Special Focus Section
273
Surgical Management of Periprosthetic Joint Infection: One-Stage Exchange Daniel Kendoff, MD1
Thorsten Gehrke, MD1
1 Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg,
Hamburg, Germany
Address for correspondence Daniel Kendoff, MD, Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Holstenstrasse 2, Hamburg 22767, Germany (e-mail: [email protected]).
Abstract
Keywords
► periprosthetic joint infection ► one-staged exchange ► antibiotic ► PJI
Although it does offer some advantages, the one-staged exchange in periprosthetic joint infection (PJI) remains rare in the orthopedic world. Besides the reduced number of surgical interventions for the patients, it is usually associated with a decreased inhospital stay and quicker mobilization. Furthermore, it might be the more cost-effective approach and allows for a reduced duration of postoperative systemic antibiotics, usually less than 14 days. Technically, the presence of a positive culture by preoperative aspiration or biopsy and respective antibiogram is mandatory. A cemented implant fixation using specified topic antibiotics, based on the antibiogram, is treatment of choice for one-staged procedures. The overall success is based on the well-defined and detailed intrahospital infrastructure, including a meticulous preoperative planning, joint aspiration regime, and aggressive intraoperative surgical approach. This article describes the one-staged exchange in infected PJI of the knee joint, which has been established 40 years ago in the HELIOS ENDO-Klinik Hamburg, Germany.
Periprosthetic joint infection (PJI) is one of the most feared and challenging complications following joint replacement. Despite improved antibiotic prophylaxis and local antibiotics in bone cement, infections occur in approximately 0.5 to 1.9% of primary cases; in revision replacement, the rate of infection has been reported to be as high as 8 to 10%.1–4 While the definitive diagnosis of PJI remains the key for success, a designated concept of preoperative planning and treatment is mandatory. Treatment options can include an early attempt of irrigation and debridement, up to the very last options including resection arthroplasty or fusion of the joint. As accepted worldwide, a two-stage exchange protocol has become the preferred procedure, while a designated onestage approach has only been advocated by a few specialized centers so far, with comparable outcomes.5,6 The therapeutic goal in either one- or two-stage revisions in PJI is defined by the control of the infection in combination with maintenance of joint function. Both techniques should be available, depending on the status of the patient, the surgeon’s expertise, and the hospital setup. Most often, an implant removal is followed by a 6- to 12-week course of
systemic antibiotic treatment and delayed reimplantation of a new prosthesis, often with an interval knee spacer applied. The introduction of mobile antibiotic-impregnated spacers seemed to improve the functional outcome of the two-stage approach and has gained increasing popularity, especially in the knee.7–9 Evaluating the current available literature and guidelines for the treatment of PJI, there is no clear evidence that a twoor more-stage procedure has a clearly higher success rate than a one-stage approach.10–12 Although the two-stage technique is described in a large number of articles as the gold standard in infection eradication, the most mentioned recommendations, for example, the duration of antibiotic treatment, static versus mobile spacer, interval of spacer retention, and cemented versus uncemented implant fixation are based on level IV evidence studies or even expert opinions, rather than on prospective randomized or comparative data.13,14 To the best of our knowledge, the one-stage exchange offers some advantages, with a comparable success rate of infection control. Obvious advantages are mainly based on the need for only one operative procedure, reduced time on antibiotics,
received January 9, 2014 accepted after revision April 2, 2014 published online May 22, 2014
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1376882. ISSN 1538-8506.
Downloaded by: University of Queensland. Copyrighted material.
J Knee Surg 2014;27:273–278.
Surgical Management of PJI
Kendoff, Gehrke
reduced hospitalization time, and reduced relative overall costs.15–17 The following article will give a detailed description of the clinical one-staged approach for PJI in total knee replacement, including diagnostics, preoperative planning, surgical treatment algorithm, and postoperative setup. On the basis of the experience of the authors’ institution and strategies of a distinct one-stage approach in PJI, additional emphasis is given to all the detailed requirements that provide the basis for a high surgical and postoperative success rate for this technique.
Diagnostics Joint Aspiration The most relevant and needed preoperative diagnostic test, for any planned one-stage exchange, is based on joint aspiration with precise identification of the bacteria. The presence of a positive bacterial culture and the corresponding antibiogram are essential for a one-stage procedure. Specific antibiotic-loaded acrylic cement is based on this diagnostic tool, to achieve a high topical antibiotic elution directly at the surgical site for the one-stage procedure.18 This strict aspiration algorithm is the gold standard for every planned total joint revision in our hospital, including all late or early aseptic loosening cases. Furthermore, we expand this regime to all the cases of unclear pain or malfunction after primary or revision joints, based on our own aspiration study, which showed that between 4 and 7% of all our patients initially planned for an aseptic revision had evidence of a subtle low-grade infection. Aspiration should always take place under strict sterile conditions, while the antibiotics administered earlier are withheld for 14 days before the procedure.19 Otherwise, falsenegative cultures may result. We also do not recommend the use of local anesthetics; bacteriostatic characteristics might result in false-negative cultures. It has been shown that a combination of serum C-reactive protein levels and joint aspiration including cultures result in a reported accuracy of 92.4%.5 An increase of accuracy up to 98% can be reached by taking additional tissue samples (from arthroscopy or an open approach) with combined histological examination and cultures.5 Furthermore, we recommend that bacteriologic cultures are performed between 5 and 14 days, because of slow growing germs or small colony variants.19 It has been shown, for instance, that propionibacteria and peptostreptococci can be detected on traditional culture plates only after an incubation time of 10 to 12 days. On the basis of the final microbiologic results and the susceptibility of the identified bacteria, the microbiologist can determine an adequate individualized antibiotic treatment plan for the patient, which is especially important for a one-stage protocol.
