salvage of infected inbone total ankle replacement
TRANSCRIPT
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Salvage of Infected INBONE Total Ankle
Replacement
Brent Roster, MD and George Lian, MD
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Salvage of Infected INBONE Total Ankle Replacement
Brent Roster, MD
My disclosure is in the Final AOFAS Mobile App.
I have no potential conflicts with this presentation.
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Introduction
Reported rates of infection after total ankle replacement (TAR) requiring surgical I&D, component removal/exchange, or revision range from 0-8.6% 1-5,7,8
Traditional two-stage revision procedures can result in significant bone loss, making reconstruction difficult or impossible
The INBONE is a fixed-bearing TAR which utilizes a modular intramedullary tibial stem
Removal of a well-fixed INBONE tibial stem can be difficult and can result in significant morbidity
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Biofilms and Periprosthetic Joint Infection
Bacterial biofilm formation on orthopaedic implants confers resistance to both host defense and antimicrobial agents 9
2-stage revision with removal of all components is therefore most commonly successful 5,9
Lombardi et al: 89% success with partial 2-stage revision of infected total hip arthroplasty (well-fixed femoral stems retained) at an average of 4 years 6
Kessler et al reported a 66.7% success rate at an average of 2 years in treatment of infected TAR with retention of one or both components 5
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Methods Clinical question:
Can patients with an infected INBONE total ankle replacement AND a well-fixed tibial stem be successfully treated with partial 2-stage revision?
Can well-fixed tibial stem components be retained?
Study Design: Retrospective review of four consecutive patients with an infected INBONE total ankle replacement with at least 2 year follow-up after partial 2-stage revision
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Methods
Well-fixed tibial stem components were left in-situ
All patients were treated with surgical I&D, removal of polyethylene, talar, and tibial tray components
Intra-operative cultures were obtained, and antibiotic management was guided by the infectious disease service
Antibiotic beads and antibiotic cement spacers were placed
TAR was re-implanted at an average of 3.75 months s/p explant and spacer placement after being off antibiotics for at least 6 weeks
Clinical exam, radiographs and inflammatory markers checked at most recent follow-up (average 26.5 months status post re-implantation)
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Results: Demographics and Risk Factors
Patient Gender Age Initial Diagnosis Risk Factors for Infection
1 M 70 Primary OA DM; debridement and synovectomy for impingement after TAR
2 M 71 Post-traumatic OA None identified
3 M 49 Post-traumatic OA
Hepatitis C; history of open pilon fracture treated with ORIF and subsequent HWR
4 M 59 Post-traumatic OA
Prior foot surgery; debridement and synovectomy for impingement after TAR
OA = osteoarthritis; DM = diabetes mellitus; ORIF = open reduction internal fixation; HWR = hardware removal; TAR = total ankle replacement
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Results: Infectious Characteristics
Pt Time to Explant (Months)
Pre-op labs Organism Antibiotic Duration of Abx therapy
Time to re-implantation (Months)
1 41 CRP 277 Alpha-hemolytic Strep
IV daptomycin
6 weeks 2
2 43 WBC 9.2, ESR 108
Propionibacterium PO rifampin & minocycline
1 year 4
3 39 CRP 0.8, ESR 31, WBC 8.1
Pseudomonas aeroginosa; GBS
cefepime 6 weeks 4
4 33 ESR 37, CRP 56.9, WBC 8.6
MSSA nafcillin 6 weeks 5
Avg = 39 Avg = 3.75
CRP = C reactive protein, mg/L, normal 0-9; WBC = white blood cell count, K/uL, normal = 4-11; ESR = erythrocyte sedimentation rate, mm/hr, normal 0-20; GBS = group B Streptococcus; MSSA = methicillin sensitive Staphylococcus aureus
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Results: Most Recent Follow-up Pt F/u after re-
implantation (months)
ROM Narcotics? Clinical signs of infection at ankle?
Labs
1 34 35 no no WBC 5.8 ESR 17 CRP 0.5
2 24 22 no no WBC 6.0 ESR 31 CRP 5.5
3 24 25 no no WBC 7.3 ESR16 CRP 2.9
4 24 30 no no *** WBC 9.2 ESR 32 CRP 25.3
Avg = 26.5
*** At most recent f/u, Patient #4 had a pressure wound over the contralateral ankle and infected abdominal hernia mesh after bowel rupture during colonoscopy with resultant colostomy; operative ankle was benign with no signs of infection
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Pre-op to Re-Implantation
Pre-op After I&D, poly and talar component removal and placement of antibiotic cement spacer
24 months after re-implantation
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Discussion/Conclusion
4/4 patients treated with this approach had functional revision TARs at an average of 26.5 months follow-up
4/4 had no clinical signs of infection of their TAR
1/4 had elevated inflammatory markers at most recent follow-up, with an explanation other than their TAR
Conclusion: In this small series of 4 patients, all were successfully treated with partial 2-stage revision for infection with retention of the well-fixed INBONE tibial components with at least 2 years follow-up.
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References
1. Adams SB, Demetracopoulos CA, Queen RA, Easley MF, DeOrio JK, Nunley JA. Early to mid-term results of fixed-bearing total ankle arthroplasty with a modular intramedullary tibial component. J Bone Jonit Surg Am. 2014;96:1983-9.
2. Daniels TR, Younger ASE, Penner M, Wing K, Dryden PJ, Wong H, Glazebrook M. Intermediate-term results of total ankle replacement and ankle arthrodesis. J Bone Joint Surg Am. 2014;96:135-42.
3. Gougoulias N, Khanna A, Maffulli N. How successful are current ankle replacements? Clin Orthop Relat Res. 2010;469:199-208.
4. Kessler B, Sendi P, Graber P, Knupp M, Zwickey L, Hintermann B, Zimmerli W. Risk factors for periprosthetic ankle joint infection: a case control study. J Bone Joint Surg Am. 2012;94:1871-6.
5. Kessler B, Knupp M, Graber P, Zwicky L, Hintermann B, Zimmerli W, Sendi P. The treatment and outcome of periprosthetic infection of the ankle. J Bone Joint Surg Br. 2014;96-B:772-7.
6. Lombardi AV, Berend KR, Adams JB. Partial two-stage exchange of the infected total hip replacement using disposable spacer moulds. J Bone Joint Surg Br. 2014;96-B(11 Supple A):66-9.
7. Myerson MS, Shariff R, Zonno AJ. The management of infection following total ankle replacement: demographics and treatment. Foot Ankle Int. 2014;35(9):855-862.
8. Sadoghi P, Roush G, Kastner N, Leithner A, Sommitsch C, Goswami T. Failure modes for total ankle arthroplasty: a statistical analysis of the Norwegian Arthroplasty Register. Arch Orthop Trauma Surg. 2014;134:1361-1368.
9. Zimmerli W, Moser C. Pathogenesis and treatment concepts of orthopaedic biofilm infections. FEMS Immunol Med Microbiol. 2012;65:158-168.