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Managing With Recurrent Infection
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Managing With Recurrent Infection
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Language: EN.
Segment:0 .
DOMINIC MEEK: Specialists in hip and knee replacements as well, particularly revision, surgery and infection. And as he puts it, horrendaplasties. He's Professor of Health and Science at Aston University with some stem cell research, but has a huge experience with periprosthetic joint infection with his tumor patients as well. So he's going to talk to us about the management of recurrent infection.
DOMINIC MEEK: Thanks very much, Lee.
LEE JEYS: Thanks very much for having me today at the meeting. It's an esteemed group of people. So I'm going to talk a bit about what we do with when the infection comes back. It's a topic that we don't talk about a lot really, because we don't like to admit our failures. For those who haven't seen me before, I work in the Royal Orthopedic Hospital in Birmingham.
LEE JEYS: We're one of the largest sarcoma units and that will have some relevance, and we're reasonably academic so we publish about a paper a month on average. So I do have a conflict of interest. We work in an ivory tower and those of us work in ivory towers, we always think that everybody is having a much better time than we are because we're often dealing with more challenging cases.
LEE JEYS: But my biggest conflict of interest is that I do both cancer and infection, and there are a lot of parallels between cancer and infection in terms of treatment strategies, the effect on the patient's life, both quality and as we're understanding now, their quantity of life. And one of the things we've adopted in the UK is a specialisation, an organization with MDT working around infection, which hopefully will pay dividends in the future.
LEE JEYS: So we get patients from all over the country predominantly because of our tumor background originally. And this is a paper that was written by Rob Grime and my sort of mentor looking at tumor procedures that had been in for more than 25 years, so all these patients had had tumor procedures for more than 25 years. And what we can see 230 patients that the risk of amputation was about 16% and the risk of lifelong infection was about 1% And unfortunately the procedures looked like they didn't do so well,
LEE JEYS: and that's because our patients end up having lots of operations because they're put in at a very young age. And the more operations you have, by the time you have four operations, each individual operation carries with it a risk of about 20% to 25% and the risk of infection remains lifelong. So these tumor patients can tell us quite a lot about periprosthetic joint infection.
LEE JEYS: So we get our first time infection and we think, oh, it's OK, we're pretty good, we're all used to dealing with that, I've got lots of options. We can do a DAIR, we can do a single stage or we could do a two stage revision. But then you get home and you've had a good night out, you've enjoyed yourself, and then you get the phone call of shame that says the patient that you operated on a few weeks ago is suddenly pussing out
LEE JEYS: and that makes you feel pretty sad. And you think, oh, I knew I shouldn't have operated on him and you tried to blame the patient as much as you can, and you know that they're going to follow you around for the rest of your career now, stalking you, wondering how you're going to get rid of that infection? So what is the chance of recurrent infection? Well, the literature is obviously very biased.
LEE JEYS: If we look at DAIRS, it's been variably reported to between 0 and 80% failure rate. Single stage is I think, probably has had a bit of a positive publication bias but even in the least optimistic there's about a 30% failure rate. And two stages are often over reported to do well but again, the literature says that there's between a 0 and 50% rate
LEE JEYS: so even though we don't like to think about it, a significant portion of our patients are going to fail their treatment for infection. These patients by Fairland's group, 221 patients, their reinfection rate was 12% pretty good, but 14% didn't get their second stage. There was a 20% complication rate and the overall mortality of the group was 41% with a median survival of five years
LEE JEYS: and I want you to think about this as we go through that talk. This recent excellent paper from the NJR showed that unfortunately, infection rates in primary knee replacements and aseptic revisions, unfortunately is increasing as we've heard, and that has a very significant effect on their ability to survive and keep the implant. So we looked at our results
LEE JEYS: and we saw, we were pretty pleased. We had a pretty much 90% success rate with DAIR's, single stages 6% failure rate and 2% about 10% failure rate. But that's all first time infections. When we looked at our salvage cases or recurrent infections, we had about a 50% failure rate and we'll come on to look at that in a bit more detail. And it's the usual risk factors; poorly patients, polymicrobial organisms, what we termed as bad organisms.
