MANAGEMENT and OF INFECTED IMPLANT.pptx

MANAGEMENT OF INFECTED IMPLANT.pptx

1. MANAGEMENT OF INFECTED PROSTHESIS Dr. K .VENKAT SANTOSH REDDY PG MS[ ORTHO] Thursday, September 12, 2013 KMC / MGMH WARANGAL 1 Presentation by Moderators Dr. T. VENKATESHWARA RAO HOD&PROF Dr.J.VENKATESHWARLU ASSOC.PROF Dr.K VENKAT SWAMY ASST.PROF Dr.PRASAD REDDY D TUTOR

2. INTRODUCTION…… Thursday, September 12, 2013 KMC / MGMH WARANGAL 2 - DEFINITION -CLASSIFICATION -MANAGEMENT –INVESTIGATIONS -TREATMENT

3. Definition of peri prosthetic infection Thursday, September 12, 2013 KMC / MGMH WARANGAL 3 Given by Musculoskeletal Infection Society ….ANY OF THE FOLLOWING A sinus tract is communicating with the prosthesis Two separate tissue or fluid samples yield a positive culture from the joint Four of the following six criteria exist : Elevated erythocyte sedimentation rate (ESR) and C-reactive protein Elevated synovial neutrophil percentage Frank purulence in the joint One culture positive Greater than 5 neutrophils per high-power field (HPF) in 5 HPf

4. Thursday, September 12, 2013 KMC / MGMH WARANGAL 4 Bacterial infections can occur by one of four mechanisms: (1) direct contamination of the wound at the time of surgery, (2) local spread of superficial wound infection in the early postoperative period, (3 ) hematogenous spread of distant bacterial colonization or infection from a separate site, or (4) reactivation of latent hip infection

5. Prevention…. . Thursday, September 12, 2013 KMC / MGMH WARANGAL 5 .

6. Thursday, September 12, 2013 KMC / MGMH WARANGAL 6 WATER REPELLENT GOWNS AND DRAPES DOUBLE GLOVES LIMITING TRAFFIC ULTRAVIOLET LIGHT LAMINAR AIR FLOW .VERTICAL > HORIZONTAL BODY EXHAUST SUIT MINIMIZE DEAD SPACE AND HEMATOMA FORMATION PER OPERATIVE MEASURES .

7. Thursday, September 12, 2013 KMC / MGMH WARANGAL 7

8. Thursday, September 12, 2013 KMC / MGMH WARANGAL 8

9. Antibiotic Prophylaxis Thursday, September 12, 2013 KMC / MGMH WARANGAL 9 SHOULD INCLUDE gram-positive organisms, particularly coagulase -negative staphylococci and Staphylococcus aureus . . Methicillin resistance has become common . Gram-negative organisms are encountered more frequently in hematogenous infections, . Mixed infections typically occur when a draining sinus has developed,

10. AAOS RECOMMENDATIONS Thursday, September 12, 2013 KMC / MGMH WARANGAL 10 Table 7-5 -- Antibiotic Administration Guidelines RECOMMENDATION 1 cefazolin and cefuroxime are the preferred Clindamycin and vancomycin may be used for patients with a confirmed b- lactam allergy. Vancomycin may be used in patients with known colonization with (MRSA

11. RECOMMENDATION 2 Thursday, September 12, 2013 KMC / MGMH WARANGAL 11 Administer within 1 hour before skin incision. Owing to an extended infusion time, vancomycin should be started within 2 hours before incision. If +tourniquet is used, the antibiotic must be infused before the inflation of the tourniquet. Dose -proportional to patient weight; for patients who weigh more than 80 kg, cefazolin dose should be doubled. Antibiotic Frequency of Administration Cefazolin Every 2-5 h Cefuroxime Every 3-4 h Clindamycin Every 3-6 h Vancomycin Every 6-12 h

12. RECOMMENDATION 3 Thursday, September 12, 2013 KMC / MGMH WARANGAL 12 Duration of prophylactic antibiotic administration should not exceed the 24-hour postoperative period.

