DIAGNOSIS & TREATMENT OF INFECTION IN TKA Dr Parag Sancheti FRCS(Ed), MS (ORTHO), MCh (U.K), F.ASIF (SWISS), DNB (ORTHO) Pune, India KENYA ORTHOPAEDIC ASSOCIATION ANNUAL MEETING 23 nd June 2016 BOMA INN, Eldoret

POST TKR 65 yrs 4 months 59 yrs 3 months

POST TKR 72 yrs 8 Months 56 yrs 6 months

INFECTION AFTER TKR Devastating complication Imparts physical and emotional trauma Financial implications Challenging complication

MSIS DEFINITION OF PERIPROSTHETIC JOINT INFECTION

Classification of PJ (TKA, THR ) infection (Modified Coventry by Segawa and tsukayama et al JBJS am 1999) Type 1 Type 2 Type 3 Type 4 Timing+ve intra Op Culture Early Post Op Infection Acute Hematogenous Infection Late Chronic Infection Definition>2 +ve Culture after surgery Infection occurs within 4 weeks after surgery Hematogenous seeding of a well functioning arthroplasty Chronic Infection present for more then 4 weeks treatmentAntibioticsDebridment with Prosthesis Salvage Prosthesis Removal Hanssen and spanghel et al CORR 2004

DETECT IT EARLY Persistent wound drainage after TJA is defined as continued drainage from the operative incision site for greater than 72 hours. Substantial drainage (>2x2 cm area of gauze) from a wound beyond 72 hours should be considered abnormal.

RISK FACTORS l Skin ulcerations / necrosis l Rheumatoid Arthritis l Previous hip/knee operation l Recurrent UTI l Oral corticosteroids l Chronic renal insufficiency l Diabetes l Neoplasm requiring chemo l Tooth extraction

WARNING SIGNS Persistent fever > than 100 degrees Increasing redness, tenderness, or swelling of the incision wound Drainage from the incision wound Increasing pain with both activity and rest

Evaluation of Patient, Implant Evaluation of Patient, Implant Physical Exam. Physical Exam. Blood test Blood test Radiological evaluation Radiological evaluation Aspiration Aspiration EARLY DIAGNOSIS IS KEY TO SUCCESS

DIAGNOSIS Diagnostic dilemma No test 100% accurate Imaging Blood tests Aspiration Imp to identify the organism Surgeon’s judgement & interpretation paramount

RADIOLOGICAL EVALUATION XRAY not useful in ealy cases Late can show loosening 3 TESLA MRI can be good diagnostic tool Can pick up early oeteolysis

RADIOGRAPHS Signs which can be present in late : Signs which can be present in late : - Periosteal reaction - Periosteal reaction − Endo osteolysis (Resorption of Cortices) − Irregular Loosening of Implant − Rapidly progressive loosening on serial X-Rays

BONE SCAN T99 scan Limited use in first two years. Indium labeled WBC scan can of use. Limited availability. Prohibitive cost.

JOINT ASPIRATION Most useful when ESR and CRP Better in ruling out infection Stop antibiotics 2-3 weeks prior; local anesthesia only to skin, irrigate with saline, 3 samples If all 3 +ve for same organism -- confirms; if 1 +ve -- repeat

ESR : Not Useful CRP : > 100 Mg/L Synovial WBC Count : > 10,000Cells/μL, Synovial PMN% : > 90% Synovial CRP: > 6.6 Mg /L Synovial leucocyte esterase : ++ Synovial alpha Defensin: > 5.2 mg/L

ESR > 30 mm/hr, CRP > 10 mg/L, Synovial WBC count > 3,000 cells /μL Synovial PMN% > 80%. Synovial CRP: > 2.5 Mg /L

Routinely between 5 and 14 days. suspected PJI with low virulence organisms OR Strong clinical suspicion 14 days or longer.

ALGORITHM OF DIAGNOSIS OF PJI ALGORITHM OF DIAGNOSIS OF PJI

TKA INFECTION CONFIRMED ONCE YOU HAVE ESTABLISHED A DIAGNOSIS OF INFECTION DON’T SIT ON IT ACT IMME. DON’T BE IN DENIAL YOU CAN STILL SALVAGE THE JOINT

WHAT CAN YOU DO ? Retention Antibiotic suppression Debridement Removal Revision One stage Two stage Fusion Excision Amputation

ANTIBIOTIC SUPPRESSION If your culture detects a bug Don’t give empirical antibiotics

Staphylococcus64 S. aureus, penicillin sensitive 14 S. aureus, penicillin resistant28 S. epidermis22 S. aureus, penicillin sensitive 14 S. aureus, penicillin resistant28 S. epidermis22 Gram negative12 Pseudomonas7 Escherichia coli5 Anærobic6 Other17 OrganismPercent COMMON ORGANISMS

DEBRIDEMENT Persistent Discharge more than 4 days Swelling Patellar tap positive Redness with Fever TAKE TO OR Thorough wash, pulse lavage Poly exchange Send deep cultures

ONE STAGE Vs TWO STAGE Remove Implant + foreign body ( antibiotic cement spacer) + 6 wks Later Implant 6 wks Later Implant Remove Implant + Thorough debridement + foreign body (prosthesis) with antibiotic cement Two Stage One-Stage Two Stage One-Stage

Indications for 1 - Stage revision Infection: Early, no sinus Patient: – OA better than RA – not medically or immuno compromised – can tolerate antibiotics for 3 months Organisms: single, Gram +, sensitive

CASE - 64 yr female with OA

TKR done

TKR loosening & subsidence

INFECTION WORK UP Organism confirmed: Staph Epidermis Patient counselling done Otherwise in good health