LEE JEYS: One surgeon didn't have a great outcomes, but polymicrobial and bad organisms and the need for a flap all unfortunately did pretty poorly. So what are we going to do now then? Should we get up and say, well, we're going to try again or, you know, enough is enough and if we've had one go at trying to treat infection, should we,
LEE JEYS: should we call it a day? Well, what's the literature on recurrent PJI? Well, actually, it's very sparse. So this paper looked at 55 patients who'd had a repeat two stage revision for a failed two stage. Reinfection rate was a third at a year and 62% by 5 years. 22% didn't get their second stage and 50% had reoperations. There was a 16% amputation rate and the overall mortality again, was about a third
LEE JEYS: so it looks pretty dire. There are three types of surgeons I always think. There's the surgeon that thinks, oh, well, I've got an infection, I want to keep my bradycardia and take it nice and easy and therefore we'll just go straight to an amputation or we'll suppress the patients, which is the idea and microbiologists sort of nightmare. Then we have our have a go heroes that think they can do everything and are not doing it in a specialized center because the skill sets for us infection surgeon compared to standard orthopedic surgery is quite significantly different, particularly when we come to debridement.
LEE JEYS: So we looked at our results. So we had a case matched series of 64 patients. This was done by Mike Parry and Jonathan Stevenson and myself. We looked at 32 who'd had their first infection treated at the ROH compared to those who'd had a two stage after having a failed two stage before. And the headlines were pretty poor. So we had a 91% if we treated it, but only a 50% if it was repeated at the ROH.
LEE JEYS: 44% required repeat operations compared to just 9% in the primary group. But when we looked in more detail, we found that only one patient had an amputation. Only two patients had died with repeat infection and actually the other 91% were able to be controlled by further DAIR's revision surgery or an arthrodesis. So actually our long term control group in both the groups were the same, but we just had to work harder at getting the infection and the patients unfortunately went through more surgery.
LEE JEYS: So Muhammad Ali said that if you don't lose, if you get knocked down, you only lose if you stay down. So our philosophy is, along with achievements, is to keep on going as long as the patient wants us to go but it is very difficult. So that's all very cool but the point is, can it work for us? What do we do to make it better? Well, what do you need? You need an MDT, you need a Micro
LEE JEYS: and ID advice that we've heard from the two excellent talks before me because we've also shown that there's a massive change in the microbiome between failed infections. You need plastic surgery to help you with flaps and skin coverage, or you have to do your own flaps. And you need experienced surgeons who are concentrating on PJI because as we've heard from the biofilm talk, that we need to have a radical debridement and we often end up using a lot of oncology style prosthesis, but also you need a lot of resilience as a team.
LEE JEYS: You need to keep on going if you can, and perhaps you need a different way of thinking about these difficult problems. So there's been lots of evidence to suggest that if we get early referrals to specialist infection units that the outcomes are better. This is Dominic's paper that looked at their introduction of an MDT showing a massive reduction in the failure rates of treating infection.
LEE JEYS: This paper that came out of the Finnish group showed that in all classes by the introduction of an MDT and a specialist team that you significantly improved your outcomes in terms of curing infection. But we've just published this paper recently with the London Group and the Oxford Group where we looked at the microbiology of the repeat infections and often the organism changes between the revisions.
LEE JEYS: So you often have a prior exposure to antibiotics, you get more drug resistant organisms, you get more gram negatives, and eventually you end up with a higher rate of fungal infection. So by the time you come to your second revision, 43% in our series showed a different organism to the original organism, and 40% of the organisms were now multidrug resistance as defined by resistant to more than two classes of antibiotics.
LEE JEYS: And this really has a practical importance, because this is why, even though when we know what the organism was last time, we stay broad with our antibiotics at the beginning covering both gram negatives and gram positives and then and dropping our gram negative cover if we haven't grown anything. So coming back to the extreme cases, you know, can we do limb salvage in these cases?
LEE JEYS: Well, clearly, this is where you need to use your plastic surgical team or do your own flaps, and often you're not going to go to another mobile prosthesis and often go into some kind of arthrodesis. Debridement for infection, as we've heard in the first talk, is absolutely paramount, especially if we're talking about multidrug resistant organisms. So this is not an adequate debridement of a hip. This is messing around with a spoon around a hip.
