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PJI in North America: Current Practices and Emerging Trends
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PJI in North America: Current Practices and Emerging Trends
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Segment:0 .
RHIDIAN MORGAN-JONES: And one of the things I've always thought is that it is geographically different around the world, and our European experience may not be directly applicable to North America or to Asia or elsewhere so I'm very interested in your thoughts on this. Simon, field is yours.
SIMON GARCEAU: Thank you very much for the introduction.
SIMON GARCEAU: OK, perfect. So. Hello. And thank you everyone from the Bone and Joint Infection Society and specifically also to Ian for inviting me to present today for your section on periprosthetic joint infections. I'm Simon Garceau. I'm an Orthopedic Surgeon working at the Ottawa Hospital in Canada as an adult joint reconstruction surgeon of the hip and knee and a member of our periprosthetic joint infection service.
SIMON GARCEAU: I was tasked today with providing you with an overview of PJI care in North America.
SIMON GARCEAU: And so I'll try to do that with a little bit of a Canadian spin on it. Next slide. So although I have some disclosures, really the most relevant disclosure for this presentation is that I've received research support from a company involved in the PJI irrigation solutions, notably NextScience.
SIMON GARCEAU: So first I'll provide a brief background about me as I don't have the same reach and circuit tour as my predecessor Dr. Professor Haddad, who you probably all know very well. Then we'll discuss the current North American models of care and where we're headed. Followed by since I'm Canadian, we'll discuss PJI regional care within Canada. And lastly, we'll highlight PJI research, which has led to regional evidence based changes in treatment patterns as well as National Collaborative efforts in PJI care.
SIMON GARCEAU: So first, a quick overview of who I am. I'm a French-Canadian who grew up in Quebec City, which is the French portion of Canada on the East Coast. I then completed my orthopedics training in Vancouver on the West Coast which is where Ian is currently situated doing this fellowship. Followed by some fellowships and adult joint reconstruction in New York City and Toronto, which is where I really developed both an interest and an exposure to PJI care and research.
SIMON GARCEAU: So now let's focus on current and emerging models of care in North America. There is this decisive evidence for several orthopedic procedures that surgery performed at high volume centers by experienced surgeons translates to superior outcomes. This is certainly true as well in PJI care, including for procedures that have been traditionally deemed as quote unquote simple, such as debridement, antibiotics and implant retention, which we assessed at our center, where the odds of success was known to be two and a half times greater if a patient was treated by surgeons with subspecialty training in arthroplasty.
SIMON GARCEAU: And so traditional models of care in North America have included both total and partial care of PJI patients following diagnosis at non specialty centers which we know also leads to inferior outcomes, which is highlighted in the study performed at the University of Toronto. As such, similar to what has or is being done in Europe,
SIMON GARCEAU: the North American Standard for PJI care is shifting with the focus on early and early referral to specialty centers to obtain definitive care. With a focus on a concept that I'm sure in the NHS you're all too very familiar with this concept of quote unquote getting it right the first time. Furthermore, there has been a shift within tertiary referral care for PJI, albeit slower than probably in Europe towards treating PJI like tumors.
SIMON GARCEAU: So that's to say via highly organized multidisciplinary care at quaternary PJI specialty referral centers. Such models have been developed with the patient at the center of a core team of Allied Health Care professionals, in addition to regular consultation with additional key players. Stability this model, this is how we've organized our multidisciplinary specialty service at the Ottawa Hospital, which is both the first and only of its kind in Canada, and also the first to develop a fellowship program with a focus on PJI care.
SIMON GARCEAU: This service is led by 3 orthopedic surgeons with clinical research led by my colleague, who you probably Dr. George Grammatopoulos and myself. And PJI basic science research led by another one of my colleagues, Dr. Hesham Abdelbary. From basic science perspective, our center has a PJI focused laboratory led by Dr. Abdelbary with recent work in developing a validated rat model for PJI using monoblock 3D printed titanium hemiarthroplasty, which won the 2021 Frank Stinchfield award from the Hip Society.
SIMON GARCEAU: So just to put things into perspective, these implants are really, really, really small and that's a skill. The picture there outlining the size of the implant. Certainly however, Canadian health care is quite different than that of our American counterparts. Notably, we are, for the most part, a fully publicly funded health care system.
