Can povidone-iodine solution be used safely in a spinal surgery?

Does Intraoperative Antiseptic Solution Soaking Reduce Microbial Contamination in Spine Surgery? A Randomized Controlled Trial

BACKGROUND CONTEXT

Surgical site infections (SSIs) are a significant complication in spine surgery, particularly in instrumented procedures, leading to increased morbidity and healthcare costs. Despite standard preoperative disinfection protocols, bacterial contamination remains prevalent. Strategies such as intraoperative antiseptic irrigation have been explored to mitigate contamination, yet the comparative efficacy of different antiseptic solutions remains unclear.

PURPOSE

This study aimed to evaluate the effectiveness of intraoperative antiseptic solution soaking with normal saline (NS), povidone-iodine (PVP-I), and chlorhexidine gluconate (CHG) in reducing bacterial contamination in lumbar instrumented fusion surgery.

STUDY DESIGN/SETTING

A single-center, single-blinded, randomized controlled trial was conducted at a tertiary medical center in Taiwan.

PATIENT SAMPLE

A total of 105 patients undergoing posterior lumbar interbody fusion surgery were enrolled and randomly assigned to three groups: NS (n=35), PVP-I (n=35), or CHG (n=35). Patients with prior lumbar procedures, known allergies to antiseptics, previous spinal infections, trauma, or tumors were excluded.

OUTCOME MEASURES

The primary outcome was the reduction in bacterial contamination, assessed via intraoperative cultures from three sites-superficial tissues, deep tissues, and implant surfaces-before and after antiseptic irrigation. Secondary outcomes included the incidence of postoperative SSIs and clinical complications over a six-month follow-up period.

METHODS

Patients were randomized into three groups, each receiving a three-minute soak with the assigned antiseptic solution before wound closure, followed by normal saline irrigation. Swab samples were collected pre- and post-irrigation for bacterial culture and 16S rRNA PCR analysis. Statistical analysis was performed using logistic regression and Bonferroni correction for multiple comparisons.

RESULTS

Among 105 patients, pre-irrigation bacterial culture positivity rates were 49.5% in superficial tissues, 31.4% in deep tissues, and 32.4% on implants. Post-irrigation, NS showed no significant bacterial reduction, while PVP-I reduced superficial contamination (55.0%, p=0.015) but no significant effect in deeper tissues and implants. CHG showed the greatest bacterial reduction, significantly outperforming NS (OR: 0.06, 95% CI: 0.01-0.54, p = 0.011) and PVP-I (OR: 0.06, 95% CI: 0.01-0.56, p = 0.012) on implant surfaces. Despite these differences in culture rate, SSI rates remained low and comparable among groups (p=0.72), with no reported antiseptic-related complications.

CONCLUSION

This study confirms that bacterial contamination remains high despite standard preoperative disinfection in lumbar fusion surgery. Among the tested antiseptic solutions, CHG demonstrated superior efficacy in reducing bacterial residues, particularly on implant surfaces. These findings support CHG as a promising antiseptic for intraoperative irrigation in spine surgery. Further multi-center studies are needed to validate its impact on reducing SSIs and improving long-term outcomes.

LEVEL OF EVIDENCE

Level II.

Analysis of adolescent idiopathic scoliosis population for Surgical Site Infection Risk Factors

Objective

The incidence of surgical site infection (SSI) in adolescent idiopathic scoliosis (AIS) patients undergoing surgical correction varies but is commonly reported between 0.5 and 6.7 %. The identification of modifiable risk factors is crucial to preventing these infections in the AIS population. Some potential modifiable risk factors include the use of stainless-steel implants, a larger volume of instrumentation and an increased volume of blood products transfused. However, evidence in support of these factors and others representing true risk for the development of SSI is limited and often varies. We aimed to determine the incidence of SSI in AIS undergoing primary scoliosis fusion at our hospital, and explore demographic and clinical variables in the development of SSI in AIS.

Methods

This was a case control retrospective study. Patients aged 10-19 year-old that underwent posterior spinal fusion for initial correction of AIS at our hospital between the years 2012-2020 were eligible. Patients with any previous spine surgery or spine fracture were excluded. A descriptive analysis was then performed on the data.

Results

Of the 334 patients on which data was collected, one SSI was identified resulting in an incidence of infection of 0.3 %. The largest ethnicity represented was Caucasian with 254 patients. The average age was 14.3 years with averaged follow-up of 6.6 years. The majority of patients (252) received implants composed of titanium and cobalt chrome. The average operation duration was 5 h and 7.7 min, and the average hospital stay was 4.2 days. The average amount of blood loss was 553 ml. Chlorhexidine wipes or some other antimicrobial preparation was used on 197 patients and betadine solution was used on 321.185 patients were recorded to have received either antibiotic-loaded allograft or antibiotic powder and 326 patients were recorded to have received intraoperative antibiotics.

Conclusions

The long term clinical follow up of our study and low incidence of infection provide additional evidence for the benefit of antimicrobial techniques and risk factor mitigation previously suggested in the literature for the prevention of SSI in AIS.

Level of evidence

Level III.