LEE JEYS: This, unfortunately, is also not an adequate debridement of a knee. This is an example of a horrible infection that's been multibly infected, and you can see when we get in, it looks pretty horrible. I'm sorry for anybody who's eating their dinner at the moment, but you need to find that layer between the healthy tissue and the pseudo-membrane and you need to do a radical debridement
LEE JEYS: and we like to try and get the pseudo-membrane out all in one layer, not because we like to show off, but because it helps us keep in the right plane all the way through the operation. And here you can see at the end of the debridement, we're now wondering whether we can do a first stage because it looks a single stage, but we bottled out and did a two stage with a functional spacer in this case. We also rely a lot on adjuvant therapy.
LEE JEYS: So we've heard about the local antibiotic delivery and a 1,000 times concentration, and so we use a lot of local adjuvants, whether it be silver on the implants or whether we use calcium sulfate with antibiotics in. And we all know that antibiotics can't save inadequate surgery. They may be able to help, but they're not going to cure the patient. The last thing that we talked about was the time and unpredictability and the resilience that's needed,
LEE JEYS: and orthopedic surgeons have always been known as rhinos for having thick skins and charging a lot. But actually, you do need to be resilient if you're going to do this. So this was a case that we dealt with 2017, came in with a clearly infected, a hip which had always been infected with a periprosthetic fracture and staph aureus, Serratia and E coli, not a great combination, with the PET scan showing that we'd had infect osteomyelitis all the way down.
LEE JEYS: So unfortunately, we did a very radical debridement of this bone, as this gentleman had already had four attempts at curing his infection. When we did our two stage, all of our cultures were negative. We were very happy with ourselves and we thought we were all superheroes. And then just a few weeks later, it comes back again with a relatively resistant organism. I don't feel so good now, but we carry on.
LEE JEYS: We did another two stage, which again showed E-coli, we did another two stage and then we ended up on real resistance. Now you can see that we've now got a fungus as well as E-coli, problems with spacers, total femurs. But actually, by 2021, after many years, we managed to successfully cure the infection with a two stage revision and you can see that his CRP was returned to normal and we ended up doing a knee replacement on the other side.
LEE JEYS: I talked briefly about maybe the way that we need to look at things differently when we're dealing with recurrent infections and this is one of my failures. Lovely lady called Doris, who unfortunately never made it to her second stage. And this risk of dying within five years of PJI is very similar to most common cancers and we know that all hosts do very badly with two operations.
LEE JEYS: So we took a policy that we decided to get radical with the unwell patients because we found that we had more of these multidrug resistant organisms in this cohort like we had talked about. And if we look at them, we can see that the multidrug resistant organisms do worse, acutely and chronically with infections and if they're associated with polymicrobial organisms in our series, they did even worse.
LEE JEYS: But what we did find that was surprising was that those that had a single stage of revision seemed to do better than the two stage revision and actually this probably makes sense because antibiotics aren't going to be your answer, because a lot of these are resistant to multiple classes of antibiotics. We therefore came up with a strategy of doing DAIR's in our good patients with early onsets as we heard, but now we do radical one stages on the worst patients because if there is a small benefit from doing a two stage and our patients are in the category where they're going to unfortunately have a poor life expectancy, then actually we want to get them up and about quickly.
LEE JEYS: And so we do radical one stages on the worst patients now and we save our two stages for the best patients. So this is a gentleman that was 81, diabetes, came in with acute infection, obviously not coping at home, came into the clinic with an abscess and not dripping, dressed and wearing clothes covered in pus. So we did a radical one stage with the distal femoral replacement for him, and you can see that his albumin improved quite significantly within the first few weeks.
LEE JEYS: His CRP improved within the first few weeks. And here he is, even though he had a sinus with a one stage with good function about a year later. 1.5 stage revisions are now very much in vogue, started by the Exeter Group showing that you could put a prosthesis back in. And you couldn't do that with tumour prostheses as well. This was a Hong Kong Group that reported it a few years ago.
