Frank Ebert, M.D. Union Memorial Hospital Baltimore, MD

Management of Management of Infections Infections

About Total Hip About Total Hip ArthroplastyArthroplasty

Frank Ebert, M.D.Frank Ebert, M.D.Union Memorial HospitalUnion Memorial Hospital

Baltimore, MDBaltimore, MD

Infections About THAInfections About THA

Range:Range: 1.1% - 12.4% - 60’s1.1% - 12.4% - 60’s

Rate 2000 – 0.5%Rate 2000 – 0.5%

Rate Primary OA – 0.06%Rate Primary OA – 0.06%

Complications in ArthroplastyComplications in Arthroplasty

Infection – Risk FactorsInfection – Risk Factors Skin ulcerations / necrosisSkin ulcerations / necrosis Rheumatoid ArthritisRheumatoid Arthritis Previous hip/knee operationPrevious hip/knee operation Recurrent UTIRecurrent UTI Oral corticosteroidsOral corticosteroids

Infection – Risk FactorsInfection – Risk Factors Chronic renal insufficiencyChronic renal insufficiency Diabetes Diabetes Neoplasm requiring chemoNeoplasm requiring chemo Tooth extractionTooth extraction

Infection – Clinical Course- Infection – Clinical Course- Acute/ChronicAcute/Chronic

Pain #1Pain #1 SwellingSwelling FeverFever Wound breakdown drainageWound breakdown drainage

Windsor et alWindsor et alJBJSJBJS; 1990; 1990

Early < 3 monthsEarly < 3 months

Lab ValueLab Value WBCs WBCs Mayo Series Mayo Series

Mean 7,500Mean 7,500

Differential Differential 67 PMN’s67 PMN’s

Sed rateSed rate 71 mm/hr71 mm/hr

ArthrocentesisArthrocentesis

Late > 3 months-ChronicLate > 3 months-Chronic

PainPain 96%96% swellingswelling 77%77% DebrideDebride 27%27% Active drainageActive drainage 27%27% Sed rate 63 mm/hrSed rate 63 mm/hr WBC - 8300WBC - 8300 Windsor et alWindsor et al

JBJSJBJS; 1990; 1990

Late > 3 months-Acute-Late Late > 3 months-Acute-Late HematogenousHematogenous

Recent Hx-surgery/dental/distal Recent Hx-surgery/dental/distal infection infection

Classic Symptoms of SepsisClassic Symptoms of Sepsis

Fever, Pain,ElevatedWBCFever, Pain,ElevatedWBC

Infection – Surgical TechniquesInfection – Surgical Techniques Avoid skin bridges-7 cm ruleAvoid skin bridges-7 cm rule Avoid creation of skin flapsAvoid creation of skin flaps HemostasisHemostasis Prolonged operating timeProlonged operating time

Infection – Work-Up – Requires a Infection – Work-Up – Requires a Combination of StudiesCombination of Studies

Wound HistoryWound History Physical ExamPhysical Exam Serial RadiographsSerial Radiographs Lab/sed rate/CRP/WBCLab/sed rate/CRP/WBC Bone scan / Indium scanBone scan / Indium scan

Complications In ArthroplastyComplications In Arthroplasty

Indium ScanIndium Scan- Superseded Tech and GalliumSuperseded Tech and Gallium- More Specific and More SensitiveMore Specific and More Sensitive- Specificity and Sensitivity > 85% Specificity and Sensitivity > 85%

Infection – Work-UpInfection – Work-UpArthrocentesisArthrocentesis

– direct smeardirect smear– gram straingram strain– aerobicaerobic– anaerobicanaerobic– acid fastacid fast– fungi fungi

InfectionInfection

ArthrocentesisArthrocentesis Cell countCell count Diff > 25,000 pmnDiff > 25,000 pmn Protein Protein – – highhigh Glucose Glucose – – low low

InfectionInfection Host ResponseHost Response

GlycocalyxGlycocalyx

GristinaGristinaJBJS;JBJS; 1983 1983

Prosthetic Joint InfectionProsthetic Joint Infection

BiofilmBiofilmBiofilmBiofilm on implants on implants and devitalized tissue and devitalized tissue causes chronic causes chronic diseasediseaseUnderstanding Understanding biofilm enlightens one biofilm enlightens one to logical treatmentto logical treatment

BiofilmBiofilm

CharacteristicsCharacteristics All bacteriaAll bacteria make biofilm make biofilm Foreign and Foreign and devitalized tissuedevitalized tissue can can

succumb to biofilm formation if succumb to biofilm formation if exposed to bacteriaexposed to bacteria

Costerton Science 284:1318. 99Costerton Science 284:1318. 99

BiofilmBiofilm

CharacteristicsCharacteristics 15% cells, 85% matrix15% cells, 85% matrix Matrix – polysaccharideMatrix – polysaccharide Biofilms have structureBiofilms have structure Cells live in a microecology and Cells live in a microecology and

communicate!communicate!

