Antibiotic Cement Spacer for Infected Hip Joint Replacement (THR) Surgery, Dr.Sandeep Agrawal,Agrasen Hospital,Gondia,Maharashtra,India
The document outlines the management of infected total hip arthroplasty (THA) using handmade antibiotic cement spacers, emphasizing the complexity of treatment due to varying infection types and patient conditions. It discusses diagnostic criteria, treatment algorithms, and the effectiveness of different surgical approaches, particularly highlighting the advantages of two-stage revision arthroplasty with antibiotic spacers. The findings suggest that proper identification of pathogens and surgical strategies significantly impact infection control and patient mobility outcomes.
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Antibiotic Cement Spacer for Infected Hip Joint Replacement (THR) Surgery, Dr.Sandeep Agrawal,Agrasen Hospital,Gondia,Maharashtra,India
- 1. Management of InfectedHip (THR) joint Replacement Surgery by Hand Made Antibiotic Cement Spacer Dr.Sandeep Agrawal MS . DNB Agrasen Hospital Gondia Maharashtra India ANTIBIOTIC CEMENT SPACER
- 2. Hip Arthroplasty: Increasingly Common somore cases of Infected hip
- 3. THA Infection: ATreatment Challenge
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- 6. Common Pathogens Zimmerli etal, 2005
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- 8. Clinical Diagnosis ► 1.ClinicalS/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
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- 10. Treatment Algorithm forManagement 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. ► Medically infirmpatients ► Low virulent pathogen ► Oral antibiotics available ► Tolerable long-term antibiotics ► Prosthesis removal is not feasible and no loose 1…Antibiotic suppression
- 12. ► Very strictcriteria : ▪ 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. ► Remove prosthesis: Girdlestoneprocedure over hip joint ► High success rate ► Poor functional status ► For the very debilitated 3..Resection Arthroplasty
- 14. Antibiotic-cement: The Keyto Success Buchholz et al, 1984 Adams et al, 1992
- 15. Girdlestone Problems ► Leglength inequality ► Inability to bear weight ► Disuse osteoporosis ► Extensive scarring ► Distorted tissue plane ► Difficult reimplantation
- 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. Do these spacerswork better than the beads?
- 18. Materials and Methods GroupA (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. Infection control 60% 64% 68% 72% 75% 79% 83% 87% 91% 95% 98% Group AGroup B Infection c 96.5%94.3% 66/70 56/58 (P=0.69)
- 20. Ambulatory status 0 15 30 45 60 Ambulatory Non-ambulator 7 4951 12 Beads Spacer 87.5% 19.0% (P=0.001)
- 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. 5.“Two stage revision arthroplasty” Asimple molding method of antibiotic-loaded cement prosthesis as an interim spacer
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- 24. Antibiotic-cement spacer isnot 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. osthesis of Antibiotic-loadedAcrylic Cement: Duncan et al, 1993 PROSTALAC
- 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
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- 30. A refined metalrod ENDOSKELETON
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- 35. FINAL FEMORAL CEMENTSPACER
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- 37. Cement-on-cement Proximal cementation Metal Rod as endoskeleton •Temporaryprosthesis •Local antibiotic delivery
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- 39. Choice of antibiotics Heat-stable ►Powdered form ► Broad spectrum ▪ G(+): vancomycin, teicoplanin ▪ G(-): tobramycin, piperacillin, aztreonam Antibiotics: bone cement = 1: 5
- 40. Complication of thecement spacer FractureDislocation
- 41.
- 42. ► Antibiotic elutionfrom 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
- 46. ► Most reliablemethod ► High success rate: 88-100% (OKU 8) ► Better functional result after revision hip reconstruction procedure Two-stage revision arthroplasty
- 47. Conclusions ► Remove prosthesisis 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
- 48. Thanks To DR.HSIEH Dr.PangHsieh Taiwan