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Coles VE, Puri L, Bhandari M, Wood TJ, Burrows LL. The effects of chlorhexidine, povidone-iodine and vancomycin on growth and biofilms of pathogens that cause prosthetic joint infections: an in-vitro model. J Hosp Infect 2024; 151:99-108. [PMID: 38992843 DOI: 10.1016/j.jhin.2024.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 06/11/2024] [Accepted: 06/23/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Chlorhexidine gluconate (CHG) and povidone-iodine (PI) are commonly used to prevent prosthetic joint infection (PJI) during total joint replacement; however, their effective concentrations and impact on biofilms are not well defined. AIM To determine: (1) the in-vitro minimum inhibitory concentration of CHG and PI against model PJI-causing organisms and clinical isolates; (2) their impact on biofilm formation; (3) whether there is a synergistic benefit to combining the two solutions; and (4) whether adding the antibiotic vancomycin impacts antiseptic activity. METHODS We measured in-vitro growth and biofilm formation of Staphylococcus epidermidis, meticillin-sensitive and meticillin-resistant Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa and Candida albicans, as well as recent clinical isolates, in the presence of increasing concentrations of CHG and/or PI. Checkerboard assays were used to measure potential synergy of the solutions together and with vancomycin. FINDINGS CHG and PI inhibited growth and biofilm formation of all model organisms tested at concentrations of 0.0004% and 0.33% or lower, respectively; highly dilute concentrations paradoxically increased biofilm formation. The solutions did not synergize with one another and acted independently of vancomycin. CONCLUSION CHG and PI are effective at lower concentrations than typically used, establishing baselines to support further clinical trials aimed at optimizing wound disinfection. There is no synergistic advantage to using both in combination. Vancomycin is effective at inhibiting the growth of S. epidermidis and S. aureus; however, it stimulates P. aeruginosa biofilm production, suggesting in the rare case of P. aeruginosa PJI, it could exacerbate infection.
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Affiliation(s)
- V E Coles
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada; Michael G. DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton, Ontario, Canada
| | - L Puri
- Hamilton Arthroplasty Group, Hamilton Health Sciences Juravinski Hospital, Hamilton, Ontario, Canada
| | - M Bhandari
- Department of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - T J Wood
- Hamilton Arthroplasty Group, Hamilton Health Sciences Juravinski Hospital, Hamilton, Ontario, Canada; Department of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - L L Burrows
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada; Michael G. DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton, Ontario, Canada.
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Williams M, Harris RM. Efficacy of a Novel Intraoperative Surgical Irrigant in Preventing Periprosthetic Joint Infections in Primary Knee, Hip, and Shoulder Arthroplasties: A Retrospective Analysis. Orthop Surg 2024; 16:1277-1283. [PMID: 38627352 PMCID: PMC11144508 DOI: 10.1111/os.14052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/15/2024] [Accepted: 03/16/2024] [Indexed: 06/04/2024] Open
Abstract
OBJECTIVE Primary joint arthroplasty (JA) is one of the most common operating room (OR) procedures, with knee and hip arthroplasties being listed in the top five most frequent OR procedures and while not as common, shoulder arthroplasties are increasing at greater rates than knee and hip arthroplasties. Periprosthetic joint/shoulder infections (PJI/PSI) are a devastating complication of primary JAs with infection prevention deemed as the single most important strategy in combating them. The objective of this study was to retrospectively evaluate the efficacy of XPERIENCE® Advanced Surgical Irrigation (XP) in preventing PJI following primary joint arthroplasty. METHODS This is a retrospective study of primary knee, hip and shoulder arthroplasties that were performed by multiple orthopedic surgeons at a single hospital setting. XPERIENCE was used as an intraoperative surgical irrigant either solely, or with other intraoperative practices for prevention of infection. Incidence of acute PJI occurring within 90 days of index surgery were retrospectively collated. RESULTS Four hundred and twenty-three (423) primary joint replacement surgeries treated intraoperatively with XP, were evaluated for acute PJI incidence. Retrospective evaluations determined that 95% of the subjects had at least one risk factor predisposing them to PJI. There were zero PJIs diagnosed in the knee and hip arthroplasty cohorts and zero PSIs diagnosed in the shoulder arthroplasty cohorts. CONCLUSION The absence of PJI/PSI diagnoses in the JA cohorts treated intraoperatively with XP indicates that it could be an efficacious antimicrobial irrigant in preventing PJI, and warrants being evaluated in prospective, randomized controlled clinical trials as the sole intraoperative irrigant, as well as in combination with the other intraoperative infection prevention regimens evaluated in this retrospective study.
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MESH Headings
- Humans
- Retrospective Studies
- Prosthesis-Related Infections/prevention & control
- Male
- Female
- Therapeutic Irrigation/methods
- Aged
- Middle Aged
- Arthroplasty, Replacement, Shoulder/methods
- Intraoperative Care/methods
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/methods
- Arthroplasty, Replacement, Hip/methods
- Arthroplasty, Replacement, Hip/adverse effects
- Aged, 80 and over
- Adult
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Affiliation(s)
- Marshall Williams
- Jack Hughston Memorial HospitalPhenix CityALUSA
- Hughston FoundationColumbusGAUSA
| | - Robert M. Harris
- Quillen College of Medicine, East Tennessee State UniversityJohnson CityTNUSA
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Singer RW. Real-World Evidence of the Impact of a Novel Surgical Irrigant on Surgical Site Infections in Primary Total Knee Arthroplasty Performed at an Ambulatory Surgery Center. Surg Infect (Larchmt) 2024; 25:240-246. [PMID: 38588520 PMCID: PMC11001957 DOI: 10.1089/sur.2023.304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024] Open
Abstract
Background: Total knee arthroplasty (TKA) is one of the most common inpatient and outpatient surgical procedures performed in the United States and is predicted to increase 401% by 2040. Surgical site infections (SSIs) at an incidence rate of approximately 2% are costly post-operative complications in TKA. Intra-operative surgical irrigants are used to decrease contaminating microbial bioburden within the surgical site to prevent SSI. The primary objective of this retrospective study was to evaluate the impact of a novel surgical irrigant called XPERIENCE® Advanced Surgical Irrigation (XP; Next Science, Jacksonville, FL) on SSI incidence in primary TKA performed at an ambulatory surgery center (ASC). Patients and Methods: Primary TKAs were performed at a free-standing ASC. The novel surgical irrigant was used intra-operatively to rinse away debris and micro-organisms from the surgical site. Retrospective data collation included SSI rates, complication rates, and re-admissions due to SSI within 90 days of index surgery. Results: Among the 524 primary TKA surgeries, one peri-prosthetic joint infection (PJI) was diagnosed within 90 days of index surgery and one superficial incisional SSI was diagnosed within 30 days of index surgery. The PJI was attributed to an exogenously acquired upper respiratory tract infection rather than due to the failure of intra-operative regimes. The 0.19% PJI incidence rate indicated significant efficacy of XP in decreasing PJI. An overall complication rate of 7.82% was noted with none of the complications associated with usage of the novel surgical irrigant. Conclusions: XPERIENCE is a promising intra-operative antimicrobial irrigant that can be easily incorporated into a broader infection prevention strategy.
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Affiliation(s)
- Ronald W. Singer
- Edgewater Surgery Center, Fort Mill, South Carolina, USA
- OrthoCarolina, Charlotte, North Carolina, USA
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Moslehyazdi M, Bielajew B, Schlechter JA, Hu JC, Athanasiou KA, Wang D. Detrimental Effects of Chlorhexidine on Articular Cartilage Viability, Matrix, and Mechanics. Am J Sports Med 2024; 52:1068-1074. [PMID: 38353029 PMCID: PMC10943607 DOI: 10.1177/03635465241226952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 11/29/2023] [Indexed: 03/17/2024]
Abstract
BACKGROUND Chlorhexidine gluconate (CHG) solution is commonly used as an antiseptic irrigation for bacterial decontamination during orthopaedic surgery. Although the chondrotoxicity of CHG on articular cartilage has been reported, the full extent of CHG-related chondrotoxicity and its effects on the extracellular matrix and mechanical properties are unknown. PURPOSE To investigate the in vitro effects of a single 1-minute CHG exposure on the viability, biochemical content, and mechanics of native articular cartilage explants. STUDY DESIGN Controlled laboratory study. METHODS Articular cartilage explants (6 per group) were harvested from femoral condyles of the porcine stifle and sectioned at tidemark. Explants were bathed in CHG solution (0.05% CHG in sterile water) at varying concentrations (0% control, 0.01% CHG, and 0.05% CHG) for 1 minute, followed by complete phosphate-buffered saline wash and culture in chondrogenic medium. At 7 days after CHG exposure, cell viability, matrix content (collagen and glycosaminoglycan [GAG]), and compressive mechanical properties (creep indentation testing) were assessed. RESULTS One-minute CHG exposure was chondrotoxic to explants, with both 0.05% CHG (2.6% ± 4.1%) and 0.01% CHG (76.3% ± 8.6%) causing a decrease in chondrocyte viability compared with controls (97.5% ± 0.6%; P < .001 for both). CHG exposure at either concentration had no significant effect on collagen content, while 0.05% CHG exposure led to a significant decrease in mean GAG per wet weight compared with the control group (2.6% ± 1.7% vs 5.2% ± 1.9%; P = .029). There was a corresponding weakening of mechanical properties in explants treated with 0.05% CHG compared with controls, with decreases in mean aggregate modulus (177.8 ± 90.1 kPa vs 280.8 ± 19.8 kPa; P < .029) and shear modulus (102.6 ± 56.5 kPa vs 167.9 ± 16.2 kPa; P < .020). CONCLUSION One-minute exposure to CHG for articular cartilage explants led to dose-dependent decreases in chondrocyte viability, GAG content, and compressive mechanical properties. This raises concern for the risk of mechanical failure of the cartilage tissue after CHG exposure. CLINICAL RELEVANCE Clinicians should be judicious regarding the use of CHG irrigation at these concentrations in the presence of native articular cartilage.
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Affiliation(s)
- Maziar Moslehyazdi
- Department of Orthopaedic Surgery, University of California, Irvine, Orange, California, USA
| | - Benjamin Bielajew
- Department of Biomedical Engineering, University of California, Irvine, Irvine, California, USA
| | - John A. Schlechter
- Pediatric Orthopedic Specialists Orange County, Children’s Hospital of Orange County, Orange, California, USA
| | - Jerry C. Hu
- Department of Biomedical Engineering, University of California, Irvine, Irvine, California, USA
| | - Kyriacos A. Athanasiou
- Department of Biomedical Engineering, University of California, Irvine, Irvine, California, USA
| | - Dean Wang
- Department of Orthopaedic Surgery, University of California, Irvine, Orange, California, USA
- Department of Biomedical Engineering, University of California, Irvine, Irvine, California, USA
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Chambers MM, Namdari S. A Review of Surgical Irrigation Solutions for Infection Prevention in Orthopaedic Surgery. JBJS Rev 2023; 11:01874474-202312000-00003. [PMID: 38079492 DOI: 10.2106/jbjs.rvw.23.00158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
» Intraoperative surgical irrigation is a common practice in orthopaedic procedures, although there is no universally established standard of care due to a lack of concrete data supporting an optimal irrigation agent.» Isotonic normal saline has long been considered a safe and cost effective solution for wound irrigation as compared with other antibiotic and antiseptic irrigation solutions.» Currently, the only adjunct to saline that is formally supported by American Academy of Orthopaedic Surgeons, the Centers for Disease Control and Prevention, and World Health Organization is povidone-iodine.» Further in vivo clinical studies are needed to identify the ideal irrigation solution that carries low cytotoxic effects while also exerting optimal antimicrobial properties.
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Ebrahimzadeh MH, Safdari MR, Moradi A, Rastaghi S, Daliri M. How effective is diluted povidone-iodine in preventing periprosthetic joint infection in total joint arthroplasty (TJA)? An updated systematic review and meta-analysis. BMC Musculoskelet Disord 2023; 24:416. [PMID: 37231378 DOI: 10.1186/s12891-023-06548-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 05/18/2023] [Indexed: 05/27/2023] Open
Abstract
PURPOSE Periprosthetic joint infection (PJI) is a serious complication with total joint arthroplasty (TJA), that necessitates reoperation. Pre-closure irrigation with dilute povidone-iodine (PI) is among the preventive measures, but its efficiency is still controversial. As a result, the focus of this systematic review and meta-analysis is on the effect of dilute PI wound irrigation in the prevention of PJI following TJA. METHODS We systematically reviewed and analyzed articles that compared PI with other agents in terms of PJI rate after TJA, searching Medline, Scopus, Web of science, and Cochrane databases. A number of 13 papers including 63,950 patients in total, were finally considered in qualitative and quantitative assessments. We have also further assessed review articles. RESULTS In comparison with normal saline (NS), PI reduced post-operative infection rate (OR: 0.44; CI 95%: 0.34-0.56). However, there was no difference between PI and chlorhexidine (CHG) (OR: 1.61; CI 95%: 0.83-3.09)) or undetermined comparators (OR: 1.08; CI 95%: 0.67-1.76). CONCLUSION PI irrigation seems an efficient preventive measure for post-operative PJI and would seem to be the most feasible for TJA protocol.
