Povidone-Iodine Wound Lavage to Prevent Infection After Revision Total Hip and Knee Arthroplasty: An Analysis of 2,884 Cases

Povidone-Iodine Versus Saline Irrigation on Reduction of Surgical Site Infections in Total Hip and Knee Arthroplasty: A Retrospective, Propensity-Matched Cohort

Introduction: Surgical site infection (SSI) after total hip and knee arthroplasty (THA/TKA) is a major complication leading to morbidity and mortality. Perioperative irrigation, frequently with antiseptic compounds including povidone-iodine (PI), is the standard of care in reducing SSI. Evidence supporting the value of PI versus nonantiseptic substances varies. This study aims to identify whether PI irrigation in THA/TKA reduces the rate of SSI versus normal saline irrigation. Patients and Methods: A retrospective, propensity-matched cohort study of patients who underwent TKA or THA was conducted using data from patient charts, hospital infection control surveillance software, and operative reports. SSI rates of patients who had received PI versus saline irrigation were compared. Patient medical status, demographics, and procedure details were considered for propensity score determination and matching. Results: The study encompassed 21,482 patients. The unadjusted univariate analysis demonstrated no statistically significant difference in SSI rate between PI and saline (p = 0.759). Multivariate analysis showed that men, patients with diabetes, and those with a 2-3 h procedure time had increased risk of SSI, but differences were not observed between irrigation groups. Propensity score matching yielded 21 (0.25%) SSI in the matched PI group and 19 (0.23%) in the saline group (odds ratio: 1.10; confidence interval: 0.59-2.06). Conclusions: This investigation proposes that PI irrigation is not significantly different to saline in reducing SSI in this population. When cost is of concern, saline irrigation is equally effective and therefore a sensible option.

Effect of Antiseptic Irrigation Solutions on Primary Human Knee Fibroblasts Cultured in Human Platelet Lysate

BACKGROUND

Native and periprosthetic joint infections are devastating conditions fraught with patient morbidity and mortality. Aseptic and septic joints are often debrided and irrigated to decrease bacterial loads when preventing or treating infection. However, the effect of clinically used irrigation solutions on the native cellular components of the synovial joint is unknown.

METHODS

Patients consented, and their suprapatellar knee tissue was surgically excised for fibroblast isolation. Cultured knee fibroblasts were treated with normal saline for three minutes or one of the following experimental solutions: acetic acid, chlorhexidine-gluconate, Dakin's solution, hydrogen peroxide, or povidone-iodine. The exposure time for the antiseptic solutions was one and three minutes. At 24 hours after irrigation treatment, metabolic activity was measured via MTS [3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium] activity assay, and deoxyribonucleic acid content was assessed by Hoechst staining as a surrogate for cell number. Phase-contrast imaging elucidated proliferation potential, progressive cell loss, and cell morphology over a 5-day period. All experiments were repeated in triplicate.

RESULTS

All experimental antiseptic irrigation solutions, regardless of application time, caused a significant reduction in metabolic activity and DNA content, indicating extensive cell death. Phase-contrast imaging showed halted cellular proliferation, progressive cell loss, and distinct changes in cellular morphology, indicating decreased cellular viability and progressive cell death.

CONCLUSIONS

All antiseptic irrigation solutions investigated in this study were severely cytotoxic to human knee fibroblasts regardless of their chemical composition. The concentrations of these solutions are commonly used in orthopaedic surgery. Although these solutions have high bactericidal properties, it may be beneficial to use them in combination at lower doses to retain their effect on bacteria while remaining benign to native synovial cells.

Not All Antiseptic Solutions Are Equivalent in Removing Biofilm: A Comparison Across Different Orthopaedic Surfaces

BACKGROUND

Antiseptic solutions are commonly utilized during total joint arthroplasty (TJA) to prevent and treat periprosthetic joint infection (PJI). The purpose of this study was to investigate which antiseptic solution is most effective against methicillin-sensitive Staphylococcus aureus (MSSA) and Escherichia coli biofilms established in vitro on orthopaedic surfaces commonly utilized in total knee arthroplasty: cobalt-chromium (CC), oxidized zirconium (OxZr), and polymethylmethacrylate (PMMA).

METHODS

MSSA and E. coli biofilms were grown on CC, OxZr, and PMMA discs for 24 and 72 hours. Biofilm-coated discs were treated with control or various antiseptic solutions for 3 minutes. Solutions included 10% povidone-iodine, a 1:1 mixture of 10% povidone-iodine plus 3% hydrogen peroxide, diluted povidone-iodine, 0.05% chlorhexidine gluconate, and a surfactant-based formulation of ethanol, acetic acid, sodium acetate, benzalkonium chloride, and water. Following treatment, discs were sonicated to quantify adherent bacteria or underwent imaging with scanning electron microscopy to identify biofilm. Antiseptic solutions were considered efficacious if they produced a 3-log (1,000-fold) reduction in colony-forming units compared with controls.

RESULTS

On both OxZr and CC, 10% povidone-iodine with hydrogen peroxide eradicated all MSSA, and it achieved clinical efficacy on PMMA at both 24-hour MSSA biofilm (p < 0.0002) and 72-hour MSSA biofilm (p = 0.002). On 72-hour MSSA biofilm, 10% povidone-iodine eradicated all bacteria on OxZr and CC, and it achieved clinical efficacy on PMMA (p = 0.04). On 24-hour MSSA biofilm, 10% povidone-iodine achieved efficacy on all surfaces (all p < 0.01). The surfactant-based formulation only achieved clinical efficacy on 72-hour MSSA biofilms on CC (p = 0.04) and OxZr (p = 0.07). On 72-hour E. coli biofilm, 10% povidone-iodine with or without hydrogen peroxide achieved clinical efficacy on all surfaces. No other solution achieved clinical efficacy on either MSSA or E. coli.

