Parvizi J

Surgical site infections (SSIs) and hospital-acquired infections (HAIs) have become two of the most feared complications associated with the delivery of medical care. The issue of infection has become so important that the American Academy of Orthopaedic Surgeons (AAOS), the Infectious Diseases Society of America (IDSA), the Musculoskeletal Infection Society (MSIS), and numerous other organizations have issued guidelines for the prevention and diagnosis of infection after orthopedic procedures. Similar efforts have taken place in other surgical disciplines.

It is fair to state that the issue of infection after surgical procedures has come to the forefront of all complications and strikes fear in the minds of patients and surgeons who enter the operating room on a daily basis. The immense financial and psychological burden associated with SSIs and HAIs has also prompted regulatory bodies and governmental agencies in the United States and other parts of the world to seek strategies to counter the rising incidence of infection. It is anticipated that “striving for lower incidence of surgical site infection” will be part of the “quality metric” that most payers in the United States, including the Centers for Medicare and Medicaid Services (CMS), will implement in the future. In fact, the incidence of infection after most surgical procedures is tracked carefully by the surveillance arm of the Centers for Disease Control and Prevention (CDC), the National Healthcare Safety Network (NHSN). Most hospitals in the United States are required to report infections occurring after surgical procedures and patient admissions. The CDC has issued specific definitions and reporting instructions for this purpose.

As part of the important mission of reducing the burden of SSIs and HAIs, the CDC has had an active role in producing guidelines for the prevention of SSI. Their latest guidelines, issued in 1999, had relevant and important expert-based recommendations that have certainly served the medical community. The CDC will soon issue their updated guidelines for the prevention of SSI. This time, the CDC has decided to issue evidence-based recommendations. To accomplish this, the CDC convened a large workgroup consisting of experts and representatives of numerous societies, including the AAOS and the MSIS, to evaluate the available literature in issuing these guidelines. The guidelines are divided into 2 sections: the “Core” addresses recommendations applicable across a broad spectrum of surgical procedures, and the new procedure-specific component sections each focus on a single high-volume, high-burden surgical procedure. The first of these component sections focuses on arthroplasty procedures.

One of the sobering discoveries of the workgroup is the fact that there is little evidence to support many of our daily practices applicable to the prevention of infection. Thus, the guidelines, when issued, will reflect the lack of evidence for some of our established and common practices. There will be, however, many other recommendations that are based on available evidence, such as the importance of administration of perioperative antibiotics, to name one. Huge effort has been invested by the CDC and the numerous experts who served in the workgroup to produce these guidelines. The literature has been evaluated extensively. Many conference calls have taken place to discuss the issues, when necessary. In addition, these recommendations have been carefully evaluated by the Healthcare Infection Control Practices Advisory Committee (HICPAC). The guidelines, when issued, will no doubt play a critical role in helping us make strides in reducing the burden of this dreaded complication. The guidelines will also provide a great impetus for the medical community to generate and seek evidence for practices that lack such evidence currently.  ◾

Click here to read the commentary on this editorial by Scott R. Nodzo, MD

Surgical site infections (SSIs) and hospital-acquired infections (HAIs) have become two of the most feared complications associated with the delivery of medical care. The issue of infection has become so important that the American Academy of Orthopaedic Surgeons (AAOS), the Infectious Diseases Society of America (IDSA), the Musculoskeletal Infection Society (MSIS), and numerous other organizations have issued guidelines for the prevention and diagnosis of infection after orthopedic procedures. Similar efforts have taken place in other surgical disciplines.

It is fair to state that the issue of infection after surgical procedures has come to the forefront of all complications and strikes fear in the minds of patients and surgeons who enter the operating room on a daily basis. The immense financial and psychological burden associated with SSIs and HAIs has also prompted regulatory bodies and governmental agencies in the United States and other parts of the world to seek strategies to counter the rising incidence of infection. It is anticipated that “striving for lower incidence of surgical site infection” will be part of the “quality metric” that most payers in the United States, including the Centers for Medicare and Medicaid Services (CMS), will implement in the future. In fact, the incidence of infection after most surgical procedures is tracked carefully by the surveillance arm of the Centers for Disease Control and Prevention (CDC), the National Healthcare Safety Network (NHSN). Most hospitals in the United States are required to report infections occurring after surgical procedures and patient admissions. The CDC has issued specific definitions and reporting instructions for this purpose.

As part of the important mission of reducing the burden of SSIs and HAIs, the CDC has had an active role in producing guidelines for the prevention of SSI. Their latest guidelines, issued in 1999, had relevant and important expert-based recommendations that have certainly served the medical community. The CDC will soon issue their updated guidelines for the prevention of SSI. This time, the CDC has decided to issue evidence-based recommendations. To accomplish this, the CDC convened a large workgroup consisting of experts and representatives of numerous societies, including the AAOS and the MSIS, to evaluate the available literature in issuing these guidelines. The guidelines are divided into 2 sections: the “Core” addresses recommendations applicable across a broad spectrum of surgical procedures, and the new procedure-specific component sections each focus on a single high-volume, high-burden surgical procedure. The first of these component sections focuses on arthroplasty procedures.