SIMON GARCEAU: And as such, there are significant differences in PJI treatment models and the challenges we face in providing care. A big issue when there is a limited pool of taxpayer funds are the costs and resource utilization incurred through providing multidisciplinary PJI care. So looking at the direct inpatient cost of PJI care for example, this represents a cost that's two to three times the cost of a similar aseptic revision.
SIMON GARCEAU: Moreover, when we look at our own data, data from the Canadian Institute for Health Information determined that PJI is the top reason for early revision surgery within the country, or in other words, one out of every three revisions performed. Similarly, the average cost of a two stage revision in Canada is roughly about 35,000 CAD. But it can reach astronomical numbers or greater than $1 million when patients stay for a prolonged period of time and require multiple surgeries with greater than 50% of the cost resulting from inpatient care.
SIMON GARCEAU: So this is simply just a snapshot highlighting the length of stay of a few of the patients that are currently on our PJI service. As you can see, patients are staying very long periods of time and this is probably one of the shorter lists that we've had in a while. And so it is very costly to the hospital and to our health care system.
SIMON GARCEAU: So due to the nature of our health care system in Canada, we certainly see many parallels with our European counterparts and have leveraged elements that have worked elsewhere with similar budgetary constraints. I'm glad Professor Haddad mentioned this model in France, so one such model that has been that of France, where care is delivered in a regional fashion as reported by one of our colleagues, Tristan Ferry in Lyon, where care is provided from a regional perspective with champion or coronary care provided at the same reference disinfection of the complex as well as multiple smaller regional partners highlighted here as corresponding partners that communicate with these champion centers.
SIMON GARCEAU: The goal of regional care therefore, is to facilitate multidisciplinary care, facilitate referrals and disseminate information and guidelines to regional centers, also serving as a platform for research and providing graduate level bone and joint infections certification, which is a similar model that we've attempted to adopt in our region.
SIMON GARCEAU: Furthermore, to address the major challenge of financial disincentive faced in providing multidisciplinary care via PJI specialty centers, an alternative funding plan has been proposed, which we similarly hope to adopt regionally. This model is based on a point system focusing on host criteria, microbiological criteria, surgical criteria as well as relapse. Such a system highlights the need for more equitable funding for more complex patients.
SIMON GARCEAU: Regionally, we're developing a similar system of PJI care under the umbrella of a term that we've coined a "community of care". The PJI service is organized in a similar fashion to TOH with a surgeon on call every day of the week to provide guidance and accept direct, streamlined referrals with care provided through all phases of treatment in a standardized fashion.
SIMON GARCEAU: So some key points of the service include. One multidisciplinary clinics. Two, dedicated specialty surgeon PJI OR's every week. And three, standardization of care for PJI patients. To further outline the model of regional care in Canada. This is where we're situated, in the South East of the country. And within this small ellipse that I've drawn here, we have a concentration of about 50% of the entire population of the country.
SIMON GARCEAU: And so that equates to about 40 million people. Within this densely populated region, we service all of Eastern Ontario so essentially everything east of Toronto that you see in the bottom left corner of the map here going into the neighboring province of Quebec, which is the French part of the country. To put this into perspective, this area represents a population slightly below that of Manchester and includes multiple community orthopedic hospitals outlined by yellow stars here, as well as a number of affiliated drawn in red here and unaffiliated drawn in blue academic centers.
SIMON GARCEAU: Such a regional initiative has allowed for the development of prospective PJI database, allowing us to track PJI outcomes in real time through the collection of patient reported outcome measures and mental health scores, as well as quality improvement metrics. This initiative has allowed us to engage in data driven, collaborative work with other centers in North America, notably the United States.
SIMON GARCEAU: And has led to evidence based changes in care within our region, notably in how we treat acute infections of the hip. In this retrospective study from our PJI database, we assessed over 100 patients with acute PJI of the hip, treated with either debridement, antibiotics and implant retention versus partial or complete single stage revision surgery.
SIMON GARCEAU: We did a univariate analysis followed by a multivariate regression analysis for factors associated with failure defined as re-operation for recalcitrant prosthetic joint infection. We noted that partial or complete single stage revision was associated with notably a 4 and 1/2 fold increase in the odds of treatment success compared to as defined as tier one or tier two, according to the MSIS reporting tool.