ASRA Pain Medicine consensus practice infection control guidelines for regional anesthesia and pain medicine

BACKGROUND

To provide recommendations on risk mitigation, diagnosis and treatment of infectious complications associated with the practice of regional anesthesia, acute and chronic pain management.

METHODS

Following board approval, in 2020 the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) commissioned evidence-based guidelines for best practices for infection control. More than 80 research questions were developed and literature searches undertaken by assigned working groups comprising four to five members. Modified US Preventive Services Task Force criteria were used to determine levels of evidence and certainty. Using a modified Delphi method, >50% agreement was needed to accept a recommendation for author review, and >75% agreement for a recommendation to be accepted. The ASRA Pain Medicine Board of Directors reviewed and approved the final guidelines.

RESULTS

After documenting the incidence and infectious complications associated with regional anesthesia and interventional pain procedures including implanted devices, we made recommendations regarding the role of the anesthesiologist and pain physician in infection control, preoperative patient risk factors and management, sterile technique, equipment use and maintenance, healthcare setting (office, hospital, operating room), surgical technique, postoperative risk reduction, and infection symptoms, diagnosis, and treatment. Consensus recommendations were based on risks associated with different settings and procedures, and keeping in mind each patient's unique characteristics.

CONCLUSIONS

The recommendations are intended to be multidisciplinary guidelines for clinical care and clinical decision-making in the regional anesthesia and chronic interventional pain practice. The issues addressed are constantly evolving, therefore, consistent updating will be required.

Wound irrigation and peritoneal lavage with antiseptic/antibiotic solution before wound closure during gastrointestinal surgery: a systematic review and meta-analysis

BACKGROUND

Surgical site infections (SSIs) can affect mortality, morbidity, and medical costs. Although it has recently been reported that washing with antiseptic/antibiotic solution can prevent SSI in clean surgery, the clinical impact in gastrointestinal surgery is still uncertain. Therefore, we performed a systematic review and meta-analysis to evaluate the efficacy of antiseptic/antibiotic solution during wound irrigation or peritoneal lavage in gastroenterological surgery.

METHODS

The database search used PubMed, MEDLINE, and Cochrane Library. The following inclusion criteria were set for the systematic review. 1) Studies comparing with or without antiseptic/antibiotic irrigation/lavage during gastrointestinal surgery. 2) Studies that described surgical site infections and adverse events. 3) Studies conducted after 2000.

RESULTS

A total of 8 randomized controlled studies (RCTs) and 3 observational studies were included in this meta-analysis. Three RCTs of wound irrigation with povidone iodine (PVI) solution revealed no significant difference between the PVI and control groups [RR 1.41, 95% CI (0.92 to 2.17): p = 0.69]. Three RCTs of peritoneal lavage with antibiotic solution showed no significant difference between the interventional group and control groups [RR 0.39, 95% CI (0.10 to 1.55): p = 0.18]. Regarding other antiseptic or antibiotic solutions, the number of studies and participants were too small for evaluation.

CONCLUSION

Wound irrigation and peritoneal lavage with antiseptic/antibiotic solution did not have enough efficacy for preventing SSI during gastroenterological surgery.

Dilute Povidone-Iodine Irrigation: The Science of Molecular Iodine (I2) Kinetics and Its Antimicrobial Activity

Dilute povidone-iodine (polyvinylpyrrolidone iodine [PVP-I]) irrigation in spine surgery and total joint arthroplasty has seen a rapid and substantial increase in its use during the past decade. Yet, most surgeons do not know the chemistry and biochemistry that explain its efficacy in preventing infections. PVP-I forms a complex with molecular iodine (I2), facilitating the delivery of I2 to the membrane of the infectious organism. Here, PVP-I establishes an equilibrium between complexed and noncomplexed (free) I2 in the aqueous solution. The I2 acts at numerous cellular targets of infecting organisms augmenting its role as a biocidal molecule. The paradoxical increase in the concentration of I2 that occurs with dilution of PVP-I is a result of equilibrium kinetics and is associated with an enhanced antimicrobial activity. Cytotoxicity studies have yielded conflicting results, but most endorse diluted concentrations as being less damaging to tissues. Clinical studies have verified notable reductions in surgical site infections with a 3-minute soak of 0.35% dilute povidone-iodine irrigation. Guidelines from the World Health Organization, Centers for Disease Control and Prevention, and International Consensus Meeting on Musculoskeletal Infection support the use of prophylactic incisional wound irrigation with aqueous PVP-I to reduce and prevent surgical site infections.

Does intraoperative wound irrigation with diluted povidone-iodine prevent surgical site infection in spine surgery?

Purpose

This study employed meta-analysis to evaluate whether the application of intraoperative wound irrigation (IOWI) with povidone-iodine (PI) in spine surgery effectively reduces the incidence of postoperative surgical site infection (SSI).

Methods

The present study was conducted strictly following the methodological guidance provided by the Cochrane Handbook. The protocol of this work was registered with PROSPERO. Two researchers independently conducted electronic searches in Medline via PubMed, Embase, Cochrane Library, and Web of Science. The bias risk of each included study was evaluated by two assessors. We performed statistical analysis on the dataset using STATA software.

