Prof. Paolo Cherubino Dipartimento di scienze ortopediche e traumatologiche Universitas Studiorum...

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Prof. Paolo CherubinoProf. Paolo Cherubino

Dipartimento di scienze ortopediche e traumatologicheDipartimento di scienze ortopediche e traumatologiche

Universitas Universitas Studiorum Studiorum Insubriae VARESEInsubriae VARESE

Total knee revision in Total knee revision in septic failureseptic failure

Epidemiology, timing and Epidemiology, timing and classificationclassification

The most commons causes of kneeThe most commons causes of knee

arthroplasty revisions:arthroplasty revisions:• Infections (Infections (25.2%)25.2%)• Mechanical failureMechanical failure ( (16.1%16.1%))

The Epidemiology of Revision Total Knee Arthroplasty in the United StatesThe Epidemiology of Revision Total Knee Arthroplasty in the United StatesKevin Bozic, MD.Kevin Bozic, MD. 2007 2007

EpidemiologyEpidemiology

The The systemic risk factorssystemic risk factors: : •rheumatoid arthritisrheumatoid arthritis•diabetes diabetes •IRCIRC•obesityobesity•advanced age advanced age •debilitationdebilitation•oral steroidsoral steroids•cancer/chemotherapic treatmentcancer/chemotherapic treatment•immunocompromised patientsimmunocompromised patients

Simmons TD, Stern SH. Diagnosis and management of the infected total Simmons TD, Stern SH. Diagnosis and management of the infected total knee arthroplasty. Am J Knee Surg. 1996knee arthroplasty. Am J Knee Surg. 1996

Risk factorsRisk factors

The The local risk factorslocal risk factors are : are : •Previews knee surgeryPreviews knee surgery•Skin complications after the Skin complications after the implant implant •psoriatic skin ulcerspsoriatic skin ulcers

Simmons TD, Stern SH. Diagnosis and management of the infected total Simmons TD, Stern SH. Diagnosis and management of the infected total knee arthroplasty. Am J Knee Surg. 1996knee arthroplasty. Am J Knee Surg. 1996

Risk factorsRisk factors

Infection is actually, Infection is actually, rare but serious problem rare but serious problem

in joints arthroplastic surgeryin joints arthroplastic surgery

INFECTION RATE AFTER INFECTION RATE AFTER TOTAL KNEE ARTHROPLASTYTOTAL KNEE ARTHROPLASTY

• GroganGrogan J. Bone Joint Surg. Am.J. Bone Joint Surg. Am.19861986; 68:226-; 68:226-3434• WilsonWilson J.Bone Joint. Surg. Am. J.Bone Joint. Surg. Am. 19901990; 72:878-; 72:878-8383• BengstonBengston Acta Orthop Scand. Acta Orthop Scand. 19911991; ; 62(4):301-1162(4):301-11• Rand JA.Rand JA. Orthop Clin North Am.Orthop Clin North Am. 19941994..

0,5 - 5%0,5 - 5%

J Bone Joint Surg Am. J Bone Joint Surg Am. 19991999 Oct;81(10):1434-45. Oct;81(10):1434-45.

““The prevalence of infection afterThe prevalence of infection afterprimary total knee arthroplasty has primary total knee arthroplasty has

been reported tobeen reported torange from range from 0.50.5 to to 55 percent.” percent.”

““Current infection rates areCurrent infection rates are in the in the 1%1% to to 2%2%.”.”

The Journal of Arthroplasty Vol. 19 No. 4 Suppl. 1 The Journal of Arthroplasty Vol. 19 No. 4 Suppl. 1 20042004

““Our known infection rates of Our known infection rates of 1%1%after primary and after primary and 5.8%5.8% after revision after revision

TKA are comparableTKA are comparablewith published reports.”with published reports.”

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

20042004

““Deep infection rates in total knee Deep infection rates in total knee joint replacement vary in the published joint replacement vary in the published

literature between literature between 0.3%0.3% and and 2.9%2.9%.”.”

20072007

HSSJ (2007) 3: 159–163HSSJ (2007) 3: 159–163

““Incidence rates for Incidence rates for primary TKA between primary TKA between 1995 and 2004, from 1995 and 2004, from

6.36.3 to to 11.0 11.0 at a rate of at a rate of 5.1% per year (p < 5.1% per year (p <

0.001).”0.001).”

EtiologyEtiology

E. ColiE. Coli Legionella P.Legionella P.

Staph. A.Staph. A.

Staph E.Staph E.

Gram -Gram -

StreptococcusStreptococcus

Pre and intra-operative pathogenPre and intra-operative pathogen ISOLATIONISOLATION

The Journal of Arthroplasty Vol. 19 No. 4 Suppl. 1 The Journal of Arthroplasty Vol. 19 No. 4 Suppl. 1 20042004

EtiologyEtiology

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

20042004

J Bone Joint Surg Am. J Bone Joint Surg Am. 19991999 Oct;81(10):1434-45. Oct;81(10):1434-45.

EtiologyEtiology

Chang Gung Med J. Chang Gung Med J. 20082008 Nov-Dec;31(6):583-91Nov-Dec;31(6):583-91. .

