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Diagnosis of infected tka (power point file d r 7)

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Diagnosis of Infected total knee arthroplasty Warakorn Jingjit, MD Orthopaedic Department, Faculty of Medicine Chiang Mai University
One of the most devastating & challenging complication Immense financial & psychological burden Cost of treatment 15,000 - 60,000 $ / TKA Hebert CK, CORR, 1996 Sculco TP, Orthopedics, 1995
Incidence 0.39% in primary TKA 0.97% in revision TKA
Kurtz S, JBJS, 2008 Projection of the TKA & THA number
Kurtz S, JBJS, 2007 Projection of the TKA & THA infection
Risk factors 1. Patient / host 2. Surgical environment 3. Surgical technique 4. Postoperative management
Risk factors Patient / host Immunocompromise RA (4.4%) Steroid therapy DM (7%) Poor nutrition Albumin <3.5g/dl: 7-fold Lymphocyte <1,500 cells/mm3: 5-fold HIV Organ transplant Hypokalemia Tobacco use Obesity Debilitation Advanced age Alcoholism Renal failure Cirrhosis Prolonged pre-op hospitalization Hypothyroidism Previous surgery Psoriasis Previous infection Concurrent infection
Risk factors Surgical environment Personnel Clean air Laminar air flow, UV light Surgical attire Operative site preparation Ritter MA, CORR,1988 Ritter MA, Orthop Clin North Am,1989 Berg M, JBJS (Br), 1991 Ritter MA, CORR, 1999 Peersman G, CORR, 2001
Risk factors Surgical technique Operative time > 2.5 hrs Peersman, CORR, 2001 Surgical time
Risk factors Surgical technique Single most effective method of infection 1st gen. cephalosporin Allergy vancomycin / clindamycin 30-60 min before incision (peak serum bone conc. within 20 min) Repeat every 4 hrs & bleed >1,000 ml Discontinue 24 hrs after surgery Prophylactic antibiotic
Risk factors Surgical technique High risk 1o TKA, revision TKA Prophylactic antibiotic bone cement
Risk factors Hinged prosthesis Infection rate at 10 yrs ~ 15% Bengtson S, Acta Orthop Scand, 1991 Hanssen AD, CORR, 1995 Schoifet SD, JBJS, 1990 Implant Surgical technique
Post operative management Bacteremia: oral > GI > GU procedure Avoid in first 3-6 mo (high incidence) AAOS & ADA 1997 First 2 yrs, specific risk factor for all pts ATB prophylaxis After 2 yrs consider in high risk pts Recommended regimens (before procedure 1 hr) Cephalexin, cephradine, amoxicillin 2 g. oral Cephalosporin 1 g / ampicillin 2 gm IV / IM Clindamycin 600 mg oral (allergy to penicillin) Clindamycin 600 mg IV / IM (allergy to penicillin) Risk factors Advisory statement. J Am Dent Assoc, 1997
Potential risks of hematojenous total joint infection All patients for the first 2 years after joint replacement lmmunocompromised / immunosuppressed patients - Inflammatory arthropathies - Drug-induced immunosuppression - Rheumatoid arthritis - Radiation-induced immunosuppression - Systemic lupus erythematosus Patients with comorbidity conditions - Previous prosthetic joint infections - HIV infection - Poor nutrition - Insulin-dependent diabetes - Hemophilia - Malignancy Advisory statement. J Am Dent Assoc, 1997
