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Total knee revision in septic failure

Total knee revision in septic failure. Epidemiology, timing and classification. Prof. Paolo Cherubino Dipartimento di scienze ortopediche e traumatologiche Universitas Studiorum Insubriae VARESE. Epidemiology. The most commons causes of knee arthroplasty revisions: Infections ( 25.2%)

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Total knee revision in septic failure

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  1. Total knee revision in septic failure Epidemiology, timing and classification Prof. Paolo Cherubino Dipartimento di scienze ortopediche e traumatologiche Universitas Studiorum Insubriae VARESE

  2. Epidemiology • The most commons causes of knee • arthroplasty revisions: • Infections (25.2%) • Mechanical failure (16.1%) The Epidemiology of Revision Total Knee Arthroplasty in the United States Kevin Bozic, MD. 2007

  3. Epidemiology Risk factors • The systemic risk factors: • rheumatoid arthritis • diabetes • IRC • obesity • advanced age • debilitation • oral steroids • cancer/chemotherapic treatment • immunocompromised patients Simmons TD, Stern SH. Diagnosis and management of the infected total knee arthroplasty. Am J Knee Surg. 1996

  4. Epidemiology Risk factors • The local risk factors are : • Previews knee surgery • Skin complications after the implant • psoriatic skin ulcers Simmons TD, Stern SH. Diagnosis and management of the infected total knee arthroplasty. Am J Knee Surg. 1996

  5. Infection is actually, rare but serious problem in joints arthroplastic surgery

  6. GroganJ. Bone Joint Surg. Am.1986; 68:226-34 Wilson J.Bone Joint. Surg. Am. 1990; 72:878-83 BengstonActa Orthop Scand. 1991; 62(4):301-11 Rand JA.Orthop Clin North Am.1994. Epidemiology INFECTION RATE AFTER TOTAL KNEE ARTHROPLASTY 0,5 - 5%

  7. Epidemiology “The prevalence of infection after primary total knee arthroplasty has been reported to range from 0.5 to 5 percent.” J Bone Joint Surg Am. 1999 Oct;81(10):1434-45.

  8. Epidemiology • “Current infection rates are • in the 1% to 2%.” The Journal of Arthroplasty Vol. 19 No. 4 Suppl. 1 2004

  9. Epidemiology A. W. Blom, J. Brown, A. H. Taylor, G. Pattison, S. Whitehouse, G. C. Bannister 2004 “Our known infection rates of 1% after primary and 5.8% after revision TKA are comparable with published reports.”

  10. Epidemiology 2007 “Deep infection rates in total knee joint replacement vary in the published literature between 0.3% and 2.9%.” HSSJ (2007) 3: 159–163

  11. Epidemiology “Incidence rates for primary TKA between 1995 and 2004, from 6.3 to 11.0 at a rate of 5.1% per year (p < 0.001).”

  12. Staph E. Staph. A. Gram - Streptococcus Legionella P. Etiology Pre and intra-operative pathogen ISOLATION E. Coli

  13. Etiology The Journal of Arthroplasty Vol. 19 No. 4 Suppl. 1 2004

  14. Etiology A. W. Blom, J. Brown, A. H. Taylor, G. Pattison, S. Whitehouse, G. C. Bannister 2004

  15. Etiology J Bone Joint Surg Am. 1999 Oct;81(10):1434-45.

  16. Etiology Chang Gung Med J. 2008 Nov-Dec;31(6):583-91.

  17. Clinical-temporal classification • Immediate: before 4 weeks • Early: between 4 wks to 2 years • Delayed: over 2 years • Occasional: positive culture in replacement Segawa et al. JBJS, 1999

  18. Classification Coventry’s state Step I = Acute infection post-operative (within 3 months after) Stage II = delayed deep infection (3 to 24 months after) Stage III = late hematogenous infection (a distance of years) Step Zero = Operating contamination (positivity of at least 2 of 3 buffers intra-op) Coventry MB. Orthop Clin North Am. 1975 Oct;6(4):991-1003.

  19. Classification J Bone Joint Surg Am. 85-A · SUPPLEMENT 1 · 2003

  20. TIMING

  21. Therapeutic option • Choice of treatment is based on: • anatomical-clinical microbiological Accurate diagnostic grading

  22. Replacement-Timing • CBC, VES and PCR • instrumental and clinical • Preoperative aspiration culture Clinical orthopaedic and related research n345, 1997

  23. Therapeutic option • Arthroscopy • Toilette • Replacement • Arthrodesis • Resection - arthroplastic • Amputation Purpose of surgery • infection eradication • save joint function

  24. IMMEDIATE INFECTION Toilette + Suppressive antibiotic therapy (at least 3 wks) ?

  25. EARLY INFECTION open surgery or arthroscopic TOILETTE + Suppressive antibiotic therapy (at least 3 wks) ?

  26. LATE INFECTION Remove implant and Surgical debridement age, general conditions, indication ARTHRODESIS REIMPLANT One stage Two stage

  27. INFEZIONE TARDIVA Remove implant and Surgical debridement age, general conditions, indication ARTHRODESIS REIMPLANT One stage Two stage

  28. Therapeutic option The two-stage exchange procedure has evolved as an effective treatment option. Clin Orthop Relat Res. 2007 Nov;464:164-78

  29. Therapeutic option The best results of treatment of an infected TKR have been reported by Windsor et al in which no spacer was used between stages Windsor RE, Insall JN, Urs WK, Miller DV, Brause BD. Two-stage reimplantation for the salvage of total knee arthroplasty complicated by infection: further follow-up and refinement of indications. J Bone Joint Surg [Am] 1990.

  30. Therapeutic option Treatment of TKA infection with a two-stage exchange had a significantly better outcome than debridement with retention of the prosthesis. Good results were obtained with two-stage revision of infected TKA International Orthopaedics (SICOT) 2008

  31. Therapeutic option Two-stage reimplantation of an infected total knee arthroplasty using a static antibiotic-cement spacer achieved an infection control rate of 86% and improvement in the clinical results.

  32. # 1 F, 75 aa PM S. Aureus PREOP

  33. # 1 F, 75 aa PM S. Aureus ESP

  34. # 1 F, 75 aa PM S. Aureus ESP

  35. # 1 F, 75 aa PM S. Aureus F-U 1 anno

  36. # 2 F, 78 aa IS Serratia marcescens PREOP

  37. # 2 F, 78 aa IS Serratia marcescens ESP

  38. # 2 F, 78 aa IS Serratia marcescens ESP

  39. # 2 F, 78 aa IS Serratia marcescens F-U 3 anni

  40. Thank you

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