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Affiliation(s)
- Mohammad-H Ebrahimzadeh
- Orthopedics Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad-R Safdari
- Orthopedics Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Surgery, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Ali Moradi
- Orthopedics Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sedighe Rastaghi
- Department of Biostatistics, School of Public Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahla Daliri
- Orthopedics Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran.
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Monstrey SJ, Govaers K, Lejuste P, Lepelletier D, de Oliveira PR. Evaluation of the role of povidone‑iodine in the prevention of surgical site infections. Surg Open Sci 2023; 13:9-17. [PMID: 37034245 PMCID: PMC10074992 DOI: 10.1016/j.sopen.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/09/2023] [Accepted: 03/11/2023] [Indexed: 03/18/2023] Open
Abstract
Background The occurrence of surgical site infections (SSIs) is associated with increased risk of mortality, development of other infections, and the need for reintervention, posing a significant health burden. The aim of this review was to examine the current data and guidelines around the use of antiseptic povidone‑iodine (PVP-I) for the prevention of SSIs at each stage of surgical intervention. Methods A literature search for selected key words was performed using PubMed. Additional papers were identified based on author expertise. Results Scientific evidence demonstrates that PVP-I can be used at every stage of surgical intervention: preoperative, intraoperative, and postoperative. PVP-I is one of the most widely used antiseptics on healthy skin and mucous membranes for preoperative surgical site preparation and is associated with a low SSI rate. For intraoperative irrigation, aqueous PVP-I is the recommended agent and has been demonstrated to decrease SSIs in a range of surgical settings, and for postoperative wound healing, there is a growing body of evidence to support the use of PVP-I. Conclusions There is a need for more stringent study designs in clinical trials to enable meaningful comparisons between antiseptic agents, particularly for preoperative skin preparation. The use of a single agent (PVP-I) at each stage of surgical intervention could potentially provide advantages, including economic benefits, over agents that can only be used at discrete stages of the surgical procedure. Key message Evidence supports the use of PVP-I at all stages of surgical intervention, from preoperative measures (including skin preparation, preoperative washing, and nasal decolonization) to intraoperative irrigation, through to postoperative wound management. However, there is a need for more stringent study designs in clinical trials to enable meaningful comparisons between antiseptic agents, particularly for preoperative skin preparation.
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Hoellwarth JS, Tetsworth K, Akhtar MA, Al Muderis M. Transcutaneous Osseointegration for Amputees: What Is It, How Did It Evolve, and What May Develop? CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2023. [DOI: 10.1007/s40141-023-00376-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Griggs R, Karpman E, Jones L, Twomey C, Henry G. Effect of 0.05% chlorhexidine gluconate in water on the hydrophilic inflatable penile prosthesis: biocompatibility, adherence, and dip time. J Sex Med 2023; 20:113-117. [PMID: 36897235 DOI: 10.1093/jsxmed/qdac007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/26/2022] [Accepted: 09/18/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Rates of infection after inflatable penile prosthesis range from 1% to 3%; however, a new surgical irrigation solution is Food and Drug Administration cleared as antimicrobial wound lavage and appears to be safe for patients and noncaustic during hydrophilic inflatable penile prosthesis (hIPP) dipping and irrigation. AIM To evaluate if 0.05% chlorhexidine (CHG) lavage is caustic to the hIPP coating and if dip adherence is dependent on time. METHODS Preconnected hIPP devices were tested at a Coloplast research and development laboratory. The devices were soaked in the 0.05% CHG lavage solution or normal saline for 1, 15, 30, and 60 minutes. Subsequently, all parts were dried for 15 minutes in a 35 °C oven. A Congo red dye test was performed following a Coloplast-validated and Food and Drug Administration-cleared test method to ensure product reliability. Implants were then visually inspected for deleterious effects as well as dip coverage. In addition, we evaluated 0.05% CHG lavage solution vs previously published hIPP dipping solutions. OUTCOMES 0.05% CHG lavage does not appear to damage the hIPP coating, and adherence of this solution is not dependent on dip time. RESULTS All components of the preconnected hydrophilic IPPs were tested for coating adherence and defects. All tested IPPs achieved a "satisfactory" coating, meaning a uniform coat without flaking or clumping. Furthermore, there were no noticeable caustic effects or differences in coating adherence between the normal saline-soaked control and 0.05% CHG-coated arms with increasing dip time. A review of the literature for 0.05% CHG lavage solutions vs previously published hIPP dipping solutions revealed that it may have some advantages over previously reported antibiotic solutions. CLINICAL IMPLICATIONS This study serves as a foundation to introduce 0.05% CHG lavage to the urologic literature as a potentially new "magic bullet" irrigation. STRENGTHS AND LIMITATIONS Major strengths of the study are that it is the first study of its kind to address the question of what dip duration should be used and whether it is scientifically reproducible. A limitation is the in vitro model, thus needing validation in a clinical setting. CONCLUSION 0.05% CHG does not appear to negatively affect the hIPP coating or differ in adherence with increasing dip time; however, long-term device performance has not been verified.
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Affiliation(s)
- Ryan Griggs
- Willis Knighton Advanced Urology, Bossier City, LA 71111, United States
| | - Edward Karpman
- El Camino Health Urology, Mountain View, CA 94040, United States
| | - LeRoy Jones
- Urology San Antonio, San Antonio, TX 78229, United States
| | - Carolyn Twomey
- Department of Medical Affairs and Research, Irrimax Corporation, Lawrenceville, GA 30043, United States
| | - Gerard Henry
- Willis Knighton Advanced Urology, Bossier City, LA 71111, United States
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Effect of commonly used lavage solutions on the polymerization of bone cement. Orthop Traumatol Surg Res 2022; 108:103243. [PMID: 35158106 DOI: 10.1016/j.otsr.2022.103243] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/22/2021] [Accepted: 02/04/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Little is known about the impact irrigation solutions have on the material properties of cement used in hip and knee arthroplasty. We sought to compare the effect of three commonly used lavage solutions on cement polymerization. METHODS Ten groups were used for cure and mechanical testing: two cement controls, and eight cement groups mixed with test solutions. Test solutions included a commercially available benzalkonium chloride/citric acid solution (BCS), chlorhexidine gluconate (0.05%) (CHG), povidone-iodine 0.35%, and normal saline added at cement mixing onset. Cement dough-time, set-time, and compression testing were performed following The American Society for Testing and Materials guidelines. RESULTS Povidone-iodine had shorter dough-time (1min 34sec, sd 1min 5sec) versus controls (1min 56sec, sd 1min 35sec), p=0.0419. Cement exposed to all lavage samples had significantly reduced set-time. Compressive strength was reduced for all surgical lavages (p<0.001). Pairwise testing revealed that all lavage treatments reduced offset strength versus controls (p<0.001). CONCLUSION Bone cement exposed to lavage solutions during the cement mixing-phase showed accelerated set-times and decreased compressive strength. If bone is not dry, and cement has not finished mixing at the time of application, cement curing time may be shortened. Additionally, bone cement should reach dough phase prior to pre-closure surgical lavage. LEVEL OF EVIDENCE III; case control study.
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Willigenburg NW, Yesilkaya F, Rutgers M, Moojen DJF, Poolman RW, Kempen DH. Prosthetic Joint Infection and Wound Leakage After the Introduction of Intraoperative Wound Irrigation With a Chlorhexidine-Cetrimide Solution: A Large-Scale Before-After Study. Arthroplast Today 2022; 19:101053. [PMID: 36845287 PMCID: PMC9947967 DOI: 10.1016/j.artd.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 09/19/2022] [Accepted: 10/11/2022] [Indexed: 11/29/2022] Open
Abstract
Background Intraoperative chlorhexidine irrigation could be a valuable additive to systemic antibiotics to prevent infections after total joint arthroplasties. However, it may cause cytotoxicity and impair wound healing. This study evaluates the incidence of infection and wound leakage before and after the introduction of intraoperative chlorhexidine lavage. Methods All 4453 patients receiving a primary hip or knee prosthesis between 2007 and 2013 in our hospital were retrospectively included. They all underwent intraoperative lavage before wound closure. Initially, wound irrigation with 0.9% NaCl was standard care (n = 2271). In 2008, additional irrigation with a chlorhexidine-cetrimide (CC) solution was gradually introduced (n = 2182). Data on the incidence of prosthetic joint infections and wound leakage, as well as relevant baseline and surgical characteristics, were derived from medical charts. Chi-square analysis was used to compare the incidence of infection and wound leakage between patients with and without CC irrigation. Multivariable logistic regression was used to assess robustness of these effects by adjusting for potential confounders. Results The prosthetic infection rate was 2.2% in the group without CC irrigation vs 1.3% in the group with CC irrigation (P = .021). Wound leakage occurred in 15.6% of the group without CC irrigation and in 18.8% of the group with CC irrigation (P = .004). However, multivariable analyses showed that both findings were likely due to confounding variables, rather than by the change in intraoperative CC irrigation. Conclusions Intraoperative wound irrigation using a CC solution does not seem to affect the risk of prosthetic joint infection or wound leakage. Observational data easily yield misleading results, so prospective randomized studies are needed to verify causal inference. Level of Evidence Level III-uncontrolled before and after the study.
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Affiliation(s)
- Nienke W. Willigenburg
- Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, Amsterdam, the Netherlands
| | - Fatih Yesilkaya
- Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, Amsterdam, the Netherlands
| | - Marijn Rutgers
- Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, Amsterdam, the Netherlands
| | - Dirk Jan F. Moojen
- Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, Amsterdam, the Netherlands
| | - Rudolf W. Poolman
- Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, Amsterdam, the Netherlands,Department of Orthopaedic Surgery, LUMC, Leiden, the Netherlands
| | - Diederik H.R. Kempen
- Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, Amsterdam, the Netherlands,Corresponding author. Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, P.O. Box 95500, 1090 HM Amsterdam, the Netherlands. Tel.: +31 20 599 2415.
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Gavrailov T, Chenchev I, Gevezova M, Draganova M, Sarafian V. Effect on Cellular Vitality In Vitro of Novel APRF-Chlorhexidine Treated Membranes. J Funct Biomater 2022; 13:jfb13040226. [PMID: 36412868 PMCID: PMC9680238 DOI: 10.3390/jfb13040226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/28/2022] [Accepted: 10/29/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Chlorhexidine (CHX) has been used for some time in clinical practice as a local antiseptic agent with excellent efficacy. The combination of CHX with APRF (Advanced-platelet rich fibrin) membrane has the potential to stimulate tissue regeneration and to provide a bactericidal effect. We hypothesize that this may reduce the rate of infections development and protect cell viability. AIM The aim of this study was two-fold-to create a stable APRF membrane treated with different concentrations of CHX (0.01% and 0.02%) and to monitor its effect on the viability of PDL cells in vitro. This benefits the introduction of a new protocol for APRF membrane production -CHX-PRF and enriches the available evidence on the effect of this antiseptic agent on PDL (Periodontal ligament) cells. MATERIALS AND METHODS APRF membranes were prepared by the addition of two concentrations (0.01% and 0.02%) of CHX. Membranes without the antiseptic were also prepared and used as control samples. PDL cells were cultivated on the membranes for 72 h. Cell number and vitality were examined by fluorescent cell viability assays. RESULTS Our results demonstrated that a concentration of 0.01% CHX allowed the production of a stable APRF membrane. This concentration slightly reduced the viability of PDL cells to 96.7%, but significantly decreased the average number of cells attached to the membrane-149 ± 16.5 cells/field compared to controls -336 ± 26.9 cells/field. APRF-CHX 0.02% membranes were unstable, indicating a dose-dependent cytotoxic effect of CHX. CONCLUSIONS The introduced novel protocol leads to the production of a new type of APRF membrane-CHX-PRF. The incorporation of an antiseptic into the APRF membrane can improve its bactericidal activity and might serve as an important step for the prevention of postoperative infections.
