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Is 6 Weeks the Gold Standard for PJI Treatment?
What factors influence your decision making on how long to keep patients on IV therapy following DAIR treatment? (check all that apply)
Pathogen responsible for PJI
Type of PJI (acute, chronic, hematogenous)
Calculation of Prognosis scores (e.g. KLIC, CRIME-80)
Patient comorbidities (can influence renal or hepatic function)
Monitoring labs (resolving ESR, CRP)
Physical findings (resolution of pain/warmth/erythema)
Other
Which of the following statements are true regarding keeping patients on IV antibiotics following DAIR treatment (check all that apply)?
I routinely try to utilize rifampin as part of the IV antibiotic treatment when possible
Patients routinely receive IV antibiotic treatment for 2 weeks or less
Patients routinely receive IV antibiotic treatment for 4 weeks or less
Patients routinely receive IV antibiotic treatment for 6 weeks or less
Patients routinely receive IV antibiotic treatment for 12 weeks or less
I do not have a routine duration for IV treatment following DAIR
For your typical DAIR patient, how long do you keep them on oral antibiotic therapy after stopping IV treatment?
I do not routinely prescribe oral therapy following IV treatment
Oral therapy is prescribed for 3 months or less
Oral therapy is prescribed for 3-6 months
Oral therapy is prescribed for 6 -12 months
Oral therapy is prescribed for over 12 months
Who do you think won the debate?
6 weeks of IV is the gold standard (Matt Squire)
IV plus oral is enough (Nemandra Sandiford)
Will you change your practice because of this debate?
Yes
No
Do you have any questions on this topic that you’d like to submit?
If you would like an answer to your question, please provide your contact information:
Name
First
Last
Email
Phone
X
Use of High-Dose Spacers
When making a PMMA spacer, which type of PMMA do you utilize before manually adding antibiotics?
Plain Cement
Antibiotic-loaded Bone Cement
What brand of bone cement do you use when constructing a spacer?
PALACOS®
Simplex®
SmartSet®
Cobalt®
Other
What types of Antibiotics do you use when constructing a spacer? (please check all that apply)
No
Yes, I usually utilize an aminoglycoside (gentamycin/tobramycin) in the spacer
Yes, I usually utilize vancomycin (or teicoplanin) in the spacer
Yes, I usually utilize another antibiotic in the spacer
Do you add any of the following in your antibiotic spacer? (please check all that apply)
Methylene blue or other dyeing agent
Porogen agent to improve porosity
Other
When battling a fungal PJI, how do you adjust your spacer cocktail? (please check all that apply)
I still utilize an aminoglycoside and/or vancomycin in my spacer
I do not utilize an aminoglycoside and/or vancomycin in my spacer
I add an antifungal in my spacer
I add antifungal powder in the surgical wound
Which of the following factors lead to you to modify antibiotic dosing of your spacer? (please check all that apply:)
Pathogen resistance profile
Presence of a sinus tract
Impaired host renal status
Host risk factors for failure (obesity, smoking, etc)
None of the above
Other
Who do you think won the debate?
Higher dosing is required (Matt Dietz)
Lower dosing mitigates toxicity while enabling satisfactory cure (Tim Tan)
Will you change your practice because of this debate?
Yes
No
Do you have any questions on this topic that you’d like to submit?
If you would like an answer to your question, please provide your contact information:
Name
First
Last
Email
Phone
X
Best Alternative to Two Stage Revisions
Over the past year, what percent of your chronic PJI cases have been managed with a 1/1.5 stage approach?
More than 50%
More than 33%
Under 33%
Under 5%
I do not utilize this approach in my practice
I don’t manage PJI cases in my practice
Which of the following techniques do you utilize when performing a debridement as part of a DAIR (please check all that apply)?
In knees, perform a radical synovectomy back to healthy bleeding tissue
In hips, perform a radical capsulectomy
Utilize methylene blue or another dyeing agent to mark tissue to debride
Resect the skin edges of the previous incision
Insert a deep drain
Routinely utilize calcium phosphate beads as an antibiotic delivery vehicle
Routinely apply vancomycin powder in the wound for sensitive organisms
Routinely utilize negative pressure dressing for wound coverage
What is your preferred type of articulating spacer when performing a two-stage KNEE revision?