One of the sobering discoveries of the workgroup is the fact that there is little evidence to support many of our daily practices applicable to the prevention of infection. Thus, the guidelines, when issued, will reflect the lack of evidence for some of our established and common practices. There will be, however, many other recommendations that are based on available evidence, such as the importance of administration of perioperative antibiotics, to name one. Huge effort has been invested by the CDC and the numerous experts who served in the workgroup to produce these guidelines. The literature has been evaluated extensively. Many conference calls have taken place to discuss the issues, when necessary. In addition, these recommendations have been carefully evaluated by the Healthcare Infection Control Practices Advisory Committee (HICPAC). The guidelines, when issued, will no doubt play a critical role in helping us make strides in reducing the burden of this dreaded complication. The guidelines will also provide a great impetus for the medical community to generate and seek evidence for practices that lack such evidence currently.  ◾

Click here to read the commentary on this editorial by Scott R. Nodzo, MD

Surgical site infections (SSIs) and hospital-acquired infections (HAIs) have become two of the most feared complications associated with the delivery of medical care. The issue of infection has become so important that the American Academy of Orthopaedic Surgeons (AAOS), the Infectious Diseases Society of America (IDSA), the Musculoskeletal Infection Society (MSIS), and numerous other organizations have issued guidelines for the prevention and diagnosis of infection after orthopedic procedures. Similar efforts have taken place in other surgical disciplines.

It is fair to state that the issue of infection after surgical procedures has come to the forefront of all complications and strikes fear in the minds of patients and surgeons who enter the operating room on a daily basis. The immense financial and psychological burden associated with SSIs and HAIs has also prompted regulatory bodies and governmental agencies in the United States and other parts of the world to seek strategies to counter the rising incidence of infection. It is anticipated that “striving for lower incidence of surgical site infection” will be part of the “quality metric” that most payers in the United States, including the Centers for Medicare and Medicaid Services (CMS), will implement in the future. In fact, the incidence of infection after most surgical procedures is tracked carefully by the surveillance arm of the Centers for Disease Control and Prevention (CDC), the National Healthcare Safety Network (NHSN). Most hospitals in the United States are required to report infections occurring after surgical procedures and patient admissions. The CDC has issued specific definitions and reporting instructions for this purpose.

As part of the important mission of reducing the burden of SSIs and HAIs, the CDC has had an active role in producing guidelines for the prevention of SSI. Their latest guidelines, issued in 1999, had relevant and important expert-based recommendations that have certainly served the medical community. The CDC will soon issue their updated guidelines for the prevention of SSI. This time, the CDC has decided to issue evidence-based recommendations. To accomplish this, the CDC convened a large workgroup consisting of experts and representatives of numerous societies, including the AAOS and the MSIS, to evaluate the available literature in issuing these guidelines. The guidelines are divided into 2 sections: the “Core” addresses recommendations applicable across a broad spectrum of surgical procedures, and the new procedure-specific component sections each focus on a single high-volume, high-burden surgical procedure. The first of these component sections focuses on arthroplasty procedures.

One of the sobering discoveries of the workgroup is the fact that there is little evidence to support many of our daily practices applicable to the prevention of infection. Thus, the guidelines, when issued, will reflect the lack of evidence for some of our established and common practices. There will be, however, many other recommendations that are based on available evidence, such as the importance of administration of perioperative antibiotics, to name one. Huge effort has been invested by the CDC and the numerous experts who served in the workgroup to produce these guidelines. The literature has been evaluated extensively. Many conference calls have taken place to discuss the issues, when necessary. In addition, these recommendations have been carefully evaluated by the Healthcare Infection Control Practices Advisory Committee (HICPAC). The guidelines, when issued, will no doubt play a critical role in helping us make strides in reducing the burden of this dreaded complication. The guidelines will also provide a great impetus for the medical community to generate and seek evidence for practices that lack such evidence currently.  ◾

Click here to read the commentary on this editorial by Scott R. Nodzo, MD

The orthopedic community continues to be concerned about venous thromboembolism (VTE) after orthopedic procedures. There is currently no consensus on the optimal strategy for prevention of VTE after knee and hip arthroplasty. In North America, the American Association of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP) have both been involved in putting forth guidelines that are intended to minimize this complication after orthopedic procedures.^1-2

Both of these guidelines have evaluated the available literature, whenever present, to reach their recommendations. Although the AAOS guidelines do not mention aspirin specifically, they do endorse any form of anticoagulation as acceptable after total hip and knee arthroplasty. The ACCP, on the other hand, gives their highest endorsement (1B) to aspirin as an effective prophylactic agent for prevention of VTE after total joint arthroplasty (TJA).¹ In the analysis, surgeon choice of VTE prophylaxis should be based on a balance between safety and efficacy of a particular anticoagulant, with risk stratification used to identify patients at standard risk (the vast majority) or high risk of VTE or bleeding.

Recent studies have helped to dispel the age-old misconception that aspirin is an effective modality for prevention of clots in the high-pressure (arterial) system but not in the low-pressure (venous) system. The ASPIRE study evaluated 822 patients and detected that the incidence of VTE was 4.8% in patients who received aspirin versus 6.5% in patients who did not receive aspirin.³ Although the difference in the incidence of VTE in the given sample size did not reach statistical significance, the difference did reach statistical significance when other major vascular issues were taken into account.³ Another study (WARFASA), evaluating 402 patients with prior VTE, detected 42% reduction in the incidence of recurrent VTE in patients that received aspirin, confirming the fact that aspirin does indeed act on the venous low-pressure system.⁴

The prevailing evidence over the last decade supports the notion that aspirin is an effective agent for prevention of VTE with a lower risk of imparting many of the harms that other aggressive anticoagulant agents are likely to cause, such as wound drainage, bleeding, increased incidence of readmission, reoperation, periprosthetic infection, and even mortality.^5-7

With the increasing scrutiny and penalties imposed on surgeons and health care systems by the regulatory bodies in the United States for a variety of “quality metric” considerations related to readmission and reoperation, including VTE prevention and its complications, the notion of using anticoagulant agents that are not only effective but also less harmful is gaining momentum and greater endorsement. Visiting the US Food and Drug Administration website reveals that among all drugs in the medical community, aggressive anticoagulants are associated with the highest number of adverse effects, including mortality.⁸