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Affiliation(s)
- Tasho Gavrailov
- Department of Oral Surgery, Medical University—Plovdiv, 4000 Plovdiv, Bulgaria
- Correspondence:
| | - Ivan Chenchev
- Department of Oral Surgery, Medical University—Plovdiv, 4000 Plovdiv, Bulgaria
- Research Institute at MU-Plovdiv, 4000 Plovdiv, Bulgaria
| | - Maria Gevezova
- Research Institute at MU-Plovdiv, 4000 Plovdiv, Bulgaria
- Department of Medical Biology, Medical University—Plovdiv, 4000 Plovdiv, Bulgaria
| | - Milena Draganova
- Research Institute at MU-Plovdiv, 4000 Plovdiv, Bulgaria
- Department of Medical Biology, Medical University—Plovdiv, 4000 Plovdiv, Bulgaria
| | - Victoria Sarafian
- Research Institute at MU-Plovdiv, 4000 Plovdiv, Bulgaria
- Department of Medical Biology, Medical University—Plovdiv, 4000 Plovdiv, Bulgaria
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Arnal Etienne A, van Maanen A, Van Eeckhout P, Magremanne M. Actinomycosis and osteonecrosis of the jaw: Every why hides a why. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2022; 123:e749-e756. [PMID: 35640875 DOI: 10.1016/j.jormas.2022.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 04/10/2022] [Accepted: 05/27/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Andrea Arnal Etienne
- Department of oral and maxillo-facial surgery, Cliniques Universitaires Saint-Luc, Universite Catholique de Louvain, 10, avenue Hippocrate, 1200 Brussels, Belgium.
| | - Aline van Maanen
- Statistical support unit, Cliniques Universitaires Saint-Luc, Universite Catholique de Louvain, 10, avenue Hippocrate, 1200 Brussels, Belgium; Institut Roi Albert II, Cancérologie et Hématologie, Cliniques Universitaires Saint-Luc, Universite Catholique de Louvain, 10, avenue Hippocrate, 1200 Brussels, Belgium
| | - Pascal Van Eeckhout
- Department of pathology, Cliniques Universitaires Saint-Luc, Universite Catholique de Louvain, 10, avenue Hippocrate, 1200 Brussels, Belgium; Institut Roi Albert II, Cancérologie et Hématologie, Cliniques Universitaires Saint-Luc, Universite Catholique de Louvain, 10, avenue Hippocrate, 1200 Brussels, Belgium
| | - Michèle Magremanne
- Department of oral and maxillo-facial surgery, Cliniques Universitaires Saint-Luc, Universite Catholique de Louvain, 10, avenue Hippocrate, 1200 Brussels, Belgium; Institut Roi Albert II, Cancérologie et Hématologie, Cliniques Universitaires Saint-Luc, Universite Catholique de Louvain, 10, avenue Hippocrate, 1200 Brussels, Belgium
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Moore C, Fernandes RJ, Manrique J, Polissar NL, Miljacic L, Hippe DS, Vaux J, Thompson MJ. Cytotoxic Effects of Common Irrigation Solutions on Chondrosarcoma and Giant Cell Tumors of Bone. J Bone Joint Surg Am 2022; 104:2153-2159. [PMID: 36367764 PMCID: PMC10168128 DOI: 10.2106/jbjs.22.00404] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Irrigation is commonly used as an adjuvant treatment during the intralesional curettage of bone tumors. The goal of the present study was to analyze the in vitro cytotoxicity of commonly used irrigation solutions on chondrosarcoma and giant cell tumor (GCT) cells as there is no consensus on which solution leads to the greatest amount of cell death. METHODS An in vitro evaluation was performed by exposing human GCT and human chondrosarcoma cell lines to 0.9% saline solution, sterile water, 70% ethanol, 3% hydrogen peroxide, 0.05% chlorhexidine gluconate (CHG), and 0.3% povidone iodine solutions independently for 2 and 5 minutes. A low-cytotoxicity control (LCC) and a high-cytotoxicity control (HCC) were established to determine the mean cytotoxicity of each solution and each solution's superiority to LCC and non-inferiority to HCC. RESULTS The present study demonstrated that 0.05% CHG was non-inferior to the HCC when chondrosarcoma was exposed for 5 minutes and when GCT was exposed for 2 and 5 minutes (mean cytotoxicity, 99% to 102%) (p < 0.003 for all). Sterile water was superior to the LCC when chondrosarcoma was exposed for 5 minutes and when GCT was exposed for 2 minutes (mean, 28% to 37%) (p < 0.05). Sterile water (mean, 18% to 38%) (p < 0.012) and 3% hydrogen peroxide (mean, 7% to 16%) (p < 0.001) were both inferior to the HCC. The 3 other solutions were non-superior to the LCC (mean, -24% to -5%) (p < 0.023). CONCLUSIONS In vitro irrigation in 0.05% CHG provided high cytotoxicity, comparable with the HCC. Therefore, the use of a 0.05% CHG solution clinically could serve as a potential chemical adjuvant during intralesional curettage of chondrosarcoma and GCT. CLINICAL RELEVANCE In an effort to reduce the burden of residual tumor cells, irrigation solutions are often utilized as adjuvant local therapy. Use of a 0.05% CHG solution clinically could serve as a potential chemical adjuvant to intralesional curettage of chondrosarcoma and GCT. Further in vivo studies may be indicated to assess clinical outcomes and safety associated with the use of 0.05% CHG in the treatment of chondrosarcoma and GCT.
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Affiliation(s)
- Chris Moore
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Russell J Fernandes
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Jorge Manrique
- Department of Orthopaedic Surgery, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Weston, Florida
| | - Nayak L Polissar
- The Mountain-Whisper-Light: Statistics & Data Science, Seattle, Washington
| | - Ljubomir Miljacic
- The Mountain-Whisper-Light: Statistics & Data Science, Seattle, Washington
| | - Daniel S Hippe
- The Mountain-Whisper-Light: Statistics & Data Science, Seattle, Washington
| | - Jonathon Vaux
- Gundarson Building Orthopedics, The Everett Clinic, Everett, Washington
| | - Matthew J Thompson
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
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15
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Caid M, Valk J, Danoff J. Irrigation Solutions in Total Joint Arthroplasty. Spartan Med Res J 2022; 7:37502. [PMID: 36128028 PMCID: PMC9448655 DOI: 10.51894/001c.37502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/02/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Despite advancements in the field of adult reconstruction, prosthetic joint infection (PJI) remains a common and devastating complication of total joint arthroplasty. Eradication of these infections can often prove difficult, and they remain a source of considerable morbidity and mortality. This clinical review paper will focus on some of the more commonly used irrigation solutions; povidone-iodine (PI), chlorhexidine (CHG), acetic acid (AA), hydrogen peroxide (HP), antibiotic irrigations, taurolidine, and polyhexanide-betaine (PB). SUMMARY OF THE EVIDENCE Significant research has been performed on the prevention of PJI, including use of intraoperative joint irrigation solutions. Several solutions have been theorized to aid in infection prevention, but no evidence-based practice guidelines in this area of orthopaedics have been established. There is a paucity of prospective randomized control trials to compare the efficacy of these joint irrigation solutions. CONCLUSIONS The authors present a review regarding seven major categories of commonly used intraoperative joint irrigation solutions. The current literature fails to demonstrate a clear consensus for a preferred solution and concentration for povidone-iodine, chlorhexidine, hydrogen peroxide, acetic acid, antibiotic irrigations, taurolidine, and polyhexanide-betaine. Prospective, randomized control trials directly comparing these different irrigation solutions are needed.
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16
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Springer BD. Irrigation Solutions and Antibiotic Powders: Should I Use Them in Primary and Revision Total Joint Arthroplasty? J Arthroplasty 2022; 37:1438-1440. [PMID: 35247486 DOI: 10.1016/j.arth.2022.02.096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/18/2022] [Accepted: 02/22/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The prevention and treatment of periprosthetic joint infection is of utmost importance to orthopedic surgeons. Irrigation solutions have become a popular additive to the prevention and treatment armamentarium. METHODS This symposium summarizes the mechanism of action, basic science, and clinical research to date on the use of irrigation solutions. The four most commonly used irrigation solutions, povidone iodine, chlorhexidine, hydrogen peroxide, and acetic acid, are discussed. In addition, the role of antibiotic powers is reviewed. RESULTS Each solution has its risks and benefits that must be weighed by the surgeon. There is no clear irrigation solution that is superior. The role of additive antibiotic powder (vancomycin) remains controversial. CONCLUSION More rigorous prospective clinical trials are needed to determine the optimal irrigation solution for the prevention and treatment of periprosthetic joint infection.
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Affiliation(s)
- Bryan D Springer
- OrthoCarolina Hip and Knee Center, Atrium Musculoskeletal Institute, Charlotte, NC
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17
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Lung BE, Le R, Callan K, McLellan M, Issagholian L, Yi J, McMaster WC, Yang S, So DH. Chlorhexidine gluconate lavage during total joint arthroplasty may improve wound healing compared to dilute betadine. J Exp Orthop 2022; 9:67. [PMID: 35819733 PMCID: PMC9276865 DOI: 10.1186/s40634-022-00503-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/29/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Intraoperative wound irrigation prior to closure during total joint arthroplasty (TJA) is an essential component of preventing infections and limiting health care system costs. While studies have shown the efficacy of dilute betadine in reducing infection risk, there remains concerns over its safety profile and theoretical inactivation by blood and serum. This study aims to compare infection and wound complications between chlorhexidine gluconate (CHG) and betadine lavage during TJA. METHODS All primary TJA between 2019-2021 were analyzed at a single institution, and periprosthetic joint infection (PJI), wound drainage, 30 and 90-day emergency room (ER) readmission due to wound complications, aseptic loosening, and revision surgery rate were compared between patients undergoing intraoperative CHG versus betadine lavage prior to closure. Baseline demographics were controlled, and multivariate logistic regression was performed to compare complication rates. RESULTS A total of 410 TJA, including 160 hip and 250 knee arthroplasties were included. Compared to the dilute betadine cohort, all TJA patients undergoing CHG lavage had a statistically significant lower 30 and 90-day emergency room readmission rate due to wound complications. Both hip and knee arthroplasty patients with CHG had a statistically significant lower rate of postoperative superficial drainage and dressing saturation at clinic follow-up, but only knee arthroplasty patients had significant decreased readmission rate for incisional wound vacuum placement and close inpatient monitoring of wound healing. Among all TJA, there was no significant association in the rate of PJI requiring return to the OR between groups. CONCLUSIONS Although betadine is cost-effective and has been shown to reduce PJI rates, there remains concerns in the literature over soft tissue toxicity and wound healing. This study suggests CHG may be as efficacious as dilute betadine in preventing PJI while also decreasing the risk of superficial drainage and wound complications needing unplanned ER visits during the acute postoperative period.
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Affiliation(s)
- Brandon E Lung
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, 101 The City Drive South, Pavilion 3, Orange, CA, 92868, USA.
| | - Ryan Le
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, 101 The City Drive South, Pavilion 3, Orange, CA, 92868, USA
| | - Kylie Callan
- School of Medicine, University of California Irvine, Irvine, CA, 92617, USA
| | - Maddison McLellan
- School of Medicine, University of California Irvine, Irvine, CA, 92617, USA
| | - Leo Issagholian
- School of Medicine, University of California Irvine, Irvine, CA, 92617, USA
| | - Justin Yi
- School of Medicine, University of California Irvine, Irvine, CA, 92617, USA
| | - William C McMaster
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, 101 The City Drive South, Pavilion 3, Orange, CA, 92868, USA
| | - Steven Yang
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, 101 The City Drive South, Pavilion 3, Orange, CA, 92868, USA
| | - David H So
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, 101 The City Drive South, Pavilion 3, Orange, CA, 92868, USA
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18
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Kotecki K, Bradford MS. Clorpactin: An Alternative Irrigation Method for Total Knee Arthroplasty Joint Infection Revisions. J Knee Surg 2022; 35:874-883. [PMID: 33231280 DOI: 10.1055/s-0040-1721087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Different combinations of irrigation solutions have been used in attempt to eradicate microorganisms for the prevention and treatment of prosthetic joint infections (PJIs). Clorpactin WCS-90 was evaluated as an alternative irrigation intraoperative technique for the treatment of PJI using both debridement, antibiotics, and implant retention (DAIR) and 2-stage total knee arthroplasty (TKA) procedures. We retrospectively reviewed PJIs irrigated with Clorpactin between January 2015 and January 2020. We found 13 patients who underwent a DAIR procedure for an acutely infected primary TKA, 18 patients underwent a 2-stage procedure for a chronically infected primary TKA, two patients underwent a DAIR procedure for an acutely infected revision TKA, and 18 patients underwent a 2-stage procedure for a chronically infected revision TKA. The odds of reinfection and need for additional surgery were analyzed at a mean follow-up of 20 to 26 months between groups. Only one patient (7.69%) became reinfected in the acute infected primary TKA group, three patients (16.67%) in the chronic infected primary TKA group, 0 patients (0%) in the acute infected revision TKA group, and six patients (33.33%) in the chronic infected revision TKA group. When the acute primary TKA infection group was compared with the chronic revision TKA infection group, the odds of reinfection (Chi-square test [χ2] = 21.7, df 3, p < 0.001) and odds of additional surgery (χ2 = 13.6, df 3, p < 0.003) were significantly higher for the chronic revision TKA infection group. Overall, the reinfection rate for DAIR revisions was 6.67% (range = 0-7.69) and 2-stage revisions was 25.00% (range = 16.67-33.33). The use of Clorpactin WCS-90 irrigation prior to wound closure is a useful option for the treatment of acute and chronic knee PJIs. Our study provides evidence that infection eradication with the use of Clorpactin is comparable to other irrigation methods and surgical techniques in reported literature.
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Affiliation(s)
- Keith Kotecki
- Valley Hospital Orthopedic Surgery Residency Program, Valley Hospital Medical Center, Las Vegas, Nevada
| | - Michael S Bradford
- Valley Hospital Orthopedic Surgery Residency Program, Valley Hospital Medical Center, Las Vegas, Nevada.,Department of Orthopedic Surgery, Nevada Orthopedic and Spine Center, Las Vegas, Nevada
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19
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Aquilina CO, Aquilina AL, Webb J, Albur M, Whitehouse MR. Are multiple-use bottles of chlorhexidine solutions at risk of contamination in joint replacement surgery? Ann R Coll Surg Engl 2022; 104:434-436. [PMID: 34939853 PMCID: PMC9158045 DOI: 10.1308/rcsann.2021.0217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Chlorhexidine gluconate 2% w/v in isopropanol 70% solutions in multiple-use bottles is commonly used in surgery as a cost-effective method for skin disinfection. However, multiple-use bottles risk contamination. This study aims to test whether bacterial contamination of multiple-use bottles or their solutions occurs once open and on use between different patients. METHODS Consecutive samples were taken each time a chlorhexidine bottle was used over a 7-day study period. Samples were tested using blood culture, agar plate and mass spectrometry. RESULTS No growth was observed in 52 samples taken from 18 bottles inoculated into blood culture bottles. Four growths on agar plate culture were determined to be contaminants from the sampling process. CONCLUSIONS This study supports the use of multiple-use bottled chlorhexidine solutions as safe and cost-effective in surgical practice.