Predominant organisms Microbiology Goldman RT, CORR, 1996
Microbiology Fungal infection = rare Candida = predominant Mycobacterium tuberculosis = rare
Microbiology Mucopolysaccharide biofilm Protect from antibodies, phagocytes, ATB., virulence
Microbiology Methicillin-resistant organism vancomycin Ries MD, J Arthroplasty, 2001 Rifampicin = good biofilm & tissue penetration improve success when use other synergistic agent Zimmerli W, JAMA, 1998
Differential diagnosis Periprosthetic fx PF problem Aseptic loosening Soft tissue disruption A painful knee is infected until proved otherwise Insall, 1981 Instability RSD HO Arthrofibrosis
Clinical history Physical examination Radiography Hematologic studies Radionuclide studies Aspiration Diagnosis Fundamental of diagnosis * * * High index of suspicion * * * Pathology
Diagnosis History Pain = most common presenting symptom Typical = rest / night / persistent / progressive pain Progressive stiffness Hx of prolong postop drainage, ATB treatment Physical examination Swelling, effusion, warmth, erythema, tenderness Painful range of motion Persistent wound drainage strongly suggestion early aggressive Rx
Diagnosis Swab wound not recommend Empirical ABO for wound drainage mask symptoms, affect subsequent C/S, predispose for drug resistant Diagnosis in early postop period ESR, CRP limit value Typically by arthrocentesis
Aspiration Leucocyte count & differentiation Gram strain (sens 97%, spec 26%) ( Culture for aerobic & anarobic bacteria >1,700/ml3, PMN > 65% (sens 94-97%, spec 88-98%) Trampuz A, Am J Med, 2004 Ongoing ATB stop for several wks before aspiration
Mark Coventry Award Paper Synovial WBC count is an excellent test for diagnosing infection within 6 wks after 1oTKA with an optimal cut-off 27,800 cells/mm3 and 89% PMN Sens 84%, spec 99%, PPV 94%, NPV 98% Craig J. Della Valle Presented at the Knee Society Specialty Day Meeting March 13, 2010, New Orleans Diagnosis of early post-operative infection following TKA: The utility of synovial fluid cell count and differential
Hematologic studies ESR Positive > 30 mm/hr (sens 80%, spec 62.5% ) False positive: infection elsewhere, inflammation, CNT dis, neoplasm, recent operation (< 3 mo) False negative: prior antibiotics CRP Positive > 10 mg/L (sens & spec 85%) Return to normal within 3 wks after operation ESR + CRP: PPV 83%, NPV 100% For chronic infection Barrack RL, CORR, 1997 Swanson KC, The adult knee, 2003
Guideline for ESR & CRP 1. Normal ESR & CRP reliable for the absence of infection 2. CRP more useful than ESR for monitoring 3. Use with other tests for the diagnosis of infection Spangehl MJ, JBJS, 1999
PCR Molecular genetic diagnosis Identify 16S RNA gene Expensive Time-dependent False positive Remain experimental modality !!! Mariani BD, CORR, 1996
X-ray Sequential plain radiographs Progressive radiolucencies Focal osteopenia / osteolysis of subchondral bone Periosteal new bone formation Morrey BF, CORR, 1989 Bone destruction infection present > 10-21 days Lytic lesion destroy 30-50% of bony matrix Early infection no abnormal finding !!!
