Reactions • Bundled Payments Risk Stratification • V A N D E R B I L T Orthopaedic Institute Outpatient •• FAI Arthroplasty • Bundled Payments V A N D E R B I L T Orthopaedic Institute • FAI 2015 Fall Meeting Symposia 2015 Fall Meeting Symposia V A N D E R B I L T Orthopaedic Institute James A. Rand Award Paper James A. Rand Award Paper A Randomized Controlled Trial of Oral and IV Tranexamic Acid: James A. Rand Award Paper The Same Efficacy at Lower Cost? A Randomized Controlled Trial of Oral and IV Tranexamic Acid: The Same Efficacy at Lower Cost? A Randomized Controlled Trial of Yale A. Fillingham, MD Oral and IV Tranexamic Acid: Rush University The Same Efficacy at Lower Cost? Yale A. Fillingham, MD Rush University Yale A. Fillingham, MD Rush University V A N D E R B I L T Orthopaedic Institute V A N D E R B I L T Orthopaedic Institute V A N D E R B I L T Orthopaedic Institute A Randomized Controlled Trial of Oral and IV Tranexamic Acid: The Same Efficacy at Lower Cost? A Randomized Controlled Trial of Yale A Fillingham MD, Erdan Kayupov, MS, Darren Plummer, MD, Mario Moric, MS, Tad Gerlinger, MD, Craig J. Dalla Valle, MD Oral and IV Tranexamic Acid: A Randomized Controlled Trial of The Same Efficacy at Lower Cost? Double‐blind, placebo‐controlled, powered, RCT Yale A Fillingham MD, Erdan Kayupov, MS, Darren Plummer, MD, Mario Moric, MS, Oral and IV Tranexamic Acid: Tad Gerlinger, MD, Craig J. Dalla Valle, MD 1.95 g oral TXA vs 1g iv bolus TXA in TKA The Same Efficacy at Lower Cost? Primary outcome: reduction in hemoglobin Double‐blind, placebo‐controlled, powered, RCT Yale A Fillingham MD, Erdan Kayupov, MS, Darren Plummer, MD, Mario Moric, MS, Tad Gerlinger, MD, Craig J. Dalla Results Valle, MD 1.95 g oral TXA vs 1g iv bolus TXA in TKA Equivalent Hb reduction: 3.45 g/dL vs 3.31 g/dL (p<0.001) Double‐blind, placebo‐controlled, powered, RCT Primary outcome: reduction in hemoglobin Equivalent blood loss: 1267 mL vs 1229 mL (p<0.007) Results Cost: $14 vs $47—108 1.95 g oral TXA vs 1g iv bolus TXA in TKA Equivalent Hb reduction: 3.45 g/dL vs 3.31 g/dL (p<0.001) Primary outcome: reduction in hemoglobin V A NEquivalent blood loss: 1267 mL vs 1229 mL (p<0.007) D E R B I L T Orthopaedic Institute Results Cost: $14 vs $47—108 Equivalent Hb reduction: 3.45 g/dL vs 3.31 g/dL (p<0.001) V A NEquivalent blood loss: 1267 mL vs 1229 mL (p<0.007) D E R B I L T Orthopaedic Institute Cost: $14 vs $47—108 V A N D E R B I L T Orthopaedic Institute First Annual AAHKS Spring Meeting | 8 3 3 3/16/2016 Highlights of the 25th AAHKS Annual Meeting 3/16/2016 3/16/2016 A Randomized Controlled Trial of Oral and IV Tranexamic Acid: The Same Efficacy at Lower Cost? A Randomized Controlled Trial of Yale A Fillingham MD, Erdan Kayupov, MS, Darren Plummer, MD, Mario Moric, MS, Tad Gerlinger, MD, Craig J. Dalla Valle, MD Oral and IV Tranexamic Acid: The Same Efficacy at Lower Cost? A Randomized Controlled Trial of Yale A Fillingham MD, Erdan Kayupov, MS, Darren Plummer, MD, Mario Moric, MS, Impact Oral and IV Tranexamic Acid: Tad Gerlinger, MD, Craig J. Dalla Valle, MD The Same Efficacy at Lower Cost? $23 million to $67 million annual savings Impact Yale A Fillingham MD, Erdan Kayupov, MS, Darren Plummer, MD, Mario Moric, MS, Tad Gerlinger, MD, Craig J. Dalla Valle, MD (700,000 TKA/year) $23 million to $67 million annual savings Impact (700,000 TKA/year) $23 million to $67 million annual savings V A N D E R B I L T Orthopaedic Institute (700,000 TKA/year) V A N D E R B I L T Orthopaedic Institute V A N D E R B I L T Orthopaedic Institute Lawrence D. Dorr Award Lawrence D. Dorr Award Conversion Total Hip Arthroplasty: Is it a Primary or Lawrence D. Dorr Award Revision Hip Arthroplasty? Conversion Total Hip Arthroplasty: Is it a Primary or Conversion Total Hip Arthroplasty: Revision Hip Arthroplasty? Ran Schwarzkopf, MD, MSc Is it a Primary or NYU Langone Revision Hip Arthroplasty? Ran Schwarzkopf, MD, MSc NYU Langone V A N D E R B I L T Orthopaedic Institute Ran Schwarzkopf, MD, MSc NYU Langone V A N D E R B I L T Orthopaedic Institute V A N D E R B I L T Orthopaedic Institute Conversion Total Hip Arthroplasty: Is it a Primary or Revision Hip Arthroplasty? Conversion Total Hip Arthroplasty: Ran Schwarzkopf, MD and Mahta Baghoolizadeh, BS Is it a Primary or Conversion Total Hip Arthroplasty: Revision Hip Arthroplasty? ACS‐NSQIP database dataset (75,000 procedures) Ran Schwarzkopf, MD and Mahta Baghoolizadeh, BS Is it a Primary or Conversion THA vs Revision THA vs Primary THA Revision Hip Arthroplasty? Ran Schwarzkopf, MD and Mahta Baghoolizadeh, BS Compared 53 pre‐ intra‐ and post‐operative variables ACS‐NSQIP database dataset (75,000 procedures) Results Conversion THA vs Revision THA vs Primary THA 17 variables different Conversion vs Primary (p<0.0003) ACS‐NSQIP database dataset (75,000 procedures) Compared 53 pre‐ intra‐ and post‐operative variables 1 variables different Conversion vs Revision (p<0.0003) Conversion = Revision Conversion ≠ Primary Results Conversion THA vs Revision THA vs Primary THA 3 variables different Conversion vs Primary (p<0.0003) 17 variables different Conversion vs Primary (p<0.0003) Compared 53 pre‐ intra‐ and post‐operative variables VA N D EConversion = Revision Conversion ≠ Primary R B I L T O r t h o p a e d i c IResults nstitute 1 variables different Conversion vs Revision (p<0.0003) 3 variables different Conversion vs Primary (p<0.0003) 17 variables different Conversion vs Primary (p<0.0003) 1 variables different Conversion vs Revision (p<0.0003) Conversion = Revision Conversion ≠ Primary V A N D E R B I L T Orthopaedic Institute 3 variables different Conversion vs Primary (p<0.0003) V A N D E R B I L T Orthopaedic Institute First Annual AAHKS Spring Meeting | 9 4 4 3/16/2016 Highlights of the 25th AAHKS Annual Meeting 3/16/2016 3/16/2016 Conversion Total Hip Arthroplasty: Is it a Primary or Conversion Total Hip Arthroplasty: Revision Hip Arthroplasty? Ran Schwarzkopf, MD and Mahta Baghoolizadeh, BS Is it a Primary or Conversion Total Hip Arthroplasty: Revision Hip Arthroplasty? Ran Schwarzkopf, MD and Mahta Baghoolizadeh, BS Is it a Primary or Impact Revision Hip Arthroplasty? Conversion = Revision Conversion ≠ Primary Impact Ran Schwarzkopf, MD and Mahta Baghoolizadeh, BS Wrong DRG Conversion = Revision Conversion ≠ Primary Impact Ongoing Discussion with CMS, CJR Implications Wrong DRG Conversion = Revision Conversion ≠ Primary V A N D EOngoing Discussion with CMS, CJR Implications R B I L T Orthopaedic Institute Wrong DRG V A N D EOngoing Discussion with CMS, CJR Implications R B I L T Orthopaedic Institute V A N D E R B I L T Orthopaedic Institute AAHKS Clinical Award AAHKS Clinical Award Liposomal Bupivacaine and Peri‐articular Injection are Not Superior to Single Shot AAHKS Clinical Award Liposomal Bupivacaine and Peri‐articular Intra‐articular Injection for Pain Control Injection are Not Superior to Single Shot In Total Knee Arthroplasty Liposomal Bupivacaine and Peri‐articular Intra‐articular Injection for Pain Control Rajesh K. Jain, MD, MPH Injection are Not Superior to Single Shot In Total Knee Arthroplasty Reconstructive Orthopaedics Intra‐articular Injection for Pain Control Rajesh K. Jain, MD, MPH Marlton, NJ In Total Knee Arthroplasty Reconstructive Orthopaedics V A N D E R B I L T Orthopaedic Institute Rajesh K. Jain, MD, MPH Marlton, NJ Reconstructive Orthopaedics V A N D E R B I L T Orthopaedic Institute Marlton, NJ V A N D E R B I L T Orthopaedic Institute Liposomal Bupivacaine and Peri‐articular Injection are Not Superior to Single Shot Intra‐articular Injection for Pain Control Liposomal Bupivacaine and Peri‐articular In Total Knee Arthroplasty Injection are Not Superior to Single Shot Rajesh K. Jain, MD, MPH, Scott D. Schoifet, MD, FACS, Manny D. Porat, MD, Gregory Intra‐articular Injection for Pain Control G. Klingenstein, MD, Jeremy J. Reid, MD, Robert E. Post, MD Liposomal Bupivacaine and Peri‐articular In Total Knee Arthroplasty Single‐blind, prospective, powered, RCT, 207 TKA Injection are Not Superior to Single Shot Rajesh K. Jain, MD, MPH, Scott D. Schoifet, MD, FACS, Manny D. Porat, MD, Gregory Intra‐articular Injection for Pain Control G. Klingenstein, MD, Jeremy J. Reid, MD, Robert E. Post, MD Intra‐articular bupivacaine/morphine vs In Total Knee Arthroplasty Single‐blind, prospective, powered, RCT, 207 TKA Rajesh K. Jain, MD, MPH, Scott D. Schoifet, MD, FACS, Manny D. Porat, MD, Gregory Peri‐articular bupivacaine/morphine Intra‐articular bupivacaine/morphine G. Klingenstein, MD, Jeremy J. Reid, MD, Robert E. Post, MD Vs vs Single‐blind, prospective, powered, RCT, 207 TKA Liposomal bupivacaine (PA) Peri‐articular bupivacaine/morphine Intra‐articular bupivacaine/morphine Vs Primary outcome: VAS Pain & narcotic need (MME) vs Liposomal bupivacaine (PA) V A N D E R B I Peri‐articular bupivacaine/morphine L T Orthopaedic Institute Primary outcome: VAS Pain & narcotic need (MME) Vs Liposomal bupivacaine (PA) V A N D E R B I L T Orthopaedic Institute Primary outcome: VAS Pain & narcotic need (MME) V A N D E R B I L T Orthopaedic Institute First Annual AAHKS Spring Meeting | 10 5 5 3/16/2016 Highlights of the 25th AAHKS Annual Meeting 3/16/2016 3/16/2016 Liposomal Bupivacaine and Peri‐articular Injection are Not Superior to Single Shot Intra‐articular Injection for Pain Control Liposomal Bupivacaine and Peri‐articular In Total Knee Arthroplasty Injection are Not Superior to Single Shot Rajesh K. Jain, MD, MPH, Scott D. Schoifet, MD, FACS, Manny D. Porat, MD, Gregory G. Klingenstein, MD, Jeremy J. Reid, MD, Robert E. Post, MD Intra‐articular Injection for Pain Control Liposomal Bupivacaine and Peri‐articular Single‐blind, prospective, powered, RCT, 207 TKA In Total Knee Arthroplasty Injection are Not Superior to Single Shot Rajesh K. Jain, MD, MPH, Scott D. Schoifet, MD, FACS, Manny D. Porat, MD, Gregory Primary outcome: VAS Pain & narcotic need (MME) G. Klingenstein, MD, Jeremy J. Reid, MD, Robert E. Post, MD Intra‐articular Injection for Pain Control Results Single‐blind, prospective, powered, RCT, 207 TKA In Total Knee Arthroplasty Rajesh K. Jain, MD, MPH, Scott D. Schoifet, MD, FACS, Manny D. Porat, MD, Gregory IA PAI Lipo Primary outcome: VAS Pain & narcotic need (MME) G. Klingenstein, MD, Jeremy J. Reid, MD, Robert E. Post, MD Mean VAS : 3.95 vs 3.97 vs 3.86 (p=0.94) Results Single‐blind, prospective, powered, RCT, 207 TKA MME/day : 100.7 vs 100.1 vs 98.9 (p=0.97) IA PAI Lipo Primary outcome: VAS Pain & narcotic need (MME) Mean VAS : 3.95 vs 3.97 vs 3.86 (p=0.94) V A N D E R B I L T O r t h o p a e d i c IResults nstitute MME/day : 100.7 vs 100.1 vs 98.9 (p=0.97) IA PAI Lipo Mean VAS : 3.95 vs 3.97 vs 3.86 (p=0.94) V A N D E R B I L T Orthopaedic Institute MME/day : 100.7 vs 100.1 vs 98.9 (p=0.97) V A N D E R B I L T Orthopaedic Institute Liposomal Bupivacaine and Peri‐articular Injection are Not Superior to Single Shot Intra‐articular Injection for Pain Control Liposomal Bupivacaine and Peri‐articular In Total Knee Arthroplasty Injection are Not Superior to Single Shot Rajesh K. Jain, MD, MPH, Scott D. Schoifet, MD, FACS, Manny D. Porat, MD, Gregory G. Klingenstein, MD, Jeremy J. Reid, MD, Robert E. Post, MD Intra‐articular Injection for Pain Control Liposomal Bupivacaine and Peri‐articular In Total Knee Arthroplasty Impact Injection are Not Superior to Single Shot Rajesh K. Jain, MD, MPH, Scott D. Schoifet, MD, FACS, Manny D. Porat, MD, Gregory G. Klingenstein, MD, Jeremy J. Reid, MD, Robert E. Post, MD Intra‐articular Injection for Pain Control Cost savings: $4.92 vs $315 In Total Knee Arthroplasty Impact Rajesh K. Jain, MD, MPH, Scott D. Schoifet, MD, FACS, Manny D. Porat, MD, Gregory G. Klingenstein, MD, Jeremy J. Reid, MD, Robert E. Post, MD Also Paper #36, DBRCT Lipo vs PAI Cost savings: $4.92 vs $315 Impact Also Paper #36, DBRCT Lipo vs PAI Cost savings: $4.92 vs $315 V A N D E R B I L T Orthopaedic Institute Also Paper #36, DBRCT Lipo vs PAI V A N D E R B I L T Orthopaedic Institute V A N D E R B I L T Orthopaedic Institute Scientific Sessions (9) 13 RCTs Scientific Sessions (9) 22% Level 1 Studies Focus: Clinically Relevant, Practice Changing 13 RCTs Scientific Sessions (9) 22% Level 1 Studies Focus: Clinically Relevant, Practice Changing 13 RCTs 22% Level 1 Studies Focus: Clinically Relevant, Practice Changing V A N D E R B I L T Orthopaedic Institute V A N D E R B I L T Orthopaedic Institute V A N D E R B I L T Orthopaedic Institute First Annual AAHKS Spring Meeting | 11 6 6 3/16/2016 Highlights of the 25th AAHKS Annual Meeting 3/16/2016 3/16/2016 Scientific Session Highlights Knee Scientific Session Highlights #9: Fixed vs Mobile TKA 10 yr RCT Knee No difference Scientific Session Highlights #9: Fixed vs Mobile TKA 10 yr RCT Knee #13: Kinematic vs Mechanical Alignment in TKA RCT No difference No difference #9: Fixed vs Mobile TKA 10 yr RCT #13: Kinematic vs Mechanical Alignment in TKA RCT No difference No difference #13: Kinematic vs Mechanical Alignment in TKA RCT No difference V A N D E R B I L T Orthopaedic Institute V A N D E R B I L T Orthopaedic Institute V A N D E R B I L T Orthopaedic Institute Scientific Session Highlights Hip Scientific Session Highlights #21: RCT Formal PT vs Independent Ex after THA Hip No Difference Scientific Session Highlights #21: RCT Formal PT vs Independent Ex after THA Hip #22: Michigan Arthroplasty Registry No Difference DA vs Post THA Same Dislocation Rates (0.4%) #21: RCT Formal PT vs Independent Ex after THA #22: Michigan Arthroplasty Registry No Difference #24/25: 13 year f/u XLPE, 28 vs 36 heads DA vs Post THA Same Dislocation Rates (0.4%) No difference in Wear Rates or Osteolysis #22: Michigan Arthroplasty Registry #24/25: 13 year f/u XLPE, 28 vs 36 heads DA vs Post THA Same Dislocation Rates (0.4%) V A N D ENo difference in Wear Rates or Osteolysis R B I L T Orthopaedic Institute #24/25: 13 year f/u XLPE, 28 vs 36 heads V A N D ENo difference in Wear Rates or Osteolysis R B I L T Orthopaedic Institute V A N D E R B I L T Orthopaedic Institute Scientific Session Highlights Infection Scientific Session Highlights #27: RCT Oral Abx after 2‐stage PJI Infection Reduces Reinfection Risk (5% vs 20%) Scientific Session Highlights #27: RCT Oral Abx after 2‐stage PJI Infection #31/32 Injections Prior to TJA Increase Infection Risk Reduces Reinfection Risk (5% vs 20%) Risk increases with shorter gap #27: RCT Oral Abx after 2‐stage PJI #31/32 Injections Prior to TJA Increase Infection Risk Reduces Reinfection Risk (5% vs 20%) Risk increases with shorter gap #31/32 Injections Prior to TJA Increase Infection Risk Risk increases with shorter gap V A N D E R B I L T Orthopaedic Institute V A N D E R B I L T Orthopaedic Institute V A N D E R B I L T Orthopaedic Institute First Annual AAHKS Spring Meeting | 12 7 7 Breakout 1, Primary Total Hip Arthroplasty (THA): Simple to Complex Breakout 1, Primary THA: Simple to Complex Daniel J. Berry, M.D. Mayo Clinic Rochester, Minnesota Challenging Primary THA: Introduction and General Principles Understand the anatomy and specific technical issues related to the specific anatomic problems posed by the problem you face. Know what you are up against. Perform careful, detailed preop planning: Template and have a plan A, plan B, and plan C. Consider which operative approach will give you all the options you need to solve the problem. When appropriate, (previous infection, retained hardware) screen for infection. Prepare for extra blood loss, consider cell saver. Make sure you have all the special instruments (for example broken screw removal set) and special implants you need. First Annual AAHKS Spring Meeting | 13 Breakout 1, Primary Total Hip Arthroplasty (THA): Simple to Complex Primary THA: Simple to Complex Berry/Page 2 WHEN FEMORAL FRACTURE FIXATION FAILS: SALVAGE OPTIONS The Failed Femoral Neck Fracture: Young patient: Attempt to preserve patient’s own femoral head. Clinical results reasonably good even if there are patches of avascular necrosis. Preferred methods of salvage: valgus-producing intertrochanteric femoral osteotomy: puts the nonunion under compression. Other treatment option: Meyer’s vascularized pedicle graft. Older patient: Most reliable treatment is prosthetic replacement. Decision to use hemiarthroplasty (such as bipolar) or THA based on quality of articular cartilage, perceived risk of instability problem. In most patients THA provides higher likelihood of excellent pain relief. Specific technical issues: (1) hardware removal: usually remove after hip has first been dislocated (to reduce risk of femur fracture); (2) Hip stability: consider anterolateral approach in older patients at risk. (3) Acetabular bone quality: poor because it is not sclerotic from previous arthritis; caution when impacting a pressfit cup; low threshold to augment fixation with screws; don’t overdo reaming; just expose the bleeding subchondral bone. The Failed Intertrochanteric Hip Fracture: Young patient: Attempt to salvage hip joint with nonunion takedown, autogenous bone grafting and internal fixation. Blade plate usually the favored internal fixation device. Older patient: Decision to preserve patient’s own hip with internal fixation versus salvage with hip arthroplasty should be individualized based on patient circumstances, fracture pattern, bone quality. THA is an effective salvage procedure for this problem in older patients. If prosthetic replacement is chosen special considerations include: 1. THA vs. hemiarthroplasty: bipolar better stability; THA more reliable pain relief. 2. Removal of hardware: be prepared to remove broken screws in intramedullary canal. 3. Management of bone loss: bone loss to level of lesser trochanter common. Often requires a calcar replacement implant. Proximal calcar build up size dictated by bone loss. 4. Length of stem: desirable to bypass screw holes from previous fixation if possible. 5. Stem fixation: cemented or uncemented fixation depending on surgeon preference, bone quality. If uncemented, consider extensively coated (damaged proximal bone). First Annual AAHKS Spring Meeting | 14 Breakout 1, Primary Total Hip Arthroplasty (THA): Simple to Complex Primary THA: Simple to Complex Berry/Page 3 6. Greater trochanter: often a separate piece, be prepared to fix with wires or cable grip. Residual trochanteric healing, hardware problems not rare after THA. 7. Bone deformity/heterotopic bone: manage in individual basis. References 1. Haidukewych GJ, Berry DJ: Hip Arthroplasty for Salvage of Failed Treatment of Intertrochanteric Hip Fractures. J Bone Joint Surg 85A(5):899-904, May 2003 2. Haidukewych GJ, Berry DJ: Salvage of Failed Treatment of Hip Fractures. J Am Acad Ortho Surg 13(2):101-9, Mar-Apr 2005. 3. Tabsh I. Waddell JP, Morton J: Total Hip Arthroplasty for Complications of Proximal Femoral Fractures. J Orthop Trauma 11:166-169, 1997. SALVAGE OF FAILED ACETABULAR FRACTURES WITH THA I. Introduction A. THA after acetabular fracture presents unique technical challenges. B. These challenges include bone deformity, bone deficiency, sclerotic or dysvascular bone, non-united bony fragments, pelvic discontinuity, retained hardware, heterotopic ossification, previous incisions, and concerns regarding the sciatic nerve. C. Despite these challenges, with current treatment methods, a high degree of success can be achieved with modern technology. II. Technical Issues A. Preoperative evaluation for infection 1. In previously operated acetabular fractures, infection is always a concern. Screening C-reactive protein and sedimentation rate may be performed. If a concern regarding infection is present, the hip may be aspirated. B. Incisions 1. In most cases, a previous incision may be utilized. If necessary, an incision may be extended or a new limb can be created. The hip is less sensitive to multiple incisions than the knee; nevertheless, attention still should be paid to maintaining optimal skin bridges. First Annual AAHKS Spring Meeting | 15 Breakout 1, Primary Total Hip Arthroplasty (THA): Simple to Complex Primary THA: Simple to Complex III. Berry/Page 4 Hardware Removal A. In cases with a high degree of concern about infection, a staged procedure may be considered. However, in most cases, hardware removal can be done selectively at the time of THA surgery. Hardware that does not compromise placement of the THA may be left in place. Sometimes hardware can be cut off within the acetabulum to minimize exposure needs. B. Reconstructive Goals 1. The reconstructive goal is to place the hip center as close as possible to normal hip center but also to gain good support of the socket on host bone. In most cases, both goals can be met. When necessary, some compromise in hip center of rotation may be considered to optimize implant stability on host bone. C. Bone Deficiencies 1. Most bone deficiencies may be managed with methods similar to revision hip surgery. However, in the acetabular fracture patient, usually the host femoral head is available and this can be used as bone graft, either in particulate or bulk form. 2. Most cavitary deficiencies can be dealt with particulate bone graft. Some superolateral bone deficiencies from posterior wall fractures may be considered for bone grafting or augmentation techniques. D. Cup Fixation 1. The principles of revision surgery are followed using uncemented acetabular components fixed with augmentation screws. E. Nonunited Fracture 1. Nonunited fractures are not uncommon in these circumstances. Small wall nonunions may be managed as noted above for bone deficiency. If pelvic discontinuity is present, it is usually best treated by following the rules established for treatment of pelvic discontinuity with pelvic plating. Pelvic plating provides a reasonable likelihood of bone healing in these circumstances when combined with bone grafting techniques. F. Heterotopic Ossification 1. Heterotopic ossification is common in previously operated acetabular fractures. Removal of heterotopic bone at the time of surgery to gain hip motion is routine. Postoperative measures to reduce the likelihood of bone formation (that is either shielded radiation or use of a nonsteroid anti-inflammatory agent) may be strongly considered. First Annual AAHKS Spring Meeting | 16 Breakout 1, Primary Total Hip Arthroplasty (THA): Simple to Complex Primary THA: Simple to Complex Berry/Page 5 G. Nerve Issues 1. The sciatic nerve is at risk during these procedures. In many cases, avoiding the nerve and the region of the nerve is a reasonable approach. When a lot of work must be done on the posterior column, the surgeon needs to know exactly where the nerve is and in such cases the nerve may be exposed distally beneath the gluteus maximus tendon and followed proximally with careful and judicious dissection. H. Results 1. Results of total hip arthroplasty after acetabular fracture have varied in the past. More recent series have shown a high rate of acetabular fixation associated with uncemented hemispherical implants. Acetabular fracture patients are disproportionately young and active with unilateral hip disease and, therefore, bearing surfaces should be chosen accordingly. References 1. Boardman KP, Charnley J: Low-friction arthroplasty after fracture-dislocation of the hip. J Bone Joint Surg Br. 1978; 60:495-497. 2. Coventry MB: The treatment of fracture-dislocation of the hip by total hip arthroplasty. J Bone Joint Surg Am. 1974; 56:1128-1134. 3. Karpos PAG, Christie MJ, Chenger JD: Total hip arthroplasty following acetabular fracture: the effect of prior open reduction, internal fixation. Orthopaedic Transactions. 1993; 17:589. 4. Malkin C, Tauber C: Total hip arthroplasty and acetabular bone grafting for unreduced fracturedislocation of the hip. Clin Orthop. 1985; 201:57-59. 5. Pritchett JW, Bortel DT: Total hip replacement after central fracture dislocation of the acetabulum. Orthopedic Review. 1991; 20:607-610. 6. Rogan IM, Weber FA, Solomon L: Total hip replacement following fracture dislocation of the acetabulum. J Bone Joint Surg Br. 1979; 61:252. 