- Email: [email protected]
The two-stage standard: Res ipsa loquitur
SE
M I N A R S I N
AR
T H R O P L A S T Y
26 (2015) 84–90
Available online at www.sciencedirect.com
www.elsevier.com/locate/semanthroplasty
The two-stage standard: Res ipsa loquitur Hayden N. Box, MD, Timothy S. Brown, MDn, Michael H. Huo, MDn, and Richard E. Jones, MD Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Rd, Dallas, TX 75390
article info
abstract
Keywords:
Periprosthetic joint infection is a morbid and costly complication of total knee arthroplasty.
revision arthroplasty
Treatment options vary depending on chronicity of the infection, causative organism, and
total knee arthroplasty
host factors. Some authors advocate single-stage exchange arthroplasty to decrease
periprosthetic joint infection
patient morbidity and healthcare utilization costs. Due to its proven efficacy for infection
two-stage revision arthroplasty
eradication and soft tissue healing, however, two-stage exchange arthroplasty remains the
revision knee arthroplasty
gold standard for treatment of periprosthetic joint infection after total knee arthroplasty. In this review, we present the technique of two-stage exchange arthroplasty and evidence supporting its use. & 2015 Elsevier Inc. All rights reserved.
1.
Introduction
1.1. Epidemiology and burden of periprosthetic joint infection Periprosthetic joint infection (PJI) is a morbid and costly complication of total knee arthroplasty (TKA). With contemporary prophylactic measures, the rate of PJI after TKA is 1–2% [1]. In the United States from 2005 to 2010, PJI was the most common indication for revision TKA. Moreover, PJI resulted in the longest length of hospital stay for any indication for revision TKA and was associated with an average hospitalization cost of $25,692 [2]. In addition to significant patient morbidity and resource utilization, revision for PJI is associated with a fivefold increase in mortality compared with revision for aseptic failure [3].
1.2.
Diagnosis of periprosthetic joint infection
Diagnosis of PJI after TKA often poses a clinical challenge. In 2011, the Workgroup of the Musculoskeletal Infection Society n
(MSIS) produced the widely accepted definition of PJI (Fig. 1) [4]. There are no definitive thresholds for serum ESR, serum CRP, synovial leukocyte count, and synovial PMN% in the diagnosis of PJI. There is strong consensus among members of the International Consensus on Periprosthetic Joint Infection that serum ESR 4 30 mm/h, serum CRP 4 10 mg/L, synovial leukocyte count 43000 cells/mL, and synovial PMN% 4 80%, if obtained more than 6 weeks postoperatively, may be consistent with PJI [5]. Novel biomarkers for the diagnosis of PJI are being tested but are not yet in widespread clinical practice. Synovial CRP was shown to be a more sensitive (84% versus 76%) and specific (97% versus 93%) marker of PJI compared to serum CRP [6]. A combination test of synovial fluid alpha-defensin and synovial CRP was found to have a sensitivity of 97% and specificity of 100% in the diagnosis of PJI [7]. In an extensive screening of synovial biomarker efficacy in the diagnosis of PJI, synovial alpha-defensin, neutrophil elastase 2 (ELA-2), bactericidal/permeability-increasing protein (BPI), lactoferrin, and neutrophil gelatinase-associated lipocalin (NGAL) each demonstrated both 100% sensitivity and specificity [8].
Corresponding authors. E-mail addresses: [email protected] (T.S. Brown), [email protected] (M.H. Huo).
http://dx.doi.org/10.1053/j.sart.2015.08.011 1045-4527/& 2015 Elsevier Inc. All rights reserved.
S
E M I N A R S I N
AR
T H R O P L A S T Y
MSIS Definition of Periprosthetic Joint Infection4 1) A pathogen is isolated by culture from at least two separate tissue or fluid samples obtained from the affected prosthetic joint; or 2) Four of the following six criteria exist: a. Elevated serum ESR and serum CRP, b. Elevated synovial leukocyte count, c. Elevated synovial neutrophil percentage (%PMN), d. Presence of purulence in the affected joint, e. Isolation of a microorganism in one culture of periprosthetic tissue or fluid, or f. Greater than five neutrophils per high-power field in five high-power fields observed from histologic analysis of periprosthetic tissue at x400 magnification
Figure 1 – Workgroup of the Musculoskeletal Infection Society definition of PJI.
Though promising, these biomarkers are currently investigational. The standard diagnostic evaluation for PJI remains a thorough history, physical examination, plain radiographs, serum inflammatory markers, and joint aspiration as suggested by both the MSIS and American Academy of Orthopaedic Surgeons [5,9].
1.3.
Treatment options
Once the diagnosis of PJI has been made, treatment options vary depending on chronicity of the infection, causative organism, and host factors. Two-stage exchange, single-stage exchange, irrigation and debridement with retention of components, and prolonged antibiotic suppression alone are all feasible options. Irrigation and debridement with antibiotic suppression or antibiotic suppression alone are not recommended for the vast majority of patients. These options are reserved for patients with poor functional status or for those who refuse prosthesis removal [10]. Knee arthrodesis, resection arthroplasty, and above-knee amputation are options when salvage is not possible. Arthrodesis after failure to eradicate PJI can be difficult to achieve [11]. One- and two-stage exchange arthroplasty will be discussed in detail in the current review.
1.4.
History of exchange arthroplasty
The management of PJI after TKA has evolved over time, but the principles of treatment have remained unchanged. In 1983, Insall et al. [12] described the results of 11 two-stage exchange TKAs after infection. The staged procedures included removal of all components and cement, thorough soft tissue and bony debridement, 6 weeks of parenteral antibiotic therapy, and reimplantation of components. At an average 34-month follow-up, there was no recurrence of the original infection. One knee was infected with a different organism, thought to be due to hematogenous seeding from a peripheral source. After Insall published this series, other investigators confirmed the efficacy of two-stage exchange arthroplasty as a reliable procedure for eradication of infection and preservation of knee function [13–16].
1.5.
One- versus two-stage revision
In order to decrease patient morbidity and hospital utilization costs, some authors have advocated single-stage exchange arthroplasty for the treatment of PJI after TKA. The indications for one-stage exchange are not well established. There is strong consensus among members of the International
26 (2015) 84–90
85
Consensus on Periprosthetic Joint Infection that a definitive contraindication to single-stage exchange is systemic manifestation of infection. Relative contraindications include infection with resistant organisms, presence of a sinus tract, and tenuous soft tissue coverage [5]. With restrictive selection criteria, some authors have reported reliable infection eradication with single-stage exchange arthroplasty. Early experience with this technique by von Foerster et al. [17] yielded an infection control rate of 73.1% with recurrence of infection in 20 of 104 TKAs. Goksan and Freeman reported an 89% rate of infection control after 5-year follow-up of one-stage exchange arthroplasty in 18 patients. All patients were infected with susceptible grampositive organisms and none had systemic signs of toxicity [18]. Buechel et al. [19] reported a 90.9% rate of infection control with one-stage exchange arthroplasty in 22 patients infected with susceptible organisms with an average follow-up of 10.2 years. Singer et al. [20] retrospectively reviewed their experience with one-stage exchange in PJI after TKA. The indications for one-stage exchange in this cohort were the identification of microorganism with an antibiotic susceptibility profile and wounds that could be closed during surgery. Patients with resistant organisms were excluded. With this highly selected cohort of 63 patients, the infection control rate was 95% with three recurrences and an average follow-up of 35.9 months. Zahar et al. [21] described the recent results of one-stage exchange to a rotating hinge device at the Helios ENDO Klinik in Hamburg, Germany, a high-volume center that pioneered the one-stage exchange technique. A total of 59 patients with an average follow-up of 10 years were included in the analysis. Indication for one-stage exchange was diagnosis of PJI after TKA with a known causative organism. No patients were excluded based on comorbid conditions. Patients with resistant organisms were included. The 10-year infection-free implant survival was 93%. Since Insall first described the two-stage exchange procedure, new implant designs, surgical techniques, and antibiotic therapies have been developed. With the goal of limiting patient morbidity and resource utilization, some surgeons are advocating one-stage exchange arthroplasty in selected patients [17–23]. If a single-stage method for treatment and reconstruction of PJI with long, cemented stems fails; however, the bone loss can be massive and not amenable to reconstruction. Additionally, there is no opportunity for host modification or optimization of comorbid conditions as there is with a two-stage approach. Due to its proven clinical efficacy for infection eradication and soft tissue healing, two-stage exchange arthroplasty remains the best option for surgeons who are only occasionally confronted with PJI or those hospitals that cannot adequately manage the intensive support services needed for one-stage treatment.