Radioisotope scan Occasionally helpful in chronic infection Tc-99m MDP In-111 leukocyte scan Tc-99m sulfur colloid
Radioisotope scan Isotope Sensitivity Specificity Accuracy Tc 99m 95% 20% 54% Indium 111 77% 75% 90% Tc 99m + In111 100% 97% 97% Palestro CJ, Radiology, 1991 Occasionally helpful in chronic infection
Intraoperative tissue frozen section Widely use Result depend on Adequate & representative tissue obtaining Accurate interpretation by skilled pathologist > 5 PMN/HPF at least 5 fields Sens 100%, spec 96% >10 PMN/HPF at least 5 fields Sens 25%, spec 98% Feldman DS, JBJS, 1995 Della Valle CJ, JBJS 1999
Reliable predictor for infection >10 PMN/HPF: sens 84%, spec 99%, PPV 89%, NPV 98% 5-10 PMN/HPF: need other test to differentiate <5 PMN/HPF: infection was highly unlikely Lonner Jh et al, JBJS,1996 Intraoperative tissue frozen section
Intraoperative gram strain Unreliable Low sensitivity = 0-14.7% Atkins BL, J Clin Microbiol, 1998 Della Valle CJ, J Arthroplasty, 1999
Intraoperative culture Gold standard Sample: fluid & tissue Joint capsule Synovial lining IM tissue Granulation tissue Bone fragments False +ve: contamination False -ve: prior ATB, transport system, lab - Duff GP, CORR, 1996 - Bauer TW, JBJS, 2006
Definite diagnosis At least one of the following 1. Same organism from c/s 2 specimens by aspiration / deep tissue from surgery 2. Intraarticular tissue histopathology = acute inflammation 3. Gross purulence at the time of surgery 4. Actively discharging sinus tract Hansen, CORR, 1994
At least one of the following 1. Open wound / sinus tract communicate joint 2. Systemic signs / symptoms pain & purulent fluid 3. At least 3 of 5 ESR > 30 mm/hr CRP >10 mg/L Frozen section > 5 PMN/HPF Preoperative aspiration c/s 1 +ve Intraoperative c/s 1 +ve Spangehl MJ, JBJS, 1999 Definite diagnosis
Diagnosis of infected tka (power point file d r 7)
Type1 Type2 Type3 Type4 Timing Positive intraop C/S Early postoperative infection Acute hematogenous infection Late (chronic) infection Definition Same organism 2 from C/S Occurring within first month after surgery Hematogenous seeding of previously well-functioning prosthesis Chronic indolent clinical course; present >1 month Segawa &Tsukayama classification * * * Guide to treatment * * * Classify on the basis of clinical presentation
Basic treatment options 1. Antibiotic suppression 2. Debridement prosthesis retention 3. Resection arthroplasty 4. Arthrodesis 5. Amputation 6. Reimplantation - one / two stage Treatment
Diagnosis of infected tka (power point file d r 7)
Diagnosis of infected tka (power point file d r 7)

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Diagnosis of infected tka (power point file d r 7)

  • 1. Diagnosis of Infected total knee arthroplasty Warakorn Jingjit, MD Orthopaedic Department, Faculty of Medicine Chiang Mai University
  • 2. One of the most devastating & challenging complication Immense financial & psychological burden Cost of treatment 15,000 - 60,000 $ / TKA Hebert CK, CORR, 1996 Sculco TP, Orthopedics, 1995
  • 3. Incidence 0.39% in primary TKA 0.97% in revision TKA
  • 4. Kurtz S, JBJS, 2008 Projection of the TKA & THA number
  • 5. Kurtz S, JBJS, 2007 Projection of the TKA & THA infection
  • 6. Risk factors 1. Patient / host 2. Surgical environment 3. Surgical technique 4. Postoperative management
  • 7. Risk factors Patient / host Immunocompromise RA (4.4%) Steroid therapy DM (7%) Poor nutrition Albumin <3.5g/dl: 7-fold Lymphocyte <1,500 cells/mm3: 5-fold HIV Organ transplant Hypokalemia Tobacco use Obesity Debilitation Advanced age Alcoholism Renal failure Cirrhosis Prolonged pre-op hospitalization Hypothyroidism Previous surgery Psoriasis Previous infection Concurrent infection
  • 8. Risk factors Surgical environment Personnel Clean air Laminar air flow, UV light Surgical attire Operative site preparation Ritter MA, CORR,1988 Ritter MA, Orthop Clin North Am,1989 Berg M, JBJS (Br), 1991 Ritter MA, CORR, 1999 Peersman G, CORR, 2001
  • 9. Risk factors Surgical technique Operative time > 2.5 hrs Peersman, CORR, 2001 Surgical time
  • 10. Risk factors Surgical technique Single most effective method of infection 1st gen. cephalosporin Allergy vancomycin / clindamycin 30-60 min before incision (peak serum bone conc. within 20 min) Repeat every 4 hrs & bleed >1,000 ml Discontinue 24 hrs after surgery Prophylactic antibiotic
