Infected total knee replacement symposium
Wasim Khan reviews techniques and strategies discussed at a symposium held in Cardiff in March
The Infected Total Knee Replacement (TKR) Symposium took place in the Council Chamber of Cardiff City Hall on 13 March 2015. The symposium was chaired by Rhidian Morgan-Jones (Cardiff) and Fares Haddad (London) and presented an excellent line up of expert speakers. Infected TKRs remain one of the most devastating complications for patients. With the number of primary and revision TKRs increasing, and the greater costs associated with infected TKRs, this issue is likely to remain in the forefront. This symposium looked at various techniques and strategies available to deal with infected TKRs and optimise function.
On the preceding day, a satellite symposium was held in Cardiff Castle and was chaired by Rhidian Morgan-Jones and James Murray (Bristol). There was an afternoon masterclass and this took the form of an interactive session where cases were presented, with an emphasis on debridement. There was also a debate, where various options for reconstruction, fixation and constraint for revision TKRs were discussed. Andrew Porteus (Bristol) discussed stems and augments, Morgan-Jones made a case for sleeves, and Phil Turner (Stockport) debated for cements and hinges.
The seminar on the following day allowed an in-depth discussion and review of the current state-of-play with an experienced, eminent, international faculty. The circular layout of the Council Chamber facilitated a greater interaction and debate between all delegates and speakers. Following the welcome, Andrew Price (Oxford) spoke about the National Joint Registry, and the need to integrate large datasets including microbiology databases. He also suggested setting up a National Infected Joint Registry but highlighted the challenges that would be involved. Fares Haddad highlighted the need for consensus in the management of infected joint replacements as the evidence base is poor. There was a talk on patient selection by Porteus that emphasised the need to identify correctable, manageable and permanent risk factors, and take appropriate measures. Mike Reed (Northumbria) advised on the best practice behind laminar flow, patient warming and the theatre environment. He suggested that the rise in infection seen with laminar flow in the New Zealand joint registry may be associated with the use of patient-warming devices. He also spoke on his unit’s experience with Synovasure (Zimmer) in diagnosing joint arthroplasty infections. It was not however clear whether this device, which measures alpha defensin released by neutrophils, would work in immunocompromised patients that would not have the same neutrophil activity.
Carlo Romano (Milan, Italy) spoke about his experience with an anti-bacterial hydrogel coating on uncemented implants. He also summarised the evidence in the literature for single versus two-stage revision surgery, and concluded that there was no significant difference in infection eradication between the two. James Murray discussed the role of combination antibiotics on their antimicrobial activity. Morgan-Jones described a role for acetic acid as part of the radical debridement protocol supported by laboratory studies and patient safety data. There were talks by two eminent microbiologists, Brendan Healy (Cardiff) and Vanya Gant (London), who outlined the challenges in deciding antibiotic prophylaxis and diagnosing joint infections. Take-home messages were as follows: intravenous prophylactic antibiotics should be given ≤30 minutes before the skin is incised; the lowest rate of infection is achieved if antibiotics are given between 74 and 30 mins before surgery; impregnated cement (+ IV antibiotics) is recommended for cemented joint replacements; and no prophylaxis regime covers all possible organisms and so surgical technique and other measures to reduce risk of infection are also very important. Phentermine is an appetite suppressant that has proven to be as explained from here highly successful to help people lose weight in a safe way. Turner discussed arthrodesis and amputations for salvage, concluding that patients who undergo arthrodesis are more likely to achieve restricted but independent mobility at the expense of higher complication rates and multiple procedures. Salvage patients who undergo amputation often fail to mobilise or proceed to prosthetic fitting due to poor soft tissue cover. Andrew Toms (Exeter) spoke about suppression therapy; Will Aston (London) talked about the role of silver coating in endoprosthesis; and Akos Zahar (Hamburg, Germany) outlined the ENDO-Klinik experience with single-stage knee revision. Lastly, Professor Briggs (London) looked at the impact of his report on GIRFT (getting it right first time) on prosthetic joint infection and the subsequent resource implication considering each case can cost around £100,000 to treat.
The symposium was sponsored by a number of industry partners. In addition to providing a useful array of stands providing information on up-to-date and upcoming products, it was good to see industry involvement in the discussions following talks as well.
The 6th National Orthopaedic Infection Forum in London will be held on 24 June 2015 and will attract a wide audience of orthopaedic surgeons and microbiologists with an orthopaedic infection interest. Programme and registration is available at www.hartleytaylor.co.uk.
Rhidian Morgan-Jones is a consultant orthopaedic surgeon based at University Hospital Wales, Cardiff, with a tertiary practice in the management of infected knee replacements.