Perils and Pearls in - PowerPoint PPT Presentation

1 / 27
About This Presentation
Title:

Perils and Pearls in

Description:

2 with subsequent bacteriologic diagnosis at time of septic failure. 34 s. aureus, 15 s. epidermidis, 3 beta ... Peril: Misapplication of Treatment Options ... – PowerPoint PPT presentation

Number of Views:119
Avg rating:3.0/5.0
Slides: 28
Provided by: markasn
Category:
Tags: pearls | perils

less

Transcript and Presenter's Notes

Title: Perils and Pearls in


1
Perils and Pearls in the Management of the
Infected Total knee
Mark A. Snyder, M.D.
2
Clinical Experience Between 1990 to 1999
  • 56 infected TKR in 56 patients
  • 54 with positive bacteriologic diagnosis by the
    time of revision
  • 2 with subsequent bacteriologic diagnosis at time
    of septic failure
  • 34 s. aureus, 15 s. epidermidis, 3 beta
    hemolytic streptococcus, 2 pseudomonas, 1
    enterococcus, 1 MRSA
  • 5 immediate exchange revision with antibiotic
    inclusion in the cement
  • 29 two-stage revision with cement spacer
  • 22 two-stage revision with articulating spacer

3
Peril The Failure to Recognize Patients at
Increased Risk for Sepsis
  • Immunologically impaired host (RA,
    chemotherapy)
  • Previous open knee surgery
  • Previous joint infection and osteomyelitis
  • Skin ulcerations
  • Diabetes
  • Thomas, CORR, 1983
  • Poss, CORR, 1984
  • Jerry, CORR, 1988
  • England, CORR, 1990
  • Wilson, JBJS, 1990
  • Windsor, JAAOS, 1994

66 WM Diabetes Prior HTO Sepsis lt1 y After TKR
4
Pearl Identify and Reduce Sepsis Risks
  • Meticulous History and Physical
  • Wait until skin ulcers healed
  • Preop aspiration if history of infection
  • Frozen section at time of surgery with less than
    5 WBC per hpf from five sites (Feldman, JBJS,
    1995)
  • Consider antibiotic inclusion in cement 1.0 gm
    Vancomycin and 1.2 gm Tobramycin per pack of
    Palacos
  • Meticulous closure
  • Be ready to flap for gaps
  • lt0.5 sepsis in gt200 high risk TKR patients since
    1990

5
Peril Failing to Diagnose the Infected TKR on a
Timely Basis
  • If sepsis is diagnosed more than 4 weeks after
    the index procedure, open debridement and
    irrigation are probably ineffective.
  • Procrastination and the use of oral antibiotics
    greatly complicate the eventual salvage of the
    infected TKR.
  • The absence of joint aspiration bacteriologic
    data before revision compromises antibiotic
    management.
  • Hartman, CORR, 1991
  • Duff, CORR, 1996
  • Barrack, CORR, 1997

6
Pearl Have a High Index of Suspicion
  • Pain with activity and at rest
  • Persistent swelling
  • Persistent drainage
  • Prolonged elevation of ESR, CRP
  • Early, progressive lucencies
  • Loose hinged arthroplasty (20 times increased
    incidence in Poss, CORR, 1984)

7
Pearl Obtain Preop Joint Aspiration Data
  • Repeat over several weeks if previously on
    antibiotics
  • Avoid skin contamination during aspiration
  • Avoid suppression of bacterial growth by using
    local anesthetics or saline wash with
    preservatives
  • Realize that preop aspiration provides
  • 75-100 sensitivity
  • 96-100 specificity
  • 90-100 accuracy (Duff, 96 and Barrack, 97)

8
Peril Misapplication of Treatment Options
  • Open debridement and irrigation if sepsis
    diagnosed greater than four weeks after index
    procedure
  • Revision without antibiotic inclusion in the
    cement
  • Immediate exchange arthroplasty without favorable
    organism and antibiotic sensitivity profile
  • Fusion in the elderly patient with adequate bone
    stock and intact extensor mechanism
  • Resection in the ambulatory patient with single
    joint disease
  • Amputation for reasons other than relentless,
    life/limb threatening infection

