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Surgical Strategies for Prosthetic Joint Infections: Expert Insights & Guidelines

Learn key points, diagnostics, and surgical interventions for acute prosthetic joint infections. Expert recommendations for managing PJI effectively. Stay informed and in control of patient care.

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Surgical Strategies for Prosthetic Joint Infections: Expert Insights & Guidelines

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  1. Evolving Technique Update: 63 year old Hedge Fund Trader Notices The Top Part of His Wound Draining Milky White Fluid & Is Concerned – He Calls at Midnight Henry D Clarke MD Professor of Orthopedics Mayo Clinic, Arizona

  2. Disclosures Henry D Clarke MD Institutional Research Vidacare Support: Stryker Paid Consultant: ConforMIS Smith & Nephew Zimmer-Biomet Royalties: ConforMIS Zimmer-Biomet Publishing Income: JAAOS

  3. 5 Key Points • Stay in control • Aspirate before antibiotics • Timely evaluation • Make an accurate diagnosis that differentiates between superficial & deep infection • Definitive intervention

  4. 5 Key Points • Stay in control • Surgical team does the evaluation • Office vs Hospital ED?

  5. 5 Key Points • Stay in control • Aspirate before antibiotics

  6. 5 Key Points • Stay in control • Aspirate before antibiotics • Timely evaluation • 24-48 hours • H&P • Labs (ESR, CRP, CBC) • Aspiration

  7. 5 Key Points • Stay in control • Aspirate before antibiotics • Timely evaluation • Make an accurate diagnosis that differentiates between superficial & deep infection • MSIS criteria help • Aspirate if any doubt

  8. Diagnosis of PJI Definite Prosthetic Joint Infection Exists where: • Sinus tract communicating with joint; or • Pathogen isolated from 2 or more separate tissue or fluid samples; or • When 3 or the following criteria exist: Workgroup convened by the Musculoskeletal Infection Society, J. Arthroplasty 25(8), 2011 Parvizi J, J. Arthroplasty 29 (2014) 1331

  9. Diagnosis of PJI Definite Prosthetic Joint Infection Exists where 3 of 5 minor criteria are met: • Elevated ESR & CRP • Elevated synovial WBC count or + Leukocyte Esterace strip • Elevated synovial PMN % • Pathogen in one fluid or tissue culture • > 5 WBC/HPF in 5 separate fields at 400X mag Parvizi J, J. Arthroplasty 29 (2014) 1331

  10. Diagnosis of Acute PJIAcute (<90 days post-op) vs Chronic • Chronic PJI • ESR >30, CRP >10 • Aspiration: 3K WBC, 80% Polys • Acute post-operative period • ESR not helpful, CRP >100 • Aspiration: 10K WBC, 90% Poly Parvizi J & GehrkeT J. Arthroplasty 29 (2014) 1331 Bedair H et al, CORR 469, 2011

  11. Diagnosis of Acute PJIAdditional Tests • Synovial fluid tests • Alpha-defensins (Synovasure) • 100% sensitivity;95% specificity • 24-96 hours Deirmengian C et al, CORR 440, 2005; Bingham J et al, CORR 472, 2014

  12. 5 Key Points • Stay in control • Aspirate before antibiotics • Timely evaluation • Make an accurate diagnosis that differentiates between superficial & deep infection • Definitive intervention • Staple /suture removal & observation • Debridement & prosthesis retention • 2 stage revision with a spacer

  13. This case:63 yo <1 month from surgery with wound drainage calls at midnight • Send picture of wound • See first thing in am at my office NPO • Evaluate • Labs & aspiration if needed • Acute post-op peri-prosthetic joint infection • To hospital for prosthesis salvage that day or next am • Hold antibiotics unless systemically sick

  14. Open Debridementwith Prosthesis Retention 1 stage open debridement with retention • 20 – 50% success • Early debridement (< 5 days) better than late • Sensitive organism Tattevin: Clin Infect Dis 29: 1999

  15. Open Debridementwith Prosthesis Retention • Open Debridement (Mayo Series) • 99 knees 1995-1999 • 60% success at 2 yr follow-up • Duration of >8 days of symptoms was associated with increase risk of failure Marculescu CE et al, Clinical Infectious Diseases 42, 2006

  16. Open Debridementwith Prosthesis Retention • Multi-center study • 2 Stage Re-implantation after failed debridement • 83 knees • 28 (34%) persistent infection Debridement burns bridges for subsequent salvage Sherrel J.C et al, CORR 469, 2011

