Management of Hip joint Management of Hip joint Infection Infection

Dr.Sandeep AgrawalDr.Sandeep AgrawalMS . DNBMS . DNB

Agrasen HospitalAgrasen HospitalGondiaGondia

Hip Arthroplasty: Hip Arthroplasty: Increasingly CommonIncreasingly Common

Hip Hip infection infection

THA Infection: A Treatment THA Infection: A Treatment ChallengeChallenge

Clinical ChallengesClinical Challenges

THA Infection: THA Infection: ClassificationClassification

Common PathogensCommon Pathogens

Zimmerli et al, 2005

BiofilmBiofilm

Clinical Diagnosis Clinical Diagnosis

► 1.Clinical S/S: Pain (rest, non-weight 1.Clinical S/S: Pain (rest, non-weight bearing), erythema, fever, discharging bearing), erythema, fever, discharging sinus, turbid joint fluidsinus, turbid joint fluid

► 2.Laboratory: 2.Laboratory: ESR/CRPESR/CRP, leukocytosis, leukocytosis► 3.Culture and cytology from 3.Culture and cytology from joint tappingjoint tapping► 4.Exploration4.Exploration► 5.Radiographic: normal or bone destraction 5.Radiographic: normal or bone destraction ► 6.Histopathological: > 5-10 PMN/HPF 6.Histopathological: > 5-10 PMN/HPF ► 7.Nuclear medicine7.Nuclear medicine

►No Single TestNo Single Test

Treatment choicesTreatment choices

Treatment Algorithm for Management of Treatment Algorithm for Management of the infected THAthe infected THA

Depth of infection

Wound debridement/

antibiotics

Debilitated patient

“Prosthesis retention with debridement”(2)

Intravenous antibiotics

Reinsertion of another prosthesis

Remove implant

Symptom onset

Well-fixed

implant

Chronic oral antibiotic

suppressionchronic

Poor soft-tissue envelope Recalcitrant infection

Poor medical condition

superficial yes

yes

failure

Resection

arthroplasty(3)

deep no acute

failure

no yes

no

failure

AAOS ADVANCED RECONSTRUCTION HIP P.234 2005

►Medically infirm patientsMedically infirm patients►Low virulent pathogenLow virulent pathogen►Oral antibiotics availableOral antibiotics available►Tolerable long-term antibioticsTolerable long-term antibiotics►Prosthesis removal is not feasible Prosthesis removal is not feasible

and no looseand no loose

►Very strict criteria :Very strict criteria : Symptoms< 3 weeksSymptoms< 3 weeks Stable prosthesisStable prosthesis No discharging sinusNo discharging sinus Susceptible pathogenSusceptible pathogen

►Success rateSuccess rate: 50-70% : 50-70% ►Acceptable early successful rate but Acceptable early successful rate but

also also high recurrencehigh recurrenceTrampuz A et al, 2005

►Remove prosthesis: Remove prosthesis: Girdlestone procedure Girdlestone procedure over hip jointover hip joint

►High success rateHigh success rate►Poor functional Poor functional

statusstatus►For the very For the very

debilitateddebilitated

Antibiotic-cement: The Key to Success

Buchholz et al, 1984

Adams et al, 1992

Girdlestone Girdlestone Problems Problems

►Leg length inequalityLeg length inequality► Inability to bear Inability to bear

weightweight►Disuse osteoporosisDisuse osteoporosis►Extensive scarringExtensive scarring►Distorted tissue planeDistorted tissue plane►Difficult Difficult

reimplantationreimplantation

Dose of antibioticsDose of antibiotics► Elution of antibiotics from the PROSTALAC is effective Elution of antibiotics from the PROSTALAC is effective

when at least when at least

3.6 g tobramycin 3.6 g tobramycin and 1g vancomycin were addedand 1g vancomycin were added

Masri et al 1998, J ArthroplastyMasri et al 1998, J Arthroplasty

Do these spacers work better than the beads?

Materials and MethodsMaterials and Methods

Group A Group A (Beads)(Beads)

► 1994-19961994-1996► 70 hips70 hips► M:F= 53:17M:F= 53:17► Age: 60 (34-85) y/oAge: 60 (34-85) y/o► Follow= 5.4 (2-8) Follow= 5.4 (2-8)

yrsyrs

Group B Group B (Spacer)(Spacer)

► 1996-20001996-2000► 58 hips58 hips► M:F=43:15M:F=43:15► Age: 63 (28-81) y/oAge: 63 (28-81) y/o► Follow= 4.2 (2-6) Follow= 4.2 (2-6)

yrsyrs

Infection controlInfection control

60%

65%

70%

75%

80%

85%

90%

95%

100%

Group A Group B

Infection control

96.5%96.5%94.3%94.3%

66/7066/70 56/5856/58

(P=0.69)

Ambulatory statusAmbulatory status

12

5149

7

0

10

20

30

40

50

60

Ambulatory Non-ambulator

BeadsSpacer87.5%

19.0%

(P=0.001)

