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Henry D Clarke MD Professor of Orthopedics Mayo Clinic

The Two Stage, Standard Technique Keeps You Out of Trouble & Out of Corners. Henry D Clarke MD Professor of Orthopedics Mayo Clinic. Disclosures Henry D Clarke MD. Institutional Research Vidacare Support: Stryker Paid Consultant: ConforMIS Smith & Nephew Zimmer-Biomet

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Henry D Clarke MD Professor of Orthopedics Mayo Clinic

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  1. The Two Stage, Standard Technique Keeps You Out of Trouble & Out of Corners Henry D Clarke MD Professor of Orthopedics Mayo Clinic

  2. Disclosures Henry D Clarke MD Institutional Research Vidacare Support: Stryker Paid Consultant: ConforMIS Smith & Nephew Zimmer-Biomet Royalties: ConforMIS Zimmer-Biomet Publishing Income: JAAOS

  3. Deep Peri-Prosthetic InfectionIntroduction • Infection #1 Reason for revision TKA • 25.2% of revisions • Aseptic loosening #2 • 16.1% of revisions Bozic et al, CORR 2010

  4. Deep Peri-Prosthetic InfectionTreatment Options • Antibiotic suppression • Arthroscopic debridement • Open debridement with polyethylene exchange • 1 versus 2 stage with abx cement beads • Prosthesis removal & re-implantation • 1 versus 2 stage • Arthrodesis • Amputation • Resection arthroplasty

  5. Deep Peri-Prosthetic Infection Goals for Infected TKA • Make the correct diagnosis • Acute vs chronic • Identify organism • Eradicate infection • Alleviate pain • Preserve a functional limb

  6. Make The Correct DiagnosisClassification Coventry MB: Ortho Clin North Am 1975

  7. Make The Correct DiagnosisMSIS Criteria Definite Prosthetic Joint Infection Exists where: • Sinus tract communicating with joint; or • Pathogen isolated from 2 or more separate tissue or fluid samples; or • When 3 of the following criteria exist: Workgroup convened by the Musculoskeletal Infection Society, J. Arthroplasty 2014

  8. Make The Correct DiagnosisMSIS Criteria Definite Prosthetic Joint Infection Exists where: • Elevated ESR & CRP • Elevated synovial WBC count • Elevated synovial PMN % • Pathogen in one fluid or tissue culture • > 5 WBC/HPF in 5 fields at 400X mag Workgroup convened by the Musculoskeletal Infection Society, J. Arthroplasty 2014

  9. Make The Correct DiagnosisAdditional Tests Improving Accuracy of intra-op cultures: • Careful technique • Clean instrument • Take at least three tissue specimens • Sonification of the extracted implant • Sen 60% tissue vs 75% sonicate-fluid • Sen 45% vs 75% if abx within 14 days Trampuz, New Eng J Med 357, 2007

  10. Make The Correct DiagnosisAdditional Tests • Serum Interleukin 6 • Synovial fluid tests • Alpha-defensins (Synovasure) • 100% sensitivity;95% specificity • 24-96 hours • Leukocyte esterase dip stick • Inaccurate in presence of bloody aspirate • Joint fluid CRP • WBC gene expression Di Cesare P et al, JBJS 87-A 2005; Jacovides CL et al, J Arthroplasty 26 (6 Suppl 1), 2011; Deirmengian C et al, CORR 440, 2005; Bingham J et al, CORR 472, 2014

  11. Deep Peri-Prosthetic InfectionChronic PJI • What are the options? • One stage revision • Two stage revision with antibiotic spacer • Static • Articulating

  12. Deep Peri-Prosthetic InfectionOne Stage Exchange One stage exchange • Becoming more popular in Europe • Especially for infected THA • Advantages • One procedure with less recovery time • Decreased expense • Improved function ? • Disadvantages • Worse results ?

