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Periprosthetic knee infections under examination at EFORT
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PRAGUE — The overall theme of this year’s EFORT Congress is infection, and the issue of periprosthetic knee infections has taken center stage.
An increasing problem, due to factors such as the growing number of total knee arthroscopy (TKA) procedures performed, increasing obesity rates, higher life expectancy and a lower age of patients undergoing TKA, periprosthetic infections come with a high cost to both patients and the overall health care system. William Jackson, BSc MBBS FRCS(Orth), illustrated this point in a press release from the 16th EFORT Congress.
“In the United Kingdom, the total burden caused by infections has risen by 92% over the past 5 years and will continue to increase exponentially,” Jackson said. “Treating infections in [TKA] can cost up to £70,000 in each case, exposing the British health care system to costs of around £160 million, or €220 million, each year.”
Carlo L. Romano, MD, talked about the current difficulty of handling these infections.
“Since surgical treatment of periprosthetic infections is highly complex and quite expensive, it calls for specially trained medical experts and dedicated facilities,” Romano said in the release. “At the moment, there is no European standard in place, and operations are often conducted by surgeons who only encounter one or two such cases each year. This raises the risk of incorrect diagnosis and treatment, which in turn leads to the additional costs associated with managing complications.”
Though most periprosthetic infections are treated via two-stage revision, one possible alternative is antibiotic cement, which was shown in a study presented at the EFORT Congress to reduce the risk of re-revision in knee endoprostheses by approximately 45%.
Jackson noted debridement, antibiotics and implant retention (DAIR) is another possible treatment.
“This approach allowed us to achieve new levels of infection control, an 80% survival rate on components after 8 years, and the functional outcome is akin to that of a complication-free joint replacement surgery,” he said in the release.
Romano also noted a shift in treatment for these infections.
“The difference in infection rates between one-stage and two-stage procedures is lower than previously thought,” Romano said in the release. “As recently as 3 years ago, we still believed that protection from infection was around 10% higher with a two-stage approach. [One-stage revision] reduces the amount of time spent in hospital and reduces the financial burden on the health care system.”
Additionally, Romano said, use of cement-free implants in a single-stage revision is supported by the availability of antibacterial coatings, such as DAC hydrogel. This, in turn, means implants are able to be removed with greater ease in the event of a malfunction than long-stem cemented revision implants, which were previously required for single-stage revisions.
However, a two-stage approach may still be preferable in cases where the pathogen is unknown, or in cases where the infections are particularly long-lasting and diffuse, as a double procedure may be better-suited to removing all of the infected tissue, according to Romano.
Romano expressed optimism that new antibacterial coatings may help cut bacterial growth on the implant by more than 90%.
“In-vivo studies demonstrate its effectiveness in reducing implant-related infection, even in animal models with high bacterial contamination,” he said in the release.
Also assisting in this process will be advancements in diagnostics, where new antibiofilm agents, which are used to rid implants of bacteria, may have the potential to completely change sampling activities and procedures surrounding non-functional prostheses, according to Romano.
Reference: www.efort.org.