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Nazal MR, Galloway JL, Dhaliwal KK, Nishiyama SK, Shields JS. Dilute Povidone-Iodine Solution Prevents Intraoperative Contamination of Sterile Water Basins During Total Joint Arthroplasty. J Arthroplasty 2020; 35:241-246. [PMID: 31537375 DOI: 10.1016/j.arth.2019.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 07/31/2019] [Accepted: 08/05/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Periprosthetic joint infection is a major complication of total joint arthroplasty (TJA). The intraoperative splash basin has been found to be a potential source of contamination. Although consensus recommendations against the use of splash basin have been made, splash basin use continues to be taught and utilized in practice. This study aims to investigate the effect of dilute betadine addition to the sterile water (SW) contents (0.02% solution) of the splash basin on contamination rates. This intervention could preserve the functionality and preferential use of the splash basin. The primary outcome of this study is the rate of splash basin contamination, with secondary outcomes of prevalence of culture speciation and mean operative times association with the rate of positive cultures. METHODS Patients undergoing primary TJA were enrolled in a randomized controlled trial with assignment to either the intervention/betadine group, in which dilute betadine was added to the standard SW splash basin, or the control/standard SW group. For a total cohort of 104 patients, a 120 mL aliquot sample of basin fluid was collected at incision ("preprocedure") and closure ("postprocedure"). Samples were cultured and monitored for 48 hours for growth, with further testing as necessary to identify microbial speciation. RESULTS Of the final 100 postprocedure samples, 0 (0.0%) were positive in the betadine group, while there were 23 (47.9%) positive samples in the SW group (P < .001). Of the positive cultures, the most common species grown were coagulase-negative Staphylococcus, Corynebacterium, and Micrococcus. The mean operative time was an average of 11 minutes longer for cases with positive cultures. CONCLUSION In conclusion, treating SW splash basins with dilute povidone-iodine (0.02% solution) eliminates intraoperative contamination of splash basins in TJA procedures. This intervention is simple, low cost, and readily implementable, making it a reasonable addition to TJA protocols. LEVEL OF EVIDENCE Level 1, Controlled Laboratory Study.
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Affiliation(s)
- Mark R Nazal
- Department of Orthopaedic Surgery, Center for Total Joint Replacement, Wake Forest Baptist Health, Winston-Salem, NC
| | - James L Galloway
- Department of Orthopaedic Surgery, Center for Total Joint Replacement, Wake Forest Baptist Health, Winston-Salem, NC
| | - Karanpreet K Dhaliwal
- Department of Orthopaedic Surgery, Center for Total Joint Replacement, Wake Forest Baptist Health, Winston-Salem, NC
| | - Steven K Nishiyama
- Department of Orthopaedic Surgery, Center for Total Joint Replacement, Wake Forest Baptist Health, Winston-Salem, NC
| | - John S Shields
- Department of Orthopaedic Surgery, Center for Total Joint Replacement, Wake Forest Baptist Health, Winston-Salem, NC
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Lindgren KE, Pelt CE, Anderson MB, Peters CL, Spivak ES, Gililland JM. A Chlorhexidine Solution Reduces Aerobic Organism Growth in Operative Splash Basins in a Randomized Controlled Trial. J Arthroplasty 2018; 33:211-215. [PMID: 28917619 DOI: 10.1016/j.arth.2017.08.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 08/04/2017] [Accepted: 08/12/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Despite recommendations against the use of splash basins, due to the potential of bacterial contamination, our observation has been that they continue to be used in operating theaters. In hopes of decontaminating the splash basin, we sought to determine if the addition of chlorhexidine gluconate (CHG) would eliminate aerobic bacterial growth within the splash basin. METHODS After Institutional Review Board approval, we began enrollment in a randomized controlled trial comparing 2 splash basin solutions. Splash basins (n = 111) were randomized to either the standard of care (control) solution of sterile water or the experimental solution containing 0.05% CHG. One 20 mL aliquot was taken from the basin at the end of the surgical case and delivered to an independent laboratory. Samples were plated on tryptic soy agar (medium) and incubated at 30°C-35°C to encourage growth. After 48-72 hours, the agar plates were examined for growth and a standard plate count of aerobic cultures was performed. RESULTS The sterile water group was found to have bacterial growth in 9% of samples compared to no growth in the CHG group (P = .045). The organisms included Micrococcus luteus, Staphylococcus hominis, Gram-variable coccobacilli, and unidentifiable Gram-positive rods. CONCLUSION Given the safety and efficacy of a concentration of 0.05% CHG in reducing the bacterial contamination in the operative splash basin, it would seem that if the practice of using a splash basin in the operating theater is to be continued, the addition of an antiseptic solution such as that studied here should be considered.
