Infected Total Joint
Replacement Of particular interest is the data from Mayo Clinic that showed an 18% incidence of positive cultures at the time of operation."1" In some cases, this may represent occult preoperative infection secondary to multiple injections or previous operations, but in most it probably represents airborne or skin contamination. Although they found an increased incidence of postoperative infection in these patients, I have been informed that with modification of their prophylactic antibiotic regimen this is no longer
joints Infecti ojoint ns replacement prosthesis problem
of bones and are always a serious with an uncertain outcome. Infections that involve are no exception. The development of air filtering and closed ventilating systems for operating room personnel and a reassessment of prophylactic antibiotics are direct results of the serious and often disastrous consequences of infection that complicate total joint replacement. Infections still occur, and whether they are from wound contamination or hematogenous spread is not the purpose of this editorial. Elsewhere in this issue (p 574) Burton and Schurman report on their methods of treatment of infected total joints in six patients and their results. Other authors have reported on infected total hips. Several recent articles that primarily report the results of various total knee prostheses also record the treatment and results of infections that complicate these
true.
The first problem, then, is what the prophylactic anti¬ biotic regimen should be, and how should it be modified when a positive operating room wound culture occurs? There are no standards, but most surgeons begin prophy¬ lactic antibiotic therapy either the day before operation, the morning of it, or in the operating room with the purpose of obtaining an effective antibiotic blood level before beginning the procedure. Antibiotics are given intravenously during the operation and for variable periods thereafter, usually 48 to 72 hours. Oral antibiotics may then be continued for another 48 to 72 hours or longer, depending on sources of potential contamination, such as pneumonia and catheterization. When a positive operating
procedures.1-11
The "best" methods of treatment have not yet been as Burton's and Schurman's that broaden our experience. Because my own experience involves total knee replacements, I will direct the following opinions toward that problem. Most comments also apply to other joints.
standardized, hence the value of reports such
Infected Total Knee Prosthesis Treatment SuctionAntibiotics
Irrigation
Arthrodesis
No. of
Type
Source, yr Gunston & McKenzie,5 1976 Evanski et al,' 1976 Wilson & Venters," 1976 Deburge & Guepar,2 1976 Englebrecht et al,3 1976 Bargren et al,' 1976 Marmor,* 1976 Skolnick et al,' 1976 Skolnick et al,'° 1976 Insali et al,» 1976 Laskin,' 1976 Present author, 1976
of
Knee
Replace--" ments
Success
Polycentric
No. of Failure 1
Success
Failure
Success
Failure
UCI Walldius
19s
Guepar St Georg Freeman-Swanson Marmor
Polycentric
7t 10
14
Geomedic
Guepar Geomedic Geomedic Variable axis
70
Total "Two others died, and two have too short tResults not given for two knees.
a
10
12
follow-up period.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/09/2015
26
10
Amputations
culture
obtained, the Mayo group continued antibiotics administering intravenously for two to three weeks, and oral antibiotics for similar period.'1 Though the initial results of this regimen apparently are favorable, the late efficacy of this program is not known. After the appearance of infection of a total joint replace¬ ment arthroplasty, a decision must be made as to therapy. The Table presents the methods of treatment used by a number of authors for 70 infected arthroplasties. Because these authors111 were reporting the results of arthroplasty, the infections were not usually discussed in detail, hence some error may exist in this Table. Treatment in 14 knees consisted of drainage, debridement, and systemic anti¬ biotic therapy, with retention of the implant. Four of these knees went on to intermittent or chronic drainage without removal of the implant. Twenty knees had closed suctionirrigation in addition to debridement and antibiotics, with apparent salvage of the implant in twelve. Thus, the infection was controlled with retention of a functioning implant in 22 of 70 knees. Knee arthrodesis was attempted either as primary treatment or after failure to control infection, with retention of the implant in 37 knees. Because all authors did not state whether or not solid bone union occurred, the frequency of successful arthrodesis cannot be