Management Management of of Infections Infections About Total About Total Hip Hip Arthroplasty Arthroplasty Frank Ebert, M.D. Frank Ebert, M.D. Union Memorial Union Memorial Hospital Hospital Baltimore, MD Baltimore, MD
Jan 20, 2016
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
Complications in ArthroplastyComplications in Arthroplasty
Infection – Risk FactorsInfection – Risk Factors Chronic renal insufficiencyChronic renal insufficiency Diabetes Diabetes Neoplasm requiring chemoNeoplasm requiring chemo Tooth extractionTooth extraction
Complications in ArthroplastyComplications in Arthroplasty
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
Infections About THAInfections About THA
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
Infections About THAInfections About THA
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
Infections About THAInfections About THA
Complications in ArthroplastyComplications in Arthroplasty
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
Complications in ArthroplastyComplications in Arthroplasty
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%
Complications in ArthroplastyComplications in Arthroplasty
Infection – Work-UpInfection – Work-UpArthrocentesisArthrocentesis
– direct smeardirect smear– gram straingram strain– aerobicaerobic– anaerobicanaerobic– acid fastacid fast– fungi fungi
Complications in ArthroplastyComplications in Arthroplasty
InfectionInfection
ArthrocentesisArthrocentesis Cell countCell count Diff > 25,000 pmnDiff > 25,000 pmn Protein Protein – – highhigh Glucose Glucose – – low low
Complications in ArthroplastyComplications in Arthroplasty
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!
Costerton Science 284:1318. 99Costerton Science 284:1318. 99
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
Costerton Science 284:1318. 99Costerton Science 284:1318. 99
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
Costerton Science 284:1318. 99Costerton Science 284:1318. 99
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
Prosthetic Joint InfectionProsthetic Joint Infection
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
Prosthetic Joint InfectionProsthetic Joint Infection
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
Prosthetic Joint InfectionProsthetic Joint Infection
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
Complications in ArthroplastyComplications in Arthroplasty
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
Complications in ArthroplastyComplications in Arthroplasty
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
Complications in ArthroplastyComplications in Arthroplasty
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
Complications in ArthroplastyComplications in Arthroplasty
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
Complications in ArthroplastyComplications in Arthroplasty
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
Complications in ArthroplastyComplications in Arthroplasty
Two-Stage Reimplantation Two-Stage Reimplantation Stage Stage II remove prosthesis / cementremove prosthesis / cement thorough debridementthorough debridement
Complications in ArthroplastyComplications in Arthroplasty
Two-Stage Reimplantation Two-Stage Reimplantation Stage Stage II create antibiotic spacer create antibiotic spacer
impregnated with antibioticsimpregnated with antibiotics wound closurewound closure
Complications in ArthroplastyComplications in Arthroplasty
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
Infections About THAInfections About THA
Complications in ArthroplastyComplications in Arthroplasty
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
Complications in ArthroplastyComplications in Arthroplasty
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
Complications in ArthroplastyComplications in Arthroplasty
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
Infections About THAInfections About THA
AlgorithmAlgorithm
DebridementDebridementAntibioticsAntibiotics
SuccessSuccess
2-stage Replant2-stage Replant
Infections About THAInfections About THA
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
Infections About THAInfections About THA
Complications in ArthroplastyComplications in Arthroplasty
Treatment OptionsTreatment Options Debridement with antibiotic Debridement with antibiotic
suppression therapysuppression therapy— Limited successLimited success— < 3 weeks< 3 weeks
SchoifetSchoifetJBJS;JBJS; 1990 1990
Complications in ArthroplastyComplications in Arthroplasty
Treatment OptionsTreatment Options Antibiotic suppressionAntibiotic suppression Aggressive wound debridementAggressive wound debridement
Complications in ArthroplastyComplications in Arthroplasty
Treatment OptionsTreatment Options Resection arthroplastyResection arthroplasty 2 Stage re-implant2 Stage re-implant ArthrodesisArthrodesis AmputationAmputation
Complications in ArthroplastyComplications in Arthroplasty
Treatment Options Treatment Options
Hip (% success)Hip (% success) Knee (% success)Knee (% success)
- - - - - - - - - - - - 1818
Complications in ArthroplastyComplications in Arthroplasty
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
Complications in ArthroplastyComplications in Arthroplasty
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
Complications in ArthroplastyComplications in Arthroplasty
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