The medical community also needs to recognize that there have been immense changes in the practice of orthopedics, particularly in the realm of knee and hip arthroplasty. The majority of patients undergoing TJA receive regional anesthesia, using expeditious surgical techniques, and are mobilized immediately in the postoperative period—all of these elements have contributed to a declining incidence of VTE after TJA. Furthermore, patients are often discharged from the hospital within a day or two, making compliance with outpatient anticoagulant therapy more of a challenge. Thus, the historical protocols related to TJA—when patients stayed in bed for days before beginning a delayed and limited physical therapy program and a lengthy hospital stay—are behind us. These major changes in surgical and anesthesia techniques as well as accelerated postoperative protocols highlight the fact that any literature from the far past needs to be examined with caution as it may not be applicable to modern-day surgical patients.

Moving forward, while we strongly endorse risk stratification for VTE prophylaxis, in our opinion aspirin will become the mainstay of prevention of VTE for the majority of patients after TJA. The challenge that lies ahead is to determine which patients are at increased risk of VTE and in need of more aggressive anticoagulants. There has been a recent development on this front that aims to provide some guidance for selection of high-risk patients.⁹ It appears that over 90% of patients undergoing TJA can safely receive aspirin as an anticoagulation prophylaxis, while a validated risk profile can be used to detect those at higher risk for VTE and in need of more aggressive agents.⁹

Thanks to the diligent work of the ACCP and AAOS workgroups and many other scholars in the field, the science of VTE prophylaxis after TJA has truly evolved. The adaptation of the recent ACCP guidelines by the Surgical Care Improvement Project (SCIP), which accepts aspirin as an effective anticoagulation modality, is yet another step in the direction of optimizing outcomes for our patients, by preventing the feared VTE while also limiting untoward bleeding complications that can occur with administration of aggressive anticoagulants.¹⁰

The orthopedic community continues to be concerned about venous thromboembolism (VTE) after orthopedic procedures. There is currently no consensus on the optimal strategy for prevention of VTE after knee and hip arthroplasty. In North America, the American Association of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP) have both been involved in putting forth guidelines that are intended to minimize this complication after orthopedic procedures.^1-2

Both of these guidelines have evaluated the available literature, whenever present, to reach their recommendations. Although the AAOS guidelines do not mention aspirin specifically, they do endorse any form of anticoagulation as acceptable after total hip and knee arthroplasty. The ACCP, on the other hand, gives their highest endorsement (1B) to aspirin as an effective prophylactic agent for prevention of VTE after total joint arthroplasty (TJA).¹ In the analysis, surgeon choice of VTE prophylaxis should be based on a balance between safety and efficacy of a particular anticoagulant, with risk stratification used to identify patients at standard risk (the vast majority) or high risk of VTE or bleeding.

Recent studies have helped to dispel the age-old misconception that aspirin is an effective modality for prevention of clots in the high-pressure (arterial) system but not in the low-pressure (venous) system. The ASPIRE study evaluated 822 patients and detected that the incidence of VTE was 4.8% in patients who received aspirin versus 6.5% in patients who did not receive aspirin.³ Although the difference in the incidence of VTE in the given sample size did not reach statistical significance, the difference did reach statistical significance when other major vascular issues were taken into account.³ Another study (WARFASA), evaluating 402 patients with prior VTE, detected 42% reduction in the incidence of recurrent VTE in patients that received aspirin, confirming the fact that aspirin does indeed act on the venous low-pressure system.⁴

The prevailing evidence over the last decade supports the notion that aspirin is an effective agent for prevention of VTE with a lower risk of imparting many of the harms that other aggressive anticoagulant agents are likely to cause, such as wound drainage, bleeding, increased incidence of readmission, reoperation, periprosthetic infection, and even mortality.^5-7

With the increasing scrutiny and penalties imposed on surgeons and health care systems by the regulatory bodies in the United States for a variety of “quality metric” considerations related to readmission and reoperation, including VTE prevention and its complications, the notion of using anticoagulant agents that are not only effective but also less harmful is gaining momentum and greater endorsement. Visiting the US Food and Drug Administration website reveals that among all drugs in the medical community, aggressive anticoagulants are associated with the highest number of adverse effects, including mortality.⁸

The medical community also needs to recognize that there have been immense changes in the practice of orthopedics, particularly in the realm of knee and hip arthroplasty. The majority of patients undergoing TJA receive regional anesthesia, using expeditious surgical techniques, and are mobilized immediately in the postoperative period—all of these elements have contributed to a declining incidence of VTE after TJA. Furthermore, patients are often discharged from the hospital within a day or two, making compliance with outpatient anticoagulant therapy more of a challenge. Thus, the historical protocols related to TJA—when patients stayed in bed for days before beginning a delayed and limited physical therapy program and a lengthy hospital stay—are behind us. These major changes in surgical and anesthesia techniques as well as accelerated postoperative protocols highlight the fact that any literature from the far past needs to be examined with caution as it may not be applicable to modern-day surgical patients.

