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Antibiotic infusion may provide high levels of concentration in knees revised for multiple infection

ORLANDO, Fla. — Although technically demanding, a single-stage procedure that infuses antibiotics directly into the joint has shown promising results in a series of patients re-revised for a previously infected total knee replacement.

During a presentation here at the Current Concepts in Joint Replacement 2010 Winter Meeting, Leo A. Whiteside, MD, referred to these cases of re-revision as “one of the worst of the worst situations” a knee replacement surgeon can face.
“In these cases, you have probably got to do everything right; otherwise, you are probably facing amputation next,” he said.

Intra-articular infusion

Whiteside presented the results of a series of 18 knees in 18 patients who were re-infected after previous revision for infection. All patients were initially treated with single-stage revision that included debridement, uncemented revision of total knee components and intra-articular infusion of 500 mg vancomycin via Hickman catheters once or twice daily for 6 weeks, according to the study abstract.

Whiteside noted that, even if administering 200 mg to 300 mg vancomycin, peak levels in many cases will reach up to 15,000 mg/mL with a trough of 733 mg/mL at the end of 12 hours.

“Now that is a remarkable antibiotic level,” he said.

In the current series, osteotomy was necessary for debridement in 17 knees, muscle flaps in seven knees, and two-stage revision or more in six knees, Whiteside said.

Successful re-revision was achieved in 15 patients. Failures were associated with re-infection, inadequate soft tissue coverage resulting in amputation and morbidity due to renal failure.

Muscle flaps

Whiteside elaborated on a patient in this series for whom muscle flaps were necessary for closure of the capsule, noting that subfascial soft tissue flaps may also be necessary in some cases.

“You have got to have a team that can manage these,” Whiteside said.

He emphasized the difficulties associated with re-revision for a previously infected total knee replacement, and encouraged surgeons to focus on debridement, soft tissue management and antibiotic delivery to achieve high rates of success in this patient population.

“If you are not good at this, you should not try these cases,” Whiteside said. “Even in the best of hands, there is a high reinfection rate in these cases of re-revision or revision for [methicillin-resistant Staphylococcus aureus] or other resistant antibiotics.” — by Thomas M. Springer

Reference:
Whiteside LA. The infected knee: one- and two-stage solution options. Paper #108. Presented at the Current Concepts in Joint Replacement 2010 Winter Meeting. December 8-11, 2010. Orlando, Fla.

Leo A. Whiteside, MD, can be reached at Missouri Bone & Joint Center, 1000 Des Peres Road, Suite 120, Saint Louis, MO 63131-2062; 314-205-2223; e-mail: Lwhite8283@aol.com.
 

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