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Potential changes to French recommendations about peri-prosthetic infections based on the international consensus
M Ollivier1, E Senneville2, M Drancourt3
1Service de chirurgie orthopédique, Hôpital Sainte-Marguerite, CHU de Marseille, Assistance Publique-Hôpitaux de Marseille, Institut du Mouvement et de l'Appareil Locomoteur, Aix-Marseille Université, 270, boulevard de Sainte-Marguerite, 13009 Marseille, France; CHU de Marseille, Assistance Publique-Hôpitaux de Marseille, Centre de référence pour le traitement des infections ostéo-articulaires Sud-Méditerranée, Aix-Marseille Université, Marseille, France.
Background:
Despite the large volume of studies on the prevention, diagnosis, and treatment of peri-prosthetic infections, surgical practice often rests on limited scientific evidence in this field. The vast International Consensus Meeting on Peri-prosthetic Joint Infection (ICMPJI) held in 2013 produced robust recommendations.
Hypothesis:
French consensus conference recommendations show no major differences with ICMPJI recommendations.
Materials And Methods:
The 207 recommendations developed by 300 experts at the ICMPJI were translated, and the translation was then examined by four reviewers, including 2 having participated in the consensus conference. The reviewers looked for any differences with French practices and recommendations.
Results:
Twenty-three major differences or innovations were identified compared to French recommendations and standard practice. Among them, pre-operative screening for nasal or urinary micro-organisms is performed routinely in France but should be reserved according to the ICMPJI for symptomatic patients and/or patients at high risk for infection. The ICMPJI emphasizes the role for the operating room environment as a vector for infection; more specifically, the operating lamp handle and suction cannula deserve close attention. A wound discharge persisting longer than 5-7 days requires irrigation and debridement. This procedure is effective only within the first 3 post-operative months and/or the first 3 weeks after symptom onset and must include exchange of all modular implants. The ICMPJI warns against both irrigation-debridement in fungal infections (suggesting two-stage prosthesis replacement) and one-stage replacement in patients with sinus tracts. The use of spacers (articulating at the knee) is recommended in the event of two-stage prosthesis replacement.
Discussion:
The ICMPJI recommendations differed in many ways with French recommendations and standard practice. They can be expected to impact practices in France, although a point worth noting is that only 1 of the 207 recommendations received unanimous agreement by the conference experts (keeping operating room traffic to a minimum).
Insights
International guidelines for peri-prosthetic joint infection (PJI) present significant differences from French practices. Key distinctions involve pre-operative screening, operating room protocols, and surgical interventions like irrigation and debridement for PJI management.
Area of Science:
- Orthopedic Surgery
- Infectious Diseases
- Evidence-Based Medicine
Background:
- Peri-prosthetic joint infections (PJI) pose a significant challenge in orthopedic surgery, with current practices often lacking robust scientific evidence.
- The International Consensus Meeting on Peri-prosthetic Joint Infection (ICMPJI) in 2013 aimed to establish comprehensive recommendations for PJI prevention, diagnosis, and treatment.
Framework:
- This study compared the 2013 ICMPJI recommendations with existing French consensus guidelines and standard surgical practices.
- A systematic translation and review process was employed, involving experts who participated in the original ICMPJI.
Implementation:
- Significant discrepancies were identified, including differing approaches to pre-operative microbial screening, emphasizing its use only for high-risk or symptomatic patients per ICMPJI.
- The ICMPJI highlights the operating room environment's role in PJI transmission, focusing on specific items like operating lamp handles.
- Recommendations for managing persistent wound discharge involve irrigation and debridement within specific timeframes and necessitate the exchange of all modular implants.
Implications:
- The ICMPJI guidelines suggest modifications to French PJI management, including warnings against irrigation-debridement for fungal infections and one-stage replacement in sinus tract cases.
- The use of articulating spacers for knee two-stage prosthesis replacement is recommended.
- These international recommendations are expected to influence French surgical practices, despite variations in expert agreement on specific points.
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