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Affiliation(s)
| | | | - J Webb
- University of Bristol, UK
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20
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O'Donnell JA, Wu M, Cochrane NH, Belay E, Myntti MF, James GA, Ryan SP, Seyler TM. Efficacy of Common Antiseptic Solutions Against Clinically Relevant Planktonic Microorganisms. Orthopedics 2022; 45:122-127. [PMID: 34978511 DOI: 10.3928/01477447-20211227-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Prosthetic joint infections (PJIs) are among the most devastating complications after joint replacement. There is limited evidence regarding the efficacy of different antiseptic solutions in reducing planktonic microorganism burden. The purpose of this study was to test the efficacy of different antiseptic solutions against clinically relevant planktonic microorganisms. We designed an experiment examining the efficacy of several antiseptic solutions against clinically relevant planktonic microorganisms in vitro. Regarding planktonic microorganisms, povidone-iodine had 99.9% or greater reduction for all microorganisms tested except for methicillin-resistant Staphylococcus aureus, which was reduced by 60.44%. Irrisept (Irrimax Corp) had 99.9% or greater reduction for all microorganisms except Staphylococcus epidermidis (98.31%) and Enterococcus faecalis (48.61%). Bactisure (Zimmer Surgical Inc) had 99.9% or greater reduction for all microorganisms tested. Various measures exist for PJI prevention, one of which is intraoperative irrigation. We tested irrigants against clinically relevant planktonic microorganisms in vitro and found significant differences in efficacy among them. Further clinical outcome data are necessary to determine whether these solutions can impact PJI in vivo. [Orthopedics. 2022;45(2):122-127.].
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21
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Needens J, Sloane E, Smith-Graham S, Leader T, Bou Zgheib N. Implementation of Novel Perioperative Protocol for Reducing Surgical Site Infections in Gynecologic Surgical Procedures. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2021.0171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jordan Needens
- Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia, USA
| | - Emily Sloane
- Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia, USA
| | - Sydney Smith-Graham
- Ochsner Health, Department of Obstetrics/Gynecology Residency Program, New Orleans, Louisiana, USA
| | - Tori Leader
- Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia, USA
| | - Nadim Bou Zgheib
- Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia, USA
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22
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Christopher ZK, Deckey DG, Pollock JR, Spangehl MJ. Antiseptic Irrigation Solutions Used in Total Joint Arthroplasty: A Critical Analysis Review. JBJS Rev 2022; 10:01874474-202203000-00005. [PMID: 35231016 DOI: 10.2106/jbjs.rvw.21.00225] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» There are limited data that directly compare the efficacy of antiseptic irrigation solutions used for the prevention and treatment of periprosthetic joint infections in orthopaedic procedures; there is a notable lack of prospective data. » For prevention of periprosthetic joint infections, the strongest evidence supports the use of low-pressure povidone-iodine. » For the treatment of periprosthetic joint infections, delivering multiple solutions sequentially may be beneficial.
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23
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Wound Closure Following Intervention for Closed Orthopedic Trauma. Injury 2022; 53:313-322. [PMID: 34865820 DOI: 10.1016/j.injury.2021.11.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/24/2021] [Indexed: 02/02/2023]
Abstract
The method of skin closure and post-operative wound management has always been important in orthopedic surgery and plays an even larger role now that surgical site infection (SSI) is a national healthcare metric for both surgeons and hospitals. Wound related issues remain some of the most feared complications following orthopedic trauma procedures and are associated with significant morbidity. In order to minimize the risk of surgical site complications, surgeons must be familiar with the physiology of wound healing as well as the patient and surgical factors affecting healing potential. The goal of all skin closure techniques is to promote rapid healing with acceptable cosmesis, all while minimizing risk of infection and dehiscence. Knowledge of the types of closure material, techniques of wound closure, surgical dressings, negative pressure wound therapy, and other local modalities is important to optimize wound healing. There is no consensus in the literature as to which closure method is superior but the available data can be used to make informed choices. Although often left to less experienced members of the surgical team, the process of wound closure and dressing the wound should not be an afterthought, and instead must be part of the surgical plan. Wounds that are in direct communication with bony fractures are particularly at risk due to local tissue trauma, resultant swelling, hematoma formation, and injured vasculature.
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24
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Use of Adjunct Antiseptic Agents in Periprosthetic Joint Infections. J Am Acad Orthop Surg 2021; 29:e1151-e1158. [PMID: 34520439 DOI: 10.5435/jaaos-d-21-00154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 08/05/2021] [Indexed: 02/01/2023] Open
Abstract
Periprosthetic joint infection is a leading cause for failure of contemporary total hip arthroplasty and total knee arthroplasty projected to nearly double in the next decade and reach an economic burden of $1.85 billion in the United Sates by 2030. Although multiple treatments for periprosthetic joint infection have been described, a thorough débridement and joint lavage to decrease bacterial bioburden and to remove biofilm remains a critical component of treatment. Various adjunct antiseptic agents such as chlorhexidine, povidone-iodine, hydrogen peroxide, acetic acid, and chlorine compounds are currently in off-label use in this capacity. Each antiseptic agent, however, has a distinct mechanism of action and targets different organisms, and some combinations of agents may lead to tissue toxicity. In this review, currently available adjunct antiseptic washes will be described in detail based on their mechanism of action and the evidence for their use will be reviewed. Furthermore, this review puts forward an evidence-based treatment algorithm based on the specific causative organism.
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25
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Kobayashi N, Kamono E, Maeda K, Misumi T, Yukizawa Y, Inaba Y. Effectiveness of diluted povidone-iodine lavage for preventing periprosthetic joint infection: an updated systematic review and meta-analysis. J Orthop Surg Res 2021; 16:569. [PMID: 34551791 PMCID: PMC8456523 DOI: 10.1186/s13018-021-02703-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 08/30/2021] [Indexed: 02/01/2023] Open
Abstract
Background Of the several methods used to prevent surgical site infection (SSI), diluted povidone-iodine (PI) lavage is used widely. However, the clinical utility of PI for preventing periprosthetic joint infection (PJI) remains controversial. The aim of this study was to perform a systematic review and meta-analysis of the utility of dilute PI lavage for preventing PJI in primary and revision surgery. Methods This study was conducted in accordance with the PRISMA checklist for systematic reviews and meta-analyses. A comprehensive literature search of PubMed, CINAHL, ClinicalTrials.gov, and Cochrane Library databases was performed. The results are summarized qualitatively and as a meta-analysis of pooled odds ratios with 95% confidence intervals (95% CIs). Heterogeneity of treatment effects among studies was classified as low, moderate, or high, corresponding to I2 values of < 25%, 25–50%, and > 50%. A random effects model was applied in cases of high heterogeneity; otherwise, the fixed effects model was applied. Subgroup analyses were conducted to identify potential sources of heterogeneity. Results After the screening and eligibility assessment process, eight studies were finally extracted for analysis. Overall, the results showed that PI had no significant effect on PJI with ununified control group. However, subgroup analysis of studies with a saline control group revealed an odds ratio of 0.33 (95% CI, 0.16–0.71) for the PI group, suggesting a significant effect for preventing PJI. Conclusion The systematic review and meta-analysis of the current literature demonstrates that diluted PI lavage is significantly better than saline solution lavage for preventing PJI. Level of evidence Level I, Systematic review and meta-analysis.
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Affiliation(s)
- Naomi Kobayashi
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, Japan.
| | - Emi Kamono
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, Japan
| | - Kento Maeda
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, Japan.,Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
| | - Toshihiro Misumi
- Department of Biostatistics, Yokohama City University, Yokohama, Japan
| | - Yohei Yukizawa
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, Japan
| | - Yutaka Inaba
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
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26
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Kia C, Cusano A, Messina J, Muench LN, Chadayammuri V, McCarthy MB, Umejiego E, Mazzocca AD. Effectiveness of topical adjuvants in reducing biofilm formation on orthopedic implants: an in vitro analysis. J Shoulder Elbow Surg 2021; 30:2177-2183. [PMID: 33529773 DOI: 10.1016/j.jse.2020.12.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/27/2020] [Accepted: 12/05/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND HYPOTHESIS The treatment of periprosthetic joint infection is complicated by the presence of residual biofilm, which resists eradication owing to bacterial adherence to orthopedic implants. The purpose of this study was to compare Bactisure (Zimmer Biomet, Warsaw, IN, USA), povidone-iodine (Betadine), and chlorhexidine gluconate solution (Irrisept; Irrimax, Gainesville, FL, USA) in reducing biofilm formation of Staphylococcus aureus, Staphylococcus epidermidis, and Cutibacterium acnes inoculated on cobalt-chrome, titanium, and stainless steel disks, representing metals commonly used for shoulder arthroplasty. The hypothesis was that there would be no significant difference in biofilm reduction among the 3 topical adjuvants. METHODS Strains of S aureus (ATCC 35556), S epidermidis (ATCC 35984), and C acnes (LMG 16711) were grown on cobalt-chrome, titanium, and stainless steel disks. For each strain, the disks were divided into 4 groups: (1) control, (2) povidone-iodine (Betadine), (3) chlorhexidine gluconate (Irrisept), and (4) Bactisure. Bacteria were grown on 5% sheep blood agar plates. Biofilm eradication was quantified using adenosine triphosphate bioluminescence and compared with controls 48 and 72 hours after implementation of the topical adjuvant. RESULTS At 72 hours after implementation of the topical adjuvant, a statistically significant reduction in colony-forming units was observed for all topical adjuvants across all tested metals, as compared with their respective control. With respect to the topical adjuvants themselves, Bactisure more consistently demonstrated the most significant reduction in colony-forming units across all bacteria when the tested medium was adjusted for, with the exception of S aureus, which showed similar results to Betadine at 72 hours. CONCLUSION By use of commonly encountered topical adjuvants on S aureus-, S epidermidis-, and C acnes-inoculated disks of various implant metals, a significant reduction in biofilm production was observed. Bactisure, a recent Food and Drug Administration-approved topical adjuvant, demonstrated the overall greatest efficacy of the agents studied.
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Affiliation(s)
- Cameron Kia
- Department of Orthopedic Surgery, UConn Health, Farmington, CT, USA
| | - Antonio Cusano
- Department of Orthopedic Surgery, UConn Health, Farmington, CT, USA.
| | - James Messina
- Department of Orthopedic Surgery, UConn Health, Farmington, CT, USA
| | - Lukas N Muench
- Department of Orthopedic Surgery, UConn Health, Farmington, CT, USA; Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
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27
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Bath MF, Suresh R, Davies J, Machesney MR. Does pulsed lavage reduce the risk of surgical site infection? A systematic review and meta-analysis. J Hosp Infect 2021; 118:32-39. [PMID: 34454976 DOI: 10.1016/j.jhin.2021.08.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) remain a significant and common postoperative complication. Whereas most surgeons use some form of wound irrigation during closure, its impact on SSI rates is debated. Preliminary studies in the use of pressurized irrigation, termed pulsed lavage, may have potential benefit to reduce the risk of SSI. AIM To perform a systematic review to identify studies that reported SSI rates following surgery, comparing the use of pulsed lavage to controls, following PRISMA guidelines. METHODS All study types and those published up to January 1st, 2021 were included. Odds ratios (ORs) were calculated for each included study using a Mantel-Haenszel statistical analysis, via a random effects model. A sub-analysis on abdominal procedures only was also performed. FINDINGS Eleven studies met the inclusion criteria, covering either orthopaedic or general surgery procedures; 1875 patients were included, with 816 patients in the pulsed lavage group and 1059 patients in the control group. Overall study quality was low. There was a significant reduction in the SSI rate with the use of pulsed lavage (odds ratio (OR): 0.39; 95% confidence interval (CI): 0.25-0.62; P < 0.0001). Sub-analysis on abdominal operations only showed further improvement to the SSI rate with pulsed lavage (OR: 0.32; 95% CI: 0.21-0.49; P < 0.0001). CONCLUSION Pulsed lavage significantly reduces the rate of SSIs in surgical procedures, the effect being most pronounced in abdominal operations; however, current study quality is low. Randomized controlled trial data are essential to fully assess the potential clinical and financial benefits pulsed lavage can confer to SSI reduction.
