Primary Total Hip Arthroplasty After Infection

1
Primary Total Hip Arthroplasty After Infection

• ICL 2001, Chapter 33
• Robbins, MD Masri, MD Garbuz, MD Duncan, MD
• Presented by Sepein Chiang, D.O.
• Garden City Hospital

2
Introduction

• More than 200,000 THAs performed annually in the
  US
• Small number performed after proven infection of
  the hip or proximal femur
• Can produce severe early destruction of the hip
  joint
• If treated early, may only need treatment much
  later in life for secondary degenerative changes

3
Introduction

• Always be aware of the possibility of previous
  infection
• Always treat previously cured bone and joint
  infections with skepticism
• First recurrence may be delayed for decades
• Gallie reported a case of femoral osteomyelitis
  in a 10 year old girl that first recurred after
  80 years

4
Introduction

• Type of infection osteomyelitis or septic
  arthritis
• Activity active or quiescent
• Time since infection recent or historic
• Organism pyogenic, tuberculous or fungal
• Treatment options

5
Osteomyelitis

• In the western world, progressive reduction in
  prevalence
• Early childhood begins in the metaphysis and
  spreads to the femoral head causing
  osteonecrosis, septic arthritis and severe hip
  destruction
• S. aureus most common (90)
• S. epidermidis, streptococci

6
Osteomyelitis

• Most recurrences are apparent within the first
  year
• 18 (119 of 655) recurrence
• 66 occurred by 6 months
• 82 by 1 year
• 6 after more than 5 years
• 50 had only one episode of recurrence
• Proximal femur 12, pelvis 5
• Gillespie and Mayo, JBJS British, 1981

7
Septic Arthritis

• 141 adult hips with septic arthritis
• S. aureus in 77
• Gram negative organisms in 16
• Streptococci in 4
• H. influenzae peak incidence at age 2 years
• Gram negatives more common in adults
• Kelly, Orthop Clin North Am, 1975

8
Septic Arthritis

• Diagnosis may be difficult and delayed in infants
• By-products of leukocytes and bacteria cause
  rapid cartilage erosions
• Of all joints, infection of the hip is
  particularly incapacitating

9
Septic Arthritis

• Osteonecrosis of the epiphysis
• Trochanteric overgrowth or coxa magna
• Bony or fibrous ankylosis
• Acetabular dysplasia
• Destruction of the proximal femur with
  dislocation
• Adverse effects on future THAs

10
Tuberculous Infections

• Prevalence of pulmonary TB has decreased
• Prevalence of extrapulmonary TB has remained
  steady
• 400 cases of skeletal TB per year in the US, of
  which 13 involved the hip
• Mainly affects adults in the 5th and 6th decades
• Immunosuppressed, malnourished
• Increased reactivation rates in pts w/ HIV

11
Tuberculous Infections

• Radiographically destructive appearance with
  adjacent osteopenia and minimal sclerosis
• May simulate pyogenic arthritis periosteal
  reaction, sclerosis and sequestrum formation

12
Fungal Infections

• Less joint destruction
• Not always necessary to irrigate or debride the
  joint
• Spontaneous infection of the natural hip joint is
  usually caused by noncandidal fungi
• Candida is the only fungus reported to have
  caused infections at a THA
• Usually associated with immunosuppression, IV
  therapy, drug abuse or direct inoculation

13
Risk Factors

• IV drug abuse 4X increase in infections of the
  hips, SI and sternocostal joints
• Hemoglobinopathies sickle-cell disease and
  Salmonella
• Ongoing sources of infections
• History of previous joint infection
• Immunosuppression
• Malnourishment

14
Exclusion of Active Infection HP

• Fever
• Discharging sinus
• Rapidly increasing hip pain that has previously
  been infected

