Efficacy of dilute betadine solution irrigation in the prevention of postoperative infection of spinal surgery

Effects of povidone-iodine wound irrigation on surgical site infection in gastroenterological surgery: A randomized controlled trial

BACKGROUND

The irrigation efficacy of a povidone-iodine solution to prevent surgical site infection is still controversial. We assessed the irrigation effect with a povidone-iodine solution on the incidence of surgical site infection after gastroenterological surgery.

METHODS

This study is a single-center, prospective, randomized, blinded-end point superiority trial for surgical wound irrigation. Patients undergoing gastroenterological surgery were randomly assigned in a 1:1 replacement ratio using computer-generated randomization. Patients were grouped according to their surgical wound treatment into the control group using the normal sterile saline and the povidone-iodine group using 10% povidone-iodine solution after the NS solution. The main finding was 30-day surgical site infections assessed in the full analysis set.

RESULTS

From November 2020 to December 2022, 697 of 894 patients were eligible for the study, among which 347 were in the povidone-iodine group and 350 in the control group. Thirty-day surgical site infections occurred in 100 (14%) patients-54 (16%) in the povidone-iodine group and 46 (13%) in the control group (odds ratio, 1.229; 95% CI, 0.800-1.889; P = .406). Superficial incisional surgical site infections occurred in 30 (9%) and 15 (4%) patients, respectively (odds ratio, 2.154; 95% CI, 1.134-4.090; P = .026). Only 3 patients (1%) in the control group developed adverse skin reactions.

CONCLUSION

This study examined the irrigation efficacy of povidone-iodine for surgical site infection prevention compared to control in gastroenterological surgery. Povidone-iodine wound irrigation has shown no additional beneficial effect on the occurrence of surgical site infections.

Does Intrawound Vancomycin Decrease Postoperative Surgical Site Infection in Spine Surgery: A Retrospective Case-control Study

STUDY DESIGN

Retrospective Case-Control series.

OBJECTIVE

The objective of this study is to define the overall postoperative rate of surgical site infection (SSI) in patients undergoing spine surgery and examine the effects of intrawound Vancomycin on postoperative infection rates.

SUMMARY OF BACKGROUND DATA

Surgical site infections (SSI) account for 22% of all health care-associated infections. The use of intrawound Vancomycin in an attempt to reduce the incidence of postoperative SSI has not been sufficiently evaluated in the existing literature.

METHODS

All spine surgeries (n=19,081) from our institution were reviewed from 2003 to 2013. All cases of verified SSI were identified from the database. Cases were then matched to controls in a 1:1 fashion based on age, gender, and date of surgery (+/-30 d). Patient demographics, comorbidities, estimated blood loss, duration of surgery, intrawound administration of Vancomycin, and smoking status were evaluated.

RESULTS

At total of 316 cases of SSI after spine surgery were identified, representing an infection rate of 1.7%. The mean follow-up for cases and controls was 31.5 and 41.6 months, respectively. OR for intrawound Vancomycin was 0.44 (95% CI 0.23-0.88, P =0.019). OR for BMI greater than 30 was 1.63 (95% CI 1.04-2.56, P =0.03).

CONCLUSIONS

In this large cohort of spine surgery patients, administration of intrawound Vancomycin was associated with a significant reduction in postoperative surgical site infections. Further studies are needed to determine appropriate dosing and application as well as long-term safety in spine surgery.

Incisional Wound Irrigation for the Prevention of Surgical Site Infection: A Systematic Review and Network Meta-Analysis

Importance

Surgical site infections (SSIs) are common postoperative complications and associated with significant morbidity, mortality, and costs. Prophylactic intraoperative incisional wound irrigation is used to reduce the risk of SSIs, and there is great variation in the type of irrigation solutions and their use.

Objective

To compare the outcomes of different types of incisional prophylactic intraoperative incisional wound irrigation for the prevention of SSIs in all types of surgery.

Data Sources

PubMed, Embase, CENTRAL, and CINAHL databases were searched up to June 12, 2023.

Study Selection

Included in this study were randomized clinical trials (RCTs) comparing incisional prophylactic intraoperative incisional wound irrigation with no irrigation or comparing irrigation using different types of solutions, with SSI as a reported outcome. Studies investigating intracavity lavage were excluded.

Data Extraction and Synthesis

This systematic review and network meta-analysis is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Two reviewers independently extracted the data and assessed the risk of bias within individual RCTs using the Cochrane Risk of Bias 2 tool and the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation framework. A frequentist network meta-analysis was conducted, and relative risks (RRs) with corresponding 95% CIs were reported.

Main Outcome and Measure

The primary study outcome was SSI.

Results

A total of 1587 articles were identified, of which 41 RCTs were included in the systematic review, with 17 188 patients reporting 1328 SSIs, resulting in an overall incidence of 7.7%. Compared with no irrigation, antiseptic solutions (RR, 0.60; 95% CI, 0.44-0.81; high level of certainty) and antibiotic solutions (RR, 0.46; 95% CI, 0.29-0.73; low level of certainty) were associated with a beneficial reduction in SSIs. Saline irrigation showed no statistically significant difference compared with no irrigation (RR, 0.83; 95% CI, 0.63-1.09; moderate level of certainty).

Conclusions and Relevance

This systematic review and network meta-analysis found high-certainty evidence that prophylactic intraoperative incisional wound irrigation with antiseptic solutions was associated with a reduction in SSIs. It is suggested that the use of antibiotic wound irrigation be avoided due to the inferior certainty of evidence for its outcome and global antimicrobial resistance concerns.

The value of sequential application of hydrogen peroxide, povidone-iodine and physiological saline in reducing postoperative infections after total knee arthroplasty: A prospective, randomized, controlled study

BACKGROUND

Currently, in the field of total joint arthroplasty (TJA), there are no studies that have demonstrated the value of the sequential application of hydrogen peroxide, povidone-iodine, and physiological saline during the surgical procedure in decreasing postoperative infections in total knee arthroplasty (TKA), and in decreasing the incidence of periprosthetic joint infections (PJI) in particular. This study aimed to assess the efficacy of the sequential application of hydrogen peroxide, povidone-iodine, and physiological saline in reducing postoperative infections in TKA.

METHODS

The study prospectively included 4743 patients, with Group A (2371, 49.9%) receiving sequential intraoperative application of hydrogen peroxide, povidone-iodine, and physiological saline irrigation of the incision, and Group B (2372, 50.1%) receiving intraoperative application of physiological saline irrigation of the incision only, to collect the patients' baseline data and clinical characteristics, and to statistically assess the incidence of superficial infections and the PJI during the follow up period to evaluate the clinical value of the study.

RESULTS

The baseline levels of patients in Groups A and B were comparable. There were 132 (2.8%) lost visits during the study period. The incidence of superficial infections within 30 days after surgery was 0.22% in Group A and 1.17% in Group B, the difference between the two groups was statistically significant (P = 0.007). The incidence of PJI was 0.17% in Group A and 1.26% in Group B, the difference between the two groups was statistically significant (P = 0.0121).

CONCLUSION

Sequential application of hydrogen peroxide, povidone-iodine, and physiological saline to irrigate incision in TKA can significantly reduce the incidence of postoperative superficial infections and PJI. The scientific and rational application of this therapy intraoperatively greatly reduces the incidence of PJI and postoperative superficial infections, which is of great benefit to the patient's prognosis.

Non-inferiority and Safety of Increased Povidone-Iodine (Betadine) Concentration for Irrigation Following Primary Total Joint Arthroplasty (TJA)

Introduction Diluted Betadine (Purdue Pharma, Stamford, Conn) irrigation following primary total joint arthroplasty (pTJA) may reduce the risk of periprosthetic joint infection (PJI). A recent in vitro study found a minimal inhibitory concentration (MIC) of 0.63% Povidone-iodine (Betadine) for several bacterial isolates. This study reports outcomes of patients undergoing TJA using 0.54% Betadine irrigation compared to a historical cohort using 0.3% Betadine irrigation. Methods A retrospective chart review of patients who underwent pTJA from September 2017 to December 2020. 0.3% Betadine was used in a historical cohort and 0.54% Betadine in the experimental group. Patient demographics, intra-operative data, all-cause revision, and infection data were collected for the three-month post-operative period. Outcome frequencies between groups were compared using Fisher-Exact tests. Results Six hundred sixty-one patients underwent pTJA: 308 total knee arthroplasty (TKA), and 353 total hip arthroplasty (THA). 0.3% Betadine group had seven (3.1%) revisions: five (2.2%) underwent a revision for non-infectious reasons, and two (0.9%) for PJI. 0.54% Betadine group had 11 (2.5%) revisions: nine (2.1%) underwent revision for non-infectious reasons, two (0.4%) for PJI. No significant difference was found for rates of all-cause revision or infection between groups. No adverse intra-operative events occurred with the higher Betadine concentration. Conclusion This study demonstrated no difference in rates of all-cause revision or PJI when using 0.3% Betadine versus 0.54% Betadine for irrigation following pTJA. No adverse intraoperative events occurred with 0.54% Betadine irrigation. Given recent in vitro data supporting increased Betadine MIC, our results showed safety and non-inferiority with respect to three-month post-operative complication rates. Further investigation through a large powered randomized controlled study is needed to determine the optimal Betadine irrigation concentration for PJI prevention is required.

Effect of Commercially Available Wound Irrigation Solutions on Uninfected Host Tissue in a Murine Model

Background

Commercially available irrigation solutions are used to reduce bacterial contamination and prevent surgical site infections. However, the effect of these solutions on the healing capacity of tissue has not been well-established. The purpose of this study was to investigate the effects of 5 commercially available irrigation solutions on host tissue in a murine model.