LEE JEYS: This is a lady we treated recently who'd had a previous failed MRSA, proximal femoral replacement done elsewhere and we could do a one stage revision with them. But because we like to protect ourselves, we'll tell them that this is just a temporary prosthesis and we may come back and change it. So we've got a tumour prosthesis wrapped in antibiotic cement and stimulan and using cement in an acetabular reconstruction, which will only be temporary
LEE JEYS: but hopefully once our infection is cured, we can go back in. And we've actually got pretty good results with this. We looked at our first small series with tumor prosthesis and we had an 87% implant survival at two years, which is short term, and we had two failures. So we've talked very briefly about what are the salvage options. Antibiotic suppression has been alluded to, but we sometimes use long term antibiotic spacers.
LEE JEYS: Around the hip,
LEE JEYS: you can use a girdlestone, but we don't like that very often. In the extreme cases we can use a rotationplasty, but we're big fans of arthrodesis around the knee. The problem is with antibiotics suppression, we find is that you have to have an oral susceptibility. A lot of the cases, which are the worst cases are multidrug resistant. You can have a low output fistula,
LEE JEYS: that's OK, but a high output fistula is pretty, pretty miserable. Long term antibiotic spacers. The advantage is that you've got no metal at the surface, so less biofilm hopefully. You can add antibiotics to suppression and we've had several places, patients that have had long term spacers. But the problem is you often can't fully weight bear on them and they will eventually break.
LEE JEYS: This is a lady that had one for 3 years, was mobile on it until it broke, and then we eventually went back in but she was culture negative when we went back in. This is a radical tumor resection that got infected in this patient, had a spacer for 12 years again until it broke and we had to change it. But he had OK function. Knee arthrodesis is a very good if you're contemplating an amputation because of the stability they are good for the soft tissues
LEE JEYS: and the lack of bending means that the soft tissues often settle down. Quite often patients don't like the idea of them, but we use a lot of static spacers and if we use a static spacer, then they've often had them for a while and get used to it. And again, their function is reasonable and can avoid an amputation and we published a small series on those as well.
LEE JEYS: So in conclusion then I think recurrent infection is difficult. It certainly has higher failure rates. I think limb salvage is successful, but it often needs multiple operations. I know the Germans are now quite keen on doing the three stage operation, I don't think we're going to go that far, but I think we do have to go back in quite quickly if we think that the two stage is not working and do a radical DAIR.
LEE JEYS: But I think you get long term success if you use a MDT input. It's done in specialist centers and unfortunately you often need to use quite radical surgery and I would suggest that different approaches may be needed in these patients because of the high rate of multidrug resistant organisms. Thank you very much.
DOMINIC MEEK: Thanks very much, Lee. Are there any, there's one or two questions? I know we're going to play the video in a second.
IAN KENNEDY: Yep and quick question. Do you think there's a role for silver coated implants?
LEE JEYS: Uh, so I think that the evidence is difficult because there's a selection bias in those that we use. I think there's been multiple papers that show it reduces your early infections, but I don't think it reduces your long term infections.
LEE JEYS: I think, um, the different types of silver. So we tend to use one with a very high concentration of silver, which eludes, um, it's actually electroplated so it needs a small drop in the pH to get a big release in the, the silver ions. I think there's, in the oncology world it's now they've become a standard of care, but I don't know, um, I certainly don't think a randomized trial is, is possible at the moment on it.
IAN KENNEDY: Perfect one further question. If you've got a patient with chronic antibiotic suppression in one joint, would you be happy to do an elective joint replacement and another side?
LEE JEYS: Uh, so I think tumor surgeons think about things a little bit differently. So, you know, when you're dealing with cancer for half a day and then you're dealing with infection, which I think is just as problematic for the patients, then we tend to take more risks.
LEE JEYS: So we do do and have done joint replacements in people with other infections. Um, actually the literature was, there's very little literature out there would suggest that the risk of infection actually in the other joint is not as high as you would think. But I think it's a risky strategy and if you're going to do it, you've got to be, you've got to make sure the patient completely understands the problem. Personally, I,
LEE JEYS: we, we really try hard not to put patients on antibiotic suppression so we would be trying to get them both in at the same time, I think.
IAN KENNEDY: Perfect Thanks so much. We'll stop the questions at that just now. I just have a quick. [VIDEO ENDS]
Segment:0 .