BiofilmBiofilm

Significance in PJISignificance in PJI In In biofilm statebiofilm state, bacteria become , bacteria become 1000x 1000x

to 1500xto 1500x more resistant to antibioctics more resistant to antibioctics In biofilm state, bacteria express up to In biofilm state, bacteria express up to

65 new genes which change cell wall 65 new genes which change cell wall and/or membrane structureand/or membrane structure

Biofilm StateBiofilm State

Significance in PJI and OsteomyelitisSignificance in PJI and Osteomyelitis Resistant to antibioticsResistant to antibiotics Biofilm permeable to antibiotics all Biofilm permeable to antibiotics all

the way to base within 90 secsthe way to base within 90 secs Resistant to WBC’s and Resistant to WBC’s and

PhagocytosisPhagocytosis Resistant to AntibioticsResistant to Antibiotics

BiofilmBiofilm

Significance in PJISignificance in PJI Biofilm can colonize, grow and Biofilm can colonize, grow and

cover a surface within cover a surface within 4-8 days!4-8 days! Prolonged wound drainage should Prolonged wound drainage should

not be allowednot be allowed

Costergan. W. MSIS 2000Costergan. W. MSIS 2000

Treatment Prosthetic Joint Treatment Prosthetic Joint InfectionInfection

Chronic InfectionsChronic Infections To effectively treat a chronic infection, To effectively treat a chronic infection,

you must be able to planktonize cellsyou must be able to planktonize cells At present time, effective treatment At present time, effective treatment

means means prosthetic removalprosthetic removal and and debridement of surrounding debridement of surrounding devitalizeddevitalized bone and tissuebone and tissue

Micro OrganismsMicro Organisms

StaphylococcusStaphylococcus 6464

S. aureusS. aureus, penicillin sensitive , penicillin sensitive 1414 S. aureusS. aureus, penicillin resistant, penicillin resistant 2828 S. epidermisS. epidermis 2222

Gram negativeGram negative 1212 PseudomonasPseudomonas 77 Escherichia coliEscherichia coli 55

AnærobicAnærobic 66

OtherOther 1717

OrganismOrganism PercentPercent

Complications in ArthroplastyComplications in ArthroplastyInfection THAInfection THA

Classification-Treatment PurposesClassification-Treatment Purposes Early Post-Op (<4 weeks)Early Post-Op (<4 weeks) Late Hematogenous Late Hematogenous Chronic Chronic

Tsukayama et al: JBJS 78A, 96Tsukayama et al: JBJS 78A, 96

Treatment Treatment

Early Post-Op Infection < 4weeksEarly Post-Op Infection < 4weeks I&D with retention of componentsI&D with retention of components Change modular partsChange modular parts Resection of components if I&D Resection of components if I&D

failsfails

TreatmentTreatment

Hematogenous InfectionHematogenous Infection I&D with retention of componentsI&D with retention of components Change modular partsChange modular parts 2 stage reimplantation if I&D fails2 stage reimplantation if I&D fails

Treatment Options-ChronicTreatment Options-Chronic Debridement with antibiotic Debridement with antibiotic

suppression therapysuppression therapy— Strep/staphepi -- bestStrep/staphepi -- best— Avoid repeated attemptsAvoid repeated attempts— Frozen tissue sectionFrozen tissue section— Suction drainsSuction drains

Treatment Options-ChronicTreatment Options-Chronic Antibiotic suppression-Acute/ChronicAntibiotic suppression-Acute/Chronic

— Indicated in med compromisedIndicated in med compromised— Organism - gram+ strep staphepiOrganism - gram+ strep staphepi

Two-Stage Reimplantation-Two-Stage Reimplantation-Chronic/Failed Acute TreatmentChronic/Failed Acute Treatment

Most successful treatmentMost successful treatment Procedure of choiceProcedure of choice Remember BiofilmRemember Biofilm

Two-Stage ReimplantationTwo-Stage Reimplantation

Stage Stage II –– Complete Complete debridementdebridement

Stage Stage IIII –– 6 wks IV 6 wks IV antibioticsantibiotics

Stage Stage IIIIII –– ReimplantReimplant

Two-Stage Reimplantation ProcedureTwo-Stage Reimplantation Procedure

Remove components, cement, Remove components, cement, II&&DD

Fabricate and place spacerFabricate and place spacer

6 weeks of antibiotics6 weeks of antibiotics

ReimplantationReimplantation

Two-Stage Reimplantation Two-Stage Reimplantation Stage Stage II remove prosthesis / cementremove prosthesis / cement thorough debridementthorough debridement

