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General Topics Feature

Landmark Agreement on Joint Infection Protocols // NFL, GE Tap UPMC to Study Concussions // and More!

Elizabeth Hofheinz, M.P.H., M.Ed. • Mon, February 10th, 2014

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Landmark Agreement on Joint Infection

Many have tried, few have succeeded. However, Javad Parvizi, M.D., director of research for The Rothman Institute in Philadelphia, has managed to get orthopedic surgeons from around the globe to agree on not one, but 207 issues! Dr. Parvizi tells OTW, “Finally, after years of trying to obtain consensus on infection-related issues, we have succeeded. Our recent meeting drew 400 participants from 52 countries; we developed 207 infection-related questions, voted on each one, and then made recommendations to establish ‘set in stone’ protocols for surgeons worldwide. We then published these recommendations in several journals, and printed and distributed 15, 000 copies of the resulting book that is being translated into more than 20 languages.”

“Incredibly, we were able to arrive at a consensus on 203 of the 207 questions. One of the main areas of consensus was to reach a definition for PJI [periprosthetic joint infection]. Infection of a joint usually presents with pain and relying on isolation of an infecting organism from the joint cannot be relied on as a gold standard. Thus, there are so many different definitions of what constitutes PJI. The consensus meeting accomplished the difficult task of reaching an acceptable definition. The Centers for Disease Control (CDC) will adopt our definition of periprosthetic joint infection moving forward. This is very exciting because many of the things we do in clinical practice vary greatly from place to place; that will no longer be the case when it comes to joint infection.”

“Some of the questions we addressed included, “‘Should you change gloves during surgery and if so, how often?’ ‘Which antibiotics should be administered to patients prior to surgery and for how long?’ There were four questions that did not reach a consensus. One was, ‘What type of dressing should be used after surgery?’ It turns out that surgeons feel pretty wedded to the dressing they are accustomed to, and it works in their hands so they did not want to make a change. We attempted to get people to switch to occlusive dressings, but despite evidence to the contrary, some are still under the impression that a regular change of dressing is necessary. Another point that did not reach a consensus was the use of tantalum. There is some research showing that tantalum can provide protection against infection, but not everyone was in agreement on this issue.”

“As a follow-up to the meeting, each participating country has organized a consensus dissemination meeting. Our biggest goal is to determine if the implementation of these consensus items will make a difference in surgical site infections. We are working with the CDC to measure the impact of the consensus, focusing on which regions of world can be most impacted by these guidelines.”

“It’s interesting to note that some of the questions we discussed don’t lend themselves to level 1 studies. For example, ‘Should one do the joint replacement in a laminar flow room?’ or ‘Should you add antibiotics to the irrigation solution? Not everything we know and practice in medicine has been developed as a result of level 1 studies. Many of our practices are in fact based on the observation of scholars and great thinkers from the past. For example, there is no level 1 study on the use of glove during surgery. Would anyone dare do a randomized, prospective study evaluating this issue? There are many other related issues in medicine that cannot be subjected to randomized, prospective study and requires the cumulative wisdom of experts. The meeting we held was intended to do this exactly. We have accomplished an important step in improving care for our patients in terms of minimizing infection in orthopedics with all its dreaded consequences. Going forward, the consensus guidelines should make a significant impact on patient care.”

Finally! THE Book on Failed ACL Reconstruction

What major resource can surgeons avail themselves of when dealing with a failed ACL [anterior cruciate ligament] reconstruction? Until now, none. Robert G. Marx, M.D. is an orthopedic surgeon on the Sports Medicine and Shoulder Service at Hospital for Special Surgery (HSS). He has recently written a textbook—“Revision ACL Reconstruction: Indications and Technique”—that tackles this challenging problem. Dr. Marx, also a professor of Orthopedic Surgery and a professor of Public Health at Weill Cornell Medical College, tells OTW, “I was approached by Springer to write this book after I delivered a presentation on failed ACL reconstructions; the editor indicated that there was no textbook that could serve as a reliable resource for orthopedic surgeons regarding such cases. It was an incredible learning process as it became clear that no matter how ‘expert’ one is at something, there is always more to be learned. For example, the chapter on revising failed double bundle reconstruction was particularly enlightening and interesting because the author (Freddie Fu, M.D.) had a significant amount of experience with these surgeries, something that isn’t normally the case. He provided vital guidelines on when to revise a double bundle to a single bundle revision and when it may be better to revise a double bundle to another double bundle.”

“By including authors from every continent we were able to gather different points of view. For example, in Japan they use a different technique—a rectangular femoral socket. Patients there are often smaller so these surgeons have more experience with small stature patients; their techniques for smaller people are unique.”

“The critical thing with revision ACL reconstruction is that each patient is often very different. Some cases can be very simple, whereas others are quite challenging because of the technical considerations (prior tunnel placement or expansion, location of prior hardware, type of hardware etc.). Because of this you must have a lot of different techniques that you are comfortable with. And you must not only have a plan, but you must be ready to alter your plan. The fact that we have so many authors from different countries is especially valuable for revision ACL reconstruction because these cases require these cases benefit from a wide variety of approaches.”

UPMC Tapped by NFL, GE to Study Concussions

To whom did the NFL turn to further the science of brain injury? The University of Pittsburgh Medical Center (UPMC). Michael Collins, Ph.D. is director of the UPMC Sports Medicine Concussion Program. He tells OTW, “When the NFL and GE decided to work together to fund research on diagnosing concussions they put out a call for proposals. Out of the 402 they received only 16 were funded. This work is so important because to date we have had no imaging or biomarker to delineate concussions. We have been utilizing a neurocognitive test but, while that information is very useful and of significant importance from a functional standpoint, it is an indirect measure of brain function and only one tool in our concussion medicine kit.”

“Our project involves an advanced imaging high definition fiber tracking that is based on standard MRI sequences. Traditional imaging cannot reveal subtle damage that can be caused by a mild traumatic brain injury. Using advanced computational methods we will be able to look at the white matter in the brain and determine—with great sensitivity and specificity—if there is a fracture or breakage of any sort. At this point we are not looking at use for the playing field, but within the first seven days after an injury. If a child is injured and a diagnosis of concussion is reached, then we will conduct a functional assessment, employ the fiber tracking, follow them, and reimage them when they return to play. We will begin enrolling patients in about two weeks and expect to have preliminary results in approximately six months.”

“If you have a knee problem we can rely on evidence-based ways to determine the prognosis, who will be quickest to recover, etc. Our goal is to make brain injuries just like any other injury. Every step that we’ve taken is scientifically geared toward understanding the phenomenology of this issue.”

“In 2000 when Freddie Fu, M.D. recruited my colleagues and I [sic] to UPMC no one was focusing on concussions. Dr. Fu could see that this issue would only increase in importance, and he had foresight to bring our program into the sports medicine division. At UPMC we have the largest concussion program in the world, with over 20, 000 patient visits annually. This work will go a long way towards increasing the safety of our most popular national sport.”

Robert A. Kayal, M.D. Receives Compassionate Doctor Award

Robert A. Kayal, M.D., founder, president, and CEO of Kayal Orthopaedic Center in New Jersey, has been awarded the Compassionate Doctor certification. This recognition is given by Vitals, a doctor review site where patients can provide online reviews and vote for their favorite doctors.

The award is given to doctors who go above and beyond in treating their patients with kindness. The award is based on a doctor’s overall and bedside manner scores. Doctor Kayal serves on the medical staff at The Valley Hospital, The Hackensack University Medical Center, Chilton Hospital and is the Director of Orthopaedic Surgery at Patient Care Associates.

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