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Orthopaedists face paradigm shift and new challenges in fight against infection
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PRAGUE — It is time for orthopedic surgeons to rethink their approach to the diagnosis, treatment and management of orthopedic infections, which are often associated with loose implants and other serious problems for patients, according to a presenter at the 16th EFORT Congress.
“The surgeon always must expect the unexpected,” Heinz Winkler, MD, of Vienna, said.
In today’s environment, “we all know about the biofilm issue,” he said, noting that orthopedic surgeons must be familiar with biofilm therapy and equipped to address nearly any type of infection scenario that affects their patients.
Heinz Winkler
During a session on musculoskeletal infections, Winkler, who is president of the European Bone and Joint Infection Society, said the biofilm concept is one that will guide the treatment of device-related orthopedic infections in the future. But, he noted that when it comes to septic revision surgery, it is becoming increasingly important for the surgeon to equally consider the control of infection through surgery along with the patient’s postoperative function when making clinical decisions.
Winkler recommended following the five basic requirements of revision for eliminating biofilm-associated infection. These requirements involve taking steps to localize, reduce and disrupt the infection, to fill any resultant defects, and to eliminate sessile bacteria within the defects using high concentrations of antibiotics in the most consistent way possible.
Localizing infection equates with identifying the infection and keeping it contained, he said.
“If you find them, then you have to reduce them. It is unavoidable doing some surgery and you should reduce the number by removing all identified bad material as radically as possible,” according to Winkler.
Furthermore, surgery disrupts the communication of the biofilm.
Debridement is another effective method that Winkler discussed, which he said both reduces and disrupts septic infection.
“You can evidently disrupt the biofilm by mechanical debridement and you also open a window of opportunity where the biofilm’s bacteria are more susceptible. With this debridement, and with the conventional antibiotics, we can remove the predominant amount of the bacterial load… We also can easily eliminate planktonic bacteria and we can disrupt the biofilm communication, but we cannot remove the microscopic remnants after the debridement,” he said.
“Once you have debrided the site, you should fill it. Dead space management is a very important part of septic surgery,” Winkler said.
He discussed some of the evidence against performing multi-stage revisions for infection and why he supports one-stage revisions. Because it is difficult, at best, to fully remove microscopic biofilm remnants with today’s surgical approaches, Winkler recommended that surgeons “aim at the minimum number of operations.“
One-stage procedures destroy the least amount of tissue and will ultimately provide patients with a better quality of life. This is because one-stage procedures are associated with shorter hospital stays and they improve the patient’s overall condition and reduce the infection burden should a two-stage revision ever be required, according to Winkler.
He noted that remnants of infection missed during debridement require high concentrations of antibiotics to disrupt them, which may be as much as 400 to 500 times the usual concentration of antibiotics.
Reference:
Winkler H. Changing paradigms in diagnosis and treatment of orthopaedic infections. Presented at: The 16th EFORT Congress; May 27-29 2015; Prague.
Disclosure: Winkler reports no relevant financial disclosures.