Frank Ebert, M.D.

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Management of Infections About Total Hip
Arthroplasty

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

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Infections About THA
Range 1.1 - 12.4 - 60s Rate 2000 0.5 Rate
Primary OA 0.06
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Complications in Arthroplasty

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

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Complications in Arthroplasty

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

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Complications in Arthroplasty

• Infection Clinical Course-
  Acute/Chronic
• Pain 1
• Swelling
• Fever
• Wound breakdown drainage

Windsor et alJBJS 1990
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Early lt 3 months
Infections About THA

• 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-Chronic
Infections About THA

• ? 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-Acute-Late Hematogenous
Infections About THA

• Recent Hx-surgery/dental/distal infection
• Classic Symptoms of Sepsis
• Fever, Pain,ElevatedWBC

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Complications in Arthroplasty

• Infection Surgical Techniques
• Avoid skin bridges-7 cm rule
• Avoid creation of skin flaps
• Hemostasis
• Prolonged operating time

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Complications in Arthroplasty

• Infection Work-Up Requires a Combination of
  Studies
• Wound History
• Physical Exam
• Serial Radiographs
• Lab/sed rate/CRP/WBC
• Bone scan / Indium scan

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Complications In Arthroplasty

• Indium Scan
• Superseded Tech and Gallium
• More Specific and More Sensitive
• Specificity and Sensitivity gt 85

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Complications in Arthroplasty

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

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Complications in Arthroplasty

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

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Complications in Arthroplasty

• Infection
• Host Response
• Glycocalyx

GristinaJBJS 1983
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Prosthetic Joint Infection

• Biofilm
• Biofilm on implants and devitalized tissue causes
  chronic disease
• Understanding biofilm enlightens one to logical
  treatment

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Biofilm

• Characteristics
• All bacteria make biofilm
• Foreign and devitalized tissue can succumb to
  biofilm formation if exposed to bacteria

Costerton Science 2841318. 99
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Biofilm

• Characteristics
• 15 cells, 85 matrix
• Matrix polysaccharide
• Biofilms have structure
• Cells live in a microecology and communicate!

Costerton Science 2841318. 99
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Biofilm

• Significance in PJI
• In biofilm state, bacteria become 1000x to 1500x
  more resistant to antibioctics
• In biofilm state, bacteria express up to 65 new
  genes which change cell wall and/or membrane
  structure

Costerton Science 2841318. 99
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Biofilm State

• Significance in PJI and Osteomyelitis
• Resistant to antibiotics
• Biofilm permeable to antibiotics all the way to
  base within 90 secs
• Resistant to WBCs and Phagocytosis
• Resistant to Antibiotics

Costerton Science 2841318. 99
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Biofilm

• Significance in PJI
• Biofilm can colonize, grow and cover a surface
  within 4-8 days!
• Prolonged wound drainage should not be allowed

Costergan. W. MSIS 2000
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Treatment Prosthetic Joint Infection

• Chronic Infections
• To effectively treat a chronic infection, you
  must be able to planktonize cells
• At present time, effective treatment means
  prosthetic removal and debridement of surrounding
  devitalized bone and tissue

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Micro Organisms
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Complications in ArthroplastyInfection THA
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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Prosthetic Joint Infection

• Classification-Treatment Purposes
• Early Post-Op (lt4 weeks)
• Late Hematogenous
• Chronic

Tsukayama et al JBJS 78A, 96
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Prosthetic Joint Infection

• Treatment
• Early Post-Op Infection lt 4weeks
• ID with retention of components
• Change modular parts
• Resection of components if ID fails

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Prosthetic Joint Infection

• Treatment
• Hematogenous Infection
• ID with retention of components
• Change modular parts
• 2 stage reimplantation if ID fails

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Complications in Arthroplasty

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

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Complications in Arthroplasty

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

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Complications in Arthroplasty

• Two-Stage Reimplantation-Chronic/Failed Acute
  Treatment
• Most successful treatment
• Procedure of choice
• Remember Biofilm

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Complications in Arthroplasty

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

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Complications in Arthroplasty

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

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Complications in Arthroplasty

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

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Complications in Arthroplasty

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

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Complications in Arthroplasty

• 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 THA

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

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Complications in Arthroplasty

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

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Stage III Reimplantation

• ? Serial aspirations
• ? Pre-op planning
• Bone scan /Indium Scan
• ESR/CRP/WBC

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Complications in Arthroplasty

• 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 Arthroplasty

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

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Algorithm
Infections About THA

• THAClinical Sepsis
• Acute/Hematogenous

(GRAM Organism)
lt 4 wks
gt 4 wks
DebridementAntibiotics (6 wks)
2-StageReplant
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Algorithm
Infections About THA

• DebridementAntibiotics

2-stage Replant
No Success
No Success
Success
Success
ResectionArthroplasty
2-stage Replant
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Thank You
Frank R. Ebert, MD
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Stage II Antibiotic Treatment
Infections About THA

• Hickman catheter / Pick Line
• MIC 18 / 6 wks

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Complications in Arthroplasty

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

SchoifetJBJS 1990
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Complications in Arthroplasty

• Treatment Options
• Antibiotic suppression
• Aggressive wound debridement

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Complications in Arthroplasty

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

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Complications in Arthroplasty

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

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Complications in Arthroplasty

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

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Complications in Arthroplasty

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

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Complications in Arthroplasty

• 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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