Methods

There were 5 treatment groups: bacitracin, Clorpactin, Irrisept, Prontosan, Bactisure, and normal saline control. The irrigation solutions were applied to the wound for 30 seconds or 1 minute, as per the manufacturer's instructions, and then washed with normal saline. Mice were sacrificed at 3 days and 10 days. The tissue was examined histologically for inflammation, edema, granulation tissue formation, and re-epithelialization. Granulation tissue formation and re-epithelialization were surrogates for effective wound healing.

Results

All of the irrigation solutions had negative effects on host tissue in the acute phase. The inflammation and edema were improved in the later phase (10 days). Recovery and healing of the open wounds were observed for all groups at 10 days. The antiseptic irrigation solutions had similar cytotoxic effects on host tissue at 3 days and did not have delayed or compromised wound healing at 10 days when compared to normal saline control.

Conclusions

Single short-duration use of these commercially available antiseptic irrigation solutions appears to be safe in an uninfected wound. Data from this study will provide surgeons with useful information regarding the safety of using antiseptic wound irrigation solutions intraoperatively for prevention of surgical site infections.

Comparing the Efficacy of Povidone-Iodine Versus Normal Saline in Laparotomy Wound Irrigation to Prevent Surgical Site Infections: A Meta-Analysis

Surgical site infections (SSIs) are a known complication of laparotomies and intra-abdominal surgical operations leading to remarkable consequences on mortality, morbidity, and expenses. The study aims to assess the efficiency of irrigating laparotomy incision sites with povidone-iodine (PVI) or normal saline (NS) in diminishing the rate of SSIs in patients undergoing gastrointestinal operations for varying indications. Randomized controlled trials (RCTs) highlighting the contribution of laparotomy wound irrigation with PVI in opposition to NS in patients planned for laparotomy addressing numerous gastrointestinal issues, and their role in reducing SSI risk were obtained via searching of standard electronic medical databases. The analysis was conducted by utilizing meta-analysis principles procured by statistical software RevMan version 5.3 (Cochrane Collaboration, London, UK). The yield of medical databases exploration and inspection was 13 RCTs on 3816 patients who underwent laparotomy for different gastrointestinal operations. There were 1900 patients in the PVI group whereas 1916 patients received NS wound irrigations preceding closure of the laparotomy skin wound. In the random effects model analysis, the use of PVI for laparotomy wound irrigation was associated with the reduced risk (odds ratio = 0.54, 95% CI (0.30, 0.98), Z = 2.04, P = 0.04) of SSIs. Nevertheless, there was outstanding heterogeneity (Tau2 = 70; chi2 = 40.19, df = 12; P = 0.0001; I2 = 70%) among the included studies. According to the comprehensive analysis outcomes, it has been clinically proven that the use of PVI is highly effective in reducing the occurrence of SSIs, as well as their subsequent implications.

Reducing surgical site infections after spine surgery: the optimal amount of normal saline for intra-wound irrigation

BACKGROUND CONTEXT

Surgical site infection (SSI) following lumbar surgery can increase healthcare costs and lead to poor clinical outcome. Irrigation of wounds with saline solution is widely accepted globally and safe for nearly all kinds of surgery. However, the efficacy of different volumes of wound irrigation has not been addressed in elective spine surgery. The role and the optimal amount of intraoperative wound saline irrigation in preventing SSI in clean spinal surgery remain unclear.

PURPOSE

We aimed to investigate if insufficient intraoperative irrigation may be a risk factor for postoperative SSI. Additionally, we investigated the optimal amount of normal saline (NS) for irrigation to prevent postoperative SSI.

STUDY DESIGN

This is a retrospective study of patients with degenerative spinal stenosis who were treated surgically. Patients were grouped according to the amount of intra-wound irrigation during surgery.

PATIENT SAMPLE

We included 444 patients with degenerative lumbar spinal conditions who had undergone one to five level open spinal fusion surgeries from January 2015 through April 2020.

OUTCOME MEASURES

The definition of superficial or deep SSI in this study was based on the Centers for Disease Control and Prevention criteria for SSI. The fusion status accessed was based on the Bridwell grading system at the final follow-up. Self-reported and clinical outcome measures include visual analog scale and Oswestry Disability Index.

METHODS

A total of 193 patients underwent irrigation with a bulb syringe with manual method (B group) with 2,000 mL NS; 251 patients underwent interpulse battery-powered device irrigation (P group) with >6,000 mL NS. Based on our protocolized departmental guidelines, all patients received the same preoperative preparation and standard surgical steps and postoperative care plan. Patients' demographic and surgical parameters were recorded. The main outcome measures included superficial wound infection, deep infection and overall infection.

RESULTS

The incidence of overall SSI was 4.66% in the B group and 1.59% in the P group. The univariate analysis revealed a significant correlation with DM and irrigation amount per hour during surgery but not age, BMI, smoking, operative duration, fusion level, or blood loss. We determined the optimal irrigation amount during surgery as 1,400 mL per hour based on the receiver operating characteristic (ROC) curve (sensitivity, 92.3%; specificity, 44.1%). This was statistically significant (p=.033) with an odds ratio of 9.284 (95% confidence interval 1.2-72.0). In the analysis of surgical factors, the infection group had a significantly lower irrigation amount during surgery. To summarize, patients with diabetes and those receiving less than 1,400 mL of NS/hour had a higher likelihood of developing SSI.

CONCLUSIONS

We observed that diabetes and lower volume of intraoperative irrigation were both risk factors for postoperative SSI following degenerative lumbar spine surgery. To reduce SSI in lumbar spine surgery, intra-wound irrigation with more than 1,400 mL/h of NS was recommended.

Chondrotoxic effects of tranexamic acid and povidone-iodine on the articular cartilage of rabbits

PURPOSE

To evaluate the chondrotoxic effects of intra-articular use of TXA 20 mg/kg and/or 0.35% PVPI on knee joint cartilage in an experimental model of rabbits.

METHODS

Forty-four male New Zealand adult rabbits were randomly assigned to four groups (control, tranexamic acid (TXA), povidone-iodine (PVPI), and PVPI + TXA). The knee joint cartilage was accessed through an arthrotomy and exposed to physiological saline SF 0.9% (control group), TXA, PVPI, and PVPI followed by TXA. Sixty days after surgical procedure, the animals were sacrificed and osteochondral specimens of the distal femur were obtained. Histological sections of cartilage from this area were stained with hematoxylin/eosin and toluidine blue. The following cartilage parameters were evaluated by the Mankin histological/histochemical grading system: structure, cellularity, glycosaminoglycan content in the extracellular matrix, and integrity of the tidemark.

RESULTS

The isolated use of PVPI causes statistically significant changes in cartilage cellularity (p-value = 0.005) and decrease glycosaminoglycan content (p = 0.001), whereas the isolated use of TXA decreased significantly the glycosaminoglycan content (p = 0.031). The sequential use of PVPI + TXA causes more pronounced alterations in the structure (p = 0.039) and cellularity (p = 0.002) and decreased content of glycosaminoglycans (p < 0.001) all with statistical significance.

CONCLUSION

Data suggest that intra-articular use of tranexamic acid 20 mg/kg and intraoperative lavage with 0.35% povidone-iodine solution for three min are toxic to the articular cartilage of the knee in an experimental in vivo study in rabbits.

Prevention of Surgical Site Infections in Spine Surgery: An International Survey of Clinical Practices Among Expert Spine Surgeons

STUDY DESIGN

Questionnaire-based survey.

OBJECTIVES

Surgical site infection (SSI) is a common complication in spine surgery but universal guidelines for SSI prevention are lacking. The objectives of this study are to depict a global status quo on implemented prevention strategies in spine surgery, common themes of practice and determine key areas for future research.

METHODS

An 80-item survey was distributed among spine surgeons worldwide via email. The questionnaire was designed and approved by an International Consensus Group on spine SSI. Consensus was defined as more than 60% of participants agreeing to a specific prevention strategy.

RESULTS

Four hundred seventy-two surgeons participated in the survey. Screening for Staphylococcus aureus (SA) is not common, whereas preoperative decolonization is performed in almost half of all hospitals. Body mass index (BMI) was not important for surgery planning. In contrast, elevated HbA1c level and hypoalbuminemia were often considered as reasons to postpone surgery. Cefazoline is the common drug for antimicrobial prophylaxis. Alcohol-based chlorhexidine is mainly used for skin disinfection. Double-gloving, wound irrigation, and tissue-conserving surgical techniques are routine in the operating room (OR). Local antibiotic administration is not common. Wound closure techniques and postoperative wound dressing routines vary greatly between the participating institutions.

CONCLUSIONS

With this study we provide an international overview on the heterogeneity of SSI prevention strategies in spine surgery. We demonstrated a large heterogeneity for pre-, peri- and postoperative measures to prevent SSI. Our data illustrated the need for developing universal guidelines and for testing areas of controversy in prospective clinical trials.

Prevention of Surgical Site Infection Following Open Spine Surgery: The Efficacy of Intraoperative Wound Irrigation with Normal Saline Containing Gentamicin Versus Dilute Povidone-Iodine

BACKGROUND

Intraoperative wound irrigation (IOWI) is an important step in preventing surgical site infection (SSI). This study compared the effectiveness of saline with gentamicin versus povidine-iodine (PI) as IOWI solutions in preventing SSI in open spine surgery.