stated. It is apparent, however, that failure to obtain bone union after removal of an implant is frequent. Amputation was required in one patient to control infec¬ tion. Based on these results, one cannot specify a "best" method of treatment of an infected total knee. I believe, however, that most surgeons would recommend incision, drainage, debridement, closed suction-irrigation, and intravenously administered antibiotics. This plan still leaves several major concerns. The first is of these concerns, when do you take the implant out? I agree with Burton's and Schurman's recom¬ mendation for removal if the infection involves the bone. This decision may be difficult or impossible in an early infection, when the implant is still firmly seated, and with stemmed implants. The likelihood of bone involvement seems to be greater in the late infections. If the implant must be removed, the surgeon must also remove all of the room
was
methyl methacrylate. The second
concern
must be the
use
of closed suction-
irrigation. This method of local treatment does provide for flushing the infected joint with antibiotic solution, but it
involves some risks. Most notable are overdose with some antibiotics and the entrance of a secondary infecting organism. Other problems such as blockage of egress tubes and wound leakage also occur. The third concern is, how long do you continue antibiotic therapy after the infection is clinically arrested? This also is an unanswered question. Treatment of a clinically infected joint from which multiple cultures show no growth
is
a particularly difficult unsolved problem. I believe one probably should continue antibiotic therapy as for osteo¬ myelitis. Assuming a satisfactory clinical course, and dependent on antibiotic sensitivity of the organism, intra¬ venously administered antibiotics would be continued for
one month, and oral antibiotics for another three months or longer. Removal of the implant presents different problems, and sequelae at the hip and at the knee. In both cases, the "cement" must be removed, and for the long-stemmed implants, this may require windowing or troughing the cortex. Implant removal at the hip leaves a Girdlestone resection, with its attendant instability and shortening. This usually requires a shoe lift and external support for ambulation. At the knee, the goal is to obtain an arthrode¬ sis. This may be impossible to achieve because of previous bone resection, loss of cancellous opposing surfaces, and infection. Arresting the infection, particularly after removal of long-stemmed implants, may also be difficult or impossible. Inability to obtain an arthrodesis or a stable, painless, fibrous ankylosis may require bracing, and inability to arrest the infection can leave an above-knee amputation as the only alternative. The best methods of treatment of an infected total joint replacement have not been standardized at this time. Certainly, the potentially great benefit of these procedures must be weighed by both the patient and the surgeon against the potentially great disaster of infection. DONALD B. KETTLEKAMP, MD
at least
Indianapolis
References Bargren 1. JH, Freeman MAR, Swanson SAV, et al: ICLH (Freeman\x=req-\ Swanson) arthroplasty in the treatment of arthritic knee: A two to four year review. Clin Orthop 120:65-75, 1976. 2. Deburge A, GUEPAR: GUEPAR hinge prosthesis: Complications and results with a two years' follow-up. Clin Orthop 120:54-63, 1976. 3. Englebrecht E, Siegel J, Rottger J, et al: Statistics of total knee replacement: Partial and total knee replacement, design St George; A review of a 4-year observation. Clin Orthop 120:54-63, 1976. 4. Evanski P, Waugh TR, Orofino CF, et al: UCI knee replacement. Clin Orthop 120:33-38, 1976. 5. Guston FH, McKenzie RI: Complication of polycentric knee arthroplasty. Clin Orthop 120:11-17, 1976. 6. Insall JV, Ranawat CS, Aglietti P, et al: A comparison of four models of total knee replacement prosthese. J Bone Joint Surg 58A: 754-765,
1976. 7. Laskin RS: Modular total knee replacement arthroplasty: A review of 89 patients. J Bone Joint Surg 58A:766-772, 1976. 8. Marmor L: The modular (Marmor) knee: Case report with a minimum follow-up of 2 years. Clin Orthop 120:86-94, 1976. 9. Skolnick MD, Bryan RS, Peterson LFA, et al: Polycentric total knee arthroplasty: A two-year follow-up study. J Bone Joint Surg 58A: 743-748, 1976. 10. Skolnick MD, Coventry MB; Ilstrup MS: Geometric total knee arthroplasty: A two-year follow-up study. J Bone Joint Surg 58A: 749-753, 1976. 11. Wilson FC, Venters, GC: Results of knee replacement with the Walldius prosthesis: An interim report. Clin Orthop 120:39-46, 1976.