CONCLUSIONS

Antiseptic solutions vary considerably in efficacy against bacterial biofilm. The 10% povidone-iodine solution with or without hydrogen peroxide consistently removed MSSA and E. coli biofilms on multiple orthopaedic surfaces and should be considered for clinical use.

CLINICAL RELEVANCE

Clinicians should be aware of the differences in the efficacy of antiseptic solutions on different orthopaedic surfaces when treating MSSA or E. coli biofilms.

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.

Preventive strategies to reduce the rate of periprosthetic infections in total joint arthroplasty; a comprehensive review

The increasing frequency of total hip (THA) and knee arthroplasties (TKA) is marred by the rise in periprosthetic joint infections (PJIs) and surgical site infections (SSIs), with PJIs incurring costs over $1.62 billion as of 2020 and individual case management averaging $90,000. SSIs additionally burden the U.S. healthcare economy with billions in expenses annually. PJI prevalence in primary THA and TKA ranges from 0.5% to 2.4%, spiking to 20% in revisions and representing 25% of TKA revision causes. Projections estimate up to 270,000 annual PJI cases by 2030. Often caused by gram-positive bacteria, particularly methicillin-resistant staphylococci, these infections demand preventive measures. This review dissects PJI prevention across preoperative, intraoperative, and perioperative phases, aligning with evidence-based CDC and WHO guidelines. Preoperative measures include managing diabetes, obesity, tobacco use, Staphylococcus aureus screening and nasal decolonization, nutritional optimization, and management of inflammatory arthropathies. Intraoperatively, antibiotic prophylaxis, skin preparation, operative room environmental controls, surgical technique precision, and irrigation options are scrutinized. Perioperative concerns focus on anticoagulation, blood management, and infection risk mitigation. Integrating these strategies promotes a patient-centric care model, aiming to reduce PJI incidence, improve patient outcomes, and increase care cost-effectiveness in joint arthroplasty.

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.

The effect of different preventive strategies during total joint arthroplasty on periprosthetic joint infection: a network meta-analysis

BACKGROUND

Periprosthetic joint infection after total joint arthroplasty has a large incidence, and it may often require two or more stages of revision, placing an additional burden on clinicians and patients. The purpose of this network meta-analysis is to evaluate the effect of four different preventive strategies during total joint arthroplasty on the prevention of periprosthetic joint infection.

METHODS

The study protocol was registered at PROSPERO (CRD: 42,023,448,868), and the literature search databases included Web of Science, PubMed, OVID Cochrane Central Register of Controlled Trials, OVID EMBASE, and OVID MEDLINE (R) ALL that met the requirements. The network meta-analysis included randomized controlled trials, retrospective cohort studies and prospective cohort studies with the outcome of periprosthetic joint infection. The gemtc R package was applied to perform the network meta-analysis to evaluate the relative results of different preventive strategies.

RESULTS

This network meta-analysis study included a total of 38 articles with 4 preventive strategies and negative controls. No improvement was observed in antibiotic-loaded bone cement compared with negative controls. Chlorhexidine showed the highest probability of delivering the best preventive effect, and povidone iodine had the second highest probability. Although vancomycin ranked after chlorhexidine and povidone iodine, it still showed a significant difference compared with negative controls. In addition, the incidence after applying chlorhexidine was significantly lower than that after applying negative controls and vancomycin. In the heterogeneity test between direct and indirect evidence, there was no apparent heterogeneity between them.

CONCLUSION

The study indicated that chlorhexidine, povidone iodine and vancomycin showed significant efficacy in preventing periprosthetic joint infection after total joint arthroplasty, while antibiotic-loaded bone cement did not. Therefore, more high-quality randomized controlled trials are needed to verify the results above.

The stability of Staphylococcal bacteriophages with commonly used prosthetic joint infection lavage solutions

The aim of this study was to assess the viability of four Staphylococcal bacteriophages when exposed to different concentrations of commonly used lavage solutions in the surgical treatment of prosthetic joint infections (PJI). Four tailed Staphylococcal bacteriophages and six different lavage solutions (chlorhexidine 4%, hydrogen peroxide 3%, acetic acid 3%, povidone iodine 10%, sodium hypochlorite 0.5%, and Vashe solution) at 100%, 1%, and 0.01% concentrations were used in this experiment. In addition, the temporal impact of exposing bacteriophages to these lavage solutions was also evaluated at 5-min exposures and 24-h exposures. The results show that the titers of the four bacteriophages were statistically significantly decreased for all lavage solutions (100% and 1%) at 5-min exposures and 24-h exposures. However, with 0.01% concentrations of the lavage solutions, only acetic acid caused a statistically significant decrease in bacteriophage titers compared to normal saline control. Our findings suggest that tailed Staphylococcal bacteriophages do not remain stable in high concentrations of the most commonly used lavage solutions. However, at very dilute concentrations the bacteriophages do remain viable. This has important clinical ramifications in that it shows when using bacteriophage therapy for PJI it is critical to thoroughly wash out any lavage solutions before the introduction of therapeutic bacteriophages especially when acetic acid is used.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Global mapping of institutional and hospital-based (Level II-IV) arthroplasty registries: a scoping review

PURPOSE

Four joint arthroplasty registries (JARs) levels exist based on the recorded data type. Level I JARs are national registries that record primary data. Hospital or institutional JARs (Level II-IV) document further data (patient-reported outcomes, demographic, radiographic). A worldwide list of Level II-IV JARs must be created to effectively assess and categorize these data.

