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A Clinical View on Outcomes After Hip & Knee Arthroplasty Infection
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A Clinical View on Outcomes After Hip & Knee Arthroplasty Infection
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Language: EN.
Segment:0 .
IAN KENNEDY: To the success of this society. I would like to take this opportunity to encourage you all to join BAJIS. Membership is free, which is a welcome change for a special society and we'll keep you updated on upcoming events, for example, our next annual Congress in Coventry and we would hope to see many of you there. This evening,
IAN KENNEDY: we're privileged to have a group of distinguished speakers who really are leaders in the field and so it's my pleasure to hand over to our current BAJIS president, Mr Rhidian Morgan-Jones, who will do the introductions. Over to you Rhidian. Ian, Thank you.
RHIDIAN MORGAN-JONES: It is indeed a pleasure to have our third BAJIS webinar and to have such a wonderful group of guest lecturers.
RHIDIAN MORGAN-JONES: I'm at my advanced stage. I'm really excited about tonight's program I've been looking forward to for a long time. We've got Dr. Joshua Jones from Dundee to talk about phage therapy, Dr. Simon Garceau from Ottawa to look at PJI trends in North America and we'll first talk is Professor Faris Hadad from London who's going to give us a realistic outcome on PJI surgery.
RHIDIAN MORGAN-JONES: But also at this point, I'd like to thank our sponsors Molnlycke will be giving a short presentation later. So if could introduce Farah Haddad, one of the key opinion leaders in World orthopedics and I'm really looking forward to see what he has to say about infection outcomes, which I think is a much neglected topic. Fares.
FARES HADDAD: Thanks, Rhidian and hanks, Ian and thank you for having me on this webinar.
FARES HADDAD: Hope you don't ultimately regret it. So I've been given the task of talking broadly to say about my focus like my clinical factors, practice is going to be on hip and knee arthroplasty infection, although I recognize that the membership is much broader than that. But I thought I would stick to the area I've worked on and understand. We always show our disclosures. My disclosures are inevitably relevant.
FARES HADDAD: I think one key one here is that I'm Editor in Chief of one of the big general orthopedic journals, and although I speak as myself this evening rather than Editor of the Journal, my views are inevitably shaped by the literature that I see and have to deal with on a day to day basis. So just setting the scene, if you like. I have a very tainted view.
FARES HADDAD: Having spent over 10 years as an editor of a journal, that the literature as a whole is actually horribly flawed. And as you'll see, I feel that's particularly the case in the infection world and that we should be working to improve it. There are many reasons for this, but in reality, one of them is that the publication world has evolved dramatically with open publishing, and this has huge benefits in terms of accessibility to research, but it has a downside in that there are too many journals and an increasing number of predatory journals, and that means that everything gets published somewhere.
FARES HADDAD: And I'm sure my colleagues speaking after me, all of whom are distinguished experts in the field, may partly fall foul of occasionally referencing some of the material that probably should not be in print, but suits the case that we are supporting at the time. And so it comes down to as a discerning listener, reader or person trying to guide the care of your patient to differentiate as to what is credible research and what's junk science, because there are not no perfect controls out there.
FARES HADDAD: And this is a real problem in the infection world. It's always been worse than other areas because of the underlying heterogeneity that we have to deal with. But beyond that, in this world that we all live in and are trying to improve, there really isn't uniformity of definitions or interventions, as I'll come back to. There's a massive fidelity problem, and my big concern is there are huge reporting problems.
FARES HADDAD: If this wasn't enough, more recently, there have been big economic drivers as the focus has come in on this area and some personalities that have driven the literature and hence the thinking of many in perhaps a direction that it would not have gone in on with sensible, proper peer review. I'm going to come back to this paper, but I thought I'd put it out at this point as a taster. This is a fantastic piece of work from Carsten Perker's group, looking at the German registry and linking it to other databases in Germany.
FARES HADDAD: So it's not just the arthroplasty registry, but it's looking at their insurance data as well, so that you get real tangible outcome because the insurance data is complete. And in reality, what this study shows is that what is reported in the literature doesn't seem to correspond with what they are finding here. Some real question marks on the material we all rely on a day to day basis and regularly reference.
FARES HADDAD: Now the problem goes deeper than that, of course, because we have even struggled to define what an infection is after arthroplasty. This is for me, what is the standard now and congratulations to all the colleagues who've contributed to this at EBJIS as this should be what we're all using. We were not until not too long ago using the MSIS definition of infection from 2013, and we were all comfortable with that.
FARES HADDAD: It was logical. It fitted in with our practice. Sam Oussedik and I with Ian Stockley and Kate Gould, made the mistake of suggesting that a numerical system might be added to this and I still think it is a sound suggestion. But what we didn't have in mind is what happened in the lead up to the 2018 consensus meeting, where a numerical definition was created that suddenly put d-dimer and alpha defensin at the heart of infection diagnosis and downplayed culture.
