Methicillin-resistant Staphylococcus aureus in TKA treated with revision and direct intra-articular antibiotic infusion

Abstract

Background: Resistant organisms are difficult to eradicate in infected total knee arthroplasty. While most surgeons use antibiotic-impregnated cement in these revisions, the delivery of the drug in adequate doses is limited in penetration and duration. Direct infusion is an alternate technique.

Questions/purposes: We asked whether single-stage revision and direct antibiotic infusion for infected TKA would control infection in patients with methicillin-resistant Staphylococcus aureus (MRSA) infections.

Methods: We retrospectively reviewed 18 patients (18 knees) with MRSA with one-stage revision protocol that included débridement, uncemented revision of total knee components, and intraarticular infusion of 500 mg vancomycin via Hickman catheter once or twice daily for 6 weeks; we used no intravenous antibiotics after the first 24 hours. We monitored serum vancomycin levels to maintain levels between 3 and 10 microg/mL. Minimum followup was 27 months (range, 27–75 months). Mean followup was 62 months, (range, 27–96 months).

Results: Infection was controlled at last followup in all but one patient with a recurrence of the MRSA. The patient was reoperated at 5 months; a necrotic bone fragment was removed, the knee was débrided and revised, and the antibiotic infusion protocol readministered. The patient remained free of infection 42 months postoperatively. At 2-year followup, the mean Knee Society score was 83. We observed no radiographic evidence of implant migration.

Conclusions: One-stage revision and 6 weeks of intraarticular vancomycin administration controlled infection in MRSA infected TKA with no apparent complications.

Level of evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Figures

Fig. 1

A preoperative lateral radiograph shows an infected TKA with evidence of deep cement penetration and massive bone loss in the femur. Reprinted with permission and © 2008 Elsevier from Whiteside LA. Two-stage exchange for infected TKA—opposes. Semin Arthroplasty. 2008;19:121–125 [51].

Fig. 2

A preoperative anteroposterior radiograph of the tibia in the same knee as Fig. 1 also shows bone loss and cement penetration along the tibial stem. Reprinted with permission and © 2008 Elsevier from Whiteside LA. Two-stage exchange for infected TKA—opposes. Semin Arthroplasty. 2008;19:121–125 [51].

Fig. 3A–D

This drawing illustrates the injection portals (A) that are outside the skin, the fibrous cuffs that are approximately 5 mm deep to the dermis (B), the catheters inside the synovial cavity of the knee (C), and outflow of the antibiotic through the synovial membrane and into the regional veins (D). The fibrous cuffs seal the catheters so that contaminants do not enter the knee and joint fluid does not leak out.

Fig. 4

An anteroposterior radiograph shows the femur for the same knee as in Fig. 1 at 1 year postoperatively. Bone healing has occurred and the cementless implant is stable. Reprinted with permission and © 2008 Elsevier from Whiteside LA. Two-stage exchange for infected TKA—opposes. Semin Arthroplasty. 2008;19:121–125 [51].

Fig. 5

An anteroposterior radiograph shows the tibia of the same knee as in Fig. 1 at 1 year postoperatively. The long-stem tibial component is stable and evidence of bone healing is apparent. Reprinted with permission and © 2008 Elsevier from Whiteside LA. Two-stage exchange for infected TKA—opposes. Semin Arthroplasty. 2008;19:121–125 [51].