METHODS

Our study is a systematic scoping review that followed the PRISMA guidelines and included 648 studies. Based on their publications, the study aimed to map the existing Level II-IV JARs worldwide. The secondary aim was to record their lifetime, publications' number and frequency and recognise differences with national JARs.

RESULTS

One hundred five Level II-IV JARs were identified. Forty-eight hospital-based, 45 institutional, and 12 regional JARs. Fifty JARs were found in America, 39 in Europe, nine in Asia, six in Oceania and one in Africa. They have published 485 cohorts, 91 case-series, 49 case-control, nine cross-sectional studies, eight registry protocols and six randomized trials. Most cohort studies were retrospective. Twenty-three per cent of papers studied patient-reported outcomes, 21.45% surgical complications, 13.73% postoperative clinical and 5.25% radiographic outcomes, and 11.88% were survival analyses. Forty-four JARs have published only one paper. Level I JARs primarily publish implant revision risk annual reports, while Level IV JARs collect comprehensive data to conduct retrospective cohort studies.

CONCLUSIONS

This is the first study mapping all Level II-IV JARs worldwide. Most JARs are found in Europe and America, reporting on retrospective cohorts, but only a few report on studies systematically.

A systematic review and meta-analysis comparing intrawound vancomycin powder and povidone iodine lavage in the prevention of periprosthetic joint infection of hip and knee arthroplasties

BACKGROUND

Focus on reviewing a vigorous research effort to improve the safety profile of vancomycin powder (VP) and its optimal dose in reducing periprosthetic joint infection (PJI) is the need of the hour. This systematic review and meta-analysis attempt to explore the ongoing use of VP and VP + povidone iodine (PI) lavage to prevent PJI of hip/knee arthroplasties and highlights its challenges among the orthopedic community about the existence of the major organism and its frequency in total joint arthroplasty (TJA) patients.

METHODS

We searched PubMed/MEDLINE, EMBASE databases regarding the outcomes of vancomycin powder (VP) and VP + povidone iodine (PI) combination in preventing periprosthetic joint infection of hip and knee arthroplasties.

RESULTS

In 5 of 7 studies, the combination of vancomycin powder (VP) and povidone iodine (PI) lavage have shown a lower risk of periprosthetic joint infection (PJI) in acute and high-risk hip and knee arthroplasties patients, with less or without serious adverse events and readmissions; while four of seven studies using VP-only found increasing rates of PJI in primary total knee arthroplasty and partial hip replacement in elderly patients with comorbidities, and significantly causes aseptic wound complications compared to the control group.

CONCLUSIONS

Intra-articular vancomycin powder (VP) and povidone iodine (PI) lavage showed a significant reduction of periprosthetic joint infection in primary and revision total joint arthroplasty. Before its widespread use in clinical settings, prospective randomized studies and, most importantly, its long-term efficacy and safety are recommended.

The Effect of Povidone-Iodine Irrigation on the Efficacy of Antibiotic Cement In Vitro

Povidone-iodine is a common antiseptic demonstrating success in reducing infection rates in primary arthroplasty; however, recent data suggest that its use in revision arthroplasty may increase infection rates. This study evaluated the effect of povidone-iodine solution on antibiotic cement and investigated the connection between povidone-iodine and increased infection rates in revision arthroplasty. Sixty antibiotic cement samples (ACSs) were formed using gentamicin-impregnated cement. The ACSs were divided into three groups: group A (n=20) was subject to a 3-minute povidone-iodine soak followed by a saline rinse; group B (n=20) underwent a 3-minute saline soak; and group C (n=20) underwent only a saline rinse. The antimicrobial activity of the samples was tested using a Kirby-Bauer-like assay using Staphylococcus epidermidis. The zone of inhibition (ZOI) was measured every 24 hours for 7 days. All groups possessed the greatest antimicrobial activity at 24 hours. Group C displayed a mass-corrected ZOI of 395.2 mm/g, which was statistically greater than the group B ZOI (313.2 mm/g, P<.05) but not the group A ZOI (346.5 mm/g, P>.05). All groups demonstrated a decrease in antimicrobial activity at 48 through 96 hours, with no significant difference at any time point. Prolonged soaking of antibiotic cement in a povidone-iodine or saline solution results in elution of the antibiotic into the irrigation solution, blunting initial antibiotic concentration. When using antibiotic cement, antiseptic soaks or irrigation should be focused prior to cementation. [Orthopedics. 2024;47(1):10-14.].

How effective is diluted povidone-iodine in preventing periprosthetic joint infection in total joint arthroplasty (TJA)? An updated systematic review and meta-analysis

PURPOSE

Periprosthetic joint infection (PJI) is a serious complication with total joint arthroplasty (TJA), that necessitates reoperation. Pre-closure irrigation with dilute povidone-iodine (PI) is among the preventive measures, but its efficiency is still controversial. As a result, the focus of this systematic review and meta-analysis is on the effect of dilute PI wound irrigation in the prevention of PJI following TJA.