DOMINIC MEEK: Specialists in hip and knee replacements as well, particularly revision, surgery and infection. And as he puts it, horrendaplasties. He's Professor of Health and Science at Aston University with some stem cell research, but has a huge experience with periprosthetic joint infection with his tumor patients as well. So he's going to talk to us about the management of recurrent infection.
DOMINIC MEEK: Thanks very much, Lee.
LEE JEYS: Thanks very much for having me today at the meeting. It's an esteemed group of people. So I'm going to talk a bit about what we do with when the infection comes back. It's a topic that we don't talk about a lot really, because we don't like to admit our failures. For those who haven't seen me before, I work in the Royal Orthopedic Hospital in Birmingham.
LEE JEYS: We're one of the largest sarcoma units and that will have some relevance, and we're reasonably academic so we publish about a paper a month on average. So I do have a conflict of interest. We work in an ivory tower and those of us work in ivory towers, we always think that everybody is having a much better time than we are because we're often dealing with more challenging cases.
LEE JEYS: But my biggest conflict of interest is that I do both cancer and infection, and there are a lot of parallels between cancer and infection in terms of treatment strategies, the effect on the patient's life, both quality and as we're understanding now, their quantity of life. And one of the things we've adopted in the UK is a specialisation, an organization with MDT working around infection, which hopefully will pay dividends in the future.
LEE JEYS: So we get patients from all over the country predominantly because of our tumor background originally. And this is a paper that was written by Rob Grime and my sort of mentor looking at tumor procedures that had been in for more than 25 years, so all these patients had had tumor procedures for more than 25 years. And what we can see 230 patients that the risk of amputation was about 16% and the risk of lifelong infection was about 1% And unfortunately the procedures looked like they didn't do so well,
LEE JEYS: and that's because our patients end up having lots of operations because they're put in at a very young age. And the more operations you have, by the time you have four operations, each individual operation carries with it a risk of about 20% to 25% and the risk of infection remains lifelong. So these tumor patients can tell us quite a lot about periprosthetic joint infection.
LEE JEYS: So we get our first time infection and we think, oh, it's OK, we're pretty good, we're all used to dealing with that, I've got lots of options. We can do a DAIR, we can do a single stage or we could do a two stage revision. But then you get home and you've had a good night out, you've enjoyed yourself, and then you get the phone call of shame that says the patient that you operated on a few weeks ago is suddenly pussing out
LEE JEYS: and that makes you feel pretty sad. And you think, oh, I knew I shouldn't have operated on him and you tried to blame the patient as much as you can, and you know that they're going to follow you around for the rest of your career now, stalking you, wondering how you're going to get rid of that infection? So what is the chance of recurrent infection? Well, the literature is obviously very biased.
LEE JEYS: If we look at DAIRS, it's been variably reported to between 0 and 80% failure rate. Single stage is I think, probably has had a bit of a positive publication bias but even in the least optimistic there's about a 30% failure rate. And two stages are often over reported to do well but again, the literature says that there's between a 0 and 50% rate
LEE JEYS: so even though we don't like to think about it, a significant portion of our patients are going to fail their treatment for infection. These patients by Fairland's group, 221 patients, their reinfection rate was 12% pretty good, but 14% didn't get their second stage. There was a 20% complication rate and the overall mortality of the group was 41% with a median survival of five years
LEE JEYS: and I want you to think about this as we go through that talk. This recent excellent paper from the NJR showed that unfortunately, infection rates in primary knee replacements and aseptic revisions, unfortunately is increasing as we've heard, and that has a very significant effect on their ability to survive and keep the implant. So we looked at our results
LEE JEYS: and we saw, we were pretty pleased. We had a pretty much 90% success rate with DAIR's, single stages 6% failure rate and 2% about 10% failure rate. But that's all first time infections. When we looked at our salvage cases or recurrent infections, we had about a 50% failure rate and we'll come on to look at that in a bit more detail. And it's the usual risk factors; poorly patients, polymicrobial organisms, what we termed as bad organisms.