One-Stage Exchange
all our infected cases in the HELIOS ENDO-Klinik Hamburg, Germany, with this technique.20 The mandatory infrastructural requirement is based on the clear evidence and identification of bacteria preoperatively, in combination with the administration of patient-specific topical and systemic antibiotics.
Contraindications The following criteria exist for deviating from a one-stage approach to a two-stage procedure21: • • • • •
Failure of 2 previous one-stage procedures Infection spreading to the nerve–vessel bundle Unknown preoperative pathogen specification Nonavailability of appropriate antibiotics Presence of a sinus tract
Preoperative Preparation and Planning It needs to be stressed again that the presence of a positive bacterial culture and antibiogram is mandatory for any onestage exchange. The proposed cemented fixation with specific antibiotics is considered to be the treatment of choice to achieve a high topical therapeutic level of antibiotic elution from the cement.22,23 Although currently not commercially available, future-oriented approaches might include local antibiotic implant or silver coatings, which could be used in a one-stage approach as well. Technical success does not only depend on the removal of all hardware material (including cement and restrictors) in combination with the topical antibiotics within the cement. Furthermore, a very extensive and complete debridement of any infected soft tissues and associated bone material is mandatory for this technique. It always includes a full synovectomy, even in the posterior aspects of the knee.
Operative Technique Skin Incision and Debridement Old scars in the line of the skin incision should be excised. The prior incision from the last operative approach should be used. In the presence of a sinus, it should be integrated into the skin incision and radically excised to the joint capsule. In the knee, a tourniquet should be applied, but not inflated from the start of the operation. Surgery should be started without a tourniquet; consequently, the interfaces between infected tissue, scar, and surrounding healthy bleeding soft tissue can be distinguished more clearly at debridement. All nonbleeding tissues and related bone need to be radically excised. After the completion of debridement and implant removal, the tourniquet can be helpful for the final intramedullary cement removal as well as for the process of recementation at the knee site. Biopsy material, preferably 3 to 6 samples, should be taken as a routine measure from all relevant areas of the operation site for combined microbiologic and histologic evaluation.5,19 Prophylactic antibiotics should not be administered before these samples are taken.
Indications
Implant Removal and Completion of Debridement
There are very few arguments against a one-stage revision in general; consequently, we have been able to fulfill around 85% of
As described earlier, in cases of long or partially cemented implants, curved chisels, long forceps, curettage instruments,
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Surgical Management of PJI
Reimplantation In cases of inadequate bone stock, we do not recommend the use of allografts; however, there are few reports on the use of antibiotic-impregnated allografts in such cases by Winkler et al.24 We prefer to fill even small defects with bone cement. The use of trabecular metal cones in larger, contained bone defects in the acetabulum and distal femur or the proximal tibia has helped us to control more challenging situations with metaphyseal bone defects, thus has gained popularity in the one-staged setup. Variations in the depth and width of the metal cones/augments allow for a proper reconstruction of the resulting bone loss, including an excellent biocompatibility, and related stiffness and porous structure (►Figs. 1 and 2). Consequently, a combined fixation of the cement with the prosthesis and tantalum wedges/cones offers an excellent addendum to the treatment portfolio. In addition, it has been suggested that
Fig. 1 Low-grade infection of total hip arthroplasty with multiple revision and incomplete removal of all hardware during last septic revision. A kind of antibiotic cement spacer was inserted into the socket.
275
tantalum should have some antibacterial properties, although this has not been proven clinically yet.25 In larger bridged defects with longer stems, modular or nonmodular, as in the case of total femur replacements, we do recommend to surround the stems with earlier mentioned topic antibiotic loaded cement (►Figs. 3–5). Antibiotic-loaded cement is prepared in the meantime. It is mandatory that the following criteria are fulfilled.26 • Appropriate antibiotic (antibiogram and adequate elusion characteristics) • Bactericidal (exception: clindamycin) • Powder form (liquid antibiotic should not be used) • Maximum addition of 10%/polymethylmethacrylate powder (for biomechanical stability) Antibiotics (e.g., vancomycin) might change the polymerization behavior of the cement, causing the acceleration of cement curing. Generally, current principles of modern cementing techniques should be applied. To achieve an improved cement–bone interface, the tourniquet should be inflated before cementing in TKA cases.
