Treatment of the Infected Total Knee Arthroplasty

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Treatment of the Infected Total Knee Arthroplasty

• David Backstein MD, MEd, FRCSC
• Associate Professor of Surgery
• Mount Sinai Hospital
• University of Toronto

EFORT Congress Vienna, 2009
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Devastating Complication

• Blom et al, JBJS(Br) 2004
• At mean of 6.5 years
• 9/931 (1) of primary TKA,
• 4/69 (5.8) of revision TKA
• Compatible with others
• Peersman et al. 2001
• Phillips et al. 2006
• Jämsen et al. 2008

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Classification Segawa
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Treatment Options

• Debridement and retention
• One stage revision
• Two stage revision

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Early Post-operative or Acute Hematogenous
Infections

• Debridement and retention is a reasonable option
  if
• Short duration of symptoms lt 3-4 weeks
• Stable, well fixed implants
• Good soft tissue envelope
• Antibiotic with activity against biofilm organism
  is available

Steckelberg 2000, Schafroth 2003, Giulieri 2004,
Westrich 1999, Fisman 2001,
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Early Post-operative or Acute Hematogenous
Infections

• Debridement and retention is a reasonable option
  if
• Short duration of symptoms lt 3-4 weeks
• Stable, well fixed implants
• Good soft tissue envelope
• Antibiotic with activity against biofilm organism
  is available

Steckelberg 2000, Schafroth 2003, Giulieri 2004,
Westrich 1999, Fisman 2001,
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Early Post-operative or Acute Hematogenous
Infections

• Debridement and retention is a reasonable option
  if
• Short duration of symptoms lt 3-4 weeks
• Stable, well fixed implants
• Good soft tissue envelope
• Antibiotic with activity against biofilm organism
  is available

Steckelberg 2000, Schafroth 2003, Giulieri 2004,
Westrich 1999, Fisman 2001,
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Early Post-operative or Acute Hematogenous
Infections

• Debridement and retention is a reasonable option
  if
• Short duration of symptoms lt 3-4 weeks
• Stable, well fixed implants
• Good soft tissue envelope
• Antibiotic with activity against biofilm organism
  is available

Steckelberg 2000, Schafroth 2003, Giulieri 2004,
Westrich 1999, Fisman 2001,
9
Early Post-operative or Acute Hematogenous
Infections

• Debridement and retention is a reasonable option
  if
• Short duration of symptoms lt 3-4 weeks
• Stable, well fixed implants
• Good soft tissue envelope
• Antibiotic with activity against biofilm organism
  is available

Steckelberg 2000, Schafroth 2003, Giulieri 2004,
Westrich 1999, Fisman 2001
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Early Post-operative or Acute Hematogenous
Infections

• Debridement and retention followed by
• 6 weeks IV antibiotics
• Followed by oral Rx
• Total antibiotics for 6 months

(Zimmerli, Trampuz, Ochsner NEJM, 2004)
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Early Post-operative or Acute Hematogenous
Infections

• Success rate if all prerequisites are met
• 82-100 for staphylococcal infections
• (Zimmerli, 1998, Widmer 1992)
• 89 for streptococcal
• (Meehan, 2003)
• If prerequisites are not met, success rate is
  much poorer (14-68)
• (Tattevin 1999, Brandt 1997)

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Early Post-operative or Acute Hematogenous
Infections

• Critical to success
• Short duration of symptoms
• Type of organism
• Stability of implant

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One Stage Exchange

• Possible Indications
• More than 3-4 weeks of symptoms
• Good soft tissue status
• Organism which is not severely virulent
• Desirable to reduce the cost duration of
  treatment (Vs. 2-stage)

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Late Infection Gold Standard
Two-stage revision is the standard of care for a
late chronic infection of joint replacement

• Cui, 2006
• Leone Hanssen, 2006
• Jämsen, 2004

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Jämsen, 2009

• Overall success rate in eradication of infection

73100 after one-stage 82100 after two-stage
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Two-Stage Exchange

• Chronic / more than 4 weeks symptoms or signs
• Compromised soft tissue envelope
• Virulent organism

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Antibiotic Impregnated Spacer

• Garvin Hanssen (1995)
• reviewed 29 studies
• 2 stage without abx spacer had a better success
  rate than 1 stage exchange (82 vs 58)
• With addition of abx to spacer it improved to 91
  

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Antibiotic Spacers

• Initially used Non-articulating spacer blocks or
  hockey pucks
• Delivers high dose local antibiotics

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Non-articulating Spacers

• Provide high dose of antibiotics
• Easy fast to make
• Maintains joint space and alignment

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Non-articulating Spacers

• Loss of ROM
• Quads shortening wasting
• Bone loss

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Articulating Antibiotic Spacers

• Several authors have advocated for articulating
  spacers
• (Masri,1994, Hofmann, 1995, Fehring, 2000)

