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

5/11/2013 Financial Disclosure Research support Consultant � � NIH Stryker Orthopaedics � � OREF Zimmer � � DOD Biomet � � � Aircast � Smith and Nephew AOA Convatech � � MTF Covidien � � Stryker Orthopaedics TissueGene � � The Knee Society Ceramtec � � 3M OsteoMEM � � Zimmer � Board Member/Adviser � Biomemetics � CD Diagnostics Wyeth � � Philadelphia Orthopaedic Soc � Hansen E*, Tetreault M^, Zmistowski B*, Intellectual Property/Royalty Eastern Orthopedic Assoc. � � DellaValle C^, Parvizi J*, Haddad FS, Hozack WJ* SmarTech United Healthcare � � Elsevier Magnifi Group (Publishers) � � Hospital, London UK ° Rothman Institute, Philadelphia PA*; Rush Wolters Kluwer 3M � � University, Chicago, IL^; University College Slack � Introduction Introduction • • Acute PJI of total joint One stage exchange arthroplasty initially described by Bucholz in 70’s arthroplasty typically treated w/ I&D and • Classically, procedure done with modular bearing exchange use of antibiotic laden bone • High published failure rate cement of I&D (≈68%) • Cementless fixation is the preferred technique for THA/rev • One stage exchange THA in the USA • arthroplasty represents an Little has been published on the attractive alternative cementless technique for one stage exchange arthroplasty 1

5/11/2013 Specific Aims Hypotheses • Assess the feasibility and efficacy of single- � Cementless, one stage exchange for acute PJI following THA has low morbidity/ stage, cementless exchange for acute surgical complexity postoperative infection following THA � Minimal bony on/ingrowth of components • Determine variables related to the success � Rate of successful control of infection or failure of this intervention following cementless, one stage exchange would surpass that of historical rates following I&D Methods Methods- Definitions • Multicenter, retrospective observational study • Rothman Institute, Rush University, • Acute post-operative infection: ≤6 University College Hospital • Inclusion criteria- weeks from index surgery • All pts who underwent 1 stage cementless exchange THA for acute postoperative PJI • ≥ 2yr clinical follow-up • Success: Retention of implants at • Exclusion criteria- • Acute hematogenous/ chronic PJI most recent clinical follow-up • Hybrid cemented one stage exchange THA • Index procedure- Revision THA 2

5/11/2013 Methods- Variables Methods- Technique � Patient related- � One stage cementless exchange THA � Age, gender, BMI, ASA/CCI � Indication/approach/ implant determined by operative surgeon � Perioperative- � Followed by post-op course of culture � Time from index procedure, inpatient specific antibiotics complications � Course determined in consultation w/ Infectious Disease specialist � Microbe related- � Organism, antibiotic resistance profile Results- Clinical Cohort Results- Surgical All procedures done via prior � • 35 patients surgical approach (inc. DA/Watson Jones/ DL/PL) • Excluded 7 hybrid- cemented one stage THA, One stage implants utilized- all � • including 6 revision THA primary type THA components DJD � Femur- 68% • 28 patients DDH � Same design, upsized 65% of cases AVN � Acetabulum- • 19M: 9F, mean age 60yo SCFE � Hemispheric, upsized 76% of cases • mean ASA 1.5, CCI 2.25 � Screws placed, 25% of cases • mean f/u 44 months NO intra-operative complications � • Mean time to 1 Stage exchange- (eg. ppx fx) 25 days (range 4-41) http://articles.latimes.com/2012/jul/25/news/la-heb-hip-knee-replacement- heart-attack-20120724 3

5/11/2013 Results- Microbiology Results- Outcomes One Stage Exchange Cohort N=28 54% 46% MSSA MRSA No Further Sx Further Sx 11% N=15 (54%) N=13 (46%) CNS 64% K pneumo 38% 62% E coli Isolated I&D 2 Stage Exchange 11% N=5 (18%) N=8 (29%) Bacteroides 7% Strep spp. 87% 13% Success of ultimate 2 stage- Component retention rate- Acetinobacter Success Repeat 2 Stage 87% (7/8) 71% (20/28) N=7 (25%) N=1 (4%) Enterococcus Results- Prognostic Factors Limitations Variable Success,n=19 Failure, n=8 p (unadjusted) � Retrospective observational study Demographics � Variability in surgical indications/technique Age (years) 56.6(12.6) 60.2 (13.3) 0.69 Female sex 6 (32%) 2 (25%) 1 � Variability in postop course of antibiotics 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 � Limited sample size Interval between index and 1-stage surgery 18.9 (11.5) 24 (11) 0.32 Inpatient complication 1 (5%) 1 (12.5%) 0.51 � Unable to definitively conclude which variables related to success/failure 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 4