Postoperative Antibiotics In the one-stage approach, associated postoperative systemic antibiotic administration is usually for a period of 10 to 14 days (exception: streptococci). While a prolonged administration of intravenous antibiotic for 6 weeks is common in the two-stage approach, the rationale for this extended period has not been completely clarified in studies. In
Fig. 2 One-staged revision with tantalum shim augmentation of the os ileum, implantation of a dual-mobility cup, due to the gluteal insufficiency and proximal femoral bone lost. Cemented modular long shaft (LINK, Hamburg, Germany). The Journal of Knee Surgery
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long drills, and cement taps are used to remove the cement. All cement and stoppers need to be removed radically. Generally, the debridement of bone and soft tissues must be as radical as possible. It must include all areas of osteolysis and nonviable bone. Finalization of the aggressive debridement often exceeds the amount of resected materials in a two-stage approach. Thus, a resection of the collateral ligaments in the knee sometimes becomes necessary, which necessitates the use of longer stemmed revision implants and a higher level of constraint such as a rotating hinge, which is frequently used in our one-stage setup. We recommend the general use of pulsatile lavage throughout the procedure; however, after complete implant removal and debridement, intramedullary canals and the acetabulum are packed with polymeric biguanide hydrochloride (polyhexanide)-soaked swabs. The complete team now rescrubs, while new instruments are used for reimplantation. A second dose of antibiotic is given after 1.5 hour of operating time or if blood loss at this point exceeds 1 L.
Kendoff, Gehrke
Surgical Management of PJI
Kendoff, Gehrke
Fig. 3 Infected tumor prosthesis, after multiple revisions due to an infected hip nail after fracture.
contrast, there is evidence for possible relevant systemic and organ-specific complications after any prolonged antibiotic administration.27
Fig. 5 The long diaphyseal part is covered by additional bone cement, added with bacteria/case specific antibiotics.
Postoperative Care and Rehabilitation A major advantage of the one-stage technique is based on the possible immediate physical therapy and mobilization of all patients. The related postoperative hospitalization time ranges from 12 to 20 days (mean, 14 days) in our setup. The physiotherapeutic approach at any one stage cannot be generalized. Because of the variety of soft tissue and bone damage and the extent of infection, in most cases, an individual plan is required. However, we generally recommend early
mobilization within the first postoperative days using walking aids. Weight bearing should be adapted to the intraoperative findings and substance defects and might be increased to full weight bearing within the first 2 weeks after surgery. In quite a large number of patients, the adequate bone stock and relative low soft tissue involvement allow an immediate mobilization under full weight bearing.
Postoperative Complications
Fig. 4 One-staged conversion to total femur replacement, in combination with a constrained cup device. The Journal of Knee Surgery
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The persistence or recurrence of infection remains the most relevant complication in the one-stage technique. Failure rates with two-stage exchange have been described to range from 9 to 20% with nonresistant bacteria.11,28,29 Our unpublished data as well as reports from other groups show comparable results in the short and midterm follow-up, using the one-stage approach.30,31 As a consequence, we advise our patients of a possible risk of recurrent or new infection of approximately 10 to 20%. Although we are unable to present general comparative data evaluating the functional outcome between a two- stage approach and one-stage approach, we truly believe that neither any articulating spacer nor partial or complete immobilization of the knee will result in a better functional outcome. We consider the risk of direct damage to the sciatic or peroneal nerve and main vessels to be relatively low with an experienced surgeon, even in such an extended aggressive debridement, and relative comparable to a two-stage
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exchange. The general risk of intra- and postoperative fractures should also be comparable to the two- or more-stage exchange.
Outcome As reported, the two-stage approach has become the most used technique worldwide, with a reported reinfection rate of between 9 and 20%.28,32 Although advocated as the “gold standard,” we established and have followed the earlier described one-stage approach in our clinic for over 35 years in over 80% of all our PJI cases so far.20 Accordingly, far more studies have been published and emphasized the two-stage revision technique. Very few studies or case series evaluating one-stage exchange are currently available. Although most reports are from or with our institution, some international experience exists, with comparable high success rates of between 75 and 90%.33,34 Besides obvious surgical benefits, by eliminating a second major operative procedure, in our eyes, a further advantage arises from the associated reduced duration of postoperative systemic antibiotics. This is rarely more than 14 days in our current setup.
