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Kułakowski M, Elster K, Szymczak M, Ślęczka P, Baumgart M, Królikowska A, Reichert P. Comparison of the effect of combined usage of povidone-iodine irrigation and topical vancomycin powder to the use of povidone-iodine irrigation alone on the periprosthetic joint infection incidence rate in patients undergoing primary total hip and knee arthroplasty: a protocol for multicenter prospective randomized clinical trial. Trials 2024; 25:468. [PMID: 38987786 PMCID: PMC11234679 DOI: 10.1186/s13063-024-08306-3] [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: 01/19/2024] [Accepted: 07/01/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND With the increasing number of joint replacement surgeries, periprosthetic joint infection (PJI) has become a significant concern in orthopedic practice, making research on PJI prevention paramount. Therefore, the study will aim to compare the effect of combined usage of povidone-iodine and topical vancomycin powder to the use of povidone-iodine alone on the PJI incidence rate in patients undergoing primary total hip (THA) and total knee arthroplasty (TKA). METHODS The prospective randomized clinical trial will be conducted in two independent voivodeship hospitals with extensive experience in lower limb arthroplasties. The studied material will comprise 840 patients referred to hospitals for primary THA or TKA. The patients will be randomly allocated to two equal groups, receiving two different interventions during joint replacement. In group I, povidone-iodine irrigation and consecutively topical vancomycin powder will be used before wound closure. In group II, only povidone-iodine lavage irrigation will be used before wound closure. The primary outcome will be the incidence rate of PJI based on the number of patients with PJI occurrence within 90 days after arthroplasty. The occurrence will be determined using a combined approach, including reviewing hospital records for readmissions and follow-up phone interviews with patients. The infection will be diagnosed based on Musculoskeletal Infection Society criteria. The chi-square test will be used to compare the infection rates between the two studied groups. Risk and odds ratios for the between-groups comparison purposes will also be estimated. Medical cost analysis will also be performed. DISCUSSION A randomized clinical trial comparing the effect of combined usage of povidone-iodine irrigation and vancomycin powder to the use of povidone-iodine irrigation alone in preventing PJIs after primary arthroplasty is crucial to advancing knowledge in orthopedic surgery, improving patient outcomes, and guiding evidence-based clinical practices. TRIAL REGISTRATION ClinicalTrials.gov NCT05972603 . Registered on 2 August 2023.
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Affiliation(s)
- Michał Kułakowski
- Orthopaedic and Trauma Surgery Department, Independent Public Healthcare Center in Rypin, Rypin, Poland
| | - Karol Elster
- Orthopaedic and Trauma Surgery Department, Independent Public Healthcare Center in Rypin, Rypin, Poland
| | - Mateusz Szymczak
- Orthopaedic and Trauma Surgery Department, Independent Public Healthcare Center in Rypin, Rypin, Poland
| | - Paweł Ślęczka
- Trauma and Orthopedic Surgery Department, Independent Public Healthcare Center in Myslenice, Myslenice, Poland
| | - Mariusz Baumgart
- Department of Normal Anatomy, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Toruń, Poland
| | - Aleksandra Królikowska
- Ergonomics and Biomedical Monitoring Laboratory, Department of Physiotherapy, Faculty of Health Sciences, Wroclaw Medical University, Wroclaw, Poland.
| | - Paweł Reichert
- Department of Orthopedics, Traumatology and Hand Surgery, Faculty of Medicine, Wroclaw Medical University, Wroclaw, Poland
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Mesfin A, Botros M, Benn L, Kulp A. Risk Factors for Surgical Site Infections and the Effects of Betadine Irrigation and Intrawound Vancomycin Powder on Infection Rates in Spine Tumor Surgery. Cureus 2024; 16:e64591. [PMID: 39144892 PMCID: PMC11324008 DOI: 10.7759/cureus.64591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2024] [Indexed: 08/16/2024] Open
Abstract
Background Surgical site infection (SSI) following spine tumor surgery results in delays in radiation therapy and the initiation of systemic treatment. The study aims to assess risk factors for SSI in malignancy-related spinal infections and rates of infection observed in a single center with the use of betadine irrigation (BI) and intrawound vancomycin powder (IVP). Methods Spine tumor patients managed from 11/2012 to 11/2023 were identified using a surgical database (JotLogs, Efficient Surgical Apps, Portland, Maine). Inclusion criteria were patients receiving BI and IVP and alive at 30 days post-op. Exclusion criteria were patients not receiving a combination of BI and IVP due to allergies and mortality within 30 days of surgery. Patient demographics, histology, history of pre-operative and post-operative radiation treatment history, tumor location, procedure type, number of procedures per patient, SSI, wound culture results, and mortality were collected. Results One hundred two patients undergoing 130 procedures had an SSI rate of 3.85% (5/130). There were 18.6% primary and 81.4% metastatic tumors. Demographics were average age 59.5 years old (range 7-92), 60.8% male, 39.2% female, White 88.2%, Black 9.8%, and others 2%. Pre-operative radiation therapy was significantly associated with the risk of SSI (p=0.005). Percutaneous instrumentation did not lead to a significant difference in infection rates (p=0.139). There was no significant difference in infection rates between primary and metastatic tumors (p=0.58). Multivariable regression analysis revealed pre-operative radiation (OR: 18.1; 95%CI: 1.9-172.7; p=0.009) as the statistically significant independent risk factor. Conclusions Pre-operative radiation therapy remains a risk factor for SSI. However, percutaneous instrumentation did not lead to SSI, and there was no significant difference in infection rates between primary and metastatic tumors. SSI rate was 3.85% in patients who had a combination of BI and IVP in spine tumor surgery.
