General Assembly, Prevention, Host Risk Mitigation - General Factors: Proceedings of International Consensus on Orthopedic Infections

Prevention of surgical site infection: a ten-step approach

Surgical site infection (SSI) is a common cause of morbidity and mortality in patients undergoing surgery. Similarly, periprosthetic joint infection (PJI), is a major cause of failure after total joint arthroplasty (TJA). As the annual volume of TJA procedures is projected to rise, so will the rate of subsequent SSI and PJI. Currently, prevention has been identified as the single most important strategy for combating SSI/PJI. Hence, the present article will serve as a summary of an evidence-based ten-step approach for SSI/PJI prevention that may help orthopedic surgeons with their infection prevention strategies.

"Recommendations for periprosthetic joint infections (PJI) prevention: the European Knee Associates (EKA)-International Committee American Association of Hip and Knee Surgeons (AAHKS)-Arthroplasty Society in Asia (ASIA) survey of members"

PURPOSE

Periprosthetic joint infections (PJIs) represent a devastating consequence of total joint arthroplasty. The European Knee Associates (EKA), the American Association of Hip and Knee Surgeons (AAHKS) International Committee, and the Arthroplasty Society in Asia (ASIA) board members were interested in quantifying differences in arthroplasty surgeons' use of various PJI prevention measures to provide clinical recommendations to reduce PJI incidence.

METHODS

A prospective Microsoft Forms online survey was distributed among EKA, AAHKS International Committee, and ASIA members and their affiliated arthroplasty surgeons. The survey consisted of 20 single and multiple response questions focused on PJI prevention strategies at three perioperative periods: preoperatively, intraoperatively, and postoperatively.

RESULTS

Three hundred and ninety-four arthroplasty surgeons from 6 different continents completed the survey. Preoperative: (A) PJI Risk Stratification: 40.6% routinely set thresholds (e.g., BMI, HgbA1C) to be met to qualify for surgery, 36.5% only review past medical history; 9.1% use machine learning to personalize PJI risk; (B) BMI limit: 36% no limit; 15.4% BMI < 35; 30.9% BMI < 40; 17.2% BMI < 45; (C) Nutritional status: 55.3% do not screen; among those who screen their patients (44.7%), albumin is the single most used marker (86.3%); (D) Hyperglycemia/Diabetes: 83.3% check this comorbidity; 88.1% use HgbA1C as single best screening test; (E) MRSA nasal colonization: 63.7% do not test; 28.9% test all patients; 7.4% test selectively. Intraoperative: (A) Antibiotic prophylaxis in high-risk patients: 43.4% use single antibiotic for 24 h; 21.3% use double antibiotic for 24 h; 14.2% use single/double antibiotic for 7 days postoperatively; (B) Skin-cleansing: 68.7% at home (45.6% chlorhexidine sponge; 11.9% clippers); (C) Intraoperative skin disinfection: 46.9% single chlorhexidine; 25% double chlorhexidine-povidone-iodine;15.4% single povidone-iodine; (D) Tranexamic acid (TXA) to reduce bleeding/SSI: 96% yes (51% double IV dose, 35.2% single IV dose, 23.6% intra-articular injection); (E) Surgical suction drain: 52% do not use drains; 19.7% use a drain < 24 h; (F) Intra-articular lavage: 64.9% use only saline; 28.1% use dilute povidone-iodine; (G) Antibiotic local delivery to prevent PJI: 82.4% use antibiotic-added cement. Postoperative: (A) Routine monitoring of PJI serologic markers: 42% only in symptomatic patients; 34.2% do not; 20.8% in all patients; (B) Serologic markers to rule in/out PJI: 95.9% CRP; 71% SEDRATE; 60.6% WBC; (C) Synovial fluid test to rule in/out PJI: 79.6% culture/sensitivity; 69.5% WBC count; 31.4% CRP.

CONCLUSIONS

This survey demonstrated that notable differences still exist in the application of PJI preventive measures across different geographic areas: Optimizing the patient preoperatively and applying multimodal intraoperative strategies represent newer, clinically relevant steps in the effort to reduce the burden of PJI. More uniform guidelines still need to be produced from international scientific societies in order facilitate a more comprehensive approach to this devastating complication.

LEVEL OF EVIDENCE

IV.