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Affiliation(s)
- Kevin E Lindgren
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | | | - Mike B Anderson
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | | | - Emily S Spivak
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
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Tripathi A, Melo JS. Development of Nano-Antimicrobial Biomaterials for Biomedical Applications. ADVANCES IN BIOMATERIALS FOR BIOMEDICAL APPLICATIONS 2017; 66. [PMCID: PMC7122509 DOI: 10.1007/978-981-10-3328-5_12] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Around the globe, there is a great concern about controlling growth of pathogenic microorganisms for the prevention of infectious diseases. Moreover, the greater incidences of cross contamination and overuse of drugs has contributed towards the development of drug resistant microbial strains making conditions even worse. Hospital acquired infections pose one of the leading complications associated with implantation of any biomaterial after surgery and critical care. In this regard, developing non-conventional antimicrobial agents which would prevent the aforementioned causes is under the quest. The rapid development in nanoscience and nanotechnology has shown promising potential for developing novel biocidal agents that would integrate with a biomaterial to prevent bacterial colonization and biofilm formation. Metals with inherent antimicrobial properties such as silver, copper, zinc at nano scale constitute a special class of antimicrobials which have broad spectrum antimicrobial nature and pose minimum toxicity to humans. Hence, novel biomaterials that inhibit microbial growth would be of great significance to eliminate medical device/instruments associated infections. This chapter comprises the state-of-art advancements in the development of nano-antimicrobial biomaterials for biomedical applications. Several strategies have been targeted to satisfy few important concern such as enhanced long term antimicrobial activity and stability, minimize leaching of antimicrobial material and promote reuse. The proposed strategies to develop new hybrid antimicrobial biomaterials would offer a potent antibacterial solution in healthcare sector such as wound healing applications, tissue scaffolds, medical implants, surgical devices and instruments.
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Affiliation(s)
- Anuj Tripathi
- Nuclear Agriculture & Biotechnology Div, Bhabha Atomic Research Centre, Mumbai, Maharashtra India
| | - Jose Savio Melo
- Nuclear Agriculture & Biotechnology Div, Bhabha Atomic Research Centre, Mumbai, Maharashtra India
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Chen Z, Wang C, Jiang W, Tang N, Chen B. A Review on Surgical Instruments of Knee Arthroscopic Debridement and Total Hip Arthroplasty. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.procir.2017.05.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Liu G, Chen S, Fang J, Xu B, Li S, Hao Y, Al-Dhabi NA, Deng S, Duraipandiyan V. Vancomycin microspheres reduce postoperative spine infection in an in vivo rabbit model. BMC Pharmacol Toxicol 2016; 17:61. [PMID: 27899142 PMCID: PMC5129598 DOI: 10.1186/s40360-016-0105-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 11/19/2016] [Indexed: 01/23/2023] Open
Abstract
Background Surgical site infections are common and devastating complications after implants related surgeries. Staphylococcus aureus contamination is a leading cause of surgical site infections. This study aims at assessing the effect of vancomycin microspheres on reducing Staphylococcus aureus infection in an in vivo rabbit model. Methods Sixty surgical sites of 20 New Zealand White rabbits underwent spinal implant were randomly divided to three groups: the control group, the vancomycin group and vancomycin microspheres group. The surgical sites were incubated with 100 μl 1 × 107 CFU S. aureus ATCC 25923. Prior to closure, vancomycin and vancomycin microspheres were placed into the wounds of the rabbits in the vancomycin group and the vancomycin microspheres group, respectively. The rabbits were killed on postoperative day 7. Standard quantification techniques were used to analyze biomaterial centered and soft tissue bacterial growth. The bacteria were further confirmed by PCR with primers from the thermostable nuclease gene of S. aureus. Results All the rabbits survived the surgery and no postoperative wound complications or systemic illness occurred. Results showed that the bacterial cultures were 76.9, 30.8, and 15.4% in the control group, vancomycin group, and vancomycin microspheres group. Vancomycin microspheres treatments significantly decreased the infection rate compared to the control group (p < 0.05). Conclusion Vancomycin microspheres combined with preoperative ceftriaxone is effective to reduce postoperative S. aureus infection compared with the control group.