13. Thursday, September 12, 2013 KMC / MGMH WARANGAL 13 The use of cefuroxime -impregnated cement was shown to be effective in the prevention of early to intermediate deep infection after primary total knee arthroplasty (TKA) performed with perioperative systemic antibiotic prophylaxis but without any so-called clean-air measures. [ 9]

14. CLASSIFICATION Thursday, September 12, 2013 KMC / MGMH WARANGAL 14 management done based on chronicity of the infection Tsukayama classified periprosthetic infections into four categories 1.Early postoperative infection—onset within the first month after surgery 2. Late chronic infection—onset more than 1 month after surgery, insidious onset 3.Acute hematogenous infection—onset more than 1 month after surgery, acute onset of symptoms in previously well-functioning prosthesis , distant source of infection 4.Positive intraoperative cultures—positive cultures obtained at the time of revision for supposedly aseptic conditions

15. Thursday, September 12, 2013 KMC / MGMH WARANGAL 15

16. MANAGEMENT OF INFECTED HIP PROSTHESIS Thursday, September 12, 2013 KMC / MGMH WARANGAL 16 DIAGNOSIS TREATMENT

17. Blood tests Thursday, September 12, 2013 KMC / MGMH WARANGAL 17 Esr – more than 30mm associated with deep infection sp -0.82 sn -0.86 Crp - peaks on post op day 2 and normals by 2-3 weeks normal in case of aseptic loosening and >10 in infections Combining crp and esr has high sp and sn Repeated measuring of crp helps in planning treatment total WBC may be helpful THE SERUM IL6 RELIABLE INDICATOR Sn 100% Sp 95 %

18. Joint fluid aspiration…. Thursday, September 12, 2013 KMC / MGMH WARANGAL 18 HIGH ACCURATE IF ABNORMAL ESR ,CRP AND ASPIRATE WBC >3000/ml. > 60% POLYMORPHS Confirm suspicion of infection and identifies organism and and its antibiotic sensitivity profile Antibiotics are discontinued 2 weeks before aspiration to establish culture positivity . positive - if culture positive in 3 samples ,culture positive in 2 and blood parameters are elevated ….otherwise repeated ASPIRATION LAND MARKS 1 2

19. Plain radiography…. Thursday, September 12, 2013 KMC / MGMH WARANGAL 19 RARELY DIAGNOSTIC Serial radiograph helps in diagnosis –d/d from aseptic loosening - periosteal reaction - on long standing lysis ,bone resorbtion adjacent to implant Arthrography in conjunction with aspiration ,

20. Thursday, September 12, 2013 KMC / MGMH WARANGAL 20 Arthrogram of infected hip . Arthrogram done at time of aspiration for cultures showed long sinus tract extending posterior to femoral shaft.

21. Nuclear scanning .. Thursday, September 12, 2013 KMC / MGMH WARANGAL 21 Technitium -99 scan and indium labelled leukocyte - sensitive, do not differentiate from aseptic loosening Sequential technitium -99 and indium labelled WBC . Sn 100 % sp 91 % RECENT – FDG -PET SCANNING +

22. Thursday, September 12, 2013 KMC / MGMH WARANGAL 22 LEUKOCYTE ESTERASE STRIPS INFLAMMATORY BIOMARKERS- IL 6 Ibis T 5000 UNIVERSAL BIO SENSOR

23. Thursday, September 12, 2013 KMC / MGMH WARANGAL 23 The treatment of infected total hip arthroplasties consists of one or more of the following: 1. Antibiotic therapy 2. Débridement and irrigation of the hip with component retention 3. Débridement and irrigation of the hip with component removal 4. One-stage or two-stage reimplantation of total hip arthroplasty 5. Arthrodesis 6. Amputation Treatment

24. Thursday, September 12, 2013 KMC / MGMH WARANGAL 24 Management choices based on the chronicity of the infection, the virulence of the offending organism, the status of the wound and surrounding soft tissues, and the physiologic status of the patient

25. Thursday, September 12, 2013 KMC / MGMH WARANGAL 25 The incidence of sepsis is higher in DIABETES, RHEUMATOID ARTHRITIS, PSORIASIS, OR SICKLE CELL DISEASE. IMMUNOCOMPROMISED

