From OT Europe

19th EFORT Congress: How experts deal with infection-related bone loss

EFORT

Every orthopaedic surgeon has faced infection during his or her career. Indeed, today, the use of orthopaedic implants is a common practice and millions of patients have had their lives changed with the help of these successful procedures. However, the encouraging results of joint arthroplasty and osteosynthesis are still associated with infection in a varying percentage, depending on the type of procedure and related risk factors. Infection of the bone is difficult and expensive to treat and may lead to tremendous suffering for the patient, mainly due to related bone loss.

Barcelona banner

The Friday program of the upcoming EFORT Congress in Barcelona showcases an Interactive Expert Exchange (IEE) session under the topic Musculoskeletal Infections to present strategies for dealing with bone loss after septic surgery through reconstruction, based on bone regeneration, use of bone substitutes and grafting procedures.

Bone defects can be found with prosthetic joint infection (PJI), in osteomyelitis (OM), after trauma surgical procedures or as hematogenous seed of bacterial infection. In cases of early infection, bone defects are usually minor but, depending on the infection duration and extent of surgical interventions with debridement of infected tissue, bone defects also can reach considerable proportions. Complete removal of dead bone is the main prerequisite for cure. Treatment modalities greatly differ depending on the infection site and defect size. Diaphyseal defects (cortical) are addressed differently than metaphyseal (cancellous) ones. In children and younger patients, regeneration is faster and more complete, but the same result cannot be expected in elderly patients, who represent most of the cases.

There is no common rule on the number of procedures required for restoring bone stock after infection. As there is a high risk of recurrence, most techniques are requiring a multiple -stage treatment. Techniques using induced membranes and bone transportation are associated with long-lasting treatments and multiple medical interventions, whereas direct fill of the defects with substitutes (metal, cement, resorbable synthetics and bone grafts) may lead to earlier rehabilitation. For all techniques, safety should be comparable and considered as a priority.

There is a wide variety of reported results. Most available data focus on the success of eliminating infection, in which results appear variably effective with reported elimination rates between 50% and 100%. However, functional results also need to be measured and, especially, the quality of life of patients during and after treatment. There is an ongoing discussion on how the patients’ burden may be alleviated. It seems reasonable to assume that new protocols may lead to shorter treatments with improved quality of life but there is no standard procedure available for all kinds of bone defects. Recent research in the area defines convenient indications for each method separately.

With all treatment options, it should be kept in mind that chronic orthopaedic infections are mediated by bacteria embedded in biofilms, which show a completely different behavior than the freely floating “planktonic” phenotypes. As biofilms are usually inaccessible to the host’s immune response and systemically applied antimicrobials, much higher concentrations of antibiotics are required to eliminate infection caused by biofilms. These can only be reached by local application. Combining aggressive debridement with restoration of bone stock and provision of effective local antimicrobials may be a promising way to overcome complicated treatment. Carriers for local application are found in bone cement, synthetic substitutes and bone grafts, whereas synthetics and allografts seem to be effective not only against planktonic bacteria, but against bacteria embedded in biofilm remnants, as well. The efficacy and safety of the new technologies remain under discussion.

Moreover, both synthetics and allografts show advantages and disadvantages. The results vary depending on the respective indication. Synthetics have been investigated mainly in cases of OM, while allografts have been mainly used in treatment of PJI. Today, still no definitive recommendations can be provided, and further research is required to define the optimal use of carriers.

To better guide the treatment choice, this session will address preoperative considerations, as well as the latest data regarding available technology. The international panel of experts will share the best tips and tricks to avoid complications and ensure the best outcome for the patient.

Dealing with Bone Loss in Septic Surgery
Friday 1 June 2018 | 10:00 – 12:15

Introduction and Conclusions
Heinz Winkler (Austria)

Questions and Presentations

  • Bone Regeneration Strategies: Current Knowledge - And What Holds the Future –Thierry Charles Bégué (France)
  • Metal - Cement - Bone Graft: Advantages and Disadvantages of Materials in Infection – Duncan Whitwell (United Kingdom)
  • Allograft Bone Loaded with Antibiotics – Martín Buttaro (Argentina)
  • Synthetic Bone Substitutes: Indications and Limitations in Septic Surgery - Carlo Luca Romanò (Italy)
  • Reconstruction of Septic Bone Defects Respecting the Biofilm Concept – Heinz Winkler (Austria)

Discussion on Clinical Cases
Lorenzo Drago (Italy) & Martin Clauss (Switzerland)

IEE banner

The lectures, debates and clinical case presentations from well-known orthopaedic surgeons will guide the audience to a deep-seated appreciation of how to deal with several types of bone defects resulting from infection. Treatment and techniques based on regeneration, bone substitution and graft approaches will be presented to highlight all the specific considerations to evaluate before any treatment decision for bone loss resulting from infection.

IEEs are paying sessions and pre-registration is mandatory on a first-come, first-serve basis (maximum of 200 participants). Only participants with a full registration for the EFORT Congress can attend the IEE sessions. All details to sign-up are available on our registration platform. Visit our Barcelona congress website regularly.