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Affiliation(s)
- Addisu Mesfin
- Department of Orthopedics Surgery, MedStar Washington Hospital Center, Washington, USA
| | - Mina Botros
- Department of Orthopedics & Physical Performance, University of Rochester Medical Center, Rochester, USA
| | - Lancelot Benn
- Department of Orthopedics Surgery, MedStar Washington Hospital Center, Washington, USA
| | - Andrea Kulp
- Department of Orthopedics & Physical Performance, University of Rochester Medical Center, Rochester, USA
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Wu X, Chen W, Rong R, Pan B, Hu X, Zheng L, Alimu A, Chu C, Tu Y, Zhang Z, Ye Y, Gu M, Sheng P. Application of the New Irrigation Protocol to Reduce Recurrence Rate in the Management Of Periprosthetic Joint Infection. Orthop Surg 2024; 16:577-584. [PMID: 38238252 PMCID: PMC10925507 DOI: 10.1111/os.13948] [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: 06/18/2023] [Revised: 10/24/2023] [Accepted: 10/24/2023] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVE Irrigation is a conventional treatment for acute and chronic periprosthetic joint infections (PJI). However, there has been no unified standard for irrigation during surgery for PJI in the past, and the efficacy is uncertain. The purpose of this study is to create a new irrigation protocol to enhance the infection control rate and reduce the postoperative recurrence rate of PJI patients. METHODS We conducted a single-institution retrospective review with a total of 56 patients who underwent revision total hip or knee arthroplasties due to PJI from January 2011 to January 2022. Conventional irrigation (CI) was used in 32 cases, and standard operating procedure of irrigation (SOPI) was used in 24. The CI protocol carries out an empirical irrigation after debridement, which is quite random. Our SOPI protocol clearly stipulates the soaking concentration and time of hydrogen peroxide and povidone-iodine. The irrigation is carried out three times, and tissue samples are taken from multiple parts before and after irrigation, which are sent for microbial culture. The important statistical indicators were the rate of positive microbiological culture and postoperative recurrence rate with an average follow-up of 24 average months. RESULTS The drainage volume was lower in the SOPI group than in the CI group on postoperative day 3 (p < 0.01) and 7 (p = 0.016). In addition, the percentage of positive microbiological cultures after the third irrigation was less than that before (p < 0.01) and after (p < 0.01) the first irrigation. The most common causative organism was Staphylococcus aureus, which was detected in 25.0% and 12.5% of the SOPI and CI groups, respectively. The failure rate at the final follow-up was 8.3% and 31.3% (p = 0.039) for the SOPI and CI groups, respectively. CONCLUSION Compared with the traditional CI method, SOPI standardized the soaking time of hydrogen peroxide and povidone-iodine, increased the frequency of and irrigation, and proved that microorganisms were almost completely removed through the microbial culture of multiple tissues. SOPI has the potential to become a standardized irrigation process worthy of promotion, effectively reducing the postoperative recurrence rate of PJI patients.
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Affiliation(s)
- Xiaoyu Wu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Weishen Chen
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Rong Rong
- Department of Nosocomial InfectionThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
| | - Baiqi Pan
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Xuantao Hu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Linli Zheng
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Aerman Alimu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Chenghan Chu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Yucheng Tu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Ziji Zhang
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Yongyu Ye
- Department of Spinal SurgeryGuangdong Provincial People's HospitalGuangzhouChina
| | - Minghui Gu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Puyi Sheng
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
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Azar A, Ryan K, Ibe I, Montgomery S. Rank-Ordered List of Cost-effective Strategies for Preventing Prosthetic Joint Infection in Total Joint Arthroplasty in an Academic US Hospital. Orthopedics 2023; 46:327-332. [PMID: 37276445 DOI: 10.3928/01477447-20230531-02] [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: 06/07/2023]
Abstract
Although the overall rate of prosthetic joint infection (PJI) is low, it remains a major complication associated with total joint arthroplasty (TJA). PJI represents a significant economic burden to the health care system that is projected to increase commensurate with increasing joint replacement volumes. This review provides a rank-ordered list of cost-effective strategies that are performable intraoperatively and have data supporting their efficacy at preventing PJI after TJA. This study may be helpful in assisting surgeons, ambulatory surgery center owners, and hospital acquisition committees to make reasonable and cost-conscious decisions in the face of changing reimbursement. [Orthopedics. 2023;46(6):327-332.].