Results

Fourteen studies involving a total of 6777 patients were included in the present work. The risk of bias of six included randomized controlled trials (RCTs) was considered as low-to-moderate risk, and the quality scores of the eight included retrospective cohort studies were rated as high quality. The results of this meta-analysis indicated a significant difference in the incidence of postoperative SSI between the two groups (RR = 0.29, 95% CI: (0.18, 0.47)). Moreover, patients who underwent IOWI with PI had lower rates of deep and superficial infections after spine surgery compared with the controlled group (superficial infection: RR = 0.28, 95%CI: (0.14, 0.54); Deep infection: RR = 0.24, 95%CI: (0.10, 0.60)). The sensitivity analysis results indicated good robustness and high evidence strength after data consolidation in the overall rate of postoperative SSI and the incidence of deep/superficial infection.

Conclusions

IOWI with PI solution during spinal surgery can effectively reduce the incidence of postoperative SSI.

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.

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.

A meta-analysis examining the impact of intrawound treatment on reducing deep surgical site infections during instrumented spine surgery

The purpose of the meta-analysis was to evaluate and compare the effect of intrawound management on decreasing deep surgical site infections (SSIs) in instrumented spinal surgery (SS). The results of this meta-analysis were analysed, and the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) were calculated using dichotomous or contentious random or fixed effect models. For the current meta-analysis, 29 examinations spanning from 2006 to 2022 were included, encompassing 11 181 people who had instrumented SS. Intrawound management had a significantly lower deep SSI when using vancomycin (OR, 0.34; 95% CI, 0.25-0.44, p < 0.001) and povidone-iodine as intrawound management (OR, 0.24; 95% CI, 0.13-0.42, p < 0.001) compared to control in instrumented SS subjects. The data that was looked at showed that using vancomycin and povidone-iodine as intrawound management had a much lower deep SSI than using a control group of instrumented SS subjects. However, given that some studies included a small number of subjects, attention should be given to their values.

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.

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.

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.

Single-stage revision for chronic periprosthetic joint infection after knee and hip arthroplasties: indications and treatments

Single-stage revision for chronic periprosthetic joint infection has been introduced 40 years ago. This option is gaining more and more attention as well as popularity. It is a reliable treatment for the chronic periprosthetic joint infection after knee and hip arthroplasties when implemented by an experienced multi-disciplinary team. However, its indications and corresponding treatments remain controversial. This review focused on the indications and specific treatments related to the option, with an attempt to help surgeons to use this method with more favorable outcomes.

Stability analysis of tranexamic acid in the presence of various antiseptic solutions

Tranexamic acid (TXA) effectively reduces blood loss and transfusion risk during total joint arthroplasty. Additionally, intraoperative irrigation with various antiseptic solutions is often utilized for the management and prevention of surgical site infection. However, interactions between various antiseptic solutions and TXA have not been investigated. The purpose of this in vitro study is to evaluate the stability of TXA in the presence of common orthopedic antiseptic solutions. Five antiseptic solutions-0.1% chlorhexidine (CHX) gluconate, 10% povidone-iodine (BTD), 0.5% sodium hypochlorite (Dakin's), 3% hydrogen peroxide (H₂ O₂ ), and 1.5% H₂ O₂ -and a 0.9% normal saline (NS) control were obtained. A stock 100 mg/ml TXA solution was diluted in each antiseptic solution to a concentration of 10.0 mg/ml to generate reference standard and stability samples. TXA stability in each solution was measured using high performance liquid chromatography at t = 0 and t = 120 min and reported as mean percent of theoretical concentration (MPT) with associated relative standard deviation (RSD). All experiments were performed in triplicate at room temperature. At t = 0 min, TXA remained stable when mixed with 0.9% NS, 0.1% CHX, 10% BTD, 3% H₂ O₂ , and 1.5% H₂ O₂ (MPT range: 102.0%-105.0%, RSD range: 0.80%-2.92%). Only 0.5% Dakin's led to significant degradation of TXA at t = 0 min (MPT: 14.3%, RSD:1.28%). At t = 120 min, TXA stability persisted for all compounds except Dakin's 0.5% (MPT: 18.4%, RSD: 28.7%). TXA efficacy may be significantly diminished when 0.5% Dakin's is used as an intraoperative irrigation solution. CHX, BTD, and H₂ O₂ do not degrade TXA.

One- or two-stage reimplantation for infected total knee prosthesis?

A prosthetic joint infection (PJI) is possibly the most significant potential complication of total knee arthroplasty (TKA) and is associated with substantial morbidity and socioeconomic burden. It is a devastating complication for both the patient and the surgeon alike. A two-stage revision approach for infected TKA has been the standard for surgical management; however, there is growing interest in single-stage revision surgery due to fewer procedures, reduced inpatient hospital stay and reduced costs to healthcare systems. A one-stage exchange is indicated when there is no sign of systemic sepsis and in cases where a microorganism has been isolated. It involves removal of the old prosthesis, debridement of all infected tissue, a copious washout and re-draping, and finally, re-implantation of a new prosthesis. The two-stage approach involves the use of an antibiotic spacer before the second stage is carried out. The length of time between the stages is discussed. Patients with a PJI should be managed by a multidisciplinary team. We recommend these patients are managed in specialist arthroplasty centres by high volume revision arthroplasty specialists.