7. Romness DW, Lewallen DG: Total hip arthroplasty after fracture of the acetabulum. J Bone Joint Surgery Br. 1990; 72:761-764. 8. Waddell JP, Morton J: Total hip arthroplasty following acetabular fracture. Presented at: the Annual Meeting of the Orthopaedic Trauma Association; 1994; Los Angeles, Calif. 9. Weber M, Berry DJ, Harmsen WS: Total hip arthroplasty after operative treatment of an acetabular fracture. J Bone Joint Surg Am.1998; 80:1295-1305. 10. Joly JM, Mears DC: The role of total hip arthroplasty in acetabular fracture management. Operative Techniques in Orthopedics. 1993; 3:80-102. 11. Judet R, Judet J, Letounel E: Fractures of the acetabulum: classification and surgical approaches for open reduction. J Bone Joint Surg Am.1964; 46:1615. 12. Letournel E: Acetabular fractures: classification and management. Clin Orthop.1980; 151:81-106. 13. Malta JM, Merritt PO: Displaced acetabular fractures. Clin Orthop. 1988; 230:83-87. 14. Mayo KA: Open reduction and internal fixation of fractures of the acetabulum. Clin Orthop.1994; 305:31-37. 15. Row CR, Lowell JD: Prognosis of fractures of the acetabulum. J Bone Joint Surg Am. 1961; 43:30-59. 16. Mears DC, Shirahama M: Stabilization of an acetabular fracture with cables for acute total hip arthroplasty. J Arthroplasty. 1998; 13:104-107. First Annual AAHKS Spring Meeting | 17 Breakout 1, Primary Total Hip Arthroplasty (THA): Simple to Complex Primary THA: Simple to Complex Berry/Page 6 THA FOR DEVELOPMENTAL HIP DYSPLASIA I. Introduction A. Developmental dysplasia of the hip is among the most common hip diagnoses leading to hip pain, arthritis and hip surgery in young patients. B. Advances in treatment have led to more technically straight forward reconstructions, and better functional results and durability. II. Indications for arthroplasty A. Advanced degenerative disease B. Anatomy/personality unfavorable for osteotomy C. Older patient III. Classification: Crowe First Annual AAHKS Spring Meeting | 18 Breakout 1, Primary Total Hip Arthroplasty (THA): Simple to Complex Primary THA: Simple to Complex IV. Berry/Page 7 Treatment Principles A. Acetabulum 1. Acetabular reconstruction at anatomic position with uncemented implant when possible. Use screws for extra fixation in most cases. 2. Anterolateral acetabular auto-grafting if needed—fix with screws 3. Accept mild medialization, elevations of hip center to get cup coverage on host bone 4. Reserve high hip center for Crowe II/III patient in whom anatomic hip center would require socket to mostly be placed on graft B. Femur 1. Cemented versus uncemented based on patient age, bone quality, anatomy. In most younger patients uncemented is preferred. 2. Problems: anteversion, length 3. Modular uncemented stems simplify management of excessive anatomic anteversion in some cases 4. Shortening/derotation subtrochanteric osteotomies in selected cases (see below) C. Lengthening 1. No definite guidelines for how much is safe but beware if lengthening more than 2 cm 2. Role of intra-operative nerve monitoring V. Treatment Based on Classification A. Crowe I 1. Acetabulum a. Reconstruction at anatomic hip center using uncemented socket b. Anterolateral structural graft only if needed (fixation with screws) 2. Femur a. Uncemented versus cemented bases on anatomy/age/activity/surgeon philosophy b. If uncemented: -avoid excessive anteversion of stem (because femur often anteverted) -in some diaphyseal fixation (extensively coated stem) or modular stems are useful because of distorted proximal femoral geometry modular stem that allows anteversion correction and use of uncemented proximally coated fixation is method of choice for many of these patients c. If cemented: -may need CDH stem (valgus medial femur may preclude routine stem) First Annual AAHKS Spring Meeting | 19 Breakout 1, Primary Total Hip Arthroplasty (THA): Simple to Complex Primary THA: Simple to Complex Berry/Page 8 B. Crowe II 1. Acetabulum a. Reconstruction at anatomic hip center or slightly above anatomic center attempting to optimize coverage of uncemented socket with native bone b. Graft if needed (usually do) 2. Femur a. Same as Crowe I C. Crowe III 1. Acetabulum a. Presents the most difficult acetabular problem of DDH cases: severe lateral bone deficiency b. Options: -high hip center with small uncemented cup fixed with screws -anatomic hip center reconstruction beneath large bone graft 2. Femur a. Same as Crowe I b. May require femoral shortening if anatomic hip center is chosen (See below for Crowe IV) D. Crowe IV 1. Acetabulum a. Reconstruction at anatomic hip center with extra small uncemented socket b. Graft usually not needed c. Technical tip: prepare socket with reverse reaming (expands socket and impacts bone making it denser) 2. Femur a. Subtrochanteric osteotomy, femoral shortening i. advantages: -elegant -maintains anatomy of femur -allows uncemented implant use -avoids trochanteric problems of earlier methods ii. technical tips: -osteotomy: transverse -length: preop plan/intraop soft tissue tension -keep resected segment vascular, split, use as struts -implant: best to get proximal and distal fixation: fully coated or an implant with diaphyseal fixation (such as flutes) distally First Annual AAHKS Spring Meeting | 20 Breakout 1, Primary Total Hip Arthroplasty (THA): Simple to Complex Primary THA: Simple to Complex Berry/Page 9 References 1. Crowe JF, Mani VJ, Ranawat CS: Total hip replacement in congenital dislocation and dysplasia of the hip. J Bone Joint Surg 61A:15, 1979. 2. Ganz R, Klaue K, Vinh TS, Mast JW: A new periacetabular osteotomy for the treatment of hip dysplasia. Clin Orthop 232:26, 1988. 3. Gerber SD, Harris WH: Femoral head autografting to augment acetabular deficiency in patients requiring total hip replacement: a minimum five-year and average seven-year followup study. J Bone Joint Surg 68:1241, 1986. 4. Jaroszynski G, Woodgate I; Saleh K; Gross, A: Total hip replacement for the dislocated hip. J Bone Joint Surg 83A(2):272, 2001. 5. Jensen JS, Retpen JB, Arnoldi CC: Arthroplasty for congenital hip dislocation and dysplasia: techniques for acetabular reconstruction. Acta Orthop Scand 60:86, 1989. 6. Sanchez-Sotelo J; Trousdale RT; Berry DJ; Cabanela ME: Surgical Treatment of Developmental Dysplasia of the Hip in Adults: I. Non-Arthroplasty Options. J Am Academy Orthopaedic Surgeons Vol 10(5):312-333, Sept/Oct 2002. 7. Sanchez-Sotelo J.; Berry DJ; Trousdale RT; Cabanela ME: Surgical Treatment of Developmental Dysplasia of the Hip in Adults: II. Arthroplasty Options. J Am Academy Orthopaedic Surgeons Vol 10(5):334-344, Sept/Oct 2002. 8. Silber DA, Engh CA: Cementless total hip arthroplasty with femoral head bone grafting for hip dysplasia. J Arthroplasty 5:231, 1990. 9. Trousdale RT, Ekkemkamp A, Ganz R: Periacetabular and intertrochanteric osteotomy for the treatment of osteoarthritis in dysplastic hips. J Bone Joint Surg 77A:73, 1995. 10. Wiberg G: Relation between congenital subluxation of the hip and arthritis deformans (a roentgenological study). Acta Orthop Scand 10:351, 1939. 11. Krych AJ; Howard JL; Trousdale RT; Cabanela ME; Berry DJ: Total Hip Arthroplasty with Shortening Subtrochanteric Osteotomy in Crowe Type-IV Developmental Dysplasia J Bone Joint Surg 91(9):2213-21, Sept 2009. 12. Krych AJ, Howard JL, Trousdale RT, Cabanela ME, Berry DJ: Total Hip Arthroplasty with Shortening Subtrochanteric Osteotomy in Crowe Type-IV Developmental Dysplasia: Surgical Technique. J Bone Joint Surg. Am., 92:176-187, Sept 2010. First Annual AAHKS Spring Meeting | 21 Breakout 1, Primary Total Hip Arthroplasty (THA): Simple to Complex Primary THA: Simple to Complex Berry/Page 10 THA IN PATIENTS WITH PROXIMAL FEMORAL DEFORMITY Introduction: Goals of THA in patients with proximal femoral deformity are: -Avoid letting deformity force suboptimal implant position -Gain good implant position -Gain acceptable hip biomechanics Classification and treatment algorithm: Based on deformity level -Very proximal (lesser trochanter level or above): -Subtrochanteric -Distal: distal to tip of standard THA stem Management based on Deformity Level: Distal deformities: Ignore Proximal deformities: Rx options: -Remove the deformity and substitute with the implant -Choose an implant that allows satisfactory position and fixation despite the deformity Subtrochanteric deformities: The toughest problems to solve (too proximal to ignore; too distal to bypass). Rx options: -Resurfacing Hip Arthroplasty: now out of favor due to metal-metal bearings in most cases -Short stem THA -Corrective osteotomy with THA: principles: maintain femur vascularity, gain fixation proximal and distal to osteotomy with optimal implant choice. Conclusions: -Majority of proximal femoral deformities in hips requiring THA can be managed in one procedure. -Main options: Use implant that compensates for deformity; excise the deformity; corrective osteotomy. References: Berry, DJ: Total Hip Arthroplasty in Patients with Proximal Femoral Deformity. Clin Orthop Rel Res 369:262272, Dec 1999 First Annual AAHKS Spring Meeting | 22 Breakout 2, Primary Total Knee Arthroplasty (TKA): Simple to Complex Breakout 2, Primary Total Knee Arthroplasty (TKA): Simple to Complex Outline Pre-‐operative evaluation Indications Physical Exam Radiographs/Imaging Conservative Treatment to Date The Role of Pre-‐hab? Evaluation of Risk Factors/Patient Optimization Anesthetic Technique/Pain Management Peri-‐capsular injections Regional blocks Positioning/Operative Room set up Surgical Approach/Exposure Operative Technique Considerations Alignment-‐ (neutral, anatomic, kinematic, etc.) Standard Instrumentation CAS Custom guides Other Gap Balancing vs Measured Resection CR vs PS PS (Post vs UC/AS), Mobile bearing Patellar resurfacing Flexion Gap and Extension Gap mismatches First Annual AAHKS Spring Meeting | 23 Breakout 2, Primary Total Knee Arthroplasty (TKA): Simple to Complex Fixation Cement Cementless Ligament Releases Medial releases Lateral releases Deformity considerations Flexion contracture Varus deformity/Valgus deformity Extra-‐articular vs Intra-‐articular Bone loss and management Other considerations Retained hardware Soft tissue defects and previous incisions Previous surgery (HTO, tubercle osteotomy, DFO, patellectomy, etc.) The Role of Intra-‐articular Drains Blood Management Strategies Wound closure and dressing selection Post-‐operative management Complications Multi-‐modal pain management Physical Therapy Discharge Disposition Outpatient follow up routine/schedule References First Annual AAHKS Spring Meeting | 24 Breakout 2, Primary Total Knee Arthroplasty (TKA): Simple to Complex 1) Barrack RL, Booth RE, Lonner JH: Section 1: The knee, in Barrack RL, Booth RE, Lonner JH, McCarthy JC, Mont MA, Rubash HE (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 1-‐177. 2) Daniels AU, Tooms RE, Harkess JW, Guyton JL: Arthroplasty, in Canale ST (ed): Campbell’s Operative Orthopaedics, ed 9. St. Louis, MO, Mosby, 1998, pp 211-‐295. 3) Engh GA, Holt BP, Parks NL: A midvastus muscle splitting approach for total knee arthroplasty. J Arthroplasty 1997;12: 322-‐331. 4) Hofmann AA, Evanich JD, Ferguson RP, Camargo MP: Tento 14-‐year clinical followup of the cementless natural knee system. Clin Orthop Relat Res 2001;388:85-‐94. 5) Hofmann AA, Plaster RL, Murdock LE: Subvastus (Southern) approach for primary total knee arthroplasty. Clin Orthop Relat Res 1991;269:70-‐77. 6) Insall JN: Surgical approaches to the knee, in Insall JN, Scott WN (eds): Surgery of the Knee. New York, NY, Churchill Livingstone, 1984, pp 41-‐54. 7) Keblish PA: The lateral approach to the valgus knee: Surgical technique and analysis of 53 cases with over two-‐year follow-‐up evaluation. Clin Orthop Relat Res 1991;271:52-‐ 62. 8) McPherson EJ: Adult reconstruction, in Miller MD (ed): Review of Orthopaedics, ed 4. Philadelphia, PA, Saunders 9) Peters CL, Crofoot CD, Froimson MI: Knee reconstruction and replacement, in Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, pp 457-‐471. 10) Ranawat CS, Flynn WF, Saddler S, et al: Long-‐term survivorship of the total condylar knee arthroplasty: A 15 year survivorship study. Clin Orthop Relat Res 1993;286:94-‐102. 11) Rand JA, Ilstrup DM: Survivorship analysis of total knee arthroplasty. J Bone Joint Surg Am 1991;73:397-‐409. 12) Ritter MA, Herbst SA, Keating EM, et al: Long-‐term survival analysis of a posterior cruciate-‐ retaining total condylar total knee arthroplasty. Clin Orthop Relat Res 1994;309:136-‐145. 13) Scuderi GR, Insall JN: Total knee arthroplasty. Clin Orthop Relat Res 1992;276:26-‐32. Some Top Testing Facts 1. Care should be taken to avoid placing the tibial component in internal rotation to avoid undesired increases in the Q angle. 2. The patellar component should be placed in a medial and superior position. 3. PCL failure should be considered in a well-‐functioning PCL-‐retaining TKA that starts to demonstrate instability, hyperextension, and recurrent effusion. 4. Correction of a gap-‐balancing mismatch requires equalization of the flexion and extension gap. 5. Successful cementless fixation requires adjunctive peripheral fixation (eg, pegs and screws). First Annual AAHKS Spring Meeting | 25 Breakout 2, Primary Total Knee Arthroplasty (TKA): Simple to Complex 6. Excellent survival outcomes exist for cruciate-‐retaining and cruciate-‐substituting TKA designs. 7. The femoral component should be lateralized, parallel to the neutral rotational axis, and externally rotated 3° to 5° to the posterior condylar axis. 8. If a peroneal nerve palsy is suspected following TKA, the patient’s leg should be immediately flexed and all compressive dressings should be removed. First Annual AAHKS Spring Meeting | 26 3/16/2016 Symposium II, Periprosthetic Joint Infection 3/16/2016 3/16/2016 Periprosthetic Joint Infection Periprosthetic Joint Infection AAHKS Spring Meeting Symposium Periprosthetic Joint Infection AAHKS Spring Meeting Symposium Bryan D. Springer, MD AAHKS OrthoCarolinaSpring Hip andMeeting Knee Center Symposium Charlotte, NC Bryan D. Springer, MD OrthoCarolina Hip and Knee Center Charlotte, NC MD Bryan D. Springer, OrthoCarolina Hip and Knee Center Charlotte, NC Disclosure Stryker Orthopedics Disclosure Consultant: ConvaTec Speakers Bureau:Disclosure Ceramtec Consultant: Stryker Orthopedics Research Support: Depuy/Wright Medical/Zimmer/Pacira ConvaTec Speakers Bureau: Consultant: Research Support: Editorial Board: Speakers Bureau: Ceramtec Stryker Orthopedics Research Support: Editorial Board: Depuy/Wright Medical/Zimmer/Pacira JoA, Arthroplasty Today Board of Directors: Medical Advisor: Editorial Board of Board: Directors: Medical Advisor: Board of Directors: Medical Advisor: ConvaTec Depuy/Wright Medical/Zimmer/Pacira JoA, Arthroplasty Today Ceramtec AJRR Joint Purification Systems JoA, AJRRArthroplasty Today Joint Purification Systems AJRR Joint Purification Systems The Infected TKA The Infected TKA • Periprosthetic Joint infection (PJI) is one of the most challenging and frequent The Infected TKA • complications Periprosthetic after Joint TJA infection (PJI) is one of the most challenging and frequent after Range from 0.5% 7% ….and increasing • complications Periprosthetic JointtoTJA infection (PJI) is one of the most challenging and frequent aftertoTJA • complications Range from 7%TKA ….and increasing #1 reason for0.5% failure of • •• • • • #3 reason for failure of THA Range from to of 7%TKA ….and increasing #1 reason for0.5% failure #3 reason for failure of THA #1 reason for failure of TKA #3 reason for failure of THA First Annual AAHKS Spring Meeting | 27 1 1 3/16/2016 Symposium II, Periprosthetic Joint Infection 3/16/2016 3/16/2016 Projected Incidence of Revision TJA for Infection Projected Incidence of Revision TJA for Infection Projected Incidence of Revision TJA for Infection 16.8 % in 2005 to 65.5% in 2030 Kurtz et al JBJS 2007 16.8 % in 2005 to 65.5% in 2030 Kurtz et al JBJS 2007 16.8 % in 2005 to 65.5% in 2030 Kurtz et al JBJS 2007 Periprosthetic Joint Infection worse than Most Cancers Periprosthetic Joint Infection worse than Most Cancers Periprosthetic Joint Infection worse than Most Cancers NEJM July 2014 NEJM July 2014 NEJM July 2014 First Annual AAHKS Spring Meeting | 28 2 Symposium II, Periprosthetic Joint Infection 3/16/2016 3/16/2016 Periprosthetic Joint Infection Periprosthetic Joint Infection Still remains a tremendous amount of variation: • How to Evaluate and Diagnose a of Still remains a tremendous amount suspected PJI variation: • How to Evaluate and Diagnose a • suspected What is thePJI appropriate Surgical Management • What is the appropriate Surgical Management Periprosthetic Joint Infection AGENDA Periprosthetic Joint Infection AGENDA • The Diagnosis of PJI: Current and Future – Dr. Javad Parvizi •• The of Irrigation Debridement The Role Diagnosis of PJI: and Current and Future – Dr. Dr. Matt – JavadAbdel Parvizi Removal OneDebridement Stage or Two ? •• The Role of of Implants: Irrigation and – Polkowski – Dr. Dr. Greg Matt Abdel • Removal of Implants: One Stage or Two ? • Interactive Discussion – Dr. Greg Polkowski • Interactive Discussion First Annual AAHKS Spring Meeting | 29 3 3/16/2016 Symposium II, Periprosthetic Joint Infection 3/16/2016 3/16/2016 Diagnosis of Periprosthetic Joint Infection Diagnosis of Periprosthetic Joint Infection Javad Parvizi MD, FRCS Diagnosis of Professor Periprosthetic Rothman Institute at Thomas Jefferson Joint Infection Javad Parvizi MD, FRCS University, Philadelphia Professor Rothman Institute at Thomas Jefferson University, Philadelphia Javad Parvizi MD, FRCS Professor Rothman Institute at Thomas Jefferson University, Philadelphia Disclosures Research support: Disclosures Rotation Medical NIH Simplify Medical Department of Defense Smith and Nephew OREF Research support: Stelkast 3M Stryker Orthopedics Rotation Medical NIH Aesculap Synthes Simplify Medical Department AO Spine of Defense TissueGene Smith and Nephew OREF Biomet Tornier Research Stelkast 3M Cempra support: Orthospace Stryker Orthopedics CeramTec Aesculap Medical Zimmer Rotation SynthesBiomet DePuy NIH AO Spine Medical Simplify TissueGene Department of Defense Integra Biomet Smith and Nephew Tornier Myoscience OREF Cempra Stelkast Orthospace NDRI 3M CeramTec Stryker ZimmerOrthopedics Biomet Novartis Aesculap DePuy Synthes Pfizer Spine AO Integra TissueGene Biomet Myoscience Tornier Cempra NDRI Rothman Institute of Orthopaedics at Orthospace Thomas Jefferson University CeramTec Novartis Zimmer Biomet DePuy Pfizer Integra Myoscience Rothman Institute of Orthopaedics at NDRI Thomas Jefferson University Novartis Pfizer Disclosures Rothman Institute of Orthopaedics at Thomas Jefferson University Disclosures Consultant Zimmer Biomet Convatech TissueGene Ceramtec Consultant Zimmer Medtronics Biomet Convatech Ethicon TissueGene Theravance Board Member/Adviser Journal of Arthroplasty Eastern Orthopedic Assoc. Disclosures 3M JBJS-A Board Member/Adviser Bone and Joint Journal (British) Journal of Arthroplasty Muller Foundation Eastern Orthopedic Assoc. Disclosures United Healthcare 3M JBJS-A Royalty Board Member/Adviser Ceramtec Consultant Bone and Joint Journal (British) Intellectual Journal of Arthroplasty Zimmer Medtronics Elsevier Biomet Muller Foundation Property/Ownership Eastern Orthopedic Assoc. Convatech Ethicon United Healthcare Wolters Kluwer Hip Innovation Technology 3M TissueGene Theravance CD Diagnostics JBJS-A Slack Royalty Ceramtec Bone and Joint Journal (British) Corentec Intellectual Medtronics Jaypee publishers Foundation Muller Elsevier ForMD Property/Ownership United Healthcare Ethicon Alphaeon Datatrace Wolters Kluwer Hip Innovation Technology Theravance Joint Purification Systems CD Diagnostics Royalty Rothman Institute ofOrthopaedics at Slack Ceribell Corentec Thomas Jefferson University Intellectual MedAp Elsevier Jaypee publishers ForMD Property/Ownership Kluwer Alphaeon Hip Innovation Technology Wolters Datatrace CD Joint Purification Systems Diagnostics Slack Rothman Institute of Orthopaedics at Corentec Ceribell Thomas Jefferson University Jaypee publishers ForMD MedAp Alphaeon Datatrace Joint Purification Systems Rothman Institute of Orthopaedics at Ceribell Thomas Jefferson University MedAp First Annual AAHKS Spring Meeting | 30 1 3/16/2016 Symposium II, Periprosthetic Joint Infection 3/16/2016 3/16/2016 Facts Facts The diagnosis of periprosthetic infection has been the subject of Facts The diagnosis of periprosthetic infection considerable research has been the subject of The diagnosis of periprosthetic infection considerable research has been the subject of considerable research Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Background Background This research has produced a large number of Background This research has produced a peer‐reviewed manuscripts large number of This research has produced a peer‐reviewed manuscripts large number of peer‐reviewed manuscripts Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Pubmed Publications for PJI by Year 200 180 160 200 Pubmed Publications for PJI by Year 140 180 120 160 200 Pubmed Publications for PJI by Year 100 140 180 80 120 160 60 100 140 40 80 120 0 40 20 0 Obtained using the keyword “periprosthetic joint infection” 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 20 60 Obtained using the keyword “periprosthetic joint infection” 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 0 40 80 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 20 60 100 Obtained using the keyword “periprosthetic joint infection” First Annual AAHKS Spring Meeting | 31 2 2 3/16/2016 Symposium II, Periprosthetic Joint Infection 3/16/2016 3/16/2016 Infected Revisions 2001-2010 Burden Infected Revisions 2001-2010 Burden 26,000 infected joints 26,000 infected joints 26,000 infected joints Infected Revisions 2001-2010 Burden Kurtz, S, Parvizi J JOA 2012 Kurtz, S, Parvizi J JOA 2012 Kurtz, S, Parvizi J JOA 2012 Infected Revisions 2001-2010 Cost Infected Revisions 2001-2010 Cost $1 billion $1 billion $1 billion Infected Revisions 2001-2010 Cost Kurtz, S, Parvizi J JOA 2012 Kurtz, S, Parvizi J JOA 2012 Kurtz, S, Parvizi J JOA 2012 Diagnosis of PJI Difficult Difficult Difficult Diagnosis of PJI Diagnosis of PJI Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University First Annual AAHKS Spring Meeting | 32 3 3 3/16/2016 Symposium II, Periprosthetic Joint Infection 3/16/2016 3/16/2016 Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Intracellular S. aureus in Periprosthetic Tissue Intracellular S. aureus in Periprosthetic Tissue Intracellular S. aureus in Periprosthetic Tissue Parham S et al, Clin Infect Dis 2006 Parham S et al, Clin Infect Dis 2006 Parham S et al, Clin Infect Dis 2006 The Problem No The Problem test with absolute Problem accuracyThe exists No test with absolute i.e. no gold standard accuracy exists No test with absolute i.e. no gold standard accuracy exists i.e. no gold standard First Annual AAHKS Spring Meeting | 33 4 3/16/2016 Symposium II, Periprosthetic Joint Infection 3/16/2016 3/16/2016 Problem Diagnosing PJI Problem Diagnosing PJI Sensitivity 87% Blood ProblemSpecificity Diagnosing PJI77% Sensitivity 87% Blood CRP 10CRP mg/L Specificity 77% Sensitivity 87% Blood 10CRP mg/L Specificity 77% • Different labs use different units ‐ mg/L vs. mg/dL 10 mg/L • The lab’s normal range has nothing to do with PJI • Different labs use different units ‐ mg/L vs. mg/dL Rothman Institute of Orthopaedics at Thomas Jefferson University • The lab’s normal range has nothing to do with PJI • Different labs use different units ‐ mg/L vs. mg/dL Rothman Institute of Orthopaedics at Thomas Jefferson University • The lab’s normal range has nothing to do with PJI Rothman Institute of Orthopaedics at Thomas Jefferson University Problem Diagnosing PJI Problem Diagnosing PJI Synovial Fluid Sensitivity 89% Problem Specificity Diagnosing PJI 92% Synovial Fluid Sensitivity 89% 3000 cells/ul Specificity 92% Synovial Fluid Sensitivity 89% 3000 cells/ul Specificity 92% • Problems with automated cell counters? WBC WBC WBC • The cutoff is about 3000 cells/ul, not 50,000 cells/ul 3000 cells/ul • Problems with automated cell counters? Rothman Institute of Orthopaedics at Thomas Jefferson University • The cutoff is about 3000 cells/ul, not 50,000 cells/ul • Problems with automated cell counters? Thomas Jefferson University • The cutoff is about 3000 cells/ul, not 50,000 cells/ul Rothman Institute of Orthopaedics at Rothman Institute of Orthopaedics at Thomas Jefferson University Problems Diagnosing PJI Problems Diagnosing PJI Sensitivity Synovial Specificity Fluid Problems Diagnosing PJI Sensitivity Synovial Specificity Fluid Sensitivity Synovial Specificity Fluid 52% 95% 52% 95% Poor Results 52% 95% Culture Culture Culture Poor Results Year 2006 2008 1999 2012 Year 2014 2006 2008 1999 2012 Year 2014 2006 2008 1999 2012 2014 Author Journal Bare et al. CORR Gallo et al. New Microbiol Spangehl et al. JBJS Gomez et al. J Clin Micro Rothman Institute of Orthopaedics at Author Journal Shanmugasundaram et al. University HSS Journal Thomas Jefferson Bare et al. CORR Gallo et al. New Microbiol Spangehl et al. JBJS Gomez et al. J Clin Micro Rothman at AuthorInstitute of Orthopaedics Journal Shanmugasundaram et al. University HSS Journal Thomas Jefferson Bare et al. CORR Gallo et al. New Microbiol Spangehl et al. JBJS Gomez et al. J Clin Micro Rothman Institute of Orthopaedics at Shanmugasundaram et al. University HSS Journal Thomas Jefferson Sensitivity 53% 44% 73%* 64% Sensitivity 45% 53% 44% 73%* 64% Sensitivity 45% 53% 44% 73%* 64% 45% Specificity 94% 94% 94% 97% Specificity 94% 94% 94% 97% Specificity 94% 94% 94% 97% Poor Results First Annual AAHKS Spring Meeting | 34 5 5 3/16/2016 Symposium II, Periprosthetic Joint Infection 3/16/2016 3/16/2016 Background Background Increasing knowledge has led to many Background Increasing knowledge official diagnostic recommendations has led to many Increasing knowledge official diagnostic recommendations has led to many IDSA MSIS ICM official diagnostic recommendations AAOS IDSA MSIS AAOS ICM IDSA MSIS AAOS ICM Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University AAOS Guidelines www.aaos.org/guidelines AAOS Guidelines www.aaos.org/guidelines AAOS Guidelines www.aaos.org/guidelines •15 recommendations ••15 Majority strong recommendations ••15 Review ofstrong literature Majority recommendations Review ofstrong literature • Majority • Review of literature Parvizi et al. JAAOS 2010 Della Valle et al. JAAOS 2010 Parvizi et al. JAAOS 2010 Rothman Institute of Orthopaedics at Thomas Jefferson University Della Valle et al. JAAOS 2010 Parvizi et al. JAAOS 2010 Rothman Institute of Orthopaedics at Thomas Jefferson University Della Valle et al. JAAOS 2010 Rothman Institute of Orthopaedics at Thomas Jefferson University First Annual AAHKS Spring Meeting | 35 6 6 3/16/2016 Symposium II, Periprosthetic Joint Infection 3/16/2016 3/16/2016 Main Principles Main Principles Every painful prosthetic Main Principles joint is potentially infected • Every painful prosthetic joint is potentially infected • Every painful prosthetic joint is potentially infected • Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Truly Aseptic? Truly Aseptic? • Infection should always be ruled outTruly Aseptic? • Infection should always be • 12% of so called “aseptic” ruled out • Infection should always be were infected • 12% of so called “aseptic” ruled out Parvizi J , et al CORR 2011 were infected • 12% of so called “aseptic” Parvizi J , et al CORR 2011 were infected Rothman Institute of Orthopaedics at Thomas Jefferson University Parvizi J , et al CORR 2011 Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University AAOS Guidelines www.aaos.org/guidelines AAOS Guidelines www.aaos.org/guidelines ESR and CRP for all patients AAOS Guidelines undergoing revision arthroplasty www.aaos.org/guidelines ESR and CRP for all patients undergoing revision arthroplasty ESR and CRP for all patients Aspiration of joint before any undergoing revision arthroplasty further imaging Aspiration of joint before any further imaging Aspiration of joint before any further imaging Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University First Annual AAHKS Spring Meeting | 36 7 7 3/16/2016 Symposium II, Periprosthetic Joint Infection 3/16/2016 3/16/2016 AAOS Guidelines www.aaos.org/guidelines AAOS Guidelines www.aaos.org/guidelines Patients be off antibiotics AAOS Guidelines before aspiration (2 weeks) Patients be off antibiotics www.aaos.org/guidelines before aspiration (2diagnosis weeks) Patients be offuntil antibiotics No Antibiotics reached or refuted before aspiration weeks) No Antibiotics until(2diagnosis reached refuted gram stain No role foror intraoperative No Antibiotics until diagnosis No role foror intraoperative reached refuted gram stain Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University No role for intraoperative gram stain Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University First Annual AAHKS Spring Meeting | 37 8 8 3/16/2016 Symposium II, Periprosthetic Joint Infection 3/16/2016 3/16/2016 AAOS Guidelines Rec 10: Inconclusive CT or MRI - CT or MRI - CT or MRI - AAOS Guidelines Rec 10: Inconclusive AAOS Guidelines Rec 10: Inconclusive Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University AAOS Guidelines Rec 9: Weak AAOS Guidelines Bone scan (leukocyte Rec 9: Weak labeled) and PET AAOS Guidelines Bone scan (leukocyte Rec 9: Weak scan is anand option labeled) PETfor Bone scan (leukocyte patients not scheduled scan is an option labeled) and PETfor for reoperation or patients not scheduled scan is an option for diagnosis not reached for reoperation or patients not scheduled diagnosis not reached for reoperation or diagnosis not reached Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University First Annual AAHKS Spring Meeting | 38 9 9 3/16/2016 Symposium II, Periprosthetic Joint Infection 3/16/2016 3/16/2016 International Consensus Meeting Philadelphia, August 2013 International Consensus Meeting Philadelphia, August 2013 International Consensus Meeting Philadelphia, August 2013 New Algorithm New Algorithm New Algorithm Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University International Consensus • •• ••• ••• •• • International Consensus Cell count International Consensus Neutrophil Cell count differential Culture Neutrophil Cell count differential ?Culture Biomarkers Neutrophil differential ?Culture Biomarkers ? Biomarkers Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University First Annual AAHKS Spring Meeting | 39 10 10 3/16/2016 Symposium II, Periprosthetic Joint Infection 3/16/2016 3/16/2016 Thresholds (Consensus) Acute PJI Thresholds (Consensus) Acute PJI ESR- No threshold Thresholds (Consensus) CRP > 100 mg/L (hip and knee) ESR- No threshold Acute PJI Synovial WCC = 10,000 cells/ul CRP > 100 mg/L (hip and knee) ESRNo PMN threshold Synovial >90% Synovial WCC = 10,000 cells/ul CRP > 100 mg/L (hip and knee) Synovial PMN >90% Synovial WCC = 10,000 cells/ul ESR CRP PMN Synovial >90% ESR+CRPRothman Institute of Orthopaedics at Thomas Jefferson University ESR CRP ESR+CRPRothman Institute of Orthopaedics at Thomas Jefferson University ESR CRP ESR+CRPRothman Institute of Orthopaedics at Thomas Jefferson University Definition of PJI Definition of PJI CDC (National Definition of PJI CDC (National Healthcare Safety CDC (National Healthcare Safety Network) adopts the Healthcare Safety Network) adopts the MSIS definition of Network) adopts the MSIS definition of PJI MSIS definition of PJI PJI Thresholds (Consensus) Chronic PJI Thresholds (Consensus) ESR > 30 Chronic mm/hrPJI Thresholds (Consensus) CRP > 10 mg/L (hip ESR > 30 Chronic mm/hrPJI and knee) Synovial WCC > 3,000 cells/ul CRP > 10 mg/L (hip and knee) ESR > 30 mm/hr Synovial PMN >80% Synovial WCC > 3,000 cells/ul CRP > 10 mg/L (hip and knee) Synovial PMN >80% Synovial WCC > 3,000 cells/ul Synovial ESR CRP Rothman Institute of Orthopaedics at ESR+CRP PMN >80% Thomas Jefferson University ESR CRP Rothman Institute of Orthopaedics at ESR+CRP Thomas Jefferson University ESR CRP Rothman Institute of Orthopaedics at ESR+CRP Thomas Jefferson University First Annual AAHKS Spring Meeting | 40 11 11 3/16/2016 Symposium II, Periprosthetic Joint Infection 3/16/2016 3/16/2016 Premature Treatment Premature Treatment • Interferes with isolation of infecting organism Premature Treatment • Interferes with isolation of • Affects cell count infecting organism Interferes with isolation of •• Affects serological markers • Affects cell count infecting Shahi A et organism al Clin Orthop 2015 •• Affects serological Affects cell count markers Shahi A et al Clin Orthop 2015 • Affects serological markers Rothman Institute of Orthopaedics at Thomas Jefferson University Shahi A et al Clin Orthop 2015 Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Opportunities in Management of PJI Era of Biomarkers Era ofisBiomarkers here Era ofisBiomarkers here is here Opportunities in Management of PJI Opportunities in Management of PJI Biomarkers in Medicine Biomarkers in Medicine Biomarkers in Medicine -hCG Cardiac -hCG Troponin Cardiac -hCG Troponin Cardiac Troponin Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University First Annual AAHKS Spring Meeting | 41 12 3/16/2016 Symposium II, Periprosthetic Joint Infection 3/16/2016 3/16/2016 Diagnosis of PJI Simple Test Diagnosis of PJI UA strips for leukocyte Simple Testesterase Diagnosis of PJI UA strips for leukocyte Simple Testesterase UA strips for leukocyte esterase Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University LE Strips LE Strips LE Strips Results ProspectiveResults study • Rothman Institute • ProspectiveResults study •31 infected / 83 uninfected • Rothman Institute • Prospective study * sensitivity •31 infected= 81% / 83 uninfected •* Rothman specificity =Institute 100% ** positive sensitivity = 81% •31 infected / 83 uninfected predictive value = 100 % • ** negative specificitypredictive = 100% value = 93.3 % ** positive sensitivity = 81%Parvizi et al. JBJS 2011 % predictive value = 100 ** negative specificitypredictive = 100% value = 93.3 % Parvizi et al. JBJS 2011 % * positive predictive value = 100 * negative predictive value = 93.3 % Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Parvizi et al. JBJS 2011 Rothman Institute of Orthopaedics at Thomas Jefferson University First Annual AAHKS Spring Meeting | 42 13 13 3/16/2016 Symposium II, Periprosthetic Joint Infection 3/16/2016 3/16/2016 Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Molecular Markers Protein Analysis Cytokines Proteins Molecular Markers IL-1α, IL-1β, IL1ra, IL-2, IL-3, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, Protein IL-12 subunit p40,Analysis IL-12 subunit p70, IL-15, IL-17, IL-23, IFN-γ, Category Adhesion Molecules Cytokines Growth Factors Proteins Molecular ICAM-1, Vascular CellMarkers Adhesion IL-1α, IL-1β, IL1ra, IL-2, IL-3, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, VEG-F, BDNF Protein Analysis IL-12 subunit p40, IL-12 subunit p70, IL-15, IL-17, IL-23, IFN-γ, Category TNF-α, TNF-β, TNF receptor-like 2 Acute-phase reactants Category Complement cascade Adhesion Molecules Cytokines Growth Factors Chemotactic proteins Acute-phase reactants Metalloproteinase Adhesion Molecules Complement compounds cascade Growth Factors Lysis/Destruction Chemotactic proteins Acute-phase reactants Metalloproteinase Complement cascade compounds Other Lysis/Destruction Chemotactic proteins Metalloproteinase compounds Other Lysis/Destruction Other CRP TNF-α, TNF-β, TNF receptor-like 2 Proteins Complement C3, α-2 Beta-2-Microglobulin, von ICAM-1, Vascular Cellmacroglobulin, Adhesion Willebrand Factor VIIIL-6, IL-7, IL-8, IL-10, IL-1α, IL-1β,Factor, IL1ra, Fibrinogen, IL-2, IL-3, IL-4, IL-5, VEG-F, BDNF IL-12 subunit p40, IL-12Protein subunit IL-15, IL-17, IL-23, IFN-γ, Monocyte Chemotactic 1, p70, Eotaxin-1 TNF-α, TNF-β, TNF receptor-like 2 CRP MMP-2, MMP-3, MMP-9, TIMP-1 ICAM-1, Vascular Cellmacroglobulin, Adhesion Complement C3, α-2 Beta-2-Microglobulin, von Willebrand Factor, Fibrinogen, Factor VII VEG-F, BDNF Alpha-1-Antitrypsin, Granulocyte-Macrophage ColonyMonocyte Chemotactic Protein 1,Inflammatory Eotaxin-1 Stimulating Factor, Macrophage Protein-1 alpha CRP Macrophage Inflammatory Protein-1 beta MMP-2, MMP-3, MMP-9, TIMP-1 Complement C3, α-2 macroglobulin, Beta-2-Microglobulin, von Ferritin, Haptoglobin, Stem CellFactor Factor,VII T-Cell-Specific Protein, Willebrand Factor, Fibrinogen, RANTES, Molecule-1,Granulocyte-Macrophage Vitamin D-Binding Protein Alpha-1-Antitrypsin, ColonyMonocyte Chemotactic Protein 1, Eotaxin-1 Stimulating Factor, Macrophage Inflammatory Protein-1 alpha Macrophage Inflammatory Protein-1 beta MMP-2, MMP-3, MMP-9, TIMP-1 Ferritin, Haptoglobin, Stem Cell Factor, T-Cell-Specific Protein, RANTES, Molecule-1,Granulocyte-Macrophage Vitamin D-Binding Protein Alpha-1-Antitrypsin, ColonyStimulating Factor, Macrophage Inflammatory Protein-1 alpha Macrophage Inflammatory Protein-1 beta Ferritin, Haptoglobin, Stem Cell Factor, T-Cell-Specific Protein, RANTES, Molecule-1, Vitamin D-Binding Protein Biomarker Screen Biomarker Screen Biomarkers Failing Prescreen Biomarkers Passing Prescreen • • • PCT • sFasL TGFa • sICAM-1 LL-37, Human, • sVCAM-1 ELISA kit Failing Biomarkers Prescreen • Granzyme B LBP HSP70 •• PCT •• sFasL CGRP IL-1α •• TGFa •• sICAM-1 •• Orsomucoid LL-37, Human, •• IL-10 sVCAM-1 • ELISA Nibrin kit Failing Biomarkers Prescreen IL-17 •• Granzyme B ••• TSG6 LBP MIP-1α HSP70 PCT •• sFasL Plekstrin ••• CGRP • MIP-1β IL-1α TGFa • sICAM-1 SOD2 Human, •• sVCAM-1 Orsomucoid MMP-8 IL-10 ••• LL-37, •• Urokinase Nibrin kit ELISA IL-17 • Granzyme B MIF TSG6 •• LBP MIP-1α • HSP70 PAI-1 (total) • IL-1α Plekstrin •• CGRP MIP-1β sFas SOD2 •• Orsomucoid MMP-8 • 45IL-10 Markers • • • • • • • • • IL-1b • LE Strip • IL-6 • Lactoferrin • IL-8 • Lipocalin2/NGAL Biomarkers Passing Prescreen • TNFa Neutrophil G-CSF •• IL-1b •• LE Strip Elastase-2 IL-1a •• IL-6 • Lactoferrin (ELA2) •• VEGF IL-8 •• LipocalinResistin Biomarkers Passing Prescreen 2/NGAL IP-10 •• TNFa • Thrombospondi Neutrophil BFGF (aka G-CSF •• IL-1b •• LE n-1 Strip (TSP-1) Elastase-2 FGF2) IL-1a • IL-6 Lactoferrin (ELA2) ••• HNP1-3, CRP VEGF •• IL-8 Lipocalin• Human Resistin , •• a2M 2/NGAL IP-10 TNFa Thrombospondi kit SKALP(aka •• ELISA Neutrophil BFGF •• G-CSF n-1 (TSP-1) Elastase-2 • BPI HNE Enzyme FGF2) •• IL-1a (ELA2) assay • HNP1-3, •• CRP VEGF • Resistin , a2M Human •• IP-10 • Thrombospondi ELISA kit SKALP(aka •• BFGF n-1 (TSP-1) • BPI • FGF2) HNE Enzyme assay • HNP1-3, • CRP Biomarker Screen Urokinase Nibrin MIF TSG6 PAI-1 (total) Plekstrin sFas SOD2 Urokinase MIF PAI-1 (total) sFas • Screened IL-17 • MIP-1α • MIP-1β • 45MMP-8 Markers Screened 45 Markers Screened • • • a2M SKALP HNE Enzyme assay Human, • ELISA kit BPI First Annual AAHKS Spring Meeting | 43 14 14 3/16/2016 Symposium II, Periprosthetic Joint Infection 3/16/2016 3/16/2016 Genomic Experiments Genomic Biomarker Marathon Experiments Genomic Biomarker Marathon Experiments Biomarker Marathon Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Data Data Data Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Alpha-Defensin Alpha-Defensin Antimicrobial Peptide Alpha-Defensin Secreted by Neutrophils Antimicrobial Peptide to fight Infection Secreted by Neutrophils Antimicrobial Peptide to fight Infection Secreted by Neutrophils to fight Infection Alpha‐Defensin Alpha‐Defensin Rothman Institute of Orthopaedics at Thomas Jefferson University Alpha‐Defensin Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University First Annual AAHKS Spring Meeting | 44 15 15 3/16/2016 Symposium II, Periprosthetic Joint Infection 3/16/2016 3/16/2016 Overall study data Overall study data Gold Standard Study N Institute Study Rothman 149 N MSIS Criteria Gold Mayo Arizona Rothman Institute 61 149 MSIS Criteria MSIS Criteria Gold Cleveland Clinic Mayo Arizona Rothman Institute Combined Cleveland Clinic Mayo Arizona 111 61 149 320 111 61 MSIS Criteria MSIS Criteria MSIS Criteria MSIS Criteria MSIS Criteria MSIS Criteria Combined Cleveland Clinic 320 111 Thomas Jefferson University MSIS Criteria 96% MSIS Criteria (95%CI: 92‐100%) Combined 320 Thomas Jefferson University MSIS Criteria Study Sensitivity Overall study data N Standard Standard 97% (95% CI: 86‐100%) Sensitivity 100% 97% (95% CI: 79‐100%) (95% CI: 86‐100%) Sensitivity 96% Specificity 96% (95% CI: 90‐99%) Specificity 95% 96% (95% CI: 83‐99%) (95% CI: 90‐99%) Specificity 99% (95%100% CI: 82‐99%) (95% CI: 79‐100%) 97% (95% CI: 86‐100%) (95% CI: 93‐100%) 95% (95% CI: 83‐99%) 96% (95% CI: 90‐99%) (95%CI: 92‐100%) (95%100% CI: 82‐99%) (95% CI: 79‐100%) (95% CI: 93‐99%) (95% CI: 93‐100%) 95% (95% CI: 83‐99%) 98% 96% 98% Rothman Institute of Orthopaedics at (95% CI: 82‐99%) 98% Rothman Institute of Orthopaedics at (95%CI: 92‐100%) 97% 99% 97% 99% (95% CI: 93‐99%) (95% CI: 93‐100%) 97% (95% CI: 93‐99%) Rothman Institute of Orthopaedics at Thomas Jefferson University Prophenoloxidase Pathway Beta Glucan (βG) Fungi Peptidoglycan (PG) Prophenoloxidase Gram & Gram Pathway + - Prophenoloxidase Pathway Peptidoglycan (PG) Beta Glucan (βG) Gram+ & GramFungi Pattern Recognition Receptors Serine Protease Cascade Peptidoglycan (PG) Beta Glucan (βG) Pattern Recognition Receptors Gram+ & GramFungi Polymerizatio n of melanin Melanin clots restrain and kill microbes. Basis for this colorimetric method: Phenoloxidase Prophenoloxidase Polymerizatio Melanin clots restrain and kill microbes. Basis for this colorimetric method: Phenoloxidase Prophenoloxidase Polymerizatio Melanin clots restrain and kill microbes. Prophenoloxidase Phenoloxidase Serine Protease Cascade Pattern Recognition Receptors n ofand melanin - Production of melanin is associated with black discoloration is Protease Cascade indicative of Serine presence of PG or βG. - Time of reaction can be used to estimate the quantity of PG or βG. n at ofand melanin - Production of melanin is associated blackofdiscoloration is Rothmanwith Institute Orthopaedics Thomas Jefferson University indicative of presence of PG or βG. - Time of reaction can be used to estimate the quantity of PG or βG. Basis for this colorimetric method: Rothmanwith Institute Orthopaedics atand is - Production of melanin is associated blackofdiscoloration Thomas Jefferson University indicative of presence of PG or βG. - Time of reaction can be used to estimate the quantity of PG or βG. Rothman Institute of Orthopaedics at Thomas Jefferson University Preliminary Results Samples from 8 patients with PJI and 5 patients Preliminary Results undergoing primary arthroplasty (control group) have been tested. Samples from 8 patients with PJI and 5 patients Preliminary Results In PJI group, the pathogens were S. aureusgroup) (4 cases), undergoing primary arthroplasty (control have coagulase negative Staphylococcus (2 cases), Strep. been tested. Intermedius and Candida tropicalis. Samples fromthe 8 patients withwere PJI S. and 5 patients In PJI group, pathogens aureus (4 cases), undergoing primary arthroplasty (control group) have The test was positive in all PJI cases negative in all coagulase negative Staphylococcus (2and cases), Strep. been tested. control cases.and Candida tropicalis. Intermedius In PJI group, the pathogens were S. aureus (4aureus) cases), The test has been done (both S. The test was positive in on all two PJI blood cases(2and negative in all coagulase negative Staphylococcus cases), Strep. and two periprosthetic solid tissue samples (S. aureus control cases.and Candida tropicalis. Intermedius and Candida tropicalis) at the time of reimplantation and positive. The all testwere has been done on two blood (both S. aureus) The test was positive insolid all PJI casessamples and negative in all and two periprosthetic tissue (S. aureus control cases. and Candida tropicalis) at the time of reimplantation and all were positive. The test has been done on two blood (both S. aureus) and two periprosthetic solid tissue samples (S. aureus and Candida tropicalis) at the time of reimplantation and all were positive. First Annual AAHKS Spring Meeting | 45 16 16 3/16/2016 Symposium II, Periprosthetic Joint Infection 3/16/2016 3/16/2016 Advantages as diagnostic method Directly targets the pathogenic bacteria Advantages as diagnostic method Most of the pathogens in PJI can be detected. Simple Directly targetsAdvantages the pathogenic bacteria as Most of the pathogens in PJI can detected. Inexpensive: (approximate costbewill depend on optimization of diagnostic method the method but can be less than 20 $ for each experiment) Simple Directly Rapid targets the pathogenic bacteria pathogens PJI can30-90 detected. Most Time of of the reaction variesin between minutes and on the of Inexpensive: (approximate costbewill depend ondepends optimization quantity PG/βG. the methodofbut can be less than 20 $ for each experiment) Simple Potentially quantitative Rapid Inexpensive: (approximate cost willminutes depend ondepends optimization Time of reaction varies between 30-90 and on the of Doable on synovial solid blood PG/βG. thequantity methodofbut can fluid, be less thantissue 20 $ samples for each and experiment) Easy to perform Potentially quantitative Rapid quantity PG/βG. fluid, solid tissue samples and blood Doable on of synovial Potentially quantitative Easy to perform Doable on synovial fluid, solid tissue samples and blood Easy to perform In-hospital & out-patient Time of reaction varies between 30-90 minutes and depends on the In-hospital & out-patient In-hospital & out-patient Issues Pathogen Pathogen Pathogen Issues Parvizi et al JBJS 2013 Issues Parvizi et al JBJS 2013 Parvizi et al JBJS 2013 Is it really infected? Is it really infected? Is it really infected? First Annual AAHKS Spring Meeting | 46 17 17 3/16/2016 Symposium II, Periprosthetic Joint Infection 3/16/2016 3/16/2016 Novel Molecular System Novel Molecular System PLEX-ID Novel 1) Amplification PLEX-ID Molecular System Broad identifiction (3100 species) 2) Amplification Targeted identification (spectrosray) 1) PLEX-ID Broad identifiction (3100 species) 1) Targeted Characterization (high resolution subtyping and drug 2) identification (spectrosray) 1) Amplification resistance) Broad identifiction (3100 species) Pathogen status 1) Characterization (high resolution subtyping and drug Genomes/Well 2) Targeted identification (spectrosray) Confidence resistance) mecA gene Pathogen status Rothman Institute of Orthopaedics at 1) Characterization (high resolution and drug Thomas Jeffersonsubtyping University Genomes/Well Confidence resistance) mecA gene Pathogen status Rothman Institute of Orthopaedics at Genomes/Well Thomas Jefferson University Confidence mecA gene Rothman Institute of Orthopaedics at Thomas Jefferson University IBIS 5000: Step 1 Sample Prep and Broad Range PCR IBIS 5000: Step 1 Sample Prep and Broad Range PCR IBIS 5000: Step 1 Sample Prep and Broad Range PCR Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University IBIS 5000: Step 2 MS Analysis and Signal Processing IBIS 5000: Step 2 MS Analysis and Signal Processing IBIS 5000: Step 2 MS Analysis and Signal Processing Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University First Annual AAHKS Spring Meeting | 47 18 18 3/16/2016 Symposium II, Periprosthetic Joint Infection 3/16/2016 3/16/2016 IBIS 5000: Step 3 Triangulation Using Multiple Primers IBIS 5000: Step 3 Triangulation Using Multiple Primers Primer #1 Mass Base Count Primer Set Mass Base BlueSet 18234.970 A12Count GCount 17C17T13 Primer Mass Base Blue 18234.970 A12 G17 C17 Blue 17948.926 ACount CT T18 Primer Set Mass Base 14G14T 1213 Blue 18234.970 A G 12 17 17 13 Blue 17948.926 A14 GC C12 TT Primer Set Mass 18610.017 Base AC GT Blue Blue 18234.970 A GCount 1114 19C1518 15 Blue 17948.926 Blue 18610.017 Blue Blue 18234.970 17936.912 Blue 17948.926 Blue 18610.017 Blue 17936.912 Blue Blue 17948.926 18877.118 Blue 18610.017 Blue 17936.912 Blue Blue Primer18610.017 #1 18877.118 Mass Blue 17936.912 Blue Primer Set18877.118 Mass Blue 17936.912 BlueSet 18234.970 