METHODS

We systematically reviewed and analyzed articles that compared PI with other agents in terms of PJI rate after TJA, searching Medline, Scopus, Web of science, and Cochrane databases. A number of 13 papers including 63,950 patients in total, were finally considered in qualitative and quantitative assessments. We have also further assessed review articles.

RESULTS

In comparison with normal saline (NS), PI reduced post-operative infection rate (OR: 0.44; CI 95%: 0.34-0.56). However, there was no difference between PI and chlorhexidine (CHG) (OR: 1.61; CI 95%: 0.83-3.09)) or undetermined comparators (OR: 1.08; CI 95%: 0.67-1.76).

CONCLUSION

PI irrigation seems an efficient preventive measure for post-operative PJI and would seem to be the most feasible for TJA protocol.

Hydrogen Peroxide, Povidone-Iodine and Chlorhexidine Fail to Eradicate Staphylococcus aureus Biofilm from Infected Implant Materials

Hydrogen peroxide, povidone-iodine, and chlorhexidine are antiseptics that are commonly added to irrigants to either prevent or treat infection. There are little clinical data available that demonstrate efficacy of adding antiseptics to irrigants in the treatment of periprosthetic joint infection after biofilm establishment. The objective of the study was to assess the bactericidal activity of the antiseptics on S. aureus planktonic and biofilm. For planktonic irrigation, S. aureus was exposed to different concentrations of antiseptics. S. aureus biofilm was developed by submerging a Kirschner wire into normalized bacteria and allowing it to grow for forty-eight hours. The Kirschner wire was then treated with irrigation solutions and plated for CFU analysis. Hydrogen peroxide, povidone-iodine, and chlorhexidine were bactericidal against planktonic bacteria with over a 3 log reduction (p < 0.0001). Unlike cefazolin, the antiseptics were not bactericidal (less than 3 log reduction) against biofilm bacteria but did have a statistical reduction in biofilm as compared to the initial time point (p < 0.0001). As compared to cefazolin treatment alone, the addition of hydrogen peroxide or povidone-iodine to cefazolin treatment only additionally reduced the biofilm burden by less than 1 log. The antiseptics demonstrated bactericidal properties with planktonic S. aureus; however, when used to irrigate S. aureus biofilms, these antiseptics were unable to decrease biofilm mass below a 3 log reduction, suggesting that S. aureus biofilm has a tolerance to antiseptics. This information should be considered when considering antibiotic tolerance in established S. aureus biofilm treatment.

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.

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.

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

Background

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

Methods

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

Results

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

Conclusions

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

Level of Evidence

Level III-uncontrolled before and after the study.

Lavado con povidona yodada diluida en el reemplazo articular de cadera y rodilla para prevenir infecciones: estudio retrospectivo comparativo

Introducción: Una de las medidas profilácticas para disminuir la incidencia de infecciones periprotésicas es el lavado con povidona yodada diluida, un agente con acción bactericida contra distintos microorganismos. El propósito de este estudio fue evaluar la incidencia de infecciones periprotésicas dentro de los primeros 90 días, en pacientes a quienes se les realizó un lavado con povidona yodada luego de implantar los componentes protésicos y antes del cierre de la herida. Materiales y Métodos: Se llevó a cabo un análisis retrospectivo comparativo de pacientes sometidos a artroplastias primarias de cadera y rodilla por artrosis y se comparó la incidencia de infecciones periprotésicas dentro de los primeros 90 días posoperatorios, entre pacientes que fueron operados antes de la introducción del lavado con povidona yodada y luego con su uso rutinario. Resultados: Se realizaron 643 (47,60%) reemplazos de rodilla y 708 (52,40%) reemplazos de cadera. Al comparar la incidencia de infecciones periprotésicas entre ambos grupos, no se observaron diferencias estadísticamente significativas (0,92% vs. 0,21%; p = 0,11). Sin embargo, se incrementó el riesgo de infección en los primeros 90 días posteriores a la cirugía (OR = 4,5; IC95% 0,56-36,19) cuando no se utilizóla solución. Conclusiones: El riesgo de desarrollar infecciones periprotésicas se incrementó 4,5 veces al realizar una artroplastia sin irrigación con povidona yodada diluida. Sin embargo, no se pudo demostrar que esto fuese estadísticamente significativo.

Irrigation Solutions in Total Joint Arthroplasty

INTRODUCTION

Despite advancements in the field of adult reconstruction, prosthetic joint infection (PJI) remains a common and devastating complication of total joint arthroplasty. Eradication of these infections can often prove difficult, and they remain a source of considerable morbidity and mortality. This clinical review paper will focus on some of the more commonly used irrigation solutions; povidone-iodine (PI), chlorhexidine (CHG), acetic acid (AA), hydrogen peroxide (HP), antibiotic irrigations, taurolidine, and polyhexanide-betaine (PB).

SUMMARY OF THE EVIDENCE

Significant research has been performed on the prevention of PJI, including use of intraoperative joint irrigation solutions. Several solutions have been theorized to aid in infection prevention, but no evidence-based practice guidelines in this area of orthopaedics have been established. There is a paucity of prospective randomized control trials to compare the efficacy of these joint irrigation solutions.

CONCLUSIONS

The authors present a review regarding seven major categories of commonly used intraoperative joint irrigation solutions. The current literature fails to demonstrate a clear consensus for a preferred solution and concentration for povidone-iodine, chlorhexidine, hydrogen peroxide, acetic acid, antibiotic irrigations, taurolidine, and polyhexanide-betaine. Prospective, randomized control trials directly comparing these different irrigation solutions are needed.