2. Two-stage exchange arthroplasty: technique 2.1.
Preoperative evaluation and patient optimization
The host classification system developed by Cierny and Mader for treatment of osteomyelitis is an effective method
86
SEM
I N A R S I N
A
R T H R O P L A S T Y
Cierny and Mader Host Classification System Host Type
Description
A B
Good immune system and delivery Compromised systemically (B ) or locally (B )
C
B - malnutrition, renal or liver failure, alcohol abuse, immune deficiency, chronic hypoxia, malignancy, diabetes mellitus, extremes of age, steroid therapy, tobacco abuse B - chronic lymphedema, venous stasis, major compromise, arteritis, extensive scarring, radiation fibrosis Poor surgical candidate, treatment worse than the disease
Figure 2 – Cierny and Mader host classification system for osteomyelitis. for stratifying patients with regard to the physiologic potential for wound healing and successful eradication of infection with either one- or two-stage exchange arthroplasty (Fig. 2) [24,25]. Type B hosts commonly present with modifiable risk factors. The most common modifiable risk factors in infected revision joint arthroplasty cases in one series included anemia (36%), UTI (33%), HIV (29%), smoking (21%), and obesity (21%) [26]. In two-stage revision TKA for PJI, morbidly obese patients (BMI 4 40 kg/m2) demonstrated increased risk for revision surgery (31% versus 11%), reinfection (22% versus 4%), and reoperation (51% versus 16%) compared to nonobese patients (BMI o 30 kg/m2). In addition, implant survival in the morbidly obese group was worse at 5 and 10 years compared to the non-obese group, 80% versus 97% at 5 years and 55% versus 82% at 10 years [27]. Smoking cessation is an important component of patient optimization prior to initiating two-stage exchange arthroplasty. Current smokers are 41% more likely than never smokers to have a surgical site infection [28]. In a systematic review of primary total hip and knee arthroplasty, current smokers were 24% more likely to have any postoperative complication and had a 63% increased risk of mortality [29]. Due to its deleterious local and systemic effects, some authors do not accept patients into an infected implant management protocol who continue to smoke [30]. Malnourished patients are at risk of postoperative wound complications. Preoperative lymphocyte count o1500 cells/mL and albumin level o3.5 g/dL results in five times and seven times greater frequency of developing a wound complication after primary total joint arthroplasty [31]. The overall complication rate of malnourished patients after elective total joint arthroplasty is increased as well, with a 12% complication rate in patients with an albumin o3.5 mg/dL or transferrin o200 mg/dL compared to a 2.9% complication rate in patients with normal nutritional status [32]. Obesity does not preclude the presence of malnourishment. In the same study, 42.9% of malnourished patients were obese (BMI 4 30 kg/m2). Preoperative evaluation and optimization of systemically compromised hosts is beneficial in revision TKA after PJI. Smoking cessation, weight loss, and nutritional supplementation should be encouraged when appropriate.
2.2. First stage: resection, debridement, and spacer placement The first stage of the two-stage protocol for revision TKA after PJI includes explant of all existing components, extensive
26 (2015) 84–90
debridement of necrotic tissue and foreign material, and placement of an antibiotic cement spacer. Extensive scarring due to prior surgical incisions is a common form of local host compromise contributing to wound complications in revision TKA for PJI. The surgical philosophy for the first stage of the two-stage exchange arthroplasty parallels the techniques described by Tetsworth and Cierny [33] for the debridement of osteomyelitis. The knee is approached through excision of the prior surgical scar. Dense, adherent overlying scar is excised to promote primary soft tissue healing. If new incisions must cross prior surgical scars, the risk of edge necrosis is minimized if the new incision is made at a right angle to the prior scar. The blood supply to the skin over the anterior knee is better medially, thus when there are multiple previous lateral incisions it is recommended to use the most lateral incision to re-enter the knee [30]. Postoperative wound complications may also be mitigated by limiting tourniquet time and pressure. Increasing tourniquet time is associated with an increased wound complication rate after primary TKA [34]. In one randomized study, tourniquet cuff pressure less than or equal to 225 mmHg was associated with a decreased postoperative wound complication rate in primary TKA [35]. In the setting of local tissue compromise due to prior surgical scars, revision TKA with no tourniquet avoids local tissue hypoxia and may reduce wound complication rates [30]. To direct antibiotic therapy, accurate organism identification is imperative. Tissue cultures are more sensitive and specific than swab culture in PJI, 93% and 98% versus 70% and 89% [36]. There is a strong consensus among members of the International Consensus on Periprosthetic Joint Infection that more than three but not more than six distinct intraoperative tissue cultures be sent [5]. Sinus tract or wound cultures are unreliable. In one study, superficial cultures from sinus tracts matched intra-articular cultures in just 47% of cases, grew additional organisms not found on intra-articular culture in 43% of cases, and failed to accurately recognize organisms on deep culture in 19% of cases [37]. It is recommended that superficial wounds and sinus tracts are not cultured. Component removal is necessary to decrease the bacterial load within the joint. Adherent biofilms are impenetrable to antibiotics. In addition, irrigation with pulse lavage has been shown to be ineffective at eradicating biofilm from ultra-high molecular weight polyethylene, polymethyl methacrylate (PMMA), and cobalt chrome total knee arthroplasty components and cement [38]. Removal of all TKA components, cement, and necrotic tissue is necessary to eradicate infection. After component removal, thorough debridement of necrotic soft tissue and bone is performed. Osteomyelitis debridement techniques described by Tetsworth and Cierny [33] are applicable. They advocate exposure in the extraperiosteal plane to avoid periosteal stripping. Periosteal stripping in addition to medullary debridement of the same segment of cortical bone may increase the risk of iatrogenic sequestrum formation. As necrotic bone is debrided, the surgeon must monitor the bone for scattered pinpoint sites of bony bleeding indicating sufficient vascular inflow and adequacy of debridement.
S
E M I N A R S I N
AR
T H R O P L A S T Y
Early series describing two-stage exchange arthroplasty did not utilize antibiotic spacers after explant of components [12,13,15,39]. Patients were either maintained in calcaneal skeletal traction or placed into a bulky Jones dressing. Booth and Lotke [14] developed an antibiotic spacer block technique to avoid disuse bone atrophy and soft tissue contracture, to maintain extremity alignment, and to achieve local delivery of antibiotic. These early static spacers consisted of a block of bone cement mixed with an antibiotic powder and allowed for no knee range of motion. Articulating spacers, first described by Cadambi et al. [40] and later by Hofmann et al. [41], were developed to provide patients a functioning leg with knee range of motion and weight bearing as tolerated in the period between resection and reimplantation. Early experience demonstrated improved ultimate knee range of motion and improved tissue compliance upon reimplantation with the use of articulating spacers [41]. A systematic review [42] of articulating versus static spacers in two-stage revision TKA showed greater knee range of motion of 1011 versus 911 in the articulating spacer group. There was no statistically significant difference in the reinfection rate. The wound complication rate in the articulating spacer group was 2% compared to 8% in the static spacer group. The study, however, was not powered to assess statistical significance of this complication. There is strong consensus among members of the International Consensus on Periprosthetic Joint Infection that the use of articulating spacers facilitates reimplantation of components in revision TKA after PJI [5]. Placement of antibiotic beads along with a cement spacer augments local antibiotic delivery and eliminates potential dead space created by debridement [33]. Due to increased total surface area, antibiotic elution from beads results in a higher local antibiotic concentration than thicker cement blocks [43]. Adams et al. [44] evaluated in vitro and in vivo elution of cefazolin, ciprofloxacin, clindamycin, ticarcillin, tobramycin, and vancomycin from PMMA beads and found that clindamycin, vancomycin, and tobramycin exhibited good elution characteristics and had consistently high levels in bone and granulation tissue. When possible, the type of antibiotic used in the cement spacer should be directed toward a known infecting organism. A number of antibiotics are available for use in PMMA cement spacers, including tobramycin, gentamicin, cefazolin, cefuroxime, ceftazidime, cefotaxime, ceftaroline, ciprofloxacin, vancomycin, clindamycin, and linezolid. Vancomycin, which is active against gram-positive bacteria including methicillin-resistant organisms, along with gentamicin or tobramycin, which are active against gram-negative organisms including Pseudomonas, is a combination used to treat most infections. Appropriate dosages include 1–4 g vancomycin powder per 40 g package of cement, and gentamicin or tobramycin, 2.4–4.8 g per 40 g package of cement [5]. Jones and Huo [45] described an effective method for placement of an articulating spacer. After the radical debridement and implant removal are completed, the original femoral component is cleaned and resterilized in the autoclave. A new tibial polyethylene component is selected of the size appropriate to obtain and maintain soft tissue balance and alignment.
26 (2015) 84–90
87
Overall, 24 cm3 of antibiotic powder (heat-stable and specific for the infecting organism) are mixed in every 40 g pack of cement. Removal of 24 cm3 of cement powder before putting the antibiotic powder in helps get the working time to 1 1/2 to 2 times normal. The senior author’s (R.E.J.) preferred antibiotic regimen for majority of the infections caused by gram-positive organism includes vancomycin 4 g or tobramycin 4.8 g mixed with each 40 g pack of cement. If the sensitivity is unknown, then 2 g of vancomycin is mixed with 2.4 g of tobramycin in each pack of cement. The cement is allowed to cure to a relatively doughy state and is then placed on the non-articulating surface of the new polyethylene insert, and the rest of the cement is molded to the defects encountered after debridement. The cement should be placed in a relatively wet field (the tourniquet can be released before this stage), and cement is prevented from full adherence to the bony surfaces by toggling the component until cement curing is completed. This allows for easy removal of the cement and implant composite at definitive reconstruction, but the irregular surfaces make a very stable construct. This procedure is repeated for the femoral component, which has been previously cleaned and flash-sterilized. The limb is then moved to extension with correct alignment and soft tissue balance to prevent migration of the components. Intramedullary antibiotic beads, if used, should be placed prior to cementation of the components. Antibiotic beads are then placed in the medial and lateral gutters and suprapatellar pouch. A watertight wound closure is performed using monofilament suture and no drains are used, allowing for high antibiotic concentration levels in the knee and surrounding tissues. The limb is then placed in a bulky compressive dressing for 48 h. Patients may ambulate on the first operative day with aids and weight bearing as tolerated is allowed. Range of motion is encouraged when a stable wound has been obtained. If there is any compromise of the wound, then the knee should remain in extension until the wound is stable in appearance.
