Prevention of Periprosthetic Joint Infections of the Hip and Knee

Operative Considerations

Surgical gloves become contaminated in almost one third of cases, half the time during draping.⁷⁵ For this reason, many surgeons change gloves after draping. In addition, double gloving prevents a breech of aseptic technique should the outer glove become perforated.⁷⁶ Demircay and colleagues⁷⁷ assessed double latex gloving in arthroplasty and found the outer and inner gloves perforated in 18.4% and 8.4% of cases, respectively. Punctures are most common along the nondominant index finger, and then the dominant thumb.^77,78 Perforation is more common when 2 latex gloves are worn—vs 1 latex glove plus an outer cloth glove—and the chance of perforation increases with surgery duration. The inner glove may become punctured in up to 100% of operations that last over 3 hours.⁷⁹ Although Dodds and colleagues⁸⁰ found no change in bacterial counts on surgeons’ hands or gloves after perforation, precautions are still recommended. Al-Maiyah and colleagues⁸¹ went as far as to recommend glove changes at 20-minute intervals and before cementation.

Surgical instruments can be sources of contamination. Some authors change the suction tip every hour to minimize the risk of deep wound infection.^82-85 Others change it before femoral canal preparation and prosthesis insertion during THA.⁸⁶ The splash basin is frequently contaminated, and instruments placed in it should not be returned to the operative field.⁸⁷ Hargrove and colleagues⁸⁸ suggested pulsatile lavage decreases PJI more than bulb syringe irrigation does, whereas others argued that high-pressure lavage allows bacteria to penetrate more deeply, which could lead to retention of more bacteria.⁸⁹ Minimizing operating room time was found by Kurtz and colleagues⁹⁰ and Peersman and colleagues⁹¹ to decrease PJI incidence. Carroll and colleagues⁷¹ correlated longer tourniquet use with a higher rate of infection after TKA; proposed mechanisms include local tissue hypoxia and lowered concentrations of prophylactic antibiotics.

Similarly, minimizing blood loss and transfusion needs is another strategy for preventing infection. Allogenic transfusion may increase the risk of PJI 2 times.^23,71,92 The mechanism seems to be immune system modulation by allogenic blood, which impairs microcirculation and oxygen delivery at the surgical site.^23,75 Transfusions should be approached with caution, and consideration given to preoperative optimization and autologous blood donation. Cherian and colleagues⁹³ reviewed different blood management strategies and found preoperative iron therapy, intravenous erythropoietin, and autologous blood donation to be equally effective in reducing the need for allogenic transfusions. Numerous studies of tranexamic acid, thrombin-based hemostatic matrix (Floseal; Baxter Inc), and bipolar sealer with radiofrequency ablation (Aquamantys; Medtronic Inc) have found no alterations in infection rates, but most have used calculated blood loss, not PJI, as the primary endpoint.^94-105 Antibiotic cement also can be used to block infection.^63,106-110 Although liquid gentamicin may weaken bone cement,¹¹¹ most antibiotics, including powdered tobramycin and vancomycin, do not weaken its fatigue strength.^111-114 A recent meta-analysis by Parvizi and colleagues¹¹⁵ revealed that deep infection rates dropped from 2.3% to 1.2% with use of antibiotic cement for primary THAs. Cummins and colleagues,¹¹⁶ however, reported the limited cost-effectiveness of antibiotic cement in primary arthroplasty. Performing povidone-iodine lavage at the end of the case may be a more inexpensive alternative. Brown and colleagues¹¹⁷ found that rinsing with dilute povidone-iodine (.35%) for 3 minutes significantly decreased the incidence of PJI.

Closure techniques and sutures have been a focus of much of the recent literature. Winiarsky and colleagues³⁴ advocated using a longer incision for obese patients and augmenting closure in fattier areas with vertical mattress retention sutures, which are removed after 5 days. A barbed monofilament suture (Quill; Angiotech Inc) is gaining in popularity. Laboratory research has shown that bacteria adhere less to barbed monofilament sutures than to braided sutures.¹¹⁸ Smith and colleagues¹¹⁹ found a statistically nonsignificant higher rate of wound complications with barbed monofilament sutures, whereas Ting and colleagues120 found no difference in complications. These studies were powered to detect differences in time and cost, not postoperative complications. Skin adhesive (Dermabond; Ethicon Inc), also used in closure, may be superior to staples in avoiding superficial skin abscesses.¹²¹ Although expensive, silver-impregnated dressing has antimicrobial activity that reduces PJI incidence by up to 74%.¹²² One brand of this dressing (Aquacel; ConvaTec Inc) has a polyurethane waterproof barrier that allows it to be worn for 7 days.