Moving forward, while we strongly endorse risk stratification for VTE prophylaxis, in our opinion aspirin will become the mainstay of prevention of VTE for the majority of patients after TJA. The challenge that lies ahead is to determine which patients are at increased risk of VTE and in need of more aggressive anticoagulants. There has been a recent development on this front that aims to provide some guidance for selection of high-risk patients.⁹ It appears that over 90% of patients undergoing TJA can safely receive aspirin as an anticoagulation prophylaxis, while a validated risk profile can be used to detect those at higher risk for VTE and in need of more aggressive agents.⁹

Thanks to the diligent work of the ACCP and AAOS workgroups and many other scholars in the field, the science of VTE prophylaxis after TJA has truly evolved. The adaptation of the recent ACCP guidelines by the Surgical Care Improvement Project (SCIP), which accepts aspirin as an effective anticoagulation modality, is yet another step in the direction of optimizing outcomes for our patients, by preventing the feared VTE while also limiting untoward bleeding complications that can occur with administration of aggressive anticoagulants.¹⁰

The orthopedic community continues to be concerned about venous thromboembolism (VTE) after orthopedic procedures. There is currently no consensus on the optimal strategy for prevention of VTE after knee and hip arthroplasty. In North America, the American Association of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP) have both been involved in putting forth guidelines that are intended to minimize this complication after orthopedic procedures.^1-2

Both of these guidelines have evaluated the available literature, whenever present, to reach their recommendations. Although the AAOS guidelines do not mention aspirin specifically, they do endorse any form of anticoagulation as acceptable after total hip and knee arthroplasty. The ACCP, on the other hand, gives their highest endorsement (1B) to aspirin as an effective prophylactic agent for prevention of VTE after total joint arthroplasty (TJA).¹ In the analysis, surgeon choice of VTE prophylaxis should be based on a balance between safety and efficacy of a particular anticoagulant, with risk stratification used to identify patients at standard risk (the vast majority) or high risk of VTE or bleeding.

Recent studies have helped to dispel the age-old misconception that aspirin is an effective modality for prevention of clots in the high-pressure (arterial) system but not in the low-pressure (venous) system. The ASPIRE study evaluated 822 patients and detected that the incidence of VTE was 4.8% in patients who received aspirin versus 6.5% in patients who did not receive aspirin.³ Although the difference in the incidence of VTE in the given sample size did not reach statistical significance, the difference did reach statistical significance when other major vascular issues were taken into account.³ Another study (WARFASA), evaluating 402 patients with prior VTE, detected 42% reduction in the incidence of recurrent VTE in patients that received aspirin, confirming the fact that aspirin does indeed act on the venous low-pressure system.⁴

The prevailing evidence over the last decade supports the notion that aspirin is an effective agent for prevention of VTE with a lower risk of imparting many of the harms that other aggressive anticoagulant agents are likely to cause, such as wound drainage, bleeding, increased incidence of readmission, reoperation, periprosthetic infection, and even mortality.^5-7

With the increasing scrutiny and penalties imposed on surgeons and health care systems by the regulatory bodies in the United States for a variety of “quality metric” considerations related to readmission and reoperation, including VTE prevention and its complications, the notion of using anticoagulant agents that are not only effective but also less harmful is gaining momentum and greater endorsement. Visiting the US Food and Drug Administration website reveals that among all drugs in the medical community, aggressive anticoagulants are associated with the highest number of adverse effects, including mortality.⁸

The medical community also needs to recognize that there have been immense changes in the practice of orthopedics, particularly in the realm of knee and hip arthroplasty. The majority of patients undergoing TJA receive regional anesthesia, using expeditious surgical techniques, and are mobilized immediately in the postoperative period—all of these elements have contributed to a declining incidence of VTE after TJA. Furthermore, patients are often discharged from the hospital within a day or two, making compliance with outpatient anticoagulant therapy more of a challenge. Thus, the historical protocols related to TJA—when patients stayed in bed for days before beginning a delayed and limited physical therapy program and a lengthy hospital stay—are behind us. These major changes in surgical and anesthesia techniques as well as accelerated postoperative protocols highlight the fact that any literature from the far past needs to be examined with caution as it may not be applicable to modern-day surgical patients.

Moving forward, while we strongly endorse risk stratification for VTE prophylaxis, in our opinion aspirin will become the mainstay of prevention of VTE for the majority of patients after TJA. The challenge that lies ahead is to determine which patients are at increased risk of VTE and in need of more aggressive anticoagulants. There has been a recent development on this front that aims to provide some guidance for selection of high-risk patients.⁹ It appears that over 90% of patients undergoing TJA can safely receive aspirin as an anticoagulation prophylaxis, while a validated risk profile can be used to detect those at higher risk for VTE and in need of more aggressive agents.⁹

Thanks to the diligent work of the ACCP and AAOS workgroups and many other scholars in the field, the science of VTE prophylaxis after TJA has truly evolved. The adaptation of the recent ACCP guidelines by the Surgical Care Improvement Project (SCIP), which accepts aspirin as an effective anticoagulation modality, is yet another step in the direction of optimizing outcomes for our patients, by preventing the feared VTE while also limiting untoward bleeding complications that can occur with administration of aggressive anticoagulants.¹⁰

In this month’s E-publishing section, we will read more interesting and clinically pertinent articles, including an article by Tateiwa and colleagues on “Ceramic Total Hip Arthroplasty in the United States: Safety and Risk Issues Revisited.”

The article, by a group of internationally recognized investigators, attempts, and accomplishes, a summary of the safety of alumina ceramic-on-ceramic bearing surface for use in THA. The main emphasis of the article is to highlight the findings of reports in the United States regarding the safety of the ceramic-on-ceramic bearing surface in general and the risk of fracture in particular.

That the article is well written and elegantly organized is not to be disputed. That the article presents the findings of various publications in an unbiased fashion is also not to be doubted. The authors nicely convince the reader that the ceramic-on-ceramic bearing surface is an important part of the armamentarium at the disposal of orthopedic surgeons who surgically treat arthritis of the hip in the young, and hence it is here to stay. I hope the authors will forgive me if I present the argument from a different and less “pro-ceramic” perspective.

