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

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

Disclosures Consultant  Board Member/ Adviser Zim m er Biom et   Convatech   Eastern Orthopedic Assoc. TissueGene   3M Ceram tec   JBJS-A Corentec   Muller Foundation Ethicon   United Healthcare Tenor  Heron  Intellectual Property/ Ownership  Parvizi Surgical Innovations   Royalty Hip Innovation Technology   Corentec Corentec   Cross Current Business Intelligence  Datatrace Alphaeon   Elsevier Joint Purification System s  Ceribell   Jaypee publishers MedAp   Slack  Physician Recom m ended Nutriceuticals PRN-Veterinary   Wolters Kluwer MD-valuate  Intellijoint  MicroGenDx 

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

Wound Drainage  Infected unless proven otherwise Parvizi J et al CORR 20 11

AAOS Guidelines www.aaos.org/ guidelines • 15 recommendations • Majority strong • Review of literature Parvizi et al. JAAOS 2010 Della Valle et al. JAAOS 2010

AAOS • ESR and CRP first line

D-dim er Sensitivity = 89% Specificity = 92% Shahi et al. JBJS 2017

AAOS • ESR and CRP will be elevated (close to surgery)

Recent Data from the RI ESR and CRP may be normal in up to 18% of PJI cases Tan T et al – JBJS 2016

International Consensus Aspiration of the joint before any further imaging

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

AAOS Guidelines Strong • Patients be off antibiotics before aspiration (2 weeks) • No Antibiotics until diagnosis reached or refuted

RI Data- 20 15 • Administration of ABX also affects the level of neutrophil % and total count in the synovial fluid Shahi et al CORR 2015

Aspiration • Leukocyte esterase • Alpha defensin-may be • Cell count • Neutophil differential • Culture

Diagnosis of PJI Simple Test  UA strips for leukocyte esterase

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

Data

Leukocyte Esterase Strip Test Sensitivity:81 % Specificity: 97 %

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

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

• 65 year old • TKA- 4 years ago • Recent red, swollen knee

• Aspiration (x2) • Cell count >50,000 • Diff > 90% • Elevated ESR/CRP • MSIS Positive for PJI

• Culture (from two centers) • Negative

Definition of PJI (MSIS)  There is a sinus tract communicating with the prosthesis; or Parvizi J et al CORR 20 11

Definition of PJI (MSIS)  There is a sinus tract communicating with the prosthesis; or  A pathogen is isolated by culture from two separate tissue or fluid samples obtained from the affected prosthetic joint; or Parvizi J et al CORR 20 11

Definition of PJI (MSIS)  There is a sinus tract communicating with the prosthesis; or  A pathogen is isolated by culture from two separate tissue or fluid samples obtained from the affected prosthetic joint; or  When four out of the following six criteria exists Parvizi J et al CORR 20 11

Definition of PJI (MSIS/ International Consensus) ESR AND CRP  synovial WBC count or ++ leukocyte  esterase synovial PMN%,   Positive histological analysis of periprosthetic tissue,  A single positive culture

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

Threshold for HbA1C  AAHKS Research Group 7.7% ADA: 7%

New Test for Diabetes Fructosam ine  Rothm an Study

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

8 0 Year Old Diabetic • Treatment • Would wait until organism known • MRSA- resection • Others- may be I and D

Consensus On Orthopedic Infections July 26-27, 2018 Philadelphia