LEE JEYS: One surgeon didn't have a great outcomes, but polymicrobial and bad organisms and the need for a flap all unfortunately did pretty poorly. So what are we going to do now then? Should we get up and say, well, we're going to try again or, you know, enough is enough and if we've had one go at trying to treat infection, should we,
LEE JEYS: should we call it a day? Well, what's the literature on recurrent PJI? Well, actually, it's very sparse. So this paper looked at 55 patients who'd had a repeat two stage revision for a failed two stage. Reinfection rate was a third at a year and 62% by 5 years. 22% didn't get their second stage and 50% had reoperations. There was a 16% amputation rate and the overall mortality again, was about a third
LEE JEYS: so it looks pretty dire. There are three types of surgeons I always think. There's the surgeon that thinks, oh, well, I've got an infection, I want to keep my bradycardia and take it nice and easy and therefore we'll just go straight to an amputation or we'll suppress the patients, which is the idea and microbiologists sort of nightmare. Then we have our have a go heroes that think they can do everything and are not doing it in a specialized center because the skill sets for us infection surgeon compared to standard orthopedic surgery is quite significantly different, particularly when we come to debridement.
LEE JEYS: So we looked at our results. So we had a case matched series of 64 patients. This was done by Mike Parry and Jonathan Stevenson and myself. We looked at 32 who'd had their first infection treated at the ROH compared to those who'd had a two stage after having a failed two stage before. And the headlines were pretty poor. So we had a 91% if we treated it, but only a 50% if it was repeated at the ROH.
LEE JEYS: 44% required repeat operations compared to just 9% in the primary group. But when we looked in more detail, we found that only one patient had an amputation. Only two patients had died with repeat infection and actually the other 91% were able to be controlled by further DAIR's revision surgery or an arthrodesis. So actually our long term control group in both the groups were the same, but we just had to work harder at getting the infection and the patients unfortunately went through more surgery.
LEE JEYS: So Muhammad Ali said that if you don't lose, if you get knocked down, you only lose if you stay down. So our philosophy is, along with achievements, is to keep on going as long as the patient wants us to go but it is very difficult. So that's all very cool but the point is, can it work for us? What do we do to make it better? Well, what do you need? You need an MDT, you need a Micro
LEE JEYS: and ID advice that we've heard from the two excellent talks before me because we've also shown that there's a massive change in the microbiome between failed infections. You need plastic surgery to help you with flaps and skin coverage, or you have to do your own flaps. And you need experienced surgeons who are concentrating on PJI because as we've heard from the biofilm talk, that we need to have a radical debridement and we often end up using a lot of oncology style prosthesis, but also you need a lot of resilience as a team.
LEE JEYS: You need to keep on going if you can, and perhaps you need a different way of thinking about these difficult problems. So there's been lots of evidence to suggest that if we get early referrals to specialist infection units that the outcomes are better. This is Dominic's paper that looked at their introduction of an MDT showing a massive reduction in the failure rates of treating infection.
LEE JEYS: This paper that came out of the Finnish group showed that in all classes by the introduction of an MDT and a specialist team that you significantly improved your outcomes in terms of curing infection. But we've just published this paper recently with the London Group and the Oxford Group where we looked at the microbiology of the repeat infections and often the organism changes between the revisions.
LEE JEYS: So you often have a prior exposure to antibiotics, you get more drug resistant organisms, you get more gram negatives, and eventually you end up with a higher rate of fungal infection. So by the time you come to your second revision, 43% in our series showed a different organism to the original organism, and 40% of the organisms were now multidrug resistance as defined by resistant to more than two classes of antibiotics.
LEE JEYS: And this really has a practical importance, because this is why, even though when we know what the organism was last time, we stay broad with our antibiotics at the beginning covering both gram negatives and gram positives and then and dropping our gram negative cover if we haven't grown anything. So coming back to the extreme cases, you know, can we do limb salvage in these cases?
LEE JEYS: Well, clearly, this is where you need to use your plastic surgical team or do your own flaps, and often you're not going to go to another mobile prosthesis and often go into some kind of arthrodesis. Debridement for infection, as we've heard in the first talk, is absolutely paramount, especially if we're talking about multidrug resistant organisms. So this is not an adequate debridement of a hip. This is messing around with a spoon around a hip.