15
Exclusion of Active Infection Hematologic
Investigations

• WBC can often be normal
• ESR nonspecific
• Transient elevation due to minor illness
• Permanent elevation in chronic conditions such as
  connective tissue disorders
• Cutoff of 30 mm/h has a sensitivity of 60 to 95
  and specificity of 65 to 85

16
Exclusion of Active Infection Hematologic
Investigations

• CRP acute phase protein
• Sanzen unless another probable cause was
  apparent, a CRP gt20 mg/L indicated deep sepsis
• Improved diagnostic accuracy by considering ESR
  and CRP together
• Spangehl all 35 of 202 THAs that were infected
  had an ESR gt30 or a CRP gt10
• Normal ESR and CRP effectively excluded infection
• Elevation of both indicates an 83 probability of
  infection

17
Exclusion of Active Infection Plain Radiographs

• Chronic osteomyelitis sclerosis with adjacent
  osteopenia, cortical thickening
• Osteoarthritis secondary to a healed septic
  arthritis should evolve slowly with subchondral
  sclerosis and marginal osteophytes
• Reactivation of infection sudden clinical
  deterioration with rapid bone destruction

18
Exclusion of Active Infection MRI

• Active osteomyelitis dark on T1, bright on T2
• With chronicity, the bright T2 marrow signal
  becomes more heterogeneous
• 95 sensitivity
• 88 specificity

19
Exclusion of Active Infection Technetium Bone
Scan

• Very sensitive, nonspecific indicator of
  osteoblastic activity
• Effectively treated chronic osteomyelitis may
  remain positive for over 1 year

20
Exclusion of Active Infection Gallium Citrate
Scanning

• Taken up by leukocytes
• Better indicator of infection than technetium
  alone
• Often used sequentially with technetium
• Less sensitive than technetium
• Less specific than indium-labeled WBC scan

21
Exclusion of Active Infection Indium-labeled
WBC Scan

• Merkel More sensitive and specific than
  sequential technetium-gallium scan for low-grade
  musculoskeletal sepsis
• Criticized in detecting chronic infections when
  PMNs were labeled
• Improved when a third of the labeled leukocytes
  were lymphocytes
• Decreased specificity where remodeling is
  occurring, such as in a degenerated hip

22
Exclusion of Active Infection Aspiration Biopsy

• Cherney and Amstutz no growth on preimplantation
  aspiration of any of the 23 (7 of 31) of hips
  that had a recurrence of infection after THA
• 86 sensitivity
• 94 specificity
• May perform multiple core needle biopsies for
  bacteriologic and histologic analysis

23
Exclusion of Active Infection Mantoux Test

• Suspected tuberculous infection
• Intradermal skin test

24
Treatment Options

• One or two stage reconstruction
• Antibiotic cement
• Girdlestone
• Arthrodesis

25
Single Stage Reconstruction

• Buchholz 10 yr f/u on 583 pts
• Antibiotic cement
• 77 eradication
• Raut 7.5 yr f/u on 57 pts w/ actively draining
  sinuses
• Gentamicin cement
• 86 eradication

26
Two Stage Reconstruction

• Garvin reviewed 29 studies
• 1 stage, no antibx cement 58 cure
• 2 stage, no antibx cement 82 cure
• 1 stage, antibx cement 82 cure
• 2 stage, antibx cement 91 cure

27
Two Stage Reconstruction

• Time interval from debridement to implantation 6
  wks to 6 months
• McDonald 5.5 yr f/u on 82 pts w/ cement without
  antibiotics
• Reinfection rate was significantly higher when
  reimplantation was lt1 year, 27 vs 7

28
Antibiotic Cement

• Addition of antibiotics to cement is unusual in
  North America
• 57 of surgeons in the United Kingdom routinely
  add antibiotics to cement in primary cases
• Masri found therapeutic levels of tobramycin in
  the periprosthetic fluid up to 4 months after
  implantation of antibx spacers

29
Antibiotic Cement

• Streptomycin cement for active tuberculous
  osteomyelitis
• Amphoteracin-B cement for fungal