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Mancino F, Yates PJ, Clark B, Jones CW. Use of topical vancomycin powder in total joint arthroplasty: Why the current literature is inconsistent? World J Orthop 2023; 14:589-597. [PMID: 37662663 PMCID: PMC10473911 DOI: 10.5312/wjo.v14.i8.589] [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: 12/28/2022] [Revised: 03/28/2023] [Accepted: 04/20/2023] [Indexed: 08/17/2023] Open
Abstract
Periprosthetic joint infection (PJI) is a rare but terrible complication in hip and knee arthroplasty, and the use of topical vancomycin powder (VP) has been investigated as a tool to potentially reduce its incidence. However, there remains no consensus on its efficacy. Therefore, the aim of this review is to provide an overview on the application of topical vancomycin in orthopaedic surgery focusing on the recent evidence and results in total joint arthroplasty. Several systematic reviews and meta-analyses on topical VP in hip and knee arthroplasty have been recently published reporting sometimes conflicting results. Apart from all being limited by the quality of the included studies (mostly level III and IV), confounding variables are often included potentially leading to biased conclusions. If taken into consideration the exclusive use of VP in isolation, the available data, although very limited, suggest that it does not reduce the infection rate in routine primary hip and knee arthroplasty. Therefore, we still cannot advise for a routinary application. A properly powered randomized-controlled trial would be necessary to clarify the role of VP in hip and knee arthroplasty. Based on the analysis of the current evidence, the use of topical VP appears to be safe when used locally in terms of systemic adverse reactions, hence, if proven to be effective, it could bring great benefits due to its low cost and accessibility.
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Affiliation(s)
- Fabio Mancino
- Department of Orthopaedics, Fiona Stanley Hospital, Perth 6150, Australia
| | - Piers J Yates
- Department of Orthopaedics, Fiona Stanley Hospital, Perth 6150, Australia
- Department of Orthopaedics, The Orthopaedic Research Foundation of Western Australia, Perth 6010, Australia
- Department of Orthopaedics, University of Western Australia, Perth 6009, Australia
| | - Benjamin Clark
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth 6150, Australia
| | - Christopher W Jones
- Department of Orthopaedics, Fiona Stanley Hospital, Perth 6150, Australia
- Department of Orthopaedics, The Orthopaedic Research Foundation of Western Australia, Perth 6010, Australia
- Department of Orthopaedics, Curtin University, Perth 6102, Australia
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Affiliation(s)
- Fabio Mancino
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK
- Princess Grace Hospital, London, UK
| | - Vanya Gant
- Department of Microbiology, University College Hospital, London, UK
| | - Dominic R M Meek
- Department of Trauma and Orthopaedic Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Fares S Haddad
- Princess Grace Hospital, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
- The Bone & Joint Journal , London, UK
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Garvin KL, Kildow BJ, Hewlett AL, Hartman CW, Fey PD. The Challenge of Emerging Resistant Gram-Positive Pathogens in Hip and Knee Periprosthetic Joint Infections. J Bone Joint Surg Am 2023:00004623-990000000-00781. [PMID: 37053296 DOI: 10.2106/jbjs.22.00792] [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: 04/15/2023]
Abstract
➤ An increase in resistant bacterial pathogens has occurred over the last 4 decades. ➤ Careful patient selection and improving or correcting risk factors for periprosthetic joint infection (PJI) before elective surgical treatment are strongly recommended. ➤ Appropriate microbiological methods, including those used to detect and grow Cutibacterium acnes, are recommended. ➤ Antimicrobial agents used in the prevention or management of infection should be selected appropriately and the duration of therapy should be carefully considered in order to mitigate the risk of developing bacterial resistance. ➤ Molecular methods including rapid polymerase chain reaction (PCR) diagnostics, 16S sequencing, and/or shotgun and/or targeted whole-genome sequencing are recommended in culture-negative cases of PJI. ➤ Expert consultation with an infectious diseases specialist (if available) is recommended to assist with the appropriate antimicrobial management and monitoring of patients with PJI.
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Affiliation(s)
- Kevin L Garvin
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska
| | - Beau J Kildow
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska
| | - Angela L Hewlett
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Curtis W Hartman
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska
| | - Paul D Fey
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, Nebraska
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Affiliation(s)
- Robin Patel
- From the Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, and the Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
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Bourget-Murray J, Azad M, Gofton W, Abdelbary H, Garceau S, Grammatopoulos G. Is the routine use of local antibiotics in the management of periprosthetic joint infections justified? Hip Int 2023; 33:4-16. [PMID: 36447342 DOI: 10.1177/11207000221139467] [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] [Indexed: 12/05/2022]
Abstract
Periprosthetic joint infection (PJI) following total hip and total knee arthroplasty continues to be a leading cause of re-operation and revision arthroplasty. Not only is the treatment of PJI notoriously challenging, but success rates are variable. Regardless of the surgical strategy used, successful management of PJI requires a comprehensive surgical debridement focused at eradicating the underlying biofilm followed by appropriate antimicrobial therapy. Although systemic antimicrobial delivery continues to be a cornerstone in the treatment of PJI, many surgeons have started using local antibiotics to deliver higher concentrations of antibiotics directly into the vulnerable joint and adjacent soft tissues, which often have compromised vascularity. Available evidence on the use of topical powder, bone cement, and calcium sulphate carriers for local delivery of antibiotics during the initial treatment of PJI is limited to studies that are extremely heterogeneous. There is currently no level-1 evidence to support routinely using these products. Further, appropriately powered, prospective studies are needed to quantify the safety and efficacy of antibiotic-located calcium-sulphate carriers to justify their added costs. These products should not encourage surgeons to deviate from best practice guidelines, such as those recommended during the International Consensus Meeting on Musculoskeletal Infections.