METHODS

It is a prospective comparative study. Patients who had noninstrumented open spine surgery were randomized into 2 groups. Group A and B patients had their surgical wounds irrigated with saline containing gentamicin solution and dilute PI solution, respectively. Both groups were assessed for the occurrence of SSI.

RESULTS

A total of 80 patients, divided into 2 groups of 40 each completed the study. Overall, the SSI rate was 17.5% for patients in the normal saline containing gentamicin group (A) and 2.5% for those in the dilute PI group (B), this difference was statistically significant (P = 0.025). The cervical and thoracic spine regions have the same SSI rate (7.1% and 0%, respectively) in both groups. However, in the lumbosacral region, the SSI rate was 31.6% in A and 0% in B, this was statistically significant (P = 0.006). The isolated organisms in patients with SSI were staphylococcus species (42.86% of SSI in A and 0% in B) and pseudomonas species (42.86% of SSI in group A and 100% in group B), and this difference was profound in the lumbosacral spine region (P = 0.008).

CONCLUSIONS

IOWI with 3.5% dilute PI solution is more efficacious in preventing SSI and has wider microbial coverage compared to normal saline containing gentamicin solution as IOWI fluid in noninstrumented open spine surgery.

Povidone-iodine irrigation reduces infection after total hip and knee arthroplasty

INTRODUCTION

One of the most important challenges faced by orthopedic surgeons is periprosthetic joint infection (PJI). PJI is a common cause for total joint arthroplasty failure with an incidence of 0.3-1.9%. PJI can be devastating for the patient and extremely costly for the healthcare system. There is concern that a major cause of PJI is intra-operative colonization and recent studies have shown a decrease in PJI with the use of dilute povidone-iodine (Betadine^®, Avrio Health L.P, Stamford, CT) irrigation prior to wound closure. This study presents our experience with the use of dilute Betadine^® irrigation prior to wound closure and its effect on our post-operative hip and knee arthroplasty acute infection rate.

MATERIALS AND METHODS

Retrospective chart review performed at our hospital looking at PJI amongst patients who underwent primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) between 2013 and 2017 comparing different irrigation methods (n = 3232). The study group (n = 1207) underwent irrigation prior to wound closure with dilute Betadine for 3 min and the control group (n = 1511) underwent irrigation using normal saline (NS).

RESULTS

Using a logistic regression model where the following variables were adjusted for; ASA, age, sex, foley insertion, surgical duration and diabetes mellitus status a statistical significant reduction was seen in any infection (OR 0.45 [0.22; 0.89], p value < 0.05) and SSI (OR 0.30 [0.13; 0.70], p value 0.01) with the Betadine group. No significant reduction was seen with deep infections with the Betadine group compared to the NS group.

CONCLUSION

PJI is a devastating complication following total joint arthroplasty and we found Betadine compared to NS irrigation provides an inexpensive and simple method to lower any PJI and more specifically SSI in THA and TKA.

LEVEL OF EVIDENCE

III.

The Effect of Local Administration of Vancomycin Suspended in Fibrin Glue for Prevention of Surgical Site Infection After Spinal Instrumentation: Comparison by Probability of Treatment Weighting Model

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

To compare the surgical site infection (SSI) rate in patients undergoing spinal instrumentation surgery who received vancomycin suspended in fibrin glue at the surgical site and those who did not.

SUMMARY OF BACKGROUND DATA

The intrawound application of vancomycin powder for preventing SSI after spinal surgery remains controversial. Vancomycin suspended in fibrin glue is another option for local administration that may be effective. The present study assessed whether vancomycin suspended in fibrin glue could prevent SSI after spinal instrumentation surgery.

MATERIALS AND METHODS

We enrolled patients who underwent posterior spinal instrumentation surgery with or without fusion for degenerative conditions, spinal trauma, or tumor. A multiple logistic regression model with inverse probability of treatment weighting based on propensity score was used to assess the efficacy of vancomycin suspended in fibrin glue and to account for confounding. A secondary multivariate logistic regression analysis was performed to identify the risk factors associated with SSI.

RESULTS

Of the 264 patients enrolled in this study, 134 underwent application of vancomycin suspended in fibrin glue at the surgical site and 130 did not. The incidence of SSI was lower in patients who were treated with vancomycin suspended in fibrin glue (2.2% vs. 8.5%) even after inverse probability of treatment weighting adjustment (adjusted odds ratio: 0.25; 95% CI, 0.0768-0.91; P =0.03). Multivariate logistic regression analysis showed that the treatment with vancomycin suspended in fibrin glue was significantly associated with a lower odds of SSI (odds ratio: 0.2; 95% CI, 0.05-0.85; P =0.03).

CONCLUSIONS

The administration of vancomycin suspended in fibrin glue was significantly associated with a lower likelihood of SSI in patients undergoing spinal instrumentation surgery.

Evaluation of the role of povidone‑iodine in the prevention of surgical site infections

Background

The occurrence of surgical site infections (SSIs) is associated with increased risk of mortality, development of other infections, and the need for reintervention, posing a significant health burden. The aim of this review was to examine the current data and guidelines around the use of antiseptic povidone‑iodine (PVP-I) for the prevention of SSIs at each stage of surgical intervention.

Methods

A literature search for selected key words was performed using PubMed. Additional papers were identified based on author expertise.

Results

Scientific evidence demonstrates that PVP-I can be used at every stage of surgical intervention: preoperative, intraoperative, and postoperative. PVP-I is one of the most widely used antiseptics on healthy skin and mucous membranes for preoperative surgical site preparation and is associated with a low SSI rate. For intraoperative irrigation, aqueous PVP-I is the recommended agent and has been demonstrated to decrease SSIs in a range of surgical settings, and for postoperative wound healing, there is a growing body of evidence to support the use of PVP-I.

Conclusions

There is a need for more stringent study designs in clinical trials to enable meaningful comparisons between antiseptic agents, particularly for preoperative skin preparation. The use of a single agent (PVP-I) at each stage of surgical intervention could potentially provide advantages, including economic benefits, over agents that can only be used at discrete stages of the surgical procedure.

Key message

Evidence supports the use of PVP-I at all stages of surgical intervention, from preoperative measures (including skin preparation, preoperative washing, and nasal decolonization) to intraoperative irrigation, through to postoperative wound management. However, there is a need for more stringent study designs in clinical trials to enable meaningful comparisons between antiseptic agents, particularly for preoperative skin preparation.

Incidence and risk factors for surgical site infection (SSI) after primary hip hemiarthroplasty: an analysis of the ACS-NSQIP hip fracture procedure targeted database

INTRODUCTION

Primary hip hemiarthroplasty (HHA) is frequently utilized to treat geriatric hip fractures, which are associated with significantly higher morbidity and mortality. While not particularly common, surgical site infection (SSI) is a major complication that frequently requires revision surgery in a frail population. The objective of this study was to determine the incidence of and risk factors for SSI after HHA in hip fracture patients.

MATERIALS AND METHODS

This retrospective cohort study was performed using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Geriatric patients (65+) who underwent HHA for non-pathologic, traumatic hip fractures between 2016-2017 were included. Demographic variables, comorbidities, operative variables, and complications were compared between "SSI" and "non-SSI" groups. Multivariate regression identified independent risk factors for postoperative SSI. Significance was set at P = 0.05.

RESULTS

A total of 6169 patients were included. The overall incidence of SSI was 1.3%. SSI was significantly associated with body mass index (BMI), preoperative functional status, congestive heart failure, chronic corticosteroid use, intraoperative time, sepsis, wound dehiscence, readmission within 30-days, and reoperation. On multivariate analysis, chronic steroid use (OR: 2.30, 95% CI: 1.13-4.70), BMI ≥ 35 kg/m² (OR: 3.59, 95% CI: 1.57-8.18), and intraoperative time ≥120 mins (OR: 2.15, 95% CI: 1.08-4.27) were found to be independent risk factors.

CONCLUSIONS

Postoperative SSI is a serious complication that is responsible for prolonged hospital stays, increased mortality, and greater healthcare costs. Here, we identified multiple risk factors for SSI after primary HHA in the US elderly population.

Prosthetic Joint Infection and Wound Leakage After the Introduction of Intraoperative Wound Irrigation With a Chlorhexidine-Cetrimide Solution: A Large-Scale Before-After Study

Background

Intraoperative chlorhexidine irrigation could be a valuable additive to systemic antibiotics to prevent infections after total joint arthroplasties. However, it may cause cytotoxicity and impair wound healing. This study evaluates the incidence of infection and wound leakage before and after the introduction of intraoperative chlorhexidine lavage.

Methods

All 4453 patients receiving a primary hip or knee prosthesis between 2007 and 2013 in our hospital were retrospectively included. They all underwent intraoperative lavage before wound closure. Initially, wound irrigation with 0.9% NaCl was standard care (n = 2271). In 2008, additional irrigation with a chlorhexidine-cetrimide (CC) solution was gradually introduced (n = 2182). Data on the incidence of prosthetic joint infections and wound leakage, as well as relevant baseline and surgical characteristics, were derived from medical charts. Chi-square analysis was used to compare the incidence of infection and wound leakage between patients with and without CC irrigation. Multivariable logistic regression was used to assess robustness of these effects by adjusting for potential confounders.

Results

The prosthetic infection rate was 2.2% in the group without CC irrigation vs 1.3% in the group with CC irrigation (P = .021). Wound leakage occurred in 15.6% of the group without CC irrigation and in 18.8% of the group with CC irrigation (P = .004). However, multivariable analyses showed that both findings were likely due to confounding variables, rather than by the change in intraoperative CC irrigation.

