Evolving Technique Update: Alternative to 2 Stage Revision, When I - PowerPoint PPT Presentation

Evolving Technique Update: Alternative to 2 Stage Revision, When I Can, When I Can’t, and What I Do 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

What are my options?  Treatment Options  Suppression – Susceptible organism – Stable implant  I&D, Liner Exchange, & Component retention  2-stage protocol  1-stage protocol  Girdlestone/Amputation – Recalcitrant / resistant organisms – Multiply re-infected patient – Medically infirmed 3 Alternatives to the 2-Stage Exchange

Antibiotic Suppression  Indications:  Acute hematogenous infection  High operative risk  Immunocompromised  Contraindications:  Resistant organisms  Late onset PJI  Chronic PJI Never my choice of treatment 4 Alternatives to the 2-Stage Exchange

Relative Success - Antibiotic Suppression 21 patients , median age of 67 years (range 21 - 88), and median follow-up of 21 months (range 3 - 81)  Coagulase negative staphylococci (CNS) (n=6), S. aureus (n=6) and polymicrobial flora (n=4) most common  Most patients with CNS and S. aureus were treated with minocycline (67%) and clindamycin (83%)  Overall, treatment was successful in 67% of patients  – Failure was due to persistent joint pain (n=1), surgical intervention because of an uncontrolled infection (n=3), and death due the infection (n=3) 34 patients (24 hips, 10 knees); 12 early, 16 delayed and six late infections  MSSA (4), MRSA (8), MSSE (4), MRSE (5), Enterococcus faecalis (2), MRSE + E. faecalis (1 mixed infection), and  MRSA + Pseudomonas aeruginosa (1 mixed infection) All patients began antimicrobial therapy within 3 months of the clinical onset of infection  Infection was suppressed in 31 (91.2%) of 34 patients, with no relapse being observed in 17 (50%) patients  after follow-up for 9–57 months following discontinuation of antibiotics 5 Alternatives to the 2-Stage Exchange

I&D, Liner Exchange, Component Retention  Indications:  Acute infection (within 2-4 weeks of surgery/symptoms)  Stable implant  Low virulence organisms identified  Soft tissue intact  Contraindications:  Loose prosthesis  Poor soft tissue coverage  Bone/cement mantle compromise  Sinus tract  MRSA or MSSA  Two or more previous I&Ds  >4 weeks of symptoms 6 Alternatives to the 2-Stage Exchange

Relative Success - I&D, Liner Exchange, Implant Retention 32 patients, mean age of 66 ± 16 years (23 hips, 16 knees) all with S. aureus PJIs  Surgical management of irrigation & debridement, antibiotics and implant retention (DAIR) – all treated with  rifampicin-containing combinations for curative antibiotic therapy Overall, treatment was successful in 75% of patients (25 of 32)  – All of the failure cases (relapse or superinfection) were diagnosed while patients were receiving suppressive antibiotics 99 PJIS in 91 patients, median age of 74 years (23-95), 47 hips & 52 knees  Surgical management of irrigation & debridement, antibiotics and implant retention (DAIR)  Median duration of IV antimicrobial therapy = 28 days , followed by chronic oral antimicrobial suppression  The 2-year survival rate free of treatment failure for the entire cohort was 60% (95% CI, 50%– 71%)  Presence of a sinus tract and a duration of symptoms > 8 days were risk factors for failure 

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 THA  Re-implantation  Closure 6

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 9

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)

Relative Success – 1 Stage Exchange  24 one-stage revision surgeries were performed for septic failure of a total hip arthroplasty in 24 patients without draining sinuses, without immunocompromise, and with adequate bone quality after debridement  Twelve patients died and none were lost to follow-up at a minimum of 10 years after the procedure  Standard approach of meticulous debridement, use of antibiotic-impregnated cement, and use of 3 to 6 months postoperative oral antibiotic therapy  Infection reoccurred around two hips (8.3%) 11 Alternatives to the 2-Stage Exchange

Relative Success – 1 Stage Exchange  N=63 one-stage revisions (6 UKAs, 37 primary TKAs, and 20 hinged knee endoprostheses)  Excluded MRSA, MRSE, and culture-negative PJIs  Mean 36 month follow-up (minimum 24 months)  Results:  One-stage revision of septic knee prostheses achieved an infection control rate of 95%  3 of the 20 hinged endoprostheses failed (infection recurrence) – All 3 had chronic PJIs >5 years in total length and had previously undergone multiple revisions 12 Title of Presentation Here

Relative Success – 1 Stage Exchange Table 1. Infection eradication rates after one-stage direct exchange for knee periprosthetic sepsis ( Romano et al, Knee Surg Sports Traumatol Arthrosc, 2012 ) Author Follow-up N No. of eradicated Eradication rate (%) (months) infections Buechel et al. [6] 22 22 20 90.9 Goksan and Freeman 60 18 16 88.9 [17] Lu et al. [38] 20 8 8 100 Silva et al. [55] 48 37 33 89.2 Sofer et al. [56] 18 15 14 93.3 von Foerster et al. [63] 76 104 76 73.1 Total 204 167 Mean 40.7 89.2 SD 24.4 8.9 Mean eradication rate 81.9 13 Alternatives to the 2-Stage Exchange

Girdlestone/Amputation  Indications:  Recalcitrant / resistant organisms  Multiply re-infected patient  Medically infirmed  Non-ambulatory patients  Patients with limited bone stock  Poor soft tissue coverage  Infections due to highly resistant organisms for which there is limited medical therapy  Previous failed two-stage revisions 14 Alternatives to the 2-Stage Exchange

What’s my best option? Relative Success Rate Treatment Option Published Risks for Failure (Infection Clearance) ~30-67% Virulent organisms, late onset Antibiotic Suppression ~50-86% Presence of sinus tract, late onset, younger age, virulent organisms, DAIR history of RA, ESR > 60 mm/h, and coagulase-negative staphylococcus, MRSA ~73.1-100% Culture negative, Polymicrobial, gram 1-Stage negative, and methicillin-resistant organisms ~74% Amputation 15 Alternatives to the 2-Stage Exchange

I & D or Removal? See Next Figure Osman et al, Clin Inf Disease, 2013 16 Alternatives to the 2-Stage Exchange

1-Stage or 2-Staged? See Next Figure Osman et al, Clin Inf Disease, 2013 17 Alternatives to the 2-Stage Exchange

Resection or Amputation? Osman et al, Clin Inf Disease, 2013 18 Alternatives to the 2-Stage Exchange

Conclusions  Suppressive antibiotic therapy in the treatment of chronic prosthesis infections has limited clinical benefit and is associated with a substantial risk of adverse effects  In the presence of an acute PJI with an identified organism I & D + liner exchange vs 1 stage revision  Depends on whether components well fixed  In the presence of a chronic PJI with an identified organism, no sinus tract, and good soft tissue coverage 1-Stage Revision  Multiple failed two stages, highly resistant organisms, nonambulatory Girdlestone vs Amputation 19 Alternatives to the 2-Stage Exchange