Irrigation Solutions and Antibiotic Powders: Should I Use Them in Primary and Revision Total Joint Arthroplasty?

Antibiotic-Loaded Calcium Sulphate Beads for Treatment of Acute Periprosthetic Joint Infection in Total Knee Arthroplasty: Results Based on Risk Stratification

Background: A post-operative or late acute periprosthetic joint infection (PJI) after Total Knee Arthroplasty (TKA) requires a protocol of aggressive joint Debridement, modular implant Exchange, Component Retention, and post-operative Antimicrobial therapy (DECRA). Recently, the novel addition of intra-articular Antimicrobial Loaded Calcium Sulphate (AL-CaSO4) beads during DECRA has been utilized to improve microbial eradication. This study reviews a consecutive series of DECRA TKA procedures with AL-CaSO4 beads with a standardized antimicrobial regimen. We hypothesize AL-CaSO4 beads will not improve infection-free implant survival in compromised hosts and limbs. Methods: This consecutive series included DECRA procedures for acute post-operative or late hematogenous PJI-TKA (primary and revision) detected within 4 weeks. One gram of vancomycin powder and 240 mg of liquid tobramycin were added to 10 cc of CaSO4 powder to create 3.0 and 4.8 mm beads delivered into the joint at closure. All patients were risk stratified according to McPherson Staging and followed for a minimum of 1 year. Results: Forty-two patients were studied. The infection-free success rate of DECRA with AL-CaSO4 was 62% (26/42) at 1 year. Average bead volume per case was 18.6 cc (range = 10-40 cc). McPherson Host stage and Limb Score were found to be significantly correlated with the success of the DECRA (p < 0.05). The success rate was highest in A-hosts (87.5%), declining to 50% in B-hosts, and 25% in C-hosts. Similarly, the success rate was highest for patients with Limb score 1 (100%), declining to 58.6% with Limb score 2, and 20% with Limb score 3. Importantly, a previous episode of infection in the affected joint was associated with significantly increased failure (p = 0.000025). Conclusions: This study reports an overall higher infection-free success rate of DECRA using AL-CaSO4 beads compared to the current literature. Antibiotic beads provide an advantage in selected groups that include A or B hosts and Limb scores of 1 or 2. In C-hosts, where the immune system is weak, or Limb score 3, where the wound is compromised and leaks, antibiotic beads do not improve success. Importantly, DECRAs should not be considered curative with a prior history of joint infection. In these difficult circumstances, one should consider an exchange protocol.

Effects of antiseptic irrigation solutions on osseointegration in a cementless tibial implantation mouse model

Despite the success of standard antiseptic irrigation solutions in reducing periprosthetic joint infection (PJI) rates, there is still a need for more effective solutions. Synergistic use of povidone-iodine (PI) and hydrogen peroxide (H2O2) has shown promising results; however, the optimal solution concentration balancing bactericidal activity and osseointegration remains unknown. This study aims to evaluate the impact of these antiseptic irrigation solutions on osseointegration and the bone-implant interface strength in vivo. Forty C57BL/6 mice underwent bilateral tibial implantation surgery and were randomly allocated into three groups receiving 0.3% PI, 10% PI mixed with 3% H2O2, or saline as irrigation solutions intraoperatively. Assessments were performed on postoperative Days 1 and 28, including plain radiographs, microcomputed tomography (microCT) evaluation, histological analysis, immunohistochemistry, and biomechanical pull-out testing. No wound complications were observed. MicroCT scans revealed no differences in peri-implant trabecular bone parameters. Biomechanical pull-out testing showed no differences in the bone-implant interface strength across groups. Histological analysis indicated no differences in bone and bone marrow percentage areas among treatment groups. Immunohistochemical analysis demonstrated no differences among groups in peri-implant osteocalcin, osterix, or endomucin-positive cells. In conclusion, using either antiseptic irrigation solution showed no differences in osseointegration parameters compared to the control group, demonstrating safety and the absence of toxicity. CLINICAL RELEVANCE: Dilute 0.3% povidone-iodine and a 1:1 combination of 10% povidone-iodine mixed with 3% hydrogen peroxide can be safely used during primary and revision total joint arthroplasty without compromising osseointegration or causing wound complications.

Early Periprosthetic Femur Fractures After Primary Cementless Total Hip Arthroplasty: High Risk of Periprosthetic Joint Infection and Subsequent Reoperation

BACKGROUND

Periprosthetic femur fracture (PFF) following total hip arthroplasty (THA) is a leading cause of early reoperation. The objective of this study was to compare rates of periprosthetic joint infection (PJI) and reoperation following PFFs occurring early postoperatively to those that occurred late.

METHODS

We retrospectively identified 173 consecutive surgically managed PFFs following primary THA. Cases were categorized as "early" if they occurred within 90 days of THA (n = 117) or "late" if they occurred following the initial 90 days (n = 56). Mean age at time of PFF was 68 years (range, 26 to 96) and 60% were women. Mean body mass index was 29 (range, 16 to 52). Mean follow-up was 2 years (range, 0 to 13). Kaplan-Meier survival analysis estimated cumulative incidences of PJI and reoperation.

RESULTS

Early PFFs had higher 2-year cumulative incidence of PJI (11% versus 0%, P < .001) and reoperation (24% versus 13%, P = .110). Following early PFF, 27 patients required reoperation (ie, 13 for PJI, 5 for instability, 2 for re-fracture, 2 for painful hardware, 2 for non-union, 1 for adverse local tissue reaction, 1 for aseptic loosening, and 1 for leg-length discrepancy). Following late PFF, 5 patients required reoperation (ie, 3 for instability, 1 for re-fracture, and 1 for non-union).

CONCLUSIONS

There are greater incidences of PJIs and overall reoperations following early PFFs compared to late PFFs after THA. In addition to focusing efforts on prevention of early PFFs, surgeons should consider antiseptic interventions to mitigate the increased risk of PJI after treatment of early PFF.

Preclosure povidone-iodine lavage in total hip replacement surgery: Infection outcomes and cost-benefit analysis

OBJECTIVE

To report the outcomes and cost-benefit analysis of preclosure povidone-iodine lavage (PrePIL) used to reduce the risk of infection following total hip replacement (THR) surgery.

STUDY DESIGN

Retrospective study.

ANIMALS

One thousand six hundred ninety-nine dogs, 17 cats.

METHODS

The medical records of 2213 consecutive THR cases were reviewed to determine the incidence of infection. The last 102 were treated with PrePIL using a commercially sourced 0.035% povidone-iodine solution. Postoperative infection rates were compared. A cost-benefit analysis was used to calculate if a PrePIL protocol is economically feasible.

RESULTS

Twenty-one THRs out of 2111 (0.99%) that did not have PrePIL developed infection. Infection occurred in none of the 102 PrePIL cases. Cost analysis revealed a PrePIL break-even cost at $49.74 and a break-even infection rate of 0.949%. No complications were identified related to the use of PrePIL.

CONCLUSION

Preclosure povidone-iodine lavage appeared to be efficacious in lowering THR infection rates, and it appeared to be safe for this use based on our 102 consecutive cases. The cost of the PrePIL was minimal compared to the overall cost to resolve THR infection and the potential effect on hip function prognosis. The math formulas developed can be used by surgeons to calculate cost effectiveness and break-even cost based on their THR infection rate, and to compare to the cost of a THR revision and infection resolution.

CLINICAL SIGNIFICANCE

At current costs, PrePIL can be used in 2415 THR cases at a similar cost of a single revision surgery and resolution of a periprosthetic infection.