Conclusions

Intraoperative wound irrigation using a CC solution does not seem to affect the risk of prosthetic joint infection or wound leakage. Observational data easily yield misleading results, so prospective randomized studies are needed to verify causal inference.

Level of Evidence

Level III-uncontrolled before and after the study.

Does the use of intrawound povidone-iodine irrigation and local vancomycin powder impact surgical site infection rate in adolescent idiopathic scoliosis surgery?

PURPOSE

Surgical site infection (SSI) is a major complication after adolescent idiopathic scoliosis (AIS) surgery, with an incidence ranging from 0.5 to 7%. Intraoperative wound decontamination with povidone-iodine (PVP-I) irrigation and/or vancomycin powder in adult spinal surgery has gained attention in the literature with controversial results. The aim of this study was to investigate the impact of using intrawound PVP-I irrigation and local vancomycin powder (LVP) on the incidence of early SSI in AIS surgery.

METHODS

All AIS patients who underwent posterior spinal fusion between October 2016 and December 2019 were retrospectively reviewed. The incidence of early SSI was reported and compared between 2 groups defined by the treating spinal surgeons' preferences: group 1-intrawound irrigation with 2L of PVP-I and application of 3 g LVP before closure and control group 2-patients that did not receive either of these measures.

RESULTS

Nine early cases of SSI (2.9%) were reported among the 307 AIS posterior spinal fusion patients. Incidence of SSI in group 1 (2/178 = 1.1%) was significantly lower than in group 2 (7/129 = 5.4%; p = 0.04). There were no adverse reactions to the use of PVP-I and LVP in our study. At latest follow-up, rate of surgical revision for mechanical failure with pseudarthrosis was significantly lower in group 1 (2/178 = 1.1%) than in group 2 (9/129 = 7.0%; p = 0.01).

CONCLUSION

Intraoperative use of intrawound PVP-I irrigation and vancomycin powder is associated with a significant reduction of early SSI after AIS spine surgery.

LEVEL OF EVIDENCE IV

Retrospective study.

Irrigation techniques used in spine surgery for surgical site infection prophylaxis: a systematic review and meta-analysis

Background

The greater likelihood of morbidity, mortality, length of hospital stays and poorer long-term outcomes as a result of surgical site infections secondary to spinal surgery makes prophylactic measures an imperative focus. Therefore, the aim of this review was to evaluate the available research related to the efficacy of different intraoperative irrigation techniques used in spinal surgery for surgical site infection (SSI) prophylaxis.

Methods

We performed a comprehensive search using Ovid Medline, EMBASE, Web of Science and the Cochrane library pertaining to this topic. Our meta-analysis was conducted according to PRISMA guidelines. The inclusion criteria consist of spine surgeries with intraoperative use of any wound irrigation technique, comparison groups with a different intraoperative irrigation technique or no irrigation, SSI identified with bacterial cultures or clinically in the postoperative period, reported SSI rates. Data extracted from eligible studies included, but was not limited to, SSI rates, irrigation technique and control technique. Exclusion criteria consist of articles with no human subjects, reviews, meta-analyses and case control studies and no details about SSI identification or rates. Pooled risk ratios were calculated. A meta-analysis was performed with a forest plot to determine risk estimates’ heterogeneity with I² index, Q-statistic, and p value under a random-effects model. Funnel plot was used to assess publication bias. All databases were last checked on January, 2022. PROBAST tool was used to assess both risk of bias and applicability concerns.

Results

After reviewing 1494 titles and abstracts, 18 articles met inclusion criteria. They included three prospective randomized-controlled trials, 13 retrospective cohort studies, two prospective cohort studies. There were 54 (1.8%) cases of SSIs in the povidone-iodine irrigation group (N = 2944) compared to 159 (4.6%) in the control group (N = 3408). Using intraoperative povidone-iodine wound irrigation produced an absolute risk reduction of 2.8%. Overall risk ratio was 0.32 (95% CI 0.20–0.53, p < 0.00001). In a global analysis, study heterogeneity and synthesizing mostly retrospective data were primary limitations.

Conclusion

The most evidence exists for povidone-iodine and has Level 2 evidence supporting SSI reduction during spinal surgery. Other antiseptic solutions such as dilute chlorhexidine lack published evidence in this patient population which limits the ability to draw conclusions related to its use in spinal surgery.

Level of Evidence

II – Systematic Review with Meta-Analysis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05763-2.

Is Iatrogenic Implant Contamination Preventable Using a 16-Step No-Touch Protocol?

BACKGROUND

Intraoperative contamination of the surgical field during aesthetic breast augmentation may lead to implant infection with devastating consequences. This study covers a period of 30 years and is divided into 2 phases: a retrospective phase from 1992-2004 when a standard approach was used and a prospective phase from 2004-2022 when a no-touch approach was implemented to avoid contamination.

METHODS

Patients in the standard and no-touch groups underwent aesthetic breast augmentation by the same senior surgeon (FDP) in the same outpatient surgical facility during the 30-year period of the study. Patients are divided into 2 groups: from 1992-2004 and from the implementation of the no-touch protocol in 2004-2022.

RESULTS

Patients who underwent breast augmentation using the no-touch approach developed no infections, whereas the standard group had an infection rate of 3.54% (P = .017). The validity of this finding is discussed.

CONCLUSIONS

The no-touch approach as described in this article was effective in reducing implant infection rate when performing aesthetic breast augmentation by 1 surgeon at 1 surgical center during an 18-year observation period. Multicenter prospective cooperative studies are necessary to validate perioperative iatrogenic contamination as the cause of implant infection and to explore optimal approaches that could eliminate implant contamination.

Efficacy of Povidone Iodine Solution in the Prevention of Surgical Site Infections in Minimally Invasive Instrumented Spinal Fusion Surgery

STUDY DESIGN

A retrospective case-controlled study.

OBJECTIVES

To evaluate overall infection rate and adverse event after harvesting bone graft soaking and surgical wound irrigation by povidone iodine solution (PVI) in the minimally invasive instrumented spinal fusion surgery. In order to reduce the rate of surgical site infection in spinal surgery, surgical wound irrigation by povidone iodine solution has been well-established. However, the efficacy of autologous bone graft soaking by PVI has not been evaluated before.

METHODS

This is a retrospective cohort study. 120 patients were enrolled in the PVI group and compared with 124 patients in the historical cohort. In the PVI group, the harvesting autologous bone graft was soaking and the surgical wound was also irrigated by diluted PVI solution. The outcome measures were overall infection rate, superficial wound infection and deep infection. In addition, the delayed union of the fusion mass was also evaluated through the radiograph evaluation.

RESULTS

Both groups shared similar patient demographics instead of body mass index. The use of PVI solution had decreased the overall infection rate (0% versus 4.03%, p = 0.026) and deep infection rate (0% versus 3.23%, p = 0.047). In addition, there was no delayed bone healing in the PVI group after autologous bone graft soaking.

CONCLUSIONS

In this study, we conclude that harvested autologous bone graft after PVI soaking in spinal fusion surgery can decrease the incidence of deep infection.

30-day postoperative sepsis risk factors following laminectomy for intradural extramedullary tumors

BACKGROUND

Posterior laminectomy (LA) for resection of intradural extramedullary tumors (IDEMTs) is associated with postoperative complications, including sepsis. Sepsis is an uncommon but serious complication that can lead to increased morbidity and mortality, prolonged hospital stays, and greater costs. Given the susceptibility of a solid tumor patients to sepsis-related complications, it is important to recognize IDEMT patients as a unique population when assessing the risk factors for sepsis after laminectomy.

METHODS

The study design was a retrospective cohort study. Adult patients undergoing LA for IDEMTs from 2012 to 2018 were identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Baseline patient characteristics/comorbidities, operative and hospital variables, and 30-day postoperative complications were collected.

RESULTS

Of 2,027 total patients undergoing LA for IDEMTs, 38 (2%) had postoperative sepsis. On bivariate analysis sepsis was associated with superficial surgical site infection [odds ratio (OR) 11.62, P<0.001], deep surgical site infection (OR 10.67, P<0.001), deep vein thrombosis (OR 10.75, P<0.001), pulmonary embolism (OR 15.27, P<0.001), transfusion (OR 6.18, P<0.001), length of stay greater than five days (OR 5.41, P<0.001), and return to the operating room within thirty days (OR 8.72, P<0.001). Subsequent multivariate analysis identified the following independent risk factors for sepsis and septic shock: operative time ≥50th percentile (OR 2.11, P=0.032), higher anesthesia class (OR 1.76, P=0.046), dependent functional status (OR 2.23, P=0.001), diabetes (OR 2.31, P=0.037), and chronic obstructive pulmonary disease (OR 3.56, P=0.037).

CONCLUSIONS

These findings can help spine surgeons identify high-risk patients and proactively deploy measures to avoid this potentially devastating complication in individuals who may be more vulnerable than the general elective spine population.

