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Management of Infected Hip (THR)
joint Replacement Surgery by Hand
Made Antibiotic Cement Spacer

Dr.Sandeep Agrawal

MS ....
Hip Arthroplasty: Increasingly
Common
so more cases of Infected hip
THA Infection: A Treatment Challenge
Clinical Challenges
THA Infection: Classification
Common Pathogens
Zimmerli et al, 2005
Biofilm
Clinical Diagnosis
► 1.Clinical S/S: Pain (rest, non-weight bearing),
erythema, fever, discharging sinus, turbid joint flu...
Treatment choices
Treatment Algorithm for Management of the infected THA
Depth of
infection
Wound
debridement/
antibiotics
Debilitated
patie...
► Medically infirm patients
► Low virulent pathogen
► Oral antibiotics available
► Tolerable long-term antibiotics
► Prost...
► Very strict criteria :
▪ Symptoms< 3 weeks
▪ Stable prosthesis
▪ No discharging sinus
▪ Susceptible pathogen
► Success r...
► Remove prosthesis:
Girdlestone procedure over
hip joint
► High success rate
► Poor functional status
► For the very debi...
Antibiotic-cement: The Key to Success
Buchholz et al, 1984
Adams et al, 1992
Girdlestone Problems
► Leg length inequality
► Inability to bear weight
► Disuse osteoporosis
► Extensive scarring
► Disto...
Dose of antibiotics
► Elution of antibiotics from the PROSTALAC is
effective when at least
!
3.6 g tobramycin
and 1g vanco...
Do these spacers work better than the beads?
Materials and Methods
Group A
(Beads)
► 1994-1996
► 70 hips
► M:F= 53:17
► Age: 60 (34-85) y/o
► Follow= 5.4 (2-8) yrs
Gro...
Infection control
60%
64%
68%
72%
75%
79%
83%
87%
91%
95%
98%
Group A Group B
Infection c
96.5%94.3%
66/70
56/58
(P=0.69)
Ambulatory status
0
15
30
45
60
Ambulatory Non-ambulator
7
49 51
12
Beads
Spacer
87.5%
19.0%
(P=0.001)
► Selected patients
▪ Low- virulent organisms
▪ Identify organism before operation
▪ No sinus tract
▪ No major bone loss
▪...
5.“Two stage revision
arthroplasty”
A simple molding method
of antibiotic-loaded
cement prosthesis as an
interim spacer
J-Trauma
Hsieh et al, 2004
Antibiotic-cement spacer is not new 

► Zilkens et al, 1990
► Ivarsson et al, 1994
► Leunig et al, 1998
► Deshmukh et al, ...
osthesis of Antibiotic-loaded Acrylic Cement:
Duncan et al, 1993
PROSTALAC
► 1st Stage :
▪ Removal of all components, debridement
▪ Antibiotic-cement spacer
► Between Stages :
▪ IV antibiotics (2 w...
ACETABULUM PREPARATION
Silicon Mould
A refined metal rod

ENDOSKELETON
ENDOSKELETON IN MOLD
Pressure Till Cement Sets
FINAL FEMORAL CEMENT SPACER
INSERTION IN MEDULLARY CANAL
Cement-on-cement
Proximal
cementation
Metal Rod as
endoskeleton
•Temporary prosthesis
•Local antibiotic delivery
AMBULATION WITH SUPPORT
Choice of antibiotics
Heat-stable
► Powdered form
► Broad spectrum
▪ G(+): vancomycin, teicoplanin
▪ G(-): tobramycin, pip...
Complication of the cement spacer
FractureDislocation
Fracture
Dislocation
► Antibiotic elution from cement:
biphasic; high initially followed by sustained
release for months
Duncan et al, 1994 JBJ...
► Most reliable method
► High success rate: 88-100% (OKU 8)
► Better functional result after revision hip
reconstruction p...
Conclusions
► Remove prosthesis is mandatory when
face a infective hip arthroplasty
► 1.Debride alone: a very limited indi...
Thanks To DR.HSIEH
Dr.Pang Hsieh
Taiwan
Antibiotic Cement Spacer for Infected Hip Joint Replacement (THR) Surgery, Dr.Sandeep Agrawal,Agrasen Hospital,Gondia,Maha...
Antibiotic Cement Spacer for Infected Hip Joint Replacement (THR) Surgery, Dr.Sandeep Agrawal,Agrasen Hospital,Gondia,Maha...
Antibiotic Cement Spacer for Infected Hip Joint Replacement (THR) Surgery, Dr.Sandeep Agrawal,Agrasen Hospital,Gondia,Maha...
Antibiotic Cement Spacer for Infected Hip Joint Replacement (THR) Surgery, Dr.Sandeep Agrawal,Agrasen Hospital,Gondia,Maha...
Antibiotic Cement Spacer for Infected Hip Joint Replacement (THR) Surgery, Dr.Sandeep Agrawal,Agrasen Hospital,Gondia,Maha...
Antibiotic Cement Spacer for Infected Hip Joint Replacement (THR) Surgery, Dr.Sandeep Agrawal,Agrasen Hospital,Gondia,Maha...
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Antibiotic Cement Spacer for Infected Hip Joint Replacement (THR) Surgery, Dr.Sandeep Agrawal,Agrasen Hospital,Gondia,Maharashtra,India