First, the authors are, in my opinion, a little unfair and somewhat dramatic in their view on the conventional polyethylene and its new sister, the highly cross-linked polyethylene. I quote the authors: “In the past, however, clinical experience with ‘new and improved’ polyethylenes has seldom been exemplary, and current clinical experience is but a blip on the radar screen. It is also likely that the adverse conditions in the hips of our high-activity patients will severely challenge even the newest cross-linked polyethylene cups.” We all know conventional polyethylene
needed improvement. It did, however, serve hundreds of thousands of young patients very well without having any of the “problems” of the modern-day ceramic. The highly cross-linked polyethylene goes further in helping all patients, including the young ones. The “blips on the radar” are adding up as more investigators report their favorable experience with the highly cross-linked polyethylene.

I have another bone to pick with the authors. What happened to the other problems and “safety hazards” of ceramic-on-ceramic? The authors make no mention of the recent and not so infrequent problem with squeaking! Although some may brush the latter aside as mere “noise,” patients experiencing the
problem see it otherwise! In fact, some of these patients are so disheartened
by the problem that they heed the call of lawyers to go after the industry for “mis-manufacturing” these components. The problem is not so infrequent. According to a questionnaire survey by Dr. Ranawat, up to 4% of patients
reported squeaking of ceramic-on-ceramic hips. Our center, the Rothman Institute, has detected a 2% incidence of squeaking with the modern generation of ceramic-on-ceramic bearing surfaces. What is most disturbing is that the etiology of this noise-generating problem remains elusive.

Although the quoted figures for fracture of modern design ceramic heads are based on the available literature and are correct, some surgeons may feel that they are
an underestimation. I am sure the authors have, since the submission of their paper, seen the most recent article from Korea that reports a 1.4% incidence of fracture of femoral heads made of third-generation ceramic.

So, as a surgeon who believes in the incredible marvel of ceramic-on-ceramic bearing surface in substantially reducing wear, I merely want to say that ceramic-on-ceramic is not without its problems either. Depending on one’s viewpoint, one bearing surface may be better than another. One thing that remains certain is that the perfect bearing surface is still the articular cartilage. Regardless of how hard we try, we will never be able to emulate the Almighty. 

In this month’s E-publishing section, we will read more interesting and clinically pertinent articles, including an article by Tateiwa and colleagues on “Ceramic Total Hip Arthroplasty in the United States: Safety and Risk Issues Revisited.”

The article, by a group of internationally recognized investigators, attempts, and accomplishes, a summary of the safety of alumina ceramic-on-ceramic bearing surface for use in THA. The main emphasis of the article is to highlight the findings of reports in the United States regarding the safety of the ceramic-on-ceramic bearing surface in general and the risk of fracture in particular.

That the article is well written and elegantly organized is not to be disputed. That the article presents the findings of various publications in an unbiased fashion is also not to be doubted. The authors nicely convince the reader that the ceramic-on-ceramic bearing surface is an important part of the armamentarium at the disposal of orthopedic surgeons who surgically treat arthritis of the hip in the young, and hence it is here to stay. I hope the authors will forgive me if I present the argument from a different and less “pro-ceramic” perspective.

First, the authors are, in my opinion, a little unfair and somewhat dramatic in their view on the conventional polyethylene and its new sister, the highly cross-linked polyethylene. I quote the authors: “In the past, however, clinical experience with ‘new and improved’ polyethylenes has seldom been exemplary, and current clinical experience is but a blip on the radar screen. It is also likely that the adverse conditions in the hips of our high-activity patients will severely challenge even the newest cross-linked polyethylene cups.” We all know conventional polyethylene
needed improvement. It did, however, serve hundreds of thousands of young patients very well without having any of the “problems” of the modern-day ceramic. The highly cross-linked polyethylene goes further in helping all patients, including the young ones. The “blips on the radar” are adding up as more investigators report their favorable experience with the highly cross-linked polyethylene.

I have another bone to pick with the authors. What happened to the other problems and “safety hazards” of ceramic-on-ceramic? The authors make no mention of the recent and not so infrequent problem with squeaking! Although some may brush the latter aside as mere “noise,” patients experiencing the
problem see it otherwise! In fact, some of these patients are so disheartened
by the problem that they heed the call of lawyers to go after the industry for “mis-manufacturing” these components. The problem is not so infrequent. According to a questionnaire survey by Dr. Ranawat, up to 4% of patients
reported squeaking of ceramic-on-ceramic hips. Our center, the Rothman Institute, has detected a 2% incidence of squeaking with the modern generation of ceramic-on-ceramic bearing surfaces. What is most disturbing is that the etiology of this noise-generating problem remains elusive.

Although the quoted figures for fracture of modern design ceramic heads are based on the available literature and are correct, some surgeons may feel that they are
an underestimation. I am sure the authors have, since the submission of their paper, seen the most recent article from Korea that reports a 1.4% incidence of fracture of femoral heads made of third-generation ceramic.

So, as a surgeon who believes in the incredible marvel of ceramic-on-ceramic bearing surface in substantially reducing wear, I merely want to say that ceramic-on-ceramic is not without its problems either. Depending on one’s viewpoint, one bearing surface may be better than another. One thing that remains certain is that the perfect bearing surface is still the articular cartilage. Regardless of how hard we try, we will never be able to emulate the Almighty. 

In this month’s E-publishing section, we will read more interesting and clinically pertinent articles, including an article by Tateiwa and colleagues on “Ceramic Total Hip Arthroplasty in the United States: Safety and Risk Issues Revisited.”