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Affiliation(s)
- Gang Liu
- Tianjin Hospital, Jiefangnan Road 406, Tianjin, 300210, China.,Tianjin Medical University, Qixiangtai Road 22, Tianjin, 300070, China
| | - Si Chen
- Tianjin Hospital, Jiefangnan Road 406, Tianjin, 300210, China.,Tianjin Medical University, Qixiangtai Road 22, Tianjin, 300070, China
| | - Jun Fang
- College of bioscience and biotechnology, Hunan Agricultural University, Changsha, Hunan, 410128, China
| | - Baoshan Xu
- Tianjin Hospital, Jiefangnan Road 406, Tianjin, 300210, China.,Tianjin Medical University, Qixiangtai Road 22, Tianjin, 300070, China
| | - Shuang Li
- Tianjin Hospital, Jiefangnan Road 406, Tianjin, 300210, China
| | - Yonghong Hao
- Tianjin Hospital, Jiefangnan Road 406, Tianjin, 300210, China
| | - Naif A Al-Dhabi
- Department of Botany and Microbiology, Addiriyah Chair for Environmental Studies, College of Science, King Saud University, P.O.Box.2455, Riyadh, 11451, Saudi Arabia
| | - Shucai Deng
- Tianjin Hospital, Jiefangnan Road 406, Tianjin, 300210, China. .,Tianjin Medical University, Qixiangtai Road 22, Tianjin, 300070, China.
| | - Veeramuthu Duraipandiyan
- Department of Botany and Microbiology, Addiriyah Chair for Environmental Studies, College of Science, King Saud University, P.O.Box.2455, Riyadh, 11451, Saudi Arabia
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Naganuma Y, Takakubo Y, Hirayama T, Tamaki Y, Pajarinen J, Sasaki K, Goodman SB, Takagi M. Lipoteichoic acid modulates inflammatory response in macrophages after phagocytosis of titanium particles through Toll-like receptor 2 cascade and inflammasomes. J Biomed Mater Res A 2015; 104:435-44. [PMID: 26440284 DOI: 10.1002/jbm.a.35581] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Revised: 09/12/2015] [Accepted: 10/01/2015] [Indexed: 12/25/2022]
Abstract
Toll-like receptor 2 (TLR2) and nucleotide-binding and oligomerization domain-like receptors with a pyrin domain 3 (NLRP3) inflammasomes have been presumed to participate in the pathogenesis of aseptic implant loosening. The aim of this study is to analyze the cellular localization of TLR2 and NLRP3 inflammasomes in the periprosthetic tissue from aseptically loose hip implants as well as the expression of these molecules in macrophages stimulated in vitro with titanium particles (Ti) coated with lipoteichoic acid (LTA). Using immunohistochemistry, immunoreactivity of TLR2 and NLRP3 inflammasomes was found in macrophages within the foreign body granulomatosis. Using RAW264.7 cells, stimulation with Ti increased the messenger RNA (mRNA) levels of TLR2 and TNF-α. Stimulation with LTA-coated Ti enhanced mRNA levels of NLRP3 and IL-1β, whereas reinforced secretion of IL-1β was not detected in spite of marked release of TNF-α. Finally, the same cells with silenced Irak2, an adaptor protein in the TLR2 cascade, suppressed this NLRP3 upregulation. This study suggests that TLR2 and NLRP3 inflammasomes are factors involved in cross-talk mediating the foreign body type response to wear particles. In addition, discrepant behavior in the release between TNF-α and IL-1β release may explain the variable pathomechanisms of aseptic implant loosening without acute inflammatory reactions.