LOOSE IMPLANTS WITH INFECTION

LOOSE FEMORAL IMPLANT

IMPLANT REMOVAL & DEBRIDEMENT WASHED AND PACKED WITH POVIDONE IODINE IMPLANT REMOVAL & DEBRIDEMENT WASHED AND PACKED WITH POVIDONE IODINE

INTRA-OP TESTS Frozen section Gram stain Surgeon’s opinion Cultures Molecular analysis: PCR

ONE STAGE REVISION

FINAL POSITION OF IMPLANT AND PATELLAR TRACKING

Post Op Xray

CONTRA INDICATIONS FOR ONE STAGE TKR Infection by MULTIPLE organisms NO reliable antibiotic SENSITIVITY Presence of a discharging SINUS POOR skin condition

Superior success rate Use of articulated spacers has improved function Probably less strenous 2 - STAGE REVISION

WHY TWO STAGE?  To avoid FB implantation in an infection setting  Remove foreign body  Opportunity to get direct culture  Opportunity to monitor progress BETTER CONTROL OF INFECTION

CASE PRIMARY TKR DONE -Work up done -Infection confirmed -Pt counselled LOOSE IMPLANTS

Ist STAGE

SECOND STAGE CEMENT SPACER REMOVED

FINAL IMPLANTATION

2nd STAGE

ANTIBIOTICS IN BONE CEMENT POWDER NOT LIQUID Vancomycin Cephalosporins, fluoroquinolones Amphoteracin-B 40 g 120g Antibiotic cement

ANTIBIOTICS IN CEMENT  Vancomycin:  96% sensitivity Gram positive  Class A and B Nephrotoxic  Cephalosporin:  61% sensitivity Gram negative  Class C More effective with Genta  Vancomycin + Cefazolin:  Deadly Mixed infection

Vary from 2 weeks to several months 4-6 weeks IV antibiotics followed by 2-8 weeks of “Antibiotic Free Interval” before reimplantation : OPTIMAL RESULTS Interval > 6 months: Suboptimal results

TYPES OF CEMENT SPACERS Simple cement block spacer Hand made articulating spacer Mould manufactured spacer Ready made spacer eg Prostalac

BENEFITS OF SPACER Soft tissue tension is maintained The muscles are active as knee mobiloity is allowed Reduced Pain in intervening period before final implantation. Revision surgery easier !

BENEFITS OF SPACER Higher local antibiotic concentration Tobramycin 3.8 gm + Vancomycin 2 gm – recommended dosage No systemic toxicity (?) 2 cases reported having ARF due to antibiotic impregnated cement use in revision TKR ( Curtis et al, Pharmacotherapy, 2005; Van Raaji et al, J Arthroplasty, 2004)

BENEFITS OF SPACER Bone loss prevented between two stages when articulating spacer is used There is NO Quadriceps shortening due to mobility. So, Exposure is easier ! –Fehring et al, CORR 2000, Nov. “Ranawat Award” paper.

SIMPLE CEMENT BLOCK

HAND MADE ARTICULATED CEMENT SPACER CEMENT SPACER

Mold Spacer

MAKE CEMENT STEMS Courtsey Dr Deodhar

READY MADE ANTIBIOTIC IMPREGNATED SPACER

READY MADE ARTICULATING SPACER IMPLANTS

ARTICULATED CEMENT SPACERS  Retain some motion  Minimise pain  Improved function in interim period  Better soft tissue planes in 2 nd stage  EXPENSIVE  Can make knee unstable

Bernard Struelen et al in Act Orth 2013 PROBLEMS OF CEMENT SPACER

Indications Patients with systemic manifestations of infection (sepsis) Culture negative suspected PJI Antibiotic-resistant organisms Presence of a sinus tract Inadequate and non-viable soft tissue coverage

Literature - Success Two stage 90% Vs one stage 69% Sherrell et al CORR 2011 " CHITRANJAN RANAWAT AWARD " FATE OF TWO-STAGE REIMPLANTATION VS ONE STAGE

- -Whether to do Single or Two stage depends circumstances -But Two stage revision is Gold Standard & Safe -Single stage revision can be done in few situations Good surgical skills Appropriate theatre setup OR discipline ONE STAGE OR TWO STAGE

CAUSATION OF INFECTION SURGEON IMPLANT HOST (Patient) The Deadly & Inevitable Trio OT SETUP & DISCIPLINE STERILISATION

INFECTED TKR : PREVENTION Appropriate antibiotics Strict Aseptic Operating practises Proper attire in OT Optimization of wound environment Careful soft tissue handling and closure REDUCTION OF BACTERIAL CONTAMINATION IN THE PERI OPERATIVE PERIOD

WHAT IS THE MESSAGE Early diagnosis = High index of suspicion Corroboration of Findings (Clinical & Investg.) Early & Adequate surgical intervention whenever in Doubt

One - Stage vs Two-Stage What is important is Thorough debridement Use of pulse lavage Meticulous surgical technique Appropriate use of antibiotics Bugs don´t care CARRY HOME MESSAGE

RECALCITRANT INFECTIONS NOT GETTING CONTROLLED Fusion Excision Amputation

SUMMARY When a surgeon starts doing TKR surgeries, he must be ready to handle revision situation and adverse situations. Infected revision are comparatively more common in our practice than the percentage mentioned abroad Higher cost of revision forces more no of patient for option of fusion

Thank You… Prof Lawerence Ndegwa Gakuu Prof Lectary Kilbor Lelei Dr Johnson Murila Dr James Kigera Dr Akhil Fazaal All Delegates and Members of KOA.