2.3.
Treatment during staged revision
Standard antibiotic therapy following resection and prior to reimplantation involves 6 weeks of parenteral antibiotics followed by antibiotic cessation for 2 weeks. Antibiotic selection is tailored based on intraoperative tissue cultures by an infectious disease specialist. There is no evidence describing the ideal length of antibiotic therapy prior to reimplantation. Clinical signs, systemic inflammatory markers, and synovial fluid analysis are used to guide timing of reimplantation. ESR peaks at postoperative day 5 and slowly decreases over the next 3–6 months [46]. Because ESR, a chronic phase reactant, may remain elevated for a prolonged period after resection, it is less useful for guiding reimplantation. CRP, an acute phase reactant, increases significantly within the first 24 h postoperatively, peaks at postoperative day 3, and returns to preoperative levels by 2 weeks postoperatively [47,48]. Because of its more rapid normalization, CRP is generally more useful than ESR for timing successful
88
SEM
I N A R S I N
A
R T H R O P L A S T Y
26 (2015) 84–90
Table – Eradication rates for two-stage exchange arthroplasty Study Rosenberg et al. [13] Booth and Lotke [14] Wilson et al. [15] Goldman et al. [53] Emerson et al. [54] Evans [55] Haleem et al. [56] Hofmann et al. [57] Jamsen et al. [58] Hsu et al. [59] Westrich et al. [1] Ocguder et al. [60] Park et al. [61] Gooding et al. [62] Mortazavi et al. [63] Castelli et al. [64] Aggregate
Knees
Follow-up (years)
Eradication rate (%)
26 25 20 64 48 31 96 42 22 28 75 17 36 115 117 50 812
2.4 2 2.8 7.5 7.5 2 7.2 6.3 2.7 8.4 4.4 1.7 3 9 3.8 7 5.7
100.0 96.0 80.0 90.6 91.7 93.5 90.6 94.0 91.0 89.3 90.7 94.1 88.9 87.8 72.0 92.0 88.1
Aggregate total number of knees in all studies and weighted average follow-up period and eradication rates are given.
reimplantation of components in two-stage exchange arthroplasty. Inflammatory marker elevation, however, does not preclude infection control. Kusuma et al. [49] retrospectively evaluated the serologies of 76 TKAs with PJI treated with twostage exchange. CRP normalized (CRP o 10 mg/L) in 79% of patients and ESR normalized (ESR o 30 mm/h) in 46% within 2 weeks prior to successful reimplantation. In a similar study by Ghanem et al. [50], a CRP cut-off of 10 mg/L upon serological testing prior to reimplantation was found to have a negative predictive value of 77.1%, despite CRP’s poor area under the curve (ROC ¼ 0.545) upon receiver-operator curve analysis. The authors recommend evaluating the CRP trend during the course of antibiotic therapy and after the period of antibiotic cessation as a tool to guide timing of reimplantation. Joint aspiration for evaluation of cell count with differential, gram stain, and culture may be useful in guiding the timing of reimplantation. Manual complete blood count differential in addition to automated complete blood count is more accurate than automated complete blood count alone in identifying bacterial infection, 89% versus 78% [51]. Synovial fluid leukocyte count with optimum cut-off of 1102.5 cells/mL was found to have a sensitivity of 75% and specificity of 61% for detection of persistent infection [49]. It is common practice to allow for 2 weeks of antibiotic cessation after a 6-week course of parenteral antibiotic therapy to monitor the patient clinically and evaluate inflammatory markers prior to reimplantation. However, there is no conclusive evidence for such an antibiotic holiday period prior to reimplantation [5].
2.4.
Second stage: reimplantation
When clinically appropriate and after a stable wound has been achieved for reimplantation, the knee is approached through the prior surgical scar. The antibiotic spacercomposite is removed. Tissue is sent to pathology for analysis of frozen sections. In a retrospective review, Della Valle et al.
[52] found frozen section analysis to have a sensitivity of 25% and specificity of 98%. Frozen sections were considered positive if a mean of 10 polymorphonuclear leukocytes or more per high-power field were identified in the five most cellular fields examined. If frozen section analysis is positive for acute inflammation, then cultures are sent and irrigation and debridement is performed with placement of an antibiotic spacer. The patient is given a second period of targeted parenteral antibiotics. If frozen section analysis is negative for acute inflammation, then reimplantation is performed with antibiotic impregnated cement. Press-fit rather cemented stems are preferred.
3.
Conclusion
A summary of the published infection eradication rates after two-stage exchange TKA for PJI are shown in the Table. Eradication rates range from 72% to 100% with a weighted average of 88.1% after a mean follow-up period of 5.7 years. In contrast to studies describing outcomes with singlestage exchange, patients with tenuous soft tissue coverage and those infected with resistant organisms were included. Infection after TKA poses a clinical challenge. Diagnosis of PJI is accomplished with a thorough history, physical examination, plain radiographs, measurement of serum inflammatory markers, and joint aspiration. Though currently investigational, biomarkers such as synovial alpha-defensin may play an important role in the future. Once diagnosed, the goals of treatment include eradication of infection and restoration of a functional lower limb. Some authors have reported success with one-stage exchange arthroplasty in highly selected patients or at specialized centers. With an eradication rate of almost 90% in non-selected patients, however, two-stage exchange arthroplasty remains the benchmark for treatment of PJI after TKA.
S
E M I N A R S I N
AR
T H R O P L A S T Y
re fe r en ces
[1] Westrich GH, Walcott-Sapp S, Bornstein LJ, et al. Modern treatment of infected total knee arthroplasty with a 2-stage reimplantation protocol. Journal of Arthroplasty 2010;25: 1015–1021 [1021.e1-1022.e1]. [2] Kamath AF, Ong KL, Lau E, et al. Quantifying the burden of revision total joint arthroplasty for periprosthetic infection. Journal of Arthroplasty 2015;30(9):1492–7. http://dx.doi.org/ 10.1016/j.arth.2015.03.035. (Epub 2015 Mar 31). [3] Zmistowski B, Karam JA, Durinka JB, et al. Periprosthetic joint infection increases the risk of one-year mortality. Journal of Bone and Joint Surgery. American Volume 2013;95:2177–84. [4] Parvizi J, Zmistowski B, Berbari EF, et al. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clinical Orthopaedics and Related Research 2011;469:2992–4. [5] Musculoskeletal Infection Society, International consensus on periprosthetic joint infection, http://www.msis-na.org/ international-consensus/; 2013. [6] Parvizi J, Jacovides C, Adeli B, et al. Coventry Award: synovial C-reactive protein: a prospective evaluation of a molecular marker for periprosthetic knee joint infection. Clinical Orthopaedics and Related Research 2012;470:54–60. [7] Deirmengian C, Kardos K, Kilmartin P, et al. Combined measurement of synovial fluid alpha-Defensin and Creactive protein levels: highly accurate for diagnosing periprosthetic joint infection. Journal of Bone and Joint Surgery. American Volume 2014;96:1439–45. [8] Deirmengian C, Kardos K, Kilmartin P, et al. Diagnosing periprosthetic joint infection: has the era of the biomarker arrived. Clinical Orthopaedics and Related Research 2014;472: 3254–62. [9] Della Valle C, Parvizi J, Bauer TW, et al. Diagnosis of periprosthetic joint infections of the hip and knee. Journal of the American Academy of Orthopaedic Surgeons 2010;18: 760–70. [10] Rao N, Crossett LS, Sinha RK, et al. Long-term suppression of infection in total joint arthroplasty. Clinical Orthopaedics and Related Research 2003;414:55–60. [11] Rohner E, Windisch C, Nuetzmann K, et al. Unsatisfactory outcome of arthrodesis performed after septic failure of revision total knee arthroplasty. Journal of Bone and Joint Surgery. American Volume 2015;97:298–301. [12] Insall JN, Thompson FM, Brause BD. Two-stage reimplantation for the salvage of infected total knee arthroplasty. Journal of Bone and Joint Surgery. American Volume 1983;65:1087–98. [13] Rosenberg AG, Haas B, Barden R, et al. Salvage of infected total knee arthroplasty. Clinical Orthopaedics and Related Research 1988;226:29–33. [14] Booth RE Jr, Lotke PA. The results of spacer block technique in revision of infected total knee arthroplasty. Clinical Orthopaedics and Related Research 1989;248:57–60. [15] Wilson MG, Kelley K, Thornhill TS. Infection as a complication of total knee-replacement arthroplasty. Risk factors and treatment in sixty-seven cases. Journal of Bone and Joint Surgery. American Volume 1990;72:878–83. [16] Windsor RE, Insall JN, Urs WK, et al. Two-stage reimplantation for the salvage of total knee arthroplasty complicated by infection. Further follow-up and refinement of indications. Journal of Bone and Joint Surgery. American Volume 1990;72:272–8. [17] von Foerster G, Kluber D, Kabler U. Mid- to long-term results after treatment of 118 cases of periprosthetic infections after knee joint replacement using one-stage exchange surgery. Orthopade 1991;20:244–52.
