hand made antibiotic cement spacer for infected hip joints: cement on cement thr:dr.sandeep...
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Cement On Cement SpacerTRANSCRIPT
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