Conquering the most complex challenges PREVENTIA® Surgical Irrigation in use In complex prosthesis surgery, hygiene and the highest level of protection against bacterial infection are essential, especially in cases where complicating health factors bring additional challenges. In one case, Prof Peter Helwig, chief medical officer and head of the Trauma and Ortho Department of Heidenheim Klinikum (Heidenheim, Germany), turned to an innovative solution from HARTMANN that directly met this challenge. In 2023, a patient with an urgent need for knee replacement surgery presented at the Heidenheim Klinikum. However, a complex medical history, advanced age and a number of complicating factors meant that a straight forward approval for surgery was not possible. At 70 years of age, the patient was admitted for a consultation having suffered years of knee pain. Analgesics and physiotherapy had proven unsuccessful in treating her condition. In many cases, the consultation for prosthetic knee surgery would have been relatively straightforward, but her comorbidities made the decision less clear cut. The patient had a secondary diagnosis of diabetes mellitus, though it was well managed with an HbA1c below 7%. Furthermore, she was clinically obese at the time of admission with a body mass index (BMI) of 45 kg/m2. ’The patient has severe osteoarthritis of the knee – a Kellgren and Lawrence Grade 4, which can mean a marked narrowing of the joint space, severe sclerosis and deformity of the bone ends,’ says Helwig. ’She had a limited range of motion with extension deficit, and her pain on the visual analogue scale (VAS) was a nine. And, according to the guidelines in Germany, we are not supposed to operate on patients with a BMI above 40.’ ’If range of motion is so bad and osteoarthritis is so extended, then there is the possibility of losing more bone through the condition and making the operation later more complicated,’ he adds. ’The patient was suggested bariatric surgery to help with weight loss, even though bariatric surgery is up to recent years rarely done on patients at the age of over 65 years. But even if she had lost weight, she would have to wait one or two years. With this in mind, I decided to do the knee surgery as one of two suboptimal possible decisions.’ The highest standards of hygiene The level of obesity made the procedure far more challenging than most cases. The surgery to fit the knee prosthesis was atypical in many respects. For example, the time between incision and suture (incision to closure time) was longer than normal. ’The procedure is not too challenging normally but, in this instance, it took more time,’ remarks Helwig. ’Usually, it takes around 60 minutes to perform a total knee prosthesis with the system we used, but this time it took 115 minutes because of exposure of the joint and the condition of the patient. This is not extraordinarily long but longer than our average patient and almost longer than suggested from the German orthopaedic society.’ Hygiene and safety are always paramount in the operating theatre, but with a longer exposure to the external environment in this procedure, there was even more emphasis than usual on keeping the implant the surrounding tissues clean and free from infection. A key part of the solution could be the use of PREVENTIA® Surgical Irrigation, a new antimicrobial surgical wound irrigation fluid from HARTMANN, which has been innovating in the medical technology sphere for more than 200 years, but was not available at the time of surgery. PREVENTIA® Surgical Irrigation consists of a unique combination of two active substances. The first is polyhexanide (PHMB), which has a broad spectrum of antimicrobial qualities and is highly effective against biofilms. PHMB kills bacteria which are part of biofilms and provides a robust defence against harmful microbes. There for it penetrates the cell membranes of bacteria, where it causes an instability of the membranes structure, inside the bacterial cell it binds to the DNA. The second substance is poloxamer, a synthetic copolymer consisting of hydrophilic polyethylene oxide (PEO) and hydrophobic polypropylene oxide (PPO). This works as a surfactant that reduces the tension between two materials. This allows the active ingredient PHMB to reach its site of action more effectively and supports the removal of affected tissue during debridement. ’The main advantage of using this product is in the prophylaxis to rinse the operation site at the end of the surgery. In addition, it can be used in already infected cases,’ Helwig explains. ‘Using PREVENTIA® Surgical Irrigation means we have a better effect against potential infections.‘ PRACTICE 26
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