26. Thursday, September 12, 2013 KMC / MGMH WARANGAL 26 If the infection is superficial, 1.Irrigated with large quantities of a physiological solution containing antibiotics, 2.Debridement 3.The skin edges are loosely approximated with interrupted sutures over suction drains. If there is any SUSPICION as to whether the infection is deep, it is wiser to insert a needle into the hip joint than to risk not draining an infected joint Early postoperative

27. Thursday, September 12, 2013 KMC / MGMH WARANGAL 27 If the infection extends to the hip joint Thoroughly débrided and irrigated with an antibiotic solution .IMPLANTS should be tested carefully for stability and should be left in situ only if there is no evidence of loosening. Cultures and antibiotic sensitivity of joint fluid or other fluid collections The appropriate antibiotic given intravenously for 6 weeks,. Early débridement within 2 weeks , CEMENTED PROSTHESIS is important for successful treatment..

28. Thursday, September 12, 2013 KMC / MGMH WARANGAL 28 Late Chronic Infection Surgical débridement and component removal Debridement done sinus tracts are débrided . After all cultures are taken, the joint is irrigated copiously with antibiotic-containing solution using pulsatile lavage . the fascia is closed with a running, nonabsorbable , monofilament suture, and the skin is closed with interrupted nonabsorbable monofilament sutures. antibiotic-containing beads or spacers are placed,

29. Thursday, September 12, 2013 KMC / MGMH WARANGAL 29 Acute Hematogenous Infection Consider antibiotic prophylaxis for joint replacement patients with one or more of the followiing risk factors prior to any invasive procedure that may cause bacteremia 1.All patients with pjr 2.Immunosupressed 3.RA,SLE 4 .radiation induced i.suppression 5.Comorbidity , htn ,dm, obesity 6.smoking 7.Malignancy 8.Megaprosthesis

30. Thursday, September 12, 2013 KMC / MGMH WARANGAL 30 If acute hematogenous infection is confirmed debridement and component retention may be attempted if time to onset of symptoms and debridement is less than 2 weeks If diagnosis is delayed beyond ,if prosthesis is loose , debridement should be combined with complete removal

31. Thursday, September 12, 2013 KMC / MGMH WARANGAL 31 Girdlestone resection arthroplasty after a total hip arthroplasty

32. Thursday, September 12, 2013 KMC / MGMH WARANGAL 32 Reconstruction after Infection and Component Removal two-stage or delayed reimplantation preferable. The advantages The adequacy of débridement the infecting organisms are identified, their sensitivities are determined, (3) diagnostic evaluation for foci of persistent infection can be done; (4 ) distant sites of infection responsible for hematogenous spread can be eradicated; and (5 ) informed decision can be made 6.Lower rates of reinfection

33. + Thursday, September 12, 2013 KMC / MGMH WARANGAL 33 . The disadvantages of a two-stage reconstruction include (1) the prolonged period of disability and the lengthy hospital stay; (2) the sizable cost, including lost wages; (3) delayed rehabilitation; and (4) technical difficulty of the procedure owing to shortening and scarring.

34. Thursday, September 12, 2013 KMC / MGMH WARANGAL 34 The decision regarding cemented or cementless reimplantation should be guided -by the available femoral bone stock and the -physiological age and expected longevity of the patient FEMORAL COMPONENT CEMENTED OR UN CEMENTED Has no effect on reinfection or mechanical complication rates

35. Interval prosthesis…… prostalac Thursday, September 12, 2013 KMC / MGMH WARANGAL 35 Prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) is implanted at the time of the initial debridement. The prosthesis is constructed intraoperatively by molding antibiotic-laden cement around a simplistic femoral component ( Rush pins, or Kirschner wires )and an all-polyethylene acetabular component. The articulated spacer maintains leg length and improves control of the limb and mobilization

36. Thursday, September 12, 2013 KMC / MGMH WARANGAL 36 Currently, we continue parenteral antibiotics for 6 – 8 weeks. Reconstruction is performed at 3 months if the ESR and CRP are improving, and repeat aspiration of the hip is negative If eradication of the infection is in doubt, frozen sections of tissues can be examined by the pathologist for evidence of residual inflammatory change. If polymorphonuclear cells are present (>10/high-power field), the hip is débrided again, and the reimplantation is not done. If multiple cultures taken at the time of surgery are positive, the appropriate antibiotics are continued for at least 6 weeks after surgery