FARES HADDAD: Many of you will know my views on this. Remarkable that d-dimer data was suddenly available from so many centers in particular and remarkable after all these years that we've downplayed infection. But I think it's a key message here that if we cannot agree the definition, then we have a problem. So for the time being, I think we have a workable solution with the EBJIS definition. But unless we're all reporting to the same metrics, we're going to struggle.
FARES HADDAD: And right now worldwide, we are not reporting to the same metrics. The other issue I mentioned at the outset is fidelity. So we talk with great confidence about incision and debridement, DAIRs, excision arthroplasty, arthrodesis and all the modalities available. But in reality, a DAIR in one set of hands is very different from a DAIR in another and a single stage revision in my hands and in somebody else's hands is very different.
FARES HADDAD: It's not just the technique of the surgery, it's the perioperative care, the microbiology input, the plastic surgery input. There are multiple variables, but even just the basis of that one line descriptor is questionable because it is not the same across the literature. The best example here is in terms of incision and drainage, wash out debridement and implant retention. There's a murky cloud in between all of those that makes all the summative analyses of them really tricky to put together.
FARES HADDAD: The next piece is how we define success in reality. Many people have tried to do this. This particularly lauded paper doesn't even have the patient perspective in it. It is purely a microbiological and surgical definition and it's been one of my gripes in the infection world that the patient perspective should be front and center of everything we do. Like everything else in the literature, when we're really trying to define success, it should have a patient centered focus, and that hasn't been the case.
FARES HADDAD: The other issue here is the outcome of the infection versus the outcome of the arthroplasty. The two may be very different and this has pushed us in a treatment direction that favors dealing with the infection, often to the detriment of the patient and their function, and those two needed balance. We've also fared to failed to standardize for follow up. So there should be a minimum follow up period for any infection reporting in arthroplasty without infection.
FARES HADDAD: We look at least two years. In reality, we didn't even report our initial single stage experience until we had five years and I think there should be a significant minimum period that we all agree on. I'm a great believer that you get infection control. I don't think you ever really get eradication, but I can't get everybody to agree with me on that. I think we really should focus, as I mentioned, on patient function and happiness, rather just on whether there is an organism or the patient requires antibiotics or further surgery.
FARES HADDAD: And so we fail to set adequate reporting standards, and that is something that we must fix. We, of course, have good literature. This is a paper from one of our chairs on single stage revision, but they're largely case series and they've got questionable fidelity in terms of other people doing the same procedure the same way and so those results may not necessarily be transferable to everybody else out there.
FARES HADDAD: There's plenty of them. They build our experience. They build our thinking. But I think you've got to just remember that what happens in those centers isn't necessarily what happens in every hospital. The reason I mentioned that is not to belittle any of these papers. I think they're all excellent papers from hard working people in good centers doing good work.
FARES HADDAD: But where it becomes questionable are when people, including myself, try and do a summative analysis of these papers when they're adding together apples and bananas and various other fruits, putting them all in a mix and trying to reach conclusions. Those are real problems. Then we get on to the outcome measures. So if we focus for example, on infection control, if we can agree what that is, we need to remember that there are other variables at play.
FARES HADDAD: And we certainly as a surgical community have largely ignored morbidity and mortality. So it's only recently come to wide understanding that those proponents of two stage revision, for example, the standard accepted approach worldwide, were largely losing a chunk of the denominator between stages, either due to morbidity or due to the patients not wishing to come back or frankly due to mortality. And then the later mortality wasn't even considered.
FARES HADDAD: So success needs to look at the entire denominator and not just those who went through to the second stage. We're very fortunate in that there are now some RCTs and some really good clinical RCTs. The Inform Group have done a wonderful job. Tom Ferring's group is about to get to their two year data, and I think this really helps and frankly, is changing practice. I've had a big focus on popularizing single stage revision.
FARES HADDAD: I think I've succeeded to a certain extent in that I now go to North American meetings where single stage revision is a procedure invented in the United States. That makes me very, very pleased because we've really changed practice through these studies and there are some useful guidelines from that have come out from the information from these studies on top of the qualitative data that we can take away. Now, a brief word about registries and databases because they're out there and they become a key resource for us to look at data and outcome, they're easily accessed.
FARES HADDAD: I think you've got to take away from this that although I'm going to give you one great paper that I've already mentioned, these are largely flawed in relation to periprosthetic infection. Just think of it in simple terms and we've written on this previously. The data that goes into the registry is recorded at the time of surgery. It doesn't separate deep or superficial infection.
FARES HADDAD: It doesn't delineate exactly which procedure the patient underwent. It doesn't have the microbiology data. It doesn't have case mix adjustment. Now, of course, there are new registries trying to address this, but in the standard registries, we know there was a poor pickup that was 40% or less. We've, of course, learned a great deal from the registries when you look at the baseline demographics.
FARES HADDAD: So looking at the number of people who are having infected revisions, that is helpful, of course or looking at morbidity, mortality, et cetera. Afterwards, there are some metrics in the registries are very useful, but you've got to remember the denominator may be completely right. And then there are failings. One, this is a reasonably well-written paper from New Zealand analyzing the impact of ultra clean air theaters, amongst other things on infection rates.