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Affiliation(s)
- Yasushi Naganuma
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Yuya Takakubo
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Tomoyuki Hirayama
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Yasunobu Tamaki
- Department of Clinical Medicine, Yamagata Saisei Hospital, Yamagata, Japan
| | - Jukka Pajarinen
- Department of Orthopaedic Surgery, Stanford University School of Medicine, California, 94063.,Department of Medicine, Biomedicum Helsinki, University of Helsinki, Helsinki, FIN-00014 HY, Finland
| | - Kan Sasaki
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Stuart B Goodman
- Department of Orthopaedic Surgery, Stanford University School of Medicine, California, 94063
| | - Michiaki Takagi
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan
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Yoon BH, Ha YC, Lee YK, Koo KH. Postoperative Deep Infection After Cemented Versus Cementless Total Hip Arthroplasty: A Meta-Analysis. J Arthroplasty 2015; 30:1823-7. [PMID: 26021907 DOI: 10.1016/j.arth.2015.04.041] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 03/30/2015] [Accepted: 04/20/2015] [Indexed: 02/01/2023] Open
Abstract
Periprosthetic joint infection (PJI) is a serious complication of total hip arthroplasty (THA). The objective of this meta-analysis was to compare the PJI rate between cemented and cementless THAs. Eight clinical studies (2 randomized controlled trials and 6 observational studies) were available for the analysis. Meta-analysis (with a fixed-effects model) and subgroup analysis were performed by research design and meta-regression was performed by continuous moderator. The overall incidence of PJI was 0.4% (357/84,200). The incidence was 0.5% (310/67,531) in cemented group, and 0.3% (47/16,669) in cementless group (P=0.008). The meta-analysis revealed that the use of cement in THA was associated with an increased risk of PJI (odds ratio 1.53; 95% confidence interval 1.120 to 2.100; P=0.008).
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Affiliation(s)
- Byung-Ho Yoon
- Department of Orthopaedic Surgery, Inje University College of Medicine, Seoul Paik Hospital, Seoul, Korea
| | - Yong-Chan Ha
- Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Young-Kyun Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Kyung-Hoi Koo
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
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8
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Risk stratified usage of antibiotic-loaded bone cement for primary total knee arthroplasty: short term infection outcomes with a standardized cement protocol. J Arthroplasty 2014; 29:1622-4. [PMID: 24703363 DOI: 10.1016/j.arth.2014.02.032] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 02/24/2014] [Accepted: 02/26/2014] [Indexed: 02/01/2023] Open
Abstract
Efficacy of antibiotic cement (ALBC) in primary knee arthroplasty (pTKA) has been debated. The study's purpose was to examine efficacy of ALBC versus plain cement (PBC) in preventing infection in high-risk patients undergoing pTKA. 3292 consecutive pTKAs were divided into three cohorts: (1) patients receiving only PBC, (2) patients receiving only ALBC, and (3) only high-risk patients receiving ALBC. Cohorts' infections were compared. The 30-day infection rates for cohorts 1, 2, 3 were 0.29%, 0.20%, and 0.13% respectively. 6-month rates were 0.39%, 0.54% and 0.38%. 1-year rates were 0.78%, 0.61%, and 0.64%. Differences in infection rates at all time intervals were not statistically significant. The study supports that even judicious risk-stratified usage of ALBC may not confer added benefit in decreasing infection at one year.
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Jonsson EÖ, Johannesdottir H, Robertsson O, Mogensen B. Bacterial contamination of the wound during primary total hip and knee replacement. Median 13 years of follow-up of 90 replacements. Acta Orthop 2014; 85:159-64. [PMID: 24650025 PMCID: PMC3967258 DOI: 10.3109/17453674.2014.899848] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Previous work has shown that despite preventive measures, intraoperative contamination of joint replacements is still common, although most of these patients seem to do well in follow-up of up to 5 years. We analyzed the prevalence and bacteriology of intraoperative contamination of primary joint replacement and assessed whether its presence is related to periprosthetic joint infection (PJI) on long-term follow-up. PATIENTS AND METHODS 49 primary total hip replacements (THRs) and 41 total knee replacements (TKRs) performed between 1990 and 1991 were included in the study. 4 bacterial swabs were collected intraoperatively during each procedure. Patients were followed up for joint-related complications until March 2011. RESULTS 19 of 49 THRs and 22 of 41 TKRs had at least 1 positive culture. Coagulase-negative staphylococci and Staphylococcus aureus were the most common organisms, contaminating 28 and 9 operations respectively. Where information was available, bacteria from 27 of 29 contaminated operations were susceptible to the prophylactic antibiotic administered. 13% of samples gathered before 130 min of surgery were contaminated, as compared to 35% collected after that time. 2 infections were diagnosed, both in TKRs. 1 of them may have been related to intraoperative contamination. INTERPRETATION Intraoperative contamination was common but few infections occurred, possibly due to the effect of prophylactic antibiotics. The rate of contamination was higher with longer duration of surgery. It appears that positive results from intraoperative swabs do not predict the occurrence of PJI.