SIMON GARCEAU: This is further highlighted in our survival analysis that demonstrates the change in success over time. As such, from a regional perspective for acute infections of the hip, our preference has been revision arthroplasty over DAIR whenever feasible, and this is especially true in the early post-operative period when cementless components can be easily exchanged or usually within the first 10 weeks after surgery.
SIMON GARCEAU: Similarly, regional trends in the treatment of hemiarthroplasty PJI have changed. As you know, this is a population, which is typically frail and comorbid and furthermore as limited reserve for additional surgery. And where treatment and where treatment success rates have traditionally been significantly lower than that for primary joint replacement PJI. And so the aim of this study performed by
SIMON GARCEAU: my colleague Dr. Grammatopoulos, was to assess factors associated with treatment outcomes following hemiarthroplasty PJI. In this study, we included a total of 2000 patients and divided into two cohorts based on the development of postoperative PJI. A notable from this study, from the treatment perspective is the low success rate of DAIR as a treatment option and the markedly superior success rate of treatment strategy
SIMON GARCEAU: we have now employed as our standard of care within the region, which is single stage revision with a conversion to total hip arthroplasty. This technique has been recently published as part of a JBJS review which is highlighted in this figure where A, a smooth, polished, cemented stem is root. B, all visible proximal cement is burred out.
SIMON GARCEAU: C, acetabular cartilage and superficial bone, both of which can harbor bacteria is reamed and D, a cement and cement technique using a high dose antibiotic cement is used for the stem and a cemented liner is then inserted. And lastly, on a national level, there's been an increased interest in PJI collaborative research efforts, most notably in the area of PJI prevention, specifically surrounding irrigation solutions.
SIMON GARCEAU: So we're currently performing a study across nine Canadian academic sites that is fully endorsed by the Canadian arthroplasty society. Which is an RCT and primary total joint arthroplasty comparing dilute betadine to a pre formulated acidic solution known as experience. The solutions and order list preformulated clear and colorless product.
SIMON GARCEAU: The primary outcome of this study is the rate of acute infection as defined as infection within 90 days post operatively and we'll also be assessing a multitude of secondary outcomes as listed here. And this also includes patient reported outcome measures. The aim of the study is to recruit a total of 7,600 hip and knee arthroplasties.
SIMON GARCEAU: And we're currently, in terms of recruiting recruitment, nearing about 1,000 patients having been recruited. Lastly, we're currently working to enhance our presence in phage therapy research, with our center being the first to administer phage therapy in a PJI patient in Canada. My colleague recently obtained a significant amount of grant funding with the active partnerships in Canada as well as abroad, including in France with Tristan Ferry.
SIMON GARCEAU: Thank you very much. I'm happy to answer any questions.
RHIDIAN MORGAN-JONES: Simon, that was excellent. Thank you so much. I always find it instructive to hear how different regions are coping with infection and the management plans you have and listening. You talk about your regional model and how you're centralizing care, and that mimics what we are trying to do in the UK.
RHIDIAN MORGAN-JONES: And the question I would have follows on from Fares's comments about do your colleagues outside of Ottawa buy in readily to sending patients. Is there any risk of them not sending a patient because of whatever factors, ego, personality, or do you find everybody's bought into your structure?
SIMON GARCEAU: So what I would say that's interesting and why I wanted to make a differentiation between perhaps the US as well as Canada.
SIMON GARCEAU: Having trained in the US for a year, you kind of see some of the differences in how they're organized, especially around New York City, where you have a multitude of centers and everyone is trying to keep patients within their own care. When you're looking at a region in when you're looking at a regional network in Canada, publicly funded, so there really isn't as much of an incentive to keep patients locally.
SIMON GARCEAU: And certainly what we've been promoting and we've had regional meetings about this concept of early referral. And I think at first there was for sure this issue with, as you outlined ego and I'm able to do this and I'm a plastic surgeon. But I think the key part that we've emphasized with our regional partners is it's not just the technical ability of the surgeon, it's the entirety of the team.
SIMON GARCEAU: So when you have surgeons that are doing this day in and day out, technique becomes very important. Set up, you know having a dual setup in the OR, clean and dirty, which we've standardized at our center and having an infectious disease specialist that's specialized in PJI, and understands what we're trying to achieve as well as the multidisciplinary team meetings we have every week with our Allied Health Care professionals is really what's making a difference.
SIMON GARCEAU: And so we're trying to work to build these networks across Canada but certainly it's the difficult part is also getting the buy in from all the Allied Health Care professionals, notably infectious diseases, which were quite lucky to have had at our center.