Premade commercial spacer
Spacer made intraoperatively in a commercial mold
Primary components fixed with antibiotic cement
Handmade spacer
What is your preferred type of articulating spacer when performing a two-stage HIP revision?
Premade commercial spacer
Spacer made intraoperatively in a commercial mold
Primary components fixed with antibiotic cement
Handmade spacer
What pre-operative conditions influence you choosing between 1/1.5 and 2 stage revision? (Select all that apply)
Presence of absence of pathologen (Culture positive versus culture negative)
Type of pathogen (e.g. staphylococcal, fungal, enterococcal)
Presence of antibiotic resistance
Presence of a sinus tract
Host status
Perceived patient compliance
Other
Who do you think won the debate?
The 1 stage (Endoklinik) protocol (Thorsten Gehrke)
The 1.5 stage (Destination spacer) protocol (Mark Spangehl)
Will you change your practice because of this debate?
Yes
No
Do you have any questions on this topic that you’d like to submit?
If you would like an answer to your question, please provide your contact information:
Name
First
Last
Email
Phone
X
Criteria for Reimplantation
What tests do you perform to help decide when to perform the second stage reimplantation? (Check all that apply)
Duration of time since first stage
CRP / ESR
D-dimer/fibrinogen
Synovial Aspiration (Cell count, differential)
Synovial Aspiration (Leukocyte Esterase)
Synovial Biopsy
Imaging results
Culture results
History and physical
What factors influence your decision regarding the optimal time to perform second stage reimplantation? (Check all that apply)
Host status
Preoperative test results
Bad pathogen: Resistant pathogen, Polymicrobial infection
Atypical pathogen (fungal, mycobacteria)
Soft tissue status (previous sinus tract, fragile wound)
How long of an antibiotic holiday do you give patients when you believe it’s time to reimplant?
0 days - I do not routinely perform an antibiotic holiday
1 – 7 days
8 – 14 days
15 -21 days
More than 21 days
How often do you perform an interim spacer exchange?
Less than 5% of cases
5 – 14.9% of cases
15 – 24.9% of cases
25 – 35.9% of cases
In 35% or more of cases
Who do you think won the debate?
We have enough markers for reimplantation. (Tom Bradbury)
We don’t have enough markers for reimplantation. (Carlos Higuera)
Will you change your practice because of this debate?
Yes
No
Do you have any questions on this topic that you’d like to submit?
Name
First
Last
Email
If you would like an answer to your question, please provide your contact information:
X
DNA Sequencing
How you often have you used DNA sequencing in the past year?
Never
1 – 9 times
10 – 25 times
More than 25 times
In what clinical situations would you use DNA sequencing? (Check all that apply)
All patients
Patients meeting MSIS criteria for PJI who have negative cultures
Patients whose history and presentation does not match the culture grown
Patients who fail two-stage exchange
Patients whose health would prevent multiple revision surgeries
None of the above
If you do use DNA sequencing, how to do you decide your treatment strategy?
I treat all detected pathogens
I treat the detected pathogens that are known causes of PJI
I treat the most dominant detected pathogen
Other strategy
Not applicable
Who do you think won the debate?
DNA sequencing can be used more broadly. (Javad Parvizi)
DNA sequencing should be used in only culture negative patients. (Wayne Moschetti)
Will you change your practice because of this debate?
Yes
No
Do you have any questions on this topic that you’d like to submit?
If you would like an answer to your question, please provide your contact information:
Name
First
Last
Email
X
Alpha Defensin and D-dimer
Which comment below best represents your use of Alpha Defensin in establishing the diagnosis of PJI?
I use it routinely to help diagnose PJI
I rely other test results first, then use alpha defensin only if necessary
I have access to it, but I do not use it as I do not find it helpful
I do not have access to alpha defensin, but wish I did.
I do not have access to alpha defensin, and do not seek its use at this time
What type of alpha defensin test does your institution have?
ELISA (Send to a Lab)
Lateral Flow
Both
Neither
I Don’t Know
What type of D-dimer test does your institution have?
Serum d-dimer
Plasma d-dimer
Both
I Don’t Know
Who do you think won the debate?
