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STIMULAN – surgeons’ views

In this Biocomposites Education series, Dr Sassoon, Dr Leighton, Dr Maale and Dr Younger share their views on how they use STIMULAN in their practice

What do you use STIMULAN for?
02:30
Why do you like using STIMULAN?
02:15
How do you typically use STIMULAN to treat bacterial infection?
02:17
How flexible is STIMULAN in allowing you to tailor your choice of antibiotic?
01:21
How does using STIMULAN benefit your patients?
01:54
How does using STIMULAN help your practice?
02:32
What economic benefit does using STIMULAN provide to your hospital?
02:41
How does using STIMULAN help with challenge of antibiotic resistance?
02:29
What do you like about working with Biocomposites?
02:50
Dr Ross Leighton

Orthopaedic Surgeon

‘In high-risk patients, you can put it in ahead of time and help prevent the wound issues to begin with. An ounce of prevention is worth a pound a cure.’

Dr Alastair Younger

Foot and Ankle Surgeon

‘I will put STIMULAN with the most appropriate antibiotic into the forefoot to treat the dead space and assist in eradicating the infection and getting wound closure in a single-stage procedure.’

Dr Adam Sassoon

Orthopaedic Surgeon

‘STIMULAN benefits my practice in the sense that it makes it easier for me to sleep at night. I rest easier knowing that there’s antibiotics being delivered to a local tissue bed around implants in high-risk patients, so that if there’s a problem later down the road…there’s an insurance policy around my implants, potentially protecting them.’

Dr Gerhard Maale

Orthopaedic Oncologist

‘It helps me do a one-stage operation for treatment of periprosthetic infection. That’s at least half the cost it would be if you did a two-stage …and still maintain the same eradication rates.’

Q & A
What do you use STIMULAN for?

Dr. Sassoon: I like to use STIMULAN. I find it to be a very effective antibiotic carrying tool that can deliver high dose antibiotics to a local tissue bed. I can tailor the antibiotics I use to target specific organisms. It’s dissolvable so it does not need to be procured at a later date and it’s been very safe in my patients. I haven’t had a problem with wound healing complications or any other systemic side effects, so I find it to be a safe and effective means of helping take care of a high-risk patient population.

Dr. Younger: It allows me to choose my antibiotic and it’s reported to have lower issues with drainage and wound healing, so it’s been effective. I’ve used a number of other carriers before and it’s been more effective.

Dr. Leighton: Well two things. One, you can mix it up early, which is nice for a surgeon because you can keep it on the table and there is not a time limit to using it. So, it’s ready when you’re ready, which is great. And number two, you can pick your antibiotic that you want to select for your wound, for your specific bacteria. You select that ahead of time and again have the STIMULAN all ready to go when you’re finished. I believe those are the two biggest improvements compared to other known antibiotic depo products.

Dr. Maale: STIMULAN’s a pellet, it’s a pure crystal, it’s hydrophilic, it’s a neutral pH. You can use it in periprosthetic joint infection, place it in the gutters after a clean out operation and it doesn’t cause any scratching to the prostheses or the poly. And I think that’s a big advantage, and you add that to the elution profiling, it makes it a perfect carrier.

Why do you like using STIMULAN?

Dr. Sassoon: I like to use STIMULAN. I find it to be a very effective antibiotic carrying tool that can deliver high dose antibiotics to a local tissue bed. I can tailor the antibiotics I use to target specific organisms. It’s dissolvable so it does not need to be procured at a later date and it’s been very safe in my patients. I haven’t had a problem with wound healing complications or any other systemic side effects, so I find it to be a safe and effective means of helping take care of a high-risk patient population.

Dr. Younger: It allows me to choose my antibiotic and it’s reported to have lower issues with drainage and wound healing, so it’s been effective. I’ve used a number of other carriers before and it’s been more effective.

Dr. Leighton: Well two things. One, you can mix it up early, which is nice for a surgeon because you can keep it on the table and there is not a time limit to using it. So, it’s ready when you’re ready, which is great. And number two, you can pick your antibiotic that you want to select for your wound, for your specific bacteria. You select that ahead of time and again have the STIMULAN all ready to go when you’re finished. I believe those are the two biggest improvements compared to other known antibiotic depo products.

Dr. Maale: STIMULAN’s a pellet, it’s a pure crystal, it’s hydrophilic, it’s a neutral pH. You can use it in periprosthetic joint infection, place it in the gutters after a clean out operation and it doesn’t cause any scratching to the prostheses or the poly. And I think that’s a big advantage, and you add that to the elution profiling, it makes it a perfect carrier.

How do you typically use STIMULAN to treat bacterial infection?