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

BACKGROUND

The prevention and treatment of periprosthetic joint infection is of utmost importance to orthopedic surgeons. Irrigation solutions have become a popular additive to the prevention and treatment armamentarium.

METHODS

This symposium summarizes the mechanism of action, basic science, and clinical research to date on the use of irrigation solutions. The four most commonly used irrigation solutions, povidone iodine, chlorhexidine, hydrogen peroxide, and acetic acid, are discussed. In addition, the role of antibiotic powers is reviewed.

RESULTS

Each solution has its risks and benefits that must be weighed by the surgeon. There is no clear irrigation solution that is superior. The role of additive antibiotic powder (vancomycin) remains controversial.

CONCLUSION

More rigorous prospective clinical trials are needed to determine the optimal irrigation solution for the prevention and treatment of periprosthetic joint infection.

Clorpactin: An Alternative Irrigation Method for Total Knee Arthroplasty Joint Infection Revisions

Different combinations of irrigation solutions have been used in attempt to eradicate microorganisms for the prevention and treatment of prosthetic joint infections (PJIs). Clorpactin WCS-90 was evaluated as an alternative irrigation intraoperative technique for the treatment of PJI using both debridement, antibiotics, and implant retention (DAIR) and 2-stage total knee arthroplasty (TKA) procedures. We retrospectively reviewed PJIs irrigated with Clorpactin between January 2015 and January 2020. We found 13 patients who underwent a DAIR procedure for an acutely infected primary TKA, 18 patients underwent a 2-stage procedure for a chronically infected primary TKA, two patients underwent a DAIR procedure for an acutely infected revision TKA, and 18 patients underwent a 2-stage procedure for a chronically infected revision TKA. The odds of reinfection and need for additional surgery were analyzed at a mean follow-up of 20 to 26 months between groups. Only one patient (7.69%) became reinfected in the acute infected primary TKA group, three patients (16.67%) in the chronic infected primary TKA group, 0 patients (0%) in the acute infected revision TKA group, and six patients (33.33%) in the chronic infected revision TKA group. When the acute primary TKA infection group was compared with the chronic revision TKA infection group, the odds of reinfection (Chi-square test [χ2] = 21.7, df 3, p < 0.001) and odds of additional surgery (χ2 = 13.6, df 3, p < 0.003) were significantly higher for the chronic revision TKA infection group. Overall, the reinfection rate for DAIR revisions was 6.67% (range = 0-7.69) and 2-stage revisions was 25.00% (range = 16.67-33.33). The use of Clorpactin WCS-90 irrigation prior to wound closure is a useful option for the treatment of acute and chronic knee PJIs. Our study provides evidence that infection eradication with the use of Clorpactin is comparable to other irrigation methods and surgical techniques in reported literature.

Antiseptic Irrigation Solutions Used in Total Joint Arthroplasty: A Critical Analysis Review

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There are limited data that directly compare the efficacy of antiseptic irrigation solutions used for the prevention and treatment of periprosthetic joint infections in orthopaedic procedures; there is a notable lack of prospective data.

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For prevention of periprosthetic joint infections, the strongest evidence supports the use of low-pressure povidone-iodine.

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For the treatment of periprosthetic joint infections, delivering multiple solutions sequentially may be beneficial.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Use of Adjunct Antiseptic Agents in Periprosthetic Joint Infections

Periprosthetic joint infection is a leading cause for failure of contemporary total hip arthroplasty and total knee arthroplasty projected to nearly double in the next decade and reach an economic burden of $1.85 billion in the United Sates by 2030. Although multiple treatments for periprosthetic joint infection have been described, a thorough débridement and joint lavage to decrease bacterial bioburden and to remove biofilm remains a critical component of treatment. Various adjunct antiseptic agents such as chlorhexidine, povidone-iodine, hydrogen peroxide, acetic acid, and chlorine compounds are currently in off-label use in this capacity. Each antiseptic agent, however, has a distinct mechanism of action and targets different organisms, and some combinations of agents may lead to tissue toxicity. In this review, currently available adjunct antiseptic washes will be described in detail based on their mechanism of action and the evidence for their use will be reviewed. Furthermore, this review puts forward an evidence-based treatment algorithm based on the specific causative organism.

Current Insights in the Evaluation and Treatment of Infected Total Knee Arthroplasty

Total knee arthroplasty is a widely successful procedure, but a small percentage of patients have a postoperative course complicated by periprosthetic joint infection (PJI). PJI is a difficult problem to diagnose and to treat, and the management of PJI differs, depending on the acuity of the infection. This paper discusses the established and newer technologies developed for the diagnosis of PJI as well as different treatment considerations and surgical solutions currently available.

What Is the Optimal Irrigation Solution in the Management of Periprosthetic Hip and Knee Joint Infections?

BACKGROUND

Thorough irrigation and debridement using an irrigation solution is a well-established treatment for both acute and chronic periprosthetic joint infections (PJIs). In the absence of concrete data, identifying the optimal irrigation agent and protocol remains challenging.

METHODS

A thorough review of the current literature on the various forms of irrigations and their additives was performed to evaluate the efficacy and limitations of each solution as pertaining to pathogen eradication in the treatment of PJI. As there is an overall paucity of high-quality literature comparing irrigation additives to each other and to any control, no meta-analyses could be performed. The literature was therefore summarized in this review article to give readers concise information on current irrigation options and their known risks and benefits.

