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Frank Ebert, M.D. Union Memorial Hospital Baltimore, MD

Management of Infections About Total Hip Arthroplasty. Frank Ebert, M.D. Union Memorial Hospital Baltimore, MD. Infections About THA. Range: 1.1% - 12.4% - 60’s Rate 2000 – 0.5% Rate Primary OA – 0.06%. Complications in Arthroplasty. Infection – Risk Factors Skin ulcerations / necrosis

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Frank Ebert, M.D. Union Memorial Hospital Baltimore, MD

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  1. Management of Infections About Total Hip Arthroplasty Frank Ebert, M.D. Union Memorial Hospital Baltimore, MD

  2. Infections About THA Range: 1.1% - 12.4% - 60’s Rate 2000 – 0.5% Rate Primary OA – 0.06%

  3. Complications in Arthroplasty • Infection – Risk Factors • Skin ulcerations / necrosis • Rheumatoid Arthritis • Previous hip/knee operation • Recurrent UTI • Oral corticosteroids

  4. Complications in Arthroplasty • Infection – Risk Factors • Chronic renal insufficiency • Diabetes • Neoplasm requiring chemo • Tooth extraction

  5. Complications in Arthroplasty • Infection – Clinical Course- Acute/Chronic • Pain #1 • Swelling • Fever • Wound breakdown drainage Windsor et alJBJS; 1990

  6. Infections About THA Early < 3 months • Lab Value • WBCs Mayo Series Mean 7,500 • Differential 67 PMN’s • Sed rate 71 mm/hr • Arthrocentesis

  7. Infections About THA Late > 3 months-Chronic •  Pain 96% swelling 77% Debride 27% Active drainage 27% Sed rate 63 mm/hr  WBC - 8300 Windsor et alJBJS; 1990

  8. Infections About THA Late > 3 months-Acute-Late Hematogenous • Recent Hx-surgery/dental/distal infection • Classic Symptoms of Sepsis • Fever, Pain,ElevatedWBC

  9. Complications in Arthroplasty • Infection – Surgical Techniques • Avoid skin bridges-7 cm rule • Avoid creation of skin flaps • Hemostasis • Prolonged operating time

  10. Complications in Arthroplasty • Infection – Work-Up – Requires a Combination of Studies • Wound History • Physical Exam • Serial Radiographs • Lab/sed rate/CRP/WBC • Bone scan / Indium scan

  11. Complications In Arthroplasty • Indium Scan • Superseded Tech and Gallium • More Specific and More Sensitive • Specificity and Sensitivity > 85%

  12. Complications in Arthroplasty • Infection – Work-Up • Arthrocentesis • direct smear • gram strain • aerobic • anaerobic • acid fast • fungi

  13. Complications in Arthroplasty • Infection • Arthrocentesis • Cell count • Diff > 25,000 pmn • Protein – high • Glucose – low

  14. Complications in Arthroplasty • Infection • Host Response • Glycocalyx GristinaJBJS; 1983

  15. Prosthetic Joint Infection • Biofilm • Biofilm on implants and devitalized tissue causes chronic disease • Understanding biofilm enlightens one to logical treatment

  16. Biofilm • Characteristics • All bacteria make biofilm • Foreign and devitalized tissue can succumb to biofilm formation if exposed to bacteria Costerton Science 284:1318. 99

  17. Biofilm • Characteristics • 15% cells, 85% matrix • Matrix – polysaccharide • Biofilms have structure • Cells live in a microecology and communicate! Costerton Science 284:1318. 99

  18. Biofilm • Significance in PJI • In biofilm state, bacteria become 1000x to 1500x more resistant to antibioctics • In biofilm state, bacteria express up to 65 new genes which change cell wall and/or membrane structure Costerton Science 284:1318. 99

  19. Biofilm State • Significance in PJI and Osteomyelitis • Resistant to antibiotics • Biofilm permeable to antibiotics all the way to base within 90 secs • Resistant to WBC’s and Phagocytosis • Resistant to Antibiotics Costerton Science 284:1318. 99