  • 11. Risk factors Surgical technique High risk 1o TKA, revision TKA Prophylactic antibiotic bone cement
  • 12. Risk factors Hinged prosthesis Infection rate at 10 yrs ~ 15% Bengtson S, Acta Orthop Scand, 1991 Hanssen AD, CORR, 1995 Schoifet SD, JBJS, 1990 Implant Surgical technique
  • 13. Post operative management Bacteremia: oral > GI > GU procedure Avoid in first 3-6 mo (high incidence) AAOS & ADA 1997 First 2 yrs, specific risk factor for all pts ATB prophylaxis After 2 yrs consider in high risk pts Recommended regimens (before procedure 1 hr) Cephalexin, cephradine, amoxicillin 2 g. oral Cephalosporin 1 g / ampicillin 2 gm IV / IM Clindamycin 600 mg oral (allergy to penicillin) Clindamycin 600 mg IV / IM (allergy to penicillin) Risk factors Advisory statement. J Am Dent Assoc, 1997
  • 14. Potential risks of hematojenous total joint infection All patients for the first 2 years after joint replacement lmmunocompromised / immunosuppressed patients - Inflammatory arthropathies - Drug-induced immunosuppression - Rheumatoid arthritis - Radiation-induced immunosuppression - Systemic lupus erythematosus Patients with comorbidity conditions - Previous prosthetic joint infections - HIV infection - Poor nutrition - Insulin-dependent diabetes - Hemophilia - Malignancy Advisory statement. J Am Dent Assoc, 1997
  • 16. Microbiology Fungal infection = rare Candida = predominant Mycobacterium tuberculosis = rare
  • 17. Microbiology Mucopolysaccharide biofilm Protect from antibodies, phagocytes, ATB., virulence
  • 18. Microbiology Methicillin-resistant organism vancomycin Ries MD, J Arthroplasty, 2001 Rifampicin = good biofilm & tissue penetration improve success when use other synergistic agent Zimmerli W, JAMA, 1998
  • 19. Differential diagnosis Periprosthetic fx PF problem Aseptic loosening Soft tissue disruption A painful knee is infected until proved otherwise Insall, 1981 Instability RSD HO Arthrofibrosis
  • 20. Clinical history Physical examination Radiography Hematologic studies Radionuclide studies Aspiration Diagnosis Fundamental of diagnosis * * * High index of suspicion * * * Pathology
  • 21. Diagnosis History Pain = most common presenting symptom Typical = rest / night / persistent / progressive pain Progressive stiffness Hx of prolong postop drainage, ATB treatment Physical examination Swelling, effusion, warmth, erythema, tenderness Painful range of motion Persistent wound drainage strongly suggestion early aggressive Rx
  • 22. Diagnosis Swab wound not recommend Empirical ABO for wound drainage mask symptoms, affect subsequent C/S, predispose for drug resistant Diagnosis in early postop period ESR, CRP limit value Typically by arthrocentesis
  • 23. Aspiration Leucocyte count & differentiation Gram strain (sens 97%, spec 26%) ( Culture for aerobic & anarobic bacteria >1,700/ml3, PMN > 65% (sens 94-97%, spec 88-98%) Trampuz A, Am J Med, 2004 Ongoing ATB stop for several wks before aspiration
  • 24. Mark Coventry Award Paper Synovial WBC count is an excellent test for diagnosing infection within 6 wks after 1oTKA with an optimal cut-off 27,800 cells/mm3 and 89% PMN Sens 84%, spec 99%, PPV 94%, NPV 98% Craig J. Della Valle Presented at the Knee Society Specialty Day Meeting March 13, 2010, New Orleans Diagnosis of early post-operative infection following TKA: The utility of synovial fluid cell count and differential
  • 25. Hematologic studies ESR Positive > 30 mm/hr (sens 80%, spec 62.5% ) False positive: infection elsewhere, inflammation, CNT dis, neoplasm, recent operation (< 3 mo) False negative: prior antibiotics CRP Positive > 10 mg/L (sens & spec 85%) Return to normal within 3 wks after operation ESR + CRP: PPV 83%, NPV 100% For chronic infection Barrack RL, CORR, 1997 Swanson KC, The adult knee, 2003
  • 26. Guideline for ESR & CRP 1. Normal ESR & CRP reliable for the absence of infection 2. CRP more useful than ESR for monitoring 3. Use with other tests for the diagnosis of infection Spangehl MJ, JBJS, 1999
  • 27. PCR Molecular genetic diagnosis Identify 16S RNA gene Expensive Time-dependent False positive Remain experimental modality !!! Mariani BD, CORR, 1996
  • 28. X-ray Sequential plain radiographs Progressive radiolucencies Focal osteopenia / osteolysis of subchondral bone Periosteal new bone formation Morrey BF, CORR, 1989 Bone destruction infection present > 10-21 days Lytic lesion destroy 30-50% of bony matrix Early infection no abnormal finding !!!