RESULTS

Antiseptic solutions include povidone-iodine, chlorhexidine gluconate, acetic acid, hydrogen peroxide, sodium hypochlorite, hypochlorous acid, and preformulated commercially available combination solutions. The current literature suggests that intraoperative use of antiseptic irrigants may play a role in treating PJI, but definitive clinical studies comparing antiseptic to no antiseptic irrigation are lacking. Furthermore, no clinical head-to-head comparisons of different antiseptic irrigants have identified an optimal irrigation solution.

CONCLUSION

Further high-quality studies on the optimal irrigation additive and protocol for the management of PJI are warranted to guide future evidence-based decisions.

Effectiveness of diluted povidone-iodine lavage for preventing periprosthetic joint infection: an updated systematic review and meta-analysis

Background

Of the several methods used to prevent surgical site infection (SSI), diluted povidone-iodine (PI) lavage is used widely. However, the clinical utility of PI for preventing periprosthetic joint infection (PJI) remains controversial. The aim of this study was to perform a systematic review and meta-analysis of the utility of dilute PI lavage for preventing PJI in primary and revision surgery.

Methods

This study was conducted in accordance with the PRISMA checklist for systematic reviews and meta-analyses. A comprehensive literature search of PubMed, CINAHL, ClinicalTrials.gov, and Cochrane Library databases was performed. The results are summarized qualitatively and as a meta-analysis of pooled odds ratios with 95% confidence intervals (95% CIs). Heterogeneity of treatment effects among studies was classified as low, moderate, or high, corresponding to I² values of < 25%, 25–50%, and > 50%. A random effects model was applied in cases of high heterogeneity; otherwise, the fixed effects model was applied. Subgroup analyses were conducted to identify potential sources of heterogeneity.

Results

After the screening and eligibility assessment process, eight studies were finally extracted for analysis. Overall, the results showed that PI had no significant effect on PJI with ununified control group. However, subgroup analysis of studies with a saline control group revealed an odds ratio of 0.33 (95% CI, 0.16–0.71) for the PI group, suggesting a significant effect for preventing PJI.

Conclusion

The systematic review and meta-analysis of the current literature demonstrates that diluted PI lavage is significantly better than saline solution lavage for preventing PJI.

Level of evidence

Level I, Systematic review and meta-analysis.

Pursuit of the ideal antiseptic irrigation solution in the management of periprosthetic joint infections

Irrigation and debridement in the treatment of periprosthetic joint infection (PJI) serve an integral role in the eradication of bacterial burden and subsequent re-infection rates. Identifying the optimal irrigation agent, however, remains challenging, as there is limited data on superiority. Direct comparison of different irrigation solutions remains difficult because of variability in treatment protocols. While basic science studies assist in the selection of irrigation fluids, in vitro results do not directly translate into clinical significance once implemented in vivo. Dilute povidone iodine, hydrogen peroxide, chlorhexidine gluconate, acetic acid, sodium hypochlorite, hypochlorous acid, and preformed combination solutions all have potential against a broad spectrum of PJI pathogens with their own unique advantages and disadvantages. Future clinical studies are needed to identify ideal irrigation solutions with optimal bactericidal properties and low cytotoxicity for PJI treatment.

Wound Irrigation in Orthopedic Open Fractures: A Review

Background: Management of open fractures remains a major clinical challenge because of the higher energy involved in the injury, the greater local trauma, tissue necrosis, and extensive contamination. Even though early surgical debridement was thought to be critical, limited available operative techniques have minimized surgery in favor of early antibiotic administration. No clear agreement on the surgical approach, debridement, or irrigation technique exists. Surgeons continue to argue about the use of various fluids, the appropriate pressure of irrigation, antiseptics, and other factors. The current work reviews the available data and summarizes the capabilities of modern orthopedic irrigation solutions. Methods: To delineate available research on the topic, the PubMed database was queried for the most common techniques, fluid variables, and chemical adjuvants utilized in current open fracture and wound irrigation methodologies. Modes of delivery, volume, pressure, temperature, timing, solution type, and additives are evaluated in the context of known outcomes to determine which solutions may be preferable. Results: Various methods have been described with their own advantages as well as limitations. Particular solutions may apply to specific clinical scenarios, presence of implants, and degree of tissue contamination. Desired irrigation solutions are isotonic, non-toxic, non-hemolytic, transparent, sterilizable, efficient in removing debris and pathogens, as well as affordable; however, no current irrigant achieves all these desired characteristics. Conclusions: Despite being crucial for the healing of open fractures, there is no clear gold standard for irrigation. Although there are some novel irrigation solutions, there has been a paucity of research on finding new, safer, and more effective irrigation solutions that will promote wound healing and reduce infection.

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.

Optimal concentration of ethylenediaminetetraacetic acid as an irrigation solution additive to reduce infection rates in rat models of contaminated wound

AIMS

In wound irrigation, 1 mM ethylenediaminetetraacetic acid (EDTA) is more efficacious than normal saline (NS) in removing bacteria from a contaminated wound. However, the optimal EDTA concentration remains unknown for different animal wound models.

