Perioperative skin preparation

The effect of different preventive strategies during total joint arthroplasty on periprosthetic joint infection: a network meta-analysis

BACKGROUND

Periprosthetic joint infection after total joint arthroplasty has a large incidence, and it may often require two or more stages of revision, placing an additional burden on clinicians and patients. The purpose of this network meta-analysis is to evaluate the effect of four different preventive strategies during total joint arthroplasty on the prevention of periprosthetic joint infection.

METHODS

The study protocol was registered at PROSPERO (CRD: 42,023,448,868), and the literature search databases included Web of Science, PubMed, OVID Cochrane Central Register of Controlled Trials, OVID EMBASE, and OVID MEDLINE (R) ALL that met the requirements. The network meta-analysis included randomized controlled trials, retrospective cohort studies and prospective cohort studies with the outcome of periprosthetic joint infection. The gemtc R package was applied to perform the network meta-analysis to evaluate the relative results of different preventive strategies.

RESULTS

This network meta-analysis study included a total of 38 articles with 4 preventive strategies and negative controls. No improvement was observed in antibiotic-loaded bone cement compared with negative controls. Chlorhexidine showed the highest probability of delivering the best preventive effect, and povidone iodine had the second highest probability. Although vancomycin ranked after chlorhexidine and povidone iodine, it still showed a significant difference compared with negative controls. In addition, the incidence after applying chlorhexidine was significantly lower than that after applying negative controls and vancomycin. In the heterogeneity test between direct and indirect evidence, there was no apparent heterogeneity between them.

CONCLUSION

The study indicated that chlorhexidine, povidone iodine and vancomycin showed significant efficacy in preventing periprosthetic joint infection after total joint arthroplasty, while antibiotic-loaded bone cement did not. Therefore, more high-quality randomized controlled trials are needed to verify the results above.

Psoriasis and Post-Surgical Infections in Primary Total Knee Arthroplasty: An Analysis of 10,727 Patients

BACKGROUND

Psoriasis is a dermatologic condition characterized by erythematous plaques that may increase wound complications and deep infections following total knee arthroplasty (TKA). There is a paucity of evidence concerning the association of this disease and complications after TKA. This study aimed to determine if patients who have psoriasis vs non-psoriatic patients have differences in demographics and various comorbidities as well as post-operative infections, specifically the following: (1) wound complications; (2) cellulitic episodes; and (3) deep surgical site infections (SSIs).

METHODS

We identified 10,727 patients undergoing primary TKA utilizing an institutional database between January 1, 2017 and April 1, 2019. A total of 133 patients who had psoriasis (1.2%) were identified using International Classification of Diseases, Tenth Revision codes and compared to non-psoriatic patients. The rate of wound complications, cellulitic episodes, and deep SSIs were determined. After controlling for age and various comorbidities, multivariate analyses were performed to identify the associated risks for post-operative infections.

RESULTS

Psoriasis patients showed an increased associated risk of deep SSIs (3.8%) compared to non-psoriasis patients (1.2%, P = .023). Multivariate analyses demonstrated a significant associated risk of deep SSIs (odds ratio 7.04, 95% confidence interval 2.38-20.9, P < .001) and wound complications (odds ratio 4.44, 95% confidence interval 1.02-19.2, P = .047).

CONCLUSION

Psoriasis is an inflammatory dermatologic condition that warrants increased pre-operative counseling, shared decision-making, and infectious precautions in the TKA population given the increased risk of wound complications and deep SSIs. Increased vigilance is required given the coexistence of certain comorbidities with this population, including depression, substance use disorder, smoking history, gastroesophageal reflux disease, and inflammatory bowel disease.

Contamination Rate of Burnt Necrotic Tissue after Electrocoagulation in Total Knee Arthroplasty

Background

Periprosthetic joint infection (PJI) is one of the commonly found catastrophic complications after total knee arthroplasty (TKA). Preoperative antibiotic prophylaxis, proper skin cleansing, shortened operative time, and sterility of surgical field and equipment are essential to minimize the risk of PJI. Although bacterial contamination of electrocautery tips has been reported, contamination of residual product of electrocoagulation, burnt necrotic tissue (BNT), is not well known. Therefore, we aimed to assess the contamination rate of BNT and association between contaminated BNT and PJI, and risk factors.