12
13
14
15
16 17 18
19
20
References 1 Bozic KJ, Kurtz SM, Lau E, et al. The epidemiology of revision total
2
3
4
5
6
7
8
9
10
11
knee arthroplasty in the United States. Clin Orthop Relat Res 2010; 468(1):45–51 Bozic KJ, Ries MD. The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization. J Bone Joint Surg Am 2005;87(8):1746–1751 Kurtz SM, Lau E, Schmier J, Ong KL, Zhao K, Parvizi J. Infection burden for hip and knee arthroplasty in the United States. J Arthroplasty 2008;23(7):984–991 Kurtz SM, Ong KL, Lau E, Bozic KJ, Berry D, Parvizi J. Prosthetic joint infection risk after TKA in the Medicare population. Clin Orthop Relat Res 2010;468(1):52–56 Fink B, Makowiak C, Fuerst M, Berger I, Schäfer P, Frommelt L. The value of synovial biopsy, joint aspiration and C-reactive protein in the diagnosis of late peri-prosthetic infection of total knee replacements. J Bone Joint Surg Br 2008;90(7):874–878 Siegel A, Frommelt L, Runde W. Therapy of bacterial knee joint infection by radical synovectomy and implantation of a cemented stabilized knee joint endoprosthesis [in German]. Chirurg 2000; 71(11):1385–1391 Fehring TK, Odum S, Calton TF, Mason JB. Articulating versus static spacers in revision total knee arthroplasty for sepsis. The Ranawat Award. Clin Orthop Relat Res 2000;((380):9–16 Haddad FS, Masri BA, Campbell D, McGraw RW, Beauchamp CP, Duncan CP. The PROSTALAC functional spacer in two-stage revision for infected knee replacements. Prosthesis of antibioticloaded acrylic cement. J Bone Joint Surg Br 2000;82(6):807–812 Pietsch M, Wenisch C, Traussnig S, Trnoska R, Hofmann S. Temporary articulating spacer with antibiotic-impregnated cement for an infected knee endoprosthesis [in German]. Orthopade 2003;32(6): 490–497 Wongworawat MD. Clinical faceoff: One- versus two-stage exchange arthroplasty for prosthetic joint infections. Clin Orthop Relat Res 2013;471(6):1750–1753 Kurd MF, Ghanem E, Steinbrecher J, Parvizi J. Two-stage exchange knee arthroplasty: does resistance of the infecting organism
21
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23
24
25
26
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influence the outcome? Clin Orthop Relat Res 2010;468(8): 2060–2066 Mortazavi SM, Vegari D, Ho A, Zmistowski B, Parvizi J. Two-stage exchange arthroplasty for infected total knee arthroplasty: predictors of failure. Clin Orthop Relat Res 2011;469(11):3049–3054 Parvizi J, Adeli B, Zmistowski B, Restrepo C, Greenwald AS. Management of periprosthetic joint infection: the current knowledge: AAOS exhibit selection. J Bone Joint Surg Am 2012;94(14): e104 Osmon DR, Berbari EF, Berendt AR, et al; Infectious Diseases Society of America. Executive summary: diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2013; 56(1):1–10 Buechel FF. The infected total knee arthroplasty: just when you thought it was over. J Arthroplasty 2004;19(4, Suppl Suppl 1):51–55 Göksan SB, Freeman MA. One-stage reimplantation for infected total knee arthroplasty. J Bone Joint Surg Br 1992;74(1):78–82 Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med 2004;351(16):1645–1654 Hanssen AD, Spangehl MJ. Practical applications of antibioticloaded bone cement for treatment of infected joint replacements. Clin Orthop Relat Res 2004;((427):79–85 Schäfer P, Fink B, Sandow D, Margull A, Berger I, Frommelt L. Prolonged bacterial culture to identify late periprosthetic joint infection: a promising strategy. Clin Infect Dis 2008;47(11): 1403–1409 von Foerster G, Klüber D, Käbler U. Mid- to long-term results after treatment of 118 cases of periprosthetic infections after knee joint replacement using one-stage exchange surgery [in German]. Orthopade 1991;20(3):244–252 Cats-Baril W, Gehrke T, Huff K, Kendoff D, Maltenfort M, Parvizi J. International consensus on periprosthetic joint infection: description of the consensus process. Clin Orthop Relat Res 2013;471(12): 4065–4075 Wahlig H, Dingeldein E, Buchholz HW, Buchholz M, Bachmann F. Pharmacokinetic study of gentamicin-loaded cement in total hip replacements. Comparative effects of varying dosage. J Bone Joint Surg Br 1984;66(2):175–179 Fink B, Vogt S, Reinsch M, Büchner H. Sufficient release of antibiotic by a spacer 6 weeks after implantation in two-stage revision of infected hip prostheses. Clin Orthop Relat Res 2011; 469(11):3141–3147 Winkler H, Kaudela K, Stoiber A, Menschik F. Bone grafts impregnated with antibiotics as a tool for treating infected implants in orthopedic surgery - one stage revision results. Cell Tissue Bank 2006;7(4):319–323 Schildhauer TA, Robie B, Muhr G, Köller M. Bacterial adherence to tantalum versus commonly used orthopedic metallic implant materials. J Orthop Trauma 2006;20(7):476–484 ICG. ICG: International Consensus Group on Periprosthetic Infection. Consensus Statements. Philadelphia, PA: Thomas Jefferson University; August 1, 2013 Hoad-Reddick DA, Evans CR, Norman P, Stockley I. Is there a role for extended antibiotic therapy in a two-stage revision of the infected knee arthroplasty? J Bone Joint Surg Br 2005;87(2):171–174 Azzam K, McHale K, Austin M, Purtill JJ, Parvizi J. Outcome of a second two-stage reimplantation for periprosthetic knee infection. Clin Orthop Relat Res 2009;467(7):1706–1714 Bauer T, Piriou P, Lhotellier L, Leclerc P, Mamoudy P, Lortat-Jacob A. Results of reimplantation for infected total knee arthroplasty: 107 cases [in French]. Rev Chir Orthop Reparatrice Appar Mot 2006; 92(7):692–700 Jenny JY, Barbe B, Gaudias J, Boeri C, Argenson JN. High infection control rate and function after routine one-stage exchange for chronically infected TKA. Clin Orthop Relat Res 2013;471(1):238–243
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31 Singer J, Merz A, Frommelt L, Fink B. High rate of infection
33 Buechel FF, Femino FP, D’Alessio J. Primary exchange revision
control with one-stage revision of septic knee prostheses excluding MRSA and MRSE. Clin Orthop Relat Res 2012;470(5): 1461–1471 32 Goldman RT, Scuderi GR, Insall JN. 2-stage reimplantation for infected total knee replacement. Clin Orthop Relat Res 1996; (331):118–124
arthroplasty for infected total knee replacement: a long-term study. Am J Orthop 2004;33(4):190–198, discussion 198 34 Schmitz HC, Schwantes B, Kendoff D. One-stage revision of knee endoprosthesis due to periprosthetic infection and Klippel-Trenaunay syndrome [in German]. Orthopade 2011;40(7):624–626, 628–629
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The Journal of Knee Surgery
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No. 4/2014
273
Surgical Management of Periprosthetic Joint Infection: One-Stage Exchange Daniel Kendoff, MD1
Thorsten Gehrke, MD1
1 Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg,
Hamburg, Germany
Address for correspondence Daniel Kendoff, MD, Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Holstenstrasse 2, Hamburg 22767, Germany (e-mail: [email protected]).