RHIDIAN MORGAN-JONES: Thank you. I'm going to use one phrase that's really stuck with me, community of care and putting your patients in the center of this community and looking after them.
RHIDIAN MORGAN-JONES: That's a really nice concept.
SIMON GARCEAU: Yeah, so I fully agree as well with what Professor Haddad said is certainly we've noticed a big change not only just in PJI care, but in orthopedics in general, where patient reported outcomes, the patient perspective is certainly valued, including when you're applying for grant funding for anything you all you always have to have nowadays. The patient health care advocates as part of the planning for research studies, also planning care.
SIMON GARCEAU: So it's certainly something that we've valued.
RHIDIAN MORGAN-JONES: Good. So Ian, are there any questions from the audience?
RHIDIAN MORGAN-JONES: No, we don't have any questions from the audience as of yet. Thank you very much, Simon, that was a superb talk. Very impressive to hear about you setting up the first PJI center in Canada. I'm sure that was a lot of work, and I'm sure that would be an excellent fellowship for anyone interested.
IAN KENNEDY: Just in interest of time, Rhidian.
Segment:0 .
RHIDIAN MORGAN-JONES: And one of the things I've always thought is that it is geographically different around the world, and our European experience may not be directly applicable to North America or to Asia or elsewhere so I'm very interested in your thoughts on this. Simon, field is yours.
SIMON GARCEAU: Thank you very much for the introduction.
SIMON GARCEAU: OK, perfect. So. Hello. And thank you everyone from the Bone and Joint Infection Society and specifically also to Ian for inviting me to present today for your section on periprosthetic joint infections. I'm Simon Garceau. I'm an Orthopedic Surgeon working at the Ottawa Hospital in Canada as an adult joint reconstruction surgeon of the hip and knee and a member of our periprosthetic joint infection service.
SIMON GARCEAU: I was tasked today with providing you with an overview of PJI care in North America.
SIMON GARCEAU: And so I'll try to do that with a little bit of a Canadian spin on it. Next slide. So although I have some disclosures, really the most relevant disclosure for this presentation is that I've received research support from a company involved in the PJI irrigation solutions, notably NextScience.
SIMON GARCEAU: So first I'll provide a brief background about me as I don't have the same reach and circuit tour as my predecessor Dr. Professor Haddad, who you probably all know very well. Then we'll discuss the current North American models of care and where we're headed. Followed by since I'm Canadian, we'll discuss PJI regional care within Canada. And lastly, we'll highlight PJI research, which has led to regional evidence based changes in treatment patterns as well as National Collaborative efforts in PJI care.
SIMON GARCEAU: So first, a quick overview of who I am. I'm a French-Canadian who grew up in Quebec City, which is the French portion of Canada on the East Coast. I then completed my orthopedics training in Vancouver on the West Coast which is where Ian is currently situated doing this fellowship. Followed by some fellowships and adult joint reconstruction in New York City and Toronto, which is where I really developed both an interest and an exposure to PJI care and research.
SIMON GARCEAU: So now let's focus on current and emerging models of care in North America. There is this decisive evidence for several orthopedic procedures that surgery performed at high volume centers by experienced surgeons translates to superior outcomes. This is certainly true as well in PJI care, including for procedures that have been traditionally deemed as quote unquote simple, such as debridement, antibiotics and implant retention, which we assessed at our center, where the odds of success was known to be two and a half times greater if a patient was treated by surgeons with subspecialty training in arthroplasty.
SIMON GARCEAU: And so traditional models of care in North America have included both total and partial care of PJI patients following diagnosis at non specialty centers which we know also leads to inferior outcomes, which is highlighted in the study performed at the University of Toronto. As such, similar to what has or is being done in Europe,
SIMON GARCEAU: the North American Standard for PJI care is shifting with the focus on early and early referral to specialty centers to obtain definitive care. With a focus on a concept that I'm sure in the NHS you're all too very familiar with this concept of quote unquote getting it right the first time. Furthermore, there has been a shift within tertiary referral care for PJI, albeit slower than probably in Europe towards treating PJI like tumors.