26 (2015) 84–90
89
[18] Goksan SB, Freeman MA. One-stage reimplantation for infected total knee arthroplasty. Journal of Bone and Joint Surgery. British Volume 1992;74:78–82. [19] Buechel FF, Femino FP, D’Alessio J. Primary exchange revision arthroplasty for infected total knee replacement: a longterm study. American Journal of Orthopedics (Belle Mead, N.J.) 2004;33:190–8 [discussion 198]. [20] Singer J, Merz A, Frommelt L, et al. High rate of infection control with one-stage revision of septic knee prostheses excluding MRSA and MRSE. Clinical Orthopaedics and Related Research 2012;470:1461–71. [21] Zahar A, Kendoff DO, Klatte TO, et al. Can good infection control be obtained in one-stage exchange of the infected TKA to a rotating hinge design? 10-year results. Clinical Orthopaedics and Related Research 2015:1–7. http://dx.doi. org/10.1007/s11999-015-4408-5. [Epub ahead of print]. [22] Parkinson RW, Kay PR, Rawal A. A case for one-stage revision in infected total knee arthroplasty. Knee 2011;18:1–4. [23] Bauer T, Piriou P, Lhotellier L, et al. Results of reimplantation for infected total knee arthroplasty: 107 cases. Revue de Chirurgie Orthopedique et Reparatrice de l’ Appareil Moteur 2006;92:692–700. [24] Cierny G 3rd, Mader JT, Penninck JJ. A clinical staging system for adult osteomyelitis. Clinical Orthopaedics and Related Research 2003;414:7–24. [25] Cierny G 3rd, DiPasquale D. Periprosthetic total joint infections: staging, treatment, and outcomes. Clinical Orthopaedics and Related Research 2002;403:23–8. [26] Pruzansky JS, Bronson MJ, Grelsamer RP, et al. Prevalence of modifiable surgical site infection risk factors in hip and knee joint arthroplasty patients at an urban academic hospital. Journal of Arthroplasty 2014;29:272–6. [27] Watts CD, Wagner ER, Houdek MT, et al. Morbid obesity: a significant risk factor for failure of two-stage revision total knee arthroplasty for infection. Journal of Bone and Joint Surgery. American Volume 2014;96e154 2014;96. [28] Singh JA, Houston TK, Ponce BA, et al. Smoking as a risk factor for short-term outcomes following primary total hip and total knee replacement in veterans. Arthritis Care Research (Hoboken) 2011;63:1365–74. [29] Singh JA. Smoking and outcomes after knee and hip arthroplasty: a systematic review. Journal of Rheumatology 2011;38:1824–34. [30] Jones RE. Wound healing in total joint arthroplasty. Orthopedics 2010;33:660. [31] Greene KA, Wilde AH, Stulberg BN. Preoperative nutritional status of total joint patients. Relationship to postoperative wound complications. Journal of Arthroplasty 1991;6:321–5. [32] Huang R, Greenky M, Kerr GJ, et al. The effect of malnutrition on patients undergoing elective joint arthroplasty. Journal of Arthroplasty 2013;28:21–4. [33] Tetsworth K, Cierny G 3rd. Osteomyelitis debridement techniques. Clinical Orthopaedics and Related Research 1999;360:87–96. [34] Carroll K, Dowsey M, Choong P, et al. Risk factors for superficial wound complications in hip and knee arthroplasty. Clinical Microbiology and Infection 2014;20:130–5. [35] Olivecrona C, Ponzer S, Hamberg P, et al. Lower tourniquet cuff pressure reduces postoperative wound complications after total knee arthroplasty: a randomized controlled study of 164 patients. Journal of Bone and Joint Surgery. American Volume 2012;94:2216–21. [36] Aggarwal VK, Higuera C, Deirmengian G, et al. Swab cultures are not as effective as tissue cultures for diagnosis of periprosthetic joint infection. Clinical Orthopaedics and Related Research 2013;471:3196–203. [37] Tetreault MW, Wetters NG, Aggarwal VK, et al. Should draining wounds and sinuses associated with hip and
90
[38]
[39]
[40]
[41]
[42]
[43]
[44]
[45] [46]
[47]
[48]
[49]
[50]
[51]
SEM
I N A R S I N
A
R T H R O P L A S T Y
knee arthroplasties be cultured? Journal of Arthroplasty 2013;28:133–6. Urish KL, DeMuth PW, Craft DW, et al. Pulse lavage is inadequate at removal of biofilm from the surface of total knee arthroplasty materials. Journal of Arthroplasty 2014;29:1128–32. Jacobs MA, Hungerford DS, Krackow KA, et al. Revision of septic total knee arthroplasty. Clinical Orthopaedics and Related Research 1989;238:159–66. Cadambi A, Jones RE, Maale GE. A protocol for staged revision of infected total hip and knee arthroplasties: the use of antibiotic-cement-implant composites. International Orthopaedics 1995;3:133–45. Hofmann AA, Kane KR, Tkach TK, et al. Treatment of infected total knee arthroplasty using an articulating spacer. Clinical Orthopaedics and Related Research 1995;321:45–54. Voleti PB, Baldwin KD, Lee GC. Use of static or articulating spacers for infection following total knee arthroplasty: a systematic literature review. Journal of Bone and Joint Surgery. American Volume 2013;95:1594–9. Anagnostakos K, Wilmes P, Schmitt E, et al. Elution of gentamicin and vancomycin from polymethylmethacrylate beads and hip spacers in vivo. Acta Orthopaedica 2009;80: 193–7. Adams K, Couch L, Cierny G, et al. In vitro and in vivo evaluation of antibiotic diffusion from antibioticimpregnated polymethylmethacrylate beads. Clinical Orthopaedics and Related Research 1992;278:244–52. Jones RE, Huo MH. The infected knee: all my troubles now. Journal of Arthroplasty 2006;21:50–3. Bilgen O, Atici T, Durak K, et al. C-reactive protein values and erythrocyte sedimentation rates after total hip and total knee arthroplasty. Journal of International Medical Research 2001;29:7–12. Honsawek S, Deepaisarnsakul B, Tanavalee A, et al. Relationship of serum IL-6, C-reactive protein, erythrocyte sedimentation rate, and knee skin temperature after total knee arthroplasty: a prospective study. International Orthopaedics 2011;35:31–5. White J, Kelly M, Dunsmuir R. C-reactive protein level after total hip and total knee replacement. Journal of Bone and Joint Surgery. British Volume 1998;80:909–11. Kusuma SK, Ward J, Jacofsky M, et al. What is the role of serological testing between stages of two-stage reconstruction of the infected prosthetic knee. Clinical Orthopaedics and Related Research 2011;469:1002–8. Ghanem E, Azzam K, Seeley M, et al. Staged revision for knee arthroplasty infection: what is the role of serologic tests before reimplantation. Clinical Orthopaedics and Related Research 2009;467:1699–705. Wile MJ, Homer LD, Gaehler S, et al. Manual differential cell counts help predict bacterial infection. A multivariate analysis. American Journal of Clinical Pathology 2001;115:644–9.
26 (2015) 84–90
[52] Della Valle CJ, Bogner E, Desai P, et al. Analysis of frozen sections of intraoperative specimens obtained at the time of reoperation after hip or knee resection arthroplasty for the treatment of infection. Journal of Bone and Joint Surgery. American Volume 1999;331:684–9. [53] Goldman RT, Scuderi GR, Insall JN. 2-stage reimplantation for infected total knee replacement. Clinical Orthopaedics and Related Research 1996;331:118–24. [54] Emerson RH Jr, Muncie M, Tarbox TR, et al. Comparison of a static with a mobile spacer in total knee infection. Clinical Orthopaedics and Related Research 2002;404:132–8. [55] Evans RP. Successful treatment of total hip and knee infection with articulating antibiotic components: a modified treatment method. Clinical Orthopaedics and Related Research 2004;427:37–46. [56] Haleem AA, Berry DJ, Hanssen AD. Mid-term to long-term followup of two-stage reimplantation for infected total knee arthroplasty. Clinical Orthopaedics and Related Research 2004;428:35–9. [57] Hofmann AA, Goldberg T, Tanner AM, et al. Treatment of infected total knee arthroplasty using an articulating spacer: 2- to 12-year experience. Clinical Orthopaedics and Related Research 2005;430:125–31. [58] Jamsen E, Sheng P, Halonen P, et al. Spacer prostheses in two-stage revision of infected knee arthroplasty. International Orthopaedics 2006;30:257–61. [59] Hsu YC, Cheng HC, Ng TP, et al. Antibiotic-loaded cement articulating spacer for 2-stage reimplantation in infected total knee arthroplasty: a simple and economic method. Journal of Arthroplasty 2007;22:1060–6. [60] Ocguder A, Firat A, Tecimel O, et al. Two-stage total infected knee arthroplasty treatment with articulating cement spacer. Archives of Orthopaedic and Trauma Surgery 2010;130:719–25. [61] Park SJ, Song EK, Seon JK, et al. Comparison of static and mobile antibiotic-impregnated cement spacers for the treatment of infected total knee arthroplasty. International Orthopaedics 2010;34:1181–6. [62] Gooding CR, Masri BA, Duncan CP, et al. Durable infection control and function with the PROSTALAC spacer in twostage revision for infected knee arthroplasty. Clinical Orthopaedics and Related Research 2011;469:985–93. [63] Mortazavi SM, Vegari D, Ho A, et al. Two-stage exchange arthroplasty for infected total knee arthroplasty: predictors of failure. Clinical Orthopaedics and Related Research 2011;469:3049–54. [64] Castelli CC, Gotti V, Ferrari R. Two-stage treatment of infected total knee arthroplasty: two to thirteen year experience using an articulating preformed spacer. International Orthopaedics 2014;38:405–12.