Abstract
Keywords
► periprosthetic joint infection ► one-staged exchange ► antibiotic ► PJI
Although it does offer some advantages, the one-staged exchange in periprosthetic joint infection (PJI) remains rare in the orthopedic world. Besides the reduced number of surgical interventions for the patients, it is usually associated with a decreased inhospital stay and quicker mobilization. Furthermore, it might be the more cost-effective approach and allows for a reduced duration of postoperative systemic antibiotics, usually less than 14 days. Technically, the presence of a positive culture by preoperative aspiration or biopsy and respective antibiogram is mandatory. A cemented implant fixation using specified topic antibiotics, based on the antibiogram, is treatment of choice for one-staged procedures. The overall success is based on the well-defined and detailed intrahospital infrastructure, including a meticulous preoperative planning, joint aspiration regime, and aggressive intraoperative surgical approach. This article describes the one-staged exchange in infected PJI of the knee joint, which has been established 40 years ago in the HELIOS ENDO-Klinik Hamburg, Germany.
Periprosthetic joint infection (PJI) is one of the most feared and challenging complications following joint replacement. Despite improved antibiotic prophylaxis and local antibiotics in bone cement, infections occur in approximately 0.5 to 1.9% of primary cases; in revision replacement, the rate of infection has been reported to be as high as 8 to 10%.1–4 While the definitive diagnosis of PJI remains the key for success, a designated concept of preoperative planning and treatment is mandatory. Treatment options can include an early attempt of irrigation and debridement, up to the very last options including resection arthroplasty or fusion of the joint. As accepted worldwide, a two-stage exchange protocol has become the preferred procedure, while a designated onestage approach has only been advocated by a few specialized centers so far, with comparable outcomes.5,6 The therapeutic goal in either one- or two-stage revisions in PJI is defined by the control of the infection in combination with maintenance of joint function. Both techniques should be available, depending on the status of the patient, the surgeon’s expertise, and the hospital setup. Most often, an implant removal is followed by a 6- to 12-week course of
systemic antibiotic treatment and delayed reimplantation of a new prosthesis, often with an interval knee spacer applied. The introduction of mobile antibiotic-impregnated spacers seemed to improve the functional outcome of the two-stage approach and has gained increasing popularity, especially in the knee.7–9 Evaluating the current available literature and guidelines for the treatment of PJI, there is no clear evidence that a twoor more-stage procedure has a clearly higher success rate than a one-stage approach.10–12 Although the two-stage technique is described in a large number of articles as the gold standard in infection eradication, the most mentioned recommendations, for example, the duration of antibiotic treatment, static versus mobile spacer, interval of spacer retention, and cemented versus uncemented implant fixation are based on level IV evidence studies or even expert opinions, rather than on prospective randomized or comparative data.13,14 To the best of our knowledge, the one-stage exchange offers some advantages, with a comparable success rate of infection control. Obvious advantages are mainly based on the need for only one operative procedure, reduced time on antibiotics,
received January 9, 2014 accepted after revision April 2, 2014 published online May 22, 2014
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1376882. ISSN 1538-8506.
Downloaded by: University of Queensland. Copyrighted material.
J Knee Surg 2014;27:273–278.
Surgical Management of PJI
Kendoff, Gehrke
reduced hospitalization time, and reduced relative overall costs.15–17 The following article will give a detailed description of the clinical one-staged approach for PJI in total knee replacement, including diagnostics, preoperative planning, surgical treatment algorithm, and postoperative setup. On the basis of the experience of the authors’ institution and strategies of a distinct one-stage approach in PJI, additional emphasis is given to all the detailed requirements that provide the basis for a high surgical and postoperative success rate for this technique.