Dr. Leighton: I tend to use two antibiotics, usually in two groups. I use tobramycin and vancomycin as my mainstay and mix in one batch of tobramycin, 6 mls in STIMULAN, and one batch of vancomycin, 1 g in STIMULAN. Then I put that in the wound to try and prevent gram-negative and gram-positive organisms from growing. So that’s my standard go to mixture. If I know exactly the organism that was involved, you might skip one of those. So, if I knew for sure it was going to be related and affected by vancomycin only, then I would just mix vancomycin up. If I knew for sure it was just tobramycin, then I would just mix that up. But for blanket coverage, I tend to use the two different antibiotics.

Dr. Younger: My commonest use would be in patients with a diabetic forefoot infection, and in that case my workhorse is usually a transmetatarsal amputation. I will put STIMULAN with the most appropriate antibiotic within it based on cultures, into the forefoot to treat the dead space and assist in eradicating the infection and getting wound closure in a single-stage procedure.

Dr. Sassoon: Commonly, I use STIMULAN as an antibiotic carrying device in patients that have had a previous periprosthetic joint infection that I’ve come back to treat. Usually at the time of the resection arthroplasty, we will place antibiotic-eluting spacer implants. But then as an adjunctive measure, I will also implant STIMULAN within the joint space so it’s delivering more antibiotic to the soft tissues. And then at the time of the reimplantation, when definitive implants are going in at the
second-stage of their infection treatment, I’m also implanting STIMULAN beads to prevent any infection that may occur at the time of the replant or during their period of wound healing.

How flexible is STIMULAN in allowing you to tailor your choice of antibiotic?

Dr. Younger: So the organism that’s causing the infection needs to be identified. And once you’ve got the profile, then you can choose one of the three antibiotics that can go in there; tobramycin, gentamicin or vancomycin, to best suit the sensitivity of the bacteria that we’re treating. Because it’s eluted into local tissue you get many times MIC anyway, so really having an antibiotic in there is important but you may not need to be precise about it.

Dr. Sassoon: Especially in the case when you’re treating a known periprosthetic joint infection – you have cultures and an ID on the bacterial agent that’s causing the problem – you can decide which antibiotic you want to put in STIMULAN to use at the time of the resection or furthermore at the time of the reimplantation to prevent a recurrence of infection.

How does using STIMULAN benefit your patients?

Dr. Leighton: The STIMULAN that you put in helps prevent secondary operations for the patient. What you’re trying to do is get everything done in the first go. Even though the tissues are a little bit marginal, if you put the STIMULAN in, you hope not to get an infection on day one, even though there’s a risk of it, say in a compound wound. And number two, if you’re treating an infection and you put STIMULAN in, then the patient hopefully won’t require a secondary debridement. So, it helps reduce their treatment by maybe one operation or more and I think that’s a real benefit to your patient and a cost savings to the system.

Dr. Sassoon: I think it benefits my patients in the sense that it potentially decreases their risk for infection in and around the surgical field, especially high-risk patients. So, I think it benefits them by decreasing their risk of infection.

Dr. Younger: Well, it means that they can go to the O.R. once rather than multiple times. It’s fewer anaesthetics, we can get them home sooner, we can keep them home, and we can do their care more as outpatient care because we don’t have to worry so much about wound healing issues.

Dr. Maale: That’s pretty obvious. In the treatment of periprosthetic infections it’s given us an 88% eradication rate. We’re using it now as prophylaxis in complex revisions. They’re aseptic, they have aseptic problems.

How does using STIMULAN help your practice?

Dr. Sassoon: STIMULAN benefits my practice in the sense that it makes it easier for me to sleep at night. After doing complex patients, I worry about infection – patient populations that traditionally have a high risk of infection. I rest easier knowing that there’s antibiotics being delivered to a local tissue bed around implants in these high-risk patients, so that if there’s a problem later on down the road, either because of delayed wound healing or systemic illness, that there’s an insurance policy around my implants, potentially protecting them.

Dr. Leighton: I believe STIMULAN helps you add to your present-day treatment with an antibiotic regime that can improve your outcomes. I think particularly with infected wounds but also for preventing infections in high-risk patients. You can put it in ahead of time and help prevent the possibility of wound issues. An ounce of prevention is worth a pound a cure. It’s very useful in those high-risk patients.

Dr. Maale: It helps me do a one-stage operation for treatment of periprosthetic infection. That’s at half the cost, at least half the cost it would be if you did a two-stage and still maintain the same eradication rates. We’re publishing this year for knees at 88%.

Dr. Younger: It assists me in getting infection eradication with fewer trips to the operating room. The challenge is that operating room time is hard to access, at least in the environment I practice in. Patients need one trip to the O.R. and then they need to be done, and if I have to do multiple trips to the operating room it’s very difficult to schedule. It is not in the patient’s best interest either as many of these patients have other comorbidities. And if I can deal with it in one operation, it’s way better than dealing with it in multiple operations. The single-stage surgery is what I really like about it.

What economic benefit does using STIMULAN provide to your hospital?