56 Diabetic Poly failure Rest pain for 2
months Preop aspiration
Schoifet, JBJS, 1990
Goksan, JBJS(B), 1992 Hanssen,
CORR, 1994 Knutson, JBJS, 1985
Falahee, JBJS, 1987
9
Pearl Two-stage Revision Techniques Offer the
Greatest Chance to Control Infection and Preserve
Function
  • Rand, JBJS, 1983
  • Insall, JBJS, 1983
  • Borden, J Arthroplasty, 1987
  • Rosenberg, CORR, 1988
  • Wilde, CORR, 1988
  • Hirakawa, J Arthroplasty, 1998
  • Tenny, J Arthroplasty, 1990
  • Wilson, JBJS, 1990
  • Windsor, JBJS, 1990
  • Hanssen, CORR, 1994
  • Masri, Semin Arthroplasty, 1994
  • Whiteside, CORR, 1994
  • Hoffman, CORR, 1995
  • Goldman, CORR, 1996

90
10
Peril Inadequate Pre-op Planning for the
Two-stage Revision
  • Sub optimal patient health status
  • Previous incisions not considered
  • Status of extensor mechanism unknown
  • Lack of bacteriologic diagnosis
  • Unanticipated osteolysis (esp. posterior femoral
    condyles)
  • Implant extraction and cement removal challenges
  • Incomplete array of surgical exposure options
  • Unanticipated wound closure problems

11
Pearl Careful Pre-op Planning
  • Complete screening of patient and knee risk
    features
  • Antibiotic profiles defined
  • Plastic surgery consult for closure and coverage
    challenges
  • Inform patient that muscle flap procedure may be
    added on
  • High speed power and ultrasonic tools available
    in addition to revision instrument tray
  • Spacer versus articulating option anticipated
  • Modular revision system sophisticated enough for
    osseous and soft tissue challenges (i.e.,
    ?adequate constraint)
  • Antibiotic cement combinations address fatigue
    strength and elution concerns

Septic nonunion with failed IF
12
Peril Failure to Confirm Infection by the Time
of Revision
  • Inadequate antibiotic coverage
  • Increased risk of septic recurrence

Immediate exchange Preop aspiration neg Frozen
sections neg MRSA reinfection
13
Pearl Remember to Utilize intraoperative Frozen
Sections
  • If all preop aspirations are negative, but
    clinical signs and radiographs suggest infection
    be sure to obtain frozen sections.
  • If at least five distinct microscopic fields
    yield more than 5 WBC/hpf, consider the
    arthroplasty infected. (Feldman, JBJS, 1995)
  • If the frozen sections are positive, proceed with
    a spacer or articulating spacer with at least 2.4
    gm of Tobramycin and 1.0 gm of Vancomycin per
    pack of Palacos.
  • If the frozen sections are negative in the face
    of clinical/radiograph suspicions, include
    antibiotics in the cement.

Use of antibiotic-impregnated bone cement for
prosthesis fixation at revision surgery was the
only variable that correlated with the cure rate
of deep infection. Hanssen AD, Rand JA, Osman
DR, CORR, 1994.
14
Peril The Challenges of Surgical Exposure Not
Anticipated
  • Loss of extensor mechanism
  • Periprosthetic fractures
  • Excessive operative length
  • Inadequate debridement

15
Pearl Know How to Gain Exposure
  • Midline incision (if possible)
  • Radical synovectomy
  • Quad snip for extension tightness (Garvin, CORR,
    1995)
  • Lateral retinacular release if unable to evert or
    displace the patella
  • Modified patellar turndown (Barrack, AAOS ICL,
    1999)
  • A 4 cm, or more, proximal tibial osteotomy
    (Whiteside, CORR, 1995)

16
Peril Stiffness After the Extraction and
Debridement Procedure
  • Particularly an issue if the second stage is
    delayed several months.
  • Can increase exposure challenges and hazards at
    the time of definitive revision
  • May compromise range of motion
  • 29 spacer revisions ROM -7.5 to 80
  • 22 articulating spacer ROM -5.0 to 104

