management of infections about total knee arthroplasty frank ebert, m.d. union memorial hospital...

Management of Management of Infections Infections

About About Total Knee Total Knee ArthroplastyArthroplasty

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

Baltimore, MDBaltimore, MD

Infections About TKRInfections About TKR

Range:Range: 1.1% - 12.4%1.1% - 12.4%

Mayo Series:Mayo Series: 1.2% - 3,000 1.2% - 3,000

Brigham/Women’sBrigham/Women’sHospital:Hospital: 1.6% - 4,1711.6% - 4,171

Complications in TKRComplications in TKR

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 CourseInfection – Clinical Course 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 monthsLate > 3 months

Symptoms: 52 patientsSymptoms: 52 patients

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 monthsLate > 3 months

More commonMore common

Hematogenos spreadHematogenos spread



Infection – Surgical TechniquesInfection – Surgical Techniques Avoid skin bridgesAvoid skin bridges Avoid creation of skin flapsAvoid creation of skin flaps HemostasisHemostasis Prolonged operating timeProlonged operating time


Infection – Work-UpInfection – Work-Up Wound HistoryWound History Physical ExamPhysical Exam Serial RadiographsSerial Radiographs Lab/sed rate/CRPLab/sed rate/CRP Bone scan / Indium scanBone scan / Indium scan


InfectionInfection

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


Infection – Work-UpInfection – Work-UpArthrocentesisArthrocentesis

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


InfectionInfection Host ResponseHost Response

GlycocalyxGlycocalyx

GristinaGristinaJBJS;JBJS; 1983 1983

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 TKRComplications in TKRInfection TKRInfection TKR


Treatment OptionsTreatment Options Antibiotic suppressionAntibiotic suppression Aggressive wound debridementAggressive wound debridement


Treatment OptionsTreatment Options Antibiotic suppressionAntibiotic suppression

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


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


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 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


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


Two-Stage ReimplantationTwo-Stage Reimplantation Most successful treatmentMost successful treatment Procedure of choiceProcedure of choice


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 IIII – Antibiotic Treatment – Antibiotic Treatment

Hickman catheterHickman catheter

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


Stage Stage IIIIII – Reimplantation – Reimplantation

Serial aspirationsSerial aspirations

Pre-op planningPre-op planning

Bone scan / Sed rateBone scan / Sed rate


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


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


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

compromised patientcompromised patient


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

AlgorithmAlgorithm

TKATKA

Clinical SepsisClinical Sepsis(GRAM + (GRAM + Organism) Organism)

< 3 wks< 3 wks > 3 wks> 3 wks

DebridementDebridementAntibiotics (6 wks)Antibiotics (6 wks)

2-Stage2-StageReplantReplant


AlgorithmAlgorithm

DebridementDebridementAntibioticsAntibiotics

SuccessSuccess

2-stage Replant2-stage Replant ArthrodesisArthrodesis


No No SuccessSuccess

2-stage Replant2-stage Replant

SuccessSuccessNo No

SuccessSuccess

ResectionResectionArthroplastyArthroplasty

Thank YouThank You

Frank R. Ebert, MDFrank R. Ebert, MD

management of infections about total knee arthroplasty frank ebert, m.d. union memorial hospital...

Documents