combination of calcium hydroxyapatite antibiotic carrier with … · 2018-06-25 · combination of...
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Combination of calcium hydroxyapatite
antibiotic carrier with spacers in
periprosthetic knee infections
A. Drakou, V.I. Sakellariou, G.I. Karaliotas,
G.C. Babis, P.J. Papagelopoulos
From the 1st Orthopaedic Department, University of Athens, ATTIKON University General Hospital, Chaidari, Greece.
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Introduction
• Two stage revision procedures is the gold standard in management of periprosthetic infections.
• Cement spacers (hand or ready-made) impregnated with antibiotics have long been impregnated with antibiotics have long been used to – preserve the space created during resection
procedure
– to release antibiotics within the created dead space.
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Introduction
• However, the problems related to cement as
an antibiotic carrier are well recognised:
– random porosity
– bone thermal necrosis– bone thermal necrosis
– unspecified antibiotic delivery rate
– possible bone damage upon cement removal
– Ready-made spacers are specific-antibiotic loaded
and are applied on bone surface only.
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Goals to achieve in the long run
• Improve already existing or invent new and
more effective ways of delivering antibiotics to
bone
• Compare new AB-delivery systems to the • Compare new AB-delivery systems to the
classic cement AB-loaded spacers
• Investigate interactions between these
systems and the Bone Biology
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Rationale
• The rationale of this study is that calcium
hydroxyapatite antibiotic carrier (PerOssal)
overlaps the known disadvantages of cement
spacers, and leads to better outcome in terms spacers, and leads to better outcome in terms
of clinical parameters and re-infection rate
when combined with ready-made articulating
spacers.
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Purpose
• To identify specific clinical and laboratory
differences between cases submitted to
conventional two stage revision arthroplasty conventional two stage revision arthroplasty
vs
cases treated with PerOssal as an additional
antibiotic carrier.
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Material & Methods
• During 2004 to 2008
• 46 patients (38 females and 8 males)
• mean age 65.3 years (range 32 to 84)
• All patients
– periprosthetic infection of their TKRs
– revision using a two-stage revision protocol.
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Material & Methods• group A
– 31 patients (25 females and 6 males)
– conventional articulating spacer impregnated with
Tobramycin was used
• group B• group B
– 15 patients (13 females, 2 males)
– a combination of an articulating spacer and
PerOssal applied intramedullary as antibiotic
carrier was used
– Antibiotics used in PerOssal beads: Vancomycin,
Amicacin, Rifambicin
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Case 1: Infected TKR, 72y, female2-stage Revision
•• Implant removal Implant removal –– cement spacercement spacer
•• PerOssalPerOssal (contained fashion) in I.M (contained fashion) in I.M canal sealed by spacercanal sealed by spacer
•• Primary wound healingPrimary wound healing
•• Revision 2nd stage at 6mthsRevision 2nd stage at 6mths
•• FU 24mths FODFU 24mths FOD•• FU 24mths FODFU 24mths FOD
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Case 2: Infected TKR, 65y, female2-stage Revision
Implant removal Implant removal ––cement spacercement spacer
PerOssalPerOssal(contained (contained fashion) in I.M fashion) in I.M canal sealed by canal sealed by canal sealed by canal sealed by spacerspacerPrimary wound Primary wound healinghealing
Revision 2Revision 2ndnd stage stage at 6mthsat 6mthsFU 18mths FODFU 18mths FOD
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Material & Methods
– All patients were reviewed with laboratory exams
(WBC, ESR, CRP) every 7 days
– Joint fluid aspiration prior to re-implantation
2 stage revision was performed at mean 8 months – 2 stage revision was performed at mean 8 months
post 1st stage (range, 6 to12 months).
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Results
• Mean follow-up of 36 months (range, 8 to 60 months)
• No patient was lost or died.
• WBC count showed no statistically significant differences at any time interval (p>0.05).
• WBC count showed no statistically significant differences at any time interval (p>0.05).
• ESR showed no statistically significant differences at any time interval (p>0.05).
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Results
• CRP values had a statistically significant difference between the two groups
• after the second week postoperatively (p3rd week= 0.032)
• group B had significantly lower CRP values compared • group B had significantly lower CRP values compared to group A at every check point thereafter (p4th
week=0.038, p5th week=0.031, p6th week=0.034).
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WBC
p>0.05
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ESR
p>0.05
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CRPP=0.134
P=0.128
P=0.078
p=0.032
p=0.038p=0.038
p=0.031
p=0.034
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Results
• Re-infection rate was 16.12% in group A and
6.6% in group B (p=0.192), All cases showing
the same microorganism as of the initial
surgery
• No adverse effects where shown with the use • No adverse effects where shown with the use
of PerOssal
• No evidence of PerOssal induced osseo-
induction or osseo-integration was found at
reinplantation (2nd Stage)
• No bone loss noted at PerOssal removal
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Take- home Messages
• PerOssal can be used as an additional
antibiotic carrier in cases of periprosthetic
infections of TKR.
• It is associated with more rapid reduction of
CRP levels, probably due to
– greater porosity – greater porosity
– bacteria-specific antibiotic delivery comparing to
impregnated cement
– and absorption via the medullary canal.
• Therefore safe shortening of the waiting
period between revision stages might be
possible
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…
However,
larger series of patients are needed to reveal
potential differences in the re-infection rates
as indicated by our study and for investigation as indicated by our study and for investigation
of this potentially Bone- friendly behaviour of
PerOssal or similar delivery systems.
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Thank you!Thank you!