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Affiliation(s)
- M F Bath
- Department of Surgery, Whipps Cross University Hospital, Barts Health NHS Trust, London, UK.
| | - R Suresh
- Department of Surgery, Whipps Cross University Hospital, Barts Health NHS Trust, London, UK
| | - J Davies
- Department of Surgery, Whipps Cross University Hospital, Barts Health NHS Trust, London, UK
| | - M R Machesney
- Department of Surgery, Whipps Cross University Hospital, Barts Health NHS Trust, London, UK
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Premkumar A, Nishtala SN, Nguyen JT, Bostrom MPG, Carli AV. The AAHKS Best Podium Presentation Research Award: Comparing the Efficacy of Irrigation Solutions on Staphylococcal Biofilm Formed on Arthroplasty Surfaces. J Arthroplasty 2021; 36:S26-S32. [PMID: 33750633 DOI: 10.1016/j.arth.2021.02.033] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/19/2021] [Accepted: 02/09/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND A diverse array of antibacterial solutions is utilized by orthopedic surgeons in an attempt to disperse bacterial biofilm. Few studies compare these agents against biofilm grown on clinically relevant orthopedic biomaterials, such as plastic, acrylic cement, and porous titanium. METHODS MSSA biofilm was grown on plastic 48-well plates, polymethylmethacrylate cement beads and porous Ti-6Al-4V acetabular screw caps. Antibacterial solutions were tested according to manufacturer guidance and included: isotonic saline, vancomycin (1 mg/mL), polymyxin-bacitracin (500,000 U/L-50,000 U/L), povidone-iodine 0.3%, povidone-iodine 10%, a 1:1 combination of povidone-iodine 10% & 4% hydrogen peroxide, polyhexamethylene biguanide (PHMB) and betaine 0.04%, a commercial solution containing chlorhexidine gluconate (CHG) 0.05%, and a commercial solution containing benzalkonium chloride and ethanol. Twenty four and 72-hour biofilms were exposed to solutions for 3 minutes to reproduce intraoperative conditions. Solution efficacy was measured through sonication of treated surfaces followed by counting colony forming units and validated with a resazurin assay to assess cell viability. Experiments were performed in triplicate and repeated at least once. A three-fold log reduction in CFU counts versus controls was considered as a measure of solution efficacy. RESULTS Saline, vancomycin and polymyxin-bacitracin were ineffective compared to other solutions against planktonic MSSA. Povidone-iodine 10% and a 1:1 solution of povidone-iodine 10% and 4% hydrogen peroxide were the only effective solutions against biofilm across all three surfaces and time points. CONCLUSION Commercial antibacterial solutions vary significantly in their efficacy against MSSA biofilm. Efficacy globally decreased as biofilm maturity increased. Increased solution cost did not confer increased efficacy.
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Affiliation(s)
- Ajay Premkumar
- Hospital for Special Surgery, Adult Reconstruction & Joint Replacement, NY
| | | | | | | | - Alberto V Carli
- Hospital for Special Surgery, Adult Reconstruction & Joint Replacement, NY
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Siddiqi A, Abdo ZE, Springer BD, Chen AF. Pursuit of the ideal antiseptic irrigation solution in the management of periprosthetic joint infections. J Bone Jt Infect 2021; 6:189-198. [PMID: 34109103 PMCID: PMC8182666 DOI: 10.5194/jbji-6-189-2021] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/07/2021] [Indexed: 12/23/2022] Open
Abstract
Irrigation and debridement in the treatment of periprosthetic joint infection
(PJI) serve an integral role in the eradication of bacterial burden and
subsequent re-infection rates. Identifying the optimal irrigation agent,
however, remains challenging, as there is limited data on superiority.
Direct comparison of different irrigation solutions remains difficult
because of variability in treatment protocols. While basic science studies
assist in the selection of irrigation fluids, in vitro results do not directly
translate into clinical significance once implemented in vivo. Dilute
povidone iodine, hydrogen peroxide, chlorhexidine gluconate, acetic acid,
sodium hypochlorite, hypochlorous acid, and preformed combination solutions
all have potential against a broad spectrum of PJI pathogens with their own
unique advantages and disadvantages. Future clinical studies are needed to
identify ideal irrigation solutions with optimal bactericidal properties and
low cytotoxicity for PJI treatment.
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Affiliation(s)
- Ahmed Siddiqi
- Orthopaedic Institute of Central Jersey, a division of Ortho Alliance NJ, 2315 Route 34 South Manasquan, NJ 08736, USA.,Hackensack Meridian School of Medicine, Department of Orthopedic Surgery, Hackensack, NJ, USA.,Jersey Shore University Medical Center, Department of Orthopedic Surgery, Neptune, NJ, USA
| | - Zuhdi E Abdo
- Rutgers New Jersey Medical School, Department of Orthopedics, Newark, NJ, 07103, USA
| | - Bryan D Springer
- OrthoCarolina Hip and Knee Center, Department of Orthopedics Atrium Musculoskeletal Institute, Charlotte, NC, 28207, USA
| | - Antonia F Chen
- Brigham & Women's Hospital, Department of Orthopedics, Boston, MA, 02115, USA
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O'Donnell JA, Wu M, Cochrane NH, Belay E, Myntti MF, James GA, Ryan SP, Seyler TM. Efficacy of common antiseptic solutions against clinically relevant microorganisms in biofilm. Bone Joint J 2021; 103-B:908-915. [PMID: 33934664 DOI: 10.1302/0301-620x.103b5.bjj-2020-1245.r2] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Periprosthetic joint infections (PJIs) are among the most devastating complications after joint arthroplasty. There is limited evidence on the efficacy of different antiseptic solutions on reducing biofilm burden. The purpose of the present study was to test the efficacy of different antiseptic solutions against clinically relevant microorganisms in biofilm. METHODS We conducted an in vitro study examining the efficacy of several antiseptic solutions against clinically relevant microorganisms. We tested antiseptic irrigants against nascent (four-hour) and mature (three-day) single-species biofilm created in vitro using a drip-flow reactor model. RESULTS With regard to irrigant efficacy against biofilms, Povidone-iodine treatment resulted in greater reductions in nascent MRSA biofilms (logarithmic reduction (LR) = 3.12; p < 0.001) compared to other solutions. Bactisure treatment had the greatest reduction of mature Pseudomonas aeruginosa biofilms (LR = 1.94; p = 0.032) and a larger reduction than Vashe or Irrisept for mature Staphylococcus epidermidis biofilms (LR = 2.12; p = 0.025). Pooled data for all biofilms tested resulted in Bactisure and Povidone-iodine with significantly greater reductions compared to Vashe, Prontosan, and Irrisept solutions (p < 0.001). CONCLUSION Treatment failure in PJI is often due to failure to clear the biofilm; antiseptics are often used as an adjunct to biofilm clearance. We tested irrigants against clinically relevant microorganisms in biofilm in vitro and showed significant differences in efficacy among the different solutions. Further clinical outcome data is necessary to determine whether these solutions can impact PJI outcome in vivo. Cite this article: Bone Joint J 2021;103-B(5):908-915.
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Affiliation(s)
- Jeffrey A O'Donnell
- Department of Orthopaedics, Duke University Hospital, Durham, North Carolina, USA
| | - Mark Wu
- Department of Orthopaedics, Duke University Hospital, Durham, North Carolina, USA
| | - Niall H Cochrane
- Department of Orthopaedics, Duke University Hospital, Durham, North Carolina, USA
| | - Elshaday Belay
- Department of Orthopaedics, Duke University Hospital, Durham, North Carolina, USA
| | | | - Garth A James
- Medical Biofilms Laboratory Center for Biofilm Engineering, Montana State University, Bozeman, Montana, USA
| | - Sean P Ryan
- Department of Orthopaedics, Duke University Hospital, Durham, North Carolina, USA
| | - Thorsten M Seyler
- Department of Orthopaedics, Duke University Hospital, Durham, North Carolina, USA
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Cawthorne DP, Castillo TE, Sivakumar BS. Effect of commonly used surgical solutions on the tensile strength of absorbable sutures: an in-vitro study. ANZ J Surg 2021; 91:1451-1454. [PMID: 33928746 DOI: 10.1111/ans.16908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 04/11/2021] [Accepted: 04/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Within recent decades the use of various surgical solutions to prevent bleeding, ward off infection or decrease post-operative pain has become common-place in orthopaedic procedures. However, little work has been done to determine the effects that these solutions have on the tensile strength of various sutures, particularly those that are used for deep closures, which are often absorbable in nature. Whilst numerous authors have attempted to reach conclusions regarding the nature of these effects, a consensus has yet to be reached and this paper is designed with the aim to contribute to the current literature on the subject and improve surgical practice. METHODS This in-vitro study incubated three different surgical sutures in five commonly used surgical solutions at 37°C for 30 min, prior to applying a constant increase in force to determine the effects these solutions have on tensile strength. A control set was included. RESULTS No significant difference was found in the tensile strength of Vicryl and PDS-II sutures, whilst Monocryl incubated in chlorhexidine exhibited a borderline significant increase in tensile strength. CONCLUSIONS Common surgical solutions used on orthopaedic procedures can impact on the tensile strength of suture materials; however, further research is required on the subject.
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Affiliation(s)
- Donald P Cawthorne
- Department of Orthopaedic Surgery, Sydney Adventist Hospital, Sydney, New South Wales, Australia
| | - Tiana E Castillo
- Department of Orthopaedic Surgery, Hornsby Ku-Ring-Gai Hospital, Sydney, New South Wales, Australia
| | - Brahman S Sivakumar
- Department of Orthopaedic Surgery, Hornsby Ku-Ring-Gai Hospital, Sydney, New South Wales, Australia.,Department of Hand and Peripheral Nerve Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
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Zlotnicki J, Gabrielli A, Urish KL, Brothers KM. Clinical Evidence of Current Irrigation Practices and the Use of Oral Antibiotics to Prevent and Treat Periprosthetic Joint Infection. Orthop Clin North Am 2021; 52:93-101. [PMID: 33752842 PMCID: PMC7990073 DOI: 10.1016/j.ocl.2020.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Jason Zlotnicki
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, College of Medicine, University of Pittsburgh, Bridgeside Point II, 450 Technology Drive, Pittsburgh, PA 15219, USA
| | - Alexandra Gabrielli
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, College of Medicine, University of Pittsburgh, Bridgeside Point II, 450 Technology Drive, Pittsburgh, PA 15219, USA
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, College of Medicine, University of Pittsburgh, Bridgeside Point II, 450 Technology Drive, Pittsburgh, PA 15219, USA
| | - Kimberly M Brothers
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, College of Medicine, University of Pittsburgh, Bridgeside Point II, 450 Technology Drive, Pittsburgh, PA 15219, USA.
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Böhle S, Röhner E, Zippelius T, Jacob B, Matziolis G, Rohe S. Cytotoxic effect of sodium hypochlorite (Lavanox 0.08%) and chlorhexidine gluconate (Irrisept 0.05%) on human osteoblasts. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:81-89. [PMID: 33738603 PMCID: PMC8741695 DOI: 10.1007/s00590-021-02907-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 02/08/2021] [Indexed: 11/30/2022]
Abstract
Purpose Soft tissue, bone and joint infections are severe complications in orthopedic and traumatological surgery. Lavanox (0.08% NaOCl) and Irrisept (0.05% chlorhexidine gluconate, CHG) are industrially produced antiseptic solutions commonly used in infection treatment. Regarding this clinical indication, the microbicidal effect is often investigated, but toxicity to osteoblasts has rarely been examined. This is important to decide whether these solutions should be used in septic situations in which bone healing must take place. The hypothesis of the present study is that NaOCl and CHG are cytotoxic to osteoblasts even after a short exposure time. Methods Human osteoblasts were isolated from donors with osteoarthritis during total knee and hip arthroplasty. Cells were cultivated and treated with both antiseptic solutions for 2, 5 and 10 min in different dilutions. Toxicity was quantified by counting cells, lactate dehydrogenase (LDH) expression, spectrophotometric quantification via XTT assay and FDA/PI fluorescence microscopy. Results Analyzing viable cells after treatment with both antiseptics showed a significant decrease in viable cells through LDH expression test, XTT assay, fluorescence microscopy and light microscopy, depending on concentration. The time dependence showed a trend to more cell death at longer exposure times, without significance. Conclusion Toxic effects on osteoblasts were shown after treatment with 0.08% NaOCl and 0.05% CHG after an exposure time of 2 min which also was concentration dependent. There was no difference in cytotoxicity between both antiseptics. In conclusion, these antiseptic solutions may be used with caution in situations requiring bone healing. Trial registration number Local ethics committee registration number: 5176–07/16 Supplementary Information The online version contains supplementary material available at 10.1007/s00590-021-02907-3.
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Affiliation(s)
- Sabrina Böhle
- Orthopedic Department of the Waldkliniken Eisenberg, Orthopedic Professorship of the University Hospital Jena, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany.
| | - Eric Röhner
- Orthopedic Department of the Waldkliniken Eisenberg, Orthopedic Professorship of the University Hospital Jena, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany
| | - Timo Zippelius
- Orthopedic Department of the Waldkliniken Eisenberg, Orthopedic Professorship of the University Hospital Jena, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany
| | - Benjamin Jacob
- Orthopedic Department of the Waldkliniken Eisenberg, Orthopedic Professorship of the University Hospital Jena, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany
| | - Georg Matziolis
- Orthopedic Department of the Waldkliniken Eisenberg, Orthopedic Professorship of the University Hospital Jena, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany
| | - Sebastian Rohe
- Orthopedic Department of the Waldkliniken Eisenberg, Orthopedic Professorship of the University Hospital Jena, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany
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Su WC, Lai YC, Lee CH, Shih CM, Chen CP, Hung LL, Wang SP. The Prevention of Periprosthetic Joint Infection in Primary Total Hip Arthroplasty Using Pre-Operative Chlorhexidine Bathing. J Clin Med 2021; 10:jcm10030434. [PMID: 33498636 PMCID: PMC7865798 DOI: 10.3390/jcm10030434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/13/2021] [Accepted: 01/20/2021] [Indexed: 11/26/2022] Open
Abstract
Periprosthetic joint infection (PJI) after total hip arthroplasty (THA) is a devastating complication. The aim of this study was to investigate whether preoperative bathing using chlorhexidine gluconate (CHG) before THA can effectively reduce the postoperative PJI rate. A total of 933 primary THA patients, with the majority being female (54.4%) were included in the study. Primary THA patients who performed preoperative chlorhexidine bathing were assigned to the CHG group (190 subjects), and those who did not have preoperative chlorhexidine bathing were in the control group (743 subjects). The effects of chlorhexidine bathing on the prevention of PJI incidence rates were investigated. Differences in age, sex, and the operated side between the two groups were not statistically significant. Postoperative PJI occurred in four subjects, indicating an infection rate of 0.43% (4/933). All four infected subjects belonged to the control group. Although the PJI cases were significantly more in the control group than in the CHG group, statistical analysis revealed no statistical significance in the risk of PJI occurrence between the two groups (p = 0.588). Preoperative skin preparation by bathing with a 2% chlorhexidine gluconate cleanser did not produce significant effects on the prevention of postoperative PJI in primary THA.