17
Pearl Consider the Articulating Spacer Technique
  • Use alignment guides and cutting jigs to correct
    deformities
  • Reuse the extracted femoral component if there is
    minimal surface damage
  • Use at least 2.4 gm Tobramycin and 1.0 gm
    Vancomycin per Palacos batch
  • Apply the antibiotic-impregnated cement in a
    dough phase onto wet bone surfaces

Beta strep septic TKR articulating spacer 1
month postop
18
Peril Bone Loss Due to Spacer Blocks
  • Increases with displacement of the spacer
  • Increases in the presence of angular deformity
    and ligamentous imbalance
  • Degree of bone loss can exceed 1 cm (Calton,
    CORR, 1997)

19
Pearl Spacers Useful with Attention to Certain
Details
  • Cut the bone and shape the spacer for maximum
    contact and best alignment
  • Determine the height of the spacer during
    extension tibiofemoral distraction
  • Shape a 1 to 2 cm IM stem on the tibial surface
    to prevent displacement
  • Optimize size for both contact and capsular
    closure
  • Consider a patellar shield to reduce
    peripatellar adhesions

20
Peril High Rates of Reinfection and Poor
Functional Outcomes
  • Procrastination in the diagnosis of infection
  • Absence of bacteriologic information at time of
    revision
  • Failure to diagnosis persistent infection at the
    time of staged revision

21
Peril High Rates of Reinfection and Poor
Functional Outcomes
  • Inadequate debridement of abscesses and
    osteomyelitis
  • Inadequate duration of parenteral antibiotics
    after excision
  • Omission of antibiotic impregnated cement at
    final revision
  • Failure to obtain durable soft tissue closure

22
Peril High Rates of Reinfection and Poor
Functional Outcomes
  • Loss of extensor mechanism
  • Poor range of motion (less than 20 to 90 degrees)
  • Bone loss beyond that managed with implant
    modularity or custom implants
  • Early revision implant loosening

23
Pearl A Systematic Approach to Septic Revision
Based on the Literature and a Large Clinical
Experience
  • Suspect infection if PAIN and SWELLING
  • Obtain joint aspiration data
  • Open debridement if sepsis diagnosed less than 4
    weeks postop
  • Two-stage reimplantation is first choice
  • Thorough debridement and aggressive soft tissue
    coverage including gastroc flaps

24
Pearl Systematic approach
  • Articulating spacer with Vancomycin and
    Tobramycin
  • Six weeks of parenteral antibiotics
  • Reimplant if aspirations and frozen sections
    negative
  • Apply reliable revision principles exposure,
    modularity, stems to bypass defects, antibiotic
    impregnated cement

25
56 Infected TKR Experience
  • 5 immediate exchange revisions
  • Ave FU 4.8 y
  • Reinfection 1 (20)
  • Rest HSS 87.5
  • No pending revisions
  • Organisms 3 beta
  • hemolytic strep,
  • 1 s. epi, 1 MRSA

26
56 Infected TKR Experience
  • 29 two-stage revisions with cement spacer
  • Ave FU 5.9 y (25)
  • Deceased 2
  • Lost to FU 2
  • Reinfection 3 (12)
  • Rest HSS 79.4
  • Poor ROM 7 (28)
  • Organisms 18 s. aureus,
  • 5 s. epi, 1 enterococcus,
  • 1 pseudomonas
  • Revised 6(24), 3 for
  • infection, 3 for extensor
  • mechanism failure

27
56 Infected TKR Experience
  • 22 two-stage with articulating spacer
  • Ave FU 2.8y (22)
  • Reinfection 1 (4.5)
  • Rest HSS 84.5
  • Poor ROM 2 (9.1)
  • Infection free and with good to excellent
    results
  • 18 (81.8)
  • Organisms 14 s. aureus,
  • 8 s. epi
  • Revised 2 (9.1), 1 for infection and 1 for
    patellar loosening and osteonecrosis
Write a Comment
User Comments (0)
About PowerShow.com