The article, by a group of internationally recognized investigators, attempts, and accomplishes, a summary of the safety of alumina ceramic-on-ceramic bearing surface for use in THA. The main emphasis of the article is to highlight the findings of reports in the United States regarding the safety of the ceramic-on-ceramic bearing surface in general and the risk of fracture in particular.

That the article is well written and elegantly organized is not to be disputed. That the article presents the findings of various publications in an unbiased fashion is also not to be doubted. The authors nicely convince the reader that the ceramic-on-ceramic bearing surface is an important part of the armamentarium at the disposal of orthopedic surgeons who surgically treat arthritis of the hip in the young, and hence it is here to stay. I hope the authors will forgive me if I present the argument from a different and less “pro-ceramic” perspective.

First, the authors are, in my opinion, a little unfair and somewhat dramatic in their view on the conventional polyethylene and its new sister, the highly cross-linked polyethylene. I quote the authors: “In the past, however, clinical experience with ‘new and improved’ polyethylenes has seldom been exemplary, and current clinical experience is but a blip on the radar screen. It is also likely that the adverse conditions in the hips of our high-activity patients will severely challenge even the newest cross-linked polyethylene cups.” We all know conventional polyethylene
needed improvement. It did, however, serve hundreds of thousands of young patients very well without having any of the “problems” of the modern-day ceramic. The highly cross-linked polyethylene goes further in helping all patients, including the young ones. The “blips on the radar” are adding up as more investigators report their favorable experience with the highly cross-linked polyethylene.

I have another bone to pick with the authors. What happened to the other problems and “safety hazards” of ceramic-on-ceramic? The authors make no mention of the recent and not so infrequent problem with squeaking! Although some may brush the latter aside as mere “noise,” patients experiencing the
problem see it otherwise! In fact, some of these patients are so disheartened
by the problem that they heed the call of lawyers to go after the industry for “mis-manufacturing” these components. The problem is not so infrequent. According to a questionnaire survey by Dr. Ranawat, up to 4% of patients
reported squeaking of ceramic-on-ceramic hips. Our center, the Rothman Institute, has detected a 2% incidence of squeaking with the modern generation of ceramic-on-ceramic bearing surfaces. What is most disturbing is that the etiology of this noise-generating problem remains elusive.

Although the quoted figures for fracture of modern design ceramic heads are based on the available literature and are correct, some surgeons may feel that they are
an underestimation. I am sure the authors have, since the submission of their paper, seen the most recent article from Korea that reports a 1.4% incidence of fracture of femoral heads made of third-generation ceramic.

So, as a surgeon who believes in the incredible marvel of ceramic-on-ceramic bearing surface in substantially reducing wear, I merely want to say that ceramic-on-ceramic is not without its problems either. Depending on one’s viewpoint, one bearing surface may be better than another. One thing that remains certain is that the perfect bearing surface is still the articular cartilage. Regardless of how hard we try, we will never be able to emulate the Almighty. 

Periprosthetic joint infection (PJI), with all its disastrous implications, continues to pose a challenge to the orthopedic community. Practicing orthopedic surgeons have invested great efforts to implement strategies to minimize surgical site infection (SSI). Although high-level evidence supports some of these practices, many have little or no scientific foundation. As a result, there is a remarkable variation in practices across the globe for prevention and management of PJI.

Some of the many questions the orthopedic community faces on a daily basis, include:

◾ Should a laminar flow room be used for elective arthroplasty?

◾ How much, and which antibiotic should be added to cement spacers?

◾ What metric should be used to decide on the optimal timing of reimplantation?

◾ What are the indications and contraindications for irrigation and debridement?

◾ How many irrigation and debridement in a joint should
be attempted before resection arthroplasty needs to be considered?

The medical community understands the importance of high-level evidence and engages in the generation of such whenever possible. The community also recognizes that some aspects of medicine will never lend themselves to the generation of high-level evidence nor should it attempt to do so. It is with the recognition of the latter that The International Consensus Meeting on Periprosthetic Joint Infection was organized. Delegates from various disciplines including orthopedic surgery, infectious disease, musculoskeletal pathology, microbiology, anesthesiology, dermatology, nuclear medicine, rheumatology, musculoskeletal radiology, veterinary surgery, pharmacy, and numerous scientists with interest in orthopedic infections came together to evaluate the available evidence, when present, or reach consensus regarding current practices for management of SSI/PJI. The process of generating the consensus has spanned over 10 months. Every stone has been turned in search of evidence for these questions, with over 3,500 related publications evaluated. The evidence, when available, has been assessed. Otherwise, the cumulative wisdom of 400 delegates from 52 countries and over 100 societies has been amassed to reach consensus about practices that lack higher level of evidence. The members of the Musculoskeletal Infection Society (MSIS) and the European Bone and Joint Infection Society (EBJIS), the 2 societies with a mission is to improve care of patients with musculoskeletal infection, have contributed to this initiative immensely.

The delegates have been engaged every step of the way by communicating through a social website generated for this purpose, with over 25,000 communications exchanged. The consensus document has been developed using the Delphi method under the leadership of Dr. Cats-Baril, a world-renowned expert in consensus development. The design of the consensus process was to include as many stakeholders as possible, allow participation in multiple forums, and provide a comprehensive review of the literature. The topics that were covered included the following: mitigation and education on comorbidities associated with increased SSI/PJI, perioperative skin preparation, perioperative antibiotics, operative environment, blood conservation, prosthesis selection, diagnosis of PJI, wound management, spacers, irrigation and debridement, antibiotic treatment and timing of reimplantation, 1-stage versus 2-stage exchange arthroplasty, management of fungal or atypical PJI, oral antibiotic therapy, and prevention of late PJI. Every consensus statement has undergone extreme scrutiny, especially by those with expertise in a specific area, to ensure that implementation of these practices will indeed lead to improvement of patient care.