METHODS

The cell toxicity of different concentrations of EDTA dissolved in NS (EDTA-NS) was assessed by Cell Counting Kit-8 (CCK-8). Various concentrations of EDTA-NS irrigation solution were compared in three female Sprague-Dawley rat models: 1) a skin defect; 2) a bone exposed; and 3) a wound with an intra-articular implant. All three models were contaminated with Staphylococcus aureus or Escherichia coli. EDTA was dissolved at a concentration of 0 (as control), 0.1, 0.5, 1, 2, 5, 10, 50, and 100 mM in sterile NS. Samples were collected from the wounds and cultured. The bacterial culture-positive rate (colony formation) and infection rate (pus formation) of each treatment group were compared after irrigation and debridement.

RESULTS

Cell viability intervened below 10 mM concentrations of EDTA-NS showed no cytotoxicity. Concentrations of 1, 2, and 5 mM EDTA-NS had lower rates of infection and positive cultures for S. aureus and E. coli compared with other concentrations in the skin defect model. For the bone exposed model, 0.5, 1, and 2 mM EDTA-NS had lower rates of infection and positive cultures. For intra-articular implant models 10 and 50 mM, EDTA-NS had the lowest rates of infection and positive cultures.

CONCLUSION

The concentrations of EDTA-NS below 10 mM are safe for irrigation. The optimal concentration of EDTA-NS varies by type of wound after experimental inoculation of three types of wound. Cite this article: Bone Joint Res 2021;10(1):68-76.

Aseptic Reoperations Within 1 Year of Primary Total Knee Arthroplasty Markedly Increase the Risk of Later Periprosthetic Joint Infection

BACKGROUND

Despite the high rate of success of primary total knee arthroplasty (TKA), some patients are candidates for early aseptic reoperation. The goal of this study is to evaluate the risk of subsequent periprosthetic joint infection (PJI) in patients treated with an aseptic reoperation within 1 year of primary TKA.

METHODS

A retrospective review of our total joint registry compared 249 primary TKAs requiring an aseptic reoperation within 1 year following index arthroplasty to a control group of 17,867 TKAs not requiring reoperation within 1 year. Patients were divided into groups based on time from index TKA: (1) 90 days or less (114 TKAs) and (2) 91 to 365 days (135 TKAs). Mean age was 68 years with 57% female. Mean follow-up was 7 years.

RESULTS

At 2 years postoperatively, patients undergoing an aseptic reoperation within 90 days subsequently had a 9% PJI rate, while patients undergoing an aseptic reoperation between 91 and 365 days subsequently had a 3% PJI rate. The control group had a 0.4% PJI rate. Compared to the control group, patients undergoing an aseptic reoperation within 90 days had an elevated risk of PJI (hazard ratio, 9; P < .0001), as did patients who had a reoperation between 91 and 365 days (hazard ratio, 4; P < .0001).

CONCLUSION

Aseptic reoperation within 1 year of primary TKA was associated with a notably increased risk of subsequent PJI.

The Effect of Povidone-Iodine Lavage in Preventing Infection After Total Hip and Knee Arthroplasties: Systematic Review and Meta-Analysis

BACKGROUND

Dilute povidone-iodine (PI) lavage, a simple disinfection method, could reduce postoperative infection risk. However, there is no clinical consensus regarding its efficacy in total joint arthroplasties (TJAs). This systematic review and meta-analysis evaluated PI lavage's efficacy in preventing infection after TJA.

METHODS

MEDLINE, Embase, and the Cochrane Library were systematically searched for studies published before November 22, 2019, that compared postoperative infection rates in patients who underwent TJA with or without PI lavage before wound closure. Subgroup analyses were designed to identify the differences in infection site (overall or deep), type of surgery (total hip arthroplasty or total knee arthroplasty), time until diagnosis of infection (3 or 12 months postoperatively), and primary/aseptic revision arthroplasties.

RESULTS

We included 7 studies with 31,213 TJA cases, comprising 8861 patients who received PI lavage and 22,352 who did not. Pooled odds ratio for overall infection rate for the PI and non-PI lavage groups was 0.67 (95% confidence interval, 0.38-1.19, P = .17) and for the deep infection rate was 0.90 (95% confidence interval, 0.27-2.98, P = .86). Subgroup analyses revealed no differences in postoperative infection rates between the PI and non-PI lavage groups in terms of total hip arthroplasty and total knee arthroplasty, diagnosis of infection at 3 and 12 months postoperatively, or primary and aseptic revision arthroplasties.

CONCLUSION

We detected no differences in the overall postoperative infection rates between the PI and non-PI lavage groups before wound closure in TJA including all studies in the subgroup analyses.

New developments and future challenges in prevention, diagnosis, and treatment of prosthetic joint infection

Prosthetic joint infection (PJI) is a devastating complication that results in substantial costs to society and patient morbidity. Advancements in our knowledge of this condition have focused on prevention, diagnosis, and treatment, in order to reduce rates of PJI and improve patient outcomes. Preventive measures such as optimization of patient comorbidities, and perioperative antibiotic usage are intensive areas of current clinical research to reduce the rate of PJI. Improved diagnostic tests such as synovial fluid (SF) α-defensin enzyme-linked immunosorbent assay, and nucleic acid-based tests for serum, SF, and tissue cultures, have improved diagnostic accuracy and organism identification. Increasing the diversity of available antibiotic therapy, immunotherapy, and alternative implant coatings remain promising treatments to improve infection eradication in the setting of PJI.