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Affiliation(s)
| | - Marisa Azad
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Wade Gofton
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Hesham Abdelbary
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Simon Garceau
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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Israel SK, Jaramillo E, Liska WD. Preclosure povidone-iodine lavage in total hip replacement surgery: Infection outcomes and cost-benefit analysis. Vet Surg 2023; 52:33-41. [PMID: 36411945 DOI: 10.1111/vsu.13910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 09/16/2022] [Accepted: 10/25/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To report the outcomes and cost-benefit analysis of preclosure povidone-iodine lavage (PrePIL) used to reduce the risk of infection following total hip replacement (THR) surgery. STUDY DESIGN Retrospective study. ANIMALS One thousand six hundred ninety-nine dogs, 17 cats. METHODS The medical records of 2213 consecutive THR cases were reviewed to determine the incidence of infection. The last 102 were treated with PrePIL using a commercially sourced 0.035% povidone-iodine solution. Postoperative infection rates were compared. A cost-benefit analysis was used to calculate if a PrePIL protocol is economically feasible. RESULTS Twenty-one THRs out of 2111 (0.99%) that did not have PrePIL developed infection. Infection occurred in none of the 102 PrePIL cases. Cost analysis revealed a PrePIL break-even cost at $49.74 and a break-even infection rate of 0.949%. No complications were identified related to the use of PrePIL. CONCLUSION Preclosure povidone-iodine lavage appeared to be efficacious in lowering THR infection rates, and it appeared to be safe for this use based on our 102 consecutive cases. The cost of the PrePIL was minimal compared to the overall cost to resolve THR infection and the potential effect on hip function prognosis. The math formulas developed can be used by surgeons to calculate cost effectiveness and break-even cost based on their THR infection rate, and to compare to the cost of a THR revision and infection resolution. CLINICAL SIGNIFICANCE At current costs, PrePIL can be used in 2415 THR cases at a similar cost of a single revision surgery and resolution of a periprosthetic infection.
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Otero JE, Brown TS, Courtney PM, Kamath AF, Nandi S, Fehring KA. What's New in Musculoskeletal Infection. J Bone Joint Surg Am 2022; 104:1228-1235. [PMID: 35700085 DOI: 10.2106/jbjs.22.00183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jesse E Otero
- OrthoCarolina Hip and Knee Center, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Timothy S Brown
- Department of Orthopedics and Sports, Houston Methodist Hospital, Houston, Texas
| | | | - Atul F Kamath
- Orthopaedic & Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sumon Nandi
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Keith A Fehring
- OrthoCarolina Hip and Knee Center, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
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12
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Systematic Review and Meta-Analysis of Intrawound Vancomycin in Total Hip and Total Knee Arthroplasty: A Continued Call for a Prospective Randomized Trial. J Arthroplasty 2022; 37:1405-1415.e1. [PMID: 35314283 DOI: 10.1016/j.arth.2022.03.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/12/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Periprosthetic joint injection (PJI) is a rare, but life-altering complication of total joint arthroplasty (TJA). Though intrawound vancomycin powder (IVP) has been studied in other orthopedic subspecialties, its efficacy and safety in TJA has not been established. METHODS PubMed and MEDLINE databases were used to identify studies utilizing IVP in primary and revision total hip (THA) and knee arthroplasty (TKA). Postoperative PJI data were pooled using random effect models with results reported as odds ratios (ORs) and 95% confidence intervals (CIs). Studies were weighted by the inverse variance of their effect estimates. RESULTS Overall, 16 of the 1871 studies identified were pooled for final analysis, yielding 33,731 patients totally. Of these, 17 164 received IVP. In aggregate, patients who received IVP had a decreased rate of PJI (OR 0.46, P < .05). Separately, TKA and THA patients who received IVP had lower rates of PJI (OR 0.41, P < .05 and OR 0.45, P < .05, respectively). Aggregate analysis of primary TKA and THA patients also revealed a decreased PJI rate (OR 0.44, P < .05). Pooled revision TKA and THA patients had a similar decrease in PJI rates (OR 0.30, P < .05). Although no publication bias was appreciated, these findings are limited by the low-quality evidence available. CONCLUSION While IVP may reduce the risk of PJI in primary and revision TJA, its widespread use cannot be recommended until higher-quality data, such as that obtained from randomized control trials, are available. This study underscores the continued need for more rigorous studies before general adoption of this practice by arthroplasty surgeons.