These tests should be used in all patients. (Elie Ghanem)
These tests have limited utility with added costs. (Chris Pelt)
Will you change your practice because of this debate?
Yes
No
Do you have any questions on this topic that you’d like to submit?
If you would like an answer to your question, please provide your contact information:
Name
First
Last
Email
Phone
X
Antibiotic Loaded Bone Cement
How often do you currently use antibiotic-loaded bone cement in primary TKA?
Routinely, in over 75% of patients
Commonly, in 25 – 75% of patients
Rarely, often in high-risk patients only
Never
If you performed cemented hip arthroplasty / hemiarthroplasty, how often do you use antibiotic-loaded bone cement?
Routinely, in over 75% of patients
Commonly, in 25 – 75% of patients
Rarely, often in high-risk patients only
Never
I do not utilize cement in hip replacement surgery
How often do you currently use antibiotic-loaded bone cement in aseptic cemented revision surgery?
Routinely, in over 75% of patients
Commonly, in 25 – 75% of patients
Rarely, often in high-risk patients only
Never
Do antibiotic elution kinetics factor in to your selection of a bone cement?
Yes
No
What antimicrobial or antimicrobial combination would you most like to see in a commercially available antibiotic loaded bone cement? (select all that apply)
Daptomycin
Gent/Tobra + Vancomycin
Gent/Tobra + Clindamycin
Gent/Tobra + Amphotericin B
Other (please write out)
Other
Who do you think won the debate?
PRO - Should be used in more than 30% of patients (Mike Reed)
CON - Should be used in less than 30% of patients (Antonia Chen)
Will you change your practice because of this debate?
Yes
No
Do you have any questions on this topic that you’d like to submit?
If you would like an answer to your question please provide your contact information
Name
First
Last
Email
X
How often do you currently use an antiseptic solution during primary total joint arthroplasty?
Routinely in all patients
In high-risk patients only
On rare occasions
Never
What antiseptic solution do you use most often?
Betadine (povidone-iodine) from a sealed, sterile pack
Betadine (povidone-iodine) from a bottle
Diluted Chlorhexidine (Irrisept)
Proprietary formulation (Bactisure, Prontosan)
Dakin’s Solution
Other (Please write out)
Other
What volume of fluid do you use for lavage?
Less than 1 L
1 – 2 L
2 – 4 L
More than 4 L of fluid
Do you use locally delivered antibiotics during primary surgery? (select all that apply)
Yes, I add antibiotics (polymyxin, bacitracin) to the intraoperative irrigation
Yes, I do administer topical vancomycin powder routinely
Yes, I do administer topical vancomycin powder, but in high-risk patients only
No, I do not use locally delivered antibiotics routinely during primary surgery
Who do you think won the debate?
PRO - Antiseptic solutions should be used in all patients (Thorsten Seyler)
CON - Antiseptic solutions should be used in high-risk patients only (Daniel Kendoff)
Will you change your practice because of this debate?
Yes
No
Do you have any questions on this topic that you’d like to submit?
If you would like an answer to your question please provide your contact information
Name
First
Last
Email
X
Admixing Antibiotics
For primary joint replacement procedures, do you currently manually mix-in antibiotics into bone cement?
Yes, routinely
Yes, occasionally (e.g. adding vancomycin when a patient is an MRSA carrier)
Yes, but on rare occasions
Never
If you have been manually mixing tobramycin into bone cement, how are you dealing with the shortage across the United States?
I have started using commercial antibiotic loaded bone cement
I have started mixing in another antibiotic into bone cement
I have began using topic vancomycin powder
I have utilized another strategy not listed here
Not applicable – I am not affected by the shortage or don’t routinely manually mix in antibiotics
Were you aware that liquid antibiotics could not be mixed into bone cement?
Yes
No
Were you aware that orthopedics surgeon assume product liability when antibiotics are manually mixed into bone cement?
Yes
No
Who do you think won the debate?
PRO – Mixing antibiotics into cement is cost-saving and effective (Derek Amanatullah)
CON – The risks of manually mixing antibiotics into cement outweigh the possible benefits (Jason Webb)
Will you change your practice because of this debate?
Yes
No
Do you have any questions on this topic that you’d like to submit?
If you would like an answer to your question please provide your contact information
Name
First
Last
Email
X