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Replacement Of particular interest is the data from Mayo Clinic that showed an 18% incidence of positive cultures at the time of operation."1" In some cases, this may represent occult preoperative infection secondary to multiple injections or previous operations, but in most it probably represents airborne or skin contamination. Although they found an increased incidence of postoperative infection in these patients, I have been informed that with modification of their prophylactic antibiotic regimen this is no longer
joints Infecti ojoint ns replacement prosthesis problem
of bones and are always a serious with an uncertain outcome. Infections that involve are no exception. The development of air filtering and closed ventilating systems for operating room personnel and a reassessment of prophylactic antibiotics are direct results of the serious and often disastrous consequences of infection that complicate total joint replacement. Infections still occur, and whether they are from wound contamination or hematogenous spread is not the purpose of this editorial. Elsewhere in this issue (p 574) Burton and Schurman report on their methods of treatment of infected total joints in six patients and their results. Other authors have reported on infected total hips. Several recent articles that primarily report the results of various total knee prostheses also record the treatment and results of infections that complicate these
true.
The first problem, then, is what the prophylactic anti¬ biotic regimen should be, and how should it be modified when a positive operating room wound culture occurs? There are no standards, but most surgeons begin prophy¬ lactic antibiotic therapy either the day before operation, the morning of it, or in the operating room with the purpose of obtaining an effective antibiotic blood level before beginning the procedure. Antibiotics are given intravenously during the operation and for variable periods thereafter, usually 48 to 72 hours. Oral antibiotics may then be continued for another 48 to 72 hours or longer, depending on sources of potential contamination, such as pneumonia and catheterization. When a positive operating
procedures.1-11
The "best" methods of treatment have not yet been as Burton's and Schurman's that broaden our experience. Because my own experience involves total knee replacements, I will direct the following opinions toward that problem. Most comments also apply to other joints.
standardized, hence the value of reports such
Infected Total Knee Prosthesis Treatment SuctionAntibiotics
Irrigation
Arthrodesis
No. of
Type
Source, yr Gunston & McKenzie,5 1976 Evanski et al,' 1976 Wilson & Venters," 1976 Deburge & Guepar,2 1976 Englebrecht et al,3 1976 Bargren et al,' 1976 Marmor,* 1976 Skolnick et al,' 1976 Skolnick et al,'° 1976 Insali et al,» 1976 Laskin,' 1976 Present author, 1976
of
Knee
Replace--" ments
Success
Polycentric
No. of Failure 1
Success
Failure
Success
Failure
UCI Walldius
19s
Guepar St Georg Freeman-Swanson Marmor
Polycentric
7t 10
14
Geomedic
Guepar Geomedic Geomedic Variable axis
70
Total "Two others died, and two have too short tResults not given for two knees.
a
10
12
follow-up period.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/09/2015
26
10
Amputations
culture
obtained, the Mayo group continued antibiotics administering intravenously for two to three weeks, and oral antibiotics for similar period.'1 Though the initial results of this regimen apparently are favorable, the late efficacy of this program is not known. After the appearance of infection of a total joint replace¬ ment arthroplasty, a decision must be made as to therapy. The Table presents the methods of treatment used by a number of authors for 70 infected arthroplasties. Because these authors111 were reporting the results of arthroplasty, the infections were not usually discussed in detail, hence some error may exist in this Table. Treatment in 14 knees consisted of drainage, debridement, and systemic anti¬ biotic therapy, with retention of the implant. Four of these knees went on to intermittent or chronic drainage without removal of the implant. Twenty knees had closed suctionirrigation in addition to debridement and antibiotics, with apparent salvage of the implant in twelve. Thus, the infection was controlled with retention of a functioning implant in 22 of 70 knees. Knee arthrodesis was attempted either as primary treatment or after failure to control infection, with retention of the implant in 37 knees. Because all authors did not state whether or not solid bone union occurred, the frequency of successful arthrodesis cannot be stated. It is