Effect of wound irrigation on the prevention of surgical site infections: A meta-analysis

We performed a meta‐analysis to evaluate the effect of wound irrigation on the prevention of surgical site infections. A systematic literature search up to January 2022 was done and 24 studies included 4967 subjects under surgery at the start of the study; antibiotic irrigation was used with 1372 of them, 1261 were aqueous povidone‐iodine irrigation, and 2334 were saline irrigation or no irrigation for surgical site infections prevention in all surgical populations. We calculated the odds ratio (OR) with 95% confidence intervals (CIs) to evaluate the effect of different wound irrigation on the prevention of surgical site infections by the dichotomous method with a random or fixed‐influence model. Antibiotic irrigation had significantly lower surgical site infections in all surgical populations (OR, 0.48; 95% CI, 0.36‐0.62, P < .001) compared with saline irrigation or no irrigation for the subject under surgery. Aqueous povidone‐iodine irrigation had significantly lower surgical site infections in all surgical populations (OR, 0.40; 95% CI, 0.20‐0.81, P = .01) compared with saline irrigation or no irrigation for the subject under surgery. Antibiotic irrigation and aqueous povidone‐iodine irrigation significantly lowered surgical site infections in all surgical populations compared with saline irrigation or no irrigation for the subject under surgery. Further studies are required.

Wound Closure Following Intervention for Closed Orthopedic Trauma

The method of skin closure and post-operative wound management has always been important in orthopedic surgery and plays an even larger role now that surgical site infection (SSI) is a national healthcare metric for both surgeons and hospitals. Wound related issues remain some of the most feared complications following orthopedic trauma procedures and are associated with significant morbidity. In order to minimize the risk of surgical site complications, surgeons must be familiar with the physiology of wound healing as well as the patient and surgical factors affecting healing potential. The goal of all skin closure techniques is to promote rapid healing with acceptable cosmesis, all while minimizing risk of infection and dehiscence. Knowledge of the types of closure material, techniques of wound closure, surgical dressings, negative pressure wound therapy, and other local modalities is important to optimize wound healing. There is no consensus in the literature as to which closure method is superior but the available data can be used to make informed choices. Although often left to less experienced members of the surgical team, the process of wound closure and dressing the wound should not be an afterthought, and instead must be part of the surgical plan. Wounds that are in direct communication with bony fractures are particularly at risk due to local tissue trauma, resultant swelling, hematoma formation, and injured vasculature.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Wound Antiseptics and European Guidelines for Antiseptic Application in Wound Treatment

Issues arising in wound healing are very common, and chronic wound infections affect approximately 1.5% of the population. The main substances used in wound washing, cleansing and treatment are antiseptics. Today, there are many compounds with a known antiseptic activity. Older antiseptics (e.g., boric acid, ethacridine lactate, potassium permanganate, hydrogen peroxide, iodoform, iodine and dyes) are not recommended for wound treatment due to a number of disadvantages. According to the newest guidelines of the Polish Society for Wound Treatment and the German Consensus on Wound Antisepsis, only the following antiseptics should be taken into account for wound treatment: octenidine (OCT), polihexanide (PHMB), povidone-iodine (PVP-I), sodium hypochlorite (NaOCl) and nanosilver. This article provides an overview of the five antiseptics mentioned above, their chemical properties, wound applications, side effects and safety.

Use of Vancomycin Mixed Bone Graft and Vancomycin Mixed Saline Wash Before Wound Closure Reduces the Rate of Infection in Lumbar Spine Fusion Surgery

This study aims to evaluate whether surgical site vancomycin mixed in bone grafts and local vancomycin mixed in normal saline wash before wound closure decrease the infection rates in patients undergoing lumbar spinal instrumentation and posterolateral fusion. A retrospective study was performed on cases between 2017 and 2019, who underwent lumbar spine instrumentation and posterolateral fusion for lumbar canal stenosis or listhesis. The routine prophylactic procedures were performed in all patients as per institutional protocol. Patients' records were analysed and categorised into two groups, the vancomycin group (VG), where vancomycin mixed in bone graft and normal saline wash was used at the surgical site, and the control group (CG), where vancomycin was not used. The study included 63 patients, 31 in VG and 32 in CG. There is no statistical difference in age, sex, and diabetes mellitus in both groups. A total of seven cases were infected, six in CG (6/32) and one in VG (1/31). Out of six infections in CG, three patients had diabetes and four infected cases underwent surgery for debridement. In VG, the only single case got infected and treated with intravenous antibiotics. We found that the use of vancomycin added to the bone graft and normal saline in posterior lumbar spinal instrumentation and posterolateral fusion is associated with significantly lower rates of infection (p value=0.049).

A narrative review of infection prevention techniques in adult and pediatric spinal deformity surgery

Spinal infections associated with pediatric and adult spinal deformity surgery are associated with postoperative morbidity and mortality along with elevated health-care costs. Prevention requires meticulous technique by the spine surgeon throughout the perioperative period. There is significant variability in the current practices of spinal deformity surgeons with regard to infection prevention, stemming from the lack of reliable evidence available in the literature. There has also been a lack of literature detailing the difference in infection rates and risk factors between pediatric and adult patients undergoing deformity correction surgery. In this narrative review we looked at 60 studies in the adult population and 9 studies in the pediatric population. Most of these studies of surgical site infections (SSI) in spinal deformity surgery have been performed in adult patients, however it is clear that the pediatric neuromuscular patient requires particular attention that we discuss in detail. This narrative review of the literature outlines evidence and compares and contrasts data for preventive strategies and modifiable risk factors to decrease rates of SSI in the pediatric and adult spinal deformity patient populations. In this review we discuss techniques relating to preoperative cleansing protocols, antibiotic administration, gentle soft tissue handling, appropriate closure, drain usage, and intraoperative technique itself to minimize EBL and operative time.

Effectiveness of topical adjuvants in reducing biofilm formation on orthopedic implants: an in vitro analysis

BACKGROUND AND HYPOTHESIS

The treatment of periprosthetic joint infection is complicated by the presence of residual biofilm, which resists eradication owing to bacterial adherence to orthopedic implants. The purpose of this study was to compare Bactisure (Zimmer Biomet, Warsaw, IN, USA), povidone-iodine (Betadine), and chlorhexidine gluconate solution (Irrisept; Irrimax, Gainesville, FL, USA) in reducing biofilm formation of Staphylococcus aureus, Staphylococcus epidermidis, and Cutibacterium acnes inoculated on cobalt-chrome, titanium, and stainless steel disks, representing metals commonly used for shoulder arthroplasty. The hypothesis was that there would be no significant difference in biofilm reduction among the 3 topical adjuvants.

METHODS

Strains of S aureus (ATCC 35556), S epidermidis (ATCC 35984), and C acnes (LMG 16711) were grown on cobalt-chrome, titanium, and stainless steel disks. For each strain, the disks were divided into 4 groups: (1) control, (2) povidone-iodine (Betadine), (3) chlorhexidine gluconate (Irrisept), and (4) Bactisure. Bacteria were grown on 5% sheep blood agar plates. Biofilm eradication was quantified using adenosine triphosphate bioluminescence and compared with controls 48 and 72 hours after implementation of the topical adjuvant.

RESULTS

At 72 hours after implementation of the topical adjuvant, a statistically significant reduction in colony-forming units was observed for all topical adjuvants across all tested metals, as compared with their respective control. With respect to the topical adjuvants themselves, Bactisure more consistently demonstrated the most significant reduction in colony-forming units across all bacteria when the tested medium was adjusted for, with the exception of S aureus, which showed similar results to Betadine at 72 hours.

CONCLUSION

By use of commonly encountered topical adjuvants on S aureus-, S epidermidis-, and C acnes-inoculated disks of various implant metals, a significant reduction in biofilm production was observed. Bactisure, a recent Food and Drug Administration-approved topical adjuvant, demonstrated the overall greatest efficacy of the agents studied.

Review of Pre-Operative Skin Preparation Options Based on Surgical Site in Orthopedic Surgery

Background: Surgical site infections (SSIs) are a primary contributor to surgical morbidity and mortality, causing a substantial financial burden on the healthcare system. Specifically, Cutibacterium acnes contributes greatly to infections in the shoulder and spine regions. Prevention of infection is crucial to improve patient outcomes and reduce costs. This article reviews current surgical skin preparation solutions, the unique distribution of organisms at common orthopedic surgical sites, and recommends solutions based on surgical location. Methods: A search of electronic databases (PubMed, MEDLINE, and Embase) was conducted for relevant literature until December 2020. Sources were compiled based on title and abstract, then full texts were read for possible inclusion. This review summarizes the most recent publications in the field of SSIs and preparation solutions. Results: The mechanism and efficacy of alcohol-, iodine-, and chlorhexidine-based preparations were reviewed, along with experimental preparations. This article identifies common colonization patterns for the shoulder, elbow, hip, knee, spine, foot, and ankle, and discusses recommendations for preparations based on current evidence. Recommendations: For shoulder and elbow operations, we recommend ChloraPrep™ (CareFusion, BD, El Paso, TX), DuraPrep™ (3M Health Care, St. Paul, MN), or Betadine^® applied with 4 × 4 gauze sponge, three-day pre-operative benzyl peroxide, and application of 3% hydrogen peroxide before skin preparation. For the hip and knee, we recommend application of 2% chlorhexidine gluconate (CHG) cloth the night before and morning of surgery and either DuraPrep or iodine-alcohol skin prep prior to surgery. For spine surgeries, we recommended ChloraPrep. For foot and ankle, our recommendations are: ChloraPrep or DuraPrep, submersion of foot in 70% ethanol/10% isopropyl alcohol for five minutes prior to procedure, application with a bristled brush, and a second vigorous scrub with 4 × 4 soaked gauze. Conclusions: The current surgical skin preparations have both benefits and drawbacks. We recommend that orthopedic surgeons choose a skin preparation based on surgical site and prevalence of unique skin flora there.

Timing of Preoperative Surgical Antibiotic Prophylaxis After Primary One-Level to Three-Level Lumbar Fusion

OBJECTIVE

The purpose of this study was to examine the relationship between timing of preoperative surgical antibiotic prophylaxis and postoperative surgical site infections (SSIs) among patients with 1-level to 3-level lumbar fusion.