FARES HADDAD: Now, little did we at the time that what it recorded was whether there was an ultra clean air theater in the hospital, not whether it was in use or not. It didn't record how it was used. And there are multiple variables missing and of course, the capture of infection was incomplete, as I've just shown you from the Danish Registry. But the conclusion of those papers have led to guidelines belittling laminar airflow ventilation for orthopedic theaters.
FARES HADDAD: You may be on one side of this equation or the other, but I think when those papers based on big data, lead to big guidelines that change practice worldwide, we do have to be a little bit cautious. I come back to this paper because this is Cast and Perker's work. Remember linking the foolproof insurance data with the German registry, which of course doesn't have 100% capture but has pretty good capture.
FARES HADDAD: That data goes completely against what is in the single hospital reports and the meta analysis from Germany. And that would suggest at the very least, that the data from big centers isn't transferable elsewhere and hence we should be centralizing and looking at different models of care. At the worst, it suggests that patients are traveling, getting treatment and their definitive outcome isn't being reported by the original center, who have deemed them a success when the patient has decided not to come back because they've already had their treatment there
FARES HADDAD: and failure means their secondary treatment will be local. So lots of tricky queries here and stuff we need to look at. The last facet that we tend to look at is consensus, and I think the 2013 consensus was a huge success. It's a great way of hearing from everybody involving everybody and getting a good conversation. But I think you've got to be careful with consensus. There's another on the horizon next year.
FARES HADDAD: There is a subtle difference between evidence and opinion, and there are some drivers behind this that can easily manipulate the output. That was certainly the case in 2018. And whilst I think consensus has helped us massively in this area, some of it does need to be taken with a pinch of salt. I think one key thing when we're looking at evidence, looking at the literature, looking at outcomes, is to look for concordance.
FARES HADDAD: If we can see similar data and similar outcomes across a number of different types of studies, be they case series, then onto control studies, onto RCTs and then onto the systematic reviews or the big databases, the observational data sets. That is very helpful and that will suggest we're moving in the right direction. Having said all of this, I think sometimes the best evidence is experience. BAJIS or the related group has a WhatsApp group and actually some of the best advice and occasionally some of the not so good advice comes through there
FARES HADDAD: but actually the experience of people who have treated infection for the last 20 or 30 years often trumps what is out there or easily accessible in the literature because there's nothing like knowledge, experience and having done it over the years. So there is a mixture here that you need to bear in mind when you're looking at outcomes. And we still have much to learn and much to research to have it all out there and discoverable and to transfer what Rhidian has learnt in the last 25, 30 years into something that everybody can reproduce.
FARES HADDAD: So just to conclude, this wasn't designed to please everybody. It is designed to highlight that there are real problems out there. I think on the positive side, we have made tremendous progress in the last 20 years. We've really put a focus on infection and that's important. But in so doing, there have been some pretty dramatic mistakes and some of them may have been done in all good faith, trying to improve things.
FARES HADDAD: My message to you is that much of the literature is flawed and you've got to be incredibly careful in this area, both unpicking what is behind the studies, what is behind their data and some of the drivers and some of the recent initiatives are questionable, moving away from culture. I think we've got to really look at how we want to go from that point of view. Above all, we need to all standardize how we collect data and how we report it.
FARES HADDAD: If we don't set minimum standards outcomes that everybody needs to collect, we're still going to be looking at a mishmash of data and that would be unfortunate as we progress in this area. But this is an important area for us to focus on and it is great that Ian, Rhidian and others are driving it so well. Thank you very much.
RHIDIAN MORGAN-JONES: Fares, that is excellent.
RHIDIAN MORGAN-JONES: Thank you. As stimulating as ever. And I couldn't agree with you more on so many things and in particular the patient perspective and it's interesting that hopefully you've seen, as I have, there's a group of us now with certain age, certain vintage, who've done everything you said, with all the mistakes that you've mentioned, God knows I've done them.
RHIDIAN MORGAN-JONES: But now the focus has changed towards the patient and putting them uniquely at the center of what we do. How strange is that.
FARES HADDAD: Well, it's so logical. And I can remember falling off my chair when a young, very bright, now eminent orthopedic surgeon presented the five criteria of success in periprosthetic infection management, and the patient wasn't mentioned in them.
FARES HADDAD: I think you were sitting next to me, Rhidian.
RHIDIAN MORGAN-JONES: Yeah, absolutely. Fares. Could I could ask you a quick question. I agree that you said and you've mentioned experience, and one of the unique things about the UK now is revision networks for knees and it'll be rolled out from knees to shoulders to foot and ankle to hip. Do you think that's going to make a difference if we centralize and have a genuine regional MDT so that everybody talks to each other.
RHIDIAN MORGAN-JONES: Experiences transferred patients move with the experiences.
FARES HADDAD: So I think the concept is right. The analogy is awful. It's been one of the worst done political stunts in British history, the revision knee network and I can't think of a worse example of mismanaging colleagues and abusing trust. But in reality the concept of centralizing and having expertise in areas that can deliver this care.