Diagnostics Joint Aspiration The most relevant and needed preoperative diagnostic test, for any planned one-stage exchange, is based on joint aspiration with precise identification of the bacteria. The presence of a positive bacterial culture and the corresponding antibiogram are essential for a one-stage procedure. Specific antibiotic-loaded acrylic cement is based on this diagnostic tool, to achieve a high topical antibiotic elution directly at the surgical site for the one-stage procedure.18 This strict aspiration algorithm is the gold standard for every planned total joint revision in our hospital, including all late or early aseptic loosening cases. Furthermore, we expand this regime to all the cases of unclear pain or malfunction after primary or revision joints, based on our own aspiration study, which showed that between 4 and 7% of all our patients initially planned for an aseptic revision had evidence of a subtle low-grade infection. Aspiration should always take place under strict sterile conditions, while the antibiotics administered earlier are withheld for 14 days before the procedure.19 Otherwise, falsenegative cultures may result. We also do not recommend the use of local anesthetics; bacteriostatic characteristics might result in false-negative cultures. It has been shown that a combination of serum C-reactive protein levels and joint aspiration including cultures result in a reported accuracy of 92.4%.5 An increase of accuracy up to 98% can be reached by taking additional tissue samples (from arthroscopy or an open approach) with combined histological examination and cultures.5 Furthermore, we recommend that bacteriologic cultures are performed between 5 and 14 days, because of slow growing germs or small colony variants.19 It has been shown, for instance, that propionibacteria and peptostreptococci can be detected on traditional culture plates only after an incubation time of 10 to 12 days. On the basis of the final microbiologic results and the susceptibility of the identified bacteria, the microbiologist can determine an adequate individualized antibiotic treatment plan for the patient, which is especially important for a one-stage protocol.
One-Stage Exchange
all our infected cases in the HELIOS ENDO-Klinik Hamburg, Germany, with this technique.20 The mandatory infrastructural requirement is based on the clear evidence and identification of bacteria preoperatively, in combination with the administration of patient-specific topical and systemic antibiotics.
Contraindications The following criteria exist for deviating from a one-stage approach to a two-stage procedure21: • • • • •
Failure of 2 previous one-stage procedures Infection spreading to the nerve–vessel bundle Unknown preoperative pathogen specification Nonavailability of appropriate antibiotics Presence of a sinus tract
Preoperative Preparation and Planning It needs to be stressed again that the presence of a positive bacterial culture and antibiogram is mandatory for any onestage exchange. The proposed cemented fixation with specific antibiotics is considered to be the treatment of choice to achieve a high topical therapeutic level of antibiotic elution from the cement.22,23 Although currently not commercially available, future-oriented approaches might include local antibiotic implant or silver coatings, which could be used in a one-stage approach as well. Technical success does not only depend on the removal of all hardware material (including cement and restrictors) in combination with the topical antibiotics within the cement. Furthermore, a very extensive and complete debridement of any infected soft tissues and associated bone material is mandatory for this technique. It always includes a full synovectomy, even in the posterior aspects of the knee.
Operative Technique Skin Incision and Debridement Old scars in the line of the skin incision should be excised. The prior incision from the last operative approach should be used. In the presence of a sinus, it should be integrated into the skin incision and radically excised to the joint capsule. In the knee, a tourniquet should be applied, but not inflated from the start of the operation. Surgery should be started without a tourniquet; consequently, the interfaces between infected tissue, scar, and surrounding healthy bleeding soft tissue can be distinguished more clearly at debridement. All nonbleeding tissues and related bone need to be radically excised. After the completion of debridement and implant removal, the tourniquet can be helpful for the final intramedullary cement removal as well as for the process of recementation at the knee site. Biopsy material, preferably 3 to 6 samples, should be taken as a routine measure from all relevant areas of the operation site for combined microbiologic and histologic evaluation.5,19 Prophylactic antibiotics should not be administered before these samples are taken.
Indications
Implant Removal and Completion of Debridement
There are very few arguments against a one-stage revision in general; consequently, we have been able to fulfill around 85% of
As described earlier, in cases of long or partially cemented implants, curved chisels, long forceps, curettage instruments,
The Journal of Knee Surgery
Vol. 27
No. 4/2014
Downloaded by: University of Queensland. Copyrighted material.
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Surgical Management of PJI
Reimplantation In cases of inadequate bone stock, we do not recommend the use of allografts; however, there are few reports on the use of antibiotic-impregnated allografts in such cases by Winkler et al.24 We prefer to fill even small defects with bone cement. The use of trabecular metal cones in larger, contained bone defects in the acetabulum and distal femur or the proximal tibia has helped us to control more challenging situations with metaphyseal bone defects, thus has gained popularity in the one-staged setup. Variations in the depth and width of the metal cones/augments allow for a proper reconstruction of the resulting bone loss, including an excellent biocompatibility, and related stiffness and porous structure (►Figs. 1 and 2). Consequently, a combined fixation of the cement with the prosthesis and tantalum wedges/cones offers an excellent addendum to the treatment portfolio. In addition, it has been suggested that
Fig. 1 Low-grade infection of total hip arthroplasty with multiple revision and incomplete removal of all hardware during last septic revision. A kind of antibiotic cement spacer was inserted into the socket.
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tantalum should have some antibacterial properties, although this has not been proven clinically yet.25 In larger bridged defects with longer stems, modular or nonmodular, as in the case of total femur replacements, we do recommend to surround the stems with earlier mentioned topic antibiotic loaded cement (►Figs. 3–5). Antibiotic-loaded cement is prepared in the meantime. It is mandatory that the following criteria are fulfilled.26 • Appropriate antibiotic (antibiogram and adequate elusion characteristics) • Bactericidal (exception: clindamycin) • Powder form (liquid antibiotic should not be used) • Maximum addition of 10%/polymethylmethacrylate powder (for biomechanical stability) Antibiotics (e.g., vancomycin) might change the polymerization behavior of the cement, causing the acceleration of cement curing. Generally, current principles of modern cementing techniques should be applied. To achieve an improved cement–bone interface, the tourniquet should be inflated before cementing in TKA cases.
