Frank Ebert, M.D.

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Management of Infections About Total Knee
Arthroplasty

• Frank Ebert, M.D.
• Union Memorial Hospital
• Baltimore, MD

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Infections About TKR
Range 1.1 - 12.4 Mayo Series 1.2 - 3,000
Brigham/WomensHospital 1.6 - 4,171
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Complications in TKR

• Infection Risk Factors
• Skin ulcerations / necrosis
• Rheumatoid Arthritis
• Previous hip/knee operation
• Recurrent UTI
• Oral corticosteroids

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Complications in TKR

• Infection Risk Factors
• Chronic renal insufficiency
• Diabetes
• Neoplasm requiring chemo
• Tooth extraction

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Complications in TKR

• Infection Clinical Course
• Pain 1
• Swelling
• Fever
• Wound breakdown drainage

Windsor et alJBJS 1990
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Early lt 3 months
Infections About TKR

• Lab Value
• WBCs Mayo Series Mean 7,500
• Differential 67 PMNs
• Sed rate 71 mm/hr
• Arthrocentesis

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Late gt 3 months
Infections About TKR

• Symptoms 52 patients
• ? Pain 96? swelling 77? Debride 27? Active
  drainage 27? Sed rate 63 mm/hr ? WBC - 8300

Windsor et alJBJS 1990
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Late gt 3 months
Infections About TKR

• More common
• Hematogenos spread

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Complications in TKR

• Infection Surgical Techniques
• Avoid skin bridges
• Avoid creation of skin flaps
• Hemostasis
• Prolonged operating time

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Complications in TKR

• Infection Work-Up
• Wound History
• Physical Exam
• Serial Radiographs
• Lab/sed rate/CRP
• Bone scan / Indium scan

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Complications in TKR

• Infection
• Arthrocentesis
• Cell count
• Diff gt 25,000 pmn
• Protein high
• Glucose low

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Complications in TKR

• Infection Work-Up
• Arthrocentesis
• direct smear
• gram strain
• aerobic
• anaerobic
• acid fast
• fungi

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Complications in TKR

• Infection
• Host Response
• Glycocalyx

GristinaJBJS 1983
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Micro Organisms
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Complications in TKRInfection TKR
Organism
Percent
Staphylococcus 64 S. aureus, penicillin
sensitive 14 S. aureus, penicillin
resistant 28 S. epidermis 22 Gram negative 12
Pseudomonas 7 Escherichia coli 5 Anærobic 6
Other 17
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Complications in TKR

• Treatment Options
• Antibiotic suppression
• Aggressive wound debridement

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Complications in TKR

• Treatment Options
• Antibiotic suppression
• Indicated in med compromised
• Organism - gram strep staphepi

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Complications in TKR

• Treatment Options
• Resection arthroplasty
• 2 Stage re-implant
• Arthrodesis
• Amputation

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Complications in TKR

• Treatment Options
• Hip ( success) Knee ( success)
• - - - - - - 18

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Complications in TKR

• Treatment Options
• Debridement with antibiotic suppression therapy
• Limited success
• lt 3 weeks

SchoifetJBJS 1990
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Complications in TKR

• Treatment Options
• Debridement with antibiotic suppression therapy
• Strep/staphepi -- best
• Avoid repeated attempts
• Frozen tissue section
• Suction drains

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Complications in TKR

• Debridement with Antibiotic Suppression
• Hip ( success) Knee ( success)
• 25 to 35 25 to 35

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Complications in TKR

• Two-Stage Reimplantation
• Most successful treatment
• Procedure of choice

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Complications in TKR

• Two-Stage Reimplantation
• Stage I Complete debridement
• Stage II 6 wks IV antibiotics
• Stage III Reimplant

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Complications in TKR

• Two-Stage Reimplantation Procedure
• Remove components, cement, ID
• Fabricate and place spacer
• 6 weeks of antibiotics
• Reimplantation

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Complications in TKR

• Two-Stage Reimplantation Stage I
• remove prosthesis / cement
• thorough debridement

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Complications in TKR

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

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Complications in TKR

• Two-Stage Reimplantation
• Spacer Antibiotic Regimen
• Tobramycin 2.4 gm/3.6 gm per 40 gms of
  PMMA
• Vancomycin gt 0.5 gm to 1 gm per 40 gms of
  PMMA

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Antibiotic Impregnated Spacer
Infections About TKR

• Cidal levels of antibiotic
• Spacer to preserve tissue tension
• Facilitates reimplant and wound exposure

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Complications in TKR

• Two-Stage Reimplantation Stage II
• Reimplantation after antibiotic regimen

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Stage II Antibiotic Treatment
Infections About TKR

• Hickman catheter
• MIC 18 / 6 wks

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Stage III Reimplantation

• ? Serial aspirations
• ? Pre-op planning
• ? Bone scan / Sed rate

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Complications in TKR

• Intra-operative Frozen Section
• lt 5 PMNs per HPF no infection
• gt 10 PMNs per HPF infection

Mirra JBJS
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Complications in TKR

• Results Gm positive
• Windsor et al 92 JBJS 1990
• Insall et al 97 JBJS 1983

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Complications in TKR

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

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Complications in TKR

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

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Advantages
Arthrodesis

• ? Definitive treatment
• ? Little chance of recurrence

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Disadvantages
Arthrodesis

• ? Difficulty with transfers / small spaces
• ? Increase energy requirements

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Algorithm
Infections About TKR

• TKA
• Clinical Sepsis

(GRAM Organism)
lt 3 wks
gt 3 wks
DebridementAntibiotics (6 wks)
2-StageReplant
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Algorithm
Infections About TKR

• DebridementAntibiotics

2-stage Replant
No Success
No Success
Success
Success
Arthrodesis
ResectionArthroplasty
2-stage Replant
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Thank You
Frank R. Ebert, MD