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Scott RD. Avoiding Sepsis After Total Knee Arthroplasty: Be Gentle, Vigilant, and Proactive. Arthroplast Today 2022; 15:9-12. [PMID: 35345442 PMCID: PMC8956843 DOI: 10.1016/j.artd.2022.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 02/16/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Richard D. Scott
- Corresponding author. 10 Nickerson Rd, Dedham, MA 02026, USA. Tel.: +1 617 966 6056.
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Li T, Zhang H, Chan PK, Fung WC, Fu H, Chiu KY. Risk factors associated with surgical site infections following joint replacement surgery: a narrative review. ARTHROPLASTY 2022; 4:11. [PMID: 35490250 PMCID: PMC9057059 DOI: 10.1186/s42836-022-00113-y] [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: 09/14/2021] [Accepted: 12/31/2021] [Indexed: 11/17/2022] Open
Abstract
Background Surgical site infection following joint replacement surgery is still a significant complication, resulting in repeated surgery, prolonged antibiotic therapy, extended postoperative hospital stay, periprosthetic joint infection, and increased morbidity and mortality. This review discusses the risk factors associated with surgical site infection. Related risk factors The patient-related factors include sex, age, body mass index (BMI), obesity, nutritional status, comorbidities, primary diagnosis, living habits, and scores of the American Society of Anesthesiologists physical status classification system, etc. Surgery-related factors involve preoperative skin preparation, prolonged duration of surgery, one-stage bilateral joint replacement surgery, blood loss, glove changes, anti-microbial prophylaxis, topical anti-bacterial preparations, wound management, postoperative hematoma, etc. Those risk factors are detailed in the review. Conclusion Preventive measures must be taken from multiple perspectives to reduce the incidence of surgical site infection after joint replacement surgery.
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Affiliation(s)
- Tao Li
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Haining Zhang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Ping Keung Chan
- Department of Orthopaedics &, Traumatology Queen Mary Hospital, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong SAR, China.
| | - Wing Chiu Fung
- Department of Orthopaedics &, Traumatology Queen Mary Hospital, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong SAR, China
| | - Henry Fu
- Department of Orthopaedics &, Traumatology Queen Mary Hospital, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong SAR, China
| | - Kwong Yuen Chiu
- Department of Orthopaedics &, Traumatology Queen Mary Hospital, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong SAR, China
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Ortiz D, Teo GM, Lygrisse K, Aggarwal VK, Long WJ. Increased Rate of Early Periprosthetic Joint Infection in Total Hip Arthroplasty With the Use of Alternatives to Cefazolin Despite Additional Gram-Negative Coverage. Arthroplast Today 2022; 14:183-188. [PMID: 35342780 PMCID: PMC8943215 DOI: 10.1016/j.artd.2022.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 01/28/2022] [Accepted: 02/14/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Dionisio Ortiz
- Department of Orthopedics, NYU Langone Health, New York, NY, USA
- Capital Region Orthopedic Associates, Albany, NY, USA
- Corresponding author. Capital Region Orthopedic Associates, 1367 Washington Ave, Suite 300, Albany, NY 12206, USA. Tel.: +1 518 261 7237.
| | - Greg M. Teo
- Department of Orthopedics, NYU Langone Health, New York, NY, USA
| | | | | | - William J. Long
- Department of Orthopedics, NYU Langone Health, New York, NY, USA
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
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16
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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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17
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Kurtz SM, Higgs GB, Lau E, Iorio RR, Courtney PM, Parvizi J. Hospital Costs for Unsuccessful Two-Stage Revisions for Periprosthetic Joint Infection. J Arthroplasty 2022; 37:205-212. [PMID: 34763048 DOI: 10.1016/j.arth.2021.10.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 10/14/2021] [Accepted: 10/27/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Although 2-stage exchange arthroplasty is the preferred surgical treatment for periprosthetic joint infection (PJI) in the United States, little is known about the risk of complications between stages, mortality, and the economic burden of unsuccessful 2-stage procedures. METHODS The 2015-2019 Medicare 100% inpatient sample was used to identify 2-stage PJI revisions in total hip and knee arthroplasty patients using procedural codes. We used the Fine and Gray sub-distribution adaptation of the conventional Kaplan-Meier method to estimate the probability of completing the second stage of the 2-stage PJI infection treatment, accounting for death as a competing risk. Hospital costs were estimated from the hospital charges using "cost-to-charge" ratios from Centers for Medicare and Medicaid Services. RESULTS A total of 5094 total hip arthroplasty and 13,062 total knee arthroplasty patients had an index revision for PJI during the study period. In the first 12 months following the first-stage explantation, the likelihood of completing a second-stage PJI revision was 43.1% (95% confidence interval [CI] 41.7-44.5) for hips and 47.9% (95% CI 47.0-48.8) for knees. Following explantation, 1-year patient survival rates for hip and knee patients were 87.4% (95% CI 85.8-88.9) and 91.4% (95% CI 90.6-92.2), respectively. The median additional cost for hospitalizations between stages was $23,582 and $20,965 per patient for hips and knees, respectively. Hospital volume, Northeast or Midwest region, and younger age were associated with reduced PJI costs (P < .05). CONCLUSION Although viewed as the most preferred, the 2-stage revision strategy for PJI had less than a 50% chance of successful completion within the first year, and was associated with high mortality rates and substantial costs for treatment failure.