  • 29. Radioisotope scan Occasionally helpful in chronic infection Tc-99m MDP In-111 leukocyte scan Tc-99m sulfur colloid
  • 30. Radioisotope scan Isotope Sensitivity Specificity Accuracy Tc 99m 95% 20% 54% Indium 111 77% 75% 90% Tc 99m + In111 100% 97% 97% Palestro CJ, Radiology, 1991 Occasionally helpful in chronic infection
  • 31. Intraoperative tissue frozen section Widely use Result depend on Adequate & representative tissue obtaining Accurate interpretation by skilled pathologist > 5 PMN/HPF at least 5 fields Sens 100%, spec 96% >10 PMN/HPF at least 5 fields Sens 25%, spec 98% Feldman DS, JBJS, 1995 Della Valle CJ, JBJS 1999
  • 32. Reliable predictor for infection >10 PMN/HPF: sens 84%, spec 99%, PPV 89%, NPV 98% 5-10 PMN/HPF: need other test to differentiate <5 PMN/HPF: infection was highly unlikely Lonner Jh et al, JBJS,1996 Intraoperative tissue frozen section
  • 33. Intraoperative gram strain Unreliable Low sensitivity = 0-14.7% Atkins BL, J Clin Microbiol, 1998 Della Valle CJ, J Arthroplasty, 1999
  • 34. Intraoperative culture Gold standard Sample: fluid & tissue Joint capsule Synovial lining IM tissue Granulation tissue Bone fragments False +ve: contamination False -ve: prior ATB, transport system, lab - Duff GP, CORR, 1996 - Bauer TW, JBJS, 2006
  • 35. Definite diagnosis At least one of the following 1. Same organism from c/s 2 specimens by aspiration / deep tissue from surgery 2. Intraarticular tissue histopathology = acute inflammation 3. Gross purulence at the time of surgery 4. Actively discharging sinus tract Hansen, CORR, 1994
  • 36. At least one of the following 1. Open wound / sinus tract communicate joint 2. Systemic signs / symptoms pain & purulent fluid 3. At least 3 of 5 ESR > 30 mm/hr CRP >10 mg/L Frozen section > 5 PMN/HPF Preoperative aspiration c/s 1 +ve Intraoperative c/s 1 +ve Spangehl MJ, JBJS, 1999 Definite diagnosis
  • 38. Type1 Type2 Type3 Type4 Timing Positive intraop C/S Early postoperative infection Acute hematogenous infection Late (chronic) infection Definition Same organism 2 from C/S Occurring within first month after surgery Hematogenous seeding of previously well-functioning prosthesis Chronic indolent clinical course; present >1 month Segawa &Tsukayama classification * * * Guide to treatment * * * Classify on the basis of clinical presentation
  • 39. Basic treatment options 1. Antibiotic suppression 2. Debridement prosthesis retention 3. Resection arthroplasty 4. Arthrodesis 5. Amputation 6. Reimplantation - one / two stage Treatment