Guest Nation Spurs International Discussion

By: Giuseppe Sessa, MD, PhD, and Paolo Cherubino, MD

Yesterday’s 2018 Guest Nation Symposium, organized by the Italian Orthopaedic Society (SIOT), covered two topics: “orthopedic surgery of the pelvis” and “controversies in diagnosis and treatment of infections after total hip arthroplasty (THA): determining the optimal moment for reimplantation.”

The first session about surgery around the pelvis produced compelling discussions from Italian and U.S. orthopaedic surgeons on a variety of topics, namely trauma, tumors, and revision THA surgery.

The second session dealt with the management of infections after THA. Data shared during the session indicated that there are 140,000 arthroplasty implants performed in Italy each year, 65 percent of which are hip implants. Of these surgeries, the incidence of infection is about 1.5 percent–2 percent. This condition is associated with a severe general health compromise and creates an economical burden for Italy’s national health system.

This scenario is somewhat concerning, especially given the increased number of hip and knee primary arthroplasty implants worldwide.

However, there is still extreme variability between surgeons about how to treat these patients. More specifically, there is debate about how to treat patients with periprosthetic joint infection (PJI) of the hip, in terms of revision of the entire construct and its eventual retention.

Management of PJI is dependent upon accurate diagnosis and successful treatment, both of which are challenging. Recently, diagnosis of PJI has greatly improved but there is still no “gold standard” diagnostic tool. In the absence of a perfect test, the combined approach of using clinical evaluation, serological investigations, diagnostic imaging, and microbiological analysis should enable the diagnosis of infection to be made with a high degree of confidence.

Every effort should be made to achieve a definitive microbiological diagnosis. There is clearly a role for surgical intervention, but the precise indications for one-stage and two-stage revisions have not been completely delineated. Proper diagnosis is essential as untreated or undetected PJI can quickly lead to biofilm formation on the implant surface, depending upon the infecting organism. Upon complete biofilm formation, successful treatment requires prosthetic resection with immediate or delayed reimplantation. Even with the most aggressive surgical treatment, PJI eradication currently has a success rate of approximately 80 percent.

This cutting-edge topic has been divided into two areas. The first concerns when and how to reimplant a hip with a periprosthetic infection. Javad Parvizi, MD, FRCS, provided the U.S. perspective, while the Italian point of view was presented by Carlo Romanò, MD.

PJI requires an integrated medical and surgical approach, which, in most cases, requires the removal of the infected implant and a two-stage revision with the use of a spacer. The international faculty present during the symposium, discussed the definition of the most appropriate antibiotic therapy, timing of the surgery, recommended implants (Fig. 1), and technical pitfalls in managing these patients.

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Fig. 1 A silver-coated mega-implant, used to manage large femoral bone defects following periprosthetic hip infection, provides extra protection against bacteria colonization of the implant.

Courtesy of f Carlo Romanò, MD

Carl Deirmengian, MD, and Andrea Ferretti, MD, led a discussion about how new technologies may affect our reimplantation strategies in the near future. In particular, new tools have improved the likeliness to correctly diagnose and characterize the disease by the identification of the causative microorganisms. New coatings (Fig. 2) and miniaturization might help improve the results associated with this demanding surgery.

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Fig. 2 Antibacterial hydrogel coating is used before revision cup or stem insertion for periprosthetic 
joint infection surgery.  

Left, courtesy of Carlo Romanò, MD
Right, courtesy of Andrea Ferretti, MD

The SIOT is proud of the keynote speakers who contributed to these sessions and enabled the compelling exchanges between Italian and U.S. orthopaedic surgeons.

Giuseppe Sessa, MD, PhD, president of SIOT, is internationally recognized for his work in joint replacement and musculoskeletal infections. He is professor of orthopaedic surgery; president of medicine school; and chief of orthopaedic and traumatology department at the University of Catania, Italy.

Paolo Cherubino, MD, retired in 2016 and is the past president of SIOT.

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