Mayo Clinic Arizona Evolving Technique Update 63 year old Hedge Fund Trader Notices The Top Part of His Wound Draining Milky White Fluid amp Is Concerned He Calls at Midnight Disclosures Henry D Clarke MD ID: 915864
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Slide1
Henry D Clarke MD
Professor of OrthopedicsMayo Clinic, Arizona
Evolving Technique Update:
63 year old Hedge Fund Trader Notices The Top Part of His Wound Draining Milky White Fluid & Is Concerned – He Calls at Midnight
Slide2Disclosures
Henry D Clarke MD
Institutional Research VidacareSupport: StrykerPaid Consultant: ConforMIS
Smith & Nephew Zimmer-BiometRoyalties: ConforMIS Zimmer-BiometPublishing Income: JAAOS
Slide35 Key Points
Stay in control
Aspirate before antibioticsTimely evaluationMake an accurate diagnosis that differentiates between superficial & deep infectionDefinitive intervention
Slide45 Key Points
Stay in control
Surgical team does the evaluationOffice vs Hospital ED?
Slide55 Key Points
Stay in control
Aspirate before antibiotics
Slide65 Key Points
Stay in control
Aspirate before antibioticsTimely evaluation24-48 hoursH&PLabs (ESR, CRP, CBC)Aspiration
Slide75 Key Points
Stay in control
Aspirate before antibioticsTimely evaluationMake an accurate diagnosis that differentiates between superficial & deep infectionMSIS criteria helpAspirate if any doubt
Slide8Diagnosis of PJI
Sinus tract communicating with joint; or
Pathogen isolated from 2 or more separate tissue or fluid samples; orWhen 3 or the following criteria exist:
Definite Prosthetic Joint Infection Exists where:Workgroup convened by the Musculoskeletal Infection Society, J. Arthroplasty 25(8), 2011
Parvizi J, J. Arthroplasty 29 (2014) 1331
Slide9Diagnosis of PJI
Elevated ESR & CRP
Elevated synovial WBC count or + Leukocyte Esterace stripElevated synovial PMN % Pathogen in one fluid or tissue culture> 5 WBC/HPF in 5 separate fields at 400X mag
Parvizi
J, J. Arthroplasty
29 (2014) 1331Definite Prosthetic Joint Infection Exists where
3 of 5 minor criteria are met:
Slide10Diagnosis of Acute PJI
Acute (<90 days post-op) vs Chronic
Chronic PJIESR >30, CRP >10Aspiration: 3K WBC, 80% PolysAcute post-operative period
ESR not helpful, CRP >100Aspiration: 10K WBC, 90% PolyParvizi J & Gehrke
T J. Arthroplasty 29 (2014) 1331Bedair H et al, CORR 469, 2011
Slide11Diagnosis of Acute PJI
Additional Tests
Synovial fluid testsAlpha-defensins (Synovasure)100% sensitivity;95% specificity24-96 hours
Deirmengian C et al, CORR 440, 2005; Bingham J et al, CORR 472, 2014
Slide125 Key Points
Stay in control
Aspirate before antibioticsTimely evaluationMake an accurate diagnosis that differentiates between superficial & deep infectionDefinitive interventionStaple /suture removal & observationDebridement & prosthesis retention2 stage revision with a spacer
Slide13This case:
63 yo <1 month from surgery with wound drainage calls at midnight
Send picture of woundSee first thing in am at my office NPOEvaluateLabs & aspiration if neededAcute post-op peri-prosthetic joint infectionTo hospital for prosthesis salvage that day or next am
Hold antibiotics unless systemically sick
Slide14Open Debridement
with Prosthesis Retention
1 stage open debridement with retention20 – 50% successEarly debridement (< 5 days) better than lateSensitive organism
Tattevin: Clin Infect Dis 29: 1999
Slide15Open Debridement
with Prosthesis Retention
Open Debridement (Mayo Series)99 knees 1995-199960% success at 2 yr follow-upDuration of >8 days of symptoms was associated with increase risk of failure
Marculescu CE et al, Clinical Infectious Diseases 42, 2006
Slide16Open Debridement
with Prosthesis Retention
Multi-center study2 Stage Re-implantation after failed debridement83 knees28 (34%) persistent infection
Sherrel J.C et al, CORR 469, 2011
Debridement burns bridges for subsequent salvage
Slide17Open Debridement
with Prosthesis Retention
Database study from California/NY750 patients with 2 stage revision57 failed prior I&D with component retentionNo difference in success rate for 2 stage revision (p=0.12)
