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Management of Infected Hip (THR)

joint Replacement Surgery by Hand


Made Antibiotic Cement Spacer
Dr.Sandeep Agrawal
MS . DNB

Agrasen Hospital
Gondia
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 THA


Depth of
infection

Debilitated
patient

deep

superficial

no

Symptom
onset

acute

Prosthesis retention
with debridement(2)

yes
Chronic oral
antibiotic

Wound
debridement/
antibiotics

Well-fixed
implant

chronic

suppression

yes
failure

no
Intravenous
antibiotics

failure

Remove implant
Reinsertion of
another
prosthesis

no

Poor soft-tissue envelope


Recalcitrant infection
Poor medical condition

failure

Resection
yes

arthroplasty(3)

AAOS ADVANCED RECONSTRUCTION HIP P.234 2005

1Antibiotic suppression

Medically infirm patients


Low virulent pathogen
Oral antibiotics available
Tolerable long-term antibiotics
Prosthesis removal is not feasible and
no loose

2Debrideemnt with prosthesis retention

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

3..Resection Arthroplasty
Remove prosthesis:
Girdlestone procedure over
hip joint
High success rate
Poor functional status
For the very debilitated

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
98%
95%
91%
87%
83%
79%
75%
72%
68%
64%
60%

94.3%

96.5%

Infection c
66/70
56/58

Group A

Group B

(P=0.69)

Ambulatory status
60
49

51

45
Beads
Spacer

30
87.5%

15

12
7
19.0%

0
Ambulatory

Non-ambulator

(P=0.001)

4..One-stage revision arthroplasty


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

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


Small series
Ivarsson et al, 1994
Hand-made prosthesis
Leunig et al, 1998
Hemiarthroplasty-like
Deshmukh et al, 1998
Younger et al, 1998
Magnan et al, 2001

osthesis of Antibiotic-loaded Acrylic Cement:


PROSTALAC

Duncan et al, 1993

Treatment Protocol

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

ACETABULUM PREPARATION

Silicon Mould

A refined metal rod

ENDOSKELETON

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

Dislocation

Fracture

Dislocation

Fracture

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

Two-stage revision arthroplasty

Most reliable method


High success rate: 88-100% (OKU 8)
Better functional result after revision hip
reconstruction procedure

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