  17. Open Debridementwith Prosthesis Retention • Database study from California/NY • 750 patients with 2 stage revision • 57 failed prior I&D with component retention • No difference in success rate for 2 stage revision (p=0.12) Brimmo O, Barsoum W et al, J Arthroplasty 31:461, 2016

  18. Surgical Management of Acute Infections • Rationale • Because of the historically poor results of single stage open debridement with prosthesis retention we started a new protocol for patients who present with acute infections • Two-stage debridement with beads protocol

  19. Surgical Management of Acute Infections • Patients presenting with acute PJI (symptoms < 4 weeks) • Post-operative • Acute hematogenous

  20. 2 Stage Debridement with Prosthesis Retention for Acute PJI in TKA Estes CS et al, CORR 468, 2010

  21. 2 Stage Debridement with Prosthesis Retention for Acute PJI in TKA Results • Min F/u 1 year, mean 3.5 years • 18 of 20 (90%) considered success with no evidence of active infection • 10 no antibiotics • 8 long-term suppression • No re-operations • 2 patients considered failures • Both on suppressive antibiotics

  22. Surgical Management of Acute Infections • Technique • Proceed to surgery urgently • Don’t need to know implant information / sizes

  23. Surgical Management of Acute Infections • Technique • Proceed to surgery urgently • Aggressive, thorough debridement & synovectomy

  24. Surgical Management of Acute Infections • Technique • Proceed to surgery urgently • Aggressive, thorough debridement • Modular parts removed • Flash sterilized / soaked in aseptic solution

  25. Surgical Management of Acute Infections • Technique • Proceed to surgery urgently • Aggressive, thorough debridement • Modular parts removed • Implants scrubbed • Sterile toothbrush / sponges

  26. Surgical Management of Acute Infections • Technique • Proceed to surgery urgently • Aggressive, thorough debridement • Modular parts removed • Implants scrubbed • Copious irrigation • Betadine • 35 ml of Povidine-iodine in 1 liter NS • Chlorhexidine

  27. Surgical Management of Acute Infections • Technique • Proceed to surgery urgently • Aggressive, thorough debridement • Modular parts removed • Implants scrubbed • Copious irrigation • Modular parts reinserted

  28. Surgical Management of Acute Infections • Technique • Proceed to surgery urgently • Aggressive, thorough debridement • Modular parts removed • Implants scrubbed • Copious irrigation • Modular parts reinserted • High Dose Antibiotic beads added • 1 mix (Palacos) with 3.6 g gentamicin or tobramycin, 3 g Vancomycin and 2 g cefazolin

  29. Surgical Management of Acute Infections Tobra 172 g/ml (2 – 20) Vanco 113 g/ml (5 – 10) Tobra 146 g/ml Vanco 67 g/ml • Technique • Proceed to surgery urgently • Aggressive, thorough debridement • Modular parts removed • Implants scrubbed • Copious irrigation • Modular parts reinserted • High Dose Antibiotic beads added • Return to O.R. 3 – 7 days later • Bead removal, repeat debridement and irrigation • Insertion of new modular parts

  30. Surgical Management of Acute Infections • Technique – Post-operative management • Started on antibiotics after 1st debridement • Antibiotics are adjusted based on cultures • 6 (occasionally 8 weeks) IV antibiotics • Oral antibiotics • Duration of oral antibiotics is variable • Many stop after about 3 months IV/PO • Some life-long suppression • Underlying co-morbidities • Age of patient • Difficulty of revision if infection recurs

  31. 2 Stage Debridement with Prosthesis Retention for Acute PJI in TKA Methods • Study period 2002-2014 • 44 knees • 25 men, 19 women • Mean age 65.7 years • 36 acute hematogenous infection • 8 immediate post-operative infection • 27 primary TKA, 17 revision TKA • Variety of organisms

  32. 2 Stage Debridement with Prosthesis Retention for Acute PJI in TKA Results • Mean F/U 43.6 months (range, 12-155) • Success 38 of 44 knees (86.4%) • Primary vs revision TKA • 88.9% vs 82.4% p=0.663 • Duration of onset of symptoms to 1st surgical intervention influences success • Successes mean 4.1 days • Failures mean 11.2 days • p=0.011

  33. 5 Key Points • Stay in control • Aspirate before antibiotics • Timely evaluation • Make an accurate diagnosis that differentiates between superficial & deep infection • Definitive intervention • Acute PJI best treated with 2 stage debridement with abx beads

  34. Thank You for Your Attention

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