Infection prevention
Hydrogel coatings and complex fracture care
Will Eardley and Helen Smith, from James Cook University Hospital, highlight the impact of implant related infections in orthopaedic surgery and the challenges around biofilm formation. In this article, they consider the role of hydrogel in preventing infections and share their valuable insights into selecting patients who could benefit.
Infection is a negative outcome for any implant related surgical procedure. Repercussions for the patient and the system in which they are cared for are considerable. Limb loss may be an ultimate consequence, while marked limitation of function and quality of life are commonplace in those unfortunate enough to become infected after orthopaedic surgery. Characterised by its multifactorial nature, contributors to prevention of infection in this field are vast. They should be judged on their efficacy, as well as their impact on the patient and the healthcare system. Clinicians should aim to identify and exploit any opportunity to reduce the risk of fracture related or periprosthetic infection for their patients. Some opportunities incur great expense and
resource use and varying risk to patients are encountered in prevention. Other methods are easier, less costly, and more patient acceptable. This article discusses the use of hydrophilic polymer coatings as one example of more acceptable management of patients in whom
infection carries especial impact. No implant is immune to the impact of contamination, bacterial adherence, and subsequent implant related infection. Likewise, there is no patient that can mitigate significant bacterial contamination through host immunity alone without risking the spectre of deep infection either early or late in the post-surgical period. There are many techniques and treatments that can correct this imbalance between the naive implant at risk and the predatory organism; the majority of which are simple and inexpensive. Meticulous haemostasis, antiseptic lavage, attention to surgical technique, and appropriate intravenous and cement laden antibiotics comprise the bulk of preventative measures. While every patient is at risk, not every patient succumbs to infection. Therefore, for most cases, simple measures should suffice. This is because of the balance between risk factors controlled by the surgeon and those that the patient contributes. There
are therefore high risk and low risk cases and similarly high risk and low risk patients. Thereby, in terms of a ‘relative-risk Venn diagram’ there are an identifiable group of patients and procedures in whom additional measures to reduce infection is appropriate. Revision surgeries in both arthroplasty and
fracture fixation failure patients are one such example of surgical risk factors. With the addition of patient factors such as diabetes, deep venous congestion, smoking, intravenous drug use and immunomodulatory medications, the risks become apparent. Fracture related and periprosthetic joint infection (FRI & PJI) are a disaster for patients. Ongoing pain with no foreseeable solution, reduced function, and reduction in quality of life has a profound impact on the patient and their families. Inability to work and meaningfully contribute to society and family has serious implications that are not often fully appreciated.1 Prolonged intravenous antibiotic management and its side effects brings logistical compromise for the patient’s lifestyle. All the above are the patient experience
of infection of fracture construct or joint replacement. There is, in addition, the impact on the healthcare systems that treat them. Direct and indirect costs vary hugely between cases and between the healthcare setting in which they are managed. It’s difficult therefore to accurately predict the financial costs of a given infected complication; however, there are estimates that have been made. It has been proposed for instance that, for FRI, the cost of case management, if infected, is eight times the index cost if no infection occurs.1
Aside
from cost, attention is also given to scale of the problem. Due to heterogeneity and accepted probable under-reporting of PJI, it is difficult to give an exact incidence of infection following arthroplasty. However, for deep infection after total knee (TKR) and total hip (THR) replacements a figure of 2% is accepted.2,3
October 2024 I
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