Musculoskeletal Infected Joint Prostheses A. Liddell

Bone and Joint Infections 5/10/04 Risk Factors • • • • • • Corticosteroids-33% Existing arthritis-24% Infection elsewhere-22% DM-13% Trauma-12% None-8% Frequency of Joints • • • • • • • Knee-48% Hip-24% Ankle-7% Elbow-11% Wrist-7% Shoulder-15% Sternoclavicular-8% Pathology • High vascularity • S. aureus collagen-binding adhesin associated with osteomyelitis but not septic joint • Disruption of normal joint by pre-existing joint disease • Proteolytic enzymes released Signs and Symptoms • Joint pain, swelling, warmth, and decreased range of motion • Joint tenderness to pressure or movement • Tendon tenderness • Fever • May resemble acute crystal dz. or hemothrosis Organisms Associated • Neisseria-1-12% • Non-gonorrhea-S. aureus-37-56%, Streptococcal-10-28%, GNR-4-19%, coagulase negative staph-5%, anaerobic-2%, PMB-less than 10% • Am Rheum Disease-2002, 61:267 Septic Arthritis-odd organisms • • • • Lyme, Mycoplasma Listeria, enterococcus, chlamydia M. tuberculosis, atypical Tb Candida,sporothrix, blastomycosis/coccidiomycosis • Rubella, hep b and c, EBV, parvovirus, mumps Synovial Effusion • Normal-clear, viscous, colorless-<200 wbc (<25% pmns) • Noninflammatory-clear, viscous, yellow 200-2000 wbc-<25% pmns • Inflammatory-cloudy, watery, yellow2000-50,000 cells (>50% polys) Synovial Effusion, continued • Infected-purulent->50,000 cells (>75% pmns) • Great overlap at times Gonococcal vs. non gc Arthritis • Gc-sexually active adults, migratory polyarthralgias, tenosynovitis, dermatitis common, >50% polyarthritis, BC positive <10%, joint fluid positive 25% GC vs. non GC • Non GC-very young or elderly, polyarthralgias, tenosynovitis rare, dermatitis rare, >85% monoarthritis, BC positive 50%, joint fluid positive 85-90% • NEJM-1985, 312:764-771 Outcome of Bacterial Arthritis • 154, 121 adults-half had joint disease • 29% of joints contained synthetic material • Poor outcome in 21% of patients-10% mortality • Poor joint outcome in nearly 50% of patients Outcome continued • Risk factors for poor outcome includeolder age, existing joint disease, synthetic joint • Arthritis and Rheumatism • 1997, 40:884. Factors Associated with Poor Prognosis • Age >60 years • Pre-existing rheumatoid arthritis or hip or shoulder infection • >1 week of infection • >4 joints involved • Positive cultures after 7 days of appropriate treatment Management • Antimicrobials do achieve adequate levels in joint fluid • Joint effusion drainage necessary but best method to drain is uncertain Prosthetic Hip Infxns, Organisms • Gram positive-CNSE>S. aureus>streptococcus>enterocc • Gram negative-Enteric>pseudomonas • Anaerobes-least common • J Bone Jt. Surg-1996, 78:512 Results of Rx of InfxnsProsthetic Hip • Positive intraoperative-28/31 good outcome (90%) 3.5 year followup • Early Postoperative 25/35 (71% good outcome) 3.3 yrs followup • Late chronic-29/34 (85%) good outcome-4.2 years followup Results of Treatment continued • Acute hematogenous-3/6 (50%) good outcome-2.6 years followup • Journal Bone and Joint Surgery 1996, 78:512 Prosthetic Joint Infection • Positive intraoperative cx-6 weeks iv with no surgical Rx • Early (one month)-surgical, remove liner, leave bone components, 4 weeks iv antibiotics Prosthetic Joint Infection • Late chronic infection-debridement, remove components and cement, 6 weeks iv antibiotics • Acute hematogenous-treatment same as early postoperative, replace components if loose • J Bone Jt Surg 1995, 77: 1576 Rifampin Containing Regimens • Proven S. aureus or coagulase negative staph infxns. • Stable joint with sms less than 21 days • Initial debridement and 2 weeks of antistaph followed by oral for 3 months if hip or 6 months if hip Rifampin Containing Regimens • • • • 12/12 cured with cipro+rifampin 7/12 cured with cipro plus placebo JAMA-1998, 279, 1537 Lancet 2001, 1:175. Suppression with oral • In one study of patients who were high risk/poor function if joint removedtreatment mean was 37.6 months • 10/13 patients required prothesis removal for recurrent infections (mean 21.6 months Suppression-continued • Conclusion-benefits are limited • Orthopaedics-1991, 14:841. Osteomyelitis classification • Cierny and Mader-Orthopaedic Review1987, 16:259 • I-medullary, II-superficial, III-localized, IV-diffuse • Host factors-A-normal, B-compromised, C-prohibitive • Waldvogel-NEJM-1970, 282:198 • Hematogenous, continguous Types of Host Compromise • Local-lymphedema, venous stasis, vessel disease, arteritis, scarring, xrt, neuropathy, tobacco • Systemic-malnutrition, liver/renal, dm, malignancy, immunosuppresion, age extremes, chronic hypoxemia Osteomyelitis diagnosis • Staging studies-MRI, CT, nuclear scans, ESR, CRP, bone biopsies and cultures Osteomyelitis treatment • Surgery and antibiotics • Controversies in length of treatment, etc. Diabetic Foot • MRI-99% sensitive, 83% specific • Plain x-ray-60% sensitive, 66% specific • Tc99m bone scan-86% sensitive, 45% specific • In111 WBC-89% sensitive, 78% specific, CID 1997: 25: 1318 Probing to Bone • Technique to determine bone infection • Sterile, steel probe used • positive test if bone can be touched with probe • Sensitivity-89%, specificity-85% JAMA1995. 273:721 Diabetic Foot • 254 isolates from 96 patients • S. aureus-38 isolates, Enterococcus-31, peptostreptococcus-31, CNSE-27, streptococcus sp-27, proteus-10, klebsiella-10 • CID-1995, 20 (supplement 2). Treatment • Surgical debridement • Avoid weight bearing • Antibiotics-4-6 weeks iv/oral combination • Surgical bone resection may shorten antibiotic course Prognosis • Risk factors for amputation were highest in the group with severe neuropathy12.9 odds ratio and no diabetes education-16.3 odds ratio vs low O2 tension and PVD-odds ratio of 1.1 Vertebral • • • • • 123 patients Back and neck pain-96% Fever-43% Increased WBC-34% ESR-84% Organisms • • • • • S. aureus-68% Enterobacteriae-28% Streptococcus-8% CNSE-3% P. aeruginosa-<1%, candida-<1% Organisms continued • Unusual causes include-bartonella henselae in association with cat scratch • Aspergillosis-41 cases in literature with 34% no predisposing factors Vertebral-epidemiology • Mean age-59 years with sms for 48 days • Blood cultures positive up to 78% • Paraspinal or epidural extension in 74%-did not correlate with neurologic deficits in 28% Vertebral • 58/101 hematogenous vertebral osteomyelitis cases who had surgery with less back pain in follow-up • Only 18% with epidural abscess and 23% with paralysis fully recovered after surg decompression Continued • 100% of patients with paraparesis recovered completely following decompression surgery