Management of Infected Hip (THR) joint Replacement Surgery by Hand Made Antibiotic Cement SpacerDr.Sandeep Agrawal MS . DNBAgrasen HospitalGondia Maharashtra India

ANTIBIOTIC CEMENT SPACER

Hip Arthroplasty: Increasingly Common

so more cases of Infected hip

THA Infection: A Treatment Challenge

Clinical Challenges

THA Infection: Classification

Common Pathogens

Zimmerli et al, 2005

Biofilm

Clinical Diagnosis ► 1.Clinical S/S: Pain (rest, non-weight bearing),

erythema, fever, discharging sinus, turbid joint fluid ► 2.Laboratory: ESR/CRP, leukocytosis ► 3.Culture and cytology from joint tapping ► 4.Exploration ► 5.Radiographic: normal or bone destraction ► 6.Histopathological: > 5-10 PMN/HPF ► 7.Nuclear medicine ► No Single Test

Treatment choices

Treatment Algorithm for Management of the infected THADepth of infection

Wound debridement/

antibiotics

Debilitated patient

“Prosthesis retention with debridement”(2)

Intravenous antibiotics

Reinsertion of another

prosthesis

Remove implant

Symptom onset

Well-fixed implant

Chronic oral antibiotic

suppressionchronic

Poor soft-tissue envelope Recalcitrant infection

Poor medical condition

superficial yes

yes

failure

Resection

arthroplasty(3)

deep no acute

failure

no yes

no

failure

AAOS ADVANCED RECONSTRUCTION HIP P.234 2005

► Medically infirm patients

► Low virulent pathogen

► Oral antibiotics available

► Tolerable long-term antibiotics

► Prosthesis removal is not feasible and no loose

1…Antibiotic suppression

► Very strict criteria :

▪ Symptoms< 3 weeks ▪ Stable prosthesis ▪ No discharging sinus ▪ Susceptible pathogen

► Success rate: 50-70%

► Acceptable early successful rate but also high recurrence Trampuz A et al, 2005

2…Debrideemnt with prosthesis retention

► Remove prosthesis: Girdlestone procedure over hip joint

► High success rate ► Poor functional status ► For the very debilitated

3..Resection Arthroplasty

Antibiotic-cement: The Key to Success

Buchholz et al, 1984

Adams et al, 1992

Girdlestone Problems ► Leg length inequality ► Inability to bear weight ► Disuse osteoporosis ► Extensive scarring ► Distorted tissue plane ► Difficult reimplantation

Dose of antibiotics► Elution of antibiotics from the PROSTALAC is

effective when at least !

3.6 g tobramycin and 1g vancomycin were added !! Masri et al 1998, J Arthroplasty

Do these spacers work better than the beads?

Materials and Methods

Group A (Beads)

► 1994-1996 ► 70 hips ► M:F= 53:17 ► Age: 60 (34-85) y/o ► Follow= 5.4 (2-8) yrs

Group B (Spacer) ► 1996-2000 ► 58 hips ► M:F=43:15 ► Age: 63 (28-81) y/o ► Follow= 4.2 (2-6) yrs

Infection control

60%64%68%72%75%79%83%87%91%95%98%

Group A Group B

Infection control

96.5%94.3%

66/7056/58

(P=0.69)

Ambulatory status

0

15

30

45

60

Ambulatory Non-ambulator

7

49 51

12

BeadsSpacer

87.5%

19.0%

(P=0.001)

► Selected patients ▪ Low- virulent organisms ▪ Identify organism before operation ▪ No sinus tract ▪ No major bone loss ▪ Antibiotic-loaded cement fixation

► More popular in Europe ► Success rate: 73%-92% (OKU 8)

!► Hope et al, 1989 ► Ure et al, 1998

Raut et al, 1994

4..One-stage revision arthroplasty

5.“Two stage revision arthroplasty”

A simple molding method of antibiotic-loaded

cement prosthesis as an interim spacer

J-Trauma

Hsieh et al, 2004

Antibiotic-cement spacer is not new

► Zilkens et al, 1990

► Ivarsson et al, 1994

► Leunig et al, 1998

► Deshmukh et al, 1998

► Younger et al, 1998

► Magnan et al, 2001

•Small series

•Hand-made prosthesis

•Hemiarthroplasty-like

Prosthesis of Antibiotic-loaded Acrylic Cement:

Duncan et al, 1993

PROSTALAC

► 1st Stage : ▪ Removal of all components, debridement ▪ Antibiotic-cement spacer

► Between Stages : ▪ IV antibiotics (2 weeks) ▪ +/- Oral antibiotics (4 weeks)

► 2nd Stage : ▪ Normal CRP ▪ Antibiotics in cement

Treatment Protocol

ACETABULUM PREPARATION

Silicon Mould

A refined metal rodENDOSKELETON

ENDOSKELETON IN MOLD

Pressure Till Cement Sets

FINAL FEMORAL CEMENT SPACER

INSERTION IN MEDULLARY CANAL

Cement-on-cement

Proximal cementation

Metal Rod as endoskeleton

•Temporary prosthesis

•Local antibiotic delivery

AMBULATION WITH SUPPORT

Choice of antibiotics

Heat-stable

► Powdered form

► Broad spectrum

▪ G(+): vancomycin, teicoplanin ▪ G(-): tobramycin, piperacillin, aztreonam

Antibiotics: bone cement = 1: 5

Complication of the cement spacer

FractureDislocation

Fracture

Dislocation

► Antibiotic elution from cement:

biphasic; high initially followed by sustained

release for months

Duncan et al, 1994 JBJS-A

► Antibiotic elution from cement spacer:

similar pattern

Minelli et al, 2004 JAC

► Most reliable method

► High success rate: 88-100% (OKU 8)

► Better functional result after revision hip reconstruction procedure

Two-stage revision arthroplasty

Conclusions ► Remove prosthesis is mandatory when

face a infective hip arthroplasty

► 1.Debride alone: a very limited indication

► 2.One-stage revision: selected cases

► 3.Two-stage revision: most reliable and effective

► With a cement spacer prosthesis: simple, safe, effective, and versatile

Thanks To DR.HSIEH

Dr.Pang Hsieh Taiwan