Methods

BNTs from 183 patients who had undergone unilateral primary TKA at our institution were retrospectively analyzed. In each patient, three to five specimens of BNT were routinely collected in the operative field of primary TKA. Collecting time was defined as the duration from start of using the electrocautery device to the first collection of BNT.

Results

Culture was positive in eight of 183 patients (4.4%; contaminated BNT group), and the most commonly isolated organism was coagulase-negative Staphylococcus (62.5%). The average operative time was 103.1 ± 44.2 minutes in the contaminated BNT group and 79.0 ± 16.7 minutes in the non-contaminated BNT group (p = 0.17), and collecting time was 48.0 ± 44.3 minutes and 29.7 ± 17.0 minutes (p = 0.28), respectively. None of the patients with contaminated BNT developed PJI, whereas four patients with culture-negative BNT developed PJI within 2 postoperative years.

Conclusions

BNT in surgical field can become a reservoir of contaminating bacteria. However, contamination of BNT was not associated with PJI. Therefore, routine removal of all BNTs may be unnecessary.

Surgical field and skin preparation

Surgical site infection (SSI) is the third most frequent healthcare-associated infection in France. SSI rates in total hip or knee replacement are around 2%. The main bacteria implicated in SSI in clean surgery are those of the skin flora, whence the importance of skin preparation to eliminate transient flora and reduce resident flora. Guidelines for the prevention of SSI have progressed in recent years in France: firstly in 2013, and then in 2016. That preoperative hair removal and scrubbing of clean skin ahead of cutaneous asepsis is non-contributive was confirmed in 2013. A shower with normal soap taken as close to the beginning of surgery as possible is still recommended, as is use of alcoholic antiseptics for cutaneous asepsis. The debate remains open between chlorhexidine and povidone-iodine in several surgical specialties in the absence of any multicenter studies. Future choices of antiseptic may need to take account of resistance, especially to chlorhexidine, and possible side-effects. Finally, antimicrobial skin sealants and adhesive surgical drapes are not recommended for the prevention of infection.

Minimising the risk of infection: a peri-operative checklist

The purpose of this article is to provide the reader with a seven-step checklist that could help in minimising the risk of PJI. The check list includes strategies that can be implemented pre-operatively such as medical optimisation, and reduction of the bioburden by effective skin preparation or actions taking during surgery such as administration of timely and appropriate antibiotics or blood conservation, and finally implementation of post-operative protocols such as efforts to minimise wound drainage and haematoma formation.

Bacterial Contamination in Tips of Electrocautery Devices During Total Hip Arthroplasty

Surgical equipment can become contaminated during surgery. It is unknown if electrocautery tips can become contaminated in clean orthopedic procedures despite the produced heat. Therefore, we conducted a prospective study to address this concern. The tips from 25 primary and 25 aseptic revision THAs were collected and an additional 5 sterile tips served as negative controls. Aerobic and anaerobic cultures were incubated for a minimum of 3 days. There were 3 positive cultures (6%); one in primary THA (4%) with Lactobacillus and Enterococcus faecalis; two among revisions (8%), one with E. faecalis and another one with alpha hemolytic streptococci and coagulase negative Staphylococcus. The mean exposure time of the contaminated tips was 132.3 minutes. Patients were followed for 90 days postoperatively and none of them developed surgical site infection. This is the first study to demonstrate that electrosurgical devices can become contaminated during THA in laminar flow equipped operating rooms.

Prevention of Periprosthetic Joint Infection

Periprosthetic joint infection (PJI) has moved into the first place as the cause of failure following total knee arthroplasty (TKA). Recent studies have shown that PJI results in higher mortality in patients than many cancers. The economic burden of treating PJI is likely to exceed $1 billion this year in the US. Thus, it is paramount that all efforts are invested to prevent this dreaded complication after total joint arthroplasty (TJA). This article summarizes some of the most effective and proven strategies for prevention of PJI. It is hoped that the article will be of benefit to the readers of the journal.