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Combining Antiseptics May Be Toxic; THA Patient Mortality Risks; Troy Wilde, DPM Joins OrthoArizona

Elizabeth Hofheinz, M.P.H., M.Ed. • Tue, November 14th, 2017

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Combining Antiseptics May Be Toxic

Researchers from Stanford University have undertaken a novel line of study, namely investigating the dangers of using multiple antiseptics to irrigate a wound. Their work, “Antiseptics Commonly Used in Total Joint Arthroplasty Interact and May Form Toxic Products,” appears in the October 25, 2017 edition of The Journal of Arthroplasty.

Sean T. Campbell, M.D., department of orthopaedic surgery at Stanford University and study co-author told OTW, “We became interested in this topic when the senior author noticed that a basin with residues from one antiseptic was filled with another antiseptic on the back table during an operation for infection. A visible reaction occurred between the two antiseptics in the basin with creation of a precipitate.”

“We were not aware of this reaction being described elsewhere in the arthroplasty or orthopaedics literature and felt that this chemical interaction was important to investigate and report as surgeons sometimes use multiple antiseptics when treating infected joint replacements. We then broadened the scope by investigating the interactions of various commonly used antiseptics.”

“We combined the various antiseptics in all possible configurations in test tubes. It turns out that antiseptics are highly reactive chemicals. This is what contributes to their efficacy. We were surprised by how many of the solutions visibly reacted when combined.”

The authors wrote, “4% Chlorhexidine gluconate (CHX), 0.5% Sodium Hypochlorite (NaOCI), 3% hydrogen peroxide (HO), and 10% provideon-iodine (BTD) solutions were obtained and all possible combinations were mixed…”

Dr. Campbell commented to OTW, “We found that an obvious, visible chemical reaction occurred with five of the six antiseptic combinations tested. We did not independently analyze or characterize the details of the actual chemical reactions that occurred as this was beyond our capabilities, and it is possible that even the final combination resulted in a reaction that was not visible to us.”

“It may be that the most important interactions involve Dakin's solution with either chlorhexidine or hydrogen peroxide. Our literature review revealed that these mixtures may be creating products that are toxic. Final determination of this, however, would have to be the subject of more detailed chemical analysis and research.”

“The most important takeaway from this work is that surgeons should not concurrently use multiple antiseptics to irrigate a wound as they are likely to react and can potentially create toxic compounds with unknown consequences.”

THA Patients With Joint Infection Have 2x Mortality Risk

Increased Mortality After Prosthetic Joint Infection in Primary THA,” was published in the November 2017 edition of Clinical Orthopaedics and Related Research. Per Hviid Gundtoft, Ph.D., researcher in the department of orthopaedic surgery at Kolding Hospital in Kolding, Denmark, told OTW, “Three previous papers have addressed this issue, but they had mixed results. Two papers stated that there was no increased risk and one papers found an increasing risk. Moreover, we believed there was still doubt about whether the increased mortality we believed our patients were facing was due to the fact that they had an infection or that only the vulnerable patients—that were already in risk of dying—got an infection.”

The authors wrote, “This population-based cohort study was based on the longitudinally maintained Danish Hip Arthroplasty Registry on primary THA [total hip arthroplasty] performed in Denmark from 2005 to 2014.”

“Data from the Danish Hip Arthroplasty Registry were linked to microbiology databases, the National Register of Patients, and the Civil Registration System to obtain data on microbiology, comorbidity, and vital status on all patients. Because reporting to the registry is compulsory for all public and private hospitals in Denmark, the completeness of registration is 98% for primary THA and 92% for revisions (2016 annual report).”

Dr. Gundtoft commented to OTW, “The key strength with the study is that we were able to get complete data on the microbiology reports from all the intraoperative cultures. Furthermore, we have exact time of death on all the patients. The most important results were that patients with PJI's [prosthetic joint infection] mortality risk within one year is more than double that of patients without, even when adjusting for various confounder e.g., comorbidity. Moreover, patients infected with enterococcus are especially at risk of dying within one year.”

“We should—in our daily work—pay extra attention to these unfortunate patients with PJI and do everything we can to optimize their treatment. Moreover, we need close cooperation with microbiologists to ensure that we treat the patients—both pre and postoperatively—with the correct antibiotics. This is because one of the reasons for an increased mortality for patients with enterococcus was that enterococcus has intrinsic resistance to the most common used antibiotics used in revision THA surgery. Patients with PJI have a very high one-year mortality risk and surgeons should be extremely aware of the bacteria causing the PJI, as it can influence their patient’s mortality.”

Troy Wilde, DPM Joins OrthoArizona

Troy Wilde, DPM has joined OrthoArizona as a Foot and Ankle Hospitalist. Dr. Wilde, who attended Temple University School of Podiatric Medicine and who later completed a three-year surgical residency at the University of Texas Health Science Center at San Antonio, will provide acute foot and ankle care within the hospital systems in the East Valley.

As OrthoArizona wrote in its October 26, 2017 news release, “His training there consisted of forefoot and rear foot surgery with an emphasis on trauma, diabetic reconstruction, and wound care. Dr. Wilde is certified by the American Board of Podiatric Surgeons and is qualified in foot surgery. He specifically treats trauma, sport injuries, and diabetic foot and ankle issues that arise, managing these problems both conservatively and surgically using a multi-team approach to care for his patients.”

“The addition of Dr. Wilde is the most recent example of growth within OrthoArizona’s Foot and Ankle division. The team is proud of its reputation as a leading foot and ankle referral center in the Southwest dedicated to developing protocols and quality standards in order to improve foot and ankle care and patient outcomes. OrthoArizona Foot and Ankle patients benefit from the collaborative care they receive from a dedicated team of experts, comprised of four fellowship-trained orthopedic surgeons, six podiatrists, and two foot and ankle hospitalists, including Dr. Wilde.”

Dr. Wilde told OTW, “As a Foot and Ankle Hospitalist, I am heavily involved in the acute care setting. This involves any trauma in the foot and ankle as well as infections and diabetic ulcerations. I have been well trained in all of these areas and through the private practice setting, cared for many sports-related injuries. I have spent time in a wound care facility using conservative and surgical management for wound healing. These skills will assist in the management of our patients coming through the hospital.”

“My main goal in which our group wants to establish in the next year is a protocol that will efficiently care for patients and provide a team approach for all patients. There are systemic issues that affect how to manage the problems with the foot and ankle. Establishing a team approach with specific protocols will benefit hospital systems to help patients receive proper care and decrease length of stay, which in turn will help reduce complications. This team will include infectious disease, vascular surgery, wound care, and the emergency department to help coordinate quality care to all patients.”

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