SIMON GARCEAU: So that's to say via highly organized multidisciplinary care at quaternary PJI specialty referral centers. Such models have been developed with the patient at the center of a core team of Allied Health Care professionals, in addition to regular consultation with additional key players. Stability this model, this is how we've organized our multidisciplinary specialty service at the Ottawa Hospital, which is both the first and only of its kind in Canada, and also the first to develop a fellowship program with a focus on PJI care.
SIMON GARCEAU: This service is led by 3 orthopedic surgeons with clinical research led by my colleague, who you probably Dr. George Grammatopoulos and myself. And PJI basic science research led by another one of my colleagues, Dr. Hesham Abdelbary. From basic science perspective, our center has a PJI focused laboratory led by Dr. Abdelbary with recent work in developing a validated rat model for PJI using monoblock 3D printed titanium hemiarthroplasty, which won the 2021 Frank Stinchfield award from the Hip Society.
SIMON GARCEAU: So just to put things into perspective, these implants are really, really, really small and that's a skill. The picture there outlining the size of the implant. Certainly however, Canadian health care is quite different than that of our American counterparts. Notably, we are, for the most part, a fully publicly funded health care system.
SIMON GARCEAU: And as such, there are significant differences in PJI treatment models and the challenges we face in providing care. A big issue when there is a limited pool of taxpayer funds are the costs and resource utilization incurred through providing multidisciplinary PJI care. So looking at the direct inpatient cost of PJI care for example, this represents a cost that's two to three times the cost of a similar aseptic revision.
SIMON GARCEAU: Moreover, when we look at our own data, data from the Canadian Institute for Health Information determined that PJI is the top reason for early revision surgery within the country, or in other words, one out of every three revisions performed. Similarly, the average cost of a two stage revision in Canada is roughly about 35,000 CAD. But it can reach astronomical numbers or greater than $1 million when patients stay for a prolonged period of time and require multiple surgeries with greater than 50% of the cost resulting from inpatient care.
SIMON GARCEAU: So this is simply just a snapshot highlighting the length of stay of a few of the patients that are currently on our PJI service. As you can see, patients are staying very long periods of time and this is probably one of the shorter lists that we've had in a while. And so it is very costly to the hospital and to our health care system.
SIMON GARCEAU: So due to the nature of our health care system in Canada, we certainly see many parallels with our European counterparts and have leveraged elements that have worked elsewhere with similar budgetary constraints. I'm glad Professor Haddad mentioned this model in France, so one such model that has been that of France, where care is delivered in a regional fashion as reported by one of our colleagues, Tristan Ferry in Lyon, where care is provided from a regional perspective with champion or coronary care provided at the same reference disinfection of the complex as well as multiple smaller regional partners highlighted here as corresponding partners that communicate with these champion centers.
SIMON GARCEAU: The goal of regional care therefore, is to facilitate multidisciplinary care, facilitate referrals and disseminate information and guidelines to regional centers, also serving as a platform for research and providing graduate level bone and joint infections certification, which is a similar model that we've attempted to adopt in our region.
SIMON GARCEAU: Furthermore, to address the major challenge of financial disincentive faced in providing multidisciplinary care via PJI specialty centers, an alternative funding plan has been proposed, which we similarly hope to adopt regionally. This model is based on a point system focusing on host criteria, microbiological criteria, surgical criteria as well as relapse. Such a system highlights the need for more equitable funding for more complex patients.
SIMON GARCEAU: Regionally, we're developing a similar system of PJI care under the umbrella of a term that we've coined a "community of care". The PJI service is organized in a similar fashion to TOH with a surgeon on call every day of the week to provide guidance and accept direct, streamlined referrals with care provided through all phases of treatment in a standardized fashion.
SIMON GARCEAU: So some key points of the service include. One multidisciplinary clinics. Two, dedicated specialty surgeon PJI OR's every week. And three, standardization of care for PJI patients. To further outline the model of regional care in Canada. This is where we're situated, in the South East of the country. And within this small ellipse that I've drawn here, we have a concentration of about 50% of the entire population of the country.
SIMON GARCEAU: And so that equates to about 40 million people. Within this densely populated region, we service all of Eastern Ontario so essentially everything east of Toronto that you see in the bottom left corner of the map here going into the neighboring province of Quebec, which is the French part of the country. To put this into perspective, this area represents a population slightly below that of Manchester and includes multiple community orthopedic hospitals outlined by yellow stars here, as well as a number of affiliated drawn in red here and unaffiliated drawn in blue academic centers.