FARES HADDAD: This is not doing down surgeons in small centers. This is just basically making sure that everybody is centered around the patient and giving the patient centered care you're referring to so it's about having the right ID, the right microbiology, the right laboratory, the right, frankly, the porters who can get the samples with the right samples from theater to the lab.
FARES HADDAD: It's about having the meetings, the feedback, the learning and if you have more volume, you have more learning. So there's no question Rhidian that centralisation and having a focus on infection in very specific centers, although it's complicated sometimes in the early presentation, how you get the patients there is going to be the way forward. I'm sad about the way it's been done in the UK. It's been done much more nicely in France.
FARES HADDAD: We're pushing to try and get some traction with it through Tom Ferring and others in the US. But no, no question, Oxford led the way. We've had an MDT for 25 years almost now in infection that's been advising externally as well as internally. I think there's no question these are complex cases that need to be centralized.
RHIDIAN MORGAN-JONES: Thank you. Agree. Ian, do we have any questions from the delegates.
IAN KENNEDY: We do. On just one point, Professor Hadad. Thank you, that was a superb talk, as you really nicely discussed, one of the big issues owith infection literature is the multiple factors that ultimately influence outcomes during patient, organism, MDT inputs, the surgery itself. Is there, is therefore it difficult to tease out which steps ultimately affect success.
IAN KENNEDY: Can we overcome this with high quality evidence or do you think we need to think we're getting
FARES HADDAD: better at capturing data and if we have data capture that is broad enough in a big enough number, we will start to be able to unpick this. There will always be unknowns and there will always be descriptors that we're not picking up. But I think this is where bigger data sets and whether you can ever get registries that are deep enough.
FARES HADDAD: I mean, I remember having discussions with Mike Reed before the infection registry was set up because I thought what you really needed was even deeper data sets and that you should collect them from the eight bigger centers or the ten biggest centers and focus on those to have real depth and then be able to go in that and then translate that. And that's where big computing will come in, et cetera, to be able to do that.
FARES HADDAD: So I think the answer to your question is that I'm not sure we're anywhere near there, but the only way we're going to get there is by capturing lots and lots of data and being able to then look at outcomes for that data and that will need everything I talked about. It will need good data capture at the front end and it will need very clear outcomes and very clear reporting at the back end.
IAN KENNEDY: Perfect. Two questions from the audience.
IAN KENNEDY: Firstly, the question is, do you see any role for AI in filtering data and investigations to have any impact on the diagnosis of PJI? And do you think that AI can replace a surgeon's experience.
FARES HADDAD: Not at the moment, but AI is going to do lots of things. It is so exciting and it can look at big data sets. So I think the answer is yes. I think there is a role here at looking at a number of metrics and trying to guide you in the right direction.
FARES HADDAD: Before we get there. There will a number of black boxes sold to us as part of the economic game behind infection that actually won't deliver this properly. And so I think we've got to be cautious there. This needs to be like all AI innovations and research going to have to be looked at really critically, but I think it will absolutely have a role to play. Will it completely replace surgical experience?
FARES HADDAD: You know what, I really don't think so. There is something you get from treating infection for 25 or 30 years that just gives you a pattern recognition and something you learn from everybody around you that right now, I think is difficult to replace. I hope I'm not proven wrong, but I think that's the little bit of value I add to my team to in order to do that. Mike Reed I think or someone called Mike R has just piped in that I can't see AI being useful.
FARES HADDAD: Data sets are too small. I think the challenge is actually his registry and a bunch of well-reported studies from multiple centers in a world of open data where all the data is uploaded is actually going to be the answer. So I hate to disagree with Mike Reed. That means I'll be excommunicated yet again from the infection world.
FARES HADDAD: But I think Mike, it is something we need to be able to do in open data will help with that.
IAN KENNEDY: Super. One final question. It's interested in your infection control rather than cure idea. Are you suggesting that different bugs can hide more or less well, perhaps for years.
FARES HADDAD: Absolutely, so I think two things here.
FARES HADDAD: I think first one is people report too short term and things come back to hurt them and increasing antibiotic time and you think you're doing well. And then bang, the problem comes back to haunt you. So the more you follow up your patients, the more you discover problems. But the other thing is, I think bugs lurk in all sorts of strange places in canaliculi, in places you can't see or can't get to.
FARES HADDAD: And when we talk about radical debridement we try and do a really good job of taking away everything that we think is abnormal. But as Vanya and others who are experts in this field there'll be a Staphylococcus lurking somewhere in a deep, dark corner you just can't get out. So yes, there are differences and I'm really I feel very strongly about that.
FARES HADDAD: Anybody who says eradication loses me, that's the rest of that talk gone so I warned the next two presenters.
IAN KENNEDY: Well that's good to know. Thank you so much, Professor Haddad, again, absolutely superb. I'm going to hand over to Rhidian to introduce our next speaker.
RHIDIAN MORGAN-JONES: Excellent well, that's certainly set the standard for the rest of this presentation
RHIDIAN MORGAN-JONES: webinar. Fares. Thank you so much. Our next speaker is Dr. Simon Garceau.