  20. Biofilm • Significance in PJI • Biofilm can colonize, grow and cover a surface within 4-8 days! • Prolonged wound drainage should not be allowed Costergan. W. MSIS 2000

  21. Treatment Prosthetic Joint Infection • Chronic Infections • To effectively treat a chronic infection, you must be able to planktonize cells • At present time, effective treatment means prosthetic removal and debridement of surrounding devitalized bone and tissue

  22. Micro Organisms

  23. Complications in ArthroplastyInfection THA Organism Percent Staphylococcus 64 S. aureus, penicillin sensitive 14S. aureus, penicillin resistant 28S. epidermis 22 Gram negative 12Pseudomonas 7Escherichia coli 5 Anærobic 6 Other 17

  24. Prosthetic Joint Infection • Classification-Treatment Purposes • Early Post-Op (<4 weeks) • Late Hematogenous • Chronic Tsukayama et al: JBJS 78A, 96

  25. Prosthetic Joint Infection • Treatment • Early Post-Op Infection < 4weeks • I&D with retention of components • Change modular parts • Resection of components if I&D fails

  26. Prosthetic Joint Infection • Treatment • Hematogenous Infection • I&D with retention of components • Change modular parts • 2 stage reimplantation if I&D fails

  27. Complications in Arthroplasty • Treatment Options-Chronic • Debridement with antibiotic suppression therapy • Strep/staphepi -- best • Avoid repeated attempts • Frozen tissue section • Suction drains

  28. Complications in Arthroplasty • Treatment Options-Chronic • Antibiotic suppression-Acute/Chronic • Indicated in med compromised • Organism - gram+ strep staphepi

  29. Complications in Arthroplasty • Two-Stage Reimplantation-Chronic/Failed Acute Treatment • Most successful treatment • Procedure of choice • Remember Biofilm

  30. Complications in Arthroplasty • Two-Stage Reimplantation • Stage I – Complete debridement • Stage II – 6 wks IV antibiotics • Stage III – Reimplant

  31. Complications in Arthroplasty • Two-Stage Reimplantation Procedure • Remove components, cement, I&D • Fabricate and place spacer • 6 weeks of antibiotics • Reimplantation

  32. Complications in Arthroplasty • Two-Stage Reimplantation Stage I • remove prosthesis / cement • thorough debridement

  33. Complications in Arthroplasty • Two-Stage Reimplantation Stage I • create antibiotic spacer impregnated with antibiotics • wound closure

  34. Complications in Arthroplasty • Two-Stage Reimplantation • Spacer Antibiotic Regimen • Tobramycin 2.4 gm/3.6 gm per 40 gms of PMMA • Vancomycin > 0.5 gm to 1 gm per 40 gms of PMMA

  35. Infections About THA Antibiotic Impregnated Spacer • Cidal levels of antibiotic • Spacer to preserve tissue tension • Facilitates reimplant and wound exposure

  36. Complications in Arthroplasty • Two-Stage Reimplantation Stage II • Reimplantation after antibiotic regimen

  37. Stage III – Reimplantation •  Serial aspirations •  Pre-op planning • Bone scan /Indium Scan • ESR/CRP/WBC

  38. Complications in Arthroplasty • Intra-operative Frozen Section • < 5 PMN’s per HPF – no infection • > 10 PMN’s per HPF – infection Mirra; JBJS

  39. Complications in Arthroplasty • Resection Arthroplasty • Removal all components • Remove all cement • Effective in medically compromised patient

  40. Infections About THA Algorithm • THAClinical Sepsis • Acute/Hematogenous (GRAM + Organism) < 4 wks > 4 wks DebridementAntibiotics (6 wks) 2-StageReplant

  41. Infections About THA Algorithm • 2-stage Replant • DebridementAntibiotics No Success No Success Success Success ResectionArthroplasty 2-stage Replant

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