SIMON GARCEAU: Such a regional initiative has allowed for the development of prospective PJI database, allowing us to track PJI outcomes in real time through the collection of patient reported outcome measures and mental health scores, as well as quality improvement metrics. This initiative has allowed us to engage in data driven, collaborative work with other centers in North America, notably the United States.
SIMON GARCEAU: And has led to evidence based changes in care within our region, notably in how we treat acute infections of the hip. In this retrospective study from our PJI database, we assessed over 100 patients with acute PJI of the hip, treated with either debridement, antibiotics and implant retention versus partial or complete single stage revision surgery.
SIMON GARCEAU: We did a univariate analysis followed by a multivariate regression analysis for factors associated with failure defined as re-operation for recalcitrant prosthetic joint infection. We noted that partial or complete single stage revision was associated with notably a 4 and 1/2 fold increase in the odds of treatment success compared to as defined as tier one or tier two, according to the MSIS reporting tool.
SIMON GARCEAU: This is further highlighted in our survival analysis that demonstrates the change in success over time. As such, from a regional perspective for acute infections of the hip, our preference has been revision arthroplasty over DAIR whenever feasible, and this is especially true in the early post-operative period when cementless components can be easily exchanged or usually within the first 10 weeks after surgery.
SIMON GARCEAU: Similarly, regional trends in the treatment of hemiarthroplasty PJI have changed. As you know, this is a population, which is typically frail and comorbid and furthermore as limited reserve for additional surgery. And where treatment and where treatment success rates have traditionally been significantly lower than that for primary joint replacement PJI. And so the aim of this study performed by
SIMON GARCEAU: my colleague Dr. Grammatopoulos, was to assess factors associated with treatment outcomes following hemiarthroplasty PJI. In this study, we included a total of 2000 patients and divided into two cohorts based on the development of postoperative PJI. A notable from this study, from the treatment perspective is the low success rate of DAIR as a treatment option and the markedly superior success rate of treatment strategy
SIMON GARCEAU: we have now employed as our standard of care within the region, which is single stage revision with a conversion to total hip arthroplasty. This technique has been recently published as part of a JBJS review which is highlighted in this figure where A, a smooth, polished, cemented stem is root. B, all visible proximal cement is burred out.
SIMON GARCEAU: C, acetabular cartilage and superficial bone, both of which can harbor bacteria is reamed and D, a cement and cement technique using a high dose antibiotic cement is used for the stem and a cemented liner is then inserted. And lastly, on a national level, there's been an increased interest in PJI collaborative research efforts, most notably in the area of PJI prevention, specifically surrounding irrigation solutions.
SIMON GARCEAU: So we're currently performing a study across nine Canadian academic sites that is fully endorsed by the Canadian arthroplasty society. Which is an RCT and primary total joint arthroplasty comparing dilute betadine to a pre formulated acidic solution known as experience. The solutions and order list preformulated clear and colorless product.
SIMON GARCEAU: The primary outcome of this study is the rate of acute infection as defined as infection within 90 days post operatively and we'll also be assessing a multitude of secondary outcomes as listed here. And this also includes patient reported outcome measures. The aim of the study is to recruit a total of 7,600 hip and knee arthroplasties.
SIMON GARCEAU: And we're currently, in terms of recruiting recruitment, nearing about 1,000 patients having been recruited. Lastly, we're currently working to enhance our presence in phage therapy research, with our center being the first to administer phage therapy in a PJI patient in Canada. My colleague recently obtained a significant amount of grant funding with the active partnerships in Canada as well as abroad, including in France with Tristan Ferry.
SIMON GARCEAU: Thank you very much. I'm happy to answer any questions.
RHIDIAN MORGAN-JONES: Simon, that was excellent. Thank you so much. I always find it instructive to hear how different regions are coping with infection and the management plans you have and listening. You talk about your regional model and how you're centralizing care, and that mimics what we are trying to do in the UK.
RHIDIAN MORGAN-JONES: And the question I would have follows on from Fares's comments about do your colleagues outside of Ottawa buy in readily to sending patients. Is there any risk of them not sending a patient because of whatever factors, ego, personality, or do you find everybody's bought into your structure?
SIMON GARCEAU: So what I would say that's interesting and why I wanted to make a differentiation between perhaps the US as well as Canada.