Segment:0 .
IAN KENNEDY: To the success of this society. I would like to take this opportunity to encourage you all to join BAJIS. Membership is free, which is a welcome change for a special society and we'll keep you updated on upcoming events, for example, our next annual Congress in Coventry and we would hope to see many of you there. This evening,
IAN KENNEDY: we're privileged to have a group of distinguished speakers who really are leaders in the field and so it's my pleasure to hand over to our current BAJIS president, Mr Rhidian Morgan-Jones, who will do the introductions. Over to you Rhidian. Ian, Thank you.
RHIDIAN MORGAN-JONES: It is indeed a pleasure to have our third BAJIS webinar and to have such a wonderful group of guest lecturers.
RHIDIAN MORGAN-JONES: I'm at my advanced stage. I'm really excited about tonight's program I've been looking forward to for a long time. We've got Dr. Joshua Jones from Dundee to talk about phage therapy, Dr. Simon Garceau from Ottawa to look at PJI trends in North America and we'll first talk is Professor Faris Hadad from London who's going to give us a realistic outcome on PJI surgery.
RHIDIAN MORGAN-JONES: But also at this point, I'd like to thank our sponsors Molnlycke will be giving a short presentation later. So if could introduce Farah Haddad, one of the key opinion leaders in World orthopedics and I'm really looking forward to see what he has to say about infection outcomes, which I think is a much neglected topic. Fares.
FARES HADDAD: Thanks, Rhidian and hanks, Ian and thank you for having me on this webinar.
FARES HADDAD: Hope you don't ultimately regret it. So I've been given the task of talking broadly to say about my focus like my clinical factors, practice is going to be on hip and knee arthroplasty infection, although I recognize that the membership is much broader than that. But I thought I would stick to the area I've worked on and understand. We always show our disclosures. My disclosures are inevitably relevant.
FARES HADDAD: I think one key one here is that I'm Editor in Chief of one of the big general orthopedic journals, and although I speak as myself this evening rather than Editor of the Journal, my views are inevitably shaped by the literature that I see and have to deal with on a day to day basis. So just setting the scene, if you like. I have a very tainted view.
FARES HADDAD: Having spent over 10 years as an editor of a journal, that the literature as a whole is actually horribly flawed. And as you'll see, I feel that's particularly the case in the infection world and that we should be working to improve it. There are many reasons for this, but in reality, one of them is that the publication world has evolved dramatically with open publishing, and this has huge benefits in terms of accessibility to research, but it has a downside in that there are too many journals and an increasing number of predatory journals, and that means that everything gets published somewhere.
FARES HADDAD: And I'm sure my colleagues speaking after me, all of whom are distinguished experts in the field, may partly fall foul of occasionally referencing some of the material that probably should not be in print, but suits the case that we are supporting at the time. And so it comes down to as a discerning listener, reader or person trying to guide the care of your patient to differentiate as to what is credible research and what's junk science, because there are not no perfect controls out there.
FARES HADDAD: And this is a real problem in the infection world. It's always been worse than other areas because of the underlying heterogeneity that we have to deal with. But beyond that, in this world that we all live in and are trying to improve, there really isn't uniformity of definitions or interventions, as I'll come back to. There's a massive fidelity problem, and my big concern is there are huge reporting problems.
FARES HADDAD: If this wasn't enough, more recently, there have been big economic drivers as the focus has come in on this area and some personalities that have driven the literature and hence the thinking of many in perhaps a direction that it would not have gone in on with sensible, proper peer review. I'm going to come back to this paper, but I thought I'd put it out at this point as a taster. This is a fantastic piece of work from Carsten Perker's group, looking at the German registry and linking it to other databases in Germany.
FARES HADDAD: So it's not just the arthroplasty registry, but it's looking at their insurance data as well, so that you get real tangible outcome because the insurance data is complete. And in reality, what this study shows is that what is reported in the literature doesn't seem to correspond with what they are finding here. Some real question marks on the material we all rely on a day to day basis and regularly reference.
FARES HADDAD: Now the problem goes deeper than that, of course, because we have even struggled to define what an infection is after arthroplasty. This is for me, what is the standard now and congratulations to all the colleagues who've contributed to this at EBJIS as this should be what we're all using. We were not until not too long ago using the MSIS definition of infection from 2013, and we were all comfortable with that.
FARES HADDAD: It was logical. It fitted in with our practice. Sam Oussedik and I with Ian Stockley and Kate Gould, made the mistake of suggesting that a numerical system might be added to this and I still think it is a sound suggestion. But what we didn't have in mind is what happened in the lead up to the 2018 consensus meeting, where a numerical definition was created that suddenly put d-dimer and alpha defensin at the heart of infection diagnosis and downplayed culture.
FARES HADDAD: Many of you will know my views on this. Remarkable that d-dimer data was suddenly available from so many centers in particular and remarkable after all these years that we've downplayed infection. But I think it's a key message here that if we cannot agree the definition, then we have a problem. So for the time being, I think we have a workable solution with the EBJIS definition. But unless we're all reporting to the same metrics, we're going to struggle.