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Affiliation(s)
- Wen-Chi Su
- Department of Nursing, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (W.-C.S.); (Y.-C.L.); (L.-L.H.)
| | - Yu-Chin Lai
- Department of Nursing, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (W.-C.S.); (Y.-C.L.); (L.-L.H.)
| | - Cheng-Hung Lee
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-H.L.); (C.-M.S.); (C.-P.C.)
- Department of Food Science and Technology, HungKuang University, Taichung 43302, Taiwan
| | - Cheng-Min Shih
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-H.L.); (C.-M.S.); (C.-P.C.)
- Department of Physical Therapy, HungKuang University, Taichung 43302, Taiwan
- Department of Biological Science and Technology, National Chiao Tung University, Hsinchu 30010, Taiwan
| | - Chao-Ping Chen
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-H.L.); (C.-M.S.); (C.-P.C.)
- Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli County 35664, Taiwan
| | - Li-Ling Hung
- Department of Nursing, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (W.-C.S.); (Y.-C.L.); (L.-L.H.)
- Department of Nursing, HungKuang University, Taichung 43302, Taiwan
| | - Shun-Ping Wang
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-H.L.); (C.-M.S.); (C.-P.C.)
- Sports Recreation and Health Management Continuing Studies-Bachelor’s Degree Completion Program, Tunghai University, Taichung 40704, Taiwan
- Correspondence:
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Budge MD, Koch JA, Mandell JB, Cappellini AJ, Orr S, Patel S, Ma D, Nourie O, Brothers KM, Urish KL. The In Vitro Efficacy of Doxycycline over Vancomycin and Penicillin in the Elimination of Cutibacterium Acnes Biofilm. ANTIMICROBIAL COMBINATION DEVICES 2020; STP1630:53-64. [PMID: 35529525 PMCID: PMC9070841 DOI: 10.1520/stp163020200019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Cutibacterium acnes (formerly Propionibacterium acnes) is a significant pathogen in periprosthetic joint infections (PJIs) in total shoulder arthroplasty. Poor outcomes seen in PJIs are due to the established C. acnes bacterial biofilms. The prolonged nature of C. acnes infections makes them difficult to treat with antibiotics. The goal of this study was to determine the relative efficacy of vancomycin compared with penicillin and doxycycline against planktonic and mature biofilms. Clinical isolates from PJI patients as well as a laboratory strain of C. acnes were tested. Planktonic minimum inhibitory concentrations (MICs) and minimum bactericidal concentrations (MBCs) were obtained using modified clinical laboratory standard index assays. Biofilm MICs and MBCs were also obtained. The MIC was determined for both using the PrestoBlue viability stain. The MBC was determined using differential reinforced clostridial medium agar plates for colony-forming unit analysis. Using the PrestoBlue viability reagent, the planktonic MIC values for vancomycin were significantly higher than doxycycline. Across 10 strains of C. acnes, all three antibiotics had decreased efficacy when comparing planktonic and biofilm cultures. Although effective antibiotic doses ranged from 1 to 1,000 μg/mL, only doxycycline achieved inhibitory and bactericidal concentrations in all tested strains. Penicillin failed to achieve the minimum biofilm inhibitory concentration (MBIC) in 60% of tested strains, whereas vancomycin failed in 80% of tested strains. Penicillin, doxycycline, and vancomycin have similar abilities in inhibiting C. acnes growth planktonically. The MBIC for doxycycline was within the clinical dosing range, suggesting C. acnes biofilm offers minimal tolerance to these antibiotics. The MBIC for penicillin was within clinical dosing ranges in only 60% of trials, suggesting the relative tolerance of C. acnes to penicillin. The minimum biofilm bactericidal concentration (MBBC) of doxycycline showed efficacy in 90% of trials, whereas penicillin and vancomycin achieved MBBC in 15% of samples.
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Affiliation(s)
- Matthew D Budge
- NW Perrnanente, 5125 Skyline Rd. S., Salem, OR 97306-9427, USA
| | - John A Koch
- NW Perrnanente, 5125 Skyline Rd. S., Salem, OR 97306-9427, USA
- Arthritis and Arthroplasty Design Group, Dept. of Orthopaedic Surgery, 100 Technology Dr., Pittsburgh, PA 15219, USA
| | - Jonathan B Mandell
- Arthritis and Arthroplasty Design Group, Dept. of Orthopaedic Surgery, 100 Technology Dr., Pittsburgh, PA 15219, USA
| | - Alex J Cappellini
- Arthritis and Arthroplasty Design Group, Dept. of Orthopaedic Surgery, 100 Technology Dr., Pittsburgh, PA 15219, USA
| | - Sara Orr
- Arthritis and Arthroplasty Design Group, Dept. of Orthopaedic Surgery, 100 Technology Dr., Pittsburgh, PA 15219, USA
| | - Samik Patel
- Arthritis and Arthroplasty Design Group, Dept. of Orthopaedic Surgery, 100 Technology Dr., Pittsburgh, PA 15219, USA
| | - Dongzhu Ma
- Arthritis and Arthroplasty Design Group, Dept. of Orthopaedic Surgery, 100 Technology Dr., Pittsburgh, PA 15219, USA
| | - Olivia Nourie
- NW Perrnanente, 5125 Skyline Rd. S., Salem, OR 97306-9427, USA
| | - Kimberly M Brothers
- Arthritis and Arthroplasty Design Group, Dept. of Orthopaedic Surgery, 100 Technology Dr., Pittsburgh, PA 15219, USA
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Group, The Bone and Joint Center, MageeWomens Hospital of the University of Pittsburgh Medical Center, 300 Halket St., Pittsburgh, PA 15213, USA; and Dept. of Orthopaedic Surgery, Dept. of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh, 100 Technology Dr., Pittsburgh, PA 15219, USA
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Pocket Irrigation and Technique During Reconstructive Surgery: An American Society of Plastic Surgery Survey of Current Practice. Ann Plast Surg 2020; 82:S427-S432. [PMID: 30882415 DOI: 10.1097/sap.0000000000001790] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Expander-to-implant is the most common breast reconstruction procedure in the United States. Irrigation with triple antibiotic solution (TAS), as described by Adams et al in 2006, has become standard of care to lower bacterial bioburden. However, several alternative solutions have been implemented with the literature lacking a consensus regarding use (Plast Reconstr Surg. 2006;117:30-36). OBJECTIVE We distributed a peer-reviewed survey among a cohort of American Society of Plastic Surgery (ASPS) members to assess pocket irrigation technique during implant-based reconstructive surgery. We then conducted a pilot in vitro study to determine antibacterial efficacy of the most preferred irrigation at preferred dwell times against select bacterial species linked to breast pocket contamination during reconstructive implant-based surgery. METHODS The survey was distributed a total of 3 times to a random cohort of 2488 ASPS members in January 2018. During in vitro studies, pure cultures of common breast flora were exposed to TAS versus saline control at 1, 2, and 5 minutes in a simulated in vivo cavity. Viable plate counts were used to assess cell viability. RESULTS The response rate was above the ASPS survey average at 16% (n = 407). The population reflected a cross-section of practice types and experience levels. Triple antibiotic solution without Betadine was the favored irrigation at 41%, with 73% of its users preferring dwell times of 2 minutes or less. Over 30 distinct breast pocket irrigation solutions were identified. Bacteria added to the in vivo cavity survived a 2-minute dwell time with TAS as follows: 51% Staphylococcus epidermidis, 69% Escherichia coli, 88% Enterococcus faecalis, 88% Pseudomonas aeruginosa, and 98% Acinetobacter baumannii. CONCLUSION Our survey data demonstrate significant variability in practice and lack of consensus among ASPS members regarding antimicrobial irrigation during reconstructive breast surgery. Our in vitro data underscores the importance of relating clinical practices with laboratory studies of microorganisms potentially linked to breast pocket contamination and suggests that TAS requires either dwell times greater than 5 minutes and/or the inclusion of efficacious antimicrobial agents (eg, Betadine). This finding has the potential to impact antimicrobial pocket irrigation and technique during breast reconstruction.
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The Effect of Povidone-Iodine Lavage in Preventing Infection After Total Hip and Knee Arthroplasties: Systematic Review and Meta-Analysis. J Arthroplasty 2020; 35:2267-2273. [PMID: 32229147 DOI: 10.1016/j.arth.2020.03.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 02/27/2020] [Accepted: 03/02/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Dilute povidone-iodine (PI) lavage, a simple disinfection method, could reduce postoperative infection risk. However, there is no clinical consensus regarding its efficacy in total joint arthroplasties (TJAs). This systematic review and meta-analysis evaluated PI lavage's efficacy in preventing infection after TJA. METHODS MEDLINE, Embase, and the Cochrane Library were systematically searched for studies published before November 22, 2019, that compared postoperative infection rates in patients who underwent TJA with or without PI lavage before wound closure. Subgroup analyses were designed to identify the differences in infection site (overall or deep), type of surgery (total hip arthroplasty or total knee arthroplasty), time until diagnosis of infection (3 or 12 months postoperatively), and primary/aseptic revision arthroplasties. RESULTS We included 7 studies with 31,213 TJA cases, comprising 8861 patients who received PI lavage and 22,352 who did not. Pooled odds ratio for overall infection rate for the PI and non-PI lavage groups was 0.67 (95% confidence interval, 0.38-1.19, P = .17) and for the deep infection rate was 0.90 (95% confidence interval, 0.27-2.98, P = .86). Subgroup analyses revealed no differences in postoperative infection rates between the PI and non-PI lavage groups in terms of total hip arthroplasty and total knee arthroplasty, diagnosis of infection at 3 and 12 months postoperatively, or primary and aseptic revision arthroplasties. CONCLUSION We detected no differences in the overall postoperative infection rates between the PI and non-PI lavage groups before wound closure in TJA including all studies in the subgroup analyses.
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Ricciardi BF, Muthukrishnan G, Masters EA, Kaplan N, Daiss JL, Schwarz EM. New developments and future challenges in prevention, diagnosis, and treatment of prosthetic joint infection. J Orthop Res 2020; 38:1423-1435. [PMID: 31965585 PMCID: PMC7304545 DOI: 10.1002/jor.24595] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/03/2020] [Indexed: 02/04/2023]
Abstract
Prosthetic joint infection (PJI) is a devastating complication that results in substantial costs to society and patient morbidity. Advancements in our knowledge of this condition have focused on prevention, diagnosis, and treatment, in order to reduce rates of PJI and improve patient outcomes. Preventive measures such as optimization of patient comorbidities, and perioperative antibiotic usage are intensive areas of current clinical research to reduce the rate of PJI. Improved diagnostic tests such as synovial fluid (SF) α-defensin enzyme-linked immunosorbent assay, and nucleic acid-based tests for serum, SF, and tissue cultures, have improved diagnostic accuracy and organism identification. Increasing the diversity of available antibiotic therapy, immunotherapy, and alternative implant coatings remain promising treatments to improve infection eradication in the setting of PJI.
