- See:
Total Hip Replacement Menu: and
Methods to Prevent Infection
- Diagnosis:
- the diagnosis of septic loosening is initially based on history, x-ray findings, and elevated
sed rate;
- clincially patients may note increasing pain at both rest and with activity;
- despite the variety of tests available, it may be difficult to distinguish aseptic loosening from an infected THR;
-
classification:
- type I: early postoperative
- type II: late chronic
- standard of care: two-stage revision arthroplasty:
- removal of the prosthesis and cement and debridement;
- placement of an antibiotic-impregnated cement spacer and IV antibiotics;
- delayed second-stage revision arthroplasty;
- type III: acute hematogenous
- type IV: positive intraoperative cultures with clinically unapparent infection
-
Prosthetic joint infection diagnosed postoperatively by intraoperative culture.
-
misc. causes:
- dental procedures:
- common infecting organisms include Streptococcus viridans and Peptostreptococcus;
- in the study by DM Laporte et al, JBJS Vol 81 Jan 1999, the authors felt that the incidence of infections associated with dental
procedures in underestimated and may account for as many as 6% of all total joint infections;
- references:
- Late infection after total hip replacement, caused by an oral organism after dental manipulation.
Sullivan PM, Johnston RC, Kelky SS: J Bone Joint Surg 1990;72A:121-123.
-
Treatment of the septic hip with total hip arthroplasty.
-
Metachronous Infections in Patients Who Have Had More Than One Total Joint Arthroplasty.
-
Delayed postbacteremic prosthetic joint infection.
-
Late infections of total joint prostheses. A review and recommendations for prevention.
- Radiographs:
- classic findings include, irregular or scalloped border on the endosteal surface of the cortex, marked periosteal reaction, or late dislocation;
- dx of THR infection that is difficult to appreciate grossly is often delayed, especially in a patient w/o fever or severe pain;
- x-ray signs of loosening of prosthesis are seen in 2/3 of late infections, but in less than 50 % of early infections;
-
arthrography: (see:
hip aspiration)
- may be helpful for determining loosening of cemented acetabular components by showing penetration of dye between cement and bone;
- note that a fibrous membrane between cement and bone will impede penetration of cement (false negative);
-
bone scans in THR:
- references:
-
Evaluation of musculoskeletal sepsis with indium-111 white blood cell imaging.
- Asymptomatic total hip prosthesis: Natural history determined using Tc-99MDP bone scans. Utz JA, Lull RJ, Galvin EG: Radiology 1986;161:509-512.
- Laboratory Evaluation and Aspiration:
-
bacteriology:
- currently
staph epidermidis has emerged as the most common infectious organism followed closely by
staph aureus;
- the above two bacterial species along with pseudomonas are slime producers (glycocalyx) which makes them
particularly resistant to treatment w/ antibiotics;
- gram negative organisms which do not produce a glycocalyx may not be as virulent as previously thought;
- consider need for Ziehl Nielsen stains, mycobacterial cultures, and fungal cultures;
- references:
-
Methicillin-resistant Staphylococcus epidermidis in infection of hip arthroplasties.
- Deep infection of cemented total hip arthroplasties caused by coagulase negative staphylococci. PG Hope et al. JBJS. Vol 71-B.(5) p 851-855. 1989.
- Management:
-
antibioics: (see local antibiotic infusion)
-
ATB treatment based on organism:
-
gram negative bacilli:
-
gram negative cocci:
-
gram positive bacilli:
-
gram positive cocci
- references:
-
Suppressive antibiotic therapy in chronic prosthetic joint infections.
- Prolonged suppression of infection in total hip arthroplasty. JA Goulet et al. J. Arthroplasty. Vol 3. p 109-116. 1988.
-
Long-term suppression of infection in total joint arthroplasty.
-
debridement and retension of components: (Tsukayama, JBJS 1996)
- success rate can be as high a 71% in well selected patients;
- selection criteria include acute infection (symptoms less than 1 month) in THR that have been inserted either acutely or years in the past;
- debridement includes exchange of the polyethylene liner, which gives better access of the components;
- following the debridement, antibiotics must be continued for atleast 6 weeks;
- references:
- Infection after Total Hip Arthroplasty. A Study of the Treatment of 106 Infections. JBJS Vol 78-A, No. 4. Apr 1996. p512.
-
Suppressive antibiotic therapy in chronic prosthetic joint infections.
-
one stage replantation: (see
revision THR);
- it is essential that all foriegn material be removed for one stage treatment to be successful;
- in addition, for one stage replantation to be successful, it is often useful to implant the femoral component w/ antibiotic laden cement;
- disadvantages w/ cemented revisions include early loosening and often cemented revisions cannot be performed due to proximal bone loss;
- references:
-
One-stage revision of total hip arthroplasty for deep infection. Long-term followup.
-
two stage replantation: (see
revision THR);
- the main advantage of delayed replantation is that it allows a press fit revision component to be inserted (with out the need for antibiotic laden cement);
- references:
-
Two-stage reconstruction of a total hip arthroplasty because of infection.
