8 0 Year Old Diabetic with Draining Wound Javad Parvizi MD, FRCS - - PowerPoint PPT Presentation

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8 0 Year Old Diabetic with Draining Wound Javad Parvizi MD, FRCS - - PowerPoint PPT Presentation

Sep 20, 2022 301 likes •720 views

8 0 Year Old Diabetic with Draining Wound Javad Parvizi MD, FRCS Professor Rothm an Institute at Thom as Jefferson University, Philadelphia Disclosures Research support : Pfizer NIH Rotation Medical Departm ent of Defense

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8 0 Year Old Diabetic with Draining Wound

Javad Parvizi MD, FRCS

Professor Rothm an Institute at Thom as Jefferson University, Philadelphia

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 Research support:

 NIH  Departm ent of Defense  OREF  3M  Aesculap  AO Spine  Biom et  Cem pra  Ceram Tec  DePuy  Integra  Lim a  Myoscience  NDRI  Novartis  Pfizer  Rotation Medical  Sim plify Medical  Sm ith and Nephew  Stelkast  Stryker Orthopedics  Synthes  TissueGene  Tornier  Orthospace  Zim m er Biom et

Disclosures

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Consultant

Zim m er Biom et

Convatech

TissueGene

Ceram tec

Corentec

Ethicon

Tenor

Heron

Intellectual Property/ Ownership

Parvizi Surgical Innovations

Hip Innovation Technology

Corentec

Cross Current Business Intelligence

Alphaeon

Joint Purification System s

Ceribell

MedAp

Physician Recom m ended Nutriceuticals

PRN-Veterinary

MD-valuate

Intellijoint

MicroGenDx

Disclosures

Board Member/ Adviser

 Eastern Orthopedic Assoc.  3M  JBJS-A  Muller Foundation  United Healthcare

 Royalty

 Corentec  Datatrace  Elsevier  Jaypee publishers  Slack  Wolters Kluwer

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8 0 Year Old Diabetic

  • Diagnosis
  • Optimization
  • Surgical Intervention
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 Infected unless

proven

  • therwise

Wound Drainage

Parvizi J et al CORR 20 11

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AAOS Guidelines www.aaos.org/ guidelines

  • 15 recommendations
  • Majority strong
  • Review of literature

Parvizi et al. JAAOS 2010 Della Valle et al. JAAOS 2010

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AAOS

  • ESR and

CRP first line

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D-dim er

Sensitivity = 89% Specificity = 92%

Shahi et al. JBJS 2017

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AAOS

  • ESR and CRP

will be elevated (close to surgery)

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Recent Data from the RI

ESR and CRP may be normal in up to 18% of PJI cases

Tan T et al – JBJS 2016

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International Consensus

Aspiration of the joint before any further imaging

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AAOS Guidelines Rec 9: Weak

Bone scan (leukocyte labeled) and PET scan is an option for patients not scheduled for reoperation or diagnosis not reached

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  • Patients be off antibiotics

before aspiration (2 weeks)

  • No Antibiotics until diagnosis

reached or refuted

AAOS Guidelines Strong

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  • Administration of ABX

also affects the level of neutrophil % and total count in the synovial fluid

Shahi et al CORR 2015

RI Data- 20 15

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Aspiration

  • Leukocyte esterase
  • Alpha defensin-may be
  • Cell count
  • Neutophil differential
  • Culture
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Diagnosis of PJI Simple Test

 UA strips for leukocyte esterase

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Leukocyte esterase strips

Study performed in 2 centers

158 aspirations of synovial fluid (127 knees, 31 hips) 36 Read as Positive 63 Read as Negative 53 Unreadable (1/ 3)

Wetters, Berend, Della Valle et. Al AAHKS 2011

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Data

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Sensitivity:81 % Specificity: 97 %

Leukocyte Esterase Strip Test

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Thresholds (Consensus) Acute PJI

 ESR- No threshold  CRP > 100 mg/ L (hip and knee)  Synovial WCC = 10,000 cells/ ul  Synovial PMN >90%

ESR CRP ESR+CRP

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Thresholds (Consensus) Chronic PJI

ESR > 30 mm/ hr CRP > 10 mg/ L (hip and knee) Synovial WCC > 3,000 cells/ ul Synovial PMN >80%

ESR CRP ESR+CRP

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  • 65 year old
  • TKA- 4 years ago
  • Recent red, swollen knee
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  • Aspiration (x2)
  • Cell count >50,000
  • Diff > 90%
  • Elevated ESR/CRP
  • MSIS Positive for PJI
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  • Culture (from two centers)
  • Negative
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 There is a sinus tract communicating

with the prosthesis; or

Definition of PJI (MSIS)

Parvizi J et al CORR 20 11

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 A pathogen is isolated by culture from

two separate tissue or fluid samples

  • btained from the affected prosthetic

joint; or

Definition of PJI (MSIS)

Parvizi J et al CORR 20 11

 There is a sinus tract communicating

with the prosthesis; or

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 There is a sinus tract communicating

with the prosthesis; or

 A pathogen is isolated by culture from

two separate tissue or fluid samples

  • btained from the affected prosthetic

joint; or

Definition of PJI (MSIS)

Parvizi J et al CORR 20 11

 When four out of the following six

criteria exists

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ESR AND CRP

synovial WBC count or ++ leukocyte esterase

synovial PMN%,

 Positive histological analysis of

periprosthetic tissue,

A single positive culture

Definition of PJI

(MSIS/ International Consensus)

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8 0 Year Old Diabetic

  • Diagnosis
  • Optimization
  • Surgical Intervention
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 AAHKS Research Group

Threshold for HbA1C

ADA: 7% 7.7%

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 Rothm an Study

New Test for Diabetes Fructosam ine

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8 0 Year Old Diabetic

  • Diagnosis
  • Optimization
  • Surgical Intervention
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8 0 Year Old Diabetic

  • Treatment
  • Would wait until
  • rganism known
  • MRSA- resection
  • Others- may be I and D
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Consensus On Orthopedic Infections July 26-27, 2018 Philadelphia