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.

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.

Dilute povidone-iodine irrigation during percutaneous nephrolithotomy to reduce postoperative infective complications - Is there any benefit?

Background and Objective

Infectious complications following stone lithotripsy is a significant source of patient morbidity and mortality. Post percutaneous nephrolithotomy fever is reported in 37% of patients undergoing PCNL and sepsis is the most common cause of mortality following PCNL. Thus, there is an urgent need to tackle lithotripsy-associated bacteremia occurring intraoperatively, keeping in mind the threat of emerging global antibiotic resistance. The aim of our study was to study the efficacy of using intermittent 0.35% dilute Povidone-Iodine (PI) irrigation during PCNL in reducing postoperative infection rate.

Materials and Methods

This is a prospective observational study done in 24 patients diagnosed with Staghorn and matrix calculi requiring PCNL. All patients were taken up for the procedure with sterile urine culture or after treating them with culture-specific antibiotic with initial positive urine culture. Intraoperative pelvic urine was sent for culture and sensitivity. 0.35% dilute PI irrigation was used intermittently during the procedure. Patients were monitored and assessed for signs of post-PCNL infection and PI-related side effects. The results were compared with similar group of patients with similar stone characteristics who underwent PCNL before adopting the dilute PI irrigation protocol (non-PI irrigation group).

Results

Among 24 patients, 18 patients had partial or complete Staghorn and 6 had matrix calculi. Five patients with Staghorn and three patients with matrix calculi had positive renal pelvic urine culture. In the non-PI irrigation group, 19 patients had Staghorn stones and 5 had matrix calculi. Three patients with Staghorn and two patients with matrix calculi had positive renal pelvic urine culture. Three patients (12.5%) had postoperative fever in the dilute PI irrigation group, compared to 11 patients (45.8%) in the non-PI irrigation group. No patient had PI-related complications.

Conclusion

Our prospective study highlights that the use of 0.35% dilute PI irrigation intermittently during PCNL reduces the postoperative infection rate significantly.

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.

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.

Postoperative Spinal Implant Infections (PSII)-A Systematic Review: What Do We Know So Far and What is Critical About It?

STUDY DESIGN

Systematic review.

OBJECTIVES

Postoperative spinal implant infections (PSII) are an increasing challenge in the daily clinical routine. This review summarizes existing knowledge in the field of PSII, including definitions, epidemiology, classifications, risk factors, pathogenesis, symptoms, diagnosis, and treatment.

METHODS

A systematic review was performed using a structured PubMed analysis, based on the PRISMA criteria. The search terminology was set as: "spinal implant associated infection OR spinal implant infection OR spinal instrumentation infection OR peri spinal implant infection." PubMed search was limited to the categories randomized controlled trials (RCT), clinical trials, meta-analysis and (systematic) reviews, whereas case reports were excluded. Studies from January 2000 to December 2020 were considered eligible. A total of 572 studies were identified, 82 references included for qualitative synthesis, and 19 for detailed sub analysis (12 meta-analysis, 7 prospective RCT).

RESULTS

Structural problems in the field of PSII were revealed, including (1) limited level of evidence in clinical studies (missing prospective RCT, metanalyzes), (2) small patient numbers, (3) missing standardized definitions, (4) heterogeneity in patient groups, and (5) redundancy in cited literature.

CONCLUSION

Evidence-based knowledge about spinal implant-associated infections is lacking. All involved medical fields should come together to define the term PSII and to combine their approaches toward research, training, and patient care.

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.

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).

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.

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.

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.

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.

Prediction tool for high risk of surgical site infection in spinal surgery

OBJECTIVE

The incidence of surgical site infection (SSI) is higher in spinal surgeries than in general orthopedic operations. In this study, we aimed to develop a scoring system with reduced health care costs for detecting spinal surgery patients at high risk for SSI.

DESIGN

Retrospective cohort study.

PATIENTS

In total, 824 patients who underwent spinal surgery at 2 university hospitals from September 2005 to May 2011.

METHODS

We reviewed the medical records of 824 patients, and we examined 19 risk factors to identify high-risk patients. After narrowing down the variables by univariate analysis, multiple logistic analysis was performed for factors with P values <.2, using SSI as a dependent variable. Only factors that showed P values <.05 were included in the final models, and each factor was scored based on the β coefficient values obtained. The clinical prediction rules were thereby prepared.

RESULTS

"Emergency operation," "blood loss >400 mL," "presence of diabetes," "presence of skin disease," and "total serum albumin value <3.2 g/dL" were detected by multivariable modeling and were incorporated into the risk scores. Applying these 5 independent predictive factors, we were able to predict the infection incidence after spinal surgery.