M I N A R S I N
AR
T H R O P L A S T Y
26 (2015) 84–90
Available online at www.sciencedirect.com
www.elsevier.com/locate/semanthroplasty
The two-stage standard: Res ipsa loquitur Hayden N. Box, MD, Timothy S. Brown, MDn, Michael H. Huo, MDn, and Richard E. Jones, MD Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Rd, Dallas, TX 75390
article info
abstract
Keywords:
Periprosthetic joint infection is a morbid and costly complication of total knee arthroplasty.
revision arthroplasty
Treatment options vary depending on chronicity of the infection, causative organism, and
total knee arthroplasty
host factors. Some authors advocate single-stage exchange arthroplasty to decrease
periprosthetic joint infection
patient morbidity and healthcare utilization costs. Due to its proven efficacy for infection
two-stage revision arthroplasty
eradication and soft tissue healing, however, two-stage exchange arthroplasty remains the
revision knee arthroplasty
gold standard for treatment of periprosthetic joint infection after total knee arthroplasty. In this review, we present the technique of two-stage exchange arthroplasty and evidence supporting its use. & 2015 Elsevier Inc. All rights reserved.
1.
Introduction
1.1. Epidemiology and burden of periprosthetic joint infection Periprosthetic joint infection (PJI) is a morbid and costly complication of total knee arthroplasty (TKA). With contemporary prophylactic measures, the rate of PJI after TKA is 1–2% [1]. In the United States from 2005 to 2010, PJI was the most common indication for revision TKA. Moreover, PJI resulted in the longest length of hospital stay for any indication for revision TKA and was associated with an average hospitalization cost of $25,692 [2]. In addition to significant patient morbidity and resource utilization, revision for PJI is associated with a fivefold increase in mortality compared with revision for aseptic failure [3].
1.2.
Diagnosis of periprosthetic joint infection
Diagnosis of PJI after TKA often poses a clinical challenge. In 2011, the Workgroup of the Musculoskeletal Infection Society n
(MSIS) produced the widely accepted definition of PJI (Fig. 1) [4]. There are no definitive thresholds for serum ESR, serum CRP, synovial leukocyte count, and synovial PMN% in the diagnosis of PJI. There is strong consensus among members of the International Consensus on Periprosthetic Joint Infection that serum ESR 4 30 mm/h, serum CRP 4 10 mg/L, synovial leukocyte count 43000 cells/mL, and synovial PMN% 4 80%, if obtained more than 6 weeks postoperatively, may be consistent with PJI [5]. Novel biomarkers for the diagnosis of PJI are being tested but are not yet in widespread clinical practice. Synovial CRP was shown to be a more sensitive (84% versus 76%) and specific (97% versus 93%) marker of PJI compared to serum CRP [6]. A combination test of synovial fluid alpha-defensin and synovial CRP was found to have a sensitivity of 97% and specificity of 100% in the diagnosis of PJI [7]. In an extensive screening of synovial biomarker efficacy in the diagnosis of PJI, synovial alpha-defensin, neutrophil elastase 2 (ELA-2), bactericidal/permeability-increasing protein (BPI), lactoferrin, and neutrophil gelatinase-associated lipocalin (NGAL) each demonstrated both 100% sensitivity and specificity [8].
Corresponding authors. E-mail addresses: [email protected] (T.S. Brown), [email protected] (M.H. Huo).
http://dx.doi.org/10.1053/j.sart.2015.08.011 1045-4527/& 2015 Elsevier Inc. All rights reserved.
S
E M I N A R S I N
AR
T H R O P L A S T Y
MSIS Definition of Periprosthetic Joint Infection4 1) A pathogen is isolated by culture from at least two separate tissue or fluid samples obtained from the affected prosthetic joint; or 2) Four of the following six criteria exist: a. Elevated serum ESR and serum CRP, b. Elevated synovial leukocyte count, c. Elevated synovial neutrophil percentage (%PMN), d. Presence of purulence in the affected joint, e. Isolation of a microorganism in one culture of periprosthetic tissue or fluid, or f. Greater than five neutrophils per high-power field in five high-power fields observed from histologic analysis of periprosthetic tissue at x400 magnification
Figure 1 – Workgroup of the Musculoskeletal Infection Society definition of PJI.
Though promising, these biomarkers are currently investigational. The standard diagnostic evaluation for PJI remains a thorough history, physical examination, plain radiographs, serum inflammatory markers, and joint aspiration as suggested by both the MSIS and American Academy of Orthopaedic Surgeons [5,9].
1.3.
Treatment options
Once the diagnosis of PJI has been made, treatment options vary depending on chronicity of the infection, causative organism, and host factors. Two-stage exchange, single-stage exchange, irrigation and debridement with retention of components, and prolonged antibiotic suppression alone are all feasible options. Irrigation and debridement with antibiotic suppression or antibiotic suppression alone are not recommended for the vast majority of patients. These options are reserved for patients with poor functional status or for those who refuse prosthesis removal [10]. Knee arthrodesis, resection arthroplasty, and above-knee amputation are options when salvage is not possible. Arthrodesis after failure to eradicate PJI can be difficult to achieve [11]. One- and two-stage exchange arthroplasty will be discussed in detail in the current review.
1.4.
History of exchange arthroplasty
The management of PJI after TKA has evolved over time, but the principles of treatment have remained unchanged. In 1983, Insall et al. [12] described the results of 11 two-stage exchange TKAs after infection. The staged procedures included removal of all components and cement, thorough soft tissue and bony debridement, 6 weeks of parenteral antibiotic therapy, and reimplantation of components. At an average 34-month follow-up, there was no recurrence of the original infection. One knee was infected with a different organism, thought to be due to hematogenous seeding from a peripheral source. After Insall published this series, other investigators confirmed the efficacy of two-stage exchange arthroplasty as a reliable procedure for eradication of infection and preservation of knee function [13–16].
1.5.
One- versus two-stage revision
In order to decrease patient morbidity and hospital utilization costs, some authors have advocated single-stage exchange arthroplasty for the treatment of PJI after TKA. The indications for one-stage exchange are not well established. There is strong consensus among members of the International
26 (2015) 84–90
85
Consensus on Periprosthetic Joint Infection that a definitive contraindication to single-stage exchange is systemic manifestation of infection. Relative contraindications include infection with resistant organisms, presence of a sinus tract, and tenuous soft tissue coverage [5]. With restrictive selection criteria, some authors have reported reliable infection eradication with single-stage exchange arthroplasty. Early experience with this technique by von Foerster et al. [17] yielded an infection control rate of 73.1% with recurrence of infection in 20 of 104 TKAs. Goksan and Freeman reported an 89% rate of infection control after 5-year follow-up of one-stage exchange arthroplasty in 18 patients. All patients were infected with susceptible grampositive organisms and none had systemic signs of toxicity [18]. Buechel et al. [19] reported a 90.9% rate of infection control with one-stage exchange arthroplasty in 22 patients infected with susceptible organisms with an average follow-up of 10.2 years. Singer et al. [20] retrospectively reviewed their experience with one-stage exchange in PJI after TKA. The indications for one-stage exchange in this cohort were the identification of microorganism with an antibiotic susceptibility profile and wounds that could be closed during surgery. Patients with resistant organisms were excluded. With this highly selected cohort of 63 patients, the infection control rate was 95% with three recurrences and an average follow-up of 35.9 months. Zahar et al. [21] described the recent results of one-stage exchange to a rotating hinge device at the Helios ENDO Klinik in Hamburg, Germany, a high-volume center that pioneered the one-stage exchange technique. A total of 59 patients with an average follow-up of 10 years were included in the analysis. Indication for one-stage exchange was diagnosis of PJI after TKA with a known causative organism. No patients were excluded based on comorbid conditions. Patients with resistant organisms were included. The 10-year infection-free implant survival was 93%. Since Insall first described the two-stage exchange procedure, new implant designs, surgical techniques, and antibiotic therapies have been developed. With the goal of limiting patient morbidity and resource utilization, some surgeons are advocating one-stage exchange arthroplasty in selected patients [17–23]. If a single-stage method for treatment and reconstruction of PJI with long, cemented stems fails; however, the bone loss can be massive and not amenable to reconstruction. Additionally, there is no opportunity for host modification or optimization of comorbid conditions as there is with a two-stage approach. Due to its proven clinical efficacy for infection eradication and soft tissue healing, two-stage exchange arthroplasty remains the best option for surgeons who are only occasionally confronted with PJI or those hospitals that cannot adequately manage the intensive support services needed for one-stage treatment.
