Periprosthetic joint infection
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Transcript of Periprosthetic joint infection
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Periprosthetic joint infectionDr. Jatinder S. Luthra
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Prevalance - PJI
Increasing Total joint arthroplasty PJI – 2-2.4% ( Nation wide ) 1.6 billion dollar – 2020
0.6% - 0.9 % - PJI ( Single institute )
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Clinical suspicion - PJI
Sinus tract Persistent wound drainage Acute onset – painful prosthesis H/o wound healing complications
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Risk Factors - PJI
Patient Factors Age Obesity Diabetes Steroid Malignancy Rheumatoid arthritis
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Risk Factors - PJI
Local Factors
Previous arthroplasty Arthroplasty for fractures Type of replaced joint Perioperative wound complications
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Risk Factors - PJI
Operative Factors Operative time Dirty wounds No antibiotic cement No antibiotic prophylaxis
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Pathogens - PJI
Gram Positive Bacteria Staphylococcus Streptococcus Enterococcus Diptheroids
Gram Negative Bacteria Pseudomonas
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Pathogens - PJI
Anaerobes Mycobacteria Fungi Polymicrobial Culture negative
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Antibiotic sensitivity - PJI
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Classification - PJI
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Acute post operative infection - PJI
Acute onset painful swelling Erythema and warmth Tenderness and discharge Sinus
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Late Chronic Infection - PJI
Subtle signs and symptoms
Chronic pain and loosening
Progressive deterioration of function
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Haematogenous seeding - PJI
Sudden onset pain
Trigger event – skin infection, dental extraction, respiratory / urinary infection
Immunosuppressed
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Pathogenesis - PJI
Bacterial adhesion to biomaterial Cannot be eliminated without removing
biomaterial Resistance to antibiotics level 1000 times
higher Formation of biofilm
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Biofilm - PJI
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Serological investigation - PJI
White blood cell count
Usually normal in pt with implant infection
When elevated – infection is usually obvious
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Serological investigation - PJI
ESR >30 – 82% sensitivity 85% specificity
CRP >10 – 96% sensitivity 92% specificity
Both elevated – 83 % probabilityBoth normal – Eliminate infection
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Serological investigation – PJIInvestigational
Interleukin -6 Produced by monocyte and macrophagesReturns to normal 48 hrs post op
Procalcitonin
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Serological investigation – PJIInvestigational
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Plain X- rays - PJI
Non sensitive & specific
Polyethylene wearEndosteal scallopingRadiolucent lines Periosteal reaction Lacy periostitisOsteopenia
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Ultrasound - PJI
Thickened capsule
Abscess
Aspiration of abscess
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Radionuclide imaging - PJIBone scintigraphy
Technitium 99
Uptake - Rate of blood flow and Bone Formation
Diffuse uptake -Infection – osteolysis
Aeptic loosening – inflammation
Accuracy 50 – 70 %High negative predictive value
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Radionuclide imaging – PJISequential Gallium scanning
Gallium 65 citrate
Bound to Transferrin
Complementary to scintigraphy
Uptake – inflammation
Accuracy – 70%- 80%
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Radionuclide imaging – PJILabelled leucocyte scintigraphy
Indium 111 Labelling inflammatory
cells – neutrophils Increased periprosthetic
activity – infection Accumulates in infection Complimentary bone
marrow scan – Tc99m Accuracy 90%
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Radionuclide imaging – PJIInvestigational agents
Technitium labelled Ciprofloxacin
Technitium labelled murine monoclonal antibody
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Radionuclide imaging – PJIPET scan
Fluoro deoxy glucose
Increased metabolic activity – increased uptake
91% Sensitivity , 72 % Specificity
False positive – particle induced inflammation – aseptic loosening
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MRI CT scan
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Joint aspiration – PJIGram Stain & Culture
Strong suspicion infectionSensitivity – 57% - 93 %Specificity – 88% - 100 %
2 weeks after antibiotics Enriched culture – 14 days False positive - Contamination
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Joint aspiration – PJILeucocyte count
Total count Differential count
> 500 /micro Liter Neutrophil – 64%
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Joint aspiration – PJIInflammatory markers
Synovial fluid – CRP
Synovial leukocyte esterase