CONCLUSIONS

Our present study could aid physicians in making decisions regarding prevention strategies in patients undergoing spinal surgery. Stratification of risks employing this scoring system will facilitate the identification of patients most likely to benefit from complex, time-consuming and expensive infection prevention strategies, thereby possibly reducing healthcare costs.

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.

Current Strategies in Prevention of Postoperative Infections in Spine Surgery

STUDY DESIGN

Narrative review.

OBJECTIVES

Postoperative surgical site infections (SSIs) are among the most common acute complications in spine surgery and have a devastating impact on outcomes. They can lead to increased morbidity and mortality as well as greater economic burden. Hence, preventive strategies to reduce the rate of SSIs after spine surgery have become vitally important. The purpose of this article was to summarize and critically analyze the available evidence related to current strategies in the prevention of SSIs after spine surgery.

METHODS

A literature search utilizing Medline database was performed. Relevant studies from all the evidence levels have been included. Recommendations to decrease the risk of SSIs have been provided based on the results from studies with the highest level of evidence.

RESULTS

SSI prevention occurs at each phase of care including the preoperative, intraoperative, and postoperative periods. Meticulous patient selection, tight glycemic control in diabetics, smoking cessation, and screening/eradication of Staphylococcus aureus are some of the main preoperative patient-related preventive strategies. Currently used intraoperative measures include alcohol-based skin preparation, topical vancomycin powder, and betadine irrigation of the surgical site before closure. Postoperative infection prophylaxis can be performed by administration of silver-impregnated or vacuum dressings, extended intravenous antibiotics, and supplemental oxygen therapy.

CONCLUSIONS

Although preventive strategies are already in use alone or in combination, further high-level research is required to prove their efficacy in reducing the rate of SSIs in spine surgery before evidence-based standard infection prophylaxis guidelines can be built.

Intraoperative and Postoperative Infection Prevention

Implementation of strategies for prevention of surgical site infection and periprosthetic joint infection is gaining further attention. We provide an overview of the pertinent evidence-based guidelines for infection prevention from the World Health Organization, the Centers for Disease Control and Prevention, and the second International Consensus Meeting on Musculoskeletal Infection. Future work is needed to ascertain clinical efficacy, optimal combinations, and the cost-effectiveness of certain measures.

Dilute Betadine Lavage Reduces the Risk of Acute Postoperative Periprosthetic Joint Infection in Aseptic Revision Total Knee and Hip Arthroplasty: A Randomized Controlled Trial

BACKGROUND

The purpose of this randomized, controlled trial is to determine whether dilute betadine lavage compared to normal saline lavage reduces the rate of acute postoperative periprosthetic joint infection (PJI) in aseptic revision total knee (TKA) and hip arthroplasty (THA).

METHODS

A total of 478 patients undergoing aseptic revision TKA and THA were randomized to receive a 3-minute dilute betadine lavage (0.35%) or normal saline lavage before surgical wound closure. Fifteen patients were excluded following randomization (3.1%) and six were lost to follow-up (1.3%), leaving 457 patients available for study. Of them, 234 patients (153 knees, 81 hips) received normal saline lavage and 223 (144 knees, 79 hips) received dilute betadine lavage. The primary outcome was PJI within 90 days of surgery with a secondary assessment of 90-day wound complications. A priori power analysis determined that 285 patients per group were needed to detect a reduction in the rate of PJI from 5% to 1% with 80% power and alpha of 0.05.

RESULTS

There were eight infections in the saline group and 1 in the betadine group (3.4% vs 0.4%, P = .038). There was no difference in wound complications between groups (1.3% vs 0%, P = .248). There were no differences in any baseline demographics or type of revision procedure between groups, suggesting appropriate randomization.

CONCLUSION

Dilute betadine lavage before surgical wound closure in aseptic revision TKA and THA appears to be a simple, safe, and effective measure to reduce the risk of acute postoperative PJI.

LEVEL OF EVIDENCE

Level I.

Measures to reduce end-of-case wound contamination: the impact of intra-wound vancomycin powder and betadine irrigation on surgical site infections in posterior spinal fusion

STUDY DESIGN

Retrospective descriptive, single-center study.

OBJECTIVES

To determine the effect of standardized intrawound vancomycin powder and betadine irrigation on surgical site infection (SSI) rates after posterior spinal fusion (PSF) in idiopathic scoliosis. Since 2005, our pediatric spine center has implemented a series of changes to lower the risk of SSI. The most recent interventions-intrawound vancomycin powder and betadine irrigation-are applied just before closure, aiming to reduce the culture-positive bacterial contamination known to occur in many cases. We sought to determine the impact of these end-of-case measures on our center's SSI rate.

METHODS

We retrospectively reviewed patients who underwent PSF for idiopathic scoliosis at our institution from January 1, 2010, to June 30, 2018, identifying all cases that returned to the operating room for surgical debridement within 90 days of PSF. Cases were surgeon-audited to ensure inclusion of all infections that met Centers for Disease Control and Prevention (CDC) criteria for acute SSI. Vertical expandable prosthetic titanium ribs, growing rods, staged procedures, and nonidiopathic cases were excluded. Annual rates of SSIs were correlated with the initiation of each SSI prevention measure.