Blue 18877.118 Primer Mass Blue 18234.970 Blue Blue 17948.926 Primer Set18877.118 Mass Blue 18234.970 Blue 17948.926 Primer Set Mass Blue 18610.017 Blue 18234.970 Blue 17948.926 Blue 18610.017 Blue Blue 18234.970 17936.912 Blue 17948.926 Blue 18610.017 Blue 17936.912 Blue Blue 17948.926 18877.118 Blue 18610.017 Blue 17936.912 Primer #1 Mass Blue 18877.118 Blue 18610.017 Blue 17936.912 Primer Set Mass Blue 18877.118 BlueSet 18234.970 Blue 17936.912 Primer Mass Blue 18877.118 Blue 18234.970 Blue 17948.926 Primer Set18877.118 Mass Blue Blue 18234.970 Blue 17948.926 Primer Set Mass Blue 18610.017 Blue 18234.970 Blue 17948.926 Blue 18610.017 Blue Blue 18234.970 17936.912 Blue 17948.926 Blue 18610.017 Blue 17936.912 Blue Blue 17948.926 18877.118 Blue 18610.017 Blue 17936.912 Blue 18877.118 Blue 18610.017 Blue 17936.912 Blue 18877.118 Blue 17936.912 Blue 18877.118 Blue 18877.118 12 A14 G14 C12 T18 A17 GT17 C13 A12 11 19 15 AC G CT T14 13 AG GC T1718 11C 1615 14 A17 G17 11 19 15 A14 G12 CT15 T 14 14 1112 17 18 16 14 A AGGCACTGT C T A GG C TT IBIS 5000: Step 3 A AG GACBase T C Count A GC CTCount T A AG GBase CACTGT C T Base Count Triangulation Using A G A Base G CACount TGC CT T Multiple Primers A G C T 18 15 15 13 11 1119 17 15 16 15 14 18 15 15 13 11 1119 17 15 16 15 14 18 15 15 13 11 17 1612 1417 17 13 18 15 15 13 12 17 17 18 15 1514 1314 1213 18 12 17 A14 G14 C12 T18 A17 GT C13 A12 11C 19T 15T15 AG GC 14 14 12 A17 GT17 C13 T15 A12 11 19 15 AC GT C18 AG GC 1112 17 16T14 14 14 18 A17 G17 C13 T15 11 19 15 A G C T14T A14 G C T 11 17 16 18 A11 G19 C1815 T15 15 13 15 A14 GA12 CG TC14T 11 17 16 A G C A11AG19 C1815 T15 15 13 15 C T 11 17 16 14 AG G C T 18CA15 12G15 17C13 17T13 A11AG17 16 14 A15 GT15 18G 13 12 17 17 AC GTC CT T18 14 14T 1213 A18GA15 C T G C 15 13C 13 12 A14 G14 12 A17 G17 CT T15 A12 1117 19 1518 17 13 AG GC CT T18 14 14 12 A G C T A12 G C T 11 19 15 A G C T14 A14 G14 C1112 T1718 1615 A17 G17 C13 T15 11 19 15 A G C T A14 11CT17 16 14 G 18 AG GC T15 18C 11 19 A14 GA12 TC1415T13 11 17 1615 AC GT15 A11AG19 18C 15TC15T13 11 17 1615 14 AG G15 18C 15C15T13 A11AG17 16T14 18G15C15T13 A18G15C15T13 Base Count Base Count Base Count Base Count Base Count Base Count Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Rothman Institute of Orthopaedics at Thomas Jefferson University Organisms Profile Organisms Profile H. influenzae [A28 G28 C25 T20] Organisms Profile H. influenzae [A28 G28 C25 T20] S. pyogenes [A27 G32 H. C24 T18] influenzae [A28 G28 C25 T20] S. pyogenes [A27 G32 C24 T18] S. pyogenes [A27 G32 C24 T18] Thank you Thank you Thank you First Annual AAHKS Spring Meeting | 48 19 Symposium II, Periprosthetic Joint Infection The Role of I&D: When, How, and What the The Role of I&D: Literature Tells Us When, How, and What the The Role of I&D: Literature Tells Us When, How, and What the Literature Tells Us Matthew P. Abdel, M.D. Associate Professor of Orthopedic Surgery Mayo Clinic,P.Rochester, MN Matthew Abdel, M.D. Associate Professor of Orthopedic Surgery Mayo Clinic, Rochester, MN Matthew P. Abdel, M.D. Associate Professor of Orthopedic Surgery Mayo Clinic, Rochester, MN Disclosures • Individual Disclosures Disclosures • BJJ Editorial Board • JOR Editorial Board • Individual Disclosures •• JOT Editorial Board Board BJJ Editorial Disclosures •• EJOST Editorial Board JOR Editorial Board • Individual Disclosures •• Minnesota Orthopedic Society Board of Directors JOT Editorial Board • BJJ Editorial Board EJOST Editorial Board ••JOR Editorial Board • Minnesota Research Orthopedic Society Board of Directors • Institutional Support • JOT Editorial Board • DePuy-Synthes, Stryker, and Zimmer-Biomet • EJOST Editorial Board • Institutional Support • Minnesota Research Orthopedic Society Board of Directors • DePuy-Synthes, Stryker, and Zimmer-Biomet • Institutional Research Support • DePuy-Synthes, Stryker, and Zimmer-Biomet Introduction • Type I: + intraop cx after presumed aseptic revision Introduction intraop cx after presumed aseptic revision • Type I: II:+Acute postoperative infection (< 4 weeks) Introduction II:+Acute postoperative infection (< 4 weeks) •• Type intraop cx after presumed aseptic revision Type I: III: Late acute hematogenous (< 4 weeks) III:Acute Late acute hematogenous (<(< 4 weeks) •• Type postoperative infection 4 weeks) Type II: IV: Chronic infections (> 4 weeks) Type III: IV: Chronic infections (> 4 weeks) •• Type Late acute hematogenous (< 4 weeks) • Type IV: Chronic infections (> 4 weeks) First Annual AAHKS Spring Meeting | 49 1 1 Symposium II, Periprosthetic Joint Infection Introduction • Type I: + intraop cx after presumed aseptic revision Introduction • Type I: II:+Acute postoperative infection (< 4 weeks) intraop cx after presumed aseptic revision Introduction intraop cx after presumed aseptic revision • Type I: III: Late acute hematogenous (< 4 weeks) II:+Acute postoperative infection (< 4 weeks) II: Acute postoperative 4 weeks) • Type IV: Chronic infections (>infection 4 weeks) III: Late acute hematogenous (< (< 4 weeks) III:Chronic Late acute hematogenous (< 4 weeks) • Type IV: infections (> 4 weeks) • Type IV: Chronic infections (> 4 weeks) Outline Outline Outline #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results Outline Outline Outline #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results First Annual AAHKS Spring Meeting | 50 2 2 Symposium II, Periprosthetic Joint Infection Outline Outline Outline #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results Outline Outline Outline #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results Outline Outline Outline #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results First Annual AAHKS Spring Meeting | 51 3 3 Symposium II, Periprosthetic Joint Infection Case 1 61 YOF, 2 Wks s/p R THR, c/o Fevers Case 1 61 YOF, 2 Wks s/p R THR, c/o Fevers Case 1 61 YOF, 2 Wks s/p R THR, c/o Fevers ESR 54 mm/hr CRP 121 mg/L WBC ESR 5423,795 mm/hr 89% PMNs CRP 121 mg/L Cx: ßWBC hemolytic 23,795strep ESR 54 mm/hr 89% PMNs CRP 121 mg/L Cx: ß hemolytic strep WBC 23,795 89% PMNs Cx: ß hemolytic strep Case 1 61 YOF, 2 Wks s/p R THR, c/o Fevers Case 1 61 YOF, 2 Wks s/p R THR, c/o Fevers Case 1 61 YOF, 2 Cx: Wks s/p R THR, ß hemolytic strep c/o Fevers I&D, Bead Placement, Cx: ß hemolytic strep Head/Liner Exchange Preop Preop Preop I&D, Bead Placement, Cx: ß hemolytic strep Head/Liner Exchange IV Abx Choice? PO Suppression? I&D, Bead Placement, Head/Liner Exchange IV Abx Choice? PO Suppression? IV Abx Choice? PO Suppression? Postop Postop Postop Antibiotics Type II or III Infections Antibiotics Type II or III Infections Before Incision Before Incision Before Incision Antibiotics After Special Surgery Circumstances Type II or III Infections After Special Surgery Circumstances After Surgery Special Circumstances * Mihalko et al. AAOS ICL. 2008 * Leone and Hanssen. AAOS ICL. 2006 * Mihalko et al. AAOS ICL. 2008 * Leone and Hanssen. AAOS ICL. 2006 * Mihalko et al. AAOS ICL. 2008 * Leone and Hanssen. AAOS ICL. 2006 First Annual AAHKS Spring Meeting | 52 4 4 Symposium II, Periprosthetic Joint Infection Antibiotics Type II or III Infections Antibiotics Type II or III Infections Before Incision Antibiotics + Preop Organism IDor - Preop Organism ID Type II III Infections Before Incision + Preop Organism ID Before - Preop Organism ID Incision Abx (Cx & Sensitivity) Hold Abx Rarely cultures have- returned + Preop Organism ID Preop Organism ID Treat with broad spectrum antibiotics (Staph & Strep) Abx (Cx & Sensitivity) Hold Abx Rarely cultures have returned Treat with broad spectrum antibiotics (Staph & Strep) Abx (Cx & Sensitivity) Hold Abx Rarely cultures have returned Treat with broad spectrum antibiotics (Staph & Strep) Antibiotics Type II or III Infections Antibiotics Type II or III Infections After Surgery Antibiotics Tailor to CxType and II 4-6 weeks of IV Abx or III Infections After Surgery Sensitivity ± PO Abx Tailor to Cx and After Surgery 4-6 weeks of IV Abx Sensitivity ± PO Abx Close coordination with4-6 ID specialist Tailor to Cx and weeks of IV Abx Sensitivity ±et PO Abx * Mihalko al. AAOS ICL. 2008 * Leone and Hanssen. AAOS ICL. 2006 Close coordination with ID specialist * Mihalko et al. AAOS ICL. 2008 * Leone and Hanssen. AAOS ICL. 2006 Close coordination with ID specialist * Mihalko et al. AAOS ICL. 2008 * Leone and Hanssen. AAOS ICL. 2006 Antibiotics Type II or III Infections Antibiotics Type II or III Infections Special Circumstances Antibiotics Oral, GI, Type GU II or High Risk for MRSA III Infections Special Circumstances Oral, GI, GU Special High Risk for MRSA Circumstances Include GN Coverage Add Vancomycin Oral, GI, GU High Risk for MRSA Include GN Coverage * Mihalko et al. AAOS ICL. 2008 * Leone and Hanssen. AAOS ICL. 2006 Include GN Coverage * Mihalko et al. AAOS ICL. 2008 * Leone and Hanssen. AAOS ICL. 2006 Add Vancomycin Add Vancomycin * Mihalko et al. AAOS ICL. 2008 * Leone and Hanssen. AAOS ICL. 2006 First Annual AAHKS Spring Meeting | 53 5 5 Symposium II, Periprosthetic Joint Infection Case 1 61 YOF, 2 Wks s/p R THR, c/o Fevers Case 1 61 YOF, 2 Wks s/p R THR, c/o Fevers Case 1 61 YOF, 2 Wks s/p R THR, c/o Fevers ESR 54 mm/hr CRP 121 mg/L WBC 23,795 ESR 54 mm/hr 89% PMNs CRP 121 mg/L Cx: ß hemolytic strep WBC 23,795 ESR 54 mm/hr 89% PMNs CRP 121 mg/L Cx: ß hemolytic strep WBC 23,795 89% PMNs Cx: ß hemolytic strep Case 1 61 YOF, 2 Wks s/p R THR, c/o Fevers Case 1 61 YOF, 2 Wks s/p R THR, c/o Fevers 61 YOF, Preop Preop Case 1 PMH: Contralateral THA BMI = 62 kg/m2 2 Cx: Wks s/p R THR, ß hemolytic strep c/o PMH: Contralateral THA BMI = 62 kg/m2 I&D, Bead Placement, Cx: ß hemolytic strep Head/Liner Exchange PMH:Contralateral IV CeftriaxoneTHA BMI = kg/m2 PO62 Duricef I&D, Bead Placement, Cx: ß hemolytic strep Head/Liner Exchange IV Ceftriaxone Bead PO Duricef I&D, Placement, Head/Liner Exchange IV Ceftriaxone PO Duricef Preop Fevers Postop Postop Postop Case 1 61 YOF, 2 Wks s/p R THR, c/o Fevers Case 1 61 YOF, 2 Wks s/p R THR, c/o Fevers 61 YOF, Preop Preop Preop Case 1 PMH: Contralateral THA BMI = 62 kg/m2 2 Cx: Wks s/p R THR, ß hemolytic strep c/o PMH: Contralateral THA BMI = 62 kg/m2 I&D, Bead Placement, Cx: ß hemolytic strep Head/Liner Exchange PMH:Contralateral THA IV Ceftriaxone BMI = 62 kg/m2 PO Duricef I&D, Bead Placement, Cx: ß hemolytic strep Head/Liner Exchange IV Ceftriaxone Bead PO Duricef I&D, Placement, Head/Liner Exchange IV Ceftriaxone PO Duricef Fevers 2 Years ESR 3 CRP < 3 2 Years ESR 3 CRP < 3 2 Years ESR 3 CRP < 3 First Annual AAHKS Spring Meeting | 54 6 6 Symposium II, Periprosthetic Joint Infection Outline Outline Outline #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results Case 2 52 YOF, 2 Yrs s/p L TKR Acute Pain, Recent Case 2Colonoscopy mm/hr 52 YOF,ESR 2 72 Yrs s/p L TKR CRP 333 mg/L Acute Pain, Recent Case 2Colonoscopy WBC 27,598 ESR 72 mm/hr 52 YOF, 70% 2 Yrs s/p L TKR PMNs 333 mg/L Acute Pain,CRP Recent Colonoscopy WBC ESR 7227,598 mm/hr 70% PMNs CRP 333 mg/L WBC 27,598 70% PMNs Case 2 52 YOF, 2 Days of Pain, Colonoscopy Case 2 52 YOF, 2 Days of Pain, Colonoscopy Case 2 52 YOF, 2 Days of Pain, Colonoscopy Cx: Enterococcus Cx: Enterococcus Preop Cx: Enterococcus Preop Preop First Annual AAHKS Spring Meeting | 55 7 7 Symposium II, Periprosthetic Joint Infection Timing Total Hip Replacement • Crockarell et al, JBJSTiming Am, 1988 Total Hip Replacement • Successful with head/liner exchanges Timing • Crockarell et al, JBJS Am, 1988 Total Hip Replacement • Successful with head/liner exchanges completed < 2 weeks from onset of symptoms completed < 2 weeks from onset of symptoms • Crockarell et al, JBJS Am, 1988 • Successful with head/liner exchanges completed < 2 weeks from onset of symptoms Timing Total Knee Replacement Timing • Schoifet and Morrey, JBJS Am, 1990 Totalwith Knee Replacement • 77% failure I&D and poly exchange • All failures in those with > 28 days of symptoms Timing • Schoifet and Morrey, JBJS Am, 1990 Knee Replacement • 77% Total failure with I&D and poly exchange • Brandt et al, Clinical ID, 1997 • All failures in those with > 28 days of symptoms • > 2 days failures rates with S. aureus • Schoifet and increased Morrey, JBJS Am, 1990 • 77% failure with I&D and poly exchange • Brandt et al, Clinical ID, 1997 • All failures in Clinical those with 28 days of symptoms • Marculescu et al, ID, > 2006 • > 2 days increased failures rates with S. aureus • > 8 days increased failure rates • Brandt et al, Clinical ID, 1997 • Marculescu al, Clinical ID, 2006 • > 2 daysetincreased failures rates with S. aureus • > 8 days increased failure rates • Marculescu et al, Clinical ID, 2006 • > 8 days increased failure rates Timing Acute Hematogenous Infections Timing Acute Hematogenous Infections 0 Days 2 Days 14 Days Timing 0 Days 2 Days 14 Days Acute Hematogenous Infections 0 Days S. aureus 2 Days 14Organisms Days Gram + S. aureus Gram + Organisms S. aureus Gram + Organisms First Annual AAHKS Spring Meeting | 56 8 8 Symposium II, Periprosthetic Joint Infection Timing Acute Postoperative Infections Timing Acute Postoperative Infections 0 Days 2 Days 14 Days Timing 28 Days 14 Days 28 Days Acute Postoperative Infections 0 Days 0 Days 2 Days S. aureus 2 Days S. aureus S. aureus Days 28 Days Gram 14 + Organisms Index Gram + Organisms Procedure Index Gram + Organisms Procedure Index Procedure Case 2 52 YOF, 2 Yrs s/p L TKR Acute Pain, Recent Case 2Colonoscopy ESR 72 mm/hr 52 YOF,CRP 2 333 Yrsmg/L s/p L TKR Acute Pain, Recent Case 2Colonoscopy WBC 27,598 ESR 72 mm/hr 52 YOF, 70% 2 Yrs s/p L TKR PMNs 333 mg/L Acute Pain,CRP Recent Colonoscopy WBC ESR 7227,598 mm/hr 70% PMNs CRP 333 mg/L WBC 27,598 70% PMNs Case 2 52 YOF, 2 Days of Pain, Colonoscopy Case 2 52 YOF, 2 Days of Pain, Colonoscopy 52 YOF, Preop Preop Preop Case 2 PMH: Contralateral TKR BMI = 59 kg/m2 2 Days of Pain, Colonoscopy Cx: Enterococcus PMH: Contralateral TKR BMI = 59 kg/m2 I&D Poly Exchange Cx: with Enterococcus IV VancomycinTKR PMH: Contralateral PO BMI =Amoxicillin 59 kg/m2 Cx: with Enterococcus I&D Poly Exchange Postop IV Vancomycin PO Amoxicillin I&D with Poly Exchange IV Vancomycin PO Amoxicillin Postop Postop First Annual AAHKS Spring Meeting | 57 9 9 Symposium II, Periprosthetic Joint Infection Outline Outline Outline #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results Case 3 78 YOM, 3.5 Weeks s/p L THR, c/o Pain Case 3 78 YOM, 3.5 Weeks s/p L THR, c/o Pain Case 3 78 YOM, 3.5 Weeks s/p L THR, c/o Pain ESR 47 mm/hr CRP 186 mg/L ESR 47 mm/hr CRP 186 mg/L ESR 47 mm/hr CRP 186 mg/L Case 3 78 YOM, 3.5 Weeks s/p L THR, c/o Pain Case 3 78 YOM, 3.5 Weeks s/p L THR, c/o Pain Case 3 PMH: DM, RA, smoker 78 YOM, 3.5 s/pstrep L THR, c/o Pain Cx:Weeks ß hemolytic PMH: DM, RA, smoker Cx: ß hemolytic strep PMH: DM, RA, smoker Cx: ß hemolytic strep Preop Preop Preop First Annual AAHKS Spring Meeting | 58 10 10 Symposium II, Periprosthetic Joint Infection Surgical Management • Antibiotic Suppression (<20%, infirm) Surgical Management •• I&D with Modular Exchange Antibiotic Suppression (<20%, infirm) • Open Surgical Management • Arthroscopic • I&D with Modular Exchange Antibiotic Suppression (<20%, infirm) • Open • Acute One-Stage Exchange • Arthroscopic • I&D with Modular Exchange • Open •• Two-Stage Exchange Acute One-Stage Exchange • Arthroscopic •• Resection Arthroplasty Two-Stage Exchange Acute One-Stage Exchange • Resection Two-StageArthroplasty Exchange • Resection Arthroplasty Surgical Management • Antibiotic Suppression Surgical Management •• Antibiotic I&D with Modular Exchange Suppression • Open Surgical Management • Arthroscopic (limited role; TKA) • I&D with Modular Exchange Antibiotic Suppression • Open • Acute One-Stage (limited Exchange • Arthroscopic role; TKA) • I&D with Modular Exchange • Open •• Two-Stage Exchange Acute One-Stage Exchange • Arthroscopic (limited role; TKA) •• Resection Arthroplasty Two-Stage Exchange Acute One-Stage Exchange • Resection Two-StageArthroplasty Exchange • Resection Arthroplasty Surgical Management • Antibiotic Suppression Surgical Management •• Antibiotic I&D with Modular Exchange Suppression • Open Surgical Management • Arthroscopic • I&D with Modular Exchange Antibiotic Suppression • Open • Acute One-Stage Exchange (hip) • Arthroscopic • I&D with Modular Exchange • Open •• Two-Stage Exchange Acute One-Stage Exchange (hip) • Arthroscopic •• Resection Arthroplasty Two-Stage Exchange Acute One-Stage Exchange (hip) • Resection Two-StageArthroplasty Exchange • Resection Arthroplasty First Annual AAHKS Spring Meeting | 59 11 11 Symposium II, Periprosthetic Joint Infection Surgical Management • Antibiotic Suppression Surgical Management •• I&D with Modular Exchange Antibiotic Suppression • Open Surgical Management • Arthroscopic •• I&D with Modular Exchange Antibiotic Suppression • Open • Acute One-Stage Exchange • Arthroscopic • I&D with Modular Exchange • Open Exchange •• Two-Stage Acute One-Stage Exchange • Arthroscopic •• Resection Arthroplasty Exchange • Two-Stage Acute One-Stage Exchange •• Resection Two-StageArthroplasty Exchange • Resection Arthroplasty Surgical Management • Antibiotic Suppression Surgical Management •• I&D with Modular Exchange Antibiotic Suppression • Open Surgical Management • Arthroscopic •• I&D with Modular Exchange Antibiotic Suppression • Open • Acute One-Stage Exchange • Arthroscopic • I&D with Modular Exchange • Open Exchange •• Two-Stage Acute One-Stage Exchange • Arthroscopic •• Resection Arthroplasty Exchange • Two-Stage Acute One-Stage Exchange •• Resection Two-StageArthroplasty Exchange • Resection Arthroplasty Surgical Management Total Hip Replacement Infected THR Surgical Management Acute (Type II or Type III) Total Hip Replacement Infected THR Surgical Management Acute (Type II or Type III)Resection Arthroplasty Total Hip Replacement Antibiotic Suppression Infected THR Acute (Type II or Type III)Resection Arthroplasty Antibiotic Suppression Irrigation & Debridement + Head/Liner Exchange Two-Stage Exchange Antibiotic Suppression Irrigation & Debridement + Head/Liner Exchange Irrigation & Debridement + Head/Liner Exchange Resection Arthroplasty Acute One-Stage Exchange Acute One-Stage Exchange Acute One-Stage Exchange Two-Stage Exchange * Hansen et al. CORR. 2013 Two-Stage Exchange * Hansen et al. CORR. 2013 * Hansen et al. CORR. 2013 First Annual AAHKS Spring Meeting | 60 12 12 Symposium II, Periprosthetic Joint Infection Important Difference Important Difference Important Difference ≠ ≠ ≠ Mode of Fixation Modecemented of Fixation • TKAs: Mostly Modecemented of Fixation • TKAs: Mostly • TKAs: Mostly cemented • THAs: Mostly uncemented • THAs: Mostly uncemented • THAs: Mostly uncemented Surgical Management Total Knee Replacement Infected TKR Surgical Management Acute (Type II or Type III) Total Knee Replacement Surgical Management Infected TKR Acute (Type II or Type III)Resection Arthroplasty Total Knee Replacement Antibiotic Suppression Infected TKR Acute (Type II or Type III) Antibiotic Suppression Resection Arthroplasty Irrigation & Debridement + Poly Exchange Antibiotic Suppression Irrigation & Debridement + Poly Exchange Irrigation & Debridement + Poly Exchange Two-Stage Exchange Resection Arthroplasty Acute One-Stage Exchange Acute One-Stage Exchange Two-Stage Exchange Two-Stage Exchange Acute One-Stage Exchange First Annual AAHKS Spring Meeting | 61 13 13 Symposium II, Periprosthetic Joint Infection Mayo Protocol • Favor open I&D with component retention in patients • Short-livedMayo symptomsProtocol • Intact soft tissue envelope • Favor open I&Dwell-functioning with componentjoint retention in patients • Previously is a must Protocol • Short-livedMayo symptoms • Intact soft tissue envelope Favordebridement open I&D with component retention in •• Open allows for the exchange of patients modular • Previously well-functioning joint is a must components andsymptoms improved joint access for synovectomy • Short-lived • Intact soft tissue envelope • Open debridement allows for thejoint exchange of modular • Previously well-functioning is a must • The results may with the addition of Rifampin components andimprove improved joint access for synovectomy in certain biofilm-producing infections (Staph)* • Open debridement allows for the exchange of modular • The results may with theaccess addition Rifampin components andimprove improved joint for of synovectomy in certain biofilm-producing infections (Staph)* * Zimmerli W et al. JAMA 1998 • The results may improve with the addition of Rifampin in certain biofilm-producing infections (Staph)* * Zimmerli W et al. JAMA 1998 * Zimmerli W et al. JAMA 1998 SURGICAL TECHNIQUE SURGICAL TECHNIQUE SURGICAL TECHNIQUE 1. Ellipse Previous Incision 1. Ellipse Previous Incision 1. Ellipse Previous Incision First Annual AAHKS Spring Meeting | 62 14 14 Symposium II, Periprosthetic Joint Infection 1. Ellipse Previous Incision 1. Ellipse Previous Incision 1. Ellipse Previous Incision 2. Full Thickness Flaps 2. Full Thickness Flaps 2. Full Thickness Flaps 3. Modular Junction Exchange 3. Modular Junction Exchange HIP 3. Modular Junction Exchange HIP HIP KNEE KNEE KNEE First Annual AAHKS Spring Meeting | 63 15 15 Symposium II, Periprosthetic Joint Infection 4. Five Cultures Synovium and Peri-Implant Tissue 4. Five Cultures Synovium and Peri-Implant Tissue 4. Five Cultures Synovium and Peri-Implant Tissue Sonication of Removed Hip and Knee Prostheses for Diagnosis of Infection Andrej Trampuz, M.D., Kerryl E. Piper, M.S., Melissa J. Jacobson, A.S., Arlen Sonication of Removed HipR. Osmon, andM.D., Knee D. Hanssen, M.D., Krishnan K. Unni, M.D., Douglas Jayawant N. Mandrekar, Ph.D., Franklin R. Cockerill, M.D., James M. Prostheses Diagnosis of Infection Steckelberg, M.D.,for James F. Greenleaf, Pxh.D., and Robin Patel, M.D. Andrej Trampuz, M.D., Kerryl E. Piper, M.S., Melissa J. Jacobson, A.S., Arlen Sonication of Removed HipR. Osmon, andM.D., Knee D. Hanssen, M.D., Krishnan K. Unni, M.D., Douglas Jayawant N. Mandrekar, Ph.D., Franklin R. Cockerill, M.D., James M. Prostheses Diagnosis of Infection Steckelberg, M.D.,for James F. Greenleaf, Pxh.D., and Robin Patel, M.D. Andrej Trampuz, M.D., Kerryl E. Piper, M.S., Melissa J. Jacobson, A.S., Arlen D. Hanssen, M.D., Krishnan K. Unni, M.D., Douglas R. Osmon, M.D., N Engl J Med N. Mandrekar, Ph.D., Franklin R. Cockerill, M.D., James M. Jayawant Volume 357(7):654-663 Steckelberg, M.D., James F. Greenleaf, Pxh.D., and Robin Patel, M.D. August 16, 2007 N Engl J Med Volume 357(7):654-663 August 16, 2007 N Engl J Med Volume 357(7):654-663 August 16, 2007 5. Frozen Section >5 WBC/hpf* 5. Frozen Section >5 WBC/hpf* 5. Frozen Section >5 WBC/hpf* * Feldman et al. JBJS. 1995 * Musso et al. Post Grad Med. 2003 * Feldman et al. JBJS. 1995 * Musso et al. Post Grad Med. 2003 * Feldman et al. JBJS. 1995 * Musso et al. Post Grad Med. 2003 First Annual AAHKS Spring Meeting | 64 16 16 Symposium II, Periprosthetic Joint Infection 6. Complete Debridement 6. Complete Debridement 6. Complete Debridement 7. Inspect Interfaces 7. Inspect Interfaces 7. Inspect Interfaces 8. Irrigation 8. Irrigation 8. Irrigation * Brown et al. JOA. 2012 * Brown et al. JOA. 2012 * Brown et al. JOA. 2012 First Annual AAHKS Spring Meeting | 65 17 17 Symposium II, Periprosthetic Joint Infection 9. Repeat Debridement 9. Repeat Debridement 9. Repeat Debridement 10. New Instruments, Drain, and Closure 10. New Instruments, Drain, and Closure 10. New Instruments, Drain, and Closure Infected THAs: Are We Doing Better with Modern Treatment Infected THAs: Are We Doing Better with Modern Treatment Infected THAs: Are We Doing Better with Modern Treatment Andrew J. Bryan, M.D. Matthew P. Abdel, M.D. Steven J. Fitzgerald, M.D. Andrew J. Bryan, M.D. Arlen D. Hanssen, M.D. Matthew Abdel,M.D. M.D. Daniel J.P.Berry, Steven J. Fitzgerald, M.D. Andrew J. Bryan, M.D. Arlen D. Hanssen, M.D. Matthew Abdel,M.D. M.D. Daniel J.P.Berry, Steven J. Fitzgerald, M.D. Arlen D. Hanssen, M.D. Daniel J. Berry, M.D. First Annual AAHKS Spring Meeting | 66 18 18 Symposium II, Periprosthetic Joint Infection Infected THA Questions Infected THA • What are modern