  13. Deep Peri-Prosthetic InfectionOne Stage Exchange One stage exchange in THA • Austria • 37 patients • 92 % success at mean of 4.4 5 years follow-up Winkler H, JBJS 90-B: 1580, 2008

  14. Deep Peri-Prosthetic InfectionOne Stage Exchange One stage exchange in TKA • Endo Clinic, Germany • 104 patients • 72 % success (76/104 patients) at minimum 5 years follow-up Von Foerster G, Orthopade 20(3), 1991

  15. Deep Peri-Prosthetic InfectionOne Stage Exchange One stage exchange • French study • 47 patients • 87% survival free of infection at 3 years • Knee function not improved versus historic controls Jenny JY et al, ClinOrthopRel Res 471:238, 2013

  16. Deep Peri-Prosthetic InfectionTwo Stage Exchange One stage versus two stage exchange 2009 Meta-analysis 159 patients 1 stage versus 926 2 stage 73-100% success 1 stage 82-100% success 2 stage “ Two stage revision…remains the Gold Standard” Jamsen E et al, Acta Orthopaedica 80, 2009

  17. Deep Peri-Prosthetic InfectionTwo Stage Exchange When to consider one stage exchange? THA>TKA Known organism No antibiotic resistance No sinus tract No massive bone loss Adequate soft tissue coverage Gerke T et al, The Infected Hip, JBJS 95-B:77, 2013

  18. Deep Peri-Prosthetic InfectionTwo Stage Exchange Treatment principles • Accurate diagnosis • Identification of organism • Removal of prosthesis, infected tissue, & ALL foreign material • HIGH dose antibiotic cement spacer • 6 weeks appropriate IV antibiotics • Delayed re-implantation with LOW dose antibiotic cement

  19. Deep Peri-Prosthetic InfectionTwo Stage Exchange High Dose Antibiotic Cement • Per batch Palacos cement • 3.6 g Tobramycin • 3 g Vanco • 2 g Cefazolin • Less with renal insufficiency or if > 3 packs • 2.4g tobra • 2g vanc • 2g cefazolin

  20. Deep Peri-Prosthetic InfectionTwo Stage Exchange Two stage exchange with static cement spacer • 64 Infected TKA • 97% cure for same organism • 2 re-infections • 91% overall cure • 4 re-infection with new organism Goldman & Insall JN et al.: CORR 331, 1996

  21. Deep Peri-Prosthetic InfectionTwo Stage Exchange Two stage exchange with articulating spacer • 90% infection cure • Facilitate re-implantation • Improves function between stages • Improves ROM & functional outcomes after re-implant Emerson: CORR 404, 2002 Fehring: CORR 380, 2000 Gooding: CORR 469, 2011 Meer: JBJS 85 A, 2003 Van Thiel CORR, 2011

  22. Deep Peri-Prosthetic InfectionTwo Stage Exchange Two stage exchange • Patient satisfaction and function after septic vs aseptic revision TKA • 54 septic revision - 2 stage with Prostalac • 57 aseptic revision • Min 2 yr follow-up No difference in WOMAC, Oxford-12, SF-12, patient satisfaction data, and range of motion Meek RM et al, J Arthroplasty, 2004

  23. Deep Peri-Prosthetic InfectionTwo Stage Exchange What happens when 2 stage revision fails ? • Mayo Series • 45 patients failed 2 stage exchange for infected TKA • Success of repeat 2 stage exchange is dependent on host and extremity grade • 70% uncompromised host (MSIS type A) with acceptable wound (MSIS 1 or 2) • 50% compromised host (MSIS B2) • 0% severely compromised (MSIS C3) Hanssen et al; JBJS 99:19, 2017

  24. How I Manage an Infected TKATake Home Message • 2 stage revision with high dose antibiotic articulating cement spacer • Gold standard • Chronic infection, especially in TKA • Let Dr McPherson and others at high volume centers experiment • Do the right thing for your patients, get on base…don’t swing big and miss!

  25. Thank You for Your Attention

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