-
Surgical treatment of the infected hip implant. Two-stage reimplantation with a one-month interval.
-
Treatment of the infected total hip arthroplasty with a two-stage reimplantation protocol.
-
The Use of Bone Allografts in Two-Stage Reconstruction after Failure of Hip Replacements Due to Infection.
-
Persistent infection associated with residual cement after resection arthroplasty of the hip.
-
Two-stage revision hip arthroplasty for infection with a custom-made, antibiotic-loaded, cement prosthesis as an interim spacer.
-
Individual bone cement spacers (IBCS) for septic hip revision-preliminary report.
-
timing:
- high recurrence rate occurs w/ virulent organisms that were not treated with intravenous antibiotics more than 28 days;
- there is no difference in success with low virulent organisms w/ regimen of IV antibiotics for more than 28 days;
-
gram-negative infections and
enterococcus;
- have dreadfully poor prognosis for successful reimplantation;
- when causal organism is gram-negative bacillus or enteroccus, reconstruction should be delayed for 12 months;
- successful reconstruction can be done earlier (three months) with the less virulent microorganisms;
- however, the finding of acute inflammatory cells at surgery is worrisome and probably indicates the presence of an active infection;
-
antibiotic spacer: (see
addition of antibiotics to cement)
- provides high level of the drugs locally w/o generating excessive levels systemically;
- antibiotic-laden cement is usually used in conjunction w/ conventional doses of antibiotic agents given systemically;
- once the cement has hardened, the component can be placed into the medullary canal and into the acetabulum;
- the spacer will deliver high concentrations of ATB and will help prevent shortening;
- consider coating a small inexpensive femoral component w/ antibioitic laden cement;
- postoperatively, these patients need to be touch down wt bearing only;
- outcomes:
- in the study by
Koo et al., 21 of 22 patients were sucessfully treated w/ staged revision using 2 g each of vanc, gent, and cefotaxime per 40 g of cement;
- references:
A temporary antibiotic loaded joint replacement system for management of complex infections involving the hip. Orthop. Clin. North Am.751-759. 1993.
Treatment of infection assoc w/ bone loss in proximal part of femur in 2 stages w/ use of an antibiotic loaded interval prosthesis. JBJS. Vol 80-A. Jan 1998.
A comparison of Gent-impregnated beads implantation to conventional IV antibiotic therapy in infected THR and TKR.
Palacos gentamicin for the treatment of deep periprosthetic hip infections.
Current Concepts Review. Antibiotic-Impregnated Cement in Total Joint Arthroplasty.
Antibiotic-leaching from polymethylmethacrylate beads.
Role of gentamicin-impregnated cement in total joint arthroplasty.
Prophylaxis with systemic antibiotics versus gentamicin bone cement in total hip arthroplasty. A five-year survey of 1688 hips.
Two-Stage Revision HA for Infection: Comparison Between the Interim Use of Antibiotic-Loaded Cement Beads and a Spacer Prosthesis.
Impregnation of vancomycin, gentamicin, and cefotaxime in a cement spacer for two-stage cementless reconstruction in infected THA.
Acute renal failure associated with vancomycin- and tobramycin-laden cement in total hip arthroplasty.
The use of two-stage exchange arthroplasty with depot antibiotics in the absence of long-term antibiotic therapy in infected THR
-
resection arthroplasty:
- references:
-
Treatment of Chronic Infected Hip Arthroplasty Wounds by Radical Debridement and Obliteration With Pedicled and Free Muscle Flaps.
-
Management of the Recalcitrant Total-Hip Arthroplasty Wound.
Treatment of Infection at the Site of Total Hip Replacement. EL Masterson et al. JBJS. Vol 79-A. No 11. Nov 1997. p 1740.
Treatment of the septic hip with total hip arthroplasty.
Total Arthroplasty and the Veterans Administration--Symposium: Total Hip Arthroplasty: Infections at the Site of a Hip Implant Successful and Unsuccessful Management.
Why use drains
Comparative study of skin closure in hip surgery.
Deep-wound infection after total hip replacement under contemporary aseptic conditions.
Infections at the site of a hip implant. Successful and unsuccessful management.
The efficacy of suction drains after routine total joint arthroplasty.
Perioperative factors associated with septic arthritis after arthroplasty. Prospective multicenter study of 362 knee and 2,651 hip operations.
Pathobiology of infection in prosthetic devices.
The Use of Porous Prostheses in Delayed Reconstruction of Total Hip Replacements That Have Failed Because of Infection.
Infection after Total Hip Arthroplasty. A Study of the Treatment of 106 Infections.
D.T. Tsukayama MD and R.B. Gustilo MD JBJS Vol 78-A, No. 4. Apr 1996. p512.
Acute and subacute deep infection after uncemented total hip replacement using antibacterial prophylaxis.
Charnley low friction arthroplasty in tuberculosis of the hip. An eight to 13-year follow-up.
Emergency hemipelvectomy as a result of uncontrolled infection after total hip arthroplasty
Antibiotic Susceptibility of Bacteria Infecting Total Joint Arthroplasty Sites.
