Bone and prosthetic joint infections: what the ID specialist needs?

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1 Bone and prosthetic joint infections: what the ID specialist needs? Andrej Trampuz Charité University Medicine Berlin Center for Septic Surgery

2 Hip and knee replacements in Europe Germany Austria Belgium Norway Switzerland France Luxembourg Sweden Netherlands United Kingdom Finland Slovenia Denmark Iceland Italy EU Greece Ireland Latvia Spain Hungary Estonia Portugal Romania Poland Cyprus Per population 289 Germany Austria Finland Switzerland Belgium Luxembourg United Kingdom Netherlands Iceland France Sweden EU Spain Denmark Italy Slovenia Latvia Portugal Hungary Cyprus Ireland Romania Per population Hip replacements in 2008 Knee replacements in 2008 Source: OECD Health Data 2010; Eurostat Statistics Database

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4 And the numbers are rising! Kurtz S et al. J. Arthroplasty 2012

5 From time to time only very subtle signs! No pain No swelling No warmth No redness No bad function

6 Low-grade infection Which side?

7 1-step exchange

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9 Imaging studies Ultrasound Plain radiographs Helpful to detect infection when studied serially over time after implantation New subperiosteal bone growth and transcortical sinus tracts are specific for infection Bone scintigraphy (technecium or with labeled leukocytes) has high sensitivity, but lacks specifity for infection

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11 Computed tomography (CT) Detection of soft tissue infection (abscesses, sinus tracts), implant loosening and bone erosion With imaging techniques metallic artefacts can be minimized More often used to estimate extent of infection than Imagerie des to infections determine sur matériel orthopédique whether or not an infection is 581 present

12 CT at admission

13 Magnetic resonance imaging (MRI) Better resolution for soft tissue abnormalities than CT Imaging interference occurs in the vicinity of metal implants Indication for MRI is similar to that for CT

14 MRI at admission

15 SPECT/CT More precise localization of the radiotracer Improves the diagnostic performance of three-phase bone scan by avoiding false positive or equivocal results. Horger et al. Arch Orthop Trauma Surg 2007

16 66 y-o First visit Painful left hip prosthesis (2004) Personal history Right hip prosthesis (2003) Left knee prosthesis (2004) Spondylodesis L2-5 (2009)

17 Left hip prosthesis 3 open revisions for dislocation in last year X-ray: ostelysis around stem CRP 16 What now?

18 Diagnostic procedures Preoperative puncture: Staphylococcus epidermidis Diagnosis? Surgical option?

19 Low-grade infection 2-step prosthesis exchange 8/2012 Mobile spacer with gentamicin & vancomycin

20 Microbiology Intraoperative tisse & sonication: Staphylococcus epidermidis - Susceptible to: cotrimoxazole, ciprofloxacin, rifampin - Resistant to: methicillin, gentamicin Vancomycin 2 x 1 g i.v. for 2 weeks

21 9/2012 Reimplantation after 2 weeks

22 Microbiology : Sonicate of spacer sterile Tissue specimens sterile Continue vancomycin for 5 days, then Oral levofloxacin + rifampin (-> ) Returns home:

23 Repeated hip dislocation Not able to reduce THA and crack (fracture)!

24 Periprosthetic fracture (Vancouver B1) Internal osteosynthesis (plate) Intraoperative: Good stability Returns home: Sonication of exchanged parts: Neg

25 November 2012 Repeated 2x dislocations (22.11., ) -> closed reduction not sucessful Decision: Open revision Day of surgery: fever 40 C, CRP 60 Suspicion of central line infection What now?

26 Surgical revision Incision of fascia -> pus! What now? What about the fracture and what about the plate?

27 Intraoperative decision Change polyethylene inlay & prosthetic neck Leave prosthesis stem & plate in place Blood cultures MRSA Sonicate + tissue cultures MRSA Rifampin resistant What now? Switch to daptomycin 1 x 10 mg/kg i.v.

28 Decision step exchange of hip prosthesis PMMA + vancomycin/gentamicin

29 February 2013 New dislocation Open reduction STABLE perop Tissue cultures sterile!

30 Girdlestone

31 Mai 2013

32 Fistula around knee prosthesis What now?

33 June stage exchange of the knee prosthesis Spacer with vancomycin & gentamicin Sonicate: MRSA (rifampin resistant, vancomycin MIC 2, daptomycin MIC 0.5)

34 Knie-prosthesis re-implantation after 4 weeks

35 Microbiology Sonicate of spacer and tissue cultures sterile Little problem: Wound breakdown

36 Change mobile parts and flap Sonicate of PE-inlay: Enterobacter cloacae (cipro S) Daptomycin + ciprofloxacin Local status OK F/E knee 75/5/0 Patient wants a hip prosthesis

37 At 12 months CRP 7, little pain New hip prosthesis No signs of infection

38 Outlook

39 Vitamin B 12 - Imaging Essencial growth factor Produced by 0.001% of living organisms, consumed by %: Low uptake: Differentiated somatic cells High uptake: Microorganisms, tumor cells Complex chemical structure (mammals & most bacteria unable to synthesize) have efficient uptake systems Can radiolabeled vitamin B 12 be used for imaging infections?

40 Vitamin B12 for tumor diagnosis Prostata carcinoma SPECT 4 h In-111 Adenosylcobalamin 650 μci (2.2 μg) i.v. Septic arthritis of the wrist (incidental finding) Accumulation in liver, spleen, salivary glands Solution: Tumor-selective derivatives (not binding to transcobalamin II = TCII) Collins et al. Mayo Clin Proc 2000;75:568

41 Sterile inflammation S. aureus cage infection Kidney Bladder SPECT/CT (4 h after 99m Tc-PAMA-4, 20 μci i.v.) Baldoni D et al (in preparation)

42 Thank you! Focus on implant, bone and joint-associated infections: Surgery: New concepts (retention, 1-stage, short interval) Diagnosis: Fast innovative methods Antibiotics: Active against biofilms