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Radical debridement, implant removal aid septic one-stage implant exchange
An experienced microbiologist should identify infecting organisms so appropriate antibiotics can be mixed into the cement in infected TKA, THA cases.
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ORLANDO, Fla., USA — A cemented one-stage total knee or hip arthroplasty component exchange using antibiotic-loaded bone cement leads to reduced hospital stays, systemic antibiotic loads and treatment costs. It is also associated with high rates of patient satisfaction, according to a presenter at the Current Concepts in Joint Replacement Winter Meeting, here.
“There are a lot of advantages of single-stage [exchange]: less pain for the patient, less complications, better surgical conditions, better functional results, and so on,” Thorsten Gehrke, MD, of the ENDO-Klinik GmbH, in Hamburg, Germany, said.
Gehrke discussed the advantages of single-stage component exchange for periprosthetic joint infections (PJI) associated with total knee arthroplasty (TKA) or total hip arthroplasty (THA).
Images: Gehrke T
The literature shows a 90% success rate with two-stage exchanges and almost the same success rates with one-stage exchanges, he said, noting survival rates are even higher for one-stage total joint replacement procedures.
A proper assessment requires mandatory joint aspiration to exactly identify the germ(s) that caused the infection. The antibiogram is required for the one-stage procedure. It helps define a specific antibiotic-loaded acrylic cement that will achieve a high therapeutic level of topical antibiotic elution at the surgical site, which is key to the overall concept.
When a surgeon decides to perform a one-stage component exchange for infected TKA or THA, he or she must first have a concept of what to do. “Otherwise you should not do it,” Gehrke said.
He noted that ever since Hans Wilhelm Buchholz, MD, first began doing one-stage exchanges for infected total joint replacement in the 1970s by mixing antibiotics with bone cement, the technique has been used at his clinic to manage 85% of all PJI.
Preoperatively, an experienced microbiologist should identify the infecting organism and perform diagnostic tests, including analyzing the joint aspirate to identify all the bacteria, Gehrke said.
The microbiologist should also complete an antibiogram, which helps the team assess which antibiotics are effective against the organisms found and should be added to the bone cement.
Adding antibiotics to the cement facilitates “high topical elution directly at the surgical site,” Gehrke said.
Next, the surgeon should remove all foreign material from the surgical site, including the original cement and any cement restrictors, and then perform aggressive debridement.
“Radical debridement and implant removal — they are just two secrets of septic exchange,” Gehrke said. “If you do it two-stage or one-stage, [then] you have to remove, in our eyes, all the material,” he said.
Gehrke said he never uses liquid bone cement. Instead, he prefers a maximum amount of antibiotics of 10% to the total amount of polymethylmethacrylate (PMMA) powder used. For example, 4 g antibiotic would be used in 40 g PMMA. Furthermore, he noted in his abstract that systemic antibiotics given postoperatively should be used an average of 10 days to 15 days, with some exceptions, including for streptococci.
Contraindications
Gehrke advised against one-stage exchanges with antibiotic mixed into cement in patients that have failed more than two one-stage TKA or THA procedures, for infections that have reached the nerve-vessel bundle, in cases where the infecting bacteria was not identified, and whenever there are no antibiotics available to use “due to high antibiotic resistance.”
Citing a 2012 study by Gulhane and colleagues, Gehrke said those researchers reported highly reproducible results with single-stage TKA revision and noted they expect the technique will become as popular and successful in TKA revision as it now is for infected THA. – by Renee Blisard Buddle
- References:
- Gehrke T. Paper #65. Presented at: Current Concepts in Joint Replacement Winter Meeting; Dec. 12-15, 2012; Orlando, Fla., USA.
- Gulhane S. J Bone Joint Surg Br. 2012; doi:10.1302/0301-620X.94B7.28710.
- Fore more information:
- Thorsten Gehrke, MD, can be reached at Department of Orthopedic Joint Surgery and Endoprosthetics, Holstenstr. 2, 22767 Hamburg, Germany; email: thorsten.gehrke@endo.de.
Disclosure: Gehrke receives funding for consulting, teaching and designing from Biomet Orthopedics, funding for participation in the advisory board of Boehringer Ingelheim, funding for consulting, speaking, teaching and designing from Waldemar Link GmbH, and funding for consulting, speaking and teaching from Zimmer.
Perspective
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Lars Lidgren, MD, PhD
There are clear differences in treatment modalities and pathways for periprosthetic joint infection (PJI), not only between countries but also depending on anatomic location, bone stock, tissue quality and bacteriology. The ENDO-Klinik has the longest experience with the one-stage procedure for PJI with sensitive low-virulent bacteria in low risk patients using polymethylmethacrylate (PMMA) cement containing multiple antibiotics. PJI is a serious condition with high morbidity and mortality in fragile and often multi-diseased patients. Repeated surgery based on reoccurrence of infection adds up. Randomized studies with defined indications comparing two- and one-stage procedures are lacking and are needed for cementless and cemented PJI revisions using synthetic bone substitutes, as well as PMMA as local carriers. Supplementary prolonged combinations with systemic antibiotics are commonly given and backed with good published studies. In response to emerging PJI, a major threat to arthroplasty surgery, several groups, like the European Bone and Joint Infection Society and the International Society of Orthopaedic Centers, are forming task forces to find new solutions for prevention, early diagnosis and treatment.
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