Questions results of I&D? Infected THA • What are modern Questions results of I&D? •• Are we doing any What are modern better than in the results of I&D? • past? Are we doing any better than in the • past? Are we doing any better than in the past? Infected THA Infected THA Infected THA Infected THA Methods • All I&D with implant retention for deep Infected THA infection after primary hip replacement at Mayo Methods • All I&D with implant retention for deep Infected THA after primary hip replacement at Mayo • infection 2000-2008 Methods • All I&D with implant retention for deep • infection 2000-2008 90 hips after primary hip replacement at Mayo 2000-2008 • 90 hips • 90 hips Infected THA Demographics Infected THA • Early postop infection: 73% Demographics Infected THA Early postop infection: 73% • Acute hematogenous: 27% Demographics Early postop infection: 73% Acute hematogenous: 27% •• Treatment : I&D PE liner/head exchange Acute hematogenous: 27% • Treatment : I&D PE liner/head exchange • Treatment : I&D PE liner/head exchange First Annual AAHKS Spring Meeting | 67 19 19 Symposium II, Periprosthetic Joint Infection Infected THA Demographics Infectedafter THA • Postop abx suppression I&D = 84% hips Demographics Infected THA • Postop abx suppression Mean followup = 6 yearsafter I&D = 84% hips Demographics •• Postop abx suppression Mean followup = 6 yearsafter I&D = 84% hips • Mean followup = 6 years Infected THA Results Infected THA • Overall failureResults rate for recurrent Infected THA infection = Results • Overall failure for recurrent 10%rate (9/90)* infection = • Overall failure for recurrent 10%rate (9/90)* infection = *Lower10% than most previous series (9/90)* *Lower than most previous series *Lower than most previous series Infected THA Results Recurrent Infections (stratified): Infected THA • Acute postop infection: Results13% vs. Infected THA Recurrent Infections (stratified): •• Acute hematogenous: 9% Acute postop infection: Results13% vs. Recurrent Infections (stratified): •• Acute Acute hematogenous: postop infection:9% 13% vs. • Acute hematogenous: 9% No Significant Difference No Significant Difference No Significant Difference First Annual AAHKS Spring Meeting | 68 20 20 Symposium II, Periprosthetic Joint Infection Infected THA Discussion Infected THA Why might results be better than previous series? Discussion Infected THA Why might results be better than previous Discussion series? reasons: • Possible - Rigorous criteria I&Dthan alone (MSIS) Why might results be for better previous series? Most patients on suppressive antibiotics • Possible reasons: -- Improved antibiotics (rifampin, etc) Rigorous criteria for I&D alone (MSIS) Mid-term follow-up - Most patients • Possible reasons:on suppressive antibiotics - Improved antibiotics (rifampin, etc) Rigorous criteria for I&D alone (MSIS) - Most Mid-term follow-up patients on suppressive antibiotics - Improved antibiotics (rifampin, etc) - Mid-term follow-up Contemporary Results I&D with Component Retention Contemporary Results I&D with Component Retention Contemporary Results • 42 patients • 76% success at 2 years I&D with Component Retention • 96% for non-staphylococcal infections • 42 patients • 76% success at 2 years • 96% for non-staphylococcal infections • 42 patients • 76% success at 2 years 96% for non-staphylococcal infections •• 26 patients • 77% success at 5 years • 26 patients • 77% success at 5 years • 26 patients • 77% success at 5 years Case 3 78 YOM, 3.5 Weeks s/p L THR, c/o Pain Case 3 78 YOM, 3.5 Weeks s/p L THR, c/o Pain Case 3 78 YOM, 3.5 Weeks s/p L THR, c/o Pain ESR 47 mm/hr CRP 186 mg/L ESR 47 mm/hr CRP 186 mg/L ESR 47 mm/hr CRP 186 mg/L First Annual AAHKS Spring Meeting | 69 21 21 Symposium II, Periprosthetic Joint Infection Case 3 78 YOM, 3.5 Weeks s/p L THR, c/o Pain Case 3 78 YOM, 3.5 Weeks s/p L THR, c/o Pain Case 3 PMH: DM, RA, smoker 78 YOM, 3.5 s/pstrep L THR, c/o Pain Cx:Weeks ß hemolytic PMH: DM, RA, smoker Preop Preop Cx: Acute 1-Stage Exchange ß hemolytic strep IV Ceftriaxone PO Duricef PMH: DM, RA, smoker Acute 1-Stage Exchange Cx: ß hemolytic strep IV Ceftriaxone PO Duricef 1 Year Acute 1-Stage Exchange IV Ceftriaxone PO Duricef 1 Year Preop 1 Year Outline Outline Outline #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results #1: Antibiotics #2: Timing #3: Surgical Treatment #4: Results Results Author Journal Year # of Pts FU Success Koyonos CORR 2011 136 54 mos 35% Results Choi CORR 2011 32 Odum Author Zmistowski Koyonos JOA Journal JOA CORR 2011 Year 2011 2011 150 # of Pts 104 136 Choi Azzam Odum Bradbury Author Zmistowski Salgado Koyonos CORR JOA JOA JOA Journal JOA CORR CORR 2011 2010 2011 2009 Year 2011 2007 2011 32 19 150 20of Pts # 104 20 136 Marculescu Choi Azzam Deirmengian Odum Bradbury Silva Zmistowski Salgado Segawa Marculescu Azzam Wasielewski Deirmengian Bradbury Kramhoft Silva Salgado Teeny Segawa Marculescu Schoifet Wasielewski Deirmengian Kramhoft Silva Teeny Segawa Schoifet Wasielewski Clin ID CORR JOA CORR JOA JOA CORR JOA CORR JBJS Clin ID JOA CORR JOA CORR CORR JOA JBJS Clin ID JBJS JOA CORR JOA CORR JOA JBJS JBJS JOA 2006 2011 2010 2003 2011 2009 2002 2011 2007 1999 2006 2010 1996 2003 2009 1994 2002 2007 1990 1999 2006 1990 1996 2003 1994 2002 1990 1999 1990 1996 99 32 19 31 150 20 530 104 20 10 99 19 10 31 20 27 530 20 21 10 99 31 10 31 27 530 21 10 31 10 Kramhoft JOA 1994 27 Teeny JOA 1990 21 4 yrs 29% Schoifet JBJS 1990 31 3 yrs 23% Results 36 mos FU 54 mos 36 mos 5.7 yrs Min 2 yrs FU 54 mos 2 yrs 36 5.7 mos yrs 4 yrs Min 2 yrs 3.7 yrs 2 yrs 5.7 yrs 32 months 4 yrs Min 2 yrs 4 yrs 3.7 yrs 2 yrs 3 32 months 4 yrs 4 yrs 3.7 yrs 3 yrs 32 months 31% 31% Success GN = 70% 35% MSSA = 33% 31% 44% 31% 16% Success GN = 70% 33% 35% MSSA = 33% 60% 31% 44% 35% 31% 16% 33% GN 33%= 70% MSSA 50% = 33% 60% 44% 75% 35% 16% 19% 33% 33% 29% 50% 60% 23% 75% 35% 19% 33% 29% 50% 23% 75% 19% First Annual AAHKS Spring Meeting | 70 22 22 Symposium II, Periprosthetic Joint Infection Results Author Journal Year # of Pts FU Success Koyonos CORR 2011 136 54 mos 35% Results Choi CORR 2011 32 Odum Author Zmistowski Koyonos JOA Journal JOA CORR 2011 Year 2011 2011 150 # of Pts 104 136 Choi Azzam Odum Bradbury Author Zmistowski Salgado Koyonos CORR JOA JOA JOA Journal JOA CORR CORR 2011 2010 2011 2009 Year 2011 2007 2011 32 19 150 20of Pts # 104 20 136 Marculescu Choi Azzam Deirmengian Odum Bradbury Silva Zmistowski Salgado Segawa Marculescu Azzam Wasielewski Deirmengian Bradbury Kramhoft Silva Salgado Teeny Segawa Marculescu Schoifet Wasielewski Deirmengian Kramhoft Silva Teeny Segawa Schoifet Wasielewski Clin ID CORR JOA CORR JOA JOA CORR JOA CORR JBJS Clin ID JOA CORR JOA CORR CORR JOA JBJS Clin ID JBJS JOA CORR JOA CORR JOA JBJS JBJS JOA 2006 2011 2010 2003 2011 2009 2002 2011 2007 1999 2006 2010 1996 2003 2009 1994 2002 2007 1990 1999 2006 1990 1996 2003 1994 2002 1990 1999 1990 1996 99 32 19 31 150 20 530 104 20 10 99 19 10 31 20 27 530 20 21 10 99 31 10 31 27 530 21 10 31 10 Kramhoft JOA 1994 27 Teeny JOA 1990 21 4 yrs 29% Schoifet JBJS 1990 31 3 yrs 23% Results 36 mos FU 54 mos 36 mos 5.7 yrs Min 2 yrs FU 54 mos 2 yrs 36 5.7 mos yrs 4 yrs Min 2 yrs 3.7 yrs 2 yrs 5.7 yrs 32 months 4 yrs Min 2 yrs 4 yrs 3.7 yrs 2 yrs 3 32 months 4 yrs 4 yrs 3.7 yrs 3 yrs 32 months 31% 31% Success GN = 70% 35% MSSA = 33% 31% 44% 31% 16% Success GN = 70% 33% 35% MSSA = 33% 60% 31% 44% 35% 31% 16% 33% GN 33%= 70% MSSA 50% = 33% 60% 44% 75% 35% 16% 19% 33% 33% 29% 50% 60% 23% 75% 35% 19% 33% 29% 50% 23% 75% 19% Results Results Results Success is ~ 60% in selected patients Range of 19% - 83% Success is ~ 60% in selected patients Range of 19% - 83% Success is ~ 60% in selected patients Range of 19% - 83% Case 4 56 YOM, 4 Yrs s/p R TKR, 7 Days Pain H/o Kidney CaseTransplant 4 ESR 67 56 YOM, 4 mm/hr Yrs s/p R TKR, 7 Days Pain H/o Kidney CRP 91 mg/L CaseTransplant 4 WBC 48,494 ESR 67 56 YOM, 4 mm/hr Yrs s/p R TKR, 7 Days Pain 86% CRP 91PMNs mg/L H/o Kidney Transplant Cx: WBC 48,494 ESR 67MRSA mm/hr 86% PMNs CRP 91 mg/L Cx: MRSA WBC 48,494 86% PMNs Cx: MRSA First Annual AAHKS Spring Meeting | 71 23 23 Symposium II, Periprosthetic Joint Infection Case 4 52 YOM, 7 Days of Pain, Transplant, MRSA Case 4 52 YOM, 7 Days of Pain, Transplant, MRSA 52 YOM, 7 Preop Case 4 PMH: Kidney Transplant Immunosuppressed Days of Cx:Pain, MRSA Transplant, PMH: Kidney Transplant Immunosuppressed Cx: MRSA PMH: Kidney Transplant Immunosuppressed Cx: MRSA MRSA Preop Preop Risk Factors for Failure I&D with Component Retention Risk Factors for Failure I&D with Component Retention Risk Factors for Failure Organism Other Host I&D with Component Retention Host Organism Other Host Organism Other * Vilchez et al. Clin Microbiol Infect. 2011 * Theis et al. ANZ J Surg. 2007 * Berbari et al. Clin ID. 2006 * Vilchez et al. Clin Microbiol Infect. 2011 * Theis et al. ANZ J Surg. 2007 * Berbari et al. Clin ID. 2006 * Vilchez et al. Clin Microbiol Infect. 2011 * Theis et al. ANZ J Surg. 2007 * Berbari et al. Clin ID. 2006 Risk Factors for Failure I&DFactors with Component Risk forRetention Failure Host I&D with Component Retention Risk Factors for Failure Non-Modifiable Modifiable Host I&D with Component Retention Non-Modifiable Host Age Immunocompromised DM Modifiable Malnourished RA Non-Modifiable Age Immunocompromised Modifiable * Vilchez et al. Clin Microbiol Infect. 2011 DM Malnourished RA Age * Vilchez et al. Clin Microbiol Infect. 2011 DM RA * Theis et Malnourished al. ANZ J Surg. 2007 Immunocompromised * Theis et al. ANZ J Surg. 2007 * Berbari et al. Clin ID. 2006 * Berbari et al. Clin ID. 2006 * Vilchez et al. Clin Microbiol Infect. 2011 * Theis et al. ANZ J Surg. 2007 * Berbari et al. Clin ID. 2006 First Annual AAHKS Spring Meeting | 72 24 24 Symposium II, Periprosthetic Joint Infection Risk Factors for Failure I&D with Component Retention Risk Factors for Failure I&D with Component Organism Retention Risk Factors for Failure I&D with Component Organism Retention S. aureus Resistant S. aureus Organism MRSA Resistant MRSE S. aureus MRSA * Vilchez etResistant al. Clin MicrobiolMRSE Infect. 2011 * Theis et al. ANZ J Surg. 2007 * Berbari et al. Clin ID. 2006 * Parvizi et al. CORR. 2009 * Vilchez et al. Clin MicrobiolMRSE Infect. 2011 MRSA * Theis et al. ANZ J Surg. 2007 * Berbari et al. Clin ID. 2006 * Parvizi et al. CORR. 2009 * Vilchez et al. Clin Microbiol Infect. 2011 * Theis et al. ANZ J Surg. 2007 * Berbari et al. Clin ID. 2006 * Parvizi et al. CORR. 2009 Risk Factors for Failure I&DFactors with Component Risk forRetention Failure Other I&D with Component Retention Risk Factors for Failure Wound Other Sinus > 2 Weeks I&D Drainage with Component Tract Retention Loosening > 2 Weeks Wound Other Drainage > 2 Weeks Wound Drainage Sinus Tract Loosening Sinus Tract Loosening * Vilchez et al. Clin Microbiol Infect. 2011 * Theis et al. ANZ J Surg. 2007 * Berbari et al. Clin ID. 2006 * Vilchez et al. Clin Microbiol Infect. 2011 * Theis et al. ANZ J Surg. 2007 * Berbari et al. Clin ID. 2006 * Vilchez et al. Clin Microbiol Infect. 2011 * Theis et al. ANZ J Surg. 2007 * Berbari et al. Clin ID. 2006 Case 4 56 YOM, 4 Yrs s/p R TKR, 7 Days Pain H/o Kidney CaseTransplant 4 56 YOM, 4 mm/hr Yrs s/p R TKR, 7 Days Pain ESR 67 H/o Kidney CRP 91 mg/L CaseTransplant 4 WBC 48,494 ESR 67 mm/hr 56 YOM, 4 Yrs s/p R TKR, 7 Days Pain 86% CRP 91PMNs mg/L H/o Kidney Transplant Cx: WBC 48,494 ESR 67MRSA mm/hr 86% CRP 91PMNs mg/L Cx: MRSA WBC 48,494 86% PMNs Cx: MRSA First Annual AAHKS Spring Meeting | 73 25 25 Symposium II, Periprosthetic Joint Infection Case 4 52 YOM, 7 Days of Pain, Transplant, MRSA Case 4 52 YOM, 7 Days of Pain, Transplant, MRSA 52 YOM, 7 Preop Preop Case 4 PMH: Kidney Transplant Immunosuppressed Days of Cx:Pain, MRSA Transplant, MRSA PMH: Kidney Transplant Immunosuppressed Two-Stage Exchange with Cx: MRSA Articulating Spacer PMH:Kidney Transplant IV Vancomycin Immunosuppressed Two-Stage Exchange with Cx: MRSA Spacer Articulating Spacer IV Vancomycin Two-Stage Exchange with Articulating Spacer IV Vancomycin Spacer Spacer Preop Summary • Indications • Acute postoperative infection (<4 weeks) Summary • Late acute hematogenous infection (<2 weeks) • Indications • Acute postoperative infection (<4 weeks) • Timing Summary Late acute hematogenous •• Most organisms < 2 weeksinfection (<2 weeks) • Indications • S. aureus 48 hours • Acute postoperative infection (<4 weeks) • Timing Late acute hematogenous infection (<2 weeks) •• Most organisms 2 abx weeks • Aggressive I&D with<IV (6 wks) ± PO abx • S. aureus 48 hours • Timing •• Success ~60% if without risk factors • Mostinorganisms 2 abx weeks Aggressive I&D with<IV (6 wks) ± PO abx • S. aureus 48 hours •• Success in ~60% if without risk factors Aggressive I&D with IV abx (6 wks) ± PO abx • Success in ~60% if without risk factors Thank You Thank You Thank You First Annual AAHKS Spring Meeting | 74 26 26 Symposium II, Periprosthetic Joint Infection AAHKS2016SpringMeeting PeriprostheticJointInfectionSymposium RemovalofImplants:OneStageorTwo? GregoryG.Polkowski,MD,MSc VanderbiltOrthopaedicInstitute Withtheincreasingburdenofperiprostheticjointinfections(PJI)expectedtoincreaseinthecoming decades,itisimperativefortheorthopaedisttobewell-versedinthesurgicalmanagementofPJI.While indicationsfordebridementwithcomponentretentionhavebeenrecognized,inmanycasesremovalof implantsisessentialforinfectioneradication.FormostsurgeonsintheUnitedStates,thegoldstandard fortreatmentofchronicandantibiotic-resistantcasesofPJIiswithatwo-stageexchange.However, orthopaedistsontheglobalstagehaveemployedone-stageproceduresforthemanagementofchronic PJIundercertaincircumstancesandhavefoundsimilaroutcomecomparedwithtwo-stageprocedures inmanycaseseries.Inthissymposiumwewilladdresssomeoftheindicationsandcontraindications betweenone-stageandtwostagetreatmentforPJI. InJuly,2013,undertheorganizationalassistanceoftheMusculoskeletalInfectionSociety,an internationalcohortoforthopedicsurgeons,infectiousdiseasemedicalspecialists,radiologists,and basicscientistswithaninterestinPJIgatheredforthe"InternationalConsensusMeetingon PeriprostheticJointInfection"inPhiladelphia,PA,USA.TheProceedingsfromtheInternational ConsensusMeetingwerepublished1andareavailableonthewebsiteoftheMSIS(http://www.msisna.org/international-consensus/).ThemethodologyhasbeenpublishedelThefollowingcriteriaand considerationsforwhenone-stageandtwo-stagetreatmentforPJIareappropriatearelargelytaken fromtheopinionsoftheworkgroupasdescribedinthatmeeting. Definitions: Onestageexchange:AonestageexchangeisdefinedasthesurgicaltreatmentPJIinwhichthesurgeon performscompleteremovalofinfectedcomponents,cement,andassociatedhardwarefromthe infectedjoint,followedbyanextensivesurgicaldebridementofthesynoviumandanyinfectedtissue. Thisisfollowedbyirrigation,partialwoundclosure,re-preppingtheextremity,newdrapesandclean instruments,andperformanceofdefinitiverevisionprocedureinthesamesetting. Two-stageexchange:Atwo-stageexchangeisdefinedasthesurgicaltreatmentPJIinwhichthesurgeon performscompleteremovalofinfectedcomponents,cement,andassociatedhardwarefromthe infectedjoint,followedbyanextensivesurgicaldebridementofthesynoviumandanyinfectedtissue. Thisisfollowedbyirrigationandwoundclosure,usuallyafterplacementofatemporaryantibiotic impregnatedspacerdeviceformaintenanceofthejointspaceandlocaldeliveryofantibiotics.A prolongedcourseofintravenousantibioticsensues,whichisfollowedbyanantibiotic“holiday”inwhich thepatientismonitoredforserologicandclinicalsignsofinfectionrecurrence.Onceinfection eradicationisdeclared,thepatientisbroughtbacktotheoperatingroomforthesecondstage procedure:removalofthetemporaryspacer,anddefinitiverevisionjointreplacementsurgerywithreimplantationofcomponents. Situations/Conditionsinwhichone-stagetreatmentforPJImaybeconsidered: 1. PJIwithknownbacterialspecies(i.e.,positivecultureandantibioticsensitivitiesavailable). 2. Antibioticavailableforsystemictreatment. 3. Ifpossible,antibioticavailableforcementationofcomponentstodeliverlocalantibiotics. First Annual AAHKS Spring Meeting | 75 Symposium II, Periprosthetic Joint Infection 4. Evolvingindication:Thereisgrowingsupportfortheuseofone-stageexchangeproceduresfor earlypost-opcementlessTHAPJI2. Contra-indicationstoconsideringone-stagetreatmentofPJI: 1. Patientwithsystemicsepsis. 2. Unknownorganism,orinfectiousagentunknown(culturenegativeinfection). 3. Presenceofsinustract. 4. Severesofttissuedamagethatmayrequireflapcoverage. Situations/Conditionsinwhichtwo-stagetreatmentforPJImaybeconsidered: 1. Anyofthecriteriapresentfortreatmentofstageone(anypatientwhoisacandidateforaonestagetreatmentisalsoacandidatefortwo-stagetreatment). 2. Patientswithsystemicsepsis. 3. Infectionwithunknownorganism,orculture-negativeinfection. 4. Preoperativeculturespositiveforhigh-virulenceordrug-resistantorganisms. 5. Severesofttissuecompromise,eitherintheformofachronicsinustractorpoorcoveragethat mayrequireadditionalflapprocedure. Otherconsiderations: 1. Thetoutedsuccessoftheone-stageprocessintheinternationalcommunityfrequentlyinvolved re-implantationwithcementedcomponents,inwhichhighdosesofantibioticsdirectedatthe infectingorganismwereincludedinthefinalreconstructionconstruct. 2. Mostadvocatesforone-stagetreatmentofPJIsupportperformanceoffairlyaggressivesurgical debridement,andcitemuchoftheirsuccessonthisstageoftheprocedure. 3. CurrentlytheoperativeimplantchoicesandsurgicaltechniquesintheUSdifferenoughfrom internationalcommunitysuchthatthetwo-stagetreatmentisstillthemostcommontechnique employedintheUS. References: 1. Cats-BarilW,GehrkeT,HuffK,KendoffD,MaltenfortM,ParviziJ.InternationalConsensuson PeriprostheticJointInfection:DescriptionoftheConsensusProcess.ClinOrthopRelatRes. 2013Dec;471(12):4065-75. 2. HansenE,TetreaultM,ZmistowskiB,DellaValleCJ,ParviziJ,HaddadFS,HozackWJ.Outcome ofone-stagecementlessexchangeforacutepostoperativeperiprosthetichipinfection.Clin OrthopRelatRes.2013Oct;471(10):3213-22. First Annual AAHKS Spring Meeting | 76 Breakout 3, UKA Breakout 3, Unicondylar Knee Replacement David F. Dalury M.D. Unicondylar knee replacements, the replacement of an isolated part of the knee joint, have a long history in knee surgery. The basic concept is to replace what is worn and retain the more normal native tissue. There are many theoretical advantages of this approach when compared to a TKR: less bone resection, a quicker and easier recovery, better knee kinematics, an easier revision if needed as well as a more cost effective way to manage isolated knee arthritis. Traditionally, the typical Uni candidate was considered to be an elderly, sedentary, female with good range of motion and an intact ACL. However, over time there have been many advances in implant and instrument design, improvements in surgical technique and now, into our 4th decade of Uni use, longer follow up that has given more confidence to cautiously expand the utilization of Unis. Use restrictions such as age, weight, activity level and status of the remaining compartments have all been challenged. Long term results of Unis now rival those of TKRs in many publications and patients who have both a Uni and a TKR routinely prefer their Unis. Typically, Unis were utilized in the medial femoral-tibial articulation but there has been a successful expansion of Unis into the lateral compartment as well as the patello-femoral joint. Not all designs have equal outcomes and joint registries have been helpful in detailing that certain devices have superior outcomes compared with others. Several controversies still exist such as, how much pre-op deformity is acceptable; how much disease in other compartments can be tolerated and can Unis be used if the ACL is deficient? New advances in Uni surgery including concepts such as computer and haptic use, cementless fixation and improvements in technique and implant design raise the potential for improved outcomes. The availability of more long term data supporting Uni’s use along with an increasingly internet savvy patient population raises the probability of an increase in popularity of Unis. References: Biswas D, Pack B, Van Thiel G, Berger RA, Della Valle C. Medial Unicompartmental Arthroplasty in Patients Less Than 55 Years Old. J Arthroplasty, 29: 101-5, 2014. Brown NM, Sheth N, Davis K, Berend ME, Lombardi AV, Berend KR, Della Valle CJ. Total Knee Arthroplasty Has Higher Post-Operative Morbidity than Unicompartmental Knee Arthroplasty. J Arthroplasty. 27 (8 Suppl), 86-90, 2012. Foran J, Brown NB, Berger RA, Della Valle CJ, Galante JO. Long Term Survivorship and Failure Modes of UKA. Clin Orthop Relat Res. 471, 102-8, 2013. Newman J, Pydisetty RV, Ackroyd C. Unicompartmental or total knee replacement: the 15-year results of a prospective randomised controlled trial. J Bone Joint Surg Br. 2009 Jan;91(1):52-7 First Annual AAHKS Spring Meeting | 77 Breakout 3, UKA Parvizi J, Nunley RM, Berend KR, Lombardi AV Jr, Ruh EL, Clohisy JC, Hamilton WG, Della Valle CJ, Barrack RL. High level of residual symptoms in young patients after total knee arthroplasty. Clin Orthop Relat Res. 2014 Jan;472(1):133-7. Berend KR, Berend ME, Dalury DF, Argenson JN, Dodd CA, Scott RD. Consensus Statement on Indications and Contraindications for Medial Unicompartmental KneeArthroplasty. J Surg Orthop Adv. 2015 Winter;24(4):252-6. Dalury DF, Fisher DA, Adams MJ, Gonzales RA. Unicompartmental knee arthroplasty compares favorably to total knee arthroplasty in the same patient. Orthopedics. 2009 Apr;32(4). First Annual AAHKS Spring Meeting | 78 Breakout 3, Non-arthroplasty Hip Breakout 3, Non-Arthroplasty Hip John C. Clohisy, M.D. Daniel C. and Betty B. Viehmann Distinguished Professor of Orthopaedic Surgery Director, Adolescent and Young Adult Hip Service Chief Adult Reconstructive Surgery Washington University School of Medicine St. Louis, MO Objectives: 1) Review concepts of patient evaluation and selection for joint preservation surgery 2) Present current surgical options in joint preservation hip surgery Introduction: Do we really need it? YES. Should we try to avoid it? YES, if better alternative. How about alternatives? YES. Early diagnosis and hip joint preservation surgery. Total hip arthroplasty (THA) is an effective surgical treatment for endstage OA of the hip, yet these procedures can have limitations in highly active, young patients. In these patients, high-level performance and long-term survivorship of the implant is the desired result. Nevertheless, bearing surface wear, osteolysis, aseptic loosening, thigh pain, dislocation, squeaking, mechanical failure, metallosis and activity limitation are some of the potential drawbacks of prosthetic joint reconstruction. As a result, the concepts of early diagnosis and hip joint preservation surgery have gained attention. The potential benefits of joint preservation procedures include symptom relief, enhanced activity, and prolonged survivorship of the natural hip joint. To obtain these goals the surgeon must be familiar with the etiologies of hip dysfunction, patient selection criteria, surgical options and anticipated clinical outcomes. These topics will be discussed. 1) Etiology of premature hip joint failure? Recent analysis of structural abnormalities associated with endstage hip disease at young age (<50 years) demonstrated the following underlying etiologies: Osteoarthritis- 56% Osteonecrosis- 30% other- 14% The OA subgroup etiology make-up included: 45% DDH 45% FAI (including Perthes and SCFE) 10% other or not able to classify Therefore, mechanical hip disease (DDH, FAI, Perthes, SCFE) should be targeted by early diagnosis and preventive treatment initiatives. 2) Concepts of patient evaluation and selection for joint preservation surgery Patient selection is a critical component of joint preservation hip surgery. Evaluation of the patient should focus on the following questions. a) What is the specific etiology of hip dysfunction (structural anatomy, associated soft tissue disease, associated muscle dysfunction)? b) Is the hip disorder surgically correctable? c) Is the hip joint adequately healthy to respond to joint preservation surgery? d) Are there significant patient-specific factors (age, BMI, activity level, etc) that will impact treatment decision-making? First Annual AAHKS Spring Meeting | 79 Breakout 3, Non-arthroplasty Hip e) What is the risk-benefit profile for the patient (compared to THA/SRA)? f) What are the expected outcomes? 