5/11/2013 Results- Microbiology Results- Outcomes One Stage - - PowerPoint PPT Presentation

5/11/2013 1

Hansen E*, Tetreault M^, Zmistowski B*, DellaValle C^, Parvizi J*, Haddad FS, Hozack WJ* Rothman Institute, Philadelphia PA*; Rush University, Chicago, IL^; University College Hospital, London UK°

• Research support
• NIH
• OREF
• DOD
• Aircast
• AOA
• MTF
• Stryker Orthopaedics
• The Knee Society
• 3M
• Zimmer
• Biomemetics
• Wyeth
• Intellectual Property/Royalty
• SmarTech
• Elsevier
• Wolters Kluwer
• Slack
• Consultant
• Stryker Orthopaedics
• Zimmer
• Biomet
• Smith and Nephew
• Convatech
• Covidien
• TissueGene
• Ceramtec
• OsteoMEM
• Board Member/Adviser
• CD Diagnostics
• Philadelphia Orthopaedic Soc
• Eastern Orthopedic Assoc.
• United Healthcare
• Magnifi Group (Publishers)
• 3M

Financial Disclosure

• Acute PJI of total joint

arthroplasty typically treated w/ I&D and modular bearing exchange

• High published failure rate
• f I&D (≈68%)
• One stage exchange

arthroplasty represents an attractive alternative

Introduction

• One stage exchange

arthroplasty initially described by Bucholz in 70’s

• Classically, procedure done with

use of antibiotic laden bone cement

• Cementless fixation is the

preferred technique for THA/rev THA in the USA

• Little has been published on the

cementless technique for one stage exchange arthroplasty

Introduction

5/11/2013 2 Specific Aims

• Assess the feasibility and efficacy of single-

stage, cementless exchange for acute postoperative infection following THA

• Determine variables related to the success
• r failure of this intervention

Cementless, one stage exchange for acute

PJI following THA has low morbidity/ surgical complexity

Minimal bony on/ingrowth of components

Rate of successful control of infection

following cementless, one stage exchange would surpass that of historical rates following I&D Hypotheses

• Multicenter, retrospective
• bservational study
• Rothman Institute, Rush University,

University College Hospital

• Inclusion criteria-
• All pts who underwent 1 stage cementless

exchange THA for acute postoperative PJI

• ≥ 2yr clinical follow-up
• Exclusion criteria-
• Acute hematogenous/ chronic PJI
• Hybrid cemented one stage exchange

THA

• Index procedure- Revision THA

Methods Methods- Definitions

• Acute post-operative infection: ≤6

weeks from index surgery

• Success: Retention of implants at

most recent clinical follow-up

5/11/2013 3

Patient related-

Age, gender, BMI, ASA/CCI

Perioperative-

Time from index procedure, inpatient

complications

Microbe related-

Organism, antibiotic resistance profile

Methods- Variables

One stage cementless exchange THA

Indication/approach/ implant determined by

• perative surgeon

Followed by post-op course of culture

specific antibiotics

Course determined in consultation w/

Infectious Disease specialist

Methods- Technique

• 35 patients
• Excluded 7 hybrid- cemented
• ne stage THA,
• including 6 revision THA
• 28 patients
• 19M: 9F, mean age 60yo
• mean ASA 1.5, CCI 2.25
• mean f/u 44 months
• Mean time to 1 Stage exchange-

25 days (range 4-41)

Results- Clinical Cohort

DJD DDH AVN SCFE

68%

• All procedures done via prior

surgical approach (inc. DA/Watson Jones/ DL/PL)

• One stage implants utilized- all

primary type THA components

Femur-

Same design, upsized 65% of cases

Acetabulum-

Hemispheric, upsized 76% of cases Screws placed, 25% of cases

• NO intra-operative complications

(eg. ppx fx)

Results- Surgical

http://articles.latimes.com/2012/jul/25/news/la-heb-hip-knee-replacement- heart-attack-20120724

5/11/2013 4 Results- Microbiology

MSSA MRSA CNS K pneumo E coli Bacteroides Strep spp. Acetinobacter Enterococcus

64%

11% 7% 11%

Results- Outcomes

One Stage Exchange Cohort N=28 No Further Sx N=15 (54%) Further Sx N=13 (46%) Isolated I&D N=5 (18%) 2 Stage Exchange N=8 (29%) Repeat 2 Stage N=1 (4%) Success N=7 (25%)

Component retention rate- 71% (20/28)

62% 38% 87% 13% 46% 54%

Success of ultimate 2 stage- 87% (7/8)

Results- Prognostic Factors

Variable Success,n=19 Failure, n=8 p (unadjusted) Demographics Age (years) 56.6(12.6) 60.2 (13.3) 0.69 Female sex 6 (32%) 2 (25%) 1 Body mass index (kg/m2) 28.1 (4.0) 28.9 (6.0) 0.69 Degenerative joint disease (DJD) as diagnosis 13 (68%) 4 (50%) 0.41 Perioperative variables Interval between index and 1-stage surgery 18.9 (11.5) 24 (11) 0.32 Inpatient complication 1 (5%) 1 (12.5%) 0.51 Microorganism- related variables Staphylococcal species 12 (63%) 7 (87.5%) 0.37 Polymicrobial infection 1 (5%) 0 (0%) 1 Methicillin resistant staph aureus (MRSA) 0 (0%) 2 (25%) 0.08