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Affiliation(s)
| | | | | | - Richard R Iorio
- Brigham and Women's Hospital, Orthopaedic and Arthritis Center, Boston, MA
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18
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Shohat N, Goh GS, Harrer SL, Brown S. Dilute Povidone-Iodine Irrigation Reduces the Rate of Periprosthetic Joint Infection Following Hip and Knee Arthroplasty: An Analysis of 31,331 Cases. J Arthroplasty 2022; 37:226-231.e1. [PMID: 34742876 DOI: 10.1016/j.arth.2021.10.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/30/2021] [Accepted: 10/27/2021] [Indexed: 02/02/2023] Open
Abstract
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.
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Affiliation(s)
- Noam Shohat
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Samantha L Harrer
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Scot Brown
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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19
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Ong J, Tang A, Rozell JC, Babb JS, Schwarzkopf R, Lin D. Factors predicting hip joint aspiration yield or “dry taps” in patients with total hip arthroplasty. J Orthop Surg Res 2022; 17:42. [PMID: 35065660 PMCID: PMC8783512 DOI: 10.1186/s13018-022-02942-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/24/2021] [Indexed: 11/29/2022] Open
Abstract
Background Image-guided joint aspirations used to assist the diagnosis of periprosthetic joint infection (PJI) may commonly result in a dry tap–or insufficient fluid for culture and cell count analysis. Dry tap aspirations are painful and invasive for patients and often utilize a subsequent saline lavage to obtain a microbiology sample. Currently, there is a paucity of the literature addressing predictors that could suggest whether a dry tap will occur. The purpose of this study was to examine the effects of various factors on “dry tap” occurrence in patients with suspected PJI following total hip arthroplasty (THA). Methods A retrospective review was performed among THA patients suspected for PJI who received image-guided joint aspiration procedures at our institution from May 2016 to February 2020. The procedural factors included the imaging modality used for aspiration, anatomic approach, needle gauge size used, and the presence of a trainee. The patient-specific factors included number of prior ipsilateral hip surgeries, femoral head size, ESR/CRP values, and BMI. Results In total, 336 patients met our inclusion criteria. One hundred and twenty hip aspirations resulted in a dry tap (35.7%) where the patients underwent a saline lavage. Among the procedural and patient-specific factors, none of the factors were found to be statistically different between the two cohorts nor conferred any greater odds of a dry tap occurring. Conclusion No associations with dry tap occurrence were found among the procedural and patient-specific factors studied. Further research is needed to identify additional factors that may be more predictive of dry taps.
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20
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Villa JM, Pannu TS, Higuera-Rueda CA. What's New in Adult Reconstructive Knee Surgery. J Bone Joint Surg Am 2022; 104:97-106. [PMID: 34780387 DOI: 10.2106/jbjs.21.01080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jesus M Villa
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
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21
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Buchalter DB, Nduaguba A, Teo GM, Kugelman D, Aggarwal VK, Long WJ. Cefazolin remains the linchpin for preventing acute periprosthetic joint infection following primary total knee arthroplasty. Bone Jt Open 2022; 3:35-41. [PMID: 35014563 PMCID: PMC9047071 DOI: 10.1302/2633-1462.31.bjo-2021-0051.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Aims Despite recent literature questioning their use, vancomycin and clindamycin often substitute cefazolin as the preoperative antibiotic prophylaxis in primary total knee arthroplasty (TKA), especially in the setting of documented allergy to penicillin. Topical povidone-iodine lavage and vancomycin powder (VIP) are adjuncts that may further broaden antimicrobial coverage, and have shown some promise in recent investigations. The purpose of this study, therefore, is to compare the risk of acute periprosthetic joint infection (PJI) in primary TKA patients who received cefazolin and VIP to those who received a non-cephalosporin alternative and VIP. Methods This was a retrospective cohort study of 11,550 primary TKAs performed at an orthopaedic hospital between 2013 and 2019. The primary outcome was PJI occurring within 90 days of surgery. Patients were stratified into two groups (cefazolin vs non-cephalosporin) based on their preoperative antibiotic. All patients also received the VIP protocol at wound closure. Bivariate and multiple logistic regression analyses were performed to control for potential confounders and identify the odds ratio of PJI. Results In all, 10,484 knees (90.8%) received cefazolin, while 1,066 knees (9.2%) received a non-cephalosporin agent (either vancomycin or clindamycin) as preoperative prophylaxis. The rate of PJI in the cefazolin group (0.5%; 48/10,484) was significantly lower than the rate of PJI in the non-cephalosporin group (1.0%; 11/1,066) (p = 0.012). After controlling for confounding variables, the odds ratio (OR) of developing a PJI was increased in the non-cephalosporin cohort compared to the cefazolin cohort (OR 2.389; 1.2 to 4.6); p = 0.01). Conclusion Despite the use of topical irrigant solutions and addition of local antimicrobial agents, the use of a non-cephalosporin perioperative antibiotic continues to be associated with a greater risk of TKA PJI compared to cefazolin. Strategies that increase the proportion of patients receiving cefazolin rather than non-cephalosporin alternatives must be emphasized. Cite this article: Bone Jt Open 2022;3(1):35–41.