SIMON GARCEAU: Having trained in the US for a year, you kind of see some of the differences in how they're organized, especially around New York City, where you have a multitude of centers and everyone is trying to keep patients within their own care. When you're looking at a region in when you're looking at a regional network in Canada, publicly funded, so there really isn't as much of an incentive to keep patients locally.
SIMON GARCEAU: And certainly what we've been promoting and we've had regional meetings about this concept of early referral. And I think at first there was for sure this issue with, as you outlined ego and I'm able to do this and I'm a plastic surgeon. But I think the key part that we've emphasized with our regional partners is it's not just the technical ability of the surgeon, it's the entirety of the team.
SIMON GARCEAU: So when you have surgeons that are doing this day in and day out, technique becomes very important. Set up, you know having a dual setup in the OR, clean and dirty, which we've standardized at our center and having an infectious disease specialist that's specialized in PJI, and understands what we're trying to achieve as well as the multidisciplinary team meetings we have every week with our Allied Health Care professionals is really what's making a difference.
SIMON GARCEAU: And so we're trying to work to build these networks across Canada but certainly it's the difficult part is also getting the buy in from all the Allied Health Care professionals, notably infectious diseases, which were quite lucky to have had at our center.
RHIDIAN MORGAN-JONES: Thank you. I'm going to use one phrase that's really stuck with me, community of care and putting your patients in the center of this community and looking after them.
RHIDIAN MORGAN-JONES: That's a really nice concept.
SIMON GARCEAU: Yeah, so I fully agree as well with what Professor Haddad said is certainly we've noticed a big change not only just in PJI care, but in orthopedics in general, where patient reported outcomes, the patient perspective is certainly valued, including when you're applying for grant funding for anything you all you always have to have nowadays. The patient health care advocates as part of the planning for research studies, also planning care.
SIMON GARCEAU: So it's certainly something that we've valued.
RHIDIAN MORGAN-JONES: Good. So Ian, are there any questions from the audience?
RHIDIAN MORGAN-JONES: No, we don't have any questions from the audience as of yet. Thank you very much, Simon, that was a superb talk. Very impressive to hear about you setting up the first PJI center in Canada. I'm sure that was a lot of work, and I'm sure that would be an excellent fellowship for anyone interested.
IAN KENNEDY: Just in interest of time, Rhidian.
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Form Title Accessibility and Keyboard Shortcuts
The cadmore media player is a professional video and audio player experience designed to deliver media as well as relevant transcript, segmentation, and metadata. On the screen is a traditional html video player with buttons such as play, pause, forward, captioning, language and play speed selection and more. Adjacent to the video player are generally tabs, one of which shows a scrolling transcript of the video and the other shows any segmentation of the media, sometimes referred to as chapters. At the top of the video is a menu bar containing an Explore button and Tools button. The Explore button allows you to dig deeper into the video by opening up an explore dialog which contains tabs for a visual navigation of the video using thumbnails, an about tab which contains rich metadata about the media, a segments tab which contains further information about the video, and a related tab which contains links to other media related to this media. The tools button opens a menu with options for sharing the media on social media, creating bookmarking links, creating embed codes for your website, generating citations, and more.
Keyboard Shortcuts
Keyboard shortcuts only work while you are in forms mode. By entering forms mode, you will be able to quickly access portions of the media player with single key commands.
Spacebar: Play/Pause Toggle
I: Info Menu,
O: Tools Menu
T: Transcript Tab,
S: Segments Tab
F: Forward 15,
R: Rewind 15
L: Languages,
P: Playspeed
M: Mute Toggle,
V: Volume Bar
N: Video Only Toggle,
B: Full Screen Toggle
C: Captions Toggle
Escape: Closes dialogs and menus / Exits Player
Z: Next Transcript Chapter
X: Previous Transcript Chapter
Q: Next Transcript Paragraph
W: Previous Transcript Paragraph
Entire Media
Segment(s)
Custom Clip
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Embed Size
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You Size - Responsive
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We Size - Responsive
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Picture Overlay Popup
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400 x 225
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512 x 288
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400 x 700
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768 x 1024
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1024 x 512
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1280 x 608
Form Title Cite
No citation provided.
Info
Segments
Related
Thumbnails
Exit Clip Mode
You have requested to see a portion of the video outside of the clip.
Click OK to switch to the full video or click if you would like to stay inside the clip. You can always go back to the clip with Tools and Clip Mode