1. In the name of God

2. How to deal with Infected Total Knee Arthroplasty
Mohsen Mardani-Kivi
Assistant Professor, Orthopedic Department, Guilan University of Medical Sciences

3. Background
Total joint replacement is one of the most commonly performed and successful operations in Orthopaedics as defined by clinical outcomes and implant survivorship*

4. Incidence
Infection has occurred in 1% to 2% of primary TKA surgeries and has been the leading cause of failure following TKA.
The rate of peri-prosthetic infection has been declining over the last two to three decades, mostly due to operating room environments and operative techniques

5. Risk Factors for Infected Arthroplasty
Prior surgery
Surgery time > 2.5 hours
Compromised immune status
Poor nutrition
Diabetes mellitus
Obesity
Smoking

6. Risk Factors for Infected Arthroplasty
Chronic renal insufficiency
Diabetes
Neoplasm requiring chemo
Tooth extraction
Skin ulcerations / necrosis
Rheumatoid Arthritis
Recurrent UTI
Oral corticosteroids

7. Surgical Techniques
Hemostasis
Prolonged operating time

8. Surgical Techniques
Avoid skin bridges
Avoid creation of skin flaps

9. Clinical Course Pain #1 Swelling Fever Wound breakdown drainage
Windsor et al JBJS; 1990

10. Work-Up Wound History Physical Exam Serial Radiographs
Lab/sed rate/CRP (returns to normal level 3 wk post op.)
Bone scan / Indium scan
Serum interlukine-6 (100%sensitivity & 95%specifity)

11. Arthrocentesis Protein  high Glucose  low
Gold standard for infection diagnosis:
WBC Cell count more than 2500 cells/mm3 & 60% PMN
Protein  high
Glucose  low

12. Arthrocentesis direct smear gram strain Aerobic Anaerobic acid fast
fungi

13. Microbacterial Majority of infections : Staphylococci
Acute hematogenous infections:
Staphylococcus aureus
Beta-hemolytic streptococci
Enterococcus species
Gram-negative bacilli and anaerobes are also seen in chronic infections but uncommon...

14. Staphylococcus aureus
Common cause of musculoskeletal infections:
Early postoperative infection
Late chronic infection
Acute hematogenous infection at the site of a prosthetic joint

15. Staphylococcus aureus
Susceptibility to methicillin treated most effectively with
Antistaphylococcal penicillin (e.g., nafcillinor oxacillin)
First-generation cephalosporin.

16. MRSA: Methicillin-resistant Staphylococcus aureus
first described in 1961
Extra penicillin-binding protein (PBP2a) which results in a low affinity for beta-lactam antibiotics such as the penicillins and cephalosporins

17. MRSA
poor clinical outcome because of the limited effectiveness of antibiotics.
Increase cost for treatment.

18. MRSA Increasing trend in MRSA infection
Staphylococcus aureus (MRSA) from the nosocomial setting and its emergence as a cause of community-acquired infection.

19. Infection TKR Organism Percent Staphylococcus 64
S. aureus, penicillin sensitive S. aureus, penicillin resistant 28 S. epidermis 22
Gram negative 12 Pseudomonas 7 Escherichia coli 5
Anærobic 6
Other 17

20. Treatment of prosthetic infection
Long-term antibiotic suppression
Surgical débridement with retention of the prosthesis
Resection arthroplasty
Arthrodesis
One-stage re-implantation procedure
Two-stage re-implantation procedures
Amputation

21. Treatment of prosthetic infection
Two-stage reconstruction is the standard practice for treating patients with infected total joint arthroplasty.
The success rate of two-stage reimplantation has ranged from %

22. Treatment Options Long-term antibiotic suppression
Surgical débridement with retention of the prosthesis
Resection arthroplasty
Arthrodesis
One-stage re-implantation procedure
Two-stage re-implantation procedures
Amputation

23. Antibiotic suppression
Indicated in:
med compromised patients that prosthesis removal is not feasible
The prosthesis is not loose
Low virulence micro-organism
Duration: life long

24. Treatment Options Long-term antibiotic suppression
Surgical débridement with retention of the prosthesis
Resection arthroplasty
Arthrodesis
One-stage re-implantation procedure
Two-stage re-implantation procedures
Amputation

25. Surgical Debridement Debridement with antibiotic suppression therapy
Limited success and Arthroscopic irrigation is not effective
< 3 weeks

26. Surgical Debridement Debridement with antibiotic suppression therapy
Strep/staphepi -- best
Avoid repeated attempts
Frozen tissue section
Suction drains
6 week antibiotic-therapy
Polyethylene exchange

28. Treatment Options Long-term antibiotic suppression
Surgical débridement with retention of the prosthesis
Resection arthroplasty
Arthrodesis
One-stage re-implantation procedure
Two-stage re-implantation procedures
Amputation

29. Two-stage Re-implantation
Most successful treatment
Procedure of choice

30. Two-Stage Re-implantation
Stage III  Reimplantation
Stage II  6 weeks IV antibiotics
Stage I  Complete debridement

31. Two-Stage Reimplantation
Stage I
remove prosthesis / cement
thorough debridement

33. Two-Stage Reimplantation
Stage I
create antibiotic spacer impregnated with antibiotics
wound closure

41. Two-Stage Re-implantation
Spacer Antibiotic Regimen
Tobramycin 2.4 gm/3.6 gm per gms of PMMA
Vancomycin > 0.5 gm to 1 gm per gms of PMMA

43. Antibiotic Impregnated Spacer
Cidal levels of antibiotic
Spacer to preserve tissue tension
Facilitates re-implant and wound exposure

44. Local Delivery of Antibiotics
Antibiotic cemen bead/spacer
local levels of antibiotics that far exceed those attained with systemic antibiotic therapy.

