Evolving Technique An Algorithm for 1-Stage Versus 2-Stage - - PowerPoint PPT Presentation

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Evolving Technique An Algorithm for 1-Stage Versus 2-Stage Exchange: Here are the Rules

Michael B. Cross, MD Assistant Attending Orthopaedic Surgeon

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Disclosures

• Consultant:
• Smith & Nephew
• Link Orthopaedics
• Exactech Inc.
• Intellijoint
• Acelity
• Theravance Biopharma
• Zimmer Biomet
• Honorarium:
• Acelity
• Editorial Board:
• Techniques in Orthopaedics
• Bone and Joint Journal 360
• Journal of Orthopaedics and Traumatology

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

The Problem

• #1 or #2 cause for revision THA and TKA
• Late PJI incidence ranges from 0.8% to 1.9%

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

• ESR/CRP

– Excellent screening tool; high sensitivity – Rarely normal in the face of infection – Easily obtained

• Joint Aspiration

– Synovial fluid WBC: cut-off 1100 - 3,000 cells/uL – Differential: > 80% very suspicious – Culture: must be off of abx for > 2 weeks prior to aspiration

• Leukocyte Esterase Strips
• α-Defensin immunoassay
• Next Generation Sequencing

Diagnosis – MSIS Criteria

The “Classics “ Recent Developments

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

What are my options?

• Treatment Options

– Suppression

• Susceptible organism
• Stable implant

– I&D, Liner Exchange, & Component retention – Two stage protocol – One stage protocol – Resection arthroplasty

• Recalcitrant / resistant organisms
• Multiply re-infected patient
• Medically infirmed

– Fusion/Amputation

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

1-Stage Protocol for Infected TJA

• Implant Removal

– All cement and cement restrictors

• Aggressive debridement

– Capsule, scar, prior incision, infected bone – Pack the canal after you are done to minimize contamination during the remaining portion of the debridement

• Closure
• Re-Prep and Drape

– New drapes, new sterile instruments, re-scrub, new suction, bovie, lavage

• Revision TKA/THA
• Prepare the cement (for TKA)
• Re-implantation
• Closure

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

2-stage Protocol for Infected TJA

• “Gold standard” (For now)
• Remove all foreign material
• High dose spacer:

– Pre-Fabricated spacers, rush rod with cement, or intraoperative molds – 3-6 grams of antibiotics per 40 grams cement – Not meant to be weight bearing

• 6 weeks parenteral antibiotics
• 2-3 week antibiotic holiday
• ESR, CRP, Aspiration to determine

eradicaton

• Re-implantation

Courtesy of Exactech, Inc.

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1-Stage Versus 2-Stage Exchange

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

My Indications for One Stage Revision in 2017

• Acute Infections (<3-6 weeks from surgery)
• THA with noncemented components without

ingrowth/ongrowth

• No data on this
• Chronic Infections
• Known organisms with known antibiotic sensitivity
• Prefer lower virulent organism
• Prefer elderly or lower demand patient but not necessary
• Intact soft tissue envelope
• No sinus tract that is outside the wound

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Contraindications – One stage (Indications for Two-Stage)

• Failure of ≥ 1 previous 1-staged procedures
• r I&D liner exchange
• Infection spreading to the neurovascular

bundle

• Organism unknown or no sensitivity data

known

• Non-availability of appropriate antibiotics
• High antibiotic resistance
• Sinus outside the incision
• Poor soft tissue envelope (i.e. needs

additional surgery to get coverage of the wound)

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Contraindications – Two Stage Revision

• Multiply re-infected

patient or failed two stage revisions

• Girdlestone, Amputation,

Fusion

• Medically infirmed

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Which is superior?

• No direct comparison studies between one stage

and two stage

• Important outcomes:

– Function – Cost – Eradication

• Both 1 and 2 stage success rates have been

reported to be 70-85% in eradicating infection

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

• N=63 patients who underwent one-stage revisions of septic knee

endoprostheses – 6 UKA, 37 primary TKA, 20 hinged knee endoprostheses – Minimum f/u 24 months (range:24-70 months) – All were treated locally and systemically with microorganism- specific antibiotics. – Exclusion : MRSA, MRSE, unknown organisms

• Results

– 0 pts with UKA and primary TKA had recurrence of infection. – 3 of 20 patients with hinged knee prostheses had recurrent infection

• One-stage revision success rate of 95% and higher knee scores

than reported for two-stage revisions

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

• N=102 patients for chronic TKA infections
• 28 (27%) were treated using a single-stage approach
• 74 (73%) were treated using a two-stage approach.
• Mean age of 65 years (range, 45-87 years) with minimum f/u of

3 years (3-9 years)

• The indications for using a single-stage approach
• Minimal/moderate bone loss, the absence of

immunocompromised host, healthy soft tissues, a known

• rganism with known sensitivities for which appropriate

antibiotics are available.

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

• Results:

– 0 patients in the single-stage revision group developed recurrence of infection – 5 patients (93%) in the two-stage revision group developed reinfection (p = 0.16) – Patients treated with a single-stage approach had higher KSS scores than patients treated with the two- stage approach (88 versus 76, p < 0.001) Use of a single-stage approach in highly selected patients with chronically infected TKAs is an alternative to a two-stage procedure

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Prospective RCT Comparing 1 vs. 2 Stage Revision TJA

• Site PIs:
• Michael Cross (HSS)
• Craig Della Valle (Rush)
• Javad Parvizi (Rothman)
• Thomas Fehring (OrthoCarolina)
• Carlos Higuera (Cleveland Clinic)
• 10 additional sites are under IRB review
• Primary Outcome: Recurrence of deep infection (MSIS)

at 1 year

• Over 55 patients enrolled to date !

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Conclusions

• The best approach for surgical treatment of an PJI remains

controversial

• I believe that a one-stage exchange still offers certain distinct

advantages with a comparative high success rate

• I consider it in:

– THA < 3-6 weeks out from surgery

• NEED DATA !

– Chronic infections with known, low virulence, sensitive organisms – In my practice more often used in elderly, low demand individuals that will not survive a two stage revision

• Results from our ongoing RCT will give more direction

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

THANK YOU