Clinical-temporal Clinical-temporal classificationclassification

• ImmediateImmediate: : before 4 weeksbefore 4 weeks

• EarlyEarly: : between 4 wks to 2 yearsbetween 4 wks to 2 years

• DelayedDelayed: : over 2 yearsover 2 years

• OccasionalOccasional: : positive culture in positive culture in replacementreplacement

Segawa et al. JBJS, Segawa et al. JBJS, 19991999

Coventry’s stateCoventry’s state

Step I = Acute infection post-operativeStep I = Acute infection post-operative

(within 3 months after)(within 3 months after)

Stage II = delayed deep infectionStage II = delayed deep infection

(3 to 24 months after(3 to 24 months after))

Stage III = late hematogenous infectionStage III = late hematogenous infection(a distance of years)(a distance of years)

Step Zero = Operating contaminationStep Zero = Operating contamination

(positivity of at least 2 of 3 buffers intra-op)(positivity of at least 2 of 3 buffers intra-op)

Classification Classification

Coventry MB. Orthop Clin North Am. Coventry MB. Orthop Clin North Am. 19751975 Oct;6(4):991-1003. Oct;6(4):991-1003.

Classification Classification

J Bone Joint Surg Am.J Bone Joint Surg Am. 85-A · SUPPLEMENT 1 · 85-A · SUPPLEMENT 1 · 20032003

Choice of treatment is based Choice of treatment is based on:on:

anatomical-clinicalanatomical-clinical

microbiologicalmicrobiological

Accurate diagnostic gradingAccurate diagnostic grading

Therapeutic optionTherapeutic option

• CBC, VES and PCRCBC, VES and PCR• instrumental and clinical instrumental and clinical • Preoperative aspiration Preoperative aspiration

cultureculture

Replacement-TimingReplacement-Timing

Clinical orthopaedic and related research n345, Clinical orthopaedic and related research n345, 19971997

• ArthroscopyArthroscopy• ToiletteToilette• ReplacementReplacement• ArthrodesisArthrodesis• Resection - arthroplasticResection - arthroplastic• AmputationAmputation

Purpose of surgeryPurpose of surgery

infection eradicationinfection eradication save joint functionsave joint function

IMMEDIATE INFECTIONIMMEDIATE INFECTION

ToiletteToilette++

Suppressive antibiotic therapy (at least 3 wks)Suppressive antibiotic therapy (at least 3 wks)

EARLY INFECTIONEARLY INFECTION

open surgery or arthroscopicopen surgery or arthroscopicTOILETTETOILETTE

++Suppressive antibiotic therapy (at least 3 wks)Suppressive antibiotic therapy (at least 3 wks)

LATE INFECTIONLATE INFECTION

Remove implant and Remove implant and Surgical debridementSurgical debridement

ARTHRODESISARTHRODESIS REIMPLANTREIMPLANT

age, general conditions, age, general conditions, indication indication

One stageOne stage Two stageTwo stage

INFEZIONE TARDIVAINFEZIONE TARDIVA

REIMPLANTREIMPLANT

One stageOne stage Two stageTwo stage

age, general conditions, age, general conditions, indication indication

Remove implant and Remove implant and Surgical debridementSurgical debridement

ARTHRODESISARTHRODESIS

The two-stage exchange procedure The two-stage exchange procedure has evolved as an effective treatment has evolved as an effective treatment

option.option.Clin Orthop Relat Res. Clin Orthop Relat Res. 20072007 Nov;464:164-78 Nov;464:164-78

The best results of treatment of an The best results of treatment of an infected TKR have been reported by infected TKR have been reported by Windsor et al in which no spacer was Windsor et al in which no spacer was

used between stagesused between stages

Windsor RE, Insall JN, Urs WK, Miller DV, Brause BDWindsor RE, Insall JN, Urs WK, Miller DV, Brause BD. . Two-stage Two-stage reimplantation for the salvage of total knee arthroplasty complicated by reimplantation for the salvage of total knee arthroplasty complicated by

infection: further follow-up and refinement of indications. J Bone Joint Surg infection: further follow-up and refinement of indications. J Bone Joint Surg [Am] [Am] 19901990..

Treatment of TKA infection with a two-Treatment of TKA infection with a two-stage exchange had a significantly better stage exchange had a significantly better

outcome than debridement with outcome than debridement with retention of the prosthesis. Good results retention of the prosthesis. Good results were obtained with two-stage revision of were obtained with two-stage revision of

infected TKAinfected TKAInternational Orthopaedics (SICOT) International Orthopaedics (SICOT) 20082008

Two-stage reimplantation of an infected total knee Two-stage reimplantation of an infected total knee arthroplasty using a static antibiotic-cement arthroplasty using a static antibiotic-cement

spacer achieved an infection control rate of 86% spacer achieved an infection control rate of 86% andand

improvement in the clinical results.improvement in the clinical results.

F, 75 aa F, 75 aa PMPM

S. AureusS. AureusPREOPPREOP

# 1# 1

S. AureusS. AureusESPESP

# 1# 1

S. AureusS. AureusESPESP

# 1# 1

S. AureusS. AureusF-U 1 annoF-U 1 anno

# 1# 1

F, 78 aa ISF, 78 aa IS

Serratia marcescensSerratia marcescensPREOPPREOP

# 2# 2

Serratia marcescensSerratia marcescensESPESP

F, 78 aa ISF, 78 aa IS# 2# 2

Serratia Serratia marcescensmarcescens

ESPESP

# 2# 2

Serratia Serratia marcescensmarcescensF-U 3 anniF-U 3 anni

# 2# 2

Prof. Paolo Cherubino Dipartimento di scienze ortopediche e traumatologiche Universitas Studiorum...

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