Total knee revision in
septic failure
Epidemiology, timing and
classification
Prof. Paolo Cherubino
Dipartimento di scienze ortopediche e traumatologiche
Universitas Studiorum Insubriae VARESE
Epidemiology
The most commons causes of knee
arthroplasty revisions:
• Infections (25.2%)
• Mechanical failure (16.1%)
The Epidemiology of Revision Total Knee Arthroplasty in the United States
Kevin Bozic, MD. 2007
Epidemiology
Risk factors
The systemic risk factors:
•rheumatoid arthritis
•diabetes
•IRC
•obesity
•advanced age
•debilitation
•oral steroids
•cancer/chemotherapic treatment
•immunocompromised patients
Simmons TD, Stern SH. Diagnosis and management of the infected total knee
arthroplasty. Am J Knee Surg. 1996
Epidemiology
Risk factors
The local risk factors are :
•Previews knee surgery
•Skin complications after the implant
•psoriatic skin ulcers
Simmons TD, Stern SH. Diagnosis and management of the infected total knee
arthroplasty. Am J Knee Surg. 1996
Infection is actually,
rare but serious problem
in joints arthroplastic surgery
Epidemiology
INFECTION RATE AFTER
TOTAL KNEE ARTHROPLASTY
0,5 - 5%
• Grogan J. Bone Joint Surg. Am.1986; 68:226-34
• Wilson J.Bone Joint. Surg. Am. 1990; 72:878-83
• Bengston Acta Orthop Scand. 1991; 62(4):301-11
• Rand JA. Orthop Clin North Am. 1994.
Epidemiology
“The prevalence of infection after
primary total knee arthroplasty has been
reported to
range from 0.5 to 5 percent.”
J Bone Joint Surg Am. 1999 Oct;81(10):1434-45.
Epidemiology
“Current infection rates are
in the 1% to 2%.”
The Journal of Arthroplasty Vol. 19 No. 4 Suppl. 1 2004
Epidemiology
A. W. Blom, J. Brown, A. H. Taylor, G.
Pattison, S. Whitehouse, G. C. Bannister
2004
“Our known infection rates of 1%
after primary and 5.8% after revision
TKA are comparable
with published reports.”
Epidemiology
2007
“Deep infection rates in total knee joint
replacement vary in the published
literature between 0.3% and 2.9%.”
HSSJ (2007) 3: 159–163
Epidemiology
“Incidence rates for
primary TKA between
1995 and 2004, from
6.3 to 11.0 at a rate of
5.1% per year (p <
0.001).”
Etiology
Pre and intra-operative pathogen
ISOLATION
Staph E.
Gram -
Staph. A.
Streptococcus
E. Coli
Legionella P.
Etiology
The Journal of Arthroplasty Vol. 19 No. 4 Suppl. 1 2004
Etiology
A. W. Blom, J. Brown, A. H. Taylor, G.
Pattison, S. Whitehouse, G. C. Bannister
2004
Etiology
J Bone Joint Surg Am. 1999 Oct;81(10):1434-45.
Etiology
Chang Gung Med J. 2008
Nov-Dec;31(6):583-91.
Clinical-temporal
classification
• Immediate: before 4 weeks
• Early: between 4 wks to 2 years
• Delayed: over 2 years
• Occasional: positive culture in replacement
Segawa et al. JBJS, 1999
Classification
Coventry’s state
Step Zero = Operating contamination
(positivity of at least 2 of 3 buffers intra-op)
Step I = Acute infection post-operative
(within 3 months after)
Stage II = delayed deep infection
(3 to 24 months after)
Stage III = late hematogenous infection
(a distance of years)
Coventry MB. Orthop Clin North Am. 1975 Oct;6(4):991-1003.
Classification
J Bone Joint Surg Am. 85-A · SUPPLEMENT 1 · 2003
Therapeutic option
Choice of treatment is based on:
anatomical-clinical
microbiological
Accurate diagnostic grading
Replacement-Timing
•
•
•
CBC, VES and PCR
instrumental and clinical
Preoperative aspiration
culture
Clinical orthopaedic and related research n345, 1997
Therapeutic option
• Arthroscopy
• Toilette
• Replacement
• Arthrodesis
• Resection - arthroplastic
• Amputation
Purpose of surgery
 infection eradication
 save joint function
IMMEDIATE INFECTION
Toilette
+
Suppressive antibiotic therapy (at least 3 wks)
EARLY INFECTION
open surgery or arthroscopic
TOILETTE
+
Suppressive antibiotic therapy (at least 3 wks)
LATE INFECTION
Remove implant and
Surgical debridement
age, general conditions,
indication
ARTHRODESIS REIMPLANT
One stage Two stage
INFEZIONE TARDIVA
Remove implant and
Surgical debridement
age, general conditions,
indication
ARTHRODESIS REIMPLANT
One stage Two stage
Therapeutic option
The two-stage exchange procedure has
evolved as an effective treatment option.
Clin Orthop Relat Res. 2007 Nov;464:164-78
Therapeutic option
The best results of treatment of an
infected TKR have been reported by
Windsor et al in which no spacer was used
between stages
Windsor RE, Insall JN, Urs WK, Miller DV, Brause BD. Two-stage reimplantation
for the salvage of total knee arthroplasty complicated by infection: further
follow-up and refinement of indications. J Bone Joint Surg [Am] 1990.
Therapeutic option
Treatment of TKA infection with a twostage exchange had a significantly better
outcome than debridement with retention of
the prosthesis. Good results were obtained
with two-stage revision of infected TKA
International Orthopaedics (SICOT) 2008
Therapeutic option
Two-stage reimplantation of an infected total knee
arthroplasty using a static antibiotic-cement spacer
achieved an infection control rate of 86% and
improvement in the clinical results.
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