3) Current surgical options in joint preservation hip surgery DDH FAI a. Acetabular reorientation (PAO) b. Proximal femoral osteotomy (PFO) c. Combined PAO/PFO a. Anteversion PAO b. surgical hip dislocation c. hip scope/limited open d. hip arthroscopy Key Points: 1) Premature hip joint osteoarthritis is commonly (90%) associated with underlying structural hip disease. 2) Careful patient selection is an important component of hip joint preservation surgery. 3) A variety of surgical techniques are required to provide comprehensive hip preservation surgical care. 4) Clinical outcomes of joint preservation surgery are good to excellent in 80% of patients and should improve with continued refinement of patient selection criteria and surgical technique. References: 1. Clohisy JC, St. John LC, Schutz AL. Surgical Treatment of Femoroacetabular Impingement: A Systematic Review of the Literature. Clin Orthop Relat Res 468(2):255-64, 2010. PMCID: PMC2806979. 2. Clohisy JC, Schutz AL, St. John LC, Schoenecker PL, Wright RW. Periacetabular Osteotomy: A Systematic Literature Review. Clin Orthop Relat Res 467(8):2041-2052, 2009. PMCID: PMC2706361 3. Clohisy JC, Beaule PE, O’Malley A, Safran MR, Schoenecker P. AOA Symposium. Hip Disease in the Young Adult: Current Concepts of Etiology and Surgical Treatment. J Bone Joint Surg 90(10):2267 - 2281, 2008. 4. Ganz R, Gill TJ, Gautier E, Ganz K, Krugel N, Berlemann U. Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br 83(8):1119-24, 2001. 5. Ganz R, Klaue K, Vinh TS, Mast JW. A new periacetabular osteotomy for the treatment of hip dysplasias. Technique and preliminary results. Clin Orthop Relat Res (232):26-36, 1988. 6. Nwachukwu BU, Rebolledo BJ, McCormick F, Rosas S, HJarris JD, Kelly BT. Arthroscopic Versus Open Treatment of Femoroacetabualr Impingement: A Systematic Review of Medium- to LongTerm Outcomes. Am J Sports Med [Epub ahead of print June 9, 2015]. 7. Steppacher SD, Tannast M, Ganz R, Siebenrock KA. Mean 20-year followup of Bernese periacetabular osteotomy. Clin Orthop Relat Res Jul;466(7):1633-44, 2008. 8. Matheney T, Kim YJ, Zurakowski D, Matero C, Millis M. Intermediate to long-term results following the Bernese periacetabular osteotomy and predictors of clinical outcome. J Bone Joint Surg Am Sep;91(9):2113-23, 2009. 9. Troelsen A, Elmengaard B, Soballe K. Medium-Term Outcome of Periacetabular Osteotomy and Predictors of Conversion to Total Hip Replacement. J Bone Joint Surg 91(9): 2169-2179, 2009. First Annual AAHKS Spring Meeting | 80 Symposium III, Preparing for the Transition to Value Based Healthcare Symposium III, Preparing for the Transition to Value Based Healthcare Kevin J. Bozic, MD, MBA Professor and Inaugural Chair Department of Surgery and Perioperative Care Dell Medical School at the University of Texas at Austin Mark I. Froimson, MD, MBA President, Euclid Hospital Cleveland Clinic Challenges Facing the US Healthcare System 1) Emphasis on healthcare, not health 2) Fragmented delivery, payment systems 3) Medical error/defensive medicine 4) “Medical arms race” 5) Moral hazard Lack of Competition Based on Value 1) Patient choice and competition for patients are powerful forces to encourage continuous improvement in value and restructuring of care 2) Today’s competition in health care is not aligned with value since the financial success of system participants is not tied to patient success Value-Based Healthcare Primary Goal: Improve Value 1) Value can be defined as patient centered health outcomes per health dollar expended 2) Outcome = Quality (e.g. clinical outcome, safety) + Service (e.g. satisfaction, convenience, communication) Keys to Success 1) Empower stakeholders with better information a) Tools for efficient, real time data collection b) Transparency of cost, quality (actionable, easy to understand/use, risk adjusted) 2) Reorganize delivery, payment system around patient-centered value (not volume) a) Align stakeholder incentives around value b) Increased accountability for providers, patients 3) Leadership from the medical profession Empowering Patients to Be Better Consumers 1) When rating factors that influenced their selection of provider for elective total joint arthroplasty, patients chose Physician Manner and Physician Quality as the two most important factors [1] 2) Patients also on average strongly agreed with statements that their choice of surgeon would impact their outcome and that there are big differences in the quality of care among different surgeons [1] Quality Measures 1) Need to measure outcomes in order to track improvement 2) Define quality measures for your practice, focusing on outcomes that matter to patients 3) Develop infrastructure to measure outcomes (e.g. clinical data registries) First Annual AAHKS Spring Meeting | 81 Symposium III, Preparing for the Transition to Value Based Healthcare 4) Use outcomes data for continuous quality improvement, public reporting, value-based payment a) Increase transparency of cost, outcomes b) “If I am through learning, I am through.” – John Wooden Reorganizing the delivery system around value 1) Existing model: care is organized by specialty and discrete service 2) Model organized around value: a. Staffed by dedicated multidisciplinary team b. Joint accountability for outcomes and costs c. Shared information platform d. Single administrative & scheduling structure e. Services co-located to the extent possible 3) Train, engage surgeons in Population Health Management a. Define appropriateness of diagnostic, therapeutic interventions b. “Downstreaming” care c. Patient Engagement d. Patient Activation i. A measurement of an individual’s propensity to engage in positive health behavior [2] ii. Patients with higher preoperative activation had better patient-reported outcomes after TJA [3] e. Shared decision making 4) Develop patient-centric, disease-based Integrated Practice Units Role of the Payment System in Improving Value 1) In order to implement value driven healthcare, must identify and eliminate or reduce non-value added care. a. Unnecessary care b. Inappropriate variation in care c. Avoidable complications/readmissions/reoperations d. Excess cost due to variation in price Principles for Successful Implementation of Value-Based Payment 1) Assess culture, operational readiness a. Risk tolerance b. Data systems, sharing c. Trust, alignment d. Leadership 2) Identify clinical, administrative champions 3) Define the episode for which you accept risk 4) Define performance metrics, gainsharing models 5) Understand care from the patient’s perspective 6) Measure the actual costs of care delivery (e.g. using time-drive activity-based costing) 7) Use data to identify opportunities for improvement 8) Redesign care to improve quality, reduce cost 9) Price/market episode of care program 10) Evaluate results, iterate First Annual AAHKS Spring Meeting | 82 Symposium III, Preparing for the Transition to Value Based Healthcare Preparing for Payment System Transformation 1) More granular cost, outcomes measurement 2) Greater integration/alignment across providers 3) Experiment with new payment methodologies What Do We Have To Lose? 1) Current fee-for-service (RVU, DRG) system: a. Set up such that as you become a better clinician (fewer complications, etc), your reimbursement decreases b. NO consideration of outcomes or value 2) Value based approaches require an up-front investment but can lead to improved provider financial performance over time First Annual AAHKS Spring Meeting | 83 Breakout 4, Revision Total Hip Arthroplasty (THA): Simple to Complex Breakout 4, Revision Total Hip Arthroplasty (THA): Simple to Complex S. J. MacDonald, MD, FRCSC Correspondence: Dr. S. J. MacDonald London Health Sciences Centre, University Campus 339 Windermere Rd. London, ON N6A 5A5 Phone: 519-663-3689 Fax: 519-663-3096 Email: [email protected] Professor & Chairman of Orthopaedic Surgery, University of Western Ontario, London, Ontario, Canada First Annual AAHKS Spring Meeting | 84 Breakout 4, Revision Total Hip Arthroplasty (THA): Simple to Complex 2 Surgical Exposures Introduction There are multiple approaches to the hip in primary total hip arthroplasty (anterior, antero-lateral, transgluteal, transtrochanteric, posterolateral, multiple miniincision approaches), however in revision total hip arthroplasty there are only 3 that are employed routinely (transgluteal, transtrochanteric, posterolateral). The advantages and disadvantages of the approaches will be discussed in this lecture as will the extensile approaches (femoral osteotomies, controlled perforation, scaphoid window, retroperitoneal approach) performed in revision procedures. Revision Approaches: Advantages/Disadvantages Approach Direct Lateral Advantages Disadvantages i Dislocation Rate Extensile exposure g Superior gluteal nerve injury Can be extensile Notes Longer period of postoperative limp Poor posterior column access Transtrochanteric Extensile Allows trochanteric advancement Posterolateral Extensile h Risk of trochanteric nonunion h Risk of dislocation Posterior column access Preservation of abductors Specialized Approaches 1) Extended Trochanteric Osteotomy • can be performed with either a posterolateral1 or transgluteal2 approach • indications - R/O cement, broken implant, ingrown stem - proximal femoral varus remodeling has occurred preventing straight shot at femoral canal - previous trochanteric malunion - significant trochanteric osteolysis precluding trochanteric osteotomy First Annual AAHKS Spring Meeting | 85 Breakout 4, Revision Total Hip Arthroplasty (THA): Simple to Complex 3 2) Controlled Perforation3 • indications – cement removal • technique - 7 mm anterior femoral perforation is created with a high-speed burr - additional perforations, depending on length of cement mantle, performed 5 cm apart - revision femoral component must bypass most distal perforation by at least 2 component diameters 3) Scaphoid Window4 • indications – cement removal • advantages – allows greater access to femoral canal • disadvantages – devascularized fragment may be created 4) Retroperitoneal Approach5 • indications - intrapelvic migration of components/cement - minimize risk of injury to neurovascular structures References 1. Younger TI, Bradford MS, Magnus RE, Paprosky WG: Extended proximal femoral osteotomy: A new technique for revision arthroplasty. J Arthroplasty 1995;10:329-338. 2. MacDonald SJ, Cole C, Guerin J, Rorabeck CH, Bourne RB, McCalden RW: Extended trochanteric osteotomy via the direct lateral approach in revision hip arthroplasty. Clin Orthop Rel Res 2003;417:210-216. 3. Head WC, Montgomery WK, Emerson RH: perforations. Instr Course Lect 1999;48:13-17. 4. Kerry RM, Masri BA, Garbuz DS, Duncan CP: The vascularized scaphoid window for access to the femoral canal in revision total hip arthroplasty. Instr Course Lect 1999;48:9-11. 5. Rorabeck CH, Partington PF: Retroperitoneal exposure in revision total hip arthroplasty. Instr Course Lect 1999;48:27-36. Vastus slide and controlled First Annual AAHKS Spring Meeting | 86 Breakout 4, Revision Total Hip Arthroplasty (THA): Simple to Complex 4 Acetabular Osteolysis: When to Graft/Exchange Polyethylene and When to Operate I. Introduction - - II. Assessment of Osteolysis - III. Modular acetabular components in THA have been the component of choice for more than three decades in North America While achieving solid bone ingrowth of these components has proved reproducible with excellent long-term clinical track records, the polyethylene has been the weak link in the system Polyethylene wear and osteolysis are seen frequently with long-term followup The current generation of highly cross-linked polyethylenes will hopefully reduce the incidence of these complications, but millions of modular components with non highly cross-linked polyethylenes were performed, and the issues related to their failure modes, and indications for revision will be important clinical issues for decades to come While there are occasional exceptions, in general once osteolysis begins to develop it will be progressive and can lead to massive bone loss and acetabular component loosening Strategies to minimize the complications of massive osteolysis include routine radiographic review of THA patients (q1-2 years), more frequent reviews once the presence of osteolysis is established, and earlier rather than later surgical intervention once progression is seen In general, plain radiographs tend to underestimate the amount of true bone loss that is present Routine imaging may include: i) AP Pelvis and AP and lateral hip views ii) Judet views iii) CT scan Fundamental Questions to Answer I) When should I operate? i) symptomatic patient (however <50% of patients with osteolysis will have symptoms) ii) asymptomatic patient with large lesion potentially compromising component fixation iii) asymptomatic patient with documented progression of osteolysis on serial radiographs First Annual AAHKS Spring Meeting | 87 Breakout 4, Revision Total Hip Arthroplasty (THA): Simple to Complex 5 II) Why has the component failed? i) specific polyethylene issues ii) cup design issues iii) technical issues iv) related to time in vivo v) r/o infection (especially if see early osteolysis) III) Is the acetabular component solid or loose? i) often difficult to assess preoperatively - if 50% of shell circumference has osteolysis on AP or lateral xray, have a suspicion for possible fixation compromise ii) may be an intraoperative decision – judiciously check acetabular component fixation intraoperatively IV) If the acetabular component is solid, can I retain it and either do a liner exchange or cement in a new polyethylene? A) Conditions necessary for a liner exchange: i) Satisfactory component position ii) Intact locking mechanism iii) Undamaged acetabular component iv) Liner of adequate thickness v) Acceptable track records of components vi) Ability to achieve intraoperative hip stability vii) Availability of polyethylene of appropriate shelf life and sterilization technique B) Conditions necessary for cementing a liner i) Satisfactory component position ii) Adequate acetabular component internal diameter for cement mantle and polyethylene thickness iii) match age/demands of patient IV. Technical Considerations A) Liner Exchange - Remove liner - Assess component stability - Assess locking mechanism - Graft osteolytic lesions either directly, or via a trapdoor technique in the ilium (note – contraindicated if this compromises the lateral buttress of the pelvis) - Always be prepared for a full revision with extraction devices and revision acetabular components and inserts and bone graft B) Cementing a liner - The acetabular component needs to be textured by design or by technique - The polyethylene component needs to be textured by design or by technique - The cement mantle should be 2-4 mm thick - Avoid over-sized and uncontained polyethylene - Performed correctly, cemented liners are equal to modular liners for pushout strength First Annual AAHKS Spring Meeting | 88 Breakout 4, Revision Total Hip Arthroplasty (THA): Simple to Complex 6 C) Bone grafting - No data to suggest what technique or material is superior - Cancellous chips probably most frequently used - BMPs have been tried by this author as they are osteoinductive, but there is a significant cost associated with them V. Results and Complications - at this point there are only short-term reports in the literature - the largest series is from the Norwegian Arthroplasty Register which demonstrated that isolated liner revisions (318 cases) had a higher re-revision rate than those cases that underwent revision of their ingrown sockets (398 cases) - most frequent complication has been postoperative dislocation - instability complication may be less with direct lateral approach References Boucher HR, Lynch C, Young AM, Engh CA, Engh C. Dislocation after polyethylene liner exchange in total hip arthroplasty. J Arth, 18:654-657, 2003 Claus AM, Engh CA, Sychterz CJ, Xenos JS, Orishimo KF, Engh C. Radiographic definition of pelvic osteolysis following total hip arthroplasty. J Bone Joint Surg (Am), 85:1519-1526, 2003 Lie SA, Hallan G, Furnes O, Havelin LI, Engesaeter LB. Isolated acetabular liner exchange compared with complete acetabular component revision in revision of primary uncemented acetabular components: a study of 1649 revisions from the Norwegian Arthroplasty Register. J Bone Joint Surg (Br), 89:591-5954, 2007 Lombardi AV Jr, Berend KR. Isolated acetabular liner exchange. J Am Acad Orthop Surg. 16:243-248, 2008 Maloney WJ, Herzwurm P, Paprosky W, Rubash HE, Engh CA. Treatment of pelvic osteolysis associated with stable acetabular component inserted without cement as part of a total hip replacement. J Bone Joint Surg (Am). 79:1628-1634, 1997. Maloney WJ, Paprosky W, Engh CA, Rubash H. Surgical treatment of pelvic osteolysis. Clin Orthop, 393: 78-84, 2001 Mehin R, Yuan X, Haydon C, Rorabeck CH, Bourne RB, McCalden RW, MacDonald SJ. Retroacetabular osteolysis: when to operate? Clin Orthop, 428: 247-255, 2004. Mehin R, MacDonald SJ. The value of anteroposterior pelvic radiographs for evaluating pelvic osteolysis. Clin Orthop, 457: 260-261, 2007 First Annual AAHKS Spring Meeting | 89 Breakout 4, Revision Total Hip Arthroplasty (THA): Simple to Complex 7 Naudie DDR, Engh CA. Surgical management of polyethylene wear and pelvic osteolysis with modular uncemented acetabular components. J Arth, 19:124-129, 2004. O’Brien JJ, Burnett RS, Yuan X, McCalden RW, MacDonald SJ, Bourne RB, Rorabeck CH. Isolated liner exchange in revision total hip arthroplasty. Clinical results using the direct lateral surgical approach. J Arth, 19(4): 414-423, 2004. Restrepo C, Ghanem E, Houssock C, Austin M, Parvizi J, Hozack WJ. Isolated polyethylene exchange versus acetabular revision for polyethylene wear. Clin Orthop, 467:194-198, 2009 Rubash HE, Sinha RK, Paprosky W, Engh CA, Maloney WJ. A new classification system for the management of acetabular osteolysis after total hip arthroplasty. Instr Course Lect, 48:37-42, 1999 Stulberg D, Wixson RL, Adams AD, Hendrix RW, Bernfield JB. Monitoring pelvic osteolysis following total hip replacement surgery: an algorithm for surveillance. J Bone Joint Surg, 116-122, 2002. First Annual AAHKS Spring Meeting | 90 Breakout 4, Revision Total Hip Arthroplasty (THA): Simple to Complex 8 THE HIP IS NOT STABLE Introduction Hip instability continues to be a significant complication following total hip arthroplasty that is devastating for the patient and frustrating for the arthroplasty surgeon. Current quoted incidence in the literature remains at approximately 1%. While dislocations cannot be eliminated, an algorithmic approach to assessing and managing intraoperative instability will assist the surgeon in addressing the issues intraoperatively and minimize the probability of postoperative instability. Preoperative Assessment Minimizing the risk of intraoperative and postoperative instability actually begins with the preoperative assessment and identifying the patient at risk and proactively discussing this with the patient and creating a plan to minimize this event. Obviously not all patient factors are modifiable, but some are. Patients at an increased risk include: 1) Morbidly obese 2) Elderly 3) Non compliant (alcohol, substance abuse) 4) Neuromuscular disease 5) DDH First Annual AAHKS Spring Meeting | 91 Breakout 4, Revision Total Hip Arthroplasty (THA): Simple to Complex 9 Intraoperative Assessment With trials in place the surgeon begins the assessment with first confirming the leg lengths and offset, assesses component orientation and then takes the hip through a range of motion assessing for the presence of impingement.; A) Leg length and offset It is most helpful to have a reproducible methodology to determine preoperative and intraop leg length and offset. A fixed device in the pelvis, with another marker of some description on the femur, is a reliable technique. This is very valuable information in maximizing the ability to achieve a stable total hip, without the added issue of lengthening the limb B) Assess component orientation Similarly the arthroplasty surgeon should develop an intraoperative technique to assessing the orientation of both the acetabular and femoral components. There is a great range of variability in acetabular component placement and malposition increases the probability of postop dislocation. While correct acetabular component orientation is critical, minor adjustments can also be made via the use of lipped or face-changing liners. The role of these liner options is greater in revision, rather than primary, total hip arthroplasty. C) Impingement Impingement can be bone-bone, component-component or bone-component. Removal of osteophytes and correct component orientation are the keys to minimizing impingement. Impingement must be carefully assessed for and corrected with trials, or components in place. First Annual AAHKS Spring Meeting | 92 Breakout 4, Revision Total Hip Arthroplasty (THA): Simple to Complex 10 References 1. Callanan MC, Jarrett B, Bragdon CR, Zurakowski D, Rubash HE, Freiberg AA, Malchau H. The John Charnley Award: risk factors for cup malpositioning: quality improvement through a joint registry at a tertiary hospital. Clin Orthop; 2011,469:319-329. 2. Elkins JM, Daniel M, Pedersen DR, Singh B, Yack HJ, Callaghan JJ, Brown TD. Morbid obesity may increase dislocation in total hip patients: a biomechanical analysis. Clin Orthop; 2013,471:971-980. 