Prevention

Antibiotic Prophylaxis

• Question 1: Is there a correlation between operative time and the risk of subsequent SSI/PJI in patients undergoing tumor resection and endoprosthetic reconstruction? If so, should postoperative antibiotics be prolonged in these patients?
• Question 2: Should factors like preoperative radiation, soft tissue vs. bone resection, presence of metal vs. structural allograft, and other factors influence the dose and duration of antibiotic prophylaxis?
• Question 3: Should patients with an oncologic endoprosthesis in place receive antibtioic prophylaxis during dental procedures?
• Question 4: Should prophylactic antibiotics be started in patients with an oncologic endoprosthesis who develop neutropenia secondary to postoperative chemotherapy?
• Question 5: What type, dose, and duration of prophylactic antibiotic(s) should be administered to patients undergoing oncologic endoprosthetic reconstruction who have received or will be receiving chemotherapy and/or radiation?
• Question 6: Does the type, dose, and duration of antibiotic prophylaxis differ for patients undergoing oncologic endoprosthetic reconstruction compared to conventional TJA?

Chemotherapy

• Question 1: Do we need to evaluate the gut and skin microbiome of patients after chemotherapy to assess the risk for potential infection after endoprosthetic reconstruction?
• Question 2: Should an absolute neutrophil count of >1000 mm³ be the minimum for patients undergoing limb salvage surgery after receiving chemotherapy?
• Question 3: Should the serum white cell count be taken into account prior to endoprosthetic reconstruction in patients who have undergone recent chemotherapy?
• Question 4: What should be the time delay between preoperative chemo/radiotherapy and a surgical tumor resection in order to minimize incidence of SSI/PJI?
• Question 5: What strategies should be implemented to minimize the risk of SSI/PJI in patients who have received chemotherapy or radiation therapy and are undergoing endoprosthetic reconstruction?

Research Caveats

• Question 1: What are the significant risk factors for SSI/PJI of an oncologic endoprosthesis following resection of a malignant bone tumor?
• Question 2: What metrics should be used to determine the optimal timing of reimplantation for patients with a resected oncologic endoprosthesis?

Surgical Technique

• Question 1: Is there an increased risk for subsequent SSI/PJI when a drainage tube is used in musculoskeletal tumor surgery?
• Question 2: When should a surgical drain be removed to minimize the risk of subsequent SSI/PJI in patients who have received endoprosthetic reconstruction following resection of a musculoskeletal tumor?
• Question 3: Does the type of fixation (cemented vs. uncemented) of an oncologic endoprosthesis influence the incidence of subsequent SSI/PJI?
• Question 4: Does the use of incise draping with antibacterial agents (iodine) influence the risk for subsequent SSI/PJI in patients undergoing musculoskeletal tumor surgeries?
• Question 5: Does the use of soft tissue attachment meshes increase the risk for subsequent PJI in patients undergoing oncologic endoprosthetic reconstruction?
• Question 6: Should endosprosthesis and/or allograft bone be soaked in antibtioic solution or antiseptic solutions prior to implantation in patients?
• Question 7: Should a coated prosthesis (silver/iodine) be used for reconstruction of patients undergoing primary bone tumour resection?
• Question 8: What is the most optimal local antimicrobial delivery strategy during limb salvage: antibiotic cement, silver-coated implant, iodine-coated implant, topical vancomycin powder, injection of antibiotics via drain tubing, other?

Treatment

Irrigation and Debridement

• Question 1: How many irrigation and debridements of an infected oncologic endoprosthesis are reasonable before consideration should be given to resection arthroplasty?
• Question 2: How should acute reinfection of an oncologic endoprosthesis be treated?
• Question 3: Is irrigation and debridement, and exchange of modular parts, a viable option for treatment of acute PJI involving oncologic endoprosthesis? If so, what are the indications?

One-Stage Exchange

• Question 1: Does the use of iodine-coated or silver-coated implants make one-stage exchange arthroplasty possible in the management of patients with infected oncologic endoprosthesis?
• Question 2: Is there a role for single stage exchange arthroplasty for patients with infected oncologic endoprosthesis?

Research Caveats

• Question 1: Should the management of PJI involving an oncologic endoprosthesis differ from that of conventional joint replacement prostheses?

Two-Stage Exchange

• Question 1: What factors may improve the outcome of a two-stage exchange arthroplasty in patients with an infected oncologic endoprosthesis?
• Question 2: What is the best reconstruction technique for an infected allograft?
• Question 3: What is the best surgical treatment for management of a chronically infected oncologic endoprosthesis? Does this change if the patient is receiving or has received recent chemotherapy and/or irradiation?