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Delegates seek better care of patients with orthopedic infections through discussion, consensus
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PHILADELPHIA — Several hundred musculoskeletal and infection professionals from 98 countries joined with Jefferson Health and Rothman Institute experts this week at the International Consensus Meeting on Musculoskeletal Infection to convey their judgment on issues of prosthetic joint infection that continue to challenge the orthopedic community and to develop a consensus document that can be used to improve the care of patients affected by musculoskeletal infection.
“The second International Consensus Meeting on Musculoskeletal Infection will differ from the first meeting held in 2013,” Javad Parvizi, MD, FRCS, told Healio.com/Orthopedics.
It will involve delegates from orthopedic subspecialties in spine, trauma, foot and ankle, shoulder and elbow, oncology, pediatrics and sports, said Parvizi, an Orthopedics Today Editorial Board Member, who co-chaired the meeting with Thorsten Gehrke, MD, of Hamburg.
The meeting will culminate in about 35,000 copies of a book that presents the meeting’s outcomes in about 17 languages, Parvizi said.
Pennsylvania Sen. Larry M. Farnese Jr., Mark Tykocinski, MD, dean of Sydney Kimmel Medical College at Thomas Jefferson University, and Richard Webster, RN, MSN, NEA-BC, chief operating officer of Thomas Jefferson University Hospitals, delivered remarks on July 26, welcoming attendees on the second day of the meeting when the voting process first got underway.
What is decided at a meeting like this “truly does change care,” Webster said.
Votes in the morning of July 26 covered such topics as the effect on infection rates from prevention methods related to the patient, surgeon and operative environment, and the best, most effective diagnostic methods.
The results of one morning vote was indicative of the challenges delegates face. Some 89% of voting delegates agreed and 5% of voting delegates disagreed that use of tranexamic acid (TXA) reduces a patient’s risk of infection. For this question, 6% of delegates abstained from voting.
Jan A.N. Verhaar, MD, PhD, professor of orthopedics and chair of the department of orthopedic surgery at Erasmus University Medical Center in Rotterdam, The Netherlands, told Healio.com/Orthopedics the conundrum with a meeting like this lies in the fact that this question focused about a strategy that, in itself, is unrelated to musculoskeletal infection, but one that undoubtedly requires discussion.
The reality is the risk of infection may indeed be greater with the kind of more-involved orthopedic procedures that may involve the need for a transfusion and use of TXA, Verhaar, an Orthopaedics Today Europe Editorial Board Member, noted. However, he said there is little, if any, direct relationship between the use of TXA and musculoskeletal or periprosthetic joint infection.
The remainder of the day was planned to include voting on more general questions and continued discussion of hip and knee arthroplasty issues that were addressed the first day of the meeting. – by Susan M. Rapp
References:
General assembly: Voting on general questions. Presented at: International Consensus Meeting on Musculoskeletal Infection; July 25-27, 2018; Philadelphia.
Perspective
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Panayiotis Papagelopoulos, MD, DSc, FACS
For first time more than 30 orthopedic oncology surgeons were delegates at the International Consensus Meeting on Periprosthetic Joint Infections this year in Philadelphia. Among them, many members of the MSTS and ISOLS.
We discussed more than 30 topics and questions specific on musculoskeletal oncology. All published work was identified and numerous recommendations were determined based on high-level evidence. Among the topics discussed were:
1. Do we need to evaluate the gut and skin microbiome of patients after chemotherapy to assess the risk for potential infection after endoprosthetic reconstruction?
2. Does the type of fixation (cemented vs. uncemented) of an oncologic endoprosthesis influence the incidence of subsequent SSI/PJI?
3. Does the type, dose, and duration of antibiotic prophylaxis differ for patients undergoing oncologic endoprosthetic reconstruction compared to conventional TJA?
4. Does the use of incise draping with antibacterial agents (iodine) influence the risk for subsequent SSI/PJI in patients undergoing musculoskeletal tumor surgeries?