3. Kalteis T, Sendtner E, Beverland D, Archbold PA, Hube R, Schuster T, Renkawitz T, Grifka J. The role of the transverse acetabular ligament for acetabular component orientation in total hip replacement: an analysis of acetabular component position and range of movement using navigation software. JBJS(Br);2011,93(8):1021-1026. First Annual AAHKS Spring Meeting | 93 Breakout 4, Revision Total Hip Arthroplasty (THA): Simple to Complex 11 Evaluation of the Symptomatic & Asymptomatic Metal on Metal THA The Metal on Metal Hip II. II Introduction - Metal on metal bearings, in both a total hip and resurfacing application, saw an increase in global utilization over the past several years - This peaked in 2008 in the US, with approximately 35% of bearings being hard on hard (metal on metal, or ceramic on ceramic) - Beginning in 2008, reports in the orthopaedic literature began to surface re local soft tissue reactions and hypersensitivity to metal on metal bearings - A major implant manufacturer recalled a resurfacing device in 2010 after national joint registries demonstrated higher than expected revision rates - Patients with painful metal on metal bearings presenting to the orthopaedic surgeon are a difficult diagnostic challenge - The surgeon must go back to basic principles, perform a complete history and physical exam, obtain serial radiographs and basic bloodwork (ESR,CRP) to rule out common causes of pain and determine if the pain is related to the bearing, or not The Asymptomatic MoM Arthroplasty - Patients will present for either routine followup, or because of concerns re their bearing - It is important to emphasize that at this point the vast majority of patients with a MoM bearing are indeed asymptomatic and their bearings are performing well - The surgeon must take into account: a) which specific implant are they dealing with and what is its track record b) what is the cup position c) when do perform metal ion testing d) when to perform further soft tissue imaging (MARS MRI, Ultrasound) e) when to discuss possible surgery - A simple algorithm for both painless and painful MoM Arthroplasties has been developed and is presented below First Annual AAHKS Spring Meeting | 94 Breakout 4, Revision Total Hip Arthroplasty (THA): Simple to Complex 12 III. Painful MoM THA causes not related to the bearing couple A) Extrinsic to the hip -spine (radiculopathy, stenosis) -vascular -metabolic -malignancy B) Intrinsic to the hip i) Extracapsular -iliopsoas tendonitis -trochanteric bursitis ii) Intracapsular -sepsis -loosening -thigh pain -prosthetic failure IV. Painful MoM THA causes related to the bearing couple There are now described a number of possible clinical scenarios and causes of pain that relate to the metal on metal bearing couple itself: A) Local hypersensitivity reaction without a significant soft tissue reaction B) Local hypersensitivity reaction with a significant soft tissue reaction 0 C) Impingement and soft tissue pain 2 to large head effect V. Factors related to a hypersensitivity reaction Some patients, and prosthesis, seem to be at a higher risk of developing issues following a metal on metal bearing, although our understanding of the interplay of these factors is still in evolution: A) Patient - female gender - smaller component sizes B) Implant -some implants have higher wear rates and perhaps are more prone to corrosion -large heads and monoblock shells C) Technique 0 -high cup inclination angles > 50 First Annual AAHKS Spring Meeting | 95 Breakout 4, Revision Total Hip Arthroplasty (THA): Simple to Complex 13 VI. Special tests There is ongoing confusion related to the relative value of the various special tests that patients with a painful MoM undergo. A) Metal Ions - obtaining serum, or whole blood, cobalt and chromium levels is recommended as a baseline test. However there is no established cutoff level to determine with certainty if a patient is having a hypersensitivity reaction. A 7 parts per billion cutoff has been suggested. This gives high specificity, but poor sensitivity. Metal ions therefore can be used as a clue, and one more test in the workup, but cannot be relied upon in isolation to make a diagnosis. B) MARS (Metal Artifact Reduction Sequence) MRI - a useful tool for demonstrating soft tissue involvement, but there are many painless, well functioning MoM implants that have soft tissue reactions, that don’t require a revision. In the painful MoM hip an MRI, or ultrasound, is recommended to look for soft tissue destruction or a fluid-filled periprosthetic lesion (pseudotumour). Significant soft tissue involvement is concerning and is commonly an indication for revision in the painful MoM hip C) CT imaging - can be utilized to help determine cup position and combined anteversion, however plain radiographs can give a rough estimate of this as well, so routine CT scan evaluations are not currently recommended VII. Treatment Management of the painful MoM hip is directly related to the etiology of the pain. Unique to MoM bearing is the issue of pain secondary to a local hypersensitivity reaction. All above test should be utilized to help determine the best course of action in any individual patient. The painful MoM bearing, that is demonstrating significant soft tissue involvement is a concerning scenario. Earlier revision, to prevent massive abductor damage, would seem prudent for these patients. The painful MoM bearing with no significant soft tissue changes can probably be followed and reviewed at regular intervals. If the pain persists and is felt to be secondary to a hypersensitivity reaction, then revision is really the only option, although the patient must be cautioned regarding the unpredictable nature of the pain relief. References Blumenfeld TJ, Bargar WL, Campbell PA A painful metal-on-metal total hip arthroplasty: a diagnostic dilemma. J Arthroplasty, 25(7):1168, 2010. Cobb JP, Davda K, Ahmad A, Harris SJ, Masjedi M, Hart AJ Why large-head metal-on-metal hip replacements are painful: the anatomical basis of psoas impingement on the femoral head-neck junction. J Bone Surg (Br), 93(7);881-885, 2011. Hart AJ, Sabah S, Henckel J, Lewis A, Cobb J, Sampson B, Mitchell A, Skinner JA The painful metal-on-metal hip resurfacing. First Annual AAHKS Spring Meeting | 96 J Arthroplasty, 26(1):71-76, 2011 2012 Australian National Joint registry at www.aoa.org.au/docs Breakout 4, Revision Total Hip Arthroplasty (THA): Simple to Complex 14 J Bone Surg (Br), 91;738-744, 2009. Kwon Y-M, Jacobs JJ, MacDonald SJ, Potter HG, Fehring TK, Lombardi AV Evidence-based understanding of management perils for metal-on-metal hip arthroplasty patients. J Arthroplasty, 27(8):20-25, 2012. Sabah SA, Mitchell AW, Henckel J, Sandison A, Skinner JA, Hart AJ Magnetic resonance imaging findings in painful metal-on-metal hips: a prospective study. J Arthroplasty, 26(1):71-76, 2011 2012 Australian National Joint registry at www.aoa.org.au/docs Management of the Infected THA Management of the Infected THA Defining the Problem In total hip replacement surgery, the incidence of infection has ranged from 1.6-2.6 % Defining the Problem after the advent of pre-operative antibiotics, to as low as 0.39% in high volume centres using special ORs and all precautions. Infection in the prosthesis is a significant problem In total replacement surgery,the theoutcome incidenceand of benefit infection and has hip been shown to decrease forhas theranged patient.from The1.6-2.6 serious% after the advent pre-operative as low asfor 0.39% in high opens volume complication of of infection leads toantibiotics, significanttomorbidity the patient, thecentres doors to using special ORs andasalla precautions. Infection in as thewell prosthesis is asubstantial significant costs problem further complications result of further surgery, as adding to andcare has been to decrease the outcome and benefit for the patient. The serious the of theshown patient. complication of infection leads to significant morbidity for the patient, opens the doors to further complications as a result of further surgery, as well as adding substantial costs to the care of the patient. Management of the Infected THA Defining the Problem In total hip replacement surgery, the incidence of infection has ranged from 1.6-2.6 % after the advent of pre-operative antibiotics, to as low as 0.39% in high volume centres using special ORs and all precautions. Infection in the prosthesis is a significant problem and has been shown to decrease the outcome and benefit for the patient. The serious complication of infection leads to significant morbidity for the patient, opens the doors to further complications as a result of further surgery, as well as adding substantial costs to the care of the patient. First Annual AAHKS Spring Meeting | 97 Breakout 4, Revision Total Hip Arthroplasty (THA): Simple to Complex 15 An approach to the prevention, diagnosis and treatment of infection is therefore critical to the arthroplasty reconstructive surgeon. A) Prevention I - Patient Factors The general pre-operative health of the patient is an important factor to consider. Patients with multiple comorbidities (ASA class III or more) are at higher risk for infection. While clearly some factors can’t be modified (ie, previous surgery), many others can be optimized. i) Diabetes - Patients with poor sugar control and higher HbA1C concentrations are at higher risk for infection. Glucose control should be optimized prior to surgery. Post-operatively tighter glucose control has also been shown to decrease the rate of infection and other complications, although the data is primarily from post-cardiac surgery. ii) Obesity -Controversy exists re the relative risk of obesity and deep infection post TKA, however clearly there is a higher risk of prolonged drainage in these hips, which increases the risk of surgical site infection. For the morbidly obese, weight loss counseling and gastroplasty consultation is recommended. iii) Rheumatoid Arthritis -Often patients coming for joint arthroplasty are on a cocktail of drugs: a) NSAIDs - weak anti-platelet effect and should be stopped if possible pre-operatively, especially aspirin with its non-reversible effect on platelets (10 days) b) Steroids - powerful effect on the inflammatory cascade, and depression of the immune system. If possible, steroid use should be tapered pre-operatively to minimum levels, and if the patient remains on supra-physiologic doses of over 5 mg daily, intravenous steroids should be administered peri-operatively to avoid adrenal insufficiency crisis. Recent literature indicates that the relatively high doses of intravenous hydrocortisone (100 mg every 8 hours) are not necessary, and for total joints 25 mg every 12 hours for three doses is adequate, with no need for prolonged therapy beyond this. c) Methotrexate – variable historical recommendations, however 2 recent publications have shown no increased complications maintaining, rather than stopping it d) Leflunomide - one of the new DMARDs has shown a significant increase in infection rate post-operatively when not stopped e) TNF blockers (infliximab, adalimumab, etanercept) - have not been definitively demonstrated to be harmful in the peri-operative context from multiple studies iv) Immunocompromised -HIV, hemophilia, previous organ transplantation, skin disorders (psoriasis) v) Previous hip surgery First Annual AAHKS Spring Meeting | 98 Breakout 4, Revision Total Hip Arthroplasty (THA): Simple to Complex 16 II - Intraoperative Factors i) Antibiotic Prophylaxis -administered <60 minutes prior to surgical incision (critical point) -Cefazolin routinely, or Vancomycin/Clindamycin in allergic patient -no evidence for extended use >24 hrs in routine primary THA ii) OR suite -high airflow turnover room (doesn’t have to be laminar flow necessarily) -vertical laminar flow improves air quality -ultra-violet light also effective -no convincing evidence for body exhaust suits iii) Sterile technique -breaks in sterile technique are more common than considered -change to new gloves prior to handling implants iv) Length of Operating Time - increased OR time is associated with increased infection rates and this has been confirmed in several papers and registry data v) Antibiotic cement - national joint registries clearly demonstrate reduced infection rates with its routine use - approved for routine use in many countries (not the US – only for 2nd stage revision procedures) III – Postoperative Factors i) Drain use - no evidence that a drain either increases or decreases the infection rates ii) VTE prophylaxis - no evidence that the routine postop use of low mw heparin increases the infection rates - evidence that preop use does increase infection rates iii) Prolonged wound drainage - should have a low threshold for returning to the OR in a patient who has had wound drainage for longer than 7-10 days, particularly in a patient with further risk factors such as obesity, diabetes, previous surgical scars in the area, poor vascularity, ongoing need for anti-coagulation, or evidence of wound edge necrosis iv) Antibiotic prophylaxis for dental work - beyond 2 years postop - joint statement from the AAOS and American Dental Association advocated its’ use only in at risk patients - if patients tolerate the antibiotics, we discuss option of prophylaxis indefinitely B) Diagnosis First Annual AAHKS Spring Meeting | 99 Breakout 4, Revision Total Hip Arthroplasty (THA): Simple to Complex 17 i) History - key – have a high index of suspicion in all failed and painful THAs - look for – wound healing problems with index procedure - “always painful/ never right” - recent systemic illness (ask about recent/current Ab use,dental procedures,etc) - rest pain and nocturnal pain ii) Physical exam - often normal - local skin changes iii) Imaging a) plain radiographs – most commonly normal, although may see periosteal b) nuclear imaging – role is ill-defined, useful to evaluate the painful hip with all tests being negative to look for incomplete boney ingrowth iv) Blood tests - ESR and CRP should be obtained on every patient assessed for a painful THA - if both are normal, probability of infection is very low - if one or both are elevated, further investigate with an aspiration v) Aspiration - confirm patient has been off all antibiotics for at least 2 weeks - performed in all cases with abnormal bloodwork, and send for: a) Cell count - indicative of infection if > 3000 WBC/mm (if both ESR and CRP elevated) - indicative of infection if > 9000 WBC/mm (if only one of ESR or CRP elevated) b) Cell count differential - be suspicious of infection if > 80% WBC count - very indicative of infection if > 90% WBC count c) Culture - send for aerobic, anaerobic and fungal and TB infections in some cases (previous cultures negative when clinical suspicion is high) vi) Intraoperative Evaluation a) Frozen section - results are pathologist specific -average of 5-10 PMNs per high powered field is normally the cut-off, although again this varies between pathologists - we have found the best approach is to speak directly with our pathologist and have them determine – is this consistent with chronic or acute inflammation b) Gram stain - can see both false positives and false negatives - can be used as a guide to determine which postoperative antibiotic to use, but can’t be used as the only method to diagnose an infection - in many institutions no longer available as a stat test - always take at least 3, if not more, independent culture swabs to help guide postop Rx First Annual AAHKS Spring Meeting | 100 Breakout 4, Revision Total Hip Arthroplasty (THA): Simple to Complex 18 There is not one widely accepted gold standard test for diagnosing the infected THA. It is a clinical judgment based on many factors, particularly in the face of negative cultures. C) Treatment Historically infected THAs have been classified into 4 broad categories based on the timing of presentation: an unexpected positive intraoperative culture, acute infection, chronic infection and acute hematogenous infection. It must be emphasized that it is often not entirely clear which category a given patient falls into, so treatment recommendations based on the categories should be viewed as general guidelines only. i) Positive intraoperative culture - in this scenario one or more of the intraoperative cultures taken at the time of a revision THA come back as positive - there is no strong evidence based medicine to guide the surgeon in this case - our routine is to involve Infectious Disease in the process and our strong leaning is to treat all of these cases with 6 weeks of IV antibiotics (although some authors would argue that if only one positive culture and no others signs of infection, those patients do not require prolonged antibiotic coverage) - we would not take the patient back to the operating room and perform a first stage revision ii) Acute postoperative infection - historically this has been defined as an infection occurring within the first 6 weeks following THA - however more recently authors are beginning to discuss this in terms of within the 3-4 weeks of the index procedure - while it seems intuitive that the longer the infection has been present the lower the success rate will be with an I&D and polyethylene exchange, there is actually very little published to guide the surgeon as to when to make the transition and perform component removal and antibiotic spacer insertion - in general, we use the cut-off of 4 weeks, but this has to be individualized to patient and in particular the organism cultured - staph infections are much harder to eradicate and will have a higher failure rate for I&D’s, strept infections on the other hand are more amenable to that intervention - Rx – in summary, patients presenting with acute infections should undergo: 1) an operative intervention with a formal I&D with removal of the polyethylene insert so that that interface can be accessed 2) multiple intraoperative cultures should be obtained 3) a postop ID consult 4) 6 weeks of IV Abs 5) some authors are actually recommending chronic oral suppression for these cases, however again there is no evidence based medicine to give clear guidelines iii) Chronic postoperative infection - divergent literature re one-stage versus two-stage procedure - majority of North American centres perform two-stage - I&D’s are not successful and simply delay ultimate treatment - a two-stage revision has an approx 90% success rate and includes: First Annual AAHKS Spring Meeting | 101 Breakout 4, Revision Total Hip Arthroplasty (THA): Simple to Complex 19 i) 1st stage: a) thorough meticulous debridement of involved soft tissue b) removal of all components and cement if present c) pulsatile lavage irrigation with 9L (at minimum) d) use of an antibiotic spacer Spacers - there are two types of antibiotic spacers, static and articulating. Spacers allow for the local delivery of antibiotics. Current recommendations are for the use of 3 doses of Vancomycin and 3 doses of Tobramycin per bag of cement (if the patient has any underlying urine clearance or kidney issues we reduce the dosage). This amount of antibiotic will create a very thick doughy cement that is hard to mix so we routinely add another ½ vial of the monomer. It must be emphasized that this amount of Ab in the cement will reduce the mechanical properties of the cement so is only recommended for spacers knowing that they will be converted to THA’s at the time of the second stage revision - there is no literature to suggest that the success rate for static vs articulating spacers is any different, however articulating spacers do offer some advantages: prevent the limb shortening allowing an easier exposure at the 2nd stage, perhaps improved functionality. One disadvantage is the risk of dislocation. In cases of severe bone loss they are difficult to use and there is the possibility for increased bone loss with movement between the articulating spacer and host bone. ii) Interval between stages - patient receives 6 weeks of IV antibiotics, guided by intra-operative cultures (in consultation with Infectious disease) - some authors recommend very frequent ESR and CRP checks. Our routine is to do this bloodwork at 6 weeks when they are seen in clinic and their antibiotics are stopped and then again 3 weeks later when they are seen in the preadmission clinic and have a repeat aspiration that same day. - approx 10% of patient will fail the first attempt at infection eradication and will need to have a repeat 1st stage and spacer insertion iii) 2nd stage: a) repeat the debridement and obtain multiple samples for cultures and frozen section. Controversial re what constitutes ongoing infection – at our site our pathologists will tell us if samples are consistent with acute or chronic inflammation b) if evidence of ongoing infection – proceed to spacer insertion c) if no evidence of ongoing infection – proceed to definitive implants d) keep patient on IV Abs until cultures back iv) Acute hematogenous infection - by history, this is a well functioning THA that acutely changes - this source of infection is often never determined - look for recent dental procedures, any infections (ie, UTIs), skin ulcers in diabetics, etc - patient presents with very short direction of ++pain, perhaps decreased ROM, difficulty ambulating, occasionally a fever - Rx is identical to that for acute postoperative infection: 1) an operative intervention with a formal I&D with removal of the polyethylene insert so that that interface can be accessed 2) multiple intraoperative cultures should be obtained 3) a postop ID consult 4) 6 weeks of IV Abs First Annual AAHKS Spring Meeting | 102 Breakout 4, Revision Total Hip Arthroplasty (THA): Simple to Complex 20 5) some authors are actually recommending chronic oral suppression for these cases, however again there is no evidence based medicine to give clear guidelines References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Advisory statement. Antibiotic prophylaxis for dental patients with total joint replacements. American Dental Association; American Academy of Orthopaedic Surgeons. J Am Dent Assoc., 128(7): 1004-8, 1997. Amin AK, P. J., Cook RE, Brenkel IJ.: Does obesity influence the clinical outcome at five years following total knee replacement for osteoarthritis? J Bone Joint Surg Br., 88(3): 335-40, 2006. Asensio A, R. A., Múñez E, Vilanova JL, Torrijos P, García FJ.: Preoperative low molecular weight heparin as venous thromboembolism prophylaxis in patients at risk for prosthetic infection after knee arthroplasty. Infect Control Hosp Epidemiol., 26(12): 903-9, 2005. Azzam KA, Seeley M, Ghanem E, Austin MS, Purtill JJ, Parvizi J.: Irrigation and debridement in the management of prosthetic infection: traditional indications revisted. J Arthoplasty, 25(7);1022-1027, 2010. Block JE, S. H.: Reducing the risk of deep wound infection in primary joint arthroplasty with antibiotic bone cement. Orthopedics., 28(11): 1134-45, 2005. Coursin DB, W. K.-. Corticosteroid supplementation for adrenal insufficiency. JAMA, 287: 236-40, 2002. den Broeder AA, C. M., Fransen J, de Jong E, de Rooij DJ, Wymenga A, de Waal-Malefijt M, van den Hoogen FH: Risk factors for surgical site infections and other complications in elective surgery in patients with rheumatoid arthritis with special attention for anti-tumor necrosis factor: a large retrospective study. Nat Clin Pract Rheumatol. , 3(8): 432-3, 2007. Der Tavitian J, O. S., Taub NA, Taylor GJ: Body-exhaust suit versus occlusive clothing. A randomised, prospective trial using air and wound bacterial counts. J Bone Joint Surg Br., 85(4): 490-4, 2003. Esler CN, B. C., Fiddian NJ.: The use of a closed-suction drain in total knee arthroplasty. A prospective, randomised study. J Bone Joint Surg Br., 85(2): 2157, 2003. Fuerst M, M. H., Baumgärtel K, Rüther W: Leflunomide increases the risk of early healing complications in patients with rheumatoid arthritis undergoing elective orthopedic surgery. Rheumatol Int., 26(12): 1138-42, 2006. Grennan DM, G. J., Loudon J, et al: Methotrexate and early postoperative complications in patients with rheumatoid arthritis undergoing elective orthopedic surgery. Ann Rheum Dis, 60(3): 214-7, 2001. Hanssen, A.: Evaluation and treatment of infection at the site of a total hip or knee arthroplasty. Instr Course Lect 48(111), 1999. Johnson AJ, Daley JA, Zywiel MG, Delanois RE, Mont MA.: Preoperative chlorhexidine preparation and the incidence of surgical site infections after hip arthroplasty. J Arthoplasty, 25(6):98-102, 2010. Knobben BA, E. Y., Neut D, van der Mei HC, Busscher HJ, van Horn JR.: Intraoperative contamination influences wound discharge and periprosthetic infection. J Hosp Infect., 62(2): 174-80, 2006.12. Malone, D. G., T; Tracy, JK; Gannon, C; Napolitano, LM;: Surgical site infections: reanalysis of risk factors. J Surg Res, 103(1): 89-95, 2002. First Annual AAHKS Spring Meeting | 103 Breakout 4, Revision Total Hip Arthroplasty (THA): Simple to Complex 21 16. Marchant MH Jr, Viens NA, Cook C, Vail TP, Bolognesi MP.: The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. J Bone Joint Surg Am., 91(7):1621-1629, 2009. 17. Murata K. Yasuda T, I. H., Yoshida M, Shimizu M, Nakamura T: Lack of increase in postoperative complications with low-dose methotrexate therapy in patients with rheumatoid arthritis undergoing elective orthopedic surgery. Mod Rheumatol., 16(1): 14-9, 2006. 18. Murphy E, Spencer SJ, Young D, Jones B, Blyth MJ: MRSA colonisation and subsequent risk of infection despite effective eradication in orthopaedic elective surgery. J Bone Joint Surg Br., 93(4): 548-551, 2011. 19. Oussedik SI, Dodd MB, Haddad FS: Outcomes of revision total hip replacement for infection after grading according to a standard protocol. J Bone Joint Surg Br., 92(9): 1222-1226, 2010. 20. Patel VP, W. M., Sehgal B, Preston C, DeWal H, Di Cesare PE.: Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty. J Bone Joint Surg Am. , 89(1): 33-8, 2007. 21. Peersman, G.: Infection in total knee replacement: a retrospective review of 6489 total knee replacements. Clin Orthop Relat Res., Nov. 2001(392): 15-23, 2001. 