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Affiliation(s)
| | - Afamefuna Nduaguba
- New York University Langone Orthopedic Hospital, New York, New York, USA
| | - Greg M. Teo
- Hospital for Special Surgery, New York, New York, USA
| | - David Kugelman
- New York University Langone Orthopedic Hospital, New York, New York, USA
| | - Vinay K. Aggarwal
- New York University Langone Orthopedic Hospital, New York, New York, USA
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22
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Lawrie CM, Kazarian GS, Barrack T, Nunley RM, Barrack RL. Intra-articular administration of vancomycin and tobramycin during primary cementless total knee arthroplasty : determination of intra-articular and serum elution profiles. Bone Joint J 2021; 103-B:1702-1708. [PMID: 34719272 DOI: 10.1302/0301-620x.103b11.bjj-2020-2453.r1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
AIMS Intra-articular administration of antibiotics during primary total knee arthroplasty (TKA) may represent a safe, cost-effective strategy to reduce the risk of acute periprosthetic joint infection (PJI). Vancomycin with an aminoglycoside provides antimicrobial cover for most organisms isolated from acute PJI after TKA. However, the intra-articular doses required to achieve sustained therapeutic intra-articular levels while remaining below toxic serum levels is unknown. The purpose of this study is to determine the intra-articular and serum levels of vancomycin and tobramycin over the first 24 hours postoperatively after intra-articular administration in primary cementless TKA. METHODS A prospective cohort study was performed. Patients were excluded if they had poor renal function, known allergic reaction to vancomycin or tobramycin, received intravenous vancomycin, or were scheduled for same-day discharge. All patients received 600 mg tobramycin and 1 g of vancomycin powder suspended in 25 cc of normal saline and injected into the joint after closure of the arthrotomy. Serum from peripheral venous blood and drain fluid samples were collected at one, four, and 24 hours postoperatively. All concentrations are reported in µg per ml. RESULTS A total of 22 patients were included in final analysis. At one, four, and 24 hours postoperatively, mean (95% confidence interval (CI)) serum concentrations were 2.4 (0.7 to 4.1), 5.0 (3.1 to 6.9), and 4.8 (2.8 to 6.9) for vancomycin and 4.9 (3.4 to 6.3), 7.0 (5.8 to 8.2), and 1.3 (0.8 to 1.8) for tobramycin; intra-articular concentrations were 1,900.6 (1,492.5 to 2,308.8), 717.9 (485.5 to 950.3), and 162.2 (20.5 to 304.0) for vancomycin and 2,105.3 (1,389.9 to 2,820.6), 403.2 (266.6 to 539.7), and 98.8 (0 to 206.5) for tobramycin. CONCLUSION Intra-articular administration of 1 g of vancomycin and 600 mg of tobramycin as a solution after closure of the arthrotomy in primary cementless TKA achieves therapeutic intra-articular concentrations over the first 24 hours postoperatively and does not reach sustained toxic levels in peripheral blood. Cite this article: Bone Joint J 2021;103-B(11):1702-1708.
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Affiliation(s)
- Charles Murray Lawrie
- Miami Orthopedics and Sports Medicine Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Gregory S Kazarian
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill-Cornell Medical School, New York, New York, USA
| | - Toby Barrack
- Department of Orthopedic Surgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Ryan M Nunley
- Department of Orthopedic Surgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Robert L Barrack
- Department of Orthopedic Surgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
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23
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Ashley BS, Parvizi J. Current Insights in the Evaluation and Treatment of Infected Total Knee Arthroplasty. J Knee Surg 2021; 34:1388-1395. [PMID: 34600438 DOI: 10.1055/s-0041-1737030] [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
Total knee arthroplasty is a widely successful procedure, but a small percentage of patients have a postoperative course complicated by periprosthetic joint infection (PJI). PJI is a difficult problem to diagnose and to treat, and the management of PJI differs, depending on the acuity of the infection. This paper discusses the established and newer technologies developed for the diagnosis of PJI as well as different treatment considerations and surgical solutions currently available.