Two-Stage Reimplantation Two-Stage Reimplantation Stage Stage II create antibiotic spacer create antibiotic spacer

impregnated with antibioticsimpregnated with antibiotics wound closurewound closure

Two-Stage Reimplantation Two-Stage Reimplantation

Spacer Antibiotic RegimenSpacer Antibiotic Regimen

Tobramycin Tobramycin 2.4 gm/3.6 gm per2.4 gm/3.6 gm per 40 gms of PMMA40 gms of PMMA

VancomycinVancomycin > 0.5 gm to 1 gm per > 0.5 gm to 1 gm per 40 gms of PMMA40 gms of PMMA

Antibiotic Impregnated SpacerAntibiotic Impregnated Spacer

Cidal levels of antibioticCidal levels of antibiotic Spacer to preserve tissue tensionSpacer to preserve tissue tension Facilitates reimplant and wound Facilitates reimplant and wound

exposureexposure

Two-Stage Reimplantation Two-Stage Reimplantation Stage Stage IIII Reimplantation after antibiotic Reimplantation after antibiotic

regimenregimen

Stage Stage IIIIII – Reimplantation – Reimplantation

Serial aspirationsSerial aspirations

Pre-op planningPre-op planningBone scan /Indium ScanBone scan /Indium ScanESR/CRP/WBCESR/CRP/WBC

Intra-operative Frozen SectionIntra-operative Frozen Section < 5 PMN’s per HPF< 5 PMN’s per HPF – – no no

infectioninfection > 10 PMN’s per HPF> 10 PMN’s per HPF –– infectioninfection

Mirra; Mirra; JBJSJBJS

Resection ArthroplastyResection Arthroplasty Removal all componentsRemoval all components Remove all cementRemove all cement Effective in medically Effective in medically

compromised patientcompromised patient

AlgorithmAlgorithm

THATHAClinical Sepsis Clinical Sepsis

Acute/HematogenousAcute/Hematogenous

(GRAM + (GRAM + Organism) Organism)

< 4 wks< 4 wks > 4 wks> 4 wks

DebridementDebridementAntibiotics (6 wks)Antibiotics (6 wks)

2-Stage2-StageReplantReplant

AlgorithmAlgorithm

DebridementDebridementAntibioticsAntibiotics

SuccessSuccess

2-stage Replant2-stage Replant

No No SuccessSuccess

2-stage Replant2-stage Replant

SuccessSuccessNo No

SuccessSuccess

ResectionResectionArthroplastyArthroplasty

Thank YouThank You

Frank R. Ebert, MDFrank R. Ebert, MD

Stage Stage IIII – Antibiotic Treatment – Antibiotic Treatment

Hickman catheter / Pick LineHickman catheter / Pick Line

MIC 1:8 / 6 wksMIC 1:8 / 6 wks

Treatment OptionsTreatment Options Debridement with antibiotic Debridement with antibiotic

suppression therapysuppression therapy— Limited successLimited success— < 3 weeks< 3 weeks

SchoifetSchoifetJBJS;JBJS; 1990 1990

Treatment OptionsTreatment Options Antibiotic suppressionAntibiotic suppression Aggressive wound debridementAggressive wound debridement

Treatment OptionsTreatment Options Resection arthroplastyResection arthroplasty 2 Stage re-implant2 Stage re-implant ArthrodesisArthrodesis AmputationAmputation

Treatment Options Treatment Options

Hip (% success)Hip (% success) Knee (% success)Knee (% success)

- - - - - - - - - - - - 1818

Debridement with Antibiotic Debridement with Antibiotic SuppressionSuppression

Hip (% success)Hip (% success) Knee (% success)Knee (% success)

25 to 3525 to 35 25 to 3525 to 35

Results — Gm positiveResults — Gm positive

Windsor et alWindsor et al 92 % 92 % JBJSJBJS 1990 1990

Insall et alInsall et al 97%97% JBJSJBJS 1983 1983

Arthrodesis IndicationsArthrodesis Indications Extensor mechanism disruptionExtensor mechanism disruption Resistant bacteriaResistant bacteria Inadequate bonestockInadequate bonestock Inadequate soft tissuesInadequate soft tissues Young patientYoung patient

AdvantagesAdvantages

Definitive treatmentDefinitive treatment

Little chance of recurrenceLittle chance of recurrence

ArthrodesisArthrodesis

DisadvantagesDisadvantages

Difficulty with transfers / small Difficulty with transfers / small spacesspaces

Increase energy requirementsIncrease energy requirements

ArthrodesisArthrodesis

Frank Ebert, M.D. Union Memorial Hospital Baltimore, MD

biofilm formation

biofilm statesignificance

antibiocticsin biofilm

pjiin biofilm state

devitalized tissue

antibioticscosterton

bacteriacosterton science

prosthetic removal

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