Postoperative Antibiotics In the one-stage approach, associated postoperative systemic antibiotic administration is usually for a period of 10 to 14 days (exception: streptococci). While a prolonged administration of intravenous antibiotic for 6 weeks is common in the two-stage approach, the rationale for this extended period has not been completely clarified in studies. In
Fig. 2 One-staged revision with tantalum shim augmentation of the os ileum, implantation of a dual-mobility cup, due to the gluteal insufficiency and proximal femoral bone lost. Cemented modular long shaft (LINK, Hamburg, Germany). The Journal of Knee Surgery
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long drills, and cement taps are used to remove the cement. All cement and stoppers need to be removed radically. Generally, the debridement of bone and soft tissues must be as radical as possible. It must include all areas of osteolysis and nonviable bone. Finalization of the aggressive debridement often exceeds the amount of resected materials in a two-stage approach. Thus, a resection of the collateral ligaments in the knee sometimes becomes necessary, which necessitates the use of longer stemmed revision implants and a higher level of constraint such as a rotating hinge, which is frequently used in our one-stage setup. We recommend the general use of pulsatile lavage throughout the procedure; however, after complete implant removal and debridement, intramedullary canals and the acetabulum are packed with polymeric biguanide hydrochloride (polyhexanide)-soaked swabs. The complete team now rescrubs, while new instruments are used for reimplantation. A second dose of antibiotic is given after 1.5 hour of operating time or if blood loss at this point exceeds 1 L.
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Fig. 3 Infected tumor prosthesis, after multiple revisions due to an infected hip nail after fracture.
contrast, there is evidence for possible relevant systemic and organ-specific complications after any prolonged antibiotic administration.27
Fig. 5 The long diaphyseal part is covered by additional bone cement, added with bacteria/case specific antibiotics.
Postoperative Care and Rehabilitation A major advantage of the one-stage technique is based on the possible immediate physical therapy and mobilization of all patients. The related postoperative hospitalization time ranges from 12 to 20 days (mean, 14 days) in our setup. The physiotherapeutic approach at any one stage cannot be generalized. Because of the variety of soft tissue and bone damage and the extent of infection, in most cases, an individual plan is required. However, we generally recommend early
mobilization within the first postoperative days using walking aids. Weight bearing should be adapted to the intraoperative findings and substance defects and might be increased to full weight bearing within the first 2 weeks after surgery. In quite a large number of patients, the adequate bone stock and relative low soft tissue involvement allow an immediate mobilization under full weight bearing.
Postoperative Complications
Fig. 4 One-staged conversion to total femur replacement, in combination with a constrained cup device. The Journal of Knee Surgery
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The persistence or recurrence of infection remains the most relevant complication in the one-stage technique. Failure rates with two-stage exchange have been described to range from 9 to 20% with nonresistant bacteria.11,28,29 Our unpublished data as well as reports from other groups show comparable results in the short and midterm follow-up, using the one-stage approach.30,31 As a consequence, we advise our patients of a possible risk of recurrent or new infection of approximately 10 to 20%. Although we are unable to present general comparative data evaluating the functional outcome between a two- stage approach and one-stage approach, we truly believe that neither any articulating spacer nor partial or complete immobilization of the knee will result in a better functional outcome. We consider the risk of direct damage to the sciatic or peroneal nerve and main vessels to be relatively low with an experienced surgeon, even in such an extended aggressive debridement, and relative comparable to a two-stage
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exchange. The general risk of intra- and postoperative fractures should also be comparable to the two- or more-stage exchange.
Outcome As reported, the two-stage approach has become the most used technique worldwide, with a reported reinfection rate of between 9 and 20%.28,32 Although advocated as the “gold standard,” we established and have followed the earlier described one-stage approach in our clinic for over 35 years in over 80% of all our PJI cases so far.20 Accordingly, far more studies have been published and emphasized the two-stage revision technique. Very few studies or case series evaluating one-stage exchange are currently available. Although most reports are from or with our institution, some international experience exists, with comparable high success rates of between 75 and 90%.33,34 Besides obvious surgical benefits, by eliminating a second major operative procedure, in our eyes, a further advantage arises from the associated reduced duration of postoperative systemic antibiotics. This is rarely more than 14 days in our current setup.