After synthesizing the literature and assembling a preliminary draft of the consensus statement, over 300 delegates attended a face-to-face meeting in Philadelphia, were involved in active discussions, and voted on the questions/consensus statements. The delegates first met on July 31, 2013, in smaller workgroups, to discuss and resolve any discrepancies and finalize their statements. Then, they met in the general assembly for further discussion of questions and consensus statements. After revising the consensus statements, the finalized consensus statement was assembled and forwarded to the Audience Response System that evening, with voting occurring on the next day. On August 1, 2013 the delegates came into the general assembly and voted on the 207 questions/consensus statements that were being presented. The voting process was conducted using electronic keypads, where one could agree with the consensus statement, disagree with the consensus statement, or abstain from voting. The strength of the consensus was judged by the following scale: 1) Simple Majority: No Consensus (50.1%-59% agreement), 2) Majority: Weak Consensus (60%-65% agreement), 3) Super Majority: Strong Consensus (66%-99% agreement) and 4) Unanimous: 100% agreement. Of the 207 questions, there was unanimous vote for one question (controlling operating room traffic), 202 questions received super majority (strong consensus), 2 questions had weak consensus, and only 3 questions did not achieve any consensus.

The document generated(REF) is the result of innumerable hours of work by the liaisons, leaders and delegates dedicated to this initiative. We are certain that the “best practice guide” set forth by this initiative will serve many of our patients for years to come.

It is essential to state that the information contained in this document is merely a guide to practicing physicians who treat patients with musculoskeletal infection and should not be considered as a standard of care. Clinicians should exercise their wisdom and clinical acumen in making decisions related to each individual patient. In some circumstances this may require implementation of care that differs from what is stated in this document.

Periprosthetic joint infection (PJI), with all its disastrous implications, continues to pose a challenge to the orthopedic community. Practicing orthopedic surgeons have invested great efforts to implement strategies to minimize surgical site infection (SSI). Although high-level evidence supports some of these practices, many have little or no scientific foundation. As a result, there is a remarkable variation in practices across the globe for prevention and management of PJI.

Some of the many questions the orthopedic community faces on a daily basis, include:

◾ Should a laminar flow room be used for elective arthroplasty?

◾ How much, and which antibiotic should be added to cement spacers?

◾ What metric should be used to decide on the optimal timing of reimplantation?

◾ What are the indications and contraindications for irrigation and debridement?

◾ How many irrigation and debridement in a joint should
be attempted before resection arthroplasty needs to be considered?

The medical community understands the importance of high-level evidence and engages in the generation of such whenever possible. The community also recognizes that some aspects of medicine will never lend themselves to the generation of high-level evidence nor should it attempt to do so. It is with the recognition of the latter that The International Consensus Meeting on Periprosthetic Joint Infection was organized. Delegates from various disciplines including orthopedic surgery, infectious disease, musculoskeletal pathology, microbiology, anesthesiology, dermatology, nuclear medicine, rheumatology, musculoskeletal radiology, veterinary surgery, pharmacy, and numerous scientists with interest in orthopedic infections came together to evaluate the available evidence, when present, or reach consensus regarding current practices for management of SSI/PJI. The process of generating the consensus has spanned over 10 months. Every stone has been turned in search of evidence for these questions, with over 3,500 related publications evaluated. The evidence, when available, has been assessed. Otherwise, the cumulative wisdom of 400 delegates from 52 countries and over 100 societies has been amassed to reach consensus about practices that lack higher level of evidence. The members of the Musculoskeletal Infection Society (MSIS) and the European Bone and Joint Infection Society (EBJIS), the 2 societies with a mission is to improve care of patients with musculoskeletal infection, have contributed to this initiative immensely.

The delegates have been engaged every step of the way by communicating through a social website generated for this purpose, with over 25,000 communications exchanged. The consensus document has been developed using the Delphi method under the leadership of Dr. Cats-Baril, a world-renowned expert in consensus development. The design of the consensus process was to include as many stakeholders as possible, allow participation in multiple forums, and provide a comprehensive review of the literature. The topics that were covered included the following: mitigation and education on comorbidities associated with increased SSI/PJI, perioperative skin preparation, perioperative antibiotics, operative environment, blood conservation, prosthesis selection, diagnosis of PJI, wound management, spacers, irrigation and debridement, antibiotic treatment and timing of reimplantation, 1-stage versus 2-stage exchange arthroplasty, management of fungal or atypical PJI, oral antibiotic therapy, and prevention of late PJI. Every consensus statement has undergone extreme scrutiny, especially by those with expertise in a specific area, to ensure that implementation of these practices will indeed lead to improvement of patient care.

After synthesizing the literature and assembling a preliminary draft of the consensus statement, over 300 delegates attended a face-to-face meeting in Philadelphia, were involved in active discussions, and voted on the questions/consensus statements. The delegates first met on July 31, 2013, in smaller workgroups, to discuss and resolve any discrepancies and finalize their statements. Then, they met in the general assembly for further discussion of questions and consensus statements. After revising the consensus statements, the finalized consensus statement was assembled and forwarded to the Audience Response System that evening, with voting occurring on the next day. On August 1, 2013 the delegates came into the general assembly and voted on the 207 questions/consensus statements that were being presented. The voting process was conducted using electronic keypads, where one could agree with the consensus statement, disagree with the consensus statement, or abstain from voting. The strength of the consensus was judged by the following scale: 1) Simple Majority: No Consensus (50.1%-59% agreement), 2) Majority: Weak Consensus (60%-65% agreement), 3) Super Majority: Strong Consensus (66%-99% agreement) and 4) Unanimous: 100% agreement. Of the 207 questions, there was unanimous vote for one question (controlling operating room traffic), 202 questions received super majority (strong consensus), 2 questions had weak consensus, and only 3 questions did not achieve any consensus.