2. Two-stage exchange arthroplasty: technique 2.1.
Preoperative evaluation and patient optimization
The host classification system developed by Cierny and Mader for treatment of osteomyelitis is an effective method
86
SEM
I N A R S I N
A
R T H R O P L A S T Y
Cierny and Mader Host Classification System Host Type
Description
A B
Good immune system and delivery Compromised systemically (B ) or locally (B )
C
B - malnutrition, renal or liver failure, alcohol abuse, immune deficiency, chronic hypoxia, malignancy, diabetes mellitus, extremes of age, steroid therapy, tobacco abuse B - chronic lymphedema, venous stasis, major compromise, arteritis, extensive scarring, radiation fibrosis Poor surgical candidate, treatment worse than the disease
Figure 2 – Cierny and Mader host classification system for osteomyelitis. for stratifying patients with regard to the physiologic potential for wound healing and successful eradication of infection with either one- or two-stage exchange arthroplasty (Fig. 2) [24,25]. Type B hosts commonly present with modifiable risk factors. The most common modifiable risk factors in infected revision joint arthroplasty cases in one series included anemia (36%), UTI (33%), HIV (29%), smoking (21%), and obesity (21%) [26]. In two-stage revision TKA for PJI, morbidly obese patients (BMI 4 40 kg/m2) demonstrated increased risk for revision surgery (31% versus 11%), reinfection (22% versus 4%), and reoperation (51% versus 16%) compared to nonobese patients (BMI o 30 kg/m2). In addition, implant survival in the morbidly obese group was worse at 5 and 10 years compared to the non-obese group, 80% versus 97% at 5 years and 55% versus 82% at 10 years [27]. Smoking cessation is an important component of patient optimization prior to initiating two-stage exchange arthroplasty. Current smokers are 41% more likely than never smokers to have a surgical site infection [28]. In a systematic review of primary total hip and knee arthroplasty, current smokers were 24% more likely to have any postoperative complication and had a 63% increased risk of mortality [29]. Due to its deleterious local and systemic effects, some authors do not accept patients into an infected implant management protocol who continue to smoke [30]. Malnourished patients are at risk of postoperative wound complications. Preoperative lymphocyte count o1500 cells/mL and albumin level o3.5 g/dL results in five times and seven times greater frequency of developing a wound complication after primary total joint arthroplasty [31]. The overall complication rate of malnourished patients after elective total joint arthroplasty is increased as well, with a 12% complication rate in patients with an albumin o3.5 mg/dL or transferrin o200 mg/dL compared to a 2.9% complication rate in patients with normal nutritional status [32]. Obesity does not preclude the presence of malnourishment. In the same study, 42.9% of malnourished patients were obese (BMI 4 30 kg/m2). Preoperative evaluation and optimization of systemically compromised hosts is beneficial in revision TKA after PJI. Smoking cessation, weight loss, and nutritional supplementation should be encouraged when appropriate.
2.2. First stage: resection, debridement, and spacer placement The first stage of the two-stage protocol for revision TKA after PJI includes explant of all existing components, extensive
26 (2015) 84–90
debridement of necrotic tissue and foreign material, and placement of an antibiotic cement spacer. Extensive scarring due to prior surgical incisions is a common form of local host compromise contributing to wound complications in revision TKA for PJI. The surgical philosophy for the first stage of the two-stage exchange arthroplasty parallels the techniques described by Tetsworth and Cierny [33] for the debridement of osteomyelitis. The knee is approached through excision of the prior surgical scar. Dense, adherent overlying scar is excised to promote primary soft tissue healing. If new incisions must cross prior surgical scars, the risk of edge necrosis is minimized if the new incision is made at a right angle to the prior scar. The blood supply to the skin over the anterior knee is better medially, thus when there are multiple previous lateral incisions it is recommended to use the most lateral incision to re-enter the knee [30]. Postoperative wound complications may also be mitigated by limiting tourniquet time and pressure. Increasing tourniquet time is associated with an increased wound complication rate after primary TKA [34]. In one randomized study, tourniquet cuff pressure less than or equal to 225 mmHg was associated with a decreased postoperative wound complication rate in primary TKA [35]. In the setting of local tissue compromise due to prior surgical scars, revision TKA with no tourniquet avoids local tissue hypoxia and may reduce wound complication rates [30]. To direct antibiotic therapy, accurate organism identification is imperative. Tissue cultures are more sensitive and specific than swab culture in PJI, 93% and 98% versus 70% and 89% [36]. There is a strong consensus among members of the International Consensus on Periprosthetic Joint Infection that more than three but not more than six distinct intraoperative tissue cultures be sent [5]. Sinus tract or wound cultures are unreliable. In one study, superficial cultures from sinus tracts matched intra-articular cultures in just 47% of cases, grew additional organisms not found on intra-articular culture in 43% of cases, and failed to accurately recognize organisms on deep culture in 19% of cases [37]. It is recommended that superficial wounds and sinus tracts are not cultured. Component removal is necessary to decrease the bacterial load within the joint. Adherent biofilms are impenetrable to antibiotics. In addition, irrigation with pulse lavage has been shown to be ineffective at eradicating biofilm from ultra-high molecular weight polyethylene, polymethyl methacrylate (PMMA), and cobalt chrome total knee arthroplasty components and cement [38]. Removal of all TKA components, cement, and necrotic tissue is necessary to eradicate infection. After component removal, thorough debridement of necrotic soft tissue and bone is performed. Osteomyelitis debridement techniques described by Tetsworth and Cierny [33] are applicable. They advocate exposure in the extraperiosteal plane to avoid periosteal stripping. Periosteal stripping in addition to medullary debridement of the same segment of cortical bone may increase the risk of iatrogenic sequestrum formation. As necrotic bone is debrided, the surgeon must monitor the bone for scattered pinpoint sites of bony bleeding indicating sufficient vascular inflow and adequacy of debridement.
S
E M I N A R S I N
AR
T H R O P L A S T Y
Early series describing two-stage exchange arthroplasty did not utilize antibiotic spacers after explant of components [12,13,15,39]. Patients were either maintained in calcaneal skeletal traction or placed into a bulky Jones dressing. Booth and Lotke [14] developed an antibiotic spacer block technique to avoid disuse bone atrophy and soft tissue contracture, to maintain extremity alignment, and to achieve local delivery of antibiotic. These early static spacers consisted of a block of bone cement mixed with an antibiotic powder and allowed for no knee range of motion. Articulating spacers, first described by Cadambi et al. [40] and later by Hofmann et al. [41], were developed to provide patients a functioning leg with knee range of motion and weight bearing as tolerated in the period between resection and reimplantation. Early experience demonstrated improved ultimate knee range of motion and improved tissue compliance upon reimplantation with the use of articulating spacers [41]. A systematic review [42] of articulating versus static spacers in two-stage revision TKA showed greater knee range of motion of 1011 versus 911 in the articulating spacer group. There was no statistically significant difference in the reinfection rate. The wound complication rate in the articulating spacer group was 2% compared to 8% in the static spacer group. The study, however, was not powered to assess statistical significance of this complication. There is strong consensus among members of the International Consensus on Periprosthetic Joint Infection that the use of articulating spacers facilitates reimplantation of components in revision TKA after PJI [5]. Placement of antibiotic beads along with a cement spacer augments local antibiotic delivery and eliminates potential dead space created by debridement [33]. Due to increased total surface area, antibiotic elution from beads results in a higher local antibiotic concentration than thicker cement blocks [43]. Adams et al. [44] evaluated in vitro and in vivo elution of cefazolin, ciprofloxacin, clindamycin, ticarcillin, tobramycin, and vancomycin from PMMA beads and found that clindamycin, vancomycin, and tobramycin exhibited good elution characteristics and had consistently high levels in bone and granulation tissue. When possible, the type of antibiotic used in the cement spacer should be directed toward a known infecting organism. A number of antibiotics are available for use in PMMA cement spacers, including tobramycin, gentamicin, cefazolin, cefuroxime, ceftazidime, cefotaxime, ceftaroline, ciprofloxacin, vancomycin, clindamycin, and linezolid. Vancomycin, which is active against gram-positive bacteria including methicillin-resistant organisms, along with gentamicin or tobramycin, which are active against gram-negative organisms including Pseudomonas, is a combination used to treat most infections. Appropriate dosages include 1–4 g vancomycin powder per 40 g package of cement, and gentamicin or tobramycin, 2.4–4.8 g per 40 g package of cement [5]. Jones and Huo [45] described an effective method for placement of an articulating spacer. After the radical debridement and implant removal are completed, the original femoral component is cleaned and resterilized in the autoclave. A new tibial polyethylene component is selected of the size appropriate to obtain and maintain soft tissue balance and alignment.
26 (2015) 84–90
87
Overall, 24 cm3 of antibiotic powder (heat-stable and specific for the infecting organism) are mixed in every 40 g pack of cement. Removal of 24 cm3 of cement powder before putting the antibiotic powder in helps get the working time to 1 1/2 to 2 times normal. The senior author’s (R.E.J.) preferred antibiotic regimen for majority of the infections caused by gram-positive organism includes vancomycin 4 g or tobramycin 4.8 g mixed with each 40 g pack of cement. If the sensitivity is unknown, then 2 g of vancomycin is mixed with 2.4 g of tobramycin in each pack of cement. The cement is allowed to cure to a relatively doughy state and is then placed on the non-articulating surface of the new polyethylene insert, and the rest of the cement is molded to the defects encountered after debridement. The cement should be placed in a relatively wet field (the tourniquet can be released before this stage), and cement is prevented from full adherence to the bony surfaces by toggling the component until cement curing is completed. This allows for easy removal of the cement and implant composite at definitive reconstruction, but the irregular surfaces make a very stable construct. This procedure is repeated for the femoral component, which has been previously cleaned and flash-sterilized. The limb is then moved to extension with correct alignment and soft tissue balance to prevent migration of the components. Intramedullary antibiotic beads, if used, should be placed prior to cementation of the components. Antibiotic beads are then placed in the medial and lateral gutters and suprapatellar pouch. A watertight wound closure is performed using monofilament suture and no drains are used, allowing for high antibiotic concentration levels in the knee and surrounding tissues. The limb is then placed in a bulky compressive dressing for 48 h. Patients may ambulate on the first operative day with aids and weight bearing as tolerated is allowed. Range of motion is encouraged when a stable wound has been obtained. If there is any compromise of the wound, then the knee should remain in extension until the wound is stable in appearance.