RESULTS

Among 740 cases of PSF for idiopathic scoliosis from 2010 to 2018, the overall acute SSI rate by CDC criteria was 0.68%. The idiopathic SSI rate dropped significantly, from 1.70 to 0.20%, after the standardized introduction of intrawound vancomycin powder and betadine irrigation before closure (p < 0.04). The implementation of these end-of-case measures in 2012-2013 was soon followed by an institution best 3.5-year SSI-free period for idiopathic cases.

CONCLUSIONS

Since intrawound vancomycin powder and betadine irrigation were added to our SSI prevention bundle, we have seen a significantly lower SSI rate after PSFs for idiopathic scoliosis. These findings suggest that anti-SSI interventions to reduce wound contamination at the end of the case may have a particularly positive impact on SSI reduction.

LEVEL OF EVIDENCE

Level III, therapeutic.

Operative Field Debris Often Rises to the Level of the Surgeon's Face Shield During Spine Surgery: Are Orthopedic Space Suits a Reasonable Solution?

Background

The present study intended to identify debris in the spine surgical field that frequently rises to the level of the surgeon's face during several different elective spine procedures. Unlike other areas of orthopedic surgery where infection risk is of high concern, in spine surgery the surgical team usually uses a nonsterile face mask instead of a protective space suit with a sterile face shield. It is possible that blood or bone burr particles striking the surgeon's face mask represent a potential source of infection if they ricochet back into the operative field.

Methods

We reviewed 46 consecutive, elective spine surgeries between May 2015 and August 2015 from a single-surgeon practice. For each surgery, every member of the surgical team wore sterile (space suit) personal protective equipment. After each procedure, the face shield was carefully inspected by 2 members of the surgical team to identify patient blood, tissue, or bone burr dust present on the face shield.

Results

The rate of surgeon face shield debris inspected for each case overall was 38/46 (83%). The rate of first assistant face shield debris inspected per case was 16/46 (35%). The scrub technician had a 0% rate of face mask debris on inspection. The highest debris exposure rates occurred with transforaminal lumbar interbody fusions (100%), open laminectomy and fusions (100%), and anterior cervical discectomy and fusions 43/46 (93%).

Conclusions

There is a high rate of blood and tissue debris contact that occurs during spine surgery, and it is procedure dependent. Spine surgeons may consider using sterile shields particularly in high-risk cases to protect themselves and their patients.

Level of Evidence

4.

Outcomes of an Intraoperative Povidone-Iodine Irrigation Protocol in Spinal Surgery for Surgical Site Infection Prevention

STUDY DESIGN

This was a retrospective observational study.

OBJECTIVE

The aim of this study was to evaluate the efficacy of our new protocol for preventing postoperative surgical site infection (SSI) following spinal surgery.

SUMMARY OF BACKGROUND DATA

SSI following spinal surgery is a serious postoperative complication. Several studies have recently assessed the effectiveness of wound irrigation with povidone-iodine (PVP-I) for SSI prevention, but no consensus has been reached as to how PVP-I should be used in clinical practice. We formed a PVP-I irrigation protocol focusing on the pharmacological properties of PVP-I. This study aimed to evaluate the efficacy and safety of our protocol for preventing SSI.

MATERIALS AND METHODS

All cases of spinal surgery at our hospital between October 2011 and September 2016 were retrospectively reviewed. The exclusion criteria were PVP-I allergy, prior surgical debridement for infection, and implant removal surgery. The patients were subdivided into those who had received normal saline irrigation after 90 seconds of 1% PVP-I pooling every 1.5 hours (study group) or only routine saline irrigation every 1.5 hours (control group). The study and control groups comprised of 177 and 146 patients, respectively. This study compared the rate of SSI with and without the use of the PVP-I irrigation protocol.

RESULTS

The SSI rates were 1.7% for the study group (3/177 patients) and 3.4% for the control group (5/146 patients), showing no significant statistical difference (P=0.32). There were no cases of deep SSI in the study group, whereas there were 4 cases in the control group. The deep SSI rate significantly decreased in the study group (P=0.027). No adverse events occurred in the study group.

CONCLUSION

In this study, 90 seconds of 1% PVP-I pooling every 1.5 hours followed by saline irrigation demonstrated the effectiveness of our protocol for the prevention of postoperative deep SSI after spinal surgery.

The efficacy of intrawound vancomycin powder and povidone-iodine irrigation to prevent surgical site infections in complex instrumented spine surgery

BACKGROUND CONTEXT

Surgical site infections (SSIs) are notorious complications in spinal surgery and cause substantial patient morbidity. Intraoperative decontamination of the wound with povidone-iodine irrigation or vancomycin powder has gained attention lately, but the efficacy of either intervention is unclear.

PURPOSE

To determine the efficacy of intrawound povidone-iodine or vancomycin in reducing the incidence of deep- and superficial SSIs in instrumented spinal surgery.

STUDY DESIGN/SETTING

Retrospective cohort study.

PATIENT SAMPLE

A retrospective chart review was performed including all consecutive adult patients undergoing open, posterior, instrumented spinal surgery at any level between January 2012 and August 2017.