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Affiliation(s)
- Blair S Ashley
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
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24
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Feder OI, Yeroushalmi D, Lin CC, Galetta MS, Meftah M, Lajam CM, Slover JD, Schwarzkopf R, Bosco JA, Macaulay WB. Incomplete Administration of Intravenous Vancomycin Prophylaxis is Common and Associated With Increased Infectious Complications After Primary Total Hip and Knee Arthroplasty. J Arthroplasty 2021; 36:2951-2956. [PMID: 33840539 DOI: 10.1016/j.arth.2021.03.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 03/03/2021] [Accepted: 03/14/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Vancomycin is often used as antimicrobial prophylaxis in patients undergoing total hip or knee arthroplasty. Vancomycin requires longer infusion times to avoid associated side effects. We hypothesized that vancomycin infusion is often started too late and that delayed infusion may predispose patients to increased rates of surgical site infections and prosthetic joint infections. METHODS We reviewed clinical data for all primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients at our institution between 2013 and 2020 who received intravenous vancomycin as primary perioperative gram-positive antibiotic prophylaxis. We calculated duration of infusion before incision or tourniquet inflation, with a cutoff of 30 minutes defining adequate administration. Patients were divided into two groups: 1) appropriate administration and 2) incomplete administration. Surgical factors and quality outcomes were compared between groups. RESULTS We reviewed 1047 primary THA and TKA patients (524 THAs and 523 TKAs). The indication for intravenous vancomycin usage was allergy (61%), methicillin-resistant staphylococcus aureus colonization (17%), both allergy and colonization (14%), and other (8%). 50.4% of patients began infusion >30 minutes preoperatively (group A), and 49.6% began infusion <30 minutes preoperatively (group B). Group B had significantly higher rates of readmissions for infectious causes (3.6 vs 1.3%, P = .017). This included a statistically significant increase in confirmed prosthetic joint infections (2.2% vs 0.6%, P = .023). Regression analysis confirmed <30 minutes of vancomycin infusion as an independent risk factor for PJI when controlling for comorbidities (OR 5.22, P = .012). CONCLUSION Late infusion of vancomycin is common and associated with increased rates of infectious causes for readmission and PJI. Preoperative protocols should be created to ensure appropriate vancomycin administration when indicated.
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Affiliation(s)
- Oren I Feder
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - David Yeroushalmi
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Charles C Lin
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Matthew S Galetta
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Moretza Meftah
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Claudette M Lajam
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - James D Slover
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Joseph A Bosco
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - William B Macaulay
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
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25
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Buchalter DB, Teo GM, Kirby DJ, Aggarwal VK, Long WJ. Surgical Approach to Total Hip Arthroplasty Affects the Organism Profile of Early Periprosthetic Joint Infections. JB JS Open Access 2020; 5:e20.00111. [PMID: 33376926 PMCID: PMC7757834 DOI: 10.2106/jbjs.oa.20.00111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The optimal approach for total hip arthroplasty (THA) remains hotly debated. While wound complications following the direct anterior approach are higher than with other approaches, the organism profile of periprosthetic joint infections (PJIs) by approach remains unknown. Our goal was to compare the organism profiles of PJIs following direct anterior and non-anterior THA. METHODS We retrospectively reviewed 12,549 primary THAs (4,515 direct anterior and 8,034 non-anterior) that had been performed between January 2012 and September 2019 at a university-affiliated single-specialty orthopaedic hospital to identify patients with an early postoperative PJI. Criteria used for the diagnosis of a PJI were the National Healthcare Safety Network, which screens for PJI that occurs within 90 days of index arthroplasty, and the Musculoskeletal Infection Society guidelines. Patient demographic information and organism characteristics were recorded for analysis. RESULTS We identified 84 patients (38 who underwent the direct anterior approach and 46 who underwent the non-anterior approach) with an early postoperative PJI following primary THA (0.67% total THA PJI rate, 0.84% direct anterior THA PJI rate, and 0.57% non-anterior THA PJI rate). The direct anterior THA cohort had a significantly lower body mass index and American Society of Anesthesiologists score than the non-anterior THA cohort (29.5 versus 35.2 kg/m2, p < 0.0001; 2.29 versus 2.63, p = 0.016, respectively). Regarding organism profile, patients in the direct anterior THA cohort had significantly more monomicrobial gram-negative infections than the non-anterior THA cohort (4 versus 0, p = 0.038). We did not identify any demographic risk factors other than approach for gram-negative PJI. There were no significant differences in methicillin-resistant Staphylococcus aureus, methicillin-sensitive Staphylococcus aureus, coagulase-negative Staphylococcus, obligate anaerobes, polymicrobial, or PJIs due to other organisms by approach. CONCLUSIONS Direct anterior THA approaches have a greater risk of monomicrobial gram-negative PJI, likely due to the unique microbiome of the inguinal region. While targeted infection prophylaxis may reduce these infections, it is not entirely effective on its own. Future studies with larger sample sizes are required to help us develop more targeted perioperative infection prophylaxis. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Daniel B. Buchalter
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - Greg M. Teo
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - David J. Kirby
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - Vinay K. Aggarwal
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - William J. Long
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
- Insall Scott Kelly Institute for Orthopaedics and Sports Medicine, New York, NY
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