Management of Infected Hip (THR) joint Replacement Surgery by Hand Made Antibiotic Cement SpacerDr.Sandeep Agrawal MS . DNBAgrasen HospitalGondia Maharashtra India
ANTIBIOTIC CEMENT SPACER
Hip Arthroplasty: Increasingly Common
so more cases of Infected hip
THA Infection: A Treatment Challenge
Clinical Challenges
THA Infection: Classification
Common Pathogens
Zimmerli et al, 2005
Biofilm
Clinical Diagnosis ► 1.Clinical S/S: Pain (rest, non-weight bearing),
erythema, fever, discharging sinus, turbid joint fluid ► 2.Laboratory: ESR/CRP, leukocytosis ► 3.Culture and cytology from joint tapping ► 4.Exploration ► 5.Radiographic: normal or bone destraction ► 6.Histopathological: > 5-10 PMN/HPF ► 7.Nuclear medicine ► No Single Test
Treatment choices
Treatment Algorithm for Management of the infected THADepth 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 patients
► Low virulent pathogen
► Oral antibiotics available
► Tolerable long-term antibiotics
► Prosthesis removal is not feasible and no loose
1…Antibiotic suppression
► Very strict criteria :
▪ Symptoms< 3 weeks ▪ Stable prosthesis ▪ No discharging sinus ▪ Susceptible pathogen
► Success rate: 50-70%
► Acceptable early successful rate but also high recurrence Trampuz A et al, 2005
2…Debrideemnt with prosthesis retention
► Remove prosthesis: Girdlestone procedure over hip joint
► High success rate ► Poor functional status ► For the very debilitated
3..Resection Arthroplasty
Antibiotic-cement: The Key to Success
Buchholz et al, 1984
Adams et al, 1992
Girdlestone Problems ► Leg length inequality ► Inability to bear weight ► Disuse osteoporosis ► Extensive scarring ► Distorted tissue plane ► Difficult reimplantation
Dose of antibiotics► Elution of antibiotics from the PROSTALAC is
effective when at least !
3.6 g tobramycin and 1g vancomycin were added !! Masri et al 1998, J Arthroplasty
Do these spacers work better than the beads?
Materials and Methods
Group A (Beads)
► 1994-1996 ► 70 hips ► M:F= 53:17 ► Age: 60 (34-85) y/o ► Follow= 5.4 (2-8) yrs
Group B (Spacer) ► 1996-2000 ► 58 hips ► M:F=43:15 ► Age: 63 (28-81) y/o ► Follow= 4.2 (2-6) yrs
Infection control
60%64%68%72%75%79%83%87%91%95%98%
Group A Group B
Infection control
96.5%94.3%
66/7056/58
(P=0.69)
Ambulatory status
0
15
30
45
60
Ambulatory Non-ambulator
7
49 51
12
BeadsSpacer
87.5%
19.0%
(P=0.001)
► Selected patients ▪ Low- virulent organisms ▪ Identify organism before operation ▪ No sinus tract ▪ No major bone loss ▪ Antibiotic-loaded cement fixation
► More popular in Europe ► Success rate: 73%-92% (OKU 8)
!► Hope et al, 1989 ► Ure et al, 1998
Raut et al, 1994
4..One-stage revision arthroplasty
5.“Two stage revision arthroplasty”
A simple molding method of antibiotic-loaded
cement prosthesis as an interim spacer
J-Trauma
Hsieh et al, 2004
Antibiotic-cement spacer is not new
► Zilkens et al, 1990
► Ivarsson et al, 1994
► Leunig et al, 1998
► Deshmukh et al, 1998
► Younger et al, 1998
► Magnan et al, 2001
•Small series
•Hand-made prosthesis
•Hemiarthroplasty-like
Prosthesis of Antibiotic-loaded Acrylic Cement:
Duncan et al, 1993
PROSTALAC
► 1st Stage : ▪ Removal of all components, debridement ▪ Antibiotic-cement spacer
► Between Stages : ▪ IV antibiotics (2 weeks) ▪ +/- Oral antibiotics (4 weeks)
► 2nd Stage : ▪ Normal CRP ▪ Antibiotics in cement
Treatment Protocol
ACETABULUM PREPARATION
Silicon Mould
A refined metal rodENDOSKELETON
ENDOSKELETON IN MOLD
Pressure Till Cement Sets
FINAL FEMORAL CEMENT SPACER
INSERTION IN MEDULLARY CANAL
Cement-on-cement
Proximal cementation
Metal Rod as endoskeleton
•Temporary prosthesis
•Local antibiotic delivery
AMBULATION WITH SUPPORT
Choice of antibiotics
Heat-stable
► Powdered form
► Broad spectrum
▪ G(+): vancomycin, teicoplanin ▪ G(-): tobramycin, piperacillin, aztreonam
Antibiotics: bone cement = 1: 5
Complication of the cement spacer
FractureDislocation
Fracture
Dislocation
► Antibiotic elution from cement:
biphasic; high initially followed by sustained
release for months
Duncan et al, 1994 JBJS-A
► Antibiotic elution from cement spacer:
similar pattern
Minelli et al, 2004 JAC
► Most reliable method
► High success rate: 88-100% (OKU 8)
► Better functional result after revision hip reconstruction procedure
Two-stage revision arthroplasty
Conclusions ► Remove prosthesis is mandatory when
face a infective hip arthroplasty
► 1.Debride alone: a very limited indication
► 2.One-stage revision: selected cases
► 3.Two-stage revision: most reliable and effective
► With a cement spacer prosthesis: simple, safe, effective, and versatile
Thanks To DR.HSIEH
Dr.Pang Hsieh Taiwan