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Affiliation(s)
- Eythor Örn Jonsson
- Department of Orthopedic Surgery, Landspitali University Hospital, Iceland.
| | | | - Otto Robertsson
- Department of Orthopedic Surgery, Landspitali University Hospital, Iceland.
| | - Brynjolfur Mogensen
- Faculty of Medicine, University of Iceland, Iceland.,Department of Emergency Medicine, Landspitali University Hospital, Reykjavik, Iceland.
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Comparison of contamination of femoral heads and pre-processed bone chips during hip revision arthroplasty. Cell Tissue Bank 2013; 14:615-20. [DOI: 10.1007/s10561-013-9362-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Accepted: 01/15/2013] [Indexed: 11/26/2022]
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Glait SA, Schwarzkopf R, Gould S, Bosco J, Slover J. Is repetitive intraoperative splash basin use a source of bacterial contamination in total joint replacement? Orthopedics 2011; 34:e546-9. [PMID: 21902155 DOI: 10.3928/01477447-20110714-06] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Splash basins are used in arthroplasty cases to wash instruments. Several studies in the literature have shown these basins being a potential source of bacterial infection. This study assesses the risk of contamination of intraoperative splash basins used to wash and store instruments. A total of 46 random clean primary arthroplasty cases (32 hips, 13 knees, and 1 unicondylar knee) were studied by taking cultures of sterile splash basins as soon as they are opened (controls) and again at wound closure after instruments and debris have come into contact with the sterile water. All cultures were taken with sterile culture swabs and sent to the laboratory for aerobic, anaerobic, and fungal culture. Outcome measured was any positive culture. A total of 92 cultures from 46 cases were tested. Only 1 (2.17%) control culture, which grew Streptococcus viridans, was positive for bacterial growth. One of 46 samples (2.17%) taken at wound closure was positive for coagulase-negative Staphylococcus. Mean time between basin opening and wound closure was 180±45 minutes. For the 1 infected sample taken at the conclusion of the case, it was 240 minutes. Previous studies show contamination rates as high as 74% for splash basins used intraoperatively. Our study contradicts the belief that splash basins are a high source of infection, with only 2.17% of basins showing contamination. Splash basins can be a potential source of contamination, but the risk is not as high as previously cited in the orthopedic literature.
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Affiliation(s)
- Sergio A Glait
- Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, New York, New York, USA
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12
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Pountos I, Georgouli T, Bird H, Kontakis G, Giannoudis PV. The effect of antibiotics on bone healing: current evidence. Expert Opin Drug Saf 2011; 10:935-45. [DOI: 10.1517/14740338.2011.589833] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Specific staphylococcal polymerase chain reaction can be a complementary tool for identifying causative organisms and guiding antibiotic management in orthopaedic infections. CURRENT ORTHOPAEDIC PRACTICE 2010. [DOI: 10.1097/bco.0b013e3181f20439] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
STUDY DESIGN Three noncontiguous spinal implant sites in 1 rabbit were challenged with Staphylococcus aureus and local antibiotic prophylaxis was given with gentamicin in controlled-release microspheres (poly(lactic-coglycolic-acid) [PLGA]). Postoperative biomaterial-centered infection on and around the titanium rods was assessed using standard bacterial quantification essays. OBJECTIVE To assess surgical site and biomaterial-centered infection reduction with controlled release gentamicin from microspheres against S. aureus. SUMMARY OF BACKGROUND DATA A postoperative biomaterial-centered infection can be devastating after successful thoracolumbar spinal surgery and puts a high burden on patients, families, surgeons, and hospitals, endangering both our healthcare budget and our ability to perform challenging cases in patients with increasing numbers of comorbidities. Systemic antibiotics often do not reach "dead-space" hematomas where bacteria harbor after surgery, whereas local, controlled release gentamicin prophylaxis through PLGA microspheres showed favorable pharmacokinetics data to achieve local bactericidal concentrations for up to 7 days after surgery. METHODS A well published rabbit spinal implant model with systemic cephalosporin prophylaxis was challenged to create a baseline infection of approximately 70% in control sites. We then challenged 3 noncontiguous titanium rods inside the laminectomy defect with 10e6 colony forming units S. aureus and randomly treated 2 sites with gentamicin PLGA microspheres and 1 site with PLGA carrier only (control). Standard quantification techniques were used to assess biomaterial centered and soft tissue bacterial growth after 7 days. RESULTS After establishing reliable infection rates in control sites, the therapeutic arm of the study was started. Surgical site infections were found in 75% of control sites, whereas gentamicin microspheres reduced the incidence down to 38% in the same rabbits. Biomaterial-centered infection was reduced from 58% to 23% only in all sites challenged with 10e6 S. aureus. CONCLUSION Postoperative, biomaterial-centered infection was reduced at least 50% with intraoperative gentamicin microspheres in the face of systemic cephalosporin prophylaxis and high dose S. aureus in a laminectomy defect in rabbits. The data are statistically and clinically significant, and further animal testing is planned to confirm these results.