Dilute Povidone-Iodine Irrigation Reduces the Rate of Periprosthetic Joint Infection Following Hip and Knee Arthroplasty: An Analysis of 31,331 Cases

BACKGROUND

Total joint arthroplasty (TJA) surgeons employ various strategies to reduce the risk of periprosthetic joint infection (PJI). Few studies have examined the efficacy of preclosure dilute povidone-iodine irrigation in a large cohort accounting for recent practice changes in TJA. This study compared the risk of PJI in TJA patients with and without dilute povidone-iodine irrigation.

METHODS

This is a retrospective study of all consecutive primary TJAs between 2009 and 2019 at a single institution. We included 31,331 cases, of which 8659 were irrigated with dilute povidone-iodine and 22,672 were irrigated with sterile saline prior to closure. The primary endpoint was PJI as defined by 2018 International Consensus Meeting criteria with a minimum follow-up of 1 year. Multivariate logistic regression was used to determine the association between dilute povidone-iodine irrigation and PJI while controlling for demographics, comorbidities, and operative factors.

RESULTS

In total, 340 patients (1.09%) developed PJI. Dilute povidone-iodine irrigation was associated with 2.34 times lower rate of PJI (0.6% vs 1.3%). Using multiple regression, dilute povidone-iodine remained significantly associated with a reduction in PJI. The absolute risk reduction was 0.73% and number needed to treat was 137 patients. Female gender, American Society of Anesthesiologists score, operative time, anesthesia type, prophylactic antibiotic type, and tranexamic acid were other significant factors in the regression model.

CONCLUSION

The routine use of dilute povidone-iodine could prevent 1 PJI for every 137 TJA patients, regardless of their preoperative risk. These findings support the use of povidone-iodine irrigation as a safe and cost-effective measure to reduce PJI.

Is It the Surgeon, the Patient, or the Device? A Comprehensive Clinical and Radiological Evaluation of Factors Influencing Patient Satisfaction in 648 Total Knee Arthroplasties

Total knee arthroplasty (TKA) is a successful and safe surgical procedure for treating osteoarthritic knees, but despite the overall good results, some patients remain dissatisfied. The aim of this study is to evaluate the influence of patient-related and surgery-related variables in a consecutive group of patients that underwent TKA. Individuals (n = 648) who had TKA performed between 01 January 2013 and 31 December 2017 were enrolled in the study. Postoperative Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, Knee Injury and Osteoarthritis Outcome Score (KOOS) and Forgotten Joint score (FJS-12) were collected at a mean follow-up of 4.79 years. Patient satisfaction was assessed with a questionnaire. Determinants of satisfaction (age, sex, smoking, presence of diabetes or cardiovascular disease, pain in other joints, preoperative arthritic stage) and components of satisfaction (slope variation, mechanical axis variation, outlier final alignment, surgeon experience) were examined to identify which variables correlated with positive outcome. Correlations with septic and mechanicals failures were also evaluated. Thirteen percent of patients were unsatisfied, despite good results in KOOS, WOMAC and FJS-12 tests. Female gender, low Kellgren–Lawrence grade and the presence of back pain and pain in other joints were factors associated with poor clinical results. Poorer clinical results were also reported in younger patients. Infection rate was correlated with active smoking and mechanical failure with an outlier final alignment. Comorbidities, smoking habits and high expectations have a big influence on TKA results and on final satisfaction after surgery.

Fructosamine is a valuable marker for glycemic control and predicting adverse outcomes following total hip arthroplasty: a prospective multi-institutional investigation

Recently, fructosamine has shown promising results in predicting adverse outcomes following total knee arthroplasty. The purpose of this study was to assess the utility of fructosamine to predict adverse outcomes following total hip arthroplasty (THA). A prospective multi-center study involving four institutions was conducted. All primary THA were evaluated for glycemic control using fructosamine levels prior to surgery. Adverse outcomes were assessed at a minimum 1 year from surgery. Primary outcome of interest was periprosthetic joint infection (PJI) based on the International Consensus Meeting (ICM) criteria. Secondary outcomes assessed were superficial infections, readmissions and death. Based on previous studies on the subject, fructosamine levels above 293 µmol/L were used to define inadequate glycemic control. Overall 1212 patients were enrolled in the present study and were available for follow up at a minimum 1 year from surgery. Of those, 54 patients (4.5%) had elevated fructosamine levels (> 293 µmol/L) and these patients were 6.7 times more likely to develop PJI compared to patients with fructosamine levels below 293 µmol/L (p = 0.002). Patients with elevated fructosamine were also associated with more readmissions (16.7% vs. 4.4%, p < 0.007) and a higher mortality rate (3.7% vs. 0.6%, p = 0.057). These associations remained statistically significant in a multi-regression analysis after adjusting for age, comorbidities and length of stay; Adjusted odds ratio were 6.37 (95% confidence interval 1.98–20.49, p = 0.002) for PJI and 2.68 (95% confidence interval 1.14–6.29, p = 0.023) for readmissions. Fructosamine is a good predictor of adverse outcomes in patients undergoing THA and should be used routinely to mitigate morbidity and mortality risk.