LEE JEYS: This, unfortunately, is also not an adequate debridement of a knee. This is an example of a horrible infection that's been multibly infected, and you can see when we get in, it looks pretty horrible. I'm sorry for anybody who's eating their dinner at the moment, but you need to find that layer between the healthy tissue and the pseudo-membrane and you need to do a radical debridement
LEE JEYS: and we like to try and get the pseudo-membrane out all in one layer, not because we like to show off, but because it helps us keep in the right plane all the way through the operation. And here you can see at the end of the debridement, we're now wondering whether we can do a first stage because it looks a single stage, but we bottled out and did a two stage with a functional spacer in this case. We also rely a lot on adjuvant therapy.
LEE JEYS: So we've heard about the local antibiotic delivery and a 1,000 times concentration, and so we use a lot of local adjuvants, whether it be silver on the implants or whether we use calcium sulfate with antibiotics in. And we all know that antibiotics can't save inadequate surgery. They may be able to help, but they're not going to cure the patient. The last thing that we talked about was the time and unpredictability and the resilience that's needed,
LEE JEYS: and orthopedic surgeons have always been known as rhinos for having thick skins and charging a lot. But actually, you do need to be resilient if you're going to do this. So this was a case that we dealt with 2017, came in with a clearly infected, a hip which had always been infected with a periprosthetic fracture and staph aureus, Serratia and E coli, not a great combination, with the PET scan showing that we'd had infect osteomyelitis all the way down.
LEE JEYS: So unfortunately, we did a very radical debridement of this bone, as this gentleman had already had four attempts at curing his infection. When we did our two stage, all of our cultures were negative. We were very happy with ourselves and we thought we were all superheroes. And then just a few weeks later, it comes back again with a relatively resistant organism. I don't feel so good now, but we carry on.
LEE JEYS: We did another two stage, which again showed E-coli, we did another two stage and then we ended up on real resistance. Now you can see that we've now got a fungus as well as E-coli, problems with spacers, total femurs. But actually, by 2021, after many years, we managed to successfully cure the infection with a two stage revision and you can see that his CRP was returned to normal and we ended up doing a knee replacement on the other side.
LEE JEYS: I talked briefly about maybe the way that we need to look at things differently when we're dealing with recurrent infections and this is one of my failures. Lovely lady called Doris, who unfortunately never made it to her second stage. And this risk of dying within five years of PJI is very similar to most common cancers and we know that all hosts do very badly with two operations.
LEE JEYS: So we took a policy that we decided to get radical with the unwell patients because we found that we had more of these multidrug resistant organisms in this cohort like we had talked about. And if we look at them, we can see that the multidrug resistant organisms do worse, acutely and chronically with infections and if they're associated with polymicrobial organisms in our series, they did even worse.
LEE JEYS: But what we did find that was surprising was that those that had a single stage of revision seemed to do better than the two stage revision and actually this probably makes sense because antibiotics aren't going to be your answer, because a lot of these are resistant to multiple classes of antibiotics. We therefore came up with a strategy of doing DAIR's in our good patients with early onsets as we heard, but now we do radical one stages on the worst patients because if there is a small benefit from doing a two stage and our patients are in the category where they're going to unfortunately have a poor life expectancy, then actually we want to get them up and about quickly.
LEE JEYS: And so we do radical one stages on the worst patients now and we save our two stages for the best patients. So this is a gentleman that was 81, diabetes, came in with acute infection, obviously not coping at home, came into the clinic with an abscess and not dripping, dressed and wearing clothes covered in pus. So we did a radical one stage with the distal femoral replacement for him, and you can see that his albumin improved quite significantly within the first few weeks.
LEE JEYS: His CRP improved within the first few weeks. And here he is, even though he had a sinus with a one stage with good function about a year later. 1.5 stage revisions are now very much in vogue, started by the Exeter Group showing that you could put a prosthesis back in. And you couldn't do that with tumour prostheses as well. This was a Hong Kong Group that reported it a few years ago.