METHODS

Patients having undergone a primary 1-level to 3-level lumbar fusion at a single institution were allocated into 5 groups based on the time from preoperative antibiotic administration to incision (group A, 0-15 minutes; group B, 16-30 minutes; group C, 31-45 minutes; group D, 46-60 minutes; and group E, 61+ minutes). Timing of antibiotic administration as a continuous variable was also analyzed. All patients received irrigation with 3 L of normal saline containing bacitracin as well as local administration of vancomycin powder. SSIs were identified by the definition set forth by the 2017 Centers for Disease Control and Prevention guidelines.

RESULTS

Among 1131 patients, 27 (2.4%) were found to have an SSI. Compared with patients with antibiotic administration within 0-15 minutes before incision, patients with administration 61+ minutes before incision (group 4) had significantly higher odds of developing an SSI (P < 0.001). Patients had a 1.05-fold higher likelihood of infection for each additional minute delay of administration before incision (P < 0.001). Receiver operating characteristic analysis reported an area under the curve of 0.733 and 0.776 for time as a continuous and categorical variable, respectively. Age (P = 0.02), body mass index (P = 0.03), diabetes mellitus diagnosis (P = 0.04), and type of antibiotic (P = 0.004) were significant predictors of SSI.

CONCLUSIONS

Our results show that preoperative antibiotic administration beyond 1 hour in patients who have undergone lumbar fusion is associated with higher rates of SSI.

Does the Organism Profile of Periprosthetic Joint Infections Change With a Topical Vancomycin Powder and Dilute Povidone-Iodine Lavage Protocol?

BACKGROUND

While vancomycin powder and dilute povidone-iodine (VIP) is associated with fewer total joint arthroplasty (TJA) periprosthetic joint infections (PJI), its effect on PJI organism profiles is unclear. This study evaluates primary TJA PJI organism profiles before and after the implementation of a VIP protocol.

METHODS

In total, 18,299 primary TJAs performed at a university-affiliated, not-for-profit orthopedic hospital from before (1/2012-12/2013) and after (1/2016-12/2019) a VIP protocol was initiated were reviewed to identify deep PJIs that occurred within 90 days of the index arthroplasty as defined by the Musculoskeletal Infection Society guidelines. Demographics, overall organism incidence (n/TJAs), and relative organism incidence (n/PJIs) from the two cohorts were compared.

RESULTS

In total, 103 TJA PJIs were identified (pre-VIP: 32/3982; VIP: 71/14,317). Following the introduction of VIP, the overall and relative incidence of coagulase-negative staphylococcal TJA PJIs significantly decreased (overall: 0.20% to 0.04%, P = .004; relative: 25.00% to 8.45%, P = .031). In response, the relative incidence of MSSA TJA PJIs significantly increased (18.75% to 40.85%, P = .042). Broken down by arthroplasty type, VIP was associated with a significantly lower overall incidence of coagulase-negative staphylococcal total knee arthroplasty (TKA) PJIs (0.27% to 0.06%, P = .015), a significantly lower overall incidence of MRSA TKA PJIs (0.18% to 0.03%, P = .031), and a nonsignificant decrease in the overall incidence of gram-negative TKA PJIs (0.18% to 0.04%, P = .059). No organism profile changes were found in total hip arthroplasty PJIs.

CONCLUSION

VIP is not associated with more difficult to treat primary TJA PJIs. While promising, these findings require a prospective randomized controlled trial for confirmation.

LEVEL OF EVIDENCE

Level III, Retrospective cohort study.

Design and Implementation of an Enhanced Recovery After Surgery Protocol in Elective Lumbar Spine Fusion by Posterior Approach: A Retrospective, Comparative Study

STUDY DESIGN

Retrospective, comparative.

OBJECTIVE

The aim of this study was to design an enhanced recovery after surgery (ERAS) protocol for elective lumbar spine fusion by posterior approach, and to compare the results after ERAS implementation in patients undergoing elective lumbar spine fusion with conventional perioperative care.

SUMMARY OF BACKGROUND DATA

Despite wide adoption in other surgical disciplines, ERAS has only been recently implemented in spine surgery. The integrated multidisciplinary approach of ERAS aims to reduce surgical stress to achieve better outcomes.

METHODS

Hospital records of adult patients who underwent one- to three-level elective lumbar spine fusion by posterior approach at a single center were retrospectively studied. An ERAS protocol was designed based on the prevalent hospital practices, local resources and supportive evidence from literature. The ERAS protocol was implemented at our institute in December 2016-dividing patients into pre-ERAS and post-ERAS groups. The outcome measures for comparison were: length of hospital stay (LOS), postoperative complications, 60-day readmission rate, 60-day reoperation rate, and patient-reported outcome measures (visual analogue scale [VAS] and Oswestry Disability Index [ODI] score) at stipulated time intervals.

RESULTS

A total of 812 patients were included - 496 in the pre-ERAS group and 316 in the post-ERAS group. There was no significant difference between the two groups in baseline demographic, clinical, and surgery-related variables. Patients in the post-ERAS group had a significantly shorter LOS (2.94 vs. 3.68 days). The rate of postoperative complications (13.5% vs. 11.7%), 60-day readmission (1.8% vs. 2.2%), and 60-day reoperation (1.2% vs. 1.3%) did not differ significantly between the pre-ERAS and post-ERAS groups. The VAS and ODI scores, similar at baseline, were significantly lower in the post-ERAS group (VAS: 49.8 ± 12.0 vs. 44 ± 10.8, ODI: 31.6 ± 14.2 vs. 28 ± 12.8) at 4 weeks after surgery. This difference however was not significant at intermediate-term follow-up (6 months and 12 months).

CONCLUSION

Implementation of an ERAS protocol is feasible for elective lumbar spine fusion, and leads to shorter LOS and improved early pain and functional outcome scores.Level of Evidence: 3.

Prevention of Surgical Site Infection in Lumbar Instrumented Fusion Using a Sterile Povidone-Iodine Solution

BACKGROUND

Surgical site infection (SSI) is a well-documented complication in patients who undergo posterior spine instrumentation with most studies reporting an incidence of 1%-12%. Some studies have documented that a diluted sterile povidone-iodine (PVI) solution can be safely used in posterior spinal fusion surgeries as an antiseptic; in this study, we analyzed its effectiveness in reducing SSI.

METHODS

This retrospective study consisted of consecutive patients who underwent elective posterior lumbar instrumentation performed by a single surgeon from 2016 to 2019. In the first 134 patients, wounds were irrigated before arthrodesis and closure with 1 L of 0.9% normal saline solution; in the subsequent 144 patients, wound irrigation was with a solution of 35 mL of sterile 10% PVI. Both groups were analyzed to determine if wound irrigation with sterile PVI solution decreased SSIs.

RESULTS

There were 9 (6.7%) SSIs in the 0.9% normal saline solution group versus 1 (0.7%) SSI in the PVI group (P = 0.008). PVI solution had a relative risk for SSI of 0.093 (P = 0.008) and an adjusted odds ratio of 0.113 (P = 0.05). Increased body mass index and posterolateral spine fusion with laminectomy were significant risk factors for SSI (P = 0.04 and P = 0.030, respectively).

CONCLUSIONS

Wound irrigation with PVI solution significantly reduced SSI in elective posterior lumbar instrumentation cases. Subgroup analysis provided significant results to recommend use of PVI solution for SSI prevention, particularly in overweight and obese patients. We also recommend its use in patients with risk factors for SSI, such as longer operative time and unintended durotomy.

Why Irrigate for the Same Contamination Rate: Wound Contamination in Pediatric Spinal Surgery Using Betadine Versus Saline

BACKGROUND

The risk of surgical site infection in pediatric posterior spine fusion (PSF) is up to 4.3% in idiopathic populations and 24% in patients with neuromuscular disease. Twenty-three percent of pediatric PSF tissue cultures are positive before closure, with a higher rate in neuromuscular patients. Our primary aim was to evaluate the feasibility of a complete randomized controlled trial to study the efficacy of surgical site irrigation with povidone-iodine (PVP-I) compared with sterile saline (SS) to reduce the bacterial contamination rate before closure in children undergoing PSF.

METHODS

One hundred seventy-five subjects undergoing PSF were enrolled in a multicenter, single-blind, pilot randomized controlled trial. We recruited patients at low-risk (LR) and high-risk (HR) for infection 3:1, respectively. Before closure, a wound culture was collected. Nonviable tissues were debrided and the wound was soaked with 0.35% PVP-I or SS for 3 minutes. The wound was then irrigated with 2 L of saline and a second sample was collected.

RESULTS

One hundred fifty-three subjects completed the protocol. Seventy-seven subjects were allocated to PVP-I (18 HR, 59 LR) and 76 to SS (19 HR, 57 LR). Cultures were positive in 18% (14/77) of PVP-I samples (2 HR, 12 LR) and in 17% (13/76) of SS samples (3 HR, 10 LR) preirrigation and in 16% (12/77) of PVP-I samples (5 HR, 7 LR) and in 18% (14/76) of SS samples (4 HR, 10 LR) postirrigation. Eight percent (3/37) HR subjects (1 PVP-I, 2 SS) experienced infection at 30 days postoperative. No LR subjects experienced infection.

CONCLUSIONS

Positive cultures were similar across treatment and risk groups. The bacterial contamination of wounds before closure remains high regardless of irrigation type. A complete randomized controlled trial would be challenging to adequately power given the similarity of tissue positivity across groups.