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Affiliation(s)
- Benjamin F Ricciardi
- Center for Musculoskeletal Research, Department of Orthopaedics, University of Rochester School of Medicine
| | - Gowrishankar Muthukrishnan
- Center for Musculoskeletal Research, Department of Orthopaedics, University of Rochester School of Medicine
| | - Elysia A Masters
- Center for Musculoskeletal Research, Department of Orthopaedics, University of Rochester School of Medicine
| | - Nathan Kaplan
- Center for Musculoskeletal Research, Department of Orthopaedics, University of Rochester School of Medicine
| | - John L Daiss
- Center for Musculoskeletal Research, Department of Orthopaedics, University of Rochester School of Medicine
| | - Edward M Schwarz
- Center for Musculoskeletal Research, Department of Orthopaedics, University of Rochester School of Medicine
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Manka MG, Yang D, Andrews J, Chalmers B, Hebert K, Köhler TS, Trost L. Intraoperative Use of Betadine Irrigation is Associated With a 9-Fold Increased Likelihood of Penile Prosthesis Infection: Results From a Retrospective Case-Control Study. Sex Med 2020; 8:422-427. [PMID: 32601002 PMCID: PMC7471124 DOI: 10.1016/j.esxm.2020.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 05/22/2020] [Accepted: 05/26/2020] [Indexed: 11/26/2022] Open
Abstract
Introduction Infection remains a persistent complication of penile prosthesis (PP) surgery. Despite popularity of Mulcahy’s PP washout protocol, Betadine has known tissue toxicity. Aim We evaluated PP infection rate based on the type of intraoperative irrigation used, ½ strength Betadine vs vancomycin/gentamicin. Methods We reviewed a prospective database of men undergoing primary, revision, and salvage PPs. No other changes to operative or perioperative techniques occurred after the change in irrigation solution. Univariate and logistic regression analyses were used to evaluate differences in infection rate with use of Betadine vs vancomycin/gentamicin irrigation. Potential confounders were reviewed. Main Outcome Measure The primary outcome was rate of PP infection before and after change of intraoperative irrigation. Results From 2014 to 2018, 217 patients underwent PP placement at our institution by a single surgeon; of whom, 21 (9.7%) experienced an infection (primary = 10 [7.1%], revision = 11 [17.19%], salvage = 0 [0%]). Overall, 152 (70%) received irrigation with Betadine and 65 (30%) with Vancomycin/Gentamicin. Univariate analysis demonstrated significantly increased infection rates with Betadine irrigation (odds ratio [OR]: 4.64, P = .006) and with revision surgery (OR: 2.68, P = .02). Significance of increased infection rate with Betadine was maintained (OR: 9.3; P = .025) after controlling for age, body mass index, Charlson comorbidity index, smoking, diabetes, primary vs revision/salvage, prior penile surgery, use of ectopic reservoir, and adjunctive glanulopexy. Conclusions Changing from intraoperative Betadine to vancomycin/gentamicin solution dramatically reduced infection rates among men undergoing PP placement in both primary and revision cases. We hypothesize that differences in infection rate may relate to the relative toxicity or non-sterile nature of Betadine. Manka MG, Yang D, Andrews J, et al. Intraoperative Use of Betadine Irrigation is Associated With a 9-Fold Increased Likelihood of Penile Prosthesis Infection: Results From a Retrospective Case-Control Study. Sex Med 2020;8:422–427.
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Affiliation(s)
- Madeleine G Manka
- Department of Urology, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | - David Yang
- Department of Urology, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | - Jack Andrews
- Department of Urology, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | - Brian Chalmers
- Department of Orthopedics, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | - Kevin Hebert
- Department of Urology, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | - Tobias S Köhler
- Department of Urology, Mayo Clinic and Mayo Medical School, Rochester, MN, USA.
| | - Landon Trost
- Department of Urology, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
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Long acting anti-infection constructs on titanium. J Control Release 2020; 326:91-105. [PMID: 32580044 DOI: 10.1016/j.jconrel.2020.06.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/23/2020] [Accepted: 06/14/2020] [Indexed: 01/12/2023]
Abstract
Peri-prosthetic joint infections (PJI) are a serious adverse event following joint replacement surgeries; antibiotics are usually added to bone cement to prevent infection offset. For uncemented prosthesis, alternative antimicrobial approaches are necessary in order to prevent PJI; however, despite elution of drug from the surface of the device being shown one of the most promising approach, no effective antimicrobial eluting uncemented device is currently available on the market. Consequently, there is a clinical need for non-antibiotic antimicrobial uncemented prosthesis as these devices present numerous benefits, particularly for young patients, over cemented artificial joints. Moreover, non-antibiotic approaches are driven by the need to address the growing threat posed by antibiotic resistance. We developed a multilayers functional coating on titanium surfaces releasing chlorhexidine, a well-known antimicrobial agent used in mouthwash products and antiseptic creams, embedding the drug between alginate and poly-beta-amino-esters. Chlorhexidine release was sustained for almost 2 months and the material efficacy and safety was proven both in vitro and in vivo. The coatings did not negatively impact osteoblast and fibroblast cells growth and were capable of reducing bacterial load and accelerating wound healing in an excisional wound model. As PJI can develop weeks and months after the initial surgery, these materials could provide a viable solution to prevent infections after arthroplasty in uncemented prosthetic devices and, simultaneously, help the fight against antibiotic resistance.
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Pan S, Rodriguez D, Thirumavalavan N, Gross MS, Eid JF, Mulcahy J, Munarriz R. The Use of Antiseptic Solutions in the Prevention and Management of Penile Prosthesis Infections: A Review of the Cytotoxic and Microbiological Effects of Common Irrigation Solutions. J Sex Med 2020; 16:781-790. [PMID: 31146926 DOI: 10.1016/j.jsxm.2019.03.271] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 03/19/2019] [Accepted: 03/22/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The Mulcahy salvage fundamentally altered the management of penile prosthesis infections (PPI). Central to this procedure is a sequence of antiseptic irrigations that aims to remove and eradicate pathogenic microflora from the infected field, thus preparing for immediate reimplantation. The antiseptic solutions and their respective concentrations, however, have never been evaluated for efficacy. AIM This review critically examines 3 commonly used antiseptic irrigation solutions (povidone-iodine [PVI], hydrogen peroxide [H2O2], and chlorhexidine gluconate [CHG]) in terms of their antimicrobial activity, cytotoxicity, and clinical use. METHODS A PubMed literature review was performed on articles published between 2003 and 2018. Both preclinical as well as clinical studies from various surgical disciplines were included in this review. MAIN OUTCOME MEASURE The original salvage protocol selected for irrigation solutions at concentrations that are likely detrimental to native tissue. RESULTS All 3 agents demonstrate in vitro cytotoxic effects at subclinical concentrations, but H2O2 is associated with the most significant deleterious properties. It does not seem to broaden antimicrobial coverage beyond what is covered by PVI. Dilute PVI (0.35-3.5% with exposure time of at least 3 minutes) possesses the most robust clinical evidence as an intraoperative adjunct, reducing the incidence of postoperative infectious complications. chlorhexidine gluconate is a promising new agent but lacks clinical data. CLINICAL IMPLICATION Improvements in the salvage protocol are warranted based on current evidence. Careful selection of lavage solution and usage of the lowest necessary concentration will help achieve desired antimicrobial activity while avoiding native tissue cytotoxicity. Strength and limitation: The study is limited by its retrospective nature, and the heterogeneity of literature reviewed precluded a formal meta-analysis. Furthermore, future studies will need to address the roles of normal saline and antibiotic irrigations as intraoperative adjuncts for infection prevention. CONCLUSION Diluted PVI (0.35-3.5% for 3 minutes) may be beneficial in the prevention of PPI. Evidence supports its use both in the setting of primary implantation as well as salvage of infected hardware. An improved, evidence-based protocol may increase positive outcomes of urologic prosthetic surgery. Pan S, Rodriguez D, Thirumavalavan N, et al. The Use of Antiseptic Solutions in the Prevention and Management of Penile Prosthesis Infections: A Review of the Cytotoxic and Microbiological Effects of Common Irrigation Solutions. J Sex Med 2019;16:781-790.
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Affiliation(s)
- Shu Pan
- Department of Urology, Boston University School of Medicine, Boston, MA, USA
| | - Dayron Rodriguez
- Department of Urology, Boston University School of Medicine, Boston, MA, USA
| | | | - Martin S Gross
- Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - J Francois Eid
- Lenox Hill Hospital Northwell Health System, New York, NY, USA
| | - John Mulcahy
- Department of Urology, University of Alabama Madison, Madison, AL, USA
| | - Ricardo Munarriz
- Department of Urology, Boston University School of Medicine, Boston, MA, USA.
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Wood T, Ekhtiari S, Mundi R, Citak M, Sancheti PK, Guerra-Farfan E, Schemitsch E, Bhandari M. The Effect of Irrigation Fluid on Periprosthetic Joint Infection in Total Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis. Cureus 2020; 12:e7813. [PMID: 32467789 PMCID: PMC7249750 DOI: 10.7759/cureus.7813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 04/24/2020] [Indexed: 11/05/2022] Open
Abstract
Introduction Rates of osteoarthritis and total joint arthroplasty (TJA) are on the rise globally. Periprosthetic joint infection (PJI) is the most devastating complication of TJA. A number of different intraoperative interventions have been proposed in an effort to reduce infection rates, including antibiotic cements, local antibiotic powder, and various irrigation solutions. The evidence on the importance of irrigation solutions is limited but has gained prominence recently, including the publication of a large randomized controlled trial (RCT). Thus, the purpose of this study was to evaluate the effectiveness of various irrigation solutions and pressures at reducing the rates of PJI. Methods A systematic review was performed using the electronic databases MEDLINE, Embase, and Web of Science. All records were screened in duplicate. Data collected included basic study characteristics, the details of the intervention and comparison solutions, if applicable, and rates of superficial and deep infection. A meta-analysis of comparative studies was performed to assess for consistency and potential direction of effect. Results A total of ten studies were included, of which one was an RCT, eight were retrospective cohorts, and one was a case series. In total, there were 29,630 TJAs in 29,596 patients. The mean age ranged from 61 to 80 years. Six studies compared povidone-iodine (Betadine®) to normal saline, two studies compared chlorhexidine to saline, one study compared "triple prophylaxis" to standard practice, and one study used gentamicin but had no comparison group. The pooled risk ratio for deep infection in studies using Betadine® compared to saline was 0.62 (95% confidence interval [CI]: 0.33-1.19), while for chlorhexidine it was 0.74 (95%CI: 0.33-1.65). Discussion Current evidence on the relative efficacy of irrigating solutions as prophylaxis for infection following TJA remains inconclusive. Imprecision of estimates vindicates the need for a definitive trial to further inform their use in surgical practice. Conclusion Antiseptic irrigation during TJA with solutions (Betadine®, chlorhexidine) may decrease PJI risk in patients undergoing primary and revision total hip and knee arthroplasties. Wide confidence intervals and heterogeneity among studies, however, render conclusions untrustworthy. Well-conducted RCTs are very much needed to help further investigate this issue.
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Affiliation(s)
- Thomas Wood
- Orthopaedic Surgery, McMaster University, Hamilton, CAN
| | | | | | - Mustafa Citak
- Orthopaedic Surgery, Helios Endo-Klinik, Hamburg, DEU
| | - Parag K Sancheti
- Orthopaedics, Sancheti Institute for Orthopaedics and Rehabilitation, Pune, IND
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Atesok K, Papavassiliou E, Heffernan MJ, Tunmire D, Sitnikov I, Tanaka N, Rajaram S, Pittman J, Gokaslan ZL, Vaccaro A, Theiss S. Current Strategies in Prevention of Postoperative Infections in Spine Surgery. Global Spine J 2020; 10:183-194. [PMID: 32206518 PMCID: PMC7076595 DOI: 10.1177/2192568218819817] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVES Postoperative surgical site infections (SSIs) are among the most common acute complications in spine surgery and have a devastating impact on outcomes. They can lead to increased morbidity and mortality as well as greater economic burden. Hence, preventive strategies to reduce the rate of SSIs after spine surgery have become vitally important. The purpose of this article was to summarize and critically analyze the available evidence related to current strategies in the prevention of SSIs after spine surgery. METHODS A literature search utilizing Medline database was performed. Relevant studies from all the evidence levels have been included. Recommendations to decrease the risk of SSIs have been provided based on the results from studies with the highest level of evidence. RESULTS SSI prevention occurs at each phase of care including the preoperative, intraoperative, and postoperative periods. Meticulous patient selection, tight glycemic control in diabetics, smoking cessation, and screening/eradication of Staphylococcus aureus are some of the main preoperative patient-related preventive strategies. Currently used intraoperative measures include alcohol-based skin preparation, topical vancomycin powder, and betadine irrigation of the surgical site before closure. Postoperative infection prophylaxis can be performed by administration of silver-impregnated or vacuum dressings, extended intravenous antibiotics, and supplemental oxygen therapy. CONCLUSIONS Although preventive strategies are already in use alone or in combination, further high-level research is required to prove their efficacy in reducing the rate of SSIs in spine surgery before evidence-based standard infection prophylaxis guidelines can be built.
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Affiliation(s)
- Kivanc Atesok
- University of Alabama at Birmingham, AL, USA,Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA,Kivanc Atesok, Department of Neurosurgery Spine Program, Beth Israel Deaconess Medical Center, Harvard University, 110 Francis Street, Boston, MA 02215, USA.
| | | | - Michael J. Heffernan
- Children’s Hospital of New Orleans, LSU Health Science Center, New Orleans, LA, USA
| | | | - Irina Sitnikov
- International Center for Minimally Invasive Spine Surgery, Wyckoff, NJ, USA
| | | | | | | | - Ziya L. Gokaslan
- Brown University, Providence, RI, USA,Rhode Island Hospital, Providence, RI, USA
| | - Alexander Vaccaro
- Thomas Jefferson University, The Rothman Institute, Philadelphia, PA, USA
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Warth LC, Hadley CJ, Grossman EL. Two-Stage Treatment for Total Knee Arthroplasty Infection Utilizing an Articulating Prefabricated Antibiotic Spacer. J Arthroplasty 2020; 35:S57-S62. [PMID: 32046834 DOI: 10.1016/j.arth.2019.10.049] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/24/2019] [Accepted: 10/24/2019] [Indexed: 02/01/2023] Open
Abstract
Periprosthetic joint infection represents a serious complication following total knee arthroplasty. In the setting of chronic or age-indeterminate total knee arthroplasty infection, a 2-staged approach has been traditionally the preferred method of treatment over single-stage debridement and reimplantation debridement or debridement, antibiotics and implant retention. Two-stage is the preferred treatment method in North America and has demonstrated better overall success than the single stage techniques. Additionally, the 2-stage method is the preferred treatment for difficult to treat pathogens as well as in patients who have already undergone a previous revision procedure. An articulating prefabricated antibiotic spacer has entered the armamentarium of 2-stage revision knee surgery, and has demonstrated comparable results to custom and static spacers in terms of the primary goal of infection control. Importantly, the potential for enhanced mobility and function hold promise by safely providing a more "livable" knee during the convalescent period prior to definitive reimplantation.
