History

1
History

• 87 year old WM transferred from Wilkes Medical
  Center with Left hip pain and discharge on
  10/7/03.
• History of THR on the Left in 1988 with a
  revision in 1995 and a second revision in Feb
  2003 at WFBMC.
• During the 2003 procedure he developed a
  trochanteric fracture and had cerclage cable
  wires placed.

2
History 2

• Developed persistent pain of the hip.
• Was thought to be due to the cerclage wires, and
  these were removed on 9/30/03.
• However he continued to have worsening pain and
  developed a discharge, and returned to the
  hospital.

3
History 3

• PMHx HTN, COPD, s/p L knee arthroplasty in 1999
  and cholecystectomy in 2002.
• MEDS Darvocet N-100 PRN, HCTZ 25mg qd, Lasix
  20mg qd, Advair bid, combivent MDI tid.
• ALL NKDA

4
Physical Exam

• SHx Lives in a rest home in Wilkesboro. No
  history of smoking or alcohol use.
• Physical Exam
• Vitals T-101.7 P-91 RR-18 BP-116/61
• HEENT- Unremarkable LUNGS CTA
• CVS S1,S2 RRR, ABD soft, NT, BS pos
• EXTLeft hip tender with manual vac in place. No
  edema. Pulses palpable

5
Labs

• Hg-13.5, Hct-39.6, plats-248
• WBC-22.9 86 Neutrophils, 2Bands
• ESR-13, CRP-11.61
• BMP-Normal with Cr-1.1, u/a Normal
• Patient taken to OR and had debridement done on
  10/7/03.
• G-stain of OR swab G positive cocci.

6
Wound Culture 10/7/03
7
Questions!

• What are this patients options?
• What is most clinically effective?
• What is most cost effective?

8
Management Strategies for the Infected Hip in the
Elderly

• Major review article by Karchmer, AW et al in CID
  200132(1 Feb)419-430.
• Reviewed exchange arthroplasty Vs debridement and
  prosthesis retention.
• Used a Markov model to simulate patients
  projected lifetime clinical course in
  hypothetical 65 and 80 year old men and women.

9
Literature Review

• 138,000 THA done in US annually.
• Approx 1 get infected.
• 50-60 due to S.aureus or CoNS.
• Standard approach is 2-stage exchange
  arthroplasty.
• Eradicates infection in gt80
• Alternative is open debridement with retention
  and 6 weeks antibiotics.

10
Literature Review 2

• 1st method involves extended immobilization with
  two major procedures.
• 2nd method is less aggressive, but most patients
  will have re-infection.
• Trade off between short term surgical morbidity
  and mortality and long term relapse of infection.

11
Markov Model

• Depict natural history of disease
• Evolving sequence of mutually exclusive health
  states
• Uses transition probabilities to move patients
  through different health states.

12
Methods

• Studies done on infected hip prosthesis from Jan
  1980 to June 1999 were used to provide the raw
  data.
• Monthly probabilities of relapse after each type
  of procedure were obtained from this published
  literature.Quality adjusted Life Years (QALY)
  were used in analysis.

13
Rate of Relapse after Debridement
14
Expected Lifetime Costs
15
Results

• There is not much difference in the QALY for the
  two procedures at 65.
• Debridement patients had more procedures done.
• Higher relapse free interval for exchange
  arthroplasty group.
• At 80, QALY were higher for the debridement and
  retain group.

16
Clinical Outcomes
17
Clinical Outcomes 2
18
Cost Effectiveness

• For 65 yr old men, debridement increased lifetime
  costs by 3600 with a cost of about 19,700 per
  QALY gained.
• Similar for 65 yr old women.
• For 80 yr olds debridement and retention- both
  life expectancy and QALY were increased with a
  cost effectiveness of 500 per QALY.

19
Cost Effectiveness 2
20
Cost Effectiveness 3
21
Conclusion

• Assuming an average relapse rate of 30 after
  debridement and retention.
• Initial debridement with antibiotics increases
  QALY for all the cohorts.
• Reasonably cost effective in gt80 yrs.
• In the absence of prospective controlled trials,
  debridement and retention is a reasonable
  strategy in older persons with a non-loose
  prosthesis.

22
Our Patient

• Was started on Vancomycin and Rifampin.
• Has had two debridement procedures.
• Has been placed on initial 6 week course of
  Vancomycin and Rifampin.

23
Parting Thoughts.

• In the end, the microbes will win
• David Stevens MD
• (Cheerfully related by Jason Kettler MD, Senior
  ID Fellow)
• We are but small soldiers in a large battle
• Aimee Wilkin, MD, MPH