Prevention of Periprosthetic Joint Infection (PJI): A Clinical Practice Protocol in High-Risk Patients

Background: Periprosthetic joint infection (PJI) represents 25% of failed total knee arthroplasties (TKA). The European Knee Associates (EKA) formed a transatlantic panel of experts to perform a literature review examining patient-related risk factors with the objective of producing perioperative recommendations in PJI high-risk patients. Methods: Multiple databases (Pubmed/MEDLINE, EMBASE, Scopus, Cochrane Library) and recommendations on TKA PJI prevention measures from the International Consensus Meetings on PJI from the AAOS and AAHKS were reviewed. This represents a Level IV study. Results: Strong evidence was found on poor glycemic control, obesity, malnutrition, and smoking being all associated with increased rates of PJI. In the preoperative period, patient optimization is key: BMI < 35, diet optimization, Hemoglobin A1c < 7.5, Fructosamine < 292 mmol/L, smoking cessation, and MRSA nasal screening all showed strong evidence on reducing PJI risk. Intraoperatively, a weight-based antibiotic prophylaxis, accurate fluid resuscitation, betadine and chlorhexidine dual skin preparation, diluted povidone iodine solution irrigation, tranexamic acid administration, and monofilament barbed triclosan-coated sutures for soft tissues closure all represented effective prevention measures. In the postoperative period, failure to reach normalization of ESR, CRP, D-dimer, and IL-6 six weeks postoperatively suggested early PJI. Conclusion: The current recommendations from this group of experts, based on published evidence, support risk stratification to identify high-risk patients requiring implementation of perioperative measures to reduce postoperative PJI.

2019 John Insall Award: Fructosamine is a better glycaemic marker compared with glycated haemoglobin (HbA1C) in predicting adverse outcomes following total knee arthroplasty: a prospective multicentre study

AIMS

The best marker for assessing glycaemic control prior to total knee arthroplasty (TKA) remains unknown. The purpose of this study was to assess the utility of fructosamine compared with glycated haemoglobin (HbA1c) in predicting early complications following TKA, and to determine the threshold above which the risk of complications increased markedly.

PATIENTS AND METHODS

This prospective multi-institutional study evaluated primary TKA patients from four academic institutions. Patients (both diabetics and non-diabetics) were assessed using fructosamine and HbA1c levels within 30 days of surgery. Complications were assessed for 12 weeks from surgery and included prosthetic joint infection (PJI), wound complication, re-admission, re-operation, and death. The Youden's index was used to determine the cut-off for fructosamine and HbA1c associated with complications. Two additional cut-offs for HbA1c were examined: 7% and 7.5% and compared with fructosamine as a predictor for complications.

RESULTS

Overall, 1119 patients (441 men, 678 women) were included in the study. Fructosamine level of 293 µmol/l was identified as the optimal cut-off associated with complications. Patients with high fructosamine (> 293 µmol/l) were 11.2 times more likely to develop PJI compared with patients with low fructosamine (p = 0.001). Re-admission and re-operation rates were 4.2 and 4.5 times higher in patients with fructosamine above the threshold (p = 0.005 and p = 0.019, respectively). One patient (1.7%) from the elevated fructosamine group died compared with one patient (0.1%) in the normal fructosamine group (p = 0.10). These complications remained statistically significant in multiple regression analysis. Unlike fructosamine, all three cut-offs for HbA1c failed to show a significant association with complications.

CONCLUSION

Fructosamine is a valid and an excellent predictor of complications following TKA. It better reflects the glycaemic control, has greater predictive power for adverse events, and responds quicker to treatment compared with HbA1c. These findings support the screening of all patients undergoing TKA using fructosamine and in those with a level above 293 µmol/l, the risk of surgery should be carefully weighed against its benefit. Cite this article: Bone Joint J 2019;101-B(7 Supple C):3-9.