ADULT RECONSTRUCTION AND JOINT REPLACEMENT Evolving Technique An Algorithm for 1-Stage Versus 2-Stage Exchange: Here are the Rules Michael B. Cross, MD Assistant Attending Orthopaedic Surgeon
Disclosures • Consultant: • Smith & Nephew • Link Orthopaedics • Exactech Inc. • Intellijoint • Acelity • Theravance Biopharma • Zimmer Biomet • Honorarium: • Acelity • Editorial Board: • Techniques in Orthopaedics • Bone and Joint Journal 360 • Journal of Orthopaedics and Traumatology ADULT RECONSTRUCTION AND JOINT REPLACEMENT
The Problem • #1 or #2 cause for revision THA and TKA • Late PJI incidence ranges from 0.8% to 1.9% ADULT RECONSTRUCTION AND JOINT REPLACEMENT 3
Diagnosis – MSIS Criteria • ESR/CRP – Excellent screening tool; high sensitivity – Rarely normal in the face of infection – Easily obtained The “Classics “ • Joint Aspiration – Synovial fluid WBC : cut-off 1100 - 3,000 cells/uL – Differential : > 80% very suspicious – Culture : must be off of abx for > 2 weeks prior to aspiration Recent Developments • Leukocyte Esterase Strips • α -Defensin immunoassay • Next Generation Sequencing ADULT RECONSTRUCTION AND JOINT REPLACEMENT 4
What are my options? • Treatment Options – Suppression • Susceptible organism • Stable implant – I&D, Liner Exchange, & Component retention – Two stage protocol – One stage protocol – Resection arthroplasty • Recalcitrant / resistant organisms • Multiply re-infected patient • Medically infirmed – Fusion/Amputation ADULT RECONSTRUCTION AND JOINT REPLACEMENT 5
1-Stage Protocol for Infected TJA • Implant Removal – All cement and cement restrictors • Aggressive debridement – Capsule, scar, prior incision, infected bone – Pack the canal after you are done to minimize contamination during the remaining portion of the debridement • Closure • Re-Prep and Drape – New drapes, new sterile instruments, re-scrub, new suction, bovie, lavage • Revision TKA/THA • Prepare the cement (for TKA) • Re-implantation • Closure ADULT RECONSTRUCTION AND JOINT REPLACEMENT 6
2-stage Protocol for Infected TJA • “Gold standard” (For now) • Remove all foreign material • High dose spacer: – Pre-Fabricated spacers, rush rod with cement, or intraoperative molds – 3-6 grams of antibiotics per 40 grams cement – Not meant to be weight bearing • 6 weeks parenteral antibiotics • 2-3 week antibiotic holiday • ESR, CRP, Aspiration to determine Courtesy of Exactech, Inc. eradicaton • Re-implantation ADULT RECONSTRUCTION AND JOINT REPLACEMENT 7 1-Stage Versus 2-Stage Exchange
My Indications for One Stage Revision in 2017 - Acute Infections (<3-6 weeks from surgery) - THA with noncemented components without ingrowth/ongrowth - No data on this - Chronic Infections - Known organisms with known antibiotic sensitivity - Prefer lower virulent organism - Prefer elderly or lower demand patient but not necessary - Intact soft tissue envelope - No sinus tract that is outside the wound 8 ADULT RECONSTRUCTION AND JOINT REPLACEMENT
Contraindications – One stage (Indications for Two-Stage) - Failure of ≥ 1 previous 1-staged procedures or I&D liner exchange - Infection spreading to the neurovascular bundle - Organism unknown or no sensitivity data known - Non-availability of appropriate antibiotics - High antibiotic resistance - Sinus outside the incision - Poor soft tissue envelope (i.e. needs additional surgery to get coverage of the wound) ADULT RECONSTRUCTION AND JOINT REPLACEMENT
Contraindications – Two Stage Revision - Multiply re-infected patient or failed two stage revisions - Girdlestone, Amputation, Fusion - Medically infirmed ADULT RECONSTRUCTION AND JOINT REPLACEMENT
Which is superior? • No direct comparison studies between one stage and two stage • Important outcomes: – Function – Cost – Eradication • Both 1 and 2 stage success rates have been reported to be 70-85% in eradicating infection ADULT RECONSTRUCTION AND JOINT REPLACEMENT
• N=63 patients who underwent one-stage revisions of septic knee endoprostheses – 6 UKA, 37 primary TKA, 20 hinged knee endoprostheses – Minimum f/u 24 months (range:24-70 months) – All were treated locally and systemically with microorganism- specific antibiotics. – Exclusion : MRSA, MRSE, unknown organisms • Results – 0 pts with UKA and primary TKA had recurrence of infection. – 3 of 20 patients with hinged knee prostheses had recurrent infection • One-stage revision success rate of 95% and higher knee scores than reported for two-stage revisions ADULT RECONSTRUCTION AND JOINT REPLACEMENT
• N=102 patients for chronic TKA infections • 28 (27%) were treated using a single-stage approach • 74 (73%) were treated using a two-stage approach. • Mean age of 65 years (range, 45-87 years) with minimum f/u of 3 years (3-9 years) • The indications for using a single-stage approach • Minimal/moderate bone loss, the absence of immunocompromised host, healthy soft tissues, a known organism with known sensitivities for which appropriate antibiotics are available. ADULT RECONSTRUCTION AND JOINT REPLACEMENT 1 1-Stage Versus 2-Stage Exchange 3
• Results: – 0 patients in the single-stage revision group developed recurrence of infection – 5 patients (93%) in the two-stage revision group developed reinfection (p = 0.16) – Patients treated with a single-stage approach had higher KSS scores than patients treated with the two- stage approach (88 versus 76, p < 0.001) Use of a single-stage approach in highly selected patients with chronically infected TKAs is an alternative to a two-stage procedure ADULT RECONSTRUCTION AND JOINT REPLACEMENT 1 4
Prospective RCT Comparing 1 vs. 2 Stage Revision TJA • Site PIs: • Michael Cross (HSS) • Craig Della Valle (Rush) • Javad Parvizi (Rothman) • Thomas Fehring (OrthoCarolina) • Carlos Higuera (Cleveland Clinic) • 10 additional sites are under IRB review • Primary Outcome: Recurrence of deep infection (MSIS) at 1 year • Over 55 patients enrolled to date ! ADULT RECONSTRUCTION AND JOINT REPLACEMENT
Conclusions • The best approach for surgical treatment of an PJI remains controversial • I believe that a one-stage exchange still offers certain distinct advantages with a comparative high success rate • I consider it in: – THA < 3-6 weeks out from surgery • NEED DATA ! – Chronic infections with known, low virulence, sensitive organisms – In my practice more often used in elderly, low demand individuals that will not survive a two stage revision • Results from our ongoing RCT will give more direction ADULT RECONSTRUCTION AND JOINT REPLACEMENT 1 6
ADULT RECONSTRUCTION AND JOINT REPLACEMENT THANK YOU
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