2.3.
Treatment during staged revision
Standard antibiotic therapy following resection and prior to reimplantation involves 6 weeks of parenteral antibiotics followed by antibiotic cessation for 2 weeks. Antibiotic selection is tailored based on intraoperative tissue cultures by an infectious disease specialist. There is no evidence describing the ideal length of antibiotic therapy prior to reimplantation. Clinical signs, systemic inflammatory markers, and synovial fluid analysis are used to guide timing of reimplantation. ESR peaks at postoperative day 5 and slowly decreases over the next 3–6 months [46]. Because ESR, a chronic phase reactant, may remain elevated for a prolonged period after resection, it is less useful for guiding reimplantation. CRP, an acute phase reactant, increases significantly within the first 24 h postoperatively, peaks at postoperative day 3, and returns to preoperative levels by 2 weeks postoperatively [47,48]. Because of its more rapid normalization, CRP is generally more useful than ESR for timing successful
88
SEM
I N A R S I N
A
R T H R O P L A S T Y
26 (2015) 84–90
Table – Eradication rates for two-stage exchange arthroplasty Study Rosenberg et al. [13] Booth and Lotke [14] Wilson et al. [15] Goldman et al. [53] Emerson et al. [54] Evans [55] Haleem et al. [56] Hofmann et al. [57] Jamsen et al. [58] Hsu et al. [59] Westrich et al. [1] Ocguder et al. [60] Park et al. [61] Gooding et al. [62] Mortazavi et al. [63] Castelli et al. [64] Aggregate
Knees
Follow-up (years)
Eradication rate (%)
26 25 20 64 48 31 96 42 22 28 75 17 36 115 117 50 812
2.4 2 2.8 7.5 7.5 2 7.2 6.3 2.7 8.4 4.4 1.7 3 9 3.8 7 5.7
100.0 96.0 80.0 90.6 91.7 93.5 90.6 94.0 91.0 89.3 90.7 94.1 88.9 87.8 72.0 92.0 88.1
Aggregate total number of knees in all studies and weighted average follow-up period and eradication rates are given.
reimplantation of components in two-stage exchange arthroplasty. Inflammatory marker elevation, however, does not preclude infection control. Kusuma et al. [49] retrospectively evaluated the serologies of 76 TKAs with PJI treated with twostage exchange. CRP normalized (CRP o 10 mg/L) in 79% of patients and ESR normalized (ESR o 30 mm/h) in 46% within 2 weeks prior to successful reimplantation. In a similar study by Ghanem et al. [50], a CRP cut-off of 10 mg/L upon serological testing prior to reimplantation was found to have a negative predictive value of 77.1%, despite CRP’s poor area under the curve (ROC ¼ 0.545) upon receiver-operator curve analysis. The authors recommend evaluating the CRP trend during the course of antibiotic therapy and after the period of antibiotic cessation as a tool to guide timing of reimplantation. Joint aspiration for evaluation of cell count with differential, gram stain, and culture may be useful in guiding the timing of reimplantation. Manual complete blood count differential in addition to automated complete blood count is more accurate than automated complete blood count alone in identifying bacterial infection, 89% versus 78% [51]. Synovial fluid leukocyte count with optimum cut-off of 1102.5 cells/mL was found to have a sensitivity of 75% and specificity of 61% for detection of persistent infection [49]. It is common practice to allow for 2 weeks of antibiotic cessation after a 6-week course of parenteral antibiotic therapy to monitor the patient clinically and evaluate inflammatory markers prior to reimplantation. However, there is no conclusive evidence for such an antibiotic holiday period prior to reimplantation [5].
2.4.
Second stage: reimplantation
When clinically appropriate and after a stable wound has been achieved for reimplantation, the knee is approached through the prior surgical scar. The antibiotic spacercomposite is removed. Tissue is sent to pathology for analysis of frozen sections. In a retrospective review, Della Valle et al.
[52] found frozen section analysis to have a sensitivity of 25% and specificity of 98%. Frozen sections were considered positive if a mean of 10 polymorphonuclear leukocytes or more per high-power field were identified in the five most cellular fields examined. If frozen section analysis is positive for acute inflammation, then cultures are sent and irrigation and debridement is performed with placement of an antibiotic spacer. The patient is given a second period of targeted parenteral antibiotics. If frozen section analysis is negative for acute inflammation, then reimplantation is performed with antibiotic impregnated cement. Press-fit rather cemented stems are preferred.
3.
Conclusion
A summary of the published infection eradication rates after two-stage exchange TKA for PJI are shown in the Table. Eradication rates range from 72% to 100% with a weighted average of 88.1% after a mean follow-up period of 5.7 years. In contrast to studies describing outcomes with singlestage exchange, patients with tenuous soft tissue coverage and those infected with resistant organisms were included. Infection after TKA poses a clinical challenge. Diagnosis of PJI is accomplished with a thorough history, physical examination, plain radiographs, measurement of serum inflammatory markers, and joint aspiration. Though currently investigational, biomarkers such as synovial alpha-defensin may play an important role in the future. Once diagnosed, the goals of treatment include eradication of infection and restoration of a functional lower limb. Some authors have reported success with one-stage exchange arthroplasty in highly selected patients or at specialized centers. With an eradication rate of almost 90% in non-selected patients, however, two-stage exchange arthroplasty remains the benchmark for treatment of PJI after TKA.
S
E M I N A R S I N
AR
T H R O P L A S T Y
re fe r en ces
[1] Westrich GH, Walcott-Sapp S, Bornstein LJ, et al. Modern treatment of infected total knee arthroplasty with a 2-stage reimplantation protocol. Journal of Arthroplasty 2010;25: 1015–1021 [1021.e1-1022.e1]. [2] Kamath AF, Ong KL, Lau E, et al. Quantifying the burden of revision total joint arthroplasty for periprosthetic infection. Journal of Arthroplasty 2015;30(9):1492–7. http://dx.doi.org/ 10.1016/j.arth.2015.03.035. (Epub 2015 Mar 31). [3] Zmistowski B, Karam JA, Durinka JB, et al. Periprosthetic joint infection increases the risk of one-year mortality. Journal of Bone and Joint Surgery. American Volume 2013;95:2177–84. [4] Parvizi J, Zmistowski B, Berbari EF, et al. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clinical Orthopaedics and Related Research 2011;469:2992–4. [5] Musculoskeletal Infection Society, International consensus on periprosthetic joint infection, http://www.msis-na.org/ international-consensus/; 2013. [6] Parvizi J, Jacovides C, Adeli B, et al. Coventry Award: synovial C-reactive protein: a prospective evaluation of a molecular marker for periprosthetic knee joint infection. Clinical Orthopaedics and Related Research 2012;470:54–60. [7] Deirmengian C, Kardos K, Kilmartin P, et al. Combined measurement of synovial fluid alpha-Defensin and Creactive protein levels: highly accurate for diagnosing periprosthetic joint infection. Journal of Bone and Joint Surgery. American Volume 2014;96:1439–45. [8] Deirmengian C, Kardos K, Kilmartin P, et al. Diagnosing periprosthetic joint infection: has the era of the biomarker arrived. Clinical Orthopaedics and Related Research 2014;472: 3254–62. [9] Della Valle C, Parvizi J, Bauer TW, et al. Diagnosis of periprosthetic joint infections of the hip and knee. Journal of the American Academy of Orthopaedic Surgeons 2010;18: 760–70. [10] Rao N, Crossett LS, Sinha RK, et al. Long-term suppression of infection in total joint arthroplasty. Clinical Orthopaedics and Related Research 2003;414:55–60. [11] Rohner E, Windisch C, Nuetzmann K, et al. Unsatisfactory outcome of arthrodesis performed after septic failure of revision total knee arthroplasty. Journal of Bone and Joint Surgery. American Volume 2015;97:298–301. [12] Insall JN, Thompson FM, Brause BD. Two-stage reimplantation for the salvage of infected total knee arthroplasty. Journal of Bone and Joint Surgery. American Volume 1983;65:1087–98. [13] Rosenberg AG, Haas B, Barden R, et al. Salvage of infected total knee arthroplasty. Clinical Orthopaedics and Related Research 1988;226:29–33. [14] Booth RE Jr, Lotke PA. The results of spacer block technique in revision of infected total knee arthroplasty. Clinical Orthopaedics and Related Research 1989;248:57–60. [15] Wilson MG, Kelley K, Thornhill TS. Infection as a complication of total knee-replacement arthroplasty. Risk factors and treatment in sixty-seven cases. Journal of Bone and Joint Surgery. American Volume 1990;72:878–83. [16] Windsor RE, Insall JN, Urs WK, et al. Two-stage reimplantation for the salvage of total knee arthroplasty complicated by infection. Further follow-up and refinement of indications. Journal of Bone and Joint Surgery. American Volume 1990;72:272–8. [17] von Foerster G, Kluber D, Kabler U. Mid- to long-term results after treatment of 118 cases of periprosthetic infections after knee joint replacement using one-stage exchange surgery. Orthopade 1991;20:244–52.