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Intraoperative Gram stain – PJI
Sensitivity – 27 % - No Role
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Intraoperative Tissue culture– PJI
Sensitivity – 94% Specificity 97% Not always positive 5-6 samples
Ultrasonification of prosthesis – disrupt glycocalyx
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Intraoperative Frozen section– PJI
Preop – false elevation of ESR and CRP
Intra- op – joint looks non healthy
Sensitivity – 85% Specificity – 90%
> 5 PMN / high power field - Infection
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Molecular Techniques - PJI
Polymerase chain reaction ( PCR ) – aspirateTarget gene – 16S RNAHigh False positive
Microarray and proteomic technologyTarget Specific bacterial genesProfile of genes ( microarray ) and proteins ( Proteomic )
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Musculoskeletal infection society (MSIS) - PJI Criteria
Sinus Tract Isolated pathogen – 2 separate tissue culture /Specimen
Four of following criteria 1. ESR2. CRP3. Synovial white cell count4. Synovial PMN %5. > 5 neutrophil/ High power field- 5 field
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Treatment options - PJI
Surgical- Debridement and retention prosthesis- Resection arthroplasty with reimplantation- Definitive resection arthroplasty with/without
arthrodesis- Amputation
Non Surgical - Suppressive antimicrobial therapy
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Surgical Treatment – PJI Debridement and retention of prosthesis
Prodedure Debridement Exchange of modular componentsProlonged antibiotic therapy
IndicationDuration of symptoms < 3 weeksJoint age < 30 days
Success Rate – 85 %
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Medical Treatment – PJI Debridement and retention of prosthesis
Staph PJI
2-6 wks – I.V. PSA + Rifampicin ( 300 mg BID )
Rifampicin + Companion drug ( Cipro /Levo ) – THA – 3 months TKA – 6 months
Non Staph PJI
4 – 6 wks of I.V. / Oral -PSA
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Surgical Treatment – PJITwo-stage replacement arthroplasty
Prodedure
Removal of prosthesis
Surgical debridement of joint
Administration of antimicrobial with delayed implantation
Antibiotics – 4 – 6 weeks
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Surgical Treatment – PJITwo-stage replacement arthroplasty
PrerequisitesAdequate bone stock
Medical fitness for multiple surgeries
Normal serology / negative aspiration
Stop antibiotics for 2 weeks
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Surgical Treatment – PJITwo-stage replacement arthroplasty
Time intervalEarly repimplantation – less success2 weeks – 35%6 weeks – 70 – 90 % Intraop. – Frozen sectionCulture and histopath evaluation
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Surgical Treatment – PJITwo-stage replacement arthroplasty
Antibiotics spacerDynamic spacer Joint mobilityEase of revision
Static spacerHigher dose of antibioticFavourable environment for wound healing
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Medical Treatment – PJITwo-stage replacement arthroplasty
4-6 weeks of i.v./ Bioavailable oral PSAMore virulent Staph aureusCefazolin / NaficillinMRSA – Vancomycin Rifampicin – no role
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Surgical Treatment – PJIOne-stage replacement arthroplasty
Procedure
Prosthesis , Infected bone , soft tissue excised – RADICAL debridement
New prosthesis implanted same surgery
Iv antibiotics
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Surgical Treatment – PJIOne-stage replacement arthroplasty
AdvantagesSingle procedureLower costEarlier mobilityPatient convenience
Disadvantage ReinfectionResidual microorganism
Organism identified – good sensitivity
Overall success rate – 75% - 100%
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Medical Treatment – PJIOne-stage replacement arthroplasty
Staph. PJI
2- 6 weeks PSA + RifampicinRifampicin + Companion Drug – 3 months
Non Staph PJI
4- 6 weeks I.V/ Oral PSA
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Surgical Treatment – PJIResection Arthroplasty
ProcedureDefinitive prosthesis removalNo subsequent implantation
DisadvantageShortened limbPoor functionPatient dissatisfaction
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Surgical Treatment – PJIResection Arthroplasty
IndicationsPoor quality bone and soft tissueRecurrent infectionMDR organismFailure of previous exchange procedure
Outcome Hip – 60% - 100%Knee 50%- 89%
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Surgical Treatment – PJIArthrodesis
Bony ankylosis of joint
Subsequent reimplantation not feasiblePoor bone stockRecurrent infectionLoss extensor mech.
Overall success – 70% - 90%
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Surgical Treatment – PJIAmputation
A/K amputation
All other option exhausted
Severe pain, soft tissue compromise, extensive bone loss , vascular compromise
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Non - Surgical Treatment – PJI
Suppressive antimicrobial therapy
Frail Elderly Sick patient
Symptomatic relief Prevent systemic spread rather than
eradication of infection
Success rate – 10% - 25%
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Summary
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Thank You