The document generated(REF) is the result of innumerable hours of work by the liaisons, leaders and delegates dedicated to this initiative. We are certain that the “best practice guide” set forth by this initiative will serve many of our patients for years to come.

It is essential to state that the information contained in this document is merely a guide to practicing physicians who treat patients with musculoskeletal infection and should not be considered as a standard of care. Clinicians should exercise their wisdom and clinical acumen in making decisions related to each individual patient. In some circumstances this may require implementation of care that differs from what is stated in this document.

Periprosthetic joint infection (PJI), with all its disastrous implications, continues to pose a challenge to the orthopedic community. Practicing orthopedic surgeons have invested great efforts to implement strategies to minimize surgical site infection (SSI). Although high-level evidence supports some of these practices, many have little or no scientific foundation. As a result, there is a remarkable variation in practices across the globe for prevention and management of PJI.

Some of the many questions the orthopedic community faces on a daily basis, include:

◾ Should a laminar flow room be used for elective arthroplasty?

◾ How much, and which antibiotic should be added to cement spacers?

◾ What metric should be used to decide on the optimal timing of reimplantation?

◾ What are the indications and contraindications for irrigation and debridement?

◾ How many irrigation and debridement in a joint should
be attempted before resection arthroplasty needs to be considered?

The medical community understands the importance of high-level evidence and engages in the generation of such whenever possible. The community also recognizes that some aspects of medicine will never lend themselves to the generation of high-level evidence nor should it attempt to do so. It is with the recognition of the latter that The International Consensus Meeting on Periprosthetic Joint Infection was organized. Delegates from various disciplines including orthopedic surgery, infectious disease, musculoskeletal pathology, microbiology, anesthesiology, dermatology, nuclear medicine, rheumatology, musculoskeletal radiology, veterinary surgery, pharmacy, and numerous scientists with interest in orthopedic infections came together to evaluate the available evidence, when present, or reach consensus regarding current practices for management of SSI/PJI. The process of generating the consensus has spanned over 10 months. Every stone has been turned in search of evidence for these questions, with over 3,500 related publications evaluated. The evidence, when available, has been assessed. Otherwise, the cumulative wisdom of 400 delegates from 52 countries and over 100 societies has been amassed to reach consensus about practices that lack higher level of evidence. The members of the Musculoskeletal Infection Society (MSIS) and the European Bone and Joint Infection Society (EBJIS), the 2 societies with a mission is to improve care of patients with musculoskeletal infection, have contributed to this initiative immensely.

The delegates have been engaged every step of the way by communicating through a social website generated for this purpose, with over 25,000 communications exchanged. The consensus document has been developed using the Delphi method under the leadership of Dr. Cats-Baril, a world-renowned expert in consensus development. The design of the consensus process was to include as many stakeholders as possible, allow participation in multiple forums, and provide a comprehensive review of the literature. The topics that were covered included the following: mitigation and education on comorbidities associated with increased SSI/PJI, perioperative skin preparation, perioperative antibiotics, operative environment, blood conservation, prosthesis selection, diagnosis of PJI, wound management, spacers, irrigation and debridement, antibiotic treatment and timing of reimplantation, 1-stage versus 2-stage exchange arthroplasty, management of fungal or atypical PJI, oral antibiotic therapy, and prevention of late PJI. Every consensus statement has undergone extreme scrutiny, especially by those with expertise in a specific area, to ensure that implementation of these practices will indeed lead to improvement of patient care.

After synthesizing the literature and assembling a preliminary draft of the consensus statement, over 300 delegates attended a face-to-face meeting in Philadelphia, were involved in active discussions, and voted on the questions/consensus statements. The delegates first met on July 31, 2013, in smaller workgroups, to discuss and resolve any discrepancies and finalize their statements. Then, they met in the general assembly for further discussion of questions and consensus statements. After revising the consensus statements, the finalized consensus statement was assembled and forwarded to the Audience Response System that evening, with voting occurring on the next day. On August 1, 2013 the delegates came into the general assembly and voted on the 207 questions/consensus statements that were being presented. The voting process was conducted using electronic keypads, where one could agree with the consensus statement, disagree with the consensus statement, or abstain from voting. The strength of the consensus was judged by the following scale: 1) Simple Majority: No Consensus (50.1%-59% agreement), 2) Majority: Weak Consensus (60%-65% agreement), 3) Super Majority: Strong Consensus (66%-99% agreement) and 4) Unanimous: 100% agreement. Of the 207 questions, there was unanimous vote for one question (controlling operating room traffic), 202 questions received super majority (strong consensus), 2 questions had weak consensus, and only 3 questions did not achieve any consensus.

The document generated(REF) is the result of innumerable hours of work by the liaisons, leaders and delegates dedicated to this initiative. We are certain that the “best practice guide” set forth by this initiative will serve many of our patients for years to come.

It is essential to state that the information contained in this document is merely a guide to practicing physicians who treat patients with musculoskeletal infection and should not be considered as a standard of care. Clinicians should exercise their wisdom and clinical acumen in making decisions related to each individual patient. In some circumstances this may require implementation of care that differs from what is stated in this document.