■ Problems After Knee Arthroplasty:
“Things That Go Bump in the Night”
Direct Exchange Treatment of Septic
Total Joint Arthroplasty With
Intra-Articular Infusion of Antibiotics:
Technique and Early Results
TARIQ NAYFEH, MD; LEO A. WHITESIDE, MD; MATTHEW HIRSCH, PA-C
nfection in total joint
replacement continues to be
a challenging and controversial topic. Treatment is expensive and often ineffective,
especially in cases with multiple bacterial species or resistant organisms. An effective
single-stage operation that
enables patients to be mobilized and treated at home
would be a major advance in
the treatment of this disease.
The standard technique for
treating infected total joints
currently is performed in two
surgical stages. Implant
removal, joint debridement,
and treating the joint locally
with an antibiotic-loaded
cement spacer generally are
done first and then are fol-
I
From Missouri Bone and Joint
Research Foundation, St Louis, Mo.
The authors thank Diane Morton,
MS, for her assistance during manuscript preparation.
Reprint requests: Leo A.
Whiteside, MD, Missouri Bone and
Joint Research Foundation, 12634
Olive Blvd, St Louis, MO 63141.
lowed by joint revision with
new implants and antibioticloaded cement several weeks
later. The high failure rate is
due possibly to the relatively
low concentration of antibiotics that can be achieved in
the joint.1 Also, the cement
spacer can harbor bacteria,
which may result in recurrent
infection and resistant organisms.2 Direct delivery of
antibiotics into the joint, however, provides high local concentration of antibiotics that
can be maintained for weeks
or months, and also achieves
therapeutic serum levels. In a
preliminary study done in
2000, antibiotic levels 100500 times higher than could be
achieved intravenously were
found in the knee, and therapeutic levels of antibiotics
were found in the serum following the direct infusion of
antibiotics into the joint.3
This article describes a new
treatment method and presents
the early results of infected
total joint arthroplasty using
SEPTEMBER 2004 | Volume 27 • Number 9
single-stage revision with
cementless total joint replacement components, and direct
antibiotic infusion into the
joint.
MATERIALS AND METHODS
Since 1999, 31 patients
have been treated with a direct
noncemented component exchange with antibiotics infused
directly into the joint via
Hickman catheters. The treatment protocol includes a single-stage surgery in which the
components are removed, the
joint is debrided thoroughly,
new porous-coated components are implanted without
cement or bone graft, and two
indwelling single lumen Hickman catheters are placed.4
After debridement and
reimplantation, the Hickman
catheters are inserted percutaneously. A long, thin, curved
clamp is passed from inside the
joint through a layer of periarticular muscle and to the skin.
A small puncture wound is
made over the clamp and the
tip of the clamp is passed
through the wound. The wound
is kept as small as possible to
allow the skin to seal around
the catheter. The clamp is
opened gently to dilate the soft
tissue. The tip of the catheter is
pulled through the skin and
into the joint. The catheter cuff
is placed deep to the dermis,
but not in the muscle. Each
catheter is secured with two
silk sutures. The sutures are
carefully released from the skin
after 2 weeks, but left attached
to the catheters to avoid damage to the catheters during
suture removal. The patient
then receives organism-specific
intra-articular
antibiotics
through the Hickman catheters
for 6 weeks.
Because of the potential
toxic effects of antibiotics such
as vancomycin and aminoglycosides, serum peaks and
troughs are monitored for the
first 3-4 days, followed by biweekly trough serum levels
until treatment is ended. The
intra-articular antibiotic dose is
987
■ Problems After Knee Arthroplasty:
“Things That Go Bump in the Night”
adjusted to maintain safe and
therapeutic peripheral levels.
For vancomycin infusions
trough serum levels are maintained between 5 ␮g/mL and
12 ␮g/mL. Serial dilution in
normal saline demonstrated
that the maximum concentration of vancomycin that will
not precipitate in vitro is 100
mg/mL (500 mg in 5 mL). If
vancomycin is used, the initial
dose is 500 mg in 10 mL of
normal saline twice daily. In
patients with renal impairment,
the dose is decreased to 250 mg
in 5 mL. The same antibiotics
used in the irrigation solution
during surgery should be
infused into the joint to avoid
precipitation.
RESULTS
Two (6%) of 31 cases
failed, resulting in a 94% success rate. One failure occurred
in a patient in whom adequate
soft-tissue coverage could not
be achieved despite multiple
surgical attempts, and the second failure occurred in a
patient who initially was treated at another institution and the
infecting organism was never
identified. He subsequently
underwent a hip disarticulation.
Two patients developed
local complications secondary
to vancomycin infusion. One
patient developed a draining
wound following revision of a
total knee replacement. The
drainage consisted of serosanguineous fluid with precipitated vancomycin particles. Joint
aspirations were negative for
infection. The drainage resolved after stopping the intraarticular antibiotic infusions.
988
Another patient initially
presented with right lower lobe
pneumonia and a septic total
hip. Revision surgery included
removal of the infected components and cement, thorough
debridement, and insertion of
cementless revision components and two Hickman catheters. Intra-articular vancomycin was infused for 6 weeks
to treat the infected hip, and
intravenous piperacillin/tazobactom was given for the first 2
weeks to treat the pneumonia.
Serum levels of vancomycin
were maintained around 4.5-5
␮g/mL. Induration, swelling,
and discoloration of the incisional area were noted 5.5
weeks postoperatively, but the
hip was not painful with passive and active motion.
Aspirated hip fluid had a
white blood cell count of
22,000 cells, and the cultures
remained negative. Vancomycin infusion was stopped and
the local inflammation resolved over the next week. The
combination of intravenous
piperacillin and intra-articular
vancomycin was suspected to
have induced precipitation of
the vancomycin, leading to an
acute sterile inflammatory
response that resolved after the
vancomycin was discontinued.
DISCUSSION
Complete eradication of
bacteria from the joint is necessary to cure infected total joint
arthroplasty. Most infected
cases are cemented and harbor
bacteria in the bone-cement
interface and on the surfaces of
the metal and cement. Implant
removal, thorough debridement, and delivery of high con-
centrations of antibiotics for a
prolonged period of time are
necessary to achieve a high
success rate in these cases. The
current technique was developed to avoid the known pitfalls of antibiotic-loaded cement, which delivers antibiotics only for a few days1 and
can harbor resistant bacteria on
its surface.2
Directly infusing antibiotics
into the infected area maintains
a high local concentration level
while minimizing systemic
toxicity.3,4 Resistant bacteria
absorbs antibiotics when a very
high local level is obtained,5
and the high intracellular levels
achieved overcome many resistance mechanisms. Local
antibiotic delivery of amikacin
using an implantable pump was
successful in treating 71% of
patients with chronic recalcitrant osteomyelitis, and salvaged 18 of 20 infected total
joint arthroplasties.6,7
Because of the high local
concentration of intra-articular
antibiotics, compatibility of all
intra-articullarly and systemically administered antibiotics
must be evaluated before and
during treatment. Local vancomycin concentrations 502095 ␮g/mL have been reported,3 and in vitro testing has
demonstrated that vancomycin
will precipitate rapidly when
mixed with small amounts of
cephalosporins, clindamycin,
and penicillins. If this occurs in
vivo, wound drainage or clinical signs of local inflammation
can occur.
CONCLUSION
This is an early report of the
treatment of septic prosthetic
joints using a single-stage noncemented revision with intraarticular antibiotic infusion.
The 94% success rate is comparable to success rates reported in the literature for delayedexchange arthroplasty using
antibiotic loaded cement. It has
the potential to avoid the morbidity associated with multiple
surgeries and prolonged immobility.
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