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Kuijer R, Jansen EJP, Emans PJ, Bulstra SK, Riesle J, Pieper J, Grainger DW, Busscher HJ. Assessing infection risk in implanted tissue-engineered devices. Biomaterials 2007; 28:5148-54. [PMID: 17597202 DOI: 10.1016/j.biomaterials.2007.06.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2007] [Accepted: 06/05/2007] [Indexed: 11/17/2022]
Abstract
Peri-operative contamination is the major cause of biomaterial-associated infections, highly complicating surgical patient outcomes. While this risk in traditional implanted biomaterials is well-recognised, newer cell-seeded, biologically conducive tissue-engineered (TE) constructs now targeted for human use have not been assessed for this possibility. We investigated infection incidence of implanted, degradable polyester TE scaffold biomaterials in rabbit knee osteochondral defects. Sterile, polyester copolymer scaffolds of different compositions and cell-accessible pore volumes were surgically inserted into rabbit osteochondral defects for periods of 3 weeks up to 9 months, either with or without initial seeding with autologous or allogeneic chondrocytes. Infection assessment included observation of pus or abscesses in or near the knee joint and post-mortem histological evaluation. Of 228 implanted TE scaffolds, 10 appeared to be infected: 6 scaffolds without cell seeding (3.6%) and 4 cell-seeded scaffolds (6.3%). These infections were evident across all scaffold types, independent of polymer composition or available pore volume, and up to 9 months. We conclude that infections in TE implants pose a serious problem with incidences similar to current biomaterials-associated infections. Infection control measures should be developed in tissue engineering to avoid further complications when TE devices emerge clinically.
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Affiliation(s)
- Roel Kuijer
- Department of Biomedical Engineering, University Medical Center Groningen, University of Groningen, P.O. Box 196, 9700 AD Groningen, The Netherlands.
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Howard JL, Hanssen AD. Principles of a clean operating room environment. J Arthroplasty 2007; 22:6-11. [PMID: 17919585 DOI: 10.1016/j.arth.2007.05.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2007] [Accepted: 05/08/2007] [Indexed: 02/01/2023] Open
Abstract
Optimizing the operating room environment is necessary to minimize the prevalence of arthroplasty infection. Reduction of bacterial contamination in the operating room should be a primary focus of all members of the operating room team. However, in recent years, there has been a decline in the emphasis of the basic principles of antisepsis in many operating rooms. The purpose of this review is to highlight important considerations for optimizing the operating room environment. These principles should be actively promoted by orthopedic surgeons in their operating rooms as part of a comprehensive approach to minimizing arthroplasty infection.
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Affiliation(s)
- James L Howard
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA
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Byrne AM, Morris S, McCarthy T, Quinlan W, O'byrne JM. Outcome following deep wound contamination in cemented arthroplasty. INTERNATIONAL ORTHOPAEDICS 2007; 31:27-31. [PMID: 16586132 PMCID: PMC2267550 DOI: 10.1007/s00264-006-0121-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2006] [Revised: 02/16/2006] [Accepted: 02/16/2006] [Indexed: 12/13/2022]
Abstract
Infection remains a devastating complication of joint replacement surgery causing a significant burden to both patient and surgeon. However, despite exhaustive prophylactic measures, intraoperative contamination still occurs during cemented arthroplasty with current infection rates of 1-2%. A study was undertaken to determine the incidence of perioperative contamination in cemented arthroplasty patients, to identify contaminating organisms, to identify contaminated regions within the operative wound, to identify factors associated with increased contamination, and finally to assess the medium-term clinical outcome in patients with confirmed intraoperative wound contamination. Eighty consecutive patients undergoing hip and knee cemented arthroplasty were prospectively enrolled over a 6-month period. All scrubbed personnel wore total body exhaust isolation suits and procedures were carried out in ultra-clean air theatres. Of 441 samples, contamination was identified at 21 sites (4.8%) representing a cohort of 18 patients (22.5%). Longer duration of surgery predisposed to higher contamination rates while lower contamination rates were significantly related to fewer gowned personnel within the ultra-clean system, and fewer total personnel in theatre during the procedure. None of the patients developed clinical evidence of deep prosthetic infection at follow-up. We noted a high incidence of intraoperative contamination despite standard prophylaxis. However, this was not reflected by a similar rate of postoperative infection. This may be due to a small bacterial inoculum in each case or may be due to the therapeutic effect of perioperative intravenous antibiotic prophylaxis.