EFORT

Every orthopaedic surgeon has faced infection during his or her career. Indeed, today, the use of orthopaedic implants is a common practice and millions of patients have had their lives changed with the help of these successful procedures. However, the encouraging results of joint arthroplasty and osteosynthesis are still associated with infection in a varying percentage, depending on the type of procedure and related risk factors. Infection of the bone is difficult and expensive to treat and may lead to tremendous suffering for the patient, mainly due to related bone loss.

Barcelona banner

The Friday program of the upcoming EFORT Congress in Barcelona showcases an Interactive Expert Exchange (IEE) session under the topic Musculoskeletal Infections to present strategies for dealing with bone loss after septic surgery through reconstruction, based on bone regeneration, use of bone substitutes and grafting procedures.

Bone defects can be found with prosthetic joint infection (PJI), in osteomyelitis (OM), after trauma surgical procedures or as hematogenous seed of bacterial infection. In cases of early infection, bone defects are usually minor but, depending on the infection duration and extent of surgical interventions with debridement of infected tissue, bone defects also can reach considerable proportions. Complete removal of dead bone is the main prerequisite for cure. Treatment modalities greatly differ depending on the infection site and defect size. Diaphyseal defects (cortical) are addressed differently than metaphyseal (cancellous) ones. In children and younger patients, regeneration is faster and more complete, but the same result cannot be expected in elderly patients, who represent most of the cases.

There is no common rule on the number of procedures required for restoring bone stock after infection. As there is a high risk of recurrence, most techniques are requiring a multiple -stage treatment. Techniques using induced membranes and bone transportation are associated with long-lasting treatments and multiple medical interventions, whereas direct fill of the defects with substitutes (metal, cement, resorbable synthetics and bone grafts) may lead to earlier rehabilitation. For all techniques, safety should be comparable and considered as a priority.

There is a wide variety of reported results. Most available data focus on the success of eliminating infection, in which results appear variably effective with reported elimination rates between 50% and 100%. However, functional results also need to be measured and, especially, the quality of life of patients during and after treatment. There is an ongoing discussion on how the patients’ burden may be alleviated. It seems reasonable to assume that new protocols may lead to shorter treatments with improved quality of life but there is no standard procedure available for all kinds of bone defects. Recent research in the area defines convenient indications for each method separately.

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With all treatment options, it should be kept in mind that chronic orthopaedic infections are mediated by bacteria embedded in biofilms, which show a completely different behavior than the freely floating “planktonic” phenotypes. As biofilms are usually inaccessible to the host’s immune response and systemically applied antimicrobials, much higher concentrations of antibiotics are required to eliminate infection caused by biofilms. These can only be reached by local application. Combining aggressive debridement with restoration of bone stock and provision of effective local antimicrobials may be a promising way to overcome complicated treatment. Carriers for local application are found in bone cement, synthetic substitutes and bone grafts, whereas synthetics and allografts seem to be effective not only against planktonic bacteria, but against bacteria embedded in biofilm remnants, as well. The efficacy and safety of the new technologies remain under discussion.

Moreover, both synthetics and allografts show advantages and disadvantages. The results vary depending on the respective indication. Synthetics have been investigated mainly in cases of OM, while allografts have been mainly used in treatment of PJI. Today, still no definitive recommendations can be provided, and further research is required to define the optimal use of carriers.

To better guide the treatment choice, this session will address preoperative considerations, as well as the latest data regarding available technology. The international panel of experts will share the best tips and tricks to avoid complications and ensure the best outcome for the patient.

Dealing with Bone Loss in Septic Surgery
Friday 1 June 2018 | 10:00 – 12:15

Introduction and Conclusions
Heinz Winkler (Austria)

Questions and Presentations

  • Bone Regeneration Strategies: Current Knowledge - And What Holds the Future –Thierry Charles Bégué (France)
  • Metal - Cement - Bone Graft: Advantages and Disadvantages of Materials in Infection – Duncan Whitwell (United Kingdom)
  • Allograft Bone Loaded with Antibiotics – Martín Buttaro (Argentina)
  • Synthetic Bone Substitutes: Indications and Limitations in Septic Surgery - Carlo Luca Romanò (Italy)
  • Reconstruction of Septic Bone Defects Respecting the Biofilm Concept – Heinz Winkler (Austria)

Discussion on Clinical Cases
Lorenzo Drago (Italy) & Martin Clauss (Switzerland)

IEE banner

The lectures, debates and clinical case presentations from well-known orthopaedic surgeons will guide the audience to a deep-seated appreciation of how to deal with several types of bone defects resulting from infection. Treatment and techniques based on regeneration, bone substitution and graft approaches will be presented to highlight all the specific considerations to evaluate before any treatment decision for bone loss resulting from infection.

IEEs are paying sessions and pre-registration is mandatory on a first-come, first-serve basis (maximum of 200 participants). Only participants with a full registration for the EFORT Congress can attend the IEE sessions. All details to sign-up are available on our registration platform. Visit our Barcelona congress website regularly.