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Periprosthetic infection is becoming more and more common and devastating.Better treatment modality of two staged antibiotic cement spacer is becoming more and more common with excellent results.Antibiotic Cement Spacer for Infected Hip Joint Replacement (THR) Surgery, Dr.Sandeep Agrawal,Agrasen Hospital,Gondia,Maharashtra,India

Published in: Health & Medicine

Antibiotic Cement Spacer for Infected Hip Joint Replacement (THR) Surgery, Dr.Sandeep Agrawal,Agrasen Hospital,Gondia,Maharashtra,India

  1. 1. Management of Infected Hip (THR) joint Replacement Surgery by Hand Made Antibiotic Cement Spacer
 Dr.Sandeep Agrawal
 MS . DNB
 Agrasen Hospital
 Gondia Maharashtra India ANTIBIOTIC CEMENT SPACER
  2. 2. Hip Arthroplasty: Increasingly Common so more cases of Infected hip
  3. 3. THA Infection: A Treatment Challenge
  4. 4. Clinical Challenges
  5. 5. THA Infection: Classification
  6. 6. Common Pathogens Zimmerli et al, 2005
  7. 7. Biofilm
  8. 8. Clinical Diagnosis ► 1.Clinical S/S: Pain (rest, non-weight bearing), erythema, fever, discharging sinus, turbid joint fluid ► 2.Laboratory: ESR/CRP, leukocytosis ► 3.Culture and cytology from joint tapping ► 4.Exploration ► 5.Radiographic: normal or bone destraction ► 6.Histopathological: > 5-10 PMN/HPF ► 7.Nuclear medicine ► No Single Test
  9. 9. Treatment choices
  10. 10. Treatment Algorithm for Management of the infected THA Depth of infection Wound debridement/ antibiotics Debilitated patient “Prosthesis retention with debridement”(2) Intravenous antibiotics Reinsertion of another prosthesis Remove implant Symptom onset Well-fixed implant Chronic oral antibiotic suppression chronic Poor soft-tissue envelope Recalcitrant infection Poor medical condition superficial yes yes failure Resection arthroplasty(3) deep no acute failure no yes no failure AAOS ADVANCED RECONSTRUCTION HIP P.234 2005
  11. 11. ► Medically infirm patients ► Low virulent pathogen ► Oral antibiotics available ► Tolerable long-term antibiotics ► Prosthesis removal is not feasible and no loose 1…Antibiotic suppression
  12. 12. ► Very strict criteria : ▪ Symptoms< 3 weeks ▪ Stable prosthesis ▪ No discharging sinus ▪ Susceptible pathogen ► Success rate: 50-70% ► Acceptable early successful rate but also high recurrence Trampuz A et al, 2005 2…Debrideemnt with prosthesis retention
  13. 13. ► Remove prosthesis: Girdlestone procedure over hip joint ► High success rate ► Poor functional status ► For the very debilitated 3..Resection Arthroplasty
  14. 14. Antibiotic-cement: The Key to Success Buchholz et al, 1984 Adams et al, 1992
  15. 15. Girdlestone Problems ► Leg length inequality ► Inability to bear weight ► Disuse osteoporosis ► Extensive scarring ► Distorted tissue plane ► Difficult reimplantation
  16. 16. Dose of antibiotics ► Elution of antibiotics from the PROSTALAC is effective when at least ! 3.6 g tobramycin and 1g vancomycin were added ! ! Masri et al 1998, J Arthroplasty