45. Local Delivery of Antibiotics
Antibiotic bead
- difficulty in removing after implantation.
Antibiotic impregnated spacers
- minimizes limb-shortening
- limits scar formation
- facilitates reimplantation

46. Antibiotic for cement spacer
Microbial Sensitivity
Bactericidal
Heat stable
Powder form

47. Antibiotic for cement spacer
Gentamycin
Tobramycin
Vancomycin
Fosfomycin

48. MRSA Vancomycin is first choice in MRSA Vancomycin bead/cement space
Intravenous vancomycin

49. Block spacers Simple tibio-femoral block Molded arthrodesis block
Articulating mobile spacers (especially in bilateral infected TKAs)

50. Block spacers
Simple tibio-femoral block

51. Block spacers
Molded arthrodesis block

52. Block spacers
Articulating mobile spacers (especially in bilateral infected TKAs)
Multiple Techniques

53. Mobile spacer technique

54. Prosthesis removal

56. Removal of debris and cement

57. Cement spacer molding

59. Insertion with a pack of cement

60. Final implantation

61. Postoperative x- ray

62. PROSTALAC COMPONENTs

63. PROSTALAC COMPONENTs

64. Haffmann’s Procedure:
Using of the patients own prosthesis

65. Stage II – Antibiotic Treatment
Infections About TKR
Stage II – Antibiotic Treatment
Hickman catheter
MIC 1:8 / 6 wks
Patient should use knee brace
In mobile articulating spacers patient is allowed up to 50% PWB and is encouraged ROM

66. Stage III – Reimplantation
 Serial aspirations
 Pre-op planning
 Bone scan / Sed rate

67. Intra-operative Frozen Section
< 5 PMN’s per HPF – no infection
> 10 PMN’s per HPF – infection

68. Treatment Options Long-term antibiotic suppression
Surgical débridement with retention of the prosthesis
Resection arthroplasty
Arthrodesis
One-stage re-implantation procedure
Two-stage re-implantation procedures
Amputation

69. Resection Arthroplasty
Removal all components
Remove all cement
Effective in medically compromised patient

71. Treatment Options Long-term antibiotic suppression
Surgical débridement with retention of the prosthesis
Resection arthroplasty
Arthrodesis
One-stage re-implantation procedure
Two-stage re-implantation procedures
Amputation

72. Arthrodesis Indications
Extensor mechanism disruption
Resistant bacteria
Inadequate bonestock
Inadequate soft tissues
Young patient

73. Advantages
 Definitive treatment
 Little chance of recurrence

74. Disadvantages  Difficulty with transfers/ small spaces
 Increase energy requirements

75. Algorithm TKA Clinical Sepsis Infections About TKR (GRAM + Organism)
< 3 wks
> 3 wks
Debridement Antibiotics (6 wks)
2-Stage Replant

76. Debridement Antibiotics
Infections About TKR
Algorithm
Debridement Antibiotics
2-stage Replant
No Success
No Success
Success
Success
2-stage Replant
Arthrodesis
Resection Arthroplasty

77. Result of treatment in MRSA infection
Yogesh Mittal retrospective cohort study
37 TKA patients with MRSA or MRSE infection
Two stage revision: success rate 76% at median duration of follow-up was 51 months (range, twentyfour to 111 months).

78. MRSA : Antibiotic

79. Alternate antibiotic Allergy to Vancomycin
Pathogen resistance to Vancomycin
increase reports of decreasing susceptibility of S. aureus to vancomycin
Juan J. Picazo.Activity of daptomycin against staphylococci collected from bloodstream infections in Spanish medical centers.Diagnostic Microbiology and Infectious Disease.2009;64 ,448–451

80. MRSA sensitivity Possible alternatives Teicoplanin Daptomycin
Leinazolid
Fosfomycin
Picazo JJ, Betriu C.Activity of daptomycin against staphylococci collected from bloodstream infections in Spanish medical centers.Diagn Microbiol Infect Dis ;64(4):
Schintler MV,High fosfomycin concentrations in bone and peripheral soft tissue in diabetic patients presenting with bacterial foot infection. J Antimicrob Chemother Jul 3.

81. Antibiotic cement in MRSA
Boonsin Buranapanithit : in vitro study
Gentamycin , Cefalexin bead cannot inhibit MRSA
Vancomycin , Fosfomycin bead effectively inhibit growth of MRSA
Boonsin Buranapanitkit.In vitro Elution Characteristics of Antibiotic Cement on MRSA organism.The journal of the asean orthopaedic association.2000,

82. Fosfomycin A synthetic broad spectrum antibiotic
Bactericidal antibiotic
Heat stable
High concentration in bone
Boselli E, Allaouchiche B.Diffusion in bone tissue of antibiotics. Presse Med 1999; 28(40):

83. Conclusions Prevension Adequate surgical debridement Staged revision
Adequate &Susceptibility antibiotic

85. Thanks