5/11/2013 Discussion Discussion Publication N= Type of Rx Postop abx Success F/U Publication N= Type of Rx Postop Success F/U PJI (avg) PJI abx (avg) Crockarell 42 (inc 19 Early postop I&D w/ 1mo IV + 6.3yr 21% (4/19) JBJS 1998 early component 2mo PO postop) retention Current study 28 Early postop Cementless 6wk IV + 3.6yr 71% (20/28) Current study 28 Early postop Cementless 1- 6wk IV + 3.6yr 71% (20/28) 1-stage variable PO stage variable PO Discussion Discussion Publication N= Type of Rx Postop Success F/U Publication N= Type of Rx Postop Success F/U PJI abx (avg) PJI abx (avg) Crockarell 42 (inc 19 Early postop I&D w/ 1mo IV + 6.3yr Crockarell 42 (inc 19 Early postop I&D w/ 1mo IV + 6.3yr 21% (4/19) 21% (4/19) JBJS 1998 early component 2mo PO JBJS 1998 early component 2mo PO postop) retention postop) retention Current study 28 Early postop Cementless 1- 6wk IV + 3.6yr Current study 28 Early postop Cementless 1- 6wk IV + 3.6yr 71% (20/28) variable PO 77% (20/26) stage variable PO stage Yoo 12 Chronic Cementless 5wk IV + 7.2yr Yoo 12 Chronic Cementless 5wk IV + 7.2yr 83.3% (10/12) 83.3% (10/12) SICOT 2009 1-stage 6wk PO SICOT 2009 1-stage 6wk PO 5

5/11/2013 Discussion Discussion Publication N= Type of Rx Postop Success F/U Publication N= Type of Rx Postop Success F/U PJI abx (avg) PJI abx (avg) Crockarell 42 (inc 19 Early postop I&D w/ 1mo IV + 6.3yr Crockarell 42 (inc 19 Early postop I&D w/ 6.3yr 21% (4/19) 1 mo IV + 21% (4/19) JBJS 1998 early component 2mo PO JBJS 1998 early component 2mo PO postop) retention postop) retention Current study 28 Early postop Cementless 1- 6wk IV + 3.6yr Current study 28 Early postop Cementless 1- 6wk IV + 3.6yr variable PO 77% (20/26) variable PO 77% (20/26) stage stage Yoo 12 Chronic Cementless 5wk IV + 7.2yr Yoo 12 Chronic Cementless 5wk IV + 7.2yr 83.3% (10/12) 83.3% (10/12) SICOT 2009 1-stage 6wk PO SICOT 2009 1-stage 6wk PO Oussedik 11 Chronic Hybrid 5d IV + 6.8yr Oussedik 11 Chronic Hybrid 5d IV + 6.8yr 100% (11/11) 100% (11/11) JBJS Br 2010 Cemented 6wk PO JBJS Br 2010 Cemented 6wk PO 1-stage 1-stage Ure 20 Chronic Cemented 5wk IV + 9.9yr 100% (20/20) JBJS 1998 1-stage 5mo PO Chronic Cemented 9.1yr Callaghan 24 10d IV + 91.7% (22/24) CORR 1999 1-stage 3-6mo PO Discussion Discussion Publication N= Type of Rx Postop abx Success F/U PJI (avg) Crockarell 42 (inc 19 Early postop I&D w/ 6.3yr � I&D as a “less morbid” solution for acute PJI? 1 mo IV + 21% (4/19) JBJS 1998 early component 2mo PO postop) retention Current study 28 Early postop Cementless 6wk IV + 3.6yr 77% (20/26) 1-stage variable PO Yoo 12 Chronic Cementless 5wk IV + 7.2yr 83.3% (10/12) � Of 83 cases that had undergone prior I&D SICOT 2009 1-stage 6wk PO Oussedik 11 Chronic Hybrid 5d IV + 6.8yr 100% (11/11) � 28 (34%) failed subsequent 2 stage revision JBJS Br 2010 Cemented 1- 6wk PO stage Ure 20 Chronic Cemented 5wk IV + 9.9yr 100% (20/20) JBJS 1998 1-stage 5mo PO � Of 8 cases that had undergone 1-stage exchange Callaghan 24 Chronic Cemented 10d IV + 9.1yr 91.7% (22/24) CORR 1999 1-stage 3-6mo PO � 7 (88%) successfully Rx’d w/ 2 stage revision Bucholz Chronic Cemented Rarely used 4.4yr 77% (448/583); 583 JBJS Br 1991 1-stage 88% (510/583) 6

5/11/2013 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 THANK YOU. 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 7