22. Schinsky MF, Della Valle CJ, Sporer SM, Rosenberg AG, Jacobs JJ, Paprosky WG.: Perioperative testing for sepsis in revision total hip arthroplasty. J Bone Joint Surg Am. , 90:1869-1875, 2008. 23. Småbrekke A, E. B., Havelin LI, Furnes O.: Operating time and survival of primary total hip replacements: an analysis of 31,745 primary cemented and uncemented total hip replacements from local hospitals reported to the Norwegian Arthroplasty Register Acta Orthop Scand., 75(5): 524-32, 2004. 24. Spangehl MJ, Masterson E, Masri BA, O’Connell JX, Duncan CP.: The role of intraoperative gram stain in the diagnosis of infection during revision total hip arthroplasty. J Arthoplasty, 14;952-956, 1999 25. Spangehl MJ, Masri BA, O’Connell JX, Duncan CP.: Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am, 81:672-683, 1999. 26. Tannenbaum DA, M. L., Grady-Benson JC.: Infection around joint replacements in patients who have a renal or liver transplantation. J Bone Joint Surg Am., 79(1): 36-43, 1997. 27. Willis-Owens CA, Konyves A, Martin DK: Factors affecting the incidence of infection in hip and knee replacement: an analysis of 5277 cases. J Bone Joint Surg Br., 92(8): 1128-1133, 2010. 28. Wolf CF, Gu NY, Doctor JN, Manner PA, Leopold SS: Comparison of one and two stage revision of total hip arthroplasty complicated by infection: a Markov expectedutility decision analysis. J Bone Joint Surg Am., 93(7): 631-639, 2011 First Annual AAHKS Spring Meeting | 104 Symposium IV, The Business of Orthopaedics Symposium IV, The Business of Healthcare Mark Froimson, MD, MBA Trinity Health Healthcare in general, and joint replacement in particular, has come under fire for being of uneven quality and cost, without a direct correlation between the two. As a result, payers and regulators are attempting to correct this perceived deficiency by incentivizing providers, that is physicians and health systems, to focus on the value of the care provided. While there is general agreement that both quality improvement and cost reduction are tandem paths to value creation, there is less agreement on the best models for achieving one or both of these. Waste and unnecessary interventions are commonly cited reasons for excess cost and lack of quality. Duplication of services occurs when there is lack of communication and coordination and when practitioners attempt to ply their craft in traditional silos. The move to alternative payment models has begun to shed light on the importance of care coordination and transitions of care, in eliminating redundancy and ensuring compliance with prescribed treatments. Such seamless care requires that providers know one another, that there are common and accepted pathways across the continuum, that communication is fostered, that follow up is assured and that complications and deviations from the expected course are managed by those with the most knowledge of the patient. Although such care can occur in a virtual network of providers who are well known to each other, there is increasing evidence that the most reliable way to ensure such quality and efficiency is through the creation of integrated delivery systems. Such systems can take the form of a unified entity with a single business model, but can also exist in the form of a clinically integrated network that is linked by shared agreements between independent entities. It is the degree of integration that matters more than the financial ties of the parties delivering the care. One additional conclusion is clear, in order for the healthcare system to be redesigned and optimized for better care deliver and better health, physicians will need to play a more central role in the leadership of such efforts. Whether in private practice, group practice, in academic medicine or as employees, physicians, and surgeons in particular, will need to understand the legislative and regulatory landscape, and, importantly, how they can either impact it or adapt to it. Change is rapid on all fronts, but what is immutable is the value that patients see in the doctor First Annual AAHKS Spring Meeting | 105 Symposium IV, The Business of Orthopaedics patient relationship. It is imperative that surgeons get educated on the non clinical drivers of the system, both financial and regulatory. Only by empowering themselves with knowledge will they be able to influence teams, build systems, eliminate waste and lay claim to the value that these activities create. References: Bhatt, Purvi B., Forster Kevin, Walter Terri L., Survive or Thrive?, Healthcare Financial Management, July 2015, p62-67. Carlin Caroline S., Dowd Bryan, Feldman Roger, Changes in Quality of Health Care Delivery after Vertical Integration, Health Services Research, August 2015, p. 1043-1069. Hwang Wenke, PhD, Chang Jongwha, PhD, LaClair Michelle, MPH, Paz Harold, MD, MS, Effects of Integrated Delivery System on Cost and Quality, The American Journal of Managed Care, May 2013, Vol 19, No. 5, e175-e184. Jacquin Laura, A Strategic Approach to Healthcare Transformation, Healthcare Financial Management, April 2014, p.74-79. May, Ellen Lanser, Achieving Physician-Led Clinical Integration, Healthcare Executive, Jan/Feb 2015, p11-17. Moore, Keith D., Eyestone, Katherine M., Coddington Dean C., The Integration Aspiration, Healthcare Financial Management, June 2014, p56-59. Sharan Alok D., MD, MHCDS, Schroeder Gregory D., MD, West, Michael E., MBA, CPA, Vaccaro Alexander R., MD, PhD, MBA, Business of Medicine, Spinal Disord Tech, Vol 00, Number 00, 2015, p1-3. First Annual AAHKS Spring Meeting | 106 Symposium IV, The Business of Orthopaedics Squazzo Jessica D., The Journey to Value-based Care for Population Health, Healthcare Executive, Jan/Feb 2015, p28-35. Teisberg Elizabeth O., Phd, Wallace Scott, JD, MBA, Creating a High-Value Delivery System for Health Care, Semin Thorac Cardiovasc Surg 21, 2009, p.35-42. First Annual AAHKS Spring Meeting | 107 Breakout 6, Managing Complications in Hip and Knee Arthroplasty Breakout 6, Complications after THA and TKA: Current Strategies for Diagnosis and Treatment Moderators: Craig J. Della Valle, MD Rush University Medical Center, Chicago, IL Jay Parvizi, MD The Rothman Institute at Thomas Jefferson University, Philadelphia, PA Greg Polkowski, MD Vanderbilt University Medical Center, Nashville, TN Diagnosis and Treatment of Infection in the Early Post-Operative Period Diagnosis can be extremely difficult in the early post-operative period secondary to normal post-operative pain, edema and peri-incisional erythema that make the appearance of the wound and normal cues to diagnosis unreliable. While the ESR, CRP, synovial fluid WBC count and differential have been found to be useful in the diagnosis of chronic infection, one would expect that they would be elevated in the early post-operative period and potentially unreliable. We performed a retrospective review of 6,033 consecutive primary total hip arthroplasties performed by (3) surgeons to determine the utility of the ESR, CRP and synovial fluid WBC count with differential in the early post-operative period; 73 patients (1.2%) underwent early re-operation within the first 6 weeks. ESR (mm/hr) CRP (mg/L) Synovial Fluid WBC Count Differential (% PMN) Mean Infected (N=36) 69 (6-140) 192 (5-395) Mean Not Infected (N=37) 46 (8-80) 30 (5-68.7) P-Value 0.016 <0.001 84,954 (1,400-455,322) 91% (64%-99%) 2,291 (260-12,680) 63% (19%-96%) < 0.001 <0.0001 We determined the following optimal cut-off values - C-Reactive Protein: 93mg/L (normal < 8 mg/L) - Synovial Fluid WBC count : 12,800 WBC/uL - Differential: 89% These numbers are similar to our experience with the diagnosis of infection in the early postoperative period following TKA (see Bedair et. Al CORR 2011) How do we use this in oury own practices? - If there is ANY question regarding the wound appearance, we get a CRP. First Annual AAHKS Spring Meeting | 108 Breakout 6, Managing Complications in Hip and Knee Arthroplasty Early Complications THA - 2 If the CRP is near or > 100mg/L, we aspirate the hip (or knee) If the synovial fluid WBC is > 10,000 and differential is > 90%, the hip is very likely infected. If you are still unsure, you can wait for the culture results Treatment of Infection in the Early Post-Operative Period Although the most common treatment for an acute post-operative infection is irrigation and debridement (I+D) with exchange of the modular bearing surface, the validity of this approach has recently been questioned given a high rate of failure. - Particularly bad results with any type of a staphyloccal infection - Or with a resistant organism Alternative options include a 1-stage exchange or a 2-stage exchange. We performed a decision analysis to compare quality of life outcomes among irrigation and debridement, one and two-stage exchange (Bedair et. al, CORR 2011). - Based on this analysis, if the rate of eradication of infection with a 1-stage exchange exceeds 69%, it is the preferred treatment option; - I+D with a bearing surface change is only preferred if the success rate is > 60%. - Advantages of a one-stage exchange include o Relative ease of cementless component removal in the early post-operative period o Greater exposure and access for debridement of the bony surfaces o Removal of colonized implants, which may harbor bacterial biofilm. Early experience with 1-Stage Exchange in the early postoperative period following THA - Multi-center study (Rush, Jefferson, University College Hospital in London) - 28 Hips; all had cementless components at index arthroplasty and all exchanged to cementless implants - 71% implant retention at mean 41 months - Hansen et. al, CORR 2013 Based on the published results of an isolated I+D, the decision analysis and the early clinical results of a 1-stage exchange, it seems reasonable to consider a 1-stage exchange for the treatment of the acute infected THA. Suggested Reading 1. Bedair H, Ting N, Moric M, Saxena A, Jacovides C, Parvizi J, Della Valle CJ. Diagnosis of infection in the early post-operative period following primary total knee arthroplasty. Clin Orthop Relat Res. 2011, 469:34-40. 2. Bedair H, Ting N, Bozic KJ, Della Valle CJ, Sporer SM. Treatment of Early Infections after THA: A Decision Analysis. CORR 2011, 469:3477-85. 3. Bradbury T, Fehring TK, Taunton M, et. al. The fate of acute methicillin-resistant staphylococcus aureus periprosthetic knee infections following debridement and retention of components. J Arthroplasty. 2009 (Suppl): 101-4. First Annual AAHKS Spring Meeting | 109 Breakout 6, Managing Complications in Hip and Knee Arthroplasty Early Complications THA 3 4. Della Valle C, Parvizi J, et. al. AAOS clinical practice guideline on the diagnosis of PJI. J Bone Joint Surg Am. 2011 Jul 20;93(14):1355-7. 5. Hansen E, Zmistowski B, Della Valle C, Parvizi J, Haddad FS, Hozack WJ. Outcome of One Stage Cementless Exchange for Acute Postoperative Periprosthetic Hip Infection. Clin Orthop, 471:3214-22, 2013. 6. Tetreault M, Wetters N, Aggarwal VK, Moric M, Parvizi J, Huddleston JI, Segreti J, Della Valle C. Should draining wounds be cultured prior to revision hip and knee arthroplasty? J Arthroplasty, 28 (8 Suppl):133-6, 2013. Management of the Unstable THA Recurrent dislocation following total hip arthroplasty (THA) is a complex, multifactorial problem that has been shown to be the most common indication for revision THA. At our center, we have tried to approach the unstable hip by identifying the primary cause of instability and correcting that at the time of revision surgery. Type 1 2 3 Reason for Instability Malposition Acetabulum Malposition Femoral Component 4 Abductor Deficiency Soft Tissue/Bony Impingement 5 6 Late Polyethylene Wear Unable to identify cause Treatment Revision acetabular component; upsize femoral head Revision femoral component; upsize femoral head Constrained liner or dual mobility bearing; optimize component position Remove sources of impingement; upsize femoral component and optimize component position Exchange of acetabular liner; upsize femoral head and optimize component position Constrained liner or dual mobility bearing The most common etiologies of instability in our experience include cup malposition (Type 1) and abductor deficiency (Type 3) We reviewed 75 hips revised for instability and at a mean 35.3 months 11 re-dislocations occurred (14.6%). Acetabular revisions were protective against re-dislocation (p<0.015). The number of previous operations (p=0.0379) and previously failed constrained liners (p<0.02) were risk factors for failure. The highest risk of failure was in patients with abductor insufficiency with revisions for other etiologies having a success rate of 90%. Although instability can be multifactorial, by identifying the primary cause of instability, a rational approach to treatment can be formulated. In general the poorest results were seen in patients with abductor deficiency. Given the high rate of failure of constrained liners (9 of the 11 failures were constrained), we currently are exploring alternatives such as dual mobility articulations. Suggested Reading First Annual AAHKS Spring Meeting | 110 Breakout 6, Managing Complications in Hip and Knee Arthroplasty Early Complications THA 4 Wera GD, Ting NT, Moric M, Paprosky WG, Sporer SM, Della Valle CJ. Classification and management of the unstable total hip arthroplasty.J Arthroplasty,27: 710-5, 2012. Leg Length Inequality Total hip arthroplasty provides an effective operative solution in managing patients with joint failure. Leg length inequality is a cause of patient morbidity with serious medicolegal implications. Management relies on an accurate understanding of the cause of LLI and is usually conservative. Revision surgery for managing LLI is occasionally required and often very successful. Suggested Reading 1. Ranawat CS; Rodriguez JA. Functional leg-length inequality following total hip arthroplasty. J Arthroplasty. 1997 Jun;12(4):359-64. 2. Gurney B; Mermier C; Robergs R; Gibson A; Rivero D. Effects of limb-length discrepancy on gait economy and lower-extremity muscle activity in older adults. J Bone Joint Surg Am. 2001 Jun;83-A(6):907-15. 3. Jones HW; Harrison T; Clifton R; Akinola B; Tucker K. The Relationship between abduction contracture and leg length discrepancy following total hip replacement.. Journal of Bone & Joint Surgery, British Volume. 2010 July 1, 2010;92-B(SUPP III):389. 4. Maloney WJ; Keeney JA. Leg length discrepancy after total hip arthroplasty. J Arthroplasty. 2004 Jun;19(4 Suppl 1):108-10. 5. Clark CR; Huddleston HD; Schoch EP, 3rd; Thomas BJ. Leg-length discrepancy after total hip arthroplasty. J Am Acad Orthop Surg. 2006 Jan;14(1):38-45. 6. Parvizi J; Sharkey PF; Bissett GA; Rothman RH; Hozack WJ. Surgical treatment of limb-length discrepancy following total hip arthroplasty. J Bone Joint Surg Am. 2003 Dec;85-A(12):2310-7 Periprosthetic Fractures: Early With the popularity of cementless stems in primary total hip arthroplasty (THA) we have seen a concomitant rise in the prevalence of intra-operative and early postoperative fractures of the femur. While initial press-fit fixation is a requirement for osseointegration to occur, there is a fine balance between optimizing initial stability and overloading the strength of the proximal femur. Hence, the risk of intra-operative fractures is intimately related to the design of the femoral component utilized (metaphyseal engaging, wedge shaped designs having the highest risk) and the strength of the bone that it is inserted into (elderly females being at highest risk). If a fracture is identified, typically during or immediately after implant insertion, the stem should be removed and the fracture examined to determine its extent; most are nondisplaced after removal of the implant. At this time, the surgeon can either place a cerclage wire or cable and re-insert the stem or switch to a femoral component that gains fixation primarily in the diaphysis. Recognition intra-operatively is preferable as First Annual AAHKS Spring Meeting | 111 Breakout 6, Managing Complications in Hip and Knee Arthroplasty Early Complications THA 5 unrecognized fractures can lead to early femoral component subsidence and/or displaced fractures that in our experience are challenging to manage. These fractures typically are associated with a loose femoral component and require revision to a stem that gains primary fixation distally. We have found a high risk of complications and problems when treating these fractures in the early postoperative period with a high risk of infection, heterotopic ossification and the requirement for subsequent surgery. Periprosthetic Fractures: Late The Vancouver Classification is based on the location of the fracture, the fixation of the implant and the quality of the surrounding host bone. The most common pitfall in treatment is mistaking a B2 fracture (stem loose) for a B1 (stem stable); treatment of a loose implant with ORIF alone will necessarily fail. Type Fracture Location Implant A Per-Trochanteric Stable B B1 B2 Around the stem B3 C Well distal to stem Stable Loose Treatment ORIF of the trochanter; concomitant bearing surface exchange if associated with osteolysis Loose ORIF; typically long locked plate of whole femur Femoral component revision to distally fixed stem As for B2 but surrounding bone stock poor; typically little isthmus for distal fixation; may require proximal femoral replacement Stable ORIF; typically long locked plate of whole femur Suggested Reading 1. Berend KR, Lombardi AV, Jr, Mallory TH, Chonko DJ, Dodds KL, Adams JB. Cerclage wires or cables for the management of intraoperative fracture associated with a cementless, tapered femoral prosthesis: results at 2 to 16 years. J Arthroplasty. 2004;19(Suppl 2):17–21. 2. Berry DJ. Management of periprosthetic fractures: the hip. J Arthroplasty. 2002;17: 11–13. 3. Brady OH, Garbuz DS, Masri BA, Duncan CP. Reliability and Validity of the Vancouver Classification of femoral fractures after hip repalcement. J Arthroplasty. 2000; 15: 59-62. 4. Sheth N, Brown NB, Moric M, Berger RA, Della Valle CJ. Operative Treatment of Early Peri-Prosthetic Femur Fractures Following Primary Total Hip Arthroplasty. J Arthroplasty. 28, 286-91, 2013 First Annual AAHKS Spring Meeting | 112 Symposium VI, Step by Step: Key Choices and Techniques in the Tough Revision Total Hip Arthroplasty (THA) and Revision Total Knee Arthroplasty (TKA) Symposium VI, Step by Step: Key Choices and Techniques in the Tough Revision Total Hip Arthroplasty (THA) and Revision Total Knee Arthroplasty (TKA) Daniel J. Berry, M.D. Mayo Clinic Rochester, Minnesota I. Revision THA A. Exposure 1. When do you perform an ETO? B. Acetabular bone loss/reconstruction 1. What is role of cancellous graft? 2. What is role of structural graft? 3. When do you use metal augments? 4. When do you need something more than a hemispheric shell? 5. Do you always use a highly porous/high friction cup surface? 6. Indications for cup-cage; triflange cup? C. Femoral bone loss 1. What percent of cases are uncemented? 2. What category of uncemented stem do you usually use? a. Fluted/tapered b. Fully coated 3. Is there still a role for impaction grafting? 4. Is there still a role for proximal femoral allografts? D. Instability 1. What head size do you use in most revisions? 2. What is the role of dual mobility implants? 3. What is the role of dual mobility constrained cups? II. Revision TKA A. Exposure 1. In a revision TKA, how often do you use a quadriceps snip? 2. In a revision TKA, how often do you use a tibial tubercle osteotomy? B. Implant removal 1. What is your favorite way to take out a well-fixed femur? 2. What is your favorite way to take out a well-fixed tibia? 3. Any tricks to take out well-fixed stems? First Annual AAHKS Spring Meeting | 113 Symposium VI, Step by Step: Key Choices and Techniques in the Tough Revision Total Hip Arthroplasty (THA) and Revision Total Knee Arthroplasty (TKA) Key Choices and Techniques in the Tough Revision THA and TKA C. Bone loss 1. Tibia a. What is the role of cancellous bone graft? b. What is the role of structural bone graft? c. What is the role of sleeves? d. What is the role of highly porous cones? 2. Femur a. What is the role of cancellous bone graft? b. What is the role of structural bone graft? c. What is the role of sleeves? d. What is the role of highly porous cones? 3. Stems a. What percent of your stems are cemented? b. What percent of your stems are uncemented? c. How do you decide how long to go with the stems? D. Constraint 1. What percentage of your revision TKA’s are posterior stabilized? 2. What percentage of your revision TKA’s are constrained condylar? 3. What percentage of your revision TKA’s are hinged? 4. What are your indications for hinged implant in 2016? First Annual AAHKS Spring Meeting | 114 Berry/Page 2 Public Disclosure Information Planners and Faculty Matthew P. Abdel, MD No financial relationships with commercial interests to disclose Stephen T. Duncan, MD Biomet; Mitek; Morph; Smith & Nephew William P. Barrett, MD DePuy, A Johnson & Johnson Company Thomas K. Fehring, MD DePuy, A Johnson & Johnson Company Daniel J. Berry, MD DePuy, A Johnson & Johnson Company Mark I. Froimson, MD, MBA Medical Compression Systems Michael Bolognesi, MD Amedica; Biomet; DePuy, A Johnson & Johnson Company; Kinamed; Zimmer William L. Griffin, MD DePuy, A Johnson & Johnson Company; Zimmer Kevin J. Bozic, MD, MBA No financial relationships with commercial interests to disclose William A. Jiranek, MD Cayenne Medical; DePuy, A Johnson & Johnson Company; Johnson & Johnson; Lifenet Health, Inc.; Stryker John J. Callaghan, MD DePuy, A Johnson & Johnson Company John C. Clohisy, MD Microport Orthopedics; Pivot Medical; Smith & Nephew; Zimmer Jay R. Lieberman, MD DePuy, A Johnson & Johnson Company; Hip Innovation Technology David F. Dalury, MD DePuy, A Johnson & Johnson Company; Johnson & Johnson Adolph V Lombardi Jr, MD Innomed; Kinamed; Orthosensor; Pacira Pharmaceuticals, Inc.; Surgical Technology International; Zimmer Biomet Craig J. Della Valle, MD Biomet; CD Diagnostics; DePuy, A Johnson & Johnson Company; Smith & Nephew; Stryker Steven J. MacDonald, MD DePuy, A Johnson & Johnson Company; Hip Innovations Technology; JointVue; Smith & Nephew; Stryker AAHKS Staff Sigita Wolfe No financial relationships with commercial interests to disclose First Annual AAHKS Spring Meeting | 115 R. Michael Meneghini, MD Stryker Mark W. Pagnano, MD DePuy, A Johnson & Johnson Company; Pacira; Stryker Brian S. Parsley, MD Conformis; DePuy, A Johnson & Johnson Company; Nimbic Systems Javad Parvizi, MD, FRCS 3M; CD Diagnostics; Cempra; CeramTec; DePuy, A Johnson & Johnson Company; Hip Innovation Technology; PRN; Smith & Nephew; StelKast; Stryker; Zimmer Gregory G. Polkowski, II MD No financial relationships with commercial interests to disclose Bryan D. Springer, MD Convatec; Polaris; DePuy, A Johnson & Johnson Company; Ceramtec; Joint Purification Systems; Stryker First Annual AAHKS Spring Meeting | 116 Call for Submissions ABSTRACT SUBMISSIONS Submit high-quality scientific and socioeconomic abstracts by June 1, 2016 for consideration as podium or poster presentations. Abstracts are blind reviewed by the AAHKS Program Committee review team. If you are interested in serving on the review team, contact meeting @ aahks.org. SYMPOSIUM PROPOSALS Submit proposals by May 2, 2016 covering all aspects of arthroplasty and health policy. Proposals are reviewed by the AAHKS Program Committee. VIDEO PROPOSALS Submit proposals for surgical technique videos that are high-quality, clinically relevant and have high overall educational value. Deadline is May 2, 2016. Submit proposals and abstracts online at www.AAHKS.org Save the Date AAHKS 26th Annual Meeting November 10 – 13, 2016 NEW LOCATION! Hilton Anatole Dallas, Texas, USA Thank you to our Sponsors DePuy Synthes DJO Global Medtronic Pacira Pharmaceuticals, Inc. Smith & Nephew Stryker Zimmer Biomet See you at the AAHKS 26th ANNUAL MEETING November 3 - 6, 2016 | Hilton Anatole, Dallas 9400 West Higgins Rd., Suite 230, Rosemont, IL USA 60018 847 – 698 – 1200 | www.AAHKS.org