apparent, however, that failure to obtain bone union after removal of an implant is frequent. Amputation was required in one patient to control infec¬ tion. Based on these results, one cannot specify a "best" method of treatment of an infected total knee. I believe, however, that most surgeons would recommend incision, drainage, debridement, closed suction-irrigation, and intravenously administered antibiotics. This plan still leaves several major concerns. The first is of these concerns, when do you take the implant out? I agree with Burton's and Schurman's recom¬ mendation for removal if the infection involves the bone. This decision may be difficult or impossible in an early infection, when the implant is still firmly seated, and with stemmed implants. The likelihood of bone involvement seems to be greater in the late infections. If the implant must be removed, the surgeon must also remove all of the room
was
methyl methacrylate. The second
concern
must be the
use
of closed suction-
irrigation. This method of local treatment does provide for flushing the infected joint with antibiotic solution, but it
involves some risks. Most notable are overdose with some antibiotics and the entrance of a secondary infecting organism. Other problems such as blockage of egress tubes and wound leakage also occur. The third concern is, how long do you continue antibiotic therapy after the infection is clinically arrested? This also is an unanswered question. Treatment of a clinically infected joint from which multiple cultures show no growth
is
a particularly difficult unsolved problem. I believe one probably should continue antibiotic therapy as for osteo¬ myelitis. Assuming a satisfactory clinical course, and dependent on antibiotic sensitivity of the organism, intra¬ venously administered antibiotics would be continued for
one month, and oral antibiotics for another three months or longer. Removal of the implant presents different problems, and sequelae at the hip and at the knee. In both cases, the "cement" must be removed, and for the long-stemmed implants, this may require windowing or troughing the cortex. Implant removal at the hip leaves a Girdlestone resection, with its attendant instability and shortening. This usually requires a shoe lift and external support for ambulation. At the knee, the goal is to obtain an arthrode¬ sis. This may be impossible to achieve because of previous bone resection, loss of cancellous opposing surfaces, and infection. Arresting the infection, particularly after removal of long-stemmed implants, may also be difficult or impossible. Inability to obtain an arthrodesis or a stable, painless, fibrous ankylosis may require bracing, and inability to arrest the infection can leave an above-knee amputation as the only alternative. The best methods of treatment of an infected total joint replacement have not been standardized at this time. Certainly, the potentially great benefit of these procedures must be weighed by both the patient and the surgeon against the potentially great disaster of infection. DONALD B. KETTLEKAMP, MD
at least
Indianapolis
References Bargren 1. JH, Freeman MAR, Swanson SAV, et al: ICLH (Freeman\x=req-\ Swanson) arthroplasty in the treatment of arthritic knee: A two to four year review. Clin Orthop 120:65-75, 1976. 2. Deburge A, GUEPAR: GUEPAR hinge prosthesis: Complications and results with a two years' follow-up. Clin Orthop 120:54-63, 1976. 3. Englebrecht E, Siegel J, Rottger J, et al: Statistics of total knee replacement: Partial and total knee replacement, design St George; A review of a 4-year observation. Clin Orthop 120:54-63, 1976. 4. Evanski P, Waugh TR, Orofino CF, et al: UCI knee replacement. Clin Orthop 120:33-38, 1976. 5. Guston FH, McKenzie RI: Complication of polycentric knee arthroplasty. Clin Orthop 120:11-17, 1976. 6. Insall JV, Ranawat CS, Aglietti P, et al: A comparison of four models of total knee replacement prosthese. J Bone Joint Surg 58A: 754-765,
1976. 7. Laskin RS: Modular total knee replacement arthroplasty: A review of 89 patients. J Bone Joint Surg 58A:766-772, 1976. 8. Marmor L: The modular (Marmor) knee: Case report with a minimum follow-up of 2 years. Clin Orthop 120:86-94, 1976. 9. Skolnick MD, Bryan RS, Peterson LFA, et al: Polycentric total knee arthroplasty: A two-year follow-up study. J Bone Joint Surg 58A: 743-748, 1976. 10. Skolnick MD, Coventry MB; Ilstrup MS: Geometric total knee arthroplasty: A two-year follow-up study. J Bone Joint Surg 58A: 749-753, 1976. 11. Wilson FC, Venters, GC: Results of knee replacement with the Walldius prosthesis: An interim report. Clin Orthop 120:39-46, 1976.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/09/2015