  17. 17. Do these spacers work better than the beads?
  18. 18. Materials and Methods Group A (Beads) ► 1994-1996 ► 70 hips ► M:F= 53:17 ► Age: 60 (34-85) y/o ► Follow= 5.4 (2-8) yrs Group B (Spacer) ► 1996-2000 ► 58 hips ► M:F=43:15 ► Age: 63 (28-81) y/o ► Follow= 4.2 (2-6) yrs
  19. 19. Infection control 60% 64% 68% 72% 75% 79% 83% 87% 91% 95% 98% Group A Group B Infection c 96.5%94.3% 66/70 56/58 (P=0.69)
  20. 20. Ambulatory status 0 15 30 45 60 Ambulatory Non-ambulator 7 49 51 12 Beads Spacer 87.5% 19.0% (P=0.001)
  21. 21. ► Selected patients ▪ Low- virulent organisms ▪ Identify organism before operation ▪ No sinus tract ▪ No major bone loss ▪ Antibiotic-loaded cement fixation ► More popular in Europe ► Success rate: 73%-92% (OKU 8) ! ► Hope et al, 1989 ► Ure et al, 1998 Raut et al, 1994 4..One-stage revision arthroplasty
  22. 22. 5.“Two stage revision arthroplasty” A simple molding method of antibiotic-loaded cement prosthesis as an interim spacer
  23. 23. J-Trauma Hsieh et al, 2004
  24. 24. Antibiotic-cement spacer is not new 
 ► Zilkens et al, 1990 ► Ivarsson et al, 1994 ► Leunig et al, 1998 ► Deshmukh et al, 1998 ► Younger et al, 1998 ► Magnan et al, 2001 •Small series •Hand-made prosthesis •Hemiarthroplasty-like
  25. 25. osthesis of Antibiotic-loaded Acrylic Cement: Duncan et al, 1993 PROSTALAC
  26. 26. ► 1st Stage : ▪ Removal of all components, debridement ▪ Antibiotic-cement spacer ► Between Stages : ▪ IV antibiotics (2 weeks) ▪ +/- Oral antibiotics (4 weeks) ► 2nd Stage : ▪ Normal CRP ▪ Antibiotics in cement Treatment Protocol
  27. 27. ACETABULUM PREPARATION
  28. 28. Silicon Mould
  29. 29. A refined metal rod
 ENDOSKELETON
  30. 30. ENDOSKELETON IN MOLD
  31. 31. Pressure Till Cement Sets
  32. 32. FINAL FEMORAL CEMENT SPACER
  33. 33. INSERTION IN MEDULLARY CANAL
  34. 34. Cement-on-cement Proximal cementation Metal Rod as endoskeleton •Temporary prosthesis •Local antibiotic delivery
  35. 35. AMBULATION WITH SUPPORT
  36. 36. Choice of antibiotics Heat-stable ► Powdered form ► Broad spectrum ▪ G(+): vancomycin, teicoplanin ▪ G(-): tobramycin, piperacillin, aztreonam Antibiotics: bone cement = 1: 5
  37. 37. Complication of the cement spacer FractureDislocation
  38. 38. Fracture Dislocation
  39. 39. ► Antibiotic elution from cement: biphasic; high initially followed by sustained release for months Duncan et al, 1994 JBJS-A ► Antibiotic elution from cement spacer: similar pattern Minelli et al, 2004 JAC
  40. 40. ► Most reliable method ► High success rate: 88-100% (OKU 8) ► Better functional result after revision hip reconstruction procedure Two-stage revision arthroplasty
  41. 41. Conclusions ► Remove prosthesis is mandatory when face a infective hip arthroplasty ► 1.Debride alone: a very limited indication ► 2.One-stage revision: selected cases ► 3.Two-stage revision: most reliable and effective ► With a cement spacer prosthesis: simple, safe, effective, and versatile
  42. 42. Thanks To DR.HSIEH Dr.Pang Hsieh Taiwan

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