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Management of TJA infection with two-stage exchange involves careful screening, team approach

Management of TJA infection with two-stage exchange involves careful screening, team approach 

  • Orthopedics Today, January 2013
ORLANDO, Fla. — A two-stage exchange is common for the treatment of an infected total hip or total knee arthroplasty, but many orthopedic surgeons in North America were taught this technique without becoming familiar with single-stage exchange, according to a presenter at the Current Concepts in Joint Replacement Winter Meeting, here.
“I was taught that you treat a total hip or total knee that is infected with a two-stage exchange. I think there is a lot of unfamiliarity in North America with the one stage exchange,” Craig J. Della Valle, MD, said.
Della Valle said the problem with adopting single-stage exchange in North America is the popularization of uncemented revision joint arthroplasty procedures – European revisions are normally cemented cups and cemented stems loaded with antibiotics. He said the indications, techniques, protocol and success for single stage exchange are unfamiliar to North Americans.
“I think mostly in North America, it is tradition. Certainly, in my residency I never saw a one-stage exchange,” Della Valle said.
For his two-stage exchange, Della Valle said he débrides all foreign and infected material. He said in North America, surgeons commonly place an interval antibiotic loaded spacer, typically with vancomycin plus powered aminoglycoside. He uses an articulating spacer except in cases of severe bone loss, where he uses a non-articulating spacer.
After 6 weeks of antibiotics, he said he communicates with an infectious disease specialist, internist and nutritionalist to optimize outcomes. He noted that erythrocyte sedimentation rate and C-reactive protein levels often times are significantly lower than baseline and do not normalize, and there is no specific cut-off predicting persistent infection. He recommended instead using an intraoperative aspiration for synovial fluid white blood cell count to identify persistent infection.
Della Valle CJ. Paper #66. Presented at: Current Concepts in Joint Replacement Winter Meeting; Dec. 12-15, 2012; Orlando, Fla.
Disclosure: Della Valle is a consultant for Biomet and Smith & Nephew, receives stock options for CD Diagnostics and receives research funds from Stryker.

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