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Treatment Failure Among Infected Periprosthetic Patients at a Highly Specialized Revision TKA Referral Practice.

Schwarzkopf R, Oh D, Wright E, Estok DM, Katz JN - Open Orthop J (2013)

Bottom Line: We defined "successful two-stage revision" as negative intraoperative cultures and no further infection-related procedure.We also observed a trend between presence of resistant staphylococcus (MRSA) (p=0.05) as well as pre-revision surgical procedures (p=0.08) and a lower likelihood of successfully two-stage revision.The relatively high rate of failure to achieve a successful two-stage revision observed in our series may be attributed to the highly specialized referral practice.

View Article: PubMed Central - PubMed

Affiliation: Orthopaedic Department, University of California Irvine Medical Center, Orange, CA, USA.

ABSTRACT
Deep infection is a serious and costly complication of total knee arthroplasty (TKA), which can increase patient morbidity and compromise functional outcome and satisfaction. Two-stage revision with an interval of parental antibiotics has been shown to be the most successful treatment in eradicating deep infection following TKA. We report a large series by a single surgeon with a highly specialized revision TKA referral practice. We identified 84 patients treated by a two-stage revision. We defined "successful two-stage revision" as negative intraoperative cultures and no further infection-related procedure. We defined "eradication of infection" on the basis of negative cultures and clinical diagnosis. After a mean follow up of 25 months, eradication of the infection was documented in 90.5% of the patients; some had undergone further surgical intervention after the index two-stage procedure. Successful two-stage revision (e.g. no I&D, fusion, amputation) was documented only in 63.5% of the patients. We also observed a trend between presence of resistant staphylococcus (MRSA) (p=0.05) as well as pre-revision surgical procedures (p=0.08) and a lower likelihood of successfully two-stage revision. Factors affecting the high failure rate included multiple surgeries prior to the two-stage revision done at our institution, and high prevalence of MRSA present among failed cases. The relatively high rate of failure to achieve a successful two-stage revision observed in our series may be attributed to the highly specialized referral practice. Thus increasing the prevalence of patients with previous failed attempts at infection eradication and delayed care as well as more fragile and immune compromised hosts.

No MeSH data available.


Related in: MedlinePlus

Antibiotic cement being pored into the costume mold forpreparation of an antibiotic spacer.
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Figure 3: Antibiotic cement being pored into the costume mold forpreparation of an antibiotic spacer.

Mentions: To conserve surgical time, we simultaneously fabricated the cement-tapered stems on the back table. Our specialized stem mold (Fig. 2) was used to produce the antibiotic canal spacers. Our protocol includes 80 grams (two packs) of polymethylmethacrylate cement (Simplex P; Stryker, Mahwah, NJ), premixed with 1 gram of tobramycin per 40 grams of cement. To this we added 4.8 grams of tobramycin powder, and 2 grams of vancomycin powder for a total of4.4 grams of antibiotics per 40 grams of cement powder. For mixing we added a third bottle of monomer due to the added volume of the antibiotics. The cement was mixed and poured into the appropriate size tapered stem molds (Fig. 3). A large threaded Steinmann pin was placed into each cement mold leaving 2 inches protruding beyond the mold (Fig. 4). After full polymerization of the cement, the mold is split and the stems are removed (Fig. 5). The stems were placed appropriately in the femoral and tibial canals, any excess length of the Steinmann pins was trimmed with a bolt cutter, and the overlapping pins were linked together with an 18-gauge cerclage wire (Fig. 6). The leg was placed in nearly full extension, with physiologic external rotation of the tibia. Three packs of 40 grams of polymethylmethacrylate each with premixed 0.5 grams of gentamycin (Palacos R+G; Zimmer, Warsaw, IN) were mixed with 7.2 grams of tobramycin powder, and 3 grams of vancomycin powder for a total of 3.9 grams of antibiotics per 40 grams of cement powder. For mixing we added a fourth bottle of monomer due to the added volume of the antibiotics. The cement was injected into the space created between the distal femur and the proximal tibia overlaying the Steinmann pins (Fig. 7). At this point, during polymerization of the cement, the tourniquet was deflated (Fig. 8).


