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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
Complications in TKRComplications in TKR
Infection – Risk FactorsInfection – Risk Factors Chronic renal insufficiencyChronic renal insufficiency Diabetes Diabetes Neoplasm requiring chemoNeoplasm requiring chemo Tooth extractionTooth extraction
Complications in TKRComplications in TKR
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
Infections About TKRInfections About TKR
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
Infections About TKRInfections About TKR
Late > 3 monthsLate > 3 months
More commonMore common
Hematogenos spreadHematogenos spread
Infections About TKRInfections About TKR
Complications in TKRComplications in TKR
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
Complications in TKRComplications in TKR
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
Complications in TKRComplications in TKR
InfectionInfection
ArthrocentesisArthrocentesis Cell countCell count Diff > 25,000 pmnDiff > 25,000 pmn Protein Protein – – highhigh Glucose Glucose – – low low
Complications in TKRComplications in TKR
Infection – Work-UpInfection – Work-UpArthrocentesisArthrocentesis
– direct smeardirect smear– gram straingram strain– aerobicaerobic– anaerobicanaerobic– acid fastacid fast– fungi fungi
Complications in TKRComplications in TKR
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
Complications in TKRComplications in TKR
Treatment OptionsTreatment Options Antibiotic suppressionAntibiotic suppression Aggressive wound debridementAggressive wound debridement
Complications in TKRComplications in TKR
Treatment OptionsTreatment Options Antibiotic suppressionAntibiotic suppression
— Indicated in med compromisedIndicated in med compromised— Organism - gram+ strep staphepiOrganism - gram+ strep staphepi
Complications in TKRComplications in TKR
Treatment OptionsTreatment Options Resection arthroplastyResection arthroplasty 2 Stage re-implant2 Stage re-implant ArthrodesisArthrodesis AmputationAmputation
Complications in TKRComplications in TKR
Treatment Options Treatment Options
Hip (% success)Hip (% success) Knee (% success)Knee (% success)
- - - - - - - - - - - - 1818
Complications in TKRComplications in TKR
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 TKRComplications in TKR
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
Complications in TKRComplications in TKR
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 TKRComplications in TKR
Two-Stage ReimplantationTwo-Stage Reimplantation Most successful treatmentMost successful treatment Procedure of choiceProcedure of choice
Complications in TKRComplications in TKR
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 TKRComplications in TKR
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 TKRComplications in TKR
Two-Stage Reimplantation Two-Stage Reimplantation Stage Stage II remove prosthesis / cementremove prosthesis / cement thorough debridementthorough debridement
Complications in TKRComplications in TKR
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 TKRComplications in TKR
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 TKRInfections About TKR
Complications in TKRComplications in TKR
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
Infections About TKRInfections About TKR
Stage Stage IIIIII – Reimplantation – Reimplantation
Serial aspirationsSerial aspirations
Pre-op planningPre-op planning
Bone scan / Sed rateBone scan / Sed rate
Complications in TKRComplications in TKR
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 TKRComplications in TKR
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 TKRComplications in TKR
Resection ArthroplastyResection Arthroplasty Removal all componentsRemoval all components Remove all cementRemove all cement Effective in medically Effective in medically
compromised patientcompromised patient
Complications in TKRComplications in TKR
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
Infections About TKRInfections About TKR
AlgorithmAlgorithm
DebridementDebridementAntibioticsAntibiotics
SuccessSuccess
2-stage Replant2-stage Replant ArthrodesisArthrodesis
Infections About TKRInfections About TKR
No No SuccessSuccess
2-stage Replant2-stage Replant
SuccessSuccessNo No
SuccessSuccess
ResectionResectionArthroplastyArthroplasty
Thank YouThank You
Frank R. Ebert, MDFrank R. Ebert, MD