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References 1 Bozic KJ, Kurtz SM, Lau E, et al. The epidemiology of revision total
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knee arthroplasty in the United States. Clin Orthop Relat Res 2010; 468(1):45–51 Bozic KJ, Ries MD. The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization. J Bone Joint Surg Am 2005;87(8):1746–1751 Kurtz SM, Lau E, Schmier J, Ong KL, Zhao K, Parvizi J. Infection burden for hip and knee arthroplasty in the United States. J Arthroplasty 2008;23(7):984–991 Kurtz SM, Ong KL, Lau E, Bozic KJ, Berry D, Parvizi J. Prosthetic joint infection risk after TKA in the Medicare population. Clin Orthop Relat Res 2010;468(1):52–56 Fink B, Makowiak C, Fuerst M, Berger I, Schäfer P, Frommelt L. The value of synovial biopsy, joint aspiration and C-reactive protein in the diagnosis of late peri-prosthetic infection of total knee replacements. J Bone Joint Surg Br 2008;90(7):874–878 Siegel A, Frommelt L, Runde W. Therapy of bacterial knee joint infection by radical synovectomy and implantation of a cemented stabilized knee joint endoprosthesis [in German]. Chirurg 2000; 71(11):1385–1391 Fehring TK, Odum S, Calton TF, Mason JB. Articulating versus static spacers in revision total knee arthroplasty for sepsis. The Ranawat Award. Clin Orthop Relat Res 2000;((380):9–16 Haddad FS, Masri BA, Campbell D, McGraw RW, Beauchamp CP, Duncan CP. The PROSTALAC functional spacer in two-stage revision for infected knee replacements. Prosthesis of antibioticloaded acrylic cement. J Bone Joint Surg Br 2000;82(6):807–812 Pietsch M, Wenisch C, Traussnig S, Trnoska R, Hofmann S. Temporary articulating spacer with antibiotic-impregnated cement for an infected knee endoprosthesis [in German]. Orthopade 2003;32(6): 490–497 Wongworawat MD. Clinical faceoff: One- versus two-stage exchange arthroplasty for prosthetic joint infections. Clin Orthop Relat Res 2013;471(6):1750–1753 Kurd MF, Ghanem E, Steinbrecher J, Parvizi J. Two-stage exchange knee arthroplasty: does resistance of the infecting organism
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influence the outcome? Clin Orthop Relat Res 2010;468(8): 2060–2066 Mortazavi SM, Vegari D, Ho A, Zmistowski B, Parvizi J. Two-stage exchange arthroplasty for infected total knee arthroplasty: predictors of failure. Clin Orthop Relat Res 2011;469(11):3049–3054 Parvizi J, Adeli B, Zmistowski B, Restrepo C, Greenwald AS. Management of periprosthetic joint infection: the current knowledge: AAOS exhibit selection. J Bone Joint Surg Am 2012;94(14): e104 Osmon DR, Berbari EF, Berendt AR, et al; Infectious Diseases Society of America. Executive summary: diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2013; 56(1):1–10 Buechel FF. The infected total knee arthroplasty: just when you thought it was over. J Arthroplasty 2004;19(4, Suppl Suppl 1):51–55 Göksan SB, Freeman MA. One-stage reimplantation for infected total knee arthroplasty. J Bone Joint Surg Br 1992;74(1):78–82 Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med 2004;351(16):1645–1654 Hanssen AD, Spangehl MJ. Practical applications of antibioticloaded bone cement for treatment of infected joint replacements. Clin Orthop Relat Res 2004;((427):79–85 Schäfer P, Fink B, Sandow D, Margull A, Berger I, Frommelt L. Prolonged bacterial culture to identify late periprosthetic joint infection: a promising strategy. Clin Infect Dis 2008;47(11): 1403–1409 von Foerster G, Klüber D, Käbler U. Mid- to long-term results after treatment of 118 cases of periprosthetic infections after knee joint replacement using one-stage exchange surgery [in German]. Orthopade 1991;20(3):244–252 Cats-Baril W, Gehrke T, Huff K, Kendoff D, Maltenfort M, Parvizi J. International consensus on periprosthetic joint infection: description of the consensus process. Clin Orthop Relat Res 2013;471(12): 4065–4075 Wahlig H, Dingeldein E, Buchholz HW, Buchholz M, Bachmann F. Pharmacokinetic study of gentamicin-loaded cement in total hip replacements. Comparative effects of varying dosage. J Bone Joint Surg Br 1984;66(2):175–179 Fink B, Vogt S, Reinsch M, Büchner H. Sufficient release of antibiotic by a spacer 6 weeks after implantation in two-stage revision of infected hip prostheses. Clin Orthop Relat Res 2011; 469(11):3141–3147 Winkler H, Kaudela K, Stoiber A, Menschik F. Bone grafts impregnated with antibiotics as a tool for treating infected implants in orthopedic surgery - one stage revision results. Cell Tissue Bank 2006;7(4):319–323 Schildhauer TA, Robie B, Muhr G, Köller M. Bacterial adherence to tantalum versus commonly used orthopedic metallic implant materials. J Orthop Trauma 2006;20(7):476–484 ICG. ICG: International Consensus Group on Periprosthetic Infection. Consensus Statements. Philadelphia, PA: Thomas Jefferson University; August 1, 2013 Hoad-Reddick DA, Evans CR, Norman P, Stockley I. Is there a role for extended antibiotic therapy in a two-stage revision of the infected knee arthroplasty? J Bone Joint Surg Br 2005;87(2):171–174 Azzam K, McHale K, Austin M, Purtill JJ, Parvizi J. Outcome of a second two-stage reimplantation for periprosthetic knee infection. Clin Orthop Relat Res 2009;467(7):1706–1714 Bauer T, Piriou P, Lhotellier L, Leclerc P, Mamoudy P, Lortat-Jacob A. Results of reimplantation for infected total knee arthroplasty: 107 cases [in French]. Rev Chir Orthop Reparatrice Appar Mot 2006; 92(7):692–700 Jenny JY, Barbe B, Gaudias J, Boeri C, Argenson JN. High infection control rate and function after routine one-stage exchange for chronically infected TKA. Clin Orthop Relat Res 2013;471(1):238–243
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31 Singer J, Merz A, Frommelt L, Fink B. High rate of infection
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