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Affiliation(s)
- Lucian C Warth
- Department of Orthopedic Surgery, Joint Replacement, Indiana University Health Physicians, Fishers, IN
| | - Christopher J Hadley
- Department of Orthopedic Surgery, Joint Replacement, Rothman Orthopaedic Institute, New York, NY
| | - Eric L Grossman
- Department of Orthopedic Surgery, Joint Replacement, Rothman Orthopaedic Institute, New York, NY
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45
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Kildow BJ, Della-Valle CJ, Springer BD. Single vs 2-Stage Revision for the Treatment of Periprosthetic Joint Infection. J Arthroplasty 2020; 35:S24-S30. [PMID: 32046827 DOI: 10.1016/j.arth.2019.10.051] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 10/27/2019] [Accepted: 10/27/2019] [Indexed: 02/01/2023] Open
Abstract
Periprosthetic joint infection (PJI) is one of the most devastating complications following total joint arthroplasty, accounting for a projected 10,000 revision surgeries per year by 2030. Chronic PJI is complicated by the presence of bacterial biofilm, requiring removal of components, thorough debridement, and administration of antibiotics for effective eradication. Chronic PJI is currently managed with single-stage or 2-stage revision surgery. To date, there are no randomized, prospective studies available evaluating eradication rates and functional outcomes between the 2 techniques. In this review, both treatment options are described with the most current literature to guide effective surgical decision-making that is cost-effective while decreasing patient morbidity.
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Affiliation(s)
- Beau J Kildow
- OrthoCarolina Hip and Knee Center, Charlotte, North Carolina
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Measures to reduce end-of-case wound contamination: the impact of intra-wound vancomycin powder and betadine irrigation on surgical site infections in posterior spinal fusion. Spine Deform 2020; 8:45-50. [PMID: 31981142 DOI: 10.1007/s43390-020-00033-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 07/11/2019] [Indexed: 10/25/2022]
Abstract
STUDY DESIGN Retrospective descriptive, single-center study. OBJECTIVES To determine the effect of standardized intrawound vancomycin powder and betadine irrigation on surgical site infection (SSI) rates after posterior spinal fusion (PSF) in idiopathic scoliosis. Since 2005, our pediatric spine center has implemented a series of changes to lower the risk of SSI. The most recent interventions-intrawound vancomycin powder and betadine irrigation-are applied just before closure, aiming to reduce the culture-positive bacterial contamination known to occur in many cases. We sought to determine the impact of these end-of-case measures on our center's SSI rate. METHODS We retrospectively reviewed patients who underwent PSF for idiopathic scoliosis at our institution from January 1, 2010, to June 30, 2018, identifying all cases that returned to the operating room for surgical debridement within 90 days of PSF. Cases were surgeon-audited to ensure inclusion of all infections that met Centers for Disease Control and Prevention (CDC) criteria for acute SSI. Vertical expandable prosthetic titanium ribs, growing rods, staged procedures, and nonidiopathic cases were excluded. Annual rates of SSIs were correlated with the initiation of each SSI prevention measure. RESULTS Among 740 cases of PSF for idiopathic scoliosis from 2010 to 2018, the overall acute SSI rate by CDC criteria was 0.68%. The idiopathic SSI rate dropped significantly, from 1.70 to 0.20%, after the standardized introduction of intrawound vancomycin powder and betadine irrigation before closure (p < 0.04). The implementation of these end-of-case measures in 2012-2013 was soon followed by an institution best 3.5-year SSI-free period for idiopathic cases. CONCLUSIONS Since intrawound vancomycin powder and betadine irrigation were added to our SSI prevention bundle, we have seen a significantly lower SSI rate after PSFs for idiopathic scoliosis. These findings suggest that anti-SSI interventions to reduce wound contamination at the end of the case may have a particularly positive impact on SSI reduction. LEVEL OF EVIDENCE Level III, therapeutic.
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Kavolus JJ, Schwarzkopf R, Rajaee SS, Chen AF. Irrigation Fluids Used for the Prevention and Treatment of Orthopaedic Infections. J Bone Joint Surg Am 2020; 102:76-84. [PMID: 31596810 DOI: 10.2106/jbjs.19.00566] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Joseph J Kavolus
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Orthopedic Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - Sean S Rajaee
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Antonia F Chen
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Holst DC, Angerame MR, Dennis DA, Jennings JM. Does the Method of Sterile Glove-Opening Influence Back Table Contamination? A Fluorescent Particle Study. J Arthroplasty 2019; 34:2075-2079. [PMID: 31208911 DOI: 10.1016/j.arth.2019.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/23/2019] [Accepted: 05/02/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Surgical site infections (SSI) may result from inadvertent intraoperative contamination events. This study investigated the method of opening surgical gloves onto the operative field (OF) and potential contamination rates. METHODS Twenty surgical glove packets were coated with a commercially available fluorescent particle powder. Two methods of glove openings (10 surgical glove packets in each cohort) were investigated: direct drop (DD) onto the OF vs opening and direct hand-off (DH) to a sterile intermediary (SI). Ultraviolet black light was used to quantify fluorescent particles for dispensed glove packets and the OF in both cohorts. The gloves of the SI were inspected in the DH cohort. A previously used contamination scale for fluorescent particle model contamination was employed: 0: no detectable fluorescent particle specks, 1: 1-5 specks, 2: 5-10 specks, 3: 11-100 specks, 4: >100 specks. RESULTS The DD cohort had a median OF contamination of 4 (range, 3-4) vs 3 for the DH trials (range, 1-3; P = .001). Likewise, the median glove contamination was higher in the DD cohort, 3 (range, 2-4) vs 1 for DH (range, 0-3; P = .007). Minimal contamination was found on the hands of the SI. Total fluorescent contamination rates, including the gloves of SI in the DH cohort, revealed greater overall contamination in DD (median, 3.5; range, 2-4) vs DH cohort (median, 1; range, 0-3); (P < .001). CONCLUSION Using a fluorescent particle model, there is a greater burden of potential contamination from dispensed glove packets and OF with DD vs DH. The DH method did not show significant fluorescent particle contamination on the SI gloves. These data support the use of the opening of gloves via DH over the DD method in total joint arthroplasty to decrease the risk of potential contamination.
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Affiliation(s)
- David C Holst
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC
| | - Marc R Angerame
- Department of Orthopaedic Surgery, Illinois Bone and Joint Institute, Barrington, IL
| | - Douglas A Dennis
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, CO; Department of Mechanical and Materials Engineering, Denver University, Denver, CO; Department of Orthopaedics, University of Colorado School of Medicine, Denver, CO; Department of Biomedical Engineering, University of Tennessee, Knoxville, TN
| | - Jason M Jennings
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, CO; Department of Mechanical and Materials Engineering, Denver University, Denver, CO
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Arslan NC, Degirmenci AK, Ozdenkaya Y, Terzi C. Wound Irrigation with Chlorhexidine Gluconate Reduces Surgical Site Infection in Pilonidal Disease: Single-Blind Prospective Study. Surg Infect (Larchmt) 2019; 21:143-149. [PMID: 31460835 DOI: 10.1089/sur.2019.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: The aim of this study was to determine whether incision irrigation with chlorhexidine gluconate (CHG) reduces surgical site infections (SSIs) in pilonidal disease surgery. Methods: Between 2013 and 2018, patients who underwent wide excision with primary closure for pilonidal disease were enrolled in this prospective observational multi-institutional cohort. The incision was irrigated with either saline or 0.05% CHG before skin closure. The infection risk of each patient was determined by the National Nosocomial Infection Surveillance System. Post-operative site care and follow-up were carried out according to the U.S. Centers for Disease Control and Prevention guideline by two surgeons blinded to the irrigation solution used. Surgical site infection rates in the saline and 0.05% CHG groups were compared. The secondary outcomes were seroma formation, incision dehiscence, and time to healing. Results: There were 129 patients in the control group and 138 patients in the CHG group. The mean age was 25.1 ± 5.4, and 225 patients (84.3%) were male. Surgical site infection was seen in 35 patients (13.1%): 26 (20.2%) in the control group and 9 (6.5%) in the CHG group (p = 0.001). There were no differences in seroma formation (n = 12; 9.3% in the control vs n = 12; 8.7% in the CHG group; p = 0.515) or incision dehiscence (n = 9; 7% in the control vs n = 9; 6.5% in the CHG group; p = 0.537). The primary healing rate was higher in the CHG group (n = 130; 94.2%) than in the control group (n = 104; 80.6%). Time to healing was 20.5 ± 7.8 days in the control group and 16 ± 4.3 days in the CHG group (p < 0.001). Conclusion: Intra-operative incision irrigation with CHG decreased the SSI rate and time to healing in pilonidal disease surgery. Further randomized trials should focus on specific irrigation methods and procedures to build a consensus on the effect of incision irrigation on SSIs.
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Affiliation(s)
| | | | - Yasar Ozdenkaya
- Department of General Surgery, Medipol University, Istanbul, Turkey
| | - Cem Terzi
- Department of General Surgery, Dokuz Eylul University, Izmir, Turkey
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Hernandez NM, Hart A, Taunton MJ, Osmon DR, Mabry TM, Abdel MP, Perry KI. Use of Povidone-Iodine Irrigation Prior to Wound Closure in Primary Total Hip and Knee Arthroplasty: An Analysis of 11,738 Cases. J Bone Joint Surg Am 2019; 101:1144-1150. [PMID: 31274715 DOI: 10.2106/jbjs.18.01285] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Povidone-iodine (PI) irrigation is often used prior to wound closure in total joint arthroplasty, but there are limited reports evaluating its efficacy in decreasing joint infections. The goal of this study was to compare the rate of any reoperation for infection (both superficial and deep) in primary total hip arthroplasty (THA) and primary total knee arthroplasty (TKA) among patients who did and did not receive PI irrigation prior to wound closure. METHODS Using our institution's total joint registry, we identified 5,534 primary THA and 6,204 primary TKA procedures performed from 2013 to 2017. Cases were grouped on the basis of whether or not the wound was irrigated with 1 L of 0.25% PI prior to closure. PI irrigation was used in 1,322 (24%) of the THA cases and in 2,410 (39%) of the TKA cases. The rates of reoperation for infection at 3 months and 1 year were compared between the 2 groups. The same comparisons were then performed using propensity scores to account for differences in baseline characteristics. RESULTS The rate of reoperation for infection as assessed at 3 months following THA was similar between those who received dilute PI irrigation (0.9%) and who did not (0.7%) (p = 0.7). At 1 year, the rate of reoperation for infection was similar between those who received dilute PI irrigation (0.7%) and those who did not (0.9%) (p = 0.6). After using the propensity score, there was no difference between the groups in the risk of septic reoperations. For TKA, the rate of reoperation as assessed at 3 months was similar between those who received dilute PI irrigation (0.8%) and those who did not (0.3%) (p = 0.06). At 1 year, there was a greater rate of reoperations for infection among those who received dilute PI irrigation (1.2%) compared with those who did not (0.6%) (p = 0.03). However, there was no difference in the risk of septic reoperations between the groups after using the propensity score. CONCLUSIONS Despite enthusiasm for and progressive adoption of the use of dilute PI irrigation at our institution, there was not a significant reduction in the risk of reoperation for infection as assessed at 3 months and 1 year following primary THA and TKA. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nicholas M Hernandez
- Departments of Orthopedic Surgery (N.M.H., A.H., M.J.T., T.M.M., M.P.A., and K.I.P.) and Infectious Disease (D.R.O.), Mayo Clinic, Rochester, Minnesota
| | - Adam Hart
- Departments of Orthopedic Surgery (N.M.H., A.H., M.J.T., T.M.M., M.P.A., and K.I.P.) and Infectious Disease (D.R.O.), Mayo Clinic, Rochester, Minnesota
| | - Michael J Taunton
- Departments of Orthopedic Surgery (N.M.H., A.H., M.J.T., T.M.M., M.P.A., and K.I.P.) and Infectious Disease (D.R.O.), Mayo Clinic, Rochester, Minnesota
| | - Douglas R Osmon
- Departments of Orthopedic Surgery (N.M.H., A.H., M.J.T., T.M.M., M.P.A., and K.I.P.) and Infectious Disease (D.R.O.), Mayo Clinic, Rochester, Minnesota
| | - Tad M Mabry
- Departments of Orthopedic Surgery (N.M.H., A.H., M.J.T., T.M.M., M.P.A., and K.I.P.) and Infectious Disease (D.R.O.), Mayo Clinic, Rochester, Minnesota
| | - Matthew P Abdel
- Departments of Orthopedic Surgery (N.M.H., A.H., M.J.T., T.M.M., M.P.A., and K.I.P.) and Infectious Disease (D.R.O.), Mayo Clinic, Rochester, Minnesota
| | - Kevin I Perry
- Departments of Orthopedic Surgery (N.M.H., A.H., M.J.T., T.M.M., M.P.A., and K.I.P.) and Infectious Disease (D.R.O.), Mayo Clinic, Rochester, Minnesota
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