5. Does the use of iodine-coated or silver-coated implants make one-stage exchange arthroplasty possible for management of patients with infected oncologic endoprosthesis?
6. Does the use of soft tissue attachment meshes increase the risk for subsequent PJI in patients undergoing oncologic endoprosthetic reconstruction?
7. How many irrigation and debridements of an infected oncologic endoprosthesis are reasonable before consideration should be given to resection arthroplasty?
8. How should acute reinfection of an oncologic endoprosthesis be treated?
9. Is irrigation and debridement, and exchange of modular parts, a viable option for treatment of acute PJI involving oncologic endoprosthesis? If so, what are the indications?
10. Is there a correlation between operative time and the risk of subsequent SSI/PJI in patients undergoing tumor resection and endoprosthetic reconstruction? If so, should postoperative antibiotics be prolonged in these patients?
11. Is there a role for single stage exchange arthroplasty for patients with infected oncologic endoprosthesis?
12. Is there an increased risk for subsequent SSI/PJI when a drainage tube is used in musculoskeletal tumor surgery?
13. Should an absolute neutrophil count of >1000 mm3 be the minimum for patients undergoing limb salvage surgery after receiving chemotherapy?
14. Should endosprosthesis and/or allograft bone be soaked in antibtioic solution or antiseptic solutions prior to implantation in patients?
15. Should factors like preoperative radiation, soft tissue vs. bone resection, presence of metal vs. structural allograft, and other factors influence the dose and duration of antibiotic prophylaxis?
16. Should patients with an oncologic endoprosthesis in place receive antibtioic prophylaxis during dental procedures?
17. Should prophylactic antibiotics be started in patients with an oncologic endoprosthesis who develop neutropenia secondary to postoperative chemotherapy?
18. Should the management of PJI involving an oncologic endoprosthesis differ from that of conventional joint replacement prostheses?
19. Should the serum white cell count be taken into account prior to endoprosthetic reconstruction in patients who have undergone recent chemotherapy?
20. Should a coated prosthesis (silver/iodine) be used for reconstruction of patients undergoing primary bone tumour resection?
21. What are the significant risk factors for SSI/PJI of an oncologic endoprosthesis following resection of a malignant bone tumor?
22. What factors may improve the outcome of a two-stage exchange arthroplasty in patients with an infected oncologic endoprosthesis?
23. What irrigation solution and how much should be used during endoprosthetic reconstruction of a patient undergoing musculoskeletal tumor resection?
24. What is the best reconstruction technique for an infected allograft?
25. What is the best surgical treatment for management of a chronically infected oncologic endoprosthesis? Does this change if the patient is receiving or has received recent chemotherapy and/or irradiation?
26. What is the most optimal local antimicrobial delivery strategy during limb salvage: antibiotic cement, silver-coated implant, iodine-coated implant, topical vancomycin powder, injection of antibiotics via drain tubing, other?
27. What metrics should be used to determine the optimal timing of reimplantation for patients with a resected oncologic endoprosthesis?
28. What should be the time delay between preoperative chemo/radiotherapy and a surgical tumor resection in order to minimize incidence of SSI/PJI?
29. What strategies should be implemented to minimize the risk of SSI/PJI in patients who have received chemotherapy or radiation therapy and are undergoing endoprosthetic reconstruction?
30. What strategies, if any, should be used to minimize the risk of subsequent PJI/SSI in patients undergoing endoprosthetic reconstruction who are receiving or have received chemotherapy and/or radiation?
31. What type, dose, and duration of prophylactic antibiotic(s) should be administered to patients undergoing oncologic endoprosthetic reconstruction who have received or will be receiving chemotherapy and/or radiation?
32. When should a surgical drain be removed to minimize the risk of subsequent SSI/PJI in patients who have received endoprosthetic reconstruction following resection of a musculoskeletal tumor?
There are still questions with unknown answers due to the lack of evidence; however, the delegates were able to achieve unanimous consensus on significant topics such as antibiotic prophylaxis for major tumor surgery and management of infected megaprostheses. Many subjects are still open for discussion and further research.
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