LEE JEYS: This is a lady we treated recently who'd had a previous failed MRSA, proximal femoral replacement done elsewhere and we could do a one stage revision with them. But because we like to protect ourselves, we'll tell them that this is just a temporary prosthesis and we may come back and change it. So we've got a tumour prosthesis wrapped in antibiotic cement and stimulan and using cement in an acetabular reconstruction, which will only be temporary
LEE JEYS: but hopefully once our infection is cured, we can go back in. And we've actually got pretty good results with this. We looked at our first small series with tumor prosthesis and we had an 87% implant survival at two years, which is short term, and we had two failures. So we've talked very briefly about what are the salvage options. Antibiotic suppression has been alluded to, but we sometimes use long term antibiotic spacers.
LEE JEYS: Around the hip,
LEE JEYS: you can use a girdlestone, but we don't like that very often. In the extreme cases we can use a rotationplasty, but we're big fans of arthrodesis around the knee. The problem is with antibiotics suppression, we find is that you have to have an oral susceptibility. A lot of the cases, which are the worst cases are multidrug resistant. You can have a low output fistula,
LEE JEYS: that's OK, but a high output fistula is pretty, pretty miserable. Long term antibiotic spacers. The advantage is that you've got no metal at the surface, so less biofilm hopefully. You can add antibiotics to suppression and we've had several places, patients that have had long term spacers. But the problem is you often can't fully weight bear on them and they will eventually break.
LEE JEYS: This is a lady that had one for 3 years, was mobile on it until it broke, and then we eventually went back in but she was culture negative when we went back in. This is a radical tumor resection that got infected in this patient, had a spacer for 12 years again until it broke and we had to change it. But he had OK function. Knee arthrodesis is a very good if you're contemplating an amputation because of the stability they are good for the soft tissues
LEE JEYS: and the lack of bending means that the soft tissues often settle down. Quite often patients don't like the idea of them, but we use a lot of static spacers and if we use a static spacer, then they've often had them for a while and get used to it. And again, their function is reasonable and can avoid an amputation and we published a small series on those as well.
LEE JEYS: So in conclusion then I think recurrent infection is difficult. It certainly has higher failure rates. I think limb salvage is successful, but it often needs multiple operations. I know the Germans are now quite keen on doing the three stage operation, I don't think we're going to go that far, but I think we do have to go back in quite quickly if we think that the two stage is not working and do a radical DAIR.
LEE JEYS: But I think you get long term success if you use a MDT input. It's done in specialist centers and unfortunately you often need to use quite radical surgery and I would suggest that different approaches may be needed in these patients because of the high rate of multidrug resistant organisms. Thank you very much.
DOMINIC MEEK: Thanks very much, Lee. Are there any, there's one or two questions? I know we're going to play the video in a second.
IAN KENNEDY: Yep and quick question. Do you think there's a role for silver coated implants?
LEE JEYS: Uh, so I think that the evidence is difficult because there's a selection bias in those that we use. I think there's been multiple papers that show it reduces your early infections, but I don't think it reduces your long term infections.
LEE JEYS: I think, um, the different types of silver. So we tend to use one with a very high concentration of silver, which eludes, um, it's actually electroplated so it needs a small drop in the pH to get a big release in the, the silver ions. I think there's, in the oncology world it's now they've become a standard of care, but I don't know, um, I certainly don't think a randomized trial is, is possible at the moment on it.
IAN KENNEDY: Perfect one further question. If you've got a patient with chronic antibiotic suppression in one joint, would you be happy to do an elective joint replacement and another side?
LEE JEYS: Uh, so I think tumor surgeons think about things a little bit differently. So, you know, when you're dealing with cancer for half a day and then you're dealing with infection, which I think is just as problematic for the patients, then we tend to take more risks.
LEE JEYS: So we do do and have done joint replacements in people with other infections. Um, actually the literature was, there's very little literature out there would suggest that the risk of infection actually in the other joint is not as high as you would think. But I think it's a risky strategy and if you're going to do it, you've got to be, you've got to make sure the patient completely understands the problem. Personally, I,
LEE JEYS: we, we really try hard not to put patients on antibiotic suppression so we would be trying to get them both in at the same time, I think.
IAN KENNEDY: Perfect Thanks so much. We'll stop the questions at that just now. I just have a quick. [VIDEO ENDS]
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