► Selected patientsSelected patients Low- virulent organismsLow- virulent organisms Identify organism before operationIdentify organism before operation No sinus tractNo sinus tract No major bone lossNo major bone loss Antibiotic-loaded cement fixationAntibiotic-loaded cement fixation

► More popular in EuropeMore popular in Europe► Success rate: 73%-92% Success rate: 73%-92% (OKU 8)(OKU 8)

► Hope et al, 1989Hope et al, 1989► Ure et al, 1998 Ure et al, 1998

Raut et al, 1994 Raut et al, 1994

5.“Two stage revision arthroplasty”

A simple molding method of antibiotic-

loaded cement prosthesis as an interim

spacer

J-TraumaJ-Trauma

Hsieh et al, 2004

Antibiotic-cement spacer is Antibiotic-cement spacer is not new not new

►Zilkens et al, 1990Zilkens et al, 1990► Ivarsson et al, 1994Ivarsson et al, 1994►Leunig et al, 1998Leunig et al, 1998►Deshmukh et al, 1998Deshmukh et al, 1998►Younger et al, 1998Younger et al, 1998►Magnan et al, 2001Magnan et al, 2001

•Small series

•Hand-made prosthesis

•Hemiarthroplasty-like

Prosthesis of Antibiotic-loaded Prosthesis of Antibiotic-loaded Acrylic Cement: Acrylic Cement:

Duncan et al, 1993

►11stst Stage : Stage : Removal of all components, debridementRemoval of all components, debridement Antibiotic-cement spacerAntibiotic-cement spacer

►Between Stages :Between Stages : IV antibiotics (2 weeks)IV antibiotics (2 weeks) +/- Oral antibiotics (4 weeks)+/- Oral antibiotics (4 weeks)

►22ndnd Stage : Stage : Normal CRPNormal CRP Antibiotics in cementAntibiotics in cement

ACETABULUM ACETABULUM PREPARATIONPREPARATION

Silicon Mould

A refined metal rodA refined metal rod

ENDOSKELETONENDOSKELETON

ENDOSKELETON IN MOLDENDOSKELETON IN MOLD

Pressure Till Cement SetsPressure Till Cement Sets

FINAL FEMORAL CEMENT FINAL FEMORAL CEMENT SPACERSPACER

INSERTION IN MEDULLARY INSERTION IN MEDULLARY CANALCANAL

Cement-on-cement

Proximal cementation

Metal Rod as endoskeleton

•Temporary prosthesis

•Local antibiotic delivery

AMBULATION WITH SUPPORTAMBULATION WITH SUPPORT

Choice of antibioticsChoice of antibiotics

Heat-stableHeat-stable►Powdered formPowdered form►Broad spectrumBroad spectrum

G(+): vancomycin, teicoplaninG(+): vancomycin, teicoplanin G(-): tobramycin, piperacillin, aztreonamG(-): tobramycin, piperacillin, aztreonam

Antibiotics: bone cement = 1: 5

Complication of the cement Complication of the cement spacerspacer

►Antibiotic elution from cement: Antibiotic elution from cement:

biphasicbiphasic; high initially followed by sustained; high initially followed by sustained

release for monthsrelease for months

Duncan et al, 1994 Duncan et al, 1994 JBJS-AJBJS-A

►Antibiotic elution from cement spacer: Antibiotic elution from cement spacer:

similar similar pattern pattern

Minelli et al, 2004 JACMinelli et al, 2004 JAC

►Most Most reliablereliable method method ►High High successsuccess rate: 88-100% rate: 88-100% (OKU 8)(OKU 8)

►Better Better functionalfunctional result after revision result after revision hip reconstruction procedurehip reconstruction procedure

AdvantagesAdvantages

►Simple and effectiveSimple and effective►Cement-on-cementCement-on-cement surface allow surface allow

weight bearing weight bearing and motionand motion►TemporaryTemporary spacer, for easily real spacer, for easily real

prosthesis re-implantationprosthesis re-implantation►Local antibiotic Local antibiotic deliverydelivery►Allow Allow cementlesscementless revision procedure revision procedure►Maintain Maintain soft tissue soft tissue TensionTension

Conclusions Conclusions ►Remove prosthesisRemove prosthesis is mandatory when is mandatory when

face a infective hip arthroplastyface a infective hip arthroplasty►11..Debride aloneDebride alone: a very limited : a very limited

indicationindication►22..One-stage revisionOne-stage revision: selected cases: selected cases►33..Two-stage revisionTwo-stage revision: most reliable : most reliable

and effectiveand effective►With a With a cement spacer prosthesiscement spacer prosthesis: :

simple, safe, effective, and versatilesimple, safe, effective, and versatile

►Two-stage exchange: Reliable methodTwo-stage exchange: Reliable method With a spacer prosthesis:With a spacer prosthesis:

simple, safe, effective, and simple, safe, effective, and versatileversatile

Dr.Pang HsiehTaiwan

Thanks…Thanks…Time for DiscussionTime for Discussion