Dr. Leighton: That’s always a big question. If you can in any way substantially reduce the hospital stay, which I think you do by improving wound healing locally, I think that’s good. And the second thing is if you treat it systemically as well as locally, then you can break down the glycocalyx including the bacterial organism and get some success. And if you can reduce one or two additional operations, you’ve saved the system a great deal. The economics of reduced operations and reduced hospital stays usually pays off in probably 90% of the group you treat, so I think its very cost effective that way.

Dr. Maale: At our hospital, we get referrals from case workers from several states because we’re able to do this at less than half the cost savings of a two-stage operation. It enables me to do a one-stage procedure for PJIs.

Dr. Sassoon: I think the economic benefits of STIMULAN are simply a decrease in a risk of revision in an arthroplasty setting. You’re potentially decreasing your risk of infection or wound healing problems that may be related to infection, either around an implant or in the soft tissue envelope surrounding an implant. I think that any time you can decrease your chance of having a revision or needing a revision, especially for infection which is extremely costly, you’re saving your institution money.

Dr. Younger: The main economic benefit is not taking patients back to the operating room. Also, there is an economic benefit in earlier discharge. For example, if I had to go back to using cement bead pouches, patients would be in hospital a lot longer. If I did repeat debridements, they’d be in a lot longer, the success rate would be lower, the bed utilization would be higher. So typically, I do the transmetatarsal amputations as an outpatient. They come in, get their amputation and then I follow them in clinic. If they’re in hospital, then I can do the transmetatarsal amputation and discharge them. One I did last week went home, they’re back at the clinic today, they’ll be back next week. It’s made it much more into an outpatient type care. As a result, we can look after more people and we can benefit the system that way around.

How does using STIMULAN help with the global challenge of antimicrobial resistance?

Dr. Younger: You’re delivering the antibiotic right to the area of infection and you’re not giving systemic antibiotics that get absorbed into the gut and go onto the skin surface. We all have three trillion bacteria on us. If we give systemic antibiotics, all of those bacteria are exposed and all of them are potentially able to then develop resistance. If we treat the local site, then none of those areas of normal commensal organisms are going to be exposed to the antibiotic, and therefore the ability to generate resistant organisms is going to be much reduced.

Dr. Leighton: You don’t know for sure, but if you can select an antibiotic that you know the bacteria is sensitive to, I think the chance of reducing the problem with that antibiotic is quite cost effective. If you’re just using the same antibiotic all of the time, it may possibly increase the chance of resistance. But if you know for sure the organism is sensitive to the antibiotic and you utilize that at a high level, the chance of success is good and the chance of resistance is low. I believe that’s really helpful in trying to reduce the chances of further operations and reduce the chance of microbial resistance.

Dr. Sassoon: I think being able to deliver high dose antibiotic locally to a tissue bed is a very good means to treat infection. Certainly, using systemic antibiotics is also important and potentially helpful, but using systemic antibiotics over long periods of time can sometimes lead to antibiotic resistance in populations and lead to selecting strains of bacteria that can persist and go on to infect other people. I think that being able to deliver high dose antibiotics at potentially killing concentrations around an infected tissue bed is preferable to potentially treating them with systemic antibiotics that may not achieve such high concentrations where the infection’s actually occurring.

What do you like about working with Biocomposites?

Dr. Younger: I like working with Biocomposites because I find that STIMULAN in particular, is very beneficial in the treatment of musculoskeletal infection around the foot. I’ve been using it for many years in various forms, but in particular to avoid having to do repeat surgery and have a second wound problem because they’ve got an absorbable antibiotic carrier.

Dr. Leighton: I think it gives you an edge of treatment that is a little bit different than what your standard of care is without STIMULAN. Standard of care for most operations would be debridement, replacement of components or replacement of fixation devices, and then trying to clean it all out and place the patient on some I.V. antibiotics to try to improve things from a systemic point of view. You can then add local antibiotic with the STIMULAN, and they permit you to give antibiotic in a concentration locally that’s above the MIC level of the bacteria. This can prove to be a huge advantage. It allows an MIC level that will destroy the bacterial locally, as well as kill of the bacteria within a glycocalyx around your component. So that may allow for retention of well-fixed components when compared to systemic treatment alone.

Dr. Maale: Well, they’ve been great to work with in the past. They always have the product available for us. We use quite a few of their packs a week, we probably go through 120 to 140 cc of the pellets. I do a lot of revisions that are complex. Our infected population has between 5 and 7 cases done prior to referral and our cure rate right now is running 85%.

Dr. Sassoon: I think, number one, it’s a great company because they offer a premium product in STIMULAN. And the support from their staff is phenomenal in terms of any questions related to technical considerations for their product use, making sure that I always have the product I need to do the procedures at a high volume center. I’ve just found them to be very supportive in terms of my clinical needs, and also in terms of educational support at my institution and research support at my institution. They’ve been really phenomenal to work with.