1. Prof. Paolo Cherubino Dipartimento di scienze ortopediche e traumatologiche Universitas Studiorum Insubriae VARESE Total knee revision in septic failure Epidemiology, timing and classification

2. The most commons causes of knee arthroplasty revisions: Infections (25.2%)Infections (25.2%) Mechanical failure (16.1%)Mechanical failure (16.1%) The Epidemiology of Revision Total Knee Arthroplasty in the United States Kevin Bozic, MD. 2007 Epidemiology

3. Epidemiology The systemic risk factors: rheumatoid arthritisrheumatoid arthritis diabetesdiabetes IRCIRC obesityobesity advanced ageadvanced age debilitationdebilitation oral steroidsoral steroids cancer/chemotherapic treatmentcancer/chemotherapic treatment immunocompromised patientsimmunocompromised patients Simmons TD, Stern SH. Diagnosis and management of the infected total knee arthroplasty. Am J Knee Surg. 1996 Risk factors

4. Epidemiology The local risk factors are : Previews knee surgeryPreviews knee surgery Skin complications after the implantSkin complications after the implant psoriatic skin ulcerspsoriatic skin ulcers Simmons TD, Stern SH. Diagnosis and management of the infected total knee arthroplasty. Am J Knee Surg. 1996 Risk factors

5. Infection is actually, rare but serious problem in joints arthroplastic surgery

6. INFECTION RATE AFTER TOTAL KNEE ARTHROPLASTY Grogan J. Bone Joint Surg. Am.1986; 68:226-34 Grogan J. Bone Joint Surg. Am.1986; 68:226-34 Wilson J.Bone Joint. Surg. Am. 1990; 72:878-83 Wilson J.Bone Joint. Surg. Am. 1990; 72:878-83 Bengston Acta Orthop Scand. 1991; 62(4):301-11 Bengston Acta Orthop Scand. 1991; 62(4):301-11 Rand JA. Orthop Clin North Am. 1994. Rand JA. Orthop Clin North Am. 1994. 0,5 - 5% Epidemiology

7. Epidemiology J Bone Joint Surg Am. 1999 Oct;81(10):1434-45. “The prevalence of infection after primary total knee arthroplasty has been reported to range from 0.5 to 5 percent.”

8. “Current infection rates are in the 1% to 2%.” in the 1% to 2%.” Epidemiology The Journal of Arthroplasty Vol. 19 No. 4 Suppl. 1 2004

9. “Our known infection rates of 1% after primary and 5.8% after revision TKA are comparable with published reports.” Epidemiology A. W. Blom, J. Brown, A. H. Taylor, G. Pattison, S. Whitehouse, G. C. Bannister 2004

10. “Deep infection rates in total knee joint replacement vary in the published literature between 0.3% and 2.9%.” Epidemiology 2007 HSSJ (2007) 3: 159–163

11. Epidemiology “Incidence rates for primary TKA between 1995 and 2004, from 6.3 to 11.0 at a rate of 5.1% per year (p < 0.001).”

12. Etiology E. Coli Legionella P. Staph. A. Staph E. Gram - Streptococcus Pre and intra-operative pathogen ISOLATION ISOLATION

13. The Journal of Arthroplasty Vol. 19 No. 4 Suppl. 1 2004 Etiology

14. Etiology A. W. Blom, J. Brown, A. H. Taylor, G. Pattison, S. Whitehouse, G. C. Bannister 2004

15. J Bone Joint Surg Am. 1999 Oct;81(10):1434-45. Etiology

16. Etiology Chang Gung Med J. 2008 Nov-Dec;31(6):583-91.

17. Clinical-temporal classification Immediate: before 4 weeksImmediate: before 4 weeks Early: between 4 wks to 2 yearsEarly: between 4 wks to 2 years Delayed: over 2 yearsDelayed: over 2 years Occasional: positive culture in replacementOccasional: positive culture in replacement Segawa et al. JBJS, 1999

18. Coventry’s state Step I = Acute infection post-operative Step I = Acute infection post-operative (within 3 months after) Stage II = delayed deep infection Stage II = delayed deep infection (3 to 24 months after) Stage III = late hematogenous infection (a distance of years) Step Zero = Operating contamination (positivity of at least 2 of 3 buffers intra-op) (positivity of at least 2 of 3 buffers intra-op) Classification Coventry MB. Orthop Clin North Am. 1975 Oct;6(4):991-1003.

19. Classification J Bone Joint Surg Am. 85-A · SUPPLEMENT 1 · 2003

21. Choice of treatment is based on: anatomical-clinical microbiological microbiological Accurate diagnostic grading Therapeutic option

22. CBC, VES and PCRCBC, VES and PCR instrumental and clinicalinstrumental and clinical Preoperative aspiration culturePreoperative aspiration culture Replacement-Timing Clinical orthopaedic and related research n345, 1997

23. Arthroscopy Arthroscopy Toilette Toilette Replacement Replacement Arthrodesis Arthrodesis Resection - arthroplastic Resection - arthroplastic Amputation Amputation Purpose of surgery infection eradication infection eradication save joint function save joint function Therapeutic option

24. IMMEDIATE INFECTION Toilette+ Suppressive antibiotic therapy (at least 3 wks)

25. EARLY INFECTION open surgery or arthroscopic TOILETTE+ Suppressive antibiotic therapy (at least 3 wks)

26. LATE INFECTION Remove implant and Surgical debridement ARTHRODESISREIMPLANT age, general conditions, indication indication One stage Two stage

27. INFEZIONE TARDIVA REIMPLANT One stage Two stage age, general conditions, indication indication Remove implant and Surgical debridement ARTHRODESIS

28. The two-stage exchange procedure has evolved as an effective treatment option. Clin Orthop Relat Res. 2007 Nov;464:164-78 Therapeutic option

29. The best results of treatment of an infected TKR have been reported by Windsor et al in which no spacer was used between stages Windsor RE, Insall JN, Urs WK, Miller DV, Brause BD. Two-stage reimplantation for the salvage of total knee arthroplasty complicated by infection: further follow-up and refinement of indications. J Bone Joint Surg [Am] 1990. Therapeutic option

30. Treatment of TKA infection with a two- stage exchange had a significantly better outcome than debridement with retention of the prosthesis. Good results were obtained with two-stage revision of infected TKA International Orthopaedics (SICOT) 2008 Therapeutic option

31. Two-stage reimplantation of an infected total knee arthroplasty using a static antibiotic-cement spacer achieved an infection control rate of 86% and improvement in the clinical results. Therapeutic option

32. F, 75 aa PM S. Aureus PREOP # 1

33. F, 75 aa PM S. Aureus ESP # 1

34. S. Aureus ESP F, 75 aa PM # 1

35. S. Aureus F-U 1 anno F, 75 aa PM # 1

36. F, 78 aa IS Serratia marcescens PREOP # 2

37. Serratia marcescens ESP F, 78 aa IS # 2

38. SerratiamarcescensESP F, 78 aa IS # 2

39. Serratiamarcescens F-U 3 anni F, 78 aa IS # 2