37. Thursday, September 12, 2013 KMC / MGMH WARANGAL 37 Recurrence of infection after two-stage reimplantation REPEATED 2 stage replacement can be done . 36 % success rate Resection arthroplasty is effective in resolving the infection, rare cases, disarticulation of the hip may be indicated as a lifesaving

38. Thursday, September 12, 2013 KMC / MGMH WARANGAL 38

39. Thursday, September 12, 2013 KMC / MGMH WARANGAL 39 Surgical treatment algorithm for pros- thetic joint infections.

40. Thursday, September 12, 2013 KMC / MGMH WARANGAL 40 MANAGEMENT OF INFECTED TKR Treatment options include antibiotic suppression, débridement with prosthesis retention, resection arthroplasty , knee arthrodesis , one-stage or two-stage reimplantation , and amputation.

41. The choice between the various options depends on Thursday, September 12, 2013 KMC / MGMH WARANGAL 41 1.General medical condition of the patient , 2.The infecting organism, 3.Timing and extent of infection , 4.The residual usable bone stock, 5.Status of the soft-tissue envelope, 5.Extensor mechanism continuity.

42. Thursday, September 12, 2013 KMC / MGMH WARANGAL 42 Suppression with antibiotics rarely is indicated . :(1) prosthesis removal is not feasible (usually because of medical comorbidities ), (2) the prosthesis is not loose, and (3) the infecting microorganism is of low virulence Risks development of resistant strains of bacteria, progressive loosening, extensive infection, and possible septicemia

43. Thursday, September 12, 2013 KMC / MGMH WARANGAL 43 patients with an early (<4 weeks) postoperative infection an acute hematogenous infection (>4 weeks postoperatively, acute onset of symptoms) with a well-fixed prosthesis. Joint débridement with prosthesis retention Staph aureus is relative contraindication

44. Thursday, September 12, 2013 KMC / MGMH WARANGAL 44 Points that could lead to higher success rates for débridement … . Diagnosis and treatment of hematogenous sources of infection . Six-week duration of postoperative intravenous antibiotics . Repeat cultures within 2 weeks of the initial débridement and repeat débridement if these cultures were positive

45. Thursday, September 12, 2013 KMC / MGMH WARANGAL 45 Resection arthroplasty , consists of removal of the infected prosthesis and cement and débridement of the synovium . To maximize stability, the leg is maintained in a cast for 6 months. Resection arthroplasty is ideal for a patient with an infected TKA and severe polyarticular rheumatoid arthritis with limited ambulation. .

46. Thursday, September 12, 2013 KMC / MGMH WARANGAL 46 arthrodesis treatment of an infected TKA can provide a stable, generally painless limb with some shortening. Relative contraindications include ipsilateral hip or ankle arthritis , contralateral knee arthritis or limb amputation, severe segmental bone loss.

47. Thursday, September 12, 2013 KMC / MGMH WARANGAL 47 Indications high functional demands, young age deficient extensor mechanism, poor soft-tissue coverage, immunocompromised patient, highly virulent microorganism

48. Thursday, September 12, 2013 KMC / MGMH WARANGAL 48 Exchange arthroplasty More commonly, exchange arthroplasty is performed in two stage s— prosthesis removal and débridement 6 weeks period of intravenous antibiotics ,bactericidal titer 1:8 reimplantation . The most commonly accepted protocol,

49. ROLE OF SPACERS……. Thursday, September 12, 2013 KMC / MGMH WARANGAL 49 Antibiotic-impregnated PMMA spacers, maintain soft-tissue tension of the knee during the interval between débridement and reimplantation in two-stage procedures high levels of local antibiotic delivery, improved exposure at the time of reimplantation , and the ability to maintain weight bearing during the interval period ..

50. Thursday, September 12, 2013 KMC / MGMH WARANGAL 50

51. Thursday, September 12, 2013 KMC / MGMH WARANGAL 51 ONE STAGE DEBRIDEMENT AND REVISION Done with cementless prosthesis and intraarticular infusion of vancomycin for mrsa . Last option includes above knee amputatin

52. Thursday, September 12, 2013 KMC / MGMH WARANGAL 52 Than q