Brimmo O, Barsoum W et al, J Arthroplasty 31:461, 2016
Slide18Surgical Management of Acute Infections
Rationale
Because of the historically poor results of single stage open debridement with prosthesis retention we started a new protocol for patients who present with acute infectionsTwo-stage debridement with beads protocol
Slide19Surgical Management of Acute Infections
Patients presenting with acute PJI (
symptoms < 4 weeks)Post-operativeAcute hematogenous
Slide202 Stage Debridement with Prosthesis Retention for Acute PJI in TKA
Estes CS et al, CORR 468, 2010
Slide212 Stage Debridement with Prosthesis Retention for Acute PJI in TKA
Results
Min F/u 1 year, mean 3.5 years18 of 20 (90%) considered success with no evidence of active infection10 no antibiotics8 long-term suppression
No re-operations2 patients considered failures Both on suppressive antibiotics
Slide22Surgical Management of Acute Infections
Technique
Proceed to surgery urgentlyDon’t need to know implant information / sizes
Slide23Surgical Management of Acute Infections
Technique
Proceed to surgery urgentlyAggressive, thorough debridement & synovectomy
Slide24Surgical Management of Acute Infections
Technique
Proceed to surgery urgentlyAggressive, thorough debridementModular parts removedFlash sterilized / soaked in aseptic solution
Slide25Surgical Management of Acute Infections
Technique
Proceed to surgery urgentlyAggressive, thorough debridementModular parts removedImplants scrubbedSterile toothbrush / sponges
Slide26Surgical Management of Acute Infections
Technique
Proceed to surgery urgently
Aggressive, thorough debridementModular parts removedImplants scrubbedCopious irrigationBetadine35 ml of
Povidine-iodine in 1 liter NSChlorhexidine
Slide27Surgical Management of Acute Infections
Technique
Proceed to surgery urgentlyAggressive, thorough debridementModular parts removedImplants scrubbedCopious irrigationModular parts reinserted
Slide28Technique
Proceed to surgery urgentlyAggressive, thorough debridement
Modular parts removedImplants scrubbedCopious irrigationModular parts reinsertedHigh Dose Antibiotic beads added1 mix (Palacos) with 3.6 g gentamicin or tobramycin, 3 g Vancomycin
and 2 g cefazolinSurgical Management of Acute Infections
Slide29Slide30Slide31Slide32Slide33Slide34Slide35Surgical Management of Acute Infections
Technique
Proceed to surgery urgentlyAggressive, thorough debridementModular parts removedImplants scrubbedCopious irrigationModular parts reinserted
High Dose Antibiotic beads addedReturn to O.R. 3 – 7 days laterBead removal, repeat debridement and irrigationInsertion of new modular parts
Tobra 172
g/ml
(2 – 20)
Vanco 113
g/ml
(5 – 10)
Tobra 146
g/ml
Vanco 67
g/ml
Slide36Surgical Management of Acute Infections
Technique – Post-operative management
Started on antibiotics after 1st debridementAntibiotics are adjusted based on cultures6 (occasionally 8 weeks) IV antibioticsOral antibioticsDuration of oral antibiotics is variable
Many stop after about 3 months IV/POSome life-long suppressionUnderlying co-morbidities Age of patientDifficulty of revision if infection recurs
Slide372 Stage Debridement with Prosthesis Retention for Acute PJI in TKA
Methods
Study period 2002-201444 knees 25 men, 19 womenMean age 65.7 years36 acute hematogenous infection 8 immediate post-operative infection27 primary TKA, 17 revision TKAVariety of organisms
Slide382 Stage Debridement with Prosthesis Retention for Acute PJI in TKA
Results
Mean F/U 43.6 months (range, 12-155)Success 38 of 44 knees (86.4%) Primary vs revision TKA88.9% vs 82.4% p=0.663Duration of onset of symptoms to 1
st surgical intervention influences successSuccesses mean 4.1 days Failures mean 11.2 daysp=0.011
Slide395 Key Points
Stay in control
Aspirate before antibioticsTimely evaluationMake an accurate diagnosis that differentiates between superficial & deep infectionDefinitive interventionAcute PJI best treated with 2 stage debridement with abx beads
Slide40Thank You for Your Attention