OUTCOME MEASURES

The presence of SSI was evaluated according to the criteria published by the Centers for Disease Control and Prevention. The SSIs were divided into deep SSIs (below the muscular fascia) and superficial SSIs (above the muscular fascia).

METHODS

A retrospective cohort without intrawound treatment was compared with two separate, consecutive intervention groups. One intrawound group received 1.3g/L povidone-iodine irrigation and the other received 1-2 grams of intrawound vancomycin powder at the end of surgery. Incidence of SSIs, as well as demographic, surgical and patient-related variables were registered and compared between groups. In patients with SSI, additional microbiological data were collected.

RESULTS

In total, 853 patients were included. In the control group (N=257), 25 (9.7%) patients developed a deep and 13 (5.1%) developed a superficial SSI. In the povidone-iodine group (N=217), 21 (9.7%) patients developed a deep and two (0.9%) developed a superficial SSI. Compared with the control group, there was no significant difference in the incidence of deep SSIs (risk ratio [RR]: 1.00, 95% CI 0.57-1.73), although the number of superficial SSIs was reduced significantly (RR 0.18, 95% CI 0.04-0.80). In the vancomycin group (N=379), 19 (5.0%) patients developed a deep and six (1.6%) developed a superficial SSI. Both deep (RR: 0.52, 95% CI 0.29-0.92) and superficial SSIs (RR: 0.31, 95% CI 0.12-0.81) were significantly reduced in the vancomycin group compared with the control group, even when correcting for several risk factors associated with SSIs in a multivariable logistic regression analysis. There were no significant differences in complications between the 3 groups. No gram-negative selection or vancomycin-resistance was seen in the vancomycin group.

CONCLUSIONS

Intrawound application of vancomycin was associated with a significant reduction in both deep and superficial SSIs in instrumented spinal surgery. A 1.3g/L intrawound povidone-iodine solution did not show a reduction in deep SSIs, although a reduction of superficial SSIs was observed.

Best Practice Guidelines for Surgical Site Infection Prevention With Surgical Treatment of Early Onset Scoliosis

BACKGROUND

Postoperative surgical site infection (SSI) is unfortunately a commonly encountered complication in the surgical treatment of children with Early Onset Scoliosis (EOS). There is documented variation in the treatment of this patient population. Previous work building consensus for the approach to high risk patients (eg, neuromuscular etiology) has been promising. The goal of the current study is to apply similar principles to develop consensus-based guidelines for the treatment of patients with EOS.

METHODS

A focus group from 2 multicenter pediatric spine deformity study groups developed a list of statements to be distributed to a larger group of EOS experts. Using the Delphi process, participants were presented with a systematic review of the literature as well as a review of current practices in growth friendly surgery. The first round was conducted using an electronic survey. Results of this survey were then discussed face-to-face and the statements were further refined. A final round was conducted using the Audience Response System, allowing participants to vote for each statement (strongly agree or agree). Agreement >80% or disagreement <20% was considered consensus.

RESULTS

A total of 29 of 57 statements reached consensus. Negative statements (statements of disagreement) were excluded, so the final consensus guidelines included 22 statements. The number of statements from the previously published Best Practice Guidelines (BPG) approved for insertion and lengthening growth friendly procedures were 12 of 14 and 11 of 14, respectively. The high risk BPG therefore does not cover all of the issues specific to the EOS population, and explains why 22 statements reached consensus in the current guideline. Upon completion of the surveys, 100% of the participants agreed to support its publication.

CONCLUSIONS

Using the Delphi process several "best practices" were developed for growth friendly surgical treatment of EOS.

LEVEL OF EVIDENCE

Level V.

The Cost Effectiveness of Dilute Betadine Lavage for Infection Prophylaxis in Total Joint Arthroplasty

BACKGROUND

This article presents a break-even analysis for intraoperative Betadine lavage for the prevention of infection in total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

Protocol costs, baseline infection rates after arthroplasty, and average revision costs were obtained from institutional records and the literature. The break-even analysis determined the absolute risk reduction (ARR) in infection rate required for cost effectiveness.

RESULTS

At our institutional price of $2.54, dilute (0.35%) Betadine lavage would be cost effective if initial infection rates of both TKA (1.10%) and THA (1.63%) have an ARR of 0.01%. At a hypothetical lowest cost of $0.50, the ARR is so low as to be immediately cost effective. At a hypothetical high price of $40.00, Betadine is cost effective with ARRs of 0.16% (TKA) and 0.13% (THA).

CONCLUSION

Intraoperative Betadine lavage, at typical institutional prices, can be highly cost effective in reducing infection after joint arthroplasty.

A Meta-analysis of Prophylaxis of Surgical Site Infections with Topical Application of Povidone Iodine Before Primary Closure

BACKGROUND

Povidone iodine (PVI) is a widely used antiseptic solution among surgeons. A meta-analysis based on randomized controlled trials (RCTs) was conducted to establish whether application of PVI before wound closure could reduce surgical site infection (SSI) rates.