Treatment Failure Among Infected Periprosthetic Patients at a Highly Specialized Revision TKA Referral Practice.

Schwarzkopf R, Oh D, Wright E, Estok DM, Katz JN - Open Orthop J (2013)

Antibiotic cement being pored into the costume mold forpreparation of an antibiotic spacer.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3722532&req=5

Figure 3: Antibiotic cement being pored into the costume mold forpreparation of an antibiotic spacer.
Mentions: To conserve surgical time, we simultaneously fabricated the cement-tapered stems on the back table. Our specialized stem mold (Fig. 2) was used to produce the antibiotic canal spacers. Our protocol includes 80 grams (two packs) of polymethylmethacrylate cement (Simplex P; Stryker, Mahwah, NJ), premixed with 1 gram of tobramycin per 40 grams of cement. To this we added 4.8 grams of tobramycin powder, and 2 grams of vancomycin powder for a total of4.4 grams of antibiotics per 40 grams of cement powder. For mixing we added a third bottle of monomer due to the added volume of the antibiotics. The cement was mixed and poured into the appropriate size tapered stem molds (Fig. 3). A large threaded Steinmann pin was placed into each cement mold leaving 2 inches protruding beyond the mold (Fig. 4). After full polymerization of the cement, the mold is split and the stems are removed (Fig. 5). The stems were placed appropriately in the femoral and tibial canals, any excess length of the Steinmann pins was trimmed with a bolt cutter, and the overlapping pins were linked together with an 18-gauge cerclage wire (Fig. 6). The leg was placed in nearly full extension, with physiologic external rotation of the tibia. Three packs of 40 grams of polymethylmethacrylate each with premixed 0.5 grams of gentamycin (Palacos R+G; Zimmer, Warsaw, IN) were mixed with 7.2 grams of tobramycin powder, and 3 grams of vancomycin powder for a total of 3.9 grams of antibiotics per 40 grams of cement powder. For mixing we added a fourth bottle of monomer due to the added volume of the antibiotics. The cement was injected into the space created between the distal femur and the proximal tibia overlaying the Steinmann pins (Fig. 7). At this point, during polymerization of the cement, the tourniquet was deflated (Fig. 8).

Bottom Line: We defined "successful two-stage revision" as negative intraoperative cultures and no further infection-related procedure.We also observed a trend between presence of resistant staphylococcus (MRSA) (p=0.05) as well as pre-revision surgical procedures (p=0.08) and a lower likelihood of successfully two-stage revision.The relatively high rate of failure to achieve a successful two-stage revision observed in our series may be attributed to the highly specialized referral practice.

View Article: PubMed Central - PubMed

Affiliation: Orthopaedic Department, University of California Irvine Medical Center, Orange, CA, USA.

ABSTRACT
Deep infection is a serious and costly complication of total knee arthroplasty (TKA), which can increase patient morbidity and compromise functional outcome and satisfaction. Two-stage revision with an interval of parental antibiotics has been shown to be the most successful treatment in eradicating deep infection following TKA. We report a large series by a single surgeon with a highly specialized revision TKA referral practice. We identified 84 patients treated by a two-stage revision. We defined "successful two-stage revision" as negative intraoperative cultures and no further infection-related procedure. We defined "eradication of infection" on the basis of negative cultures and clinical diagnosis. After a mean follow up of 25 months, eradication of the infection was documented in 90.5% of the patients; some had undergone further surgical intervention after the index two-stage procedure. Successful two-stage revision (e.g. no I&D, fusion, amputation) was documented only in 63.5% of the patients. We also observed a trend between presence of resistant staphylococcus (MRSA) (p=0.05) as well as pre-revision surgical procedures (p=0.08) and a lower likelihood of successfully two-stage revision. Factors affecting the high failure rate included multiple surgeries prior to the two-stage revision done at our institution, and high prevalence of MRSA present among failed cases. The relatively high rate of failure to achieve a successful two-stage revision observed in our series may be attributed to the highly specialized referral practice. Thus increasing the prevalence of patients with previous failed attempts at infection eradication and delayed care as well as more fragile and immune compromised hosts.

No MeSH data available.


Related in: MedlinePlus