FARES HADDAD: And right now worldwide, we are not reporting to the same metrics. The other issue I mentioned at the outset is fidelity. So we talk with great confidence about incision and debridement, DAIRs, excision arthroplasty, arthrodesis and all the modalities available. But in reality, a DAIR in one set of hands is very different from a DAIR in another and a single stage revision in my hands and in somebody else's hands is very different.
FARES HADDAD: It's not just the technique of the surgery, it's the perioperative care, the microbiology input, the plastic surgery input. There are multiple variables, but even just the basis of that one line descriptor is questionable because it is not the same across the literature. The best example here is in terms of incision and drainage, wash out debridement and implant retention. There's a murky cloud in between all of those that makes all the summative analyses of them really tricky to put together.
FARES HADDAD: The next piece is how we define success in reality. Many people have tried to do this. This particularly lauded paper doesn't even have the patient perspective in it. It is purely a microbiological and surgical definition and it's been one of my gripes in the infection world that the patient perspective should be front and center of everything we do. Like everything else in the literature, when we're really trying to define success, it should have a patient centered focus, and that hasn't been the case.
FARES HADDAD: The other issue here is the outcome of the infection versus the outcome of the arthroplasty. The two may be very different and this has pushed us in a treatment direction that favors dealing with the infection, often to the detriment of the patient and their function, and those two needed balance. We've also fared to failed to standardize for follow up. So there should be a minimum follow up period for any infection reporting in arthroplasty without infection.
FARES HADDAD: We look at least two years. In reality, we didn't even report our initial single stage experience until we had five years and I think there should be a significant minimum period that we all agree on. I'm a great believer that you get infection control. I don't think you ever really get eradication, but I can't get everybody to agree with me on that. I think we really should focus, as I mentioned, on patient function and happiness, rather just on whether there is an organism or the patient requires antibiotics or further surgery.
FARES HADDAD: And so we fail to set adequate reporting standards, and that is something that we must fix. We, of course, have good literature. This is a paper from one of our chairs on single stage revision, but they're largely case series and they've got questionable fidelity in terms of other people doing the same procedure the same way and so those results may not necessarily be transferable to everybody else out there.
FARES HADDAD: There's plenty of them. They build our experience. They build our thinking. But I think you've got to just remember that what happens in those centers isn't necessarily what happens in every hospital. The reason I mentioned that is not to belittle any of these papers. I think they're all excellent papers from hard working people in good centers doing good work.
FARES HADDAD: But where it becomes questionable are when people, including myself, try and do a summative analysis of these papers when they're adding together apples and bananas and various other fruits, putting them all in a mix and trying to reach conclusions. Those are real problems. Then we get on to the outcome measures. So if we focus for example, on infection control, if we can agree what that is, we need to remember that there are other variables at play.
FARES HADDAD: And we certainly as a surgical community have largely ignored morbidity and mortality. So it's only recently come to wide understanding that those proponents of two stage revision, for example, the standard accepted approach worldwide, were largely losing a chunk of the denominator between stages, either due to morbidity or due to the patients not wishing to come back or frankly due to mortality. And then the later mortality wasn't even considered.
FARES HADDAD: So success needs to look at the entire denominator and not just those who went through to the second stage. We're very fortunate in that there are now some RCTs and some really good clinical RCTs. The Inform Group have done a wonderful job. Tom Ferring's group is about to get to their two year data, and I think this really helps and frankly, is changing practice. I've had a big focus on popularizing single stage revision.
FARES HADDAD: I think I've succeeded to a certain extent in that I now go to North American meetings where single stage revision is a procedure invented in the United States. That makes me very, very pleased because we've really changed practice through these studies and there are some useful guidelines from that have come out from the information from these studies on top of the qualitative data that we can take away. Now, a brief word about registries and databases because they're out there and they become a key resource for us to look at data and outcome, they're easily accessed.
FARES HADDAD: I think you've got to take away from this that although I'm going to give you one great paper that I've already mentioned, these are largely flawed in relation to periprosthetic infection. Just think of it in simple terms and we've written on this previously. The data that goes into the registry is recorded at the time of surgery. It doesn't separate deep or superficial infection.
FARES HADDAD: It doesn't delineate exactly which procedure the patient underwent. It doesn't have the microbiology data. It doesn't have case mix adjustment. Now, of course, there are new registries trying to address this, but in the standard registries, we know there was a poor pickup that was 40% or less. We've, of course, learned a great deal from the registries when you look at the baseline demographics.
FARES HADDAD: So looking at the number of people who are having infected revisions, that is helpful, of course or looking at morbidity, mortality, et cetera. Afterwards, there are some metrics in the registries are very useful, but you've got to remember the denominator may be completely right. And then there are failings. One, this is a reasonably well-written paper from New Zealand analyzing the impact of ultra clean air theaters, amongst other things on infection rates.