Retrospective observational study

Variability in surgical indications/technique Variability in postop course of antibiotics

Limited sample size

Unable to definitively conclude which

variables related to success/failure

Limitations

5/11/2013 5 Discussion

Publication N= Type of PJI Rx Postop abx (avg) Success F/U Current study 28 Early postop Cementless 1-stage 6wk IV + variable PO

71% (20/28)

3.6yr

Discussion

Publication N= Type of PJI Rx Postop abx (avg) Success F/U Crockarell JBJS 1998 42 (inc 19 early postop) Early postop I&D w/ component retention 1mo IV + 2mo PO

21% (4/19)

6.3yr Current study 28 Early postop Cementless 1- stage 6wk IV + variable PO

71% (20/28)

3.6yr

Discussion

Publication N= Type of PJI Rx Postop abx (avg) Success F/U Crockarell JBJS 1998 42 (inc 19 early postop) Early postop I&D w/ component retention 1mo IV + 2mo PO

21% (4/19)

6.3yr Current study 28 Early postop Cementless 1- stage 6wk IV + variable PO

71% (20/28)

3.6yr Yoo SICOT 2009 12 Chronic Cementless 1-stage 5wk IV + 6wk PO

83.3% (10/12)

7.2yr

Discussion

Publication N= Type of PJI Rx Postop abx (avg) Success F/U Crockarell JBJS 1998 42 (inc 19 early postop) Early postop I&D w/ component retention 1mo IV + 2mo PO

21% (4/19)

6.3yr Current study 28 Early postop Cementless 1- stage 6wk IV + variable PO 77% (20/26) 3.6yr Yoo SICOT 2009 12 Chronic Cementless 1-stage 5wk IV + 6wk PO

83.3% (10/12)

7.2yr

5/11/2013 6 Discussion

Publication N= Type of PJI Rx Postop abx (avg) Success F/U Crockarell JBJS 1998 42 (inc 19 early postop) Early postop I&D w/ component retention 1mo IV + 2mo PO

21% (4/19)

6.3yr Current study 28 Early postop Cementless 1- stage 6wk IV + variable PO 77% (20/26) 3.6yr Yoo SICOT 2009 12 Chronic Cementless 1-stage 5wk IV + 6wk PO

83.3% (10/12)

7.2yr Oussedik JBJS Br 2010 11 Chronic Hybrid Cemented 1-stage 5d IV + 6wk PO

100% (11/11)

6.8yr

Discussion

Publication N= Type of PJI Rx Postop abx (avg) Success F/U Crockarell JBJS 1998 42 (inc 19 early postop) Early postop I&D w/ component retention

1mo IV +

2mo PO

21% (4/19)

6.3yr Current study 28 Early postop Cementless 1- stage 6wk IV + variable PO 77% (20/26) 3.6yr Yoo SICOT 2009 12 Chronic Cementless 1-stage 5wk IV + 6wk PO

83.3% (10/12)

7.2yr Oussedik JBJS Br 2010 11 Chronic Hybrid Cemented 1-stage 5d IV + 6wk PO

100% (11/11)

6.8yr Ure JBJS 1998 20 Chronic Cemented 1-stage 5wk IV + 5mo PO

100% (20/20)

9.9yr Callaghan CORR 1999 24 Chronic Cemented 1-stage 10d IV + 3-6mo PO

91.7% (22/24)

9.1yr

Discussion

Publication N= Type of PJI Rx Postop abx (avg) Success F/U Crockarell JBJS 1998 42 (inc 19 early postop) Early postop I&D w/ component retention

1mo IV +

2mo PO

21% (4/19)

6.3yr Current study 28 Early postop Cementless 1-stage 6wk IV + variable PO

77% (20/26)

3.6yr Yoo SICOT 2009 12 Chronic Cementless 1-stage 5wk IV + 6wk PO

83.3% (10/12)

7.2yr Oussedik JBJS Br 2010 11 Chronic Hybrid Cemented 1- stage 5d IV + 6wk PO

100% (11/11)

6.8yr Ure JBJS 1998 20 Chronic Cemented 1-stage 5wk IV + 5mo PO

100% (20/20)

9.9yr Callaghan CORR 1999 24 Chronic Cemented 1-stage 10d IV + 3-6mo PO

91.7% (22/24)

9.1yr Bucholz JBJS Br 1991

583

Chronic Cemented 1-stage Rarely used

77% (448/583); 88% (510/583)

4.4yr

I&D as a “less morbid” solution for acute PJI?

Discussion

Of 83 cases that had undergone prior I&D

28 (34%) failed subsequent 2 stage revision

Of 8 cases that had undergone 1-stage exchange

7 (88%) successfully Rx’d w/ 2 stage revision

5/11/2013 7 Conclusion

• For acute postoperative PJI, one stage

cementless exchange THA is a reasonable alternative to I&D w/ modular exchange

• Feasible- safe; low morbidity/ surgical

complexity

• Effective- relative high component retention

rate; no compromise of future 2 stage results

• Further prospective work is needed to

elucidate the variables related to success/ failure of this treatment

THANK YOU.