LEVEL OF EVIDENCE

Level II-pilot randomized controlled trial.

Comparative in vitro evaluation of the antimicrobial activities of povidone-iodine and other commercially available antiseptics against clinically relevant pathogens

Aims: Antiseptics, such as povidone-iodine (PVP-I), play an important role in infection control across a wide range of clinical settings. This study aimed to evaluate the comparative in vitro efficacy and rate of onset of action of a range of formulations of PVP-I and other commonly used antiseptics. Methods: The antimicrobial efficacy of a range of antiseptics and antimicrobial agents used for skin, wound, vagina and oral antisepsis was evaluated according to the EU Standards DIN EN1276 and EN14476. The panel of organisms tested included bacterial and fungal pathogens and two enteroviruses (Coxsackievirus A16 [CA16] and Enterovirus 71 [EV71]). Results: All PVP-I products tested were highly efficacious in vitro (>99.99% kill rate) against a range of clinically relevant bacterial and fungal pathogens with rapid onset of action (30-60 seconds), at both high and low concentrations. By comparison, the efficacy of other antiseptics tested was generally reduced upon dilution. PVP-I products used in wound and oral care were found to be more effective in vitro against CA16 and EV71, and had a faster onset of action than most other agents tested. Conclusion: This study provides valuable insights into the in vitro efficacy of a range of commonly used antiseptics and may help inform the selection of appropriate antiseptics by healthcare professionals.

Intrathecal Baclofen Pump Infection With Meningitis: Effective Treatment by Radical Debridement and Intrareservoir Baclofen-Vancomycin Co-Infusion

OBJECTIVES

Intrathecal baclofen pump associated central nervous system (CNS) infection and meningitis is a rare but serious complication and may have dire consequences. Due to bacterial biofilm formation, the optimal treatment strategy is usually for removal of the pump, followed by systemic antibiotics for treatment of local and CNS infection. We describe this case of a patient with recurrent Staphylococcus aureus pump site empyema and meningitis leading to status dystonicus, who was successfully managed with radical debridement and intrareservoir baclofen-vancomycin co-infusion.

MATERIALS AND METHODS

We retrospectively report a case of infected intrathecal baclofen pump with meningitis and provide a full review of literature.

CONCLUSIONS

To the best of our knowledge, this is the first reported case of intrathecal baclofen (ITB)-associated pump site empyema and meningitis successfully treated with this technique. In selected cases where surgical explantation is deemed not feasible, this method can provide clinicians with an additional option for pump salvage and retention, while eradicating CNS infection and maintaining optimal control of spasticity and dystonia.

Topical Vancomycin Powder and Dilute Povidone-Iodine Lavage Reduce the Rate of Early Periprosthetic Joint Infection After Primary Total Knee Arthroplasty

BACKGROUND

Vancomycin powder and dilute povidone-iodine lavage (VIP) was introduced to reduce the incidence of periprosthetic joint infection (PJI) in high-risk total knee arthroplasty (TKA) patients. We hypothesize that VIP can reduce the incidence of early PJI in all primary TKA patients, regardless of preoperative risk.

METHODS

An infection database of primary TKAs performed before a VIP protocol was implemented (January 2012-December 2013), during a time when only high-risk TKAs received VIP (January 2014-December 2015), and when all TKAs received VIP (January 2016-September 2019) at an urban, university-affiliated, not-for-profit orthopedic hospital was retrospectively reviewed to identify patients with PJI. Criteria used for diagnosis of PJI were the National Healthcare Safety Network and Musculoskeletal Infection Society guidelines.

RESULTS

VIP reduced early primary TKA PJI incidence in both the high-risk and all-risk cohorts compared with the pre-VIP cohort by 44.6% and 56.4%, respectively (1.01% vs 0.56% vs 0.44%, P = .0088). In addition, after introducing VIP to all-risk TKA patients, compared with high-risk TKA patients, the relative risk of PJI dropped an additional 21.4%, but this finding did not reach statistical significance (0.56% vs 0.44%, P = .4212). There were no demographic differences between the 3 VIP PJI cohorts.

CONCLUSION

VIP is associated with a reduced early PJI incidence after primary TKA, regardless of preoperative risk. With the literature supporting its safety and cost-effectiveness, VIP is a value-based intervention, but given the nature of this historical cohort study, a multicenter randomized controlled trial is underway to definitively confirm its efficacy.

Povidone-iodine irrigation combined with Vancomycin powder lowers infection rates in pediatric deformity surgery

BACKGROUND

Surgical site infection is a morbid, devastating complication after spinal procedures. Studies have investigated the effect of wound lavage with 3.5% Povidone-iodine solution or the use of intrawound Vancomycin powder. We examined the effect of Povidone-iodine irrigation, intrawound Vancomycin powder, or a combination of both agents in a tertiary care Pediatric Hospital.

METHODS

We queried our health system database for patients undergoing spinal surgery over an eight-year span between January 2008 and June 2016 and identified patient cohorts who received no intervention, intrawound Vancomycin alone, Povidone-iodine irrigation alone, or a combination of both agents. Infection rates were determined. The effect of treatment on outcome was analyzed using a logistic regression model.

RESULTS

475 patients were identified who met study inclusion criteria. 88 non-neuromuscular patients received no intra-operative agent. The surgical site infection (SSI) rate in this group of patients was 10%. For the 194 non-neuromuscular scoliosis patients who received Povidone-iodine and Vancomycin powder, the infection rate was reduced to 0.7%. The SSI rate in the 180 non-neuromuscular patients who were treated with Vancomycin powder alone was 1.4%. 13 patients were treated with Povidone-iodine lavage only, with a small sample size precluding statistical comparison. Infection rate in the 132 neuromuscular disease patients decreased from 14 to 7% overall during this time span: while the odds ratio of infection was reduced in all neuromuscular treatment groups receiving intra-operative measures, statistical significance was not reached in any neuromuscular group studied.

CONCLUSIONS

A protocol using combined 3.5% weight/volume Povidone-iodine and Vancomycin powder was associated with the lowest infection rate in our non-neuromuscular patient population and should be considered as a low cost intervention in pediatric patients undergoing spinal deformity procedures.

LEVEL OF EVIDENCE

Level II.

Surgical site infection following surgery for spinal deformity: About 102 patients

INTRODUCTION

Complex spinal surgery is known to be at risk of complications. Surgical site infection is a serious complication in spine surgery and its frequency is significantly increased in adult spinal deformity correction. The aim of this study is to identify patients' characteristics and risk factors of surgical site infection (SSI) following an osteotomy.

METHODS

This is a single-center retrospective study of patients who underwent an osteotomy between January 2015 and December 2017. Surgical site infection diagnosis was based upon patient's clinical evidence of infection, biologic parameters, microbiological criteria and/or image findings.

RESULTS

In total, 102 patients were eligible and 70 were women (68.6%). Mean age was 65 years old (27-83 years) and mean body mass index (BMI) was 26.14kg.m^-2 (18.4-44.1). Eleven patients were in the SSI group and 91 in the No-SSI group. The mean Schwab grade was 1.5 (1-4) in the SSI group vs. 1.4 (1-5) in the No-SSI group (P=0.435). The mean operative time was on 201.9 minutes (67-377). Mean length of stay was 20.6 days (10-73) in the SSI group vs. 15 days (5-44) in the No-SSI group (P=0.041). Favorable outcome was found in 10 patients (90.9%) in the SSI group.

CONCLUSION

Correction surgery for adult spinal deformity with osteotomies carries a high risk of complications specially SSI. Identification of risk factors, prevention and medical management of SSI should be well assessed.

Utilization, Utility, and Variability in Usage of Adjunctive Hyperbaric Oxygen Therapy in Spinal Management: A Review of the Literature

The objective of this review was to understand the clinical utilization, utility, and variability in the usage of adjunctive hyperbaric oxygen therapy (HBOT). Surgical site infection is associated with high morbidity and mortality, increased health care expenditure, and decreased quality of life. With the increasing prevalence of adult spinal deformity and spinal fusion surgery, it is imperative to understand the potential benefits of adjunctive treatments. HBOT is a safe and common procedure indicated to treat various medical conditions. We conducted a literature search across 3 databases for English articles published between December 1, 2019 and December 1, 2000. Thirteen studies were included. HBOT may lessen the duration of antimicrobial therapy and mitigate instrument removal and revision surgery. The current usage indications for HBOT are supported by level III evidence for chronic osteomyelitis and level IV evidence for osteoradionecrosis. However, the same level of evidence exists to support the beneficial use of adjunctive HBOT for noncomplicated spinal infections within 2 months after surgery. When cultured, the most common organisms were Staphylococcus aureus and other low-virulence organisms. The most common treatment protocol consists of 90-minute sessions of 100% Fio₂ at 2-3 atmosphere absolute with a mean of 35.3 ± 11.6 sessions for 5.2 ± 1.4 weeks. Adjunctive HBOT should be considered in select high-risk patients. Further improvements in diagnosis and categorization of spinal infections are necessary and will indelibly aid the decision making for the initiation of HBOT.

Muscle Flap Closure following Complex Spine Surgery: A Decade of Experience

BACKGROUND

Advances in surgical technology and adjuvant therapies along with an aging and increasingly morbid U.S. population have led to an increase in complex spine surgery. With this increase comes an elevated risk of complications, including those related to the surgical wound, with some studies demonstrating wound complication incidences approaching 45 percent. The authors hypothesize that immediate muscle flap closure improves outcomes in high-risk patients.