FARES HADDAD: Now, little did we at the time that what it recorded was whether there was an ultra clean air theater in the hospital, not whether it was in use or not. It didn't record how it was used. And there are multiple variables missing and of course, the capture of infection was incomplete, as I've just shown you from the Danish Registry. But the conclusion of those papers have led to guidelines belittling laminar airflow ventilation for orthopedic theaters.
FARES HADDAD: You may be on one side of this equation or the other, but I think when those papers based on big data, lead to big guidelines that change practice worldwide, we do have to be a little bit cautious. I come back to this paper because this is Cast and Perker's work. Remember linking the foolproof insurance data with the German registry, which of course doesn't have 100% capture but has pretty good capture.
FARES HADDAD: That data goes completely against what is in the single hospital reports and the meta analysis from Germany. And that would suggest at the very least, that the data from big centers isn't transferable elsewhere and hence we should be centralizing and looking at different models of care. At the worst, it suggests that patients are traveling, getting treatment and their definitive outcome isn't being reported by the original center, who have deemed them a success when the patient has decided not to come back because they've already had their treatment there
FARES HADDAD: and failure means their secondary treatment will be local. So lots of tricky queries here and stuff we need to look at. The last facet that we tend to look at is consensus, and I think the 2013 consensus was a huge success. It's a great way of hearing from everybody involving everybody and getting a good conversation. But I think you've got to be careful with consensus. There's another on the horizon next year.
FARES HADDAD: There is a subtle difference between evidence and opinion, and there are some drivers behind this that can easily manipulate the output. That was certainly the case in 2018. And whilst I think consensus has helped us massively in this area, some of it does need to be taken with a pinch of salt. I think one key thing when we're looking at evidence, looking at the literature, looking at outcomes, is to look for concordance.
FARES HADDAD: If we can see similar data and similar outcomes across a number of different types of studies, be they case series, then onto control studies, onto RCTs and then onto the systematic reviews or the big databases, the observational data sets. That is very helpful and that will suggest we're moving in the right direction. Having said all of this, I think sometimes the best evidence is experience. BAJIS or the related group has a WhatsApp group and actually some of the best advice and occasionally some of the not so good advice comes through there
FARES HADDAD: but actually the experience of people who have treated infection for the last 20 or 30 years often trumps what is out there or easily accessible in the literature because there's nothing like knowledge, experience and having done it over the years. So there is a mixture here that you need to bear in mind when you're looking at outcomes. And we still have much to learn and much to research to have it all out there and discoverable and to transfer what Rhidian has learnt in the last 25, 30 years into something that everybody can reproduce.
FARES HADDAD: So just to conclude, this wasn't designed to please everybody. It is designed to highlight that there are real problems out there. I think on the positive side, we have made tremendous progress in the last 20 years. We've really put a focus on infection and that's important. But in so doing, there have been some pretty dramatic mistakes and some of them may have been done in all good faith, trying to improve things.
FARES HADDAD: My message to you is that much of the literature is flawed and you've got to be incredibly careful in this area, both unpicking what is behind the studies, what is behind their data and some of the drivers and some of the recent initiatives are questionable, moving away from culture. I think we've got to really look at how we want to go from that point of view. Above all, we need to all standardize how we collect data and how we report it.
FARES HADDAD: If we don't set minimum standards outcomes that everybody needs to collect, we're still going to be looking at a mishmash of data and that would be unfortunate as we progress in this area. But this is an important area for us to focus on and it is great that Ian, Rhidian and others are driving it so well. Thank you very much.
RHIDIAN MORGAN-JONES: Fares, that is excellent.
RHIDIAN MORGAN-JONES: Thank you. As stimulating as ever. And I couldn't agree with you more on so many things and in particular the patient perspective and it's interesting that hopefully you've seen, as I have, there's a group of us now with certain age, certain vintage, who've done everything you said, with all the mistakes that you've mentioned, God knows I've done them.
RHIDIAN MORGAN-JONES: But now the focus has changed towards the patient and putting them uniquely at the center of what we do. How strange is that.
FARES HADDAD: Well, it's so logical. And I can remember falling off my chair when a young, very bright, now eminent orthopedic surgeon presented the five criteria of success in periprosthetic infection management, and the patient wasn't mentioned in them.
FARES HADDAD: I think you were sitting next to me, Rhidian.
RHIDIAN MORGAN-JONES: Yeah, absolutely. Fares. Could I could ask you a quick question. I agree that you said and you've mentioned experience, and one of the unique things about the UK now is revision networks for knees and it'll be rolled out from knees to shoulders to foot and ankle to hip. Do you think that's going to make a difference if we centralize and have a genuine regional MDT so that everybody talks to each other.
RHIDIAN MORGAN-JONES: Experiences transferred patients move with the experiences.
FARES HADDAD: So I think the concept is right. The analogy is awful. It's been one of the worst done political stunts in British history, the revision knee network and I can't think of a worse example of mismanaging colleagues and abusing trust. But in reality the concept of centralizing and having expertise in areas that can deliver this care.