METHODS

Systematic review of MEDLINE/PubMed, Scopus, CINAHL, and Web of Science databases from inception to September 2017, with no language restrictions. Only RCTs were retrieved. The primary outcome was the SSI rate. Meta-analysis was complemented with trial sequential analysis (TSA).

RESULTS

A total of 7601 patients collected from 16 RCTs were analyzed. A reduction in overall SSI rate was found (RR 0.64, 95% CI 0.48-0.85, P = 0.002, I² = 65%), which was attributed to patients undergoing elective operations (n = 2358) and mixed elective/urgent operations (n = 2019). When RCTs of uncertain quality (n = 9) were excluded, the use of PVI before wound closure (n = 4322 patients) was not associated with a significant reduction of SSI (RR 0.81, 95% CI 0.55-1.20, P = 0.29, I² = 51%) and was only significant in clean wounds (RR 0.25, 95% CI 0.09-0.70, P = 0.008, I² = 0%). For the primary outcome, the TSA calculation using a relative risk reduction of 19% and an 11% proportion of control event rate (CER) with 51% of I², the accrued information size (n = 4322) was 32.8% of the estimated optimal information size (n = 13,148).

CONCLUSIONS

There is no conclusive evidence for a strong recommendation of topical PVI before wound closure to prevent SSI.

Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: prevention of periprosthetic shoulder infection

The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. Over 800 international experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology were assembled to form a consensus workgroup. The following proceedings on the prevention of periprosthetic shoulder infection come from 16 questions evaluated by delegates from the shoulder section.

Intraoperative povidone-iodine irrigation for infection prevention

Although prevention of infection following arthroplasty requires a multifaceted approach, the use of intraoperative irrigation is an important component of any protocol. Recent clinical practice guidelines from the Centers for Disease Control, World Health Organization, and International Consensus Meeting on Musculoskeletal Infection advocate the use of a dilute povidone-iodine solution prior to wound closure. Our experience suggests that this practice is safe, inexpensive, and easily implemented. The present article describes our institutional irrigation protocol and reviews the current literature regarding povidone-iodine solutions.

Pilot Study to Evaluate the Adjunct Use of a Povidone-Iodine Topical Antiseptic in Patients with Soft Tissue Abscesses

BACKGROUND

Povidone-iodine (PVP-I) antiseptic solutions have been shown to be effective against methicillin-resistant Staphylococcal aureus, a common cause of superficial skin abscesses.

OBJECTIVES

Our objective was to study the feasibility of using PVP-I as a treatment adjunct in patients with superficial skin abscesses and determine if it confers any benefit over incision and drainage (I&D) alone.

METHODS

This was a randomized controlled pilot study of adult patients with an uncomplicated skin abscess. Patients were randomized to PVP-I or standard treatment. All patients had I&D and abscess packing. Patients randomized to PVP-I were instructed on daily application of the agent to hands, wound, and surrounding skin with dressing changes. Subjects returned at 48-72 h and 7-10 days and followed-up by phone at 30 days. The primary outcome was clinical cure 7-10 days after I&D. The secondary outcomes were rate of development of new skin lesions and spread in household contacts within 30 days.

RESULTS

Clinical cure occurred in 91.3% of patients in the standard group vs. 88.2% of patients in the PVP-I group (difference, 3.1%; 95% confidence interval [CI] -10.7 to 16.8; p = 0.53). There was a significantly higher adverse event rate in the group who received PVP-I (59.6%) vs. standard care (26.5%) (difference 33.1%, 95% CI 13.2-50.2; p < 0.001).

CONCLUSIONS

There was no difference in clinical cure rates among patients using PVP-I (88.2%) vs. standard care (91.3%) after I&D. There were no major adverse events, but the addition of PVP-I was commonly associated with local skin irritation.

Intrawound Treatment for Prevention of Surgical Site Infections in Instrumented Spinal Surgery: A Systematic Comparative Effectiveness Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

To determine the efficacy of intrawound treatments in reducing deep surgical site infections (SSIs) in instrumented spinal surgery.

METHODS

The electronic databases MEDLINE, EMBASE, and Cochrane were systematically searched for intrawound treatments for the prevention of SSIs in clean instrumented spine surgery. Both randomized controlled trials and comparative cohort studies were included. The results of included studies were pooled for meta-analysis.

RESULTS

After full text- and reference screening, 20 articles were included. There were 2 randomized controlled trials and 18 observational studies. Sixteen studies investigated the use of intrawound antibiotics, and 4 studies investigated the use of intrawound antiseptics. The relative risk of deep SSI for any treatment was 0.26 (95% confidence interval [CI] 0.16-0.44, P < .0001), a significant reduction compared with controls receiving no treatment. For patients treated with local antibiotics the relative risk was 0.29 (95% CI 0.17-0.51, P < .0001), and patients treated with local antiseptics had a relative risk of 0.14 (95% CI 0.05-0.44, P = .0006).

CONCLUSIONS

Both the use of antibiotic and antiseptic intrawound prophylactics was associated with a significant 3 to 7 times reduction of deep SSIs in instrumented spine surgery. No adverse events were reported in the included studies.