METHODS

Three hundred one consecutive index cases of spinal wound closure using local muscle flaps performed by the senior author at a single institution between 2006 and 2018 were reviewed. The primary outcome was major wound complication (reoperation and/or readmission because of surgical-site infection, late infection, dehiscence, seroma, or hematoma). Logistic regression analysis was performed to identify predictors of this endpoint.

RESULTS

Major wound complications occurred in 6.6 percent of patients (reoperation, 3.6 percent; readmission, 3.0 percent), with a 6.0 percent infection rate and five cases requiring instrumentation removal because of infection. Risk factors identified included radiotherapy (OR, 5.9; p = 0.004), age 65 years or older (OR, 2.8; p = 0.046), and prior spine surgery (OR, 4.3; p = 0.027). The incidence of major wound complication increased dramatically with each additional risk factor. Mean drain dwell duration was 21.1 ± 10.0 days and not associated with major wound complications, including infection (OR, 1.04; p = 0.112).

CONCLUSIONS

Immediate local muscle flap closure following complex spine surgery on high-risk patients is associated with an acceptable rate of wound complications and, as these data demonstrate, is safe and effective. Consideration should be given to immediate muscle flap closure in appropriately selected patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

The Use of Antiseptic Solutions in the Prevention and Management of Penile Prosthesis Infections: A Review of the Cytotoxic and Microbiological Effects of Common Irrigation Solutions

INTRODUCTION

The Mulcahy salvage fundamentally altered the management of penile prosthesis infections (PPI). Central to this procedure is a sequence of antiseptic irrigations that aims to remove and eradicate pathogenic microflora from the infected field, thus preparing for immediate reimplantation. The antiseptic solutions and their respective concentrations, however, have never been evaluated for efficacy.

AIM

This review critically examines 3 commonly used antiseptic irrigation solutions (povidone-iodine [PVI], hydrogen peroxide [H₂O₂], and chlorhexidine gluconate [CHG]) in terms of their antimicrobial activity, cytotoxicity, and clinical use.

METHODS

A PubMed literature review was performed on articles published between 2003 and 2018. Both preclinical as well as clinical studies from various surgical disciplines were included in this review.

MAIN OUTCOME MEASURE

The original salvage protocol selected for irrigation solutions at concentrations that are likely detrimental to native tissue.

RESULTS

All 3 agents demonstrate in vitro cytotoxic effects at subclinical concentrations, but H₂O₂ is associated with the most significant deleterious properties. It does not seem to broaden antimicrobial coverage beyond what is covered by PVI. Dilute PVI (0.35-3.5% with exposure time of at least 3 minutes) possesses the most robust clinical evidence as an intraoperative adjunct, reducing the incidence of postoperative infectious complications. chlorhexidine gluconate is a promising new agent but lacks clinical data.

CLINICAL IMPLICATION

Improvements in the salvage protocol are warranted based on current evidence. Careful selection of lavage solution and usage of the lowest necessary concentration will help achieve desired antimicrobial activity while avoiding native tissue cytotoxicity. Strength and limitation: The study is limited by its retrospective nature, and the heterogeneity of literature reviewed precluded a formal meta-analysis. Furthermore, future studies will need to address the roles of normal saline and antibiotic irrigations as intraoperative adjuncts for infection prevention.

CONCLUSION

Diluted PVI (0.35-3.5% for 3 minutes) may be beneficial in the prevention of PPI. Evidence supports its use both in the setting of primary implantation as well as salvage of infected hardware. An improved, evidence-based protocol may increase positive outcomes of urologic prosthetic surgery. Pan S, Rodriguez D, Thirumavalavan N, et al. The Use of Antiseptic Solutions in the Prevention and Management of Penile Prosthesis Infections: A Review of the Cytotoxic and Microbiological Effects of Common Irrigation Solutions. J Sex Med 2019;16:781-790.

Is There a Role for Preclosure Dilute Betadine Irrigation in the Prevention of Postoperative Infection Following Total Joint Arthroplasty?

BACKGROUND

Conflicting evidence exists surrounding the use of preclosure irrigation solutions in primary total joint arthroplasty (TJA). We aimed to determine the role of dilute betadine lavage in preventing early infection after primary TJA.

METHODS

We retrospectively reviewed primary TJAs between 2010 and 2018. Dilute betadine lavage was introduced to our practice in November 2014. We included 3513 total hip arthroplasties, 3932 total knee arthroplasties, and 1033 hip resurfacings (HRs). In group 1 (n = 5588), surgical wounds were irrigated with saline; group 2 used dilute betadine solution (n = 2890). Subanalyses using propensity matching based on known risk factors of infection-age, body mass index, American Society of Anesthesiologists grade, diabetes, and procedure-were completed.

RESULTS

There were 48 acute infections in group 1 (0.9%) and 23 in group 2 (0.8%) (P = .762). HR without betadine had the highest acute infection prevalence (P = .028). When groups in the whole cohort were propensity score-matched, group 1 had more acute infections than group 2 (P = .033). The effect of betadine was isolated to HR patients. After excluding HR cases, betadine continued to reduce the acute infection rate when compared with the no betadine group, but this was not statistically significant (0.4% vs 0.8%; P = .101). Likewise, we did not find a significant difference in total hip arthroplasty and total knee arthroplasty patients (P = .796).

CONCLUSION

There was a decreased infection rate in the betadine group overall when groups were propensity-matched. Because the reduction in the acute infection rate was clinically significant, we feel this practice is an effective means to prevent infections.

Intra-Cavity Lavage and Wound Irrigation for Prevention of Surgical Site Infection: Systematic Review and Network Meta-Analysis

Background: Surgical site infections (SSIs) are costly and associated with poorer patient outcomes. Intra-operative surgical site irrigation and intra-cavity lavage may reduce the risk of SSIs through removal of dead or damaged tissue, metabolic waste, and site exudate. Irrigation with antibiotic or antiseptic solutions may further reduce the risk of SSI because of bacteriocidal properties. Randomized controlled trials (RCTs) have been conducted comparing irrigation solutions, but important comparisons (e.g., antibiotic vs. antiseptic irrigation) are absent. We use systematic review-based network meta-analysis (NMA) of RCTs to compare irrigation solutions for prevention of SSI. Methods: We used Cochrane methodology and included all RCTs of participants undergoing a surgical procedure with primary site closure, in which method of irrigation was the only systematic difference between groups. We used a random effects Bayesian NMA to create a connected network of comparisons. Results are presented as odds ratios (OR) of SSI, where OR <1 indicates a beneficial effect. Results: We identified 42 eligible RCTs with 11,726 participants. Most were at unclear or high risk of bias. The RCTs included groups given no irrigation or non-antibacterial, antiseptic, or antibiotic irrigation. There was substantial heterogeneity, and a random effects model was selected. Relative to non-antibacterial irrigation, mean OR of SSI was 0.439 (95% credible interval: 0.282, 0.667) for antibiotic irrigation and 0.573 (0.321, 0.953) for antiseptic agents. No irrigation was similar to non-antibacterial irrigation (OR 0.959 [0.555, 1.660]). Antibiotic and antiseptic irrigation were ranked as most effective for preventing SSIs; this conclusion was robust to potential bias. Conclusions: Our NMA found that antibiotic and antiseptic irrigation had the lowest odds of SSI. There was high heterogeneity, however, and studies were at high risk of bias. A large RCT directly comparing antibiotic irrigation with both antiseptic and non-antibacterial irrigation is needed to define the standard of care for SSI prevention by site irrigation.

The Effect of Irrigation Fluid on Periprosthetic Joint Infection in Total Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis

Introduction Rates of osteoarthritis and total joint arthroplasty (TJA) are on the rise globally. Periprosthetic joint infection (PJI) is the most devastating complication of TJA. A number of different intraoperative interventions have been proposed in an effort to reduce infection rates, including antibiotic cements, local antibiotic powder, and various irrigation solutions. The evidence on the importance of irrigation solutions is limited but has gained prominence recently, including the publication of a large randomized controlled trial (RCT). Thus, the purpose of this study was to evaluate the effectiveness of various irrigation solutions and pressures at reducing the rates of PJI. Methods A systematic review was performed using the electronic databases MEDLINE, Embase, and Web of Science. All records were screened in duplicate. Data collected included basic study characteristics, the details of the intervention and comparison solutions, if applicable, and rates of superficial and deep infection. A meta-analysis of comparative studies was performed to assess for consistency and potential direction of effect.  Results A total of ten studies were included, of which one was an RCT, eight were retrospective cohorts, and one was a case series. In total, there were 29,630 TJAs in 29,596 patients. The mean age ranged from 61 to 80 years. Six studies compared povidone-iodine (Betadine®) to normal saline, two studies compared chlorhexidine to saline, one study compared "triple prophylaxis" to standard practice, and one study used gentamicin but had no comparison group. The pooled risk ratio for deep infection in studies using Betadine® compared to saline was 0.62 (95% confidence interval [CI]: 0.33-1.19), while for chlorhexidine it was 0.74 (95%CI: 0.33-1.65). Discussion Current evidence on the relative efficacy of irrigating solutions as prophylaxis for infection following TJA remains inconclusive. Imprecision of estimates vindicates the need for a definitive trial to further inform their use in surgical practice.  Conclusion Antiseptic irrigation during TJA with solutions (Betadine®, chlorhexidine) may decrease PJI risk in patients undergoing primary and revision total hip and knee arthroplasties. Wide confidence intervals and heterogeneity among studies, however, render conclusions untrustworthy. Well-conducted RCTs are very much needed to help further investigate this issue.