FARES HADDAD: This is not doing down surgeons in small centers. This is just basically making sure that everybody is centered around the patient and giving the patient centered care you're referring to so it's about having the right ID, the right microbiology, the right laboratory, the right, frankly, the porters who can get the samples with the right samples from theater to the lab.
FARES HADDAD: It's about having the meetings, the feedback, the learning and if you have more volume, you have more learning. So there's no question Rhidian that centralisation and having a focus on infection in very specific centers, although it's complicated sometimes in the early presentation, how you get the patients there is going to be the way forward. I'm sad about the way it's been done in the UK. It's been done much more nicely in France.
FARES HADDAD: We're pushing to try and get some traction with it through Tom Ferring and others in the US. But no, no question, Oxford led the way. We've had an MDT for 25 years almost now in infection that's been advising externally as well as internally. I think there's no question these are complex cases that need to be centralized.
RHIDIAN MORGAN-JONES: Thank you. Agree. Ian, do we have any questions from the delegates.
IAN KENNEDY: We do. On just one point, Professor Hadad. Thank you, that was a superb talk, as you really nicely discussed, one of the big issues owith infection literature is the multiple factors that ultimately influence outcomes during patient, organism, MDT inputs, the surgery itself. Is there, is therefore it difficult to tease out which steps ultimately affect success.
IAN KENNEDY: Can we overcome this with high quality evidence or do you think we need to think we're getting
FARES HADDAD: better at capturing data and if we have data capture that is broad enough in a big enough number, we will start to be able to unpick this. There will always be unknowns and there will always be descriptors that we're not picking up. But I think this is where bigger data sets and whether you can ever get registries that are deep enough.
FARES HADDAD: I mean, I remember having discussions with Mike Reed before the infection registry was set up because I thought what you really needed was even deeper data sets and that you should collect them from the eight bigger centers or the ten biggest centers and focus on those to have real depth and then be able to go in that and then translate that. And that's where big computing will come in, et cetera, to be able to do that.
FARES HADDAD: So I think the answer to your question is that I'm not sure we're anywhere near there, but the only way we're going to get there is by capturing lots and lots of data and being able to then look at outcomes for that data and that will need everything I talked about. It will need good data capture at the front end and it will need very clear outcomes and very clear reporting at the back end.
IAN KENNEDY: Perfect. Two questions from the audience.
IAN KENNEDY: Firstly, the question is, do you see any role for AI in filtering data and investigations to have any impact on the diagnosis of PJI? And do you think that AI can replace a surgeon's experience.
FARES HADDAD: Not at the moment, but AI is going to do lots of things. It is so exciting and it can look at big data sets. So I think the answer is yes. I think there is a role here at looking at a number of metrics and trying to guide you in the right direction.
FARES HADDAD: Before we get there. There will a number of black boxes sold to us as part of the economic game behind infection that actually won't deliver this properly. And so I think we've got to be cautious there. This needs to be like all AI innovations and research going to have to be looked at really critically, but I think it will absolutely have a role to play. Will it completely replace surgical experience?
FARES HADDAD: You know what, I really don't think so. There is something you get from treating infection for 25 or 30 years that just gives you a pattern recognition and something you learn from everybody around you that right now, I think is difficult to replace. I hope I'm not proven wrong, but I think that's the little bit of value I add to my team to in order to do that. Mike Reed I think or someone called Mike R has just piped in that I can't see AI being useful.
FARES HADDAD: Data sets are too small. I think the challenge is actually his registry and a bunch of well-reported studies from multiple centers in a world of open data where all the data is uploaded is actually going to be the answer. So I hate to disagree with Mike Reed. That means I'll be excommunicated yet again from the infection world.
FARES HADDAD: But I think Mike, it is something we need to be able to do in open data will help with that.
IAN KENNEDY: Super. One final question. It's interested in your infection control rather than cure idea. Are you suggesting that different bugs can hide more or less well, perhaps for years.
FARES HADDAD: Absolutely, so I think two things here.
FARES HADDAD: I think first one is people report too short term and things come back to hurt them and increasing antibiotic time and you think you're doing well. And then bang, the problem comes back to haunt you. So the more you follow up your patients, the more you discover problems. But the other thing is, I think bugs lurk in all sorts of strange places in canaliculi, in places you can't see or can't get to.
FARES HADDAD: And when we talk about radical debridement we try and do a really good job of taking away everything that we think is abnormal. But as Vanya and others who are experts in this field there'll be a Staphylococcus lurking somewhere in a deep, dark corner you just can't get out. So yes, there are differences and I'm really I feel very strongly about that.
FARES HADDAD: Anybody who says eradication loses me, that's the rest of that talk gone so I warned the next two presenters.
IAN KENNEDY: Well that's good to know. Thank you so much, Professor Haddad, again, absolutely superb. I'm going to hand over to Rhidian to introduce our next speaker.
RHIDIAN MORGAN-JONES: Excellent well, that's certainly set the standard for the rest of this presentation
RHIDIAN MORGAN-JONES: webinar. Fares. Thank you so much. Our next speaker is Dr. Simon Garceau.
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