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Affiliation(s)
- A M Byrne
- Cappagh National Orthopaedic Hospital, Dublin, 11, Ireland.
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Knobben BAS, van der Mei HC, van Horn JR, Busscher HJ. Transfer of bacteria between biomaterials surfaces in the operating room—An experimental study. J Biomed Mater Res A 2006; 80:790-9. [PMID: 17058211 DOI: 10.1002/jbm.a.30978] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Bacterial adhesion to and transfer between surfaces is a complicated process. With regard to the success of biomaterials implants, studies on bacterial adhesion and transfer should not be confined to biomaterials surfaces in the human body, but also encompass surfaces in the operating room, where the origin of many biomaterials related infections is found. The purpose of this study was to quantify the transfer of Staphylococcus aureus, Staphylococcus epidermidis, and Propionibacterium acnes from one operating room material to another, while accounting for surface hydrophobicity and roughness, moistness and application of friction during transfer. The tested operating room materials were gloves, broaches (orthopaedic drills), theatre gowns, and light handles. As a possible clinical intervention method to prevent transfer, it was investigated whether dipping the gloves in a chlorhexidine splash-basin affected the viability of the transferred bacteria. Transfer (moist and without friction) was demonstrated to some extent with all bacterial strains and with every material, ranging from 17% to 71%, and was influenced by the bacterial strain, moistness of the inoculum, the application of friction, and the characteristics of both the donating and the receiving surface. Dipping the glove material in 4% or 0.4% chlorhexidine solutions killed all bacteria present, regardless of whether surfaces were dried or moist and thus prevented transfer.
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Affiliation(s)
- Bas A S Knobben
- Department of Biomedical Engineering, University Medical Center Groningen, and University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
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Engesaeter LB, Espehaug B, Lie SA, Furnes O, Havelin LI. Does cement increase the risk of infection in primary total hip arthroplasty? Revision rates in 56,275 cemented and uncemented primary THAs followed for 0-16 years in the Norwegian Arthroplasty Register. Acta Orthop 2006; 77:351-8. [PMID: 16819671 DOI: 10.1080/17453670610046253] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The cementation of a total hip prosthesis may cause bone necrosis, either by direct toxicity or by generation of heat during the polymerization process. This necrotic bone may create conditions that encourage the growth of bacteria. We compared the revision rates due to infection in primary uncemented total hip arthroplasties (THAs) with those of cemented THAs with antibiotic-loaded cement and to those of cemented THAs without antibiotic cement. METHODS Data from the Norwegian Arthroplasty Register for the period 1987-2003 were used. To have comparable groups, we analyzed only primary THAs performed because of primary osteoarthrosis, and where both the acetabular and the femoral component of the prosthesis were either uncemented or cemented (n = 56,275). RESULTS In total, 252 revisions due to infection were reported. Compared to the uncemented THAs (n = 5,259), the risk of revision due to infection for THAs without antibiotic cement (n = 15,802) was increased 1.8 times (CI 1.0-3.1; p = 0.04). No differences could be detected when compared to THAs with antibiotic-loaded cement (n = 35,214) (RR 1.2, CI 0.7-2.0; p = 0.5). The average operating time for uncemented THAs was 15 min less than for cemented THAs. INTERPRETATION The risk of revision due to infection was the same for uncemented and for cemented arthroplasties with antibiotic-loaded cement, but higher for cemented arthroplasties without antibiotic cement. Our findings can be explained by reduced resistance to infection caused by the cement, which appears to be neutralized by adding antibiotic to the cement.
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Affiliation(s)
- Lars B Engesaeter
- Department of Orthopaedic Surgery, Department of Surgical Sciences, University of Bergen. Bergen, NO-5021, Norway.
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