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Use of a new ployethylene insert and femoral
component
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Articulating Spacers

• Successful reports going back to 1990
• Allow high dose of antibiotics
• Maintains joint space and alignment

• Maintains ROM
• Maintain quads length and strength
• Allows better patient mobility between stages
• Allows easier and better exposure for the 2nd
  stage
• Rate of success the same as static spacers in
  the literature

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PROSTALACProsthesis with Antibiotic-Loaded
Acrylic Cement

• Antibiotic loaded tibial and femoral components
• Metal-on-polyethylene articular surface
• Haddad (2000)
• 45 pts followed for 48 months
• Eradication of infection in 41 (91)
• Better ROM, less pain, better function and easier
  exposure for revision

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Prefabricated All-Cement Spacers
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Static Vs. Articulating

• The highest average postoperative ranges of
  motion or maximal flexion exceeding 100 degrees
  (104112 degrees) were achieved with articulating
  spacers
• (Fehring et al. 2000, Emerson et al. 2002,
  Durbhakula et al. 2004, Cuckler 2005),

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Jämsen, 2009

• the results of our review and of the most recent
  reports strongly suggest that the use of
  articulating spacersor even definitive new knee
  prosthesesdoes not affect the chances of
  eradicating an infection.

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Leone Hanssen, 2005
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My Antibiotic Dose in Cement

• Spacer (1st stage)
• 8g of antibiotics / bag
• 4g Ceftazidime 4g Vancomycin
• Revision (2nd stage)
• 1g Tobramycin per bag

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Spacer Technique

• Hand mix abx into cement
• Release tourniquet to allow bloody bone surfaces
• Toggle components to prevent excessive fixation
  and easy removal
• Traction on leg while hardening
• pack cement under implants to maximize cement
  volume
• maximize soft tissue tension
• No drain

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Effectiveness of Articulating Spacers

• Hoffman (2005)
• Technique Autoclave the femoral cmpt new poly
  liner antibiotic cement
• Dose 4.8g tobramycin/bag
• Results
• Avg 73 mo post 2nd stage only 6/50 re-infected
• 90 good or excellent results

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Effectiveness of Articulating Spacers

• Emerson (2002)
• Compared 26 pts with non-articulating to 22
  articulating static
• 9 re-infection in articulating
• 8 non-articulating
• ROM of articulating was an avg. 14? better (108
  deg) in articulating group at last F/U

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Effectiveness of Articulating Spacers

• Hart (2006)
• 48 pts, articulating spacer (pre-fab molds)
• 14 days of of IV antibiotics
• Mean f/u 48.5 months
• Eradication in 42/48 (88)
• Concluded that a protracted course of antibiotics
  may not be needed

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Effectiveness of Articulating Spacers

• Other studies showing no negative impact of
  articulation
• Huang (2006)
• Allister (2006)
• Cuckler (2005)

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• English or English abstract, 1980-2005
• 31 original articles
• describing the results of
• 154 one-stage
• 926 two-stage exchange

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Jämsen, 2009

• Re-infection rates lowest in series with
  articulating cement spacer used
• No correlation between clinical outcome and
• length of follow-up
• type of revision
• type of spacer
• Knee scores ROM of one-stage revisions was no
  different from two-stage revisions.

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One Stage Exchange Success Rate

• In THA
• 86-100
• (Ure 1998, Hope 1989, Raut 1994, Callaghan 1999)

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One Vs Two-Stage Exchange

• Re-infection rates of only 9 and 11 after
  one-stage revision have been reported
• (Göksan and Freeman1992, Buechel et al. 2004)
• However
• Failure rate of 27 reported by von Foerster et
  al. (1991) and 42 failure (Hanssen)
• Indicates outcome may not be as predictable as
  two-stage

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Summary

• Chronic infection two-stage remains gold
  standard
• lt4 weeks post op or acute hematogenous
  debridement and retention depending on soft
  tissues and microorganism.

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Post Operative Activity

• Partial weight bearing
• Begin early ROM exercises once wound appears to
  be healing
• PICC line

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Post Operative Antibiotic Regimen

• Optimal type and length of antibiotic therapy is
  not absolutely clear
• Most studies 4-6 week regimen
• Longer duration for MRSA, multi-drug resistant,
  enterococci, fungi
• Antibiotics selected based on the results of
  culture sensitivity

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Antibiotic Regimen

• Recently reports of shorter (23-week) antibiotic
  treatment
• (Hoad-Reddick et al. 2005, Hart, 2006)
• Only short term
• No direct comparison to 4-6 week course

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Second Stage

• 2 weeks prior to re-implantation all antibiotics
  are stopped
• Repeat work up (ESR, CRP, /- re-aspirate)

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Summary of Infection Treatment
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Thank You