26 (2015) 84–90
89
[18] Goksan SB, Freeman MA. One-stage reimplantation for infected total knee arthroplasty. Journal of Bone and Joint Surgery. British Volume 1992;74:78–82. [19] Buechel FF, Femino FP, D’Alessio J. Primary exchange revision arthroplasty for infected total knee replacement: a longterm study. American Journal of Orthopedics (Belle Mead, N.J.) 2004;33:190–8 [discussion 198]. [20] Singer J, Merz A, Frommelt L, et al. High rate of infection control with one-stage revision of septic knee prostheses excluding MRSA and MRSE. Clinical Orthopaedics and Related Research 2012;470:1461–71. [21] Zahar A, Kendoff DO, Klatte TO, et al. Can good infection control be obtained in one-stage exchange of the infected TKA to a rotating hinge design? 10-year results. Clinical Orthopaedics and Related Research 2015:1–7. http://dx.doi. org/10.1007/s11999-015-4408-5. [Epub ahead of print]. [22] Parkinson RW, Kay PR, Rawal A. A case for one-stage revision in infected total knee arthroplasty. Knee 2011;18:1–4. [23] Bauer T, Piriou P, Lhotellier L, et al. Results of reimplantation for infected total knee arthroplasty: 107 cases. Revue de Chirurgie Orthopedique et Reparatrice de l’ Appareil Moteur 2006;92:692–700. [24] Cierny G 3rd, Mader JT, Penninck JJ. A clinical staging system for adult osteomyelitis. Clinical Orthopaedics and Related Research 2003;414:7–24. [25] Cierny G 3rd, DiPasquale D. Periprosthetic total joint infections: staging, treatment, and outcomes. Clinical Orthopaedics and Related Research 2002;403:23–8. [26] Pruzansky JS, Bronson MJ, Grelsamer RP, et al. Prevalence of modifiable surgical site infection risk factors in hip and knee joint arthroplasty patients at an urban academic hospital. Journal of Arthroplasty 2014;29:272–6. [27] Watts CD, Wagner ER, Houdek MT, et al. Morbid obesity: a significant risk factor for failure of two-stage revision total knee arthroplasty for infection. Journal of Bone and Joint Surgery. American Volume 2014;96e154 2014;96. [28] Singh JA, Houston TK, Ponce BA, et al. Smoking as a risk factor for short-term outcomes following primary total hip and total knee replacement in veterans. Arthritis Care Research (Hoboken) 2011;63:1365–74. [29] Singh JA. Smoking and outcomes after knee and hip arthroplasty: a systematic review. Journal of Rheumatology 2011;38:1824–34. [30] Jones RE. Wound healing in total joint arthroplasty. Orthopedics 2010;33:660. [31] Greene KA, Wilde AH, Stulberg BN. Preoperative nutritional status of total joint patients. Relationship to postoperative wound complications. Journal of Arthroplasty 1991;6:321–5. [32] Huang R, Greenky M, Kerr GJ, et al. The effect of malnutrition on patients undergoing elective joint arthroplasty. Journal of Arthroplasty 2013;28:21–4. [33] Tetsworth K, Cierny G 3rd. Osteomyelitis debridement techniques. Clinical Orthopaedics and Related Research 1999;360:87–96. [34] Carroll K, Dowsey M, Choong P, et al. Risk factors for superficial wound complications in hip and knee arthroplasty. Clinical Microbiology and Infection 2014;20:130–5. [35] Olivecrona C, Ponzer S, Hamberg P, et al. Lower tourniquet cuff pressure reduces postoperative wound complications after total knee arthroplasty: a randomized controlled study of 164 patients. Journal of Bone and Joint Surgery. American Volume 2012;94:2216–21. [36] Aggarwal VK, Higuera C, Deirmengian G, et al. Swab cultures are not as effective as tissue cultures for diagnosis of periprosthetic joint infection. Clinical Orthopaedics and Related Research 2013;471:3196–203. [37] Tetreault MW, Wetters NG, Aggarwal VK, et al. Should draining wounds and sinuses associated with hip and
90
[38]
[39]
[40]
[41]
[42]
[43]
[44]
[45] [46]
[47]
[48]
[49]
[50]
[51]
SEM
I N A R S I N
A
R T H R O P L A S T Y
knee arthroplasties be cultured? Journal of Arthroplasty 2013;28:133–6. Urish KL, DeMuth PW, Craft DW, et al. Pulse lavage is inadequate at removal of biofilm from the surface of total knee arthroplasty materials. Journal of Arthroplasty 2014;29:1128–32. Jacobs MA, Hungerford DS, Krackow KA, et al. Revision of septic total knee arthroplasty. Clinical Orthopaedics and Related Research 1989;238:159–66. Cadambi A, Jones RE, Maale GE. A protocol for staged revision of infected total hip and knee arthroplasties: the use of antibiotic-cement-implant composites. International Orthopaedics 1995;3:133–45. Hofmann AA, Kane KR, Tkach TK, et al. Treatment of infected total knee arthroplasty using an articulating spacer. Clinical Orthopaedics and Related Research 1995;321:45–54. Voleti PB, Baldwin KD, Lee GC. Use of static or articulating spacers for infection following total knee arthroplasty: a systematic literature review. Journal of Bone and Joint Surgery. American Volume 2013;95:1594–9. Anagnostakos K, Wilmes P, Schmitt E, et al. Elution of gentamicin and vancomycin from polymethylmethacrylate beads and hip spacers in vivo. Acta Orthopaedica 2009;80: 193–7. Adams K, Couch L, Cierny G, et al. In vitro and in vivo evaluation of antibiotic diffusion from antibioticimpregnated polymethylmethacrylate beads. Clinical Orthopaedics and Related Research 1992;278:244–52. Jones RE, Huo MH. The infected knee: all my troubles now. Journal of Arthroplasty 2006;21:50–3. Bilgen O, Atici T, Durak K, et al. C-reactive protein values and erythrocyte sedimentation rates after total hip and total knee arthroplasty. Journal of International Medical Research 2001;29:7–12. Honsawek S, Deepaisarnsakul B, Tanavalee A, et al. Relationship of serum IL-6, C-reactive protein, erythrocyte sedimentation rate, and knee skin temperature after total knee arthroplasty: a prospective study. International Orthopaedics 2011;35:31–5. White J, Kelly M, Dunsmuir R. C-reactive protein level after total hip and total knee replacement. Journal of Bone and Joint Surgery. British Volume 1998;80:909–11. Kusuma SK, Ward J, Jacofsky M, et al. What is the role of serological testing between stages of two-stage reconstruction of the infected prosthetic knee. Clinical Orthopaedics and Related Research 2011;469:1002–8. Ghanem E, Azzam K, Seeley M, et al. Staged revision for knee arthroplasty infection: what is the role of serologic tests before reimplantation. Clinical Orthopaedics and Related Research 2009;467:1699–705. Wile MJ, Homer LD, Gaehler S, et al. Manual differential cell counts help predict bacterial infection. A multivariate analysis. American Journal of Clinical Pathology 2001;115:644–9.
26 (2015) 84–90
[52] Della Valle CJ, Bogner E, Desai P, et al. Analysis of frozen sections of intraoperative specimens obtained at the time of reoperation after hip or knee resection arthroplasty for the treatment of infection. Journal of Bone and Joint Surgery. American Volume 1999;331:684–9. [53] Goldman RT, Scuderi GR, Insall JN. 2-stage reimplantation for infected total knee replacement. Clinical Orthopaedics and Related Research 1996;331:118–24. [54] Emerson RH Jr, Muncie M, Tarbox TR, et al. Comparison of a static with a mobile spacer in total knee infection. Clinical Orthopaedics and Related Research 2002;404:132–8. [55] Evans RP. Successful treatment of total hip and knee infection with articulating antibiotic components: a modified treatment method. Clinical Orthopaedics and Related Research 2004;427:37–46. [56] Haleem AA, Berry DJ, Hanssen AD. Mid-term to long-term followup of two-stage reimplantation for infected total knee arthroplasty. Clinical Orthopaedics and Related Research 2004;428:35–9. [57] Hofmann AA, Goldberg T, Tanner AM, et al. Treatment of infected total knee arthroplasty using an articulating spacer: 2- to 12-year experience. Clinical Orthopaedics and Related Research 2005;430:125–31. [58] Jamsen E, Sheng P, Halonen P, et al. Spacer prostheses in two-stage revision of infected knee arthroplasty. International Orthopaedics 2006;30:257–61. [59] Hsu YC, Cheng HC, Ng TP, et al. Antibiotic-loaded cement articulating spacer for 2-stage reimplantation in infected total knee arthroplasty: a simple and economic method. Journal of Arthroplasty 2007;22:1060–6. [60] Ocguder A, Firat A, Tecimel O, et al. Two-stage total infected knee arthroplasty treatment with articulating cement spacer. Archives of Orthopaedic and Trauma Surgery 2010;130:719–25. [61] Park SJ, Song EK, Seon JK, et al. Comparison of static and mobile antibiotic-impregnated cement spacers for the treatment of infected total knee arthroplasty. International Orthopaedics 2010;34:1181–6. [62] Gooding CR, Masri BA, Duncan CP, et al. Durable infection control and function with the PROSTALAC spacer in twostage revision for infected knee arthroplasty. Clinical Orthopaedics and Related Research 2011;469:985–93. [63] Mortazavi SM, Vegari D, Ho A, et al. Two-stage exchange arthroplasty for infected total knee arthroplasty: predictors of failure. Clinical Orthopaedics and Related Research 2011;469:3049–54. [64] Castelli CC, Gotti V, Ferrari R. Two-stage treatment of infected total knee arthroplasty: two to thirteen year experience using an articulating preformed spacer. International Orthopaedics 2014;38:405–12.