Vancomycin Powder and Dilute Povidone-Iodine Lavage for Infection Prophylaxis in High-Risk Total Joint Arthroplasty

BACKGROUND

Dilute povidone-iodine lavage has been shown to be safe and effective in decreasing acute periprosthetic joint infection (PJI) following total joint arthroplasty (TJA). Vancomycin powder is reported to be effective in preventing infection in spine surgery. We hypothesize that a "vanco-povidone protocol" (VIP) for TJA patients at high risk for infection is safe and will decrease the rate of PJI.

METHODS

High-risk TJA patients (body mass index >40, active smokers, American Society of Anesthesiologists ≥3, immunosuppression/diabetes, methicillin-resistant Staphylococcus aureus colonization, revision surgery) utilizing VIP were compared to a high-risk historical cohort not treated with VIP, at a single institution. VIP consisted of dilute povidone-iodine lavage followed by application of vancomycin powder prior to wound closure. Primary endpoint was PJI within 3 months postoperatively.

RESULTS

The historical, high-risk control cohort consisted of 3251 patients with a PJI incidence of 1.8%. A total of 1413 subjects received the VIP protocol with a PJI incidence of 1.3%. There was a 27.8% risk reduction when compared to the control group of high-risk subjects not treated with the VIP. There were no medical complications secondary to the use of VIP, no increase in vancomycin-resistant enterococcus or vancomycin-resistant Staph aureus, and no cases of acute renal impairment secondary to application of the local vancomycin.

CONCLUSIONS

PJI remains a common complication of TJA, especially in high-risk populations. This study indicates that a protocol of dilute povidone-iodine lavage combined with topical vancomycin powder is safe and may reduce PJI incidence in high-risk TJA patients. Due to low, current PJI rates, a multi-institutional randomized controlled trial is necessary to assess interventions that minimize the risk of PJI.

LEVEL OF EVIDENCE

Retrospective Observational Cohort.

The Lawrence D. Dorr Surgical Techniques & Technologies Award: Aseptic Reoperations Within One Year of Primary Total Hip Arthroplasty Markedly Increase the Risk of Later Periprosthetic Joint Infection

BACKGROUND

Despite the success of primary total hip arthroplasties (THAs), some patients will require an aseptic reoperation within 1 year of the index THA. The goal of this study is to evaluate the risk of subsequent periprosthetic joint infection (PJI) in patients undergoing an aseptic reoperation within 1 year of a primary THA.

METHODS

A retrospective review utilizing our institutional joint registry identified 211 primary THAs requiring aseptic reoperation within 1 year following index arthroplasty. A control group of 15,357 primary THAs not requiring reoperation within 1 year was identified. Patients were divided into groups based on time from primary THA to reoperation: (1) within 90 days (n = 112 THAs; 40% for dislocation, 34% for periprosthetic fracture) or (2) 91-365 days (n = 99 THAs; 37% for dislocation, 29% for periprosthetic fracture). Mean follow-up was 7 years.

RESULTS

Patients undergoing an aseptic reoperation within 90 days had a PJI rate of 4.8% at 2 years, while the 91-365 day group had a PJI rate of 3.2% at 2 years. The control group had a PJI rate of 0.2% at 2 years. Employing a multivariate analysis, reoperation within 90 days of index arthroplasty had an elevated risk of PJI (hazard ratio 8, P < .001) as did a reoperation between 91 and 365 days (hazard ratio 13, P < .001).

CONCLUSION

Aseptic reoperations within 1 year following primary THA resulted in an 8- to 13-fold increased risk of subsequent PJI. The risk was similar whether the aseptic reoperation was early (within 90 days) or later (91-365 days).

LEVEL OF EVIDENCE

Level III (Prognostic).

Is EDTA Irrigation Effective in Reducing Bacterial Infection in a Rat Model of Contaminated Intra-articular Knee Implants?

BACKGROUND

To mitigate the possibility of infection after arthroplasty, intraoperative irrigation is essential to remove contaminating bacteria. Previous studies have demonstrated that irrigation with an EDTA solution before wound closure is superior to irrigation with normal saline in removing contaminating bacteria in a rat model of open fractures. However, the effectiveness of an EDTA solution in a model with a contaminated intra-articular implant remains unclear.

QUESTIONS/PURPOSES

(1) Does irrigation with an EDTA solution decrease the proportion of culture-positive joints compared with normal saline, benzalkonium chloride, and povidone iodine? (2) Is an EDTA solution toxic to cells resident in joints including chondrocytes, osteoblasts, and synovial fibroblasts? (3) Does irrigation with an EDTA solution have adverse effects including arthrofibrosis and hypocalcemia?

METHODS

We first established a model of contaminated intra-articular implants. Female Sprague-Dawley rats (n = 30 for each treatment group) underwent knee arthrotomy and implantation of a femoral intramedullary wire with 1 mm of intra-articular communication. To simulate bacterial contamination, the inserted wire was inoculated with either Staphylococcus aureus or Escherichia coli. After 1 hour, the wound and implant were irrigated with normal saline, benzalkonium chloride, povidone iodine, or an EDTA solution (1 mM). The animals were euthanized 1 week later, and the distal femur, knee capsule, and implanted wire were harvested for bacterial culture using standard techniques. In this study, we used a well-established animal model of an intra-articular implant and inoculated the implant to simulate the clinical setting of intraoperative contamination. The proportion of culture-positive joints in normal saline, benzalkonium chloride, povidone-iodine, and EDTA groups were compared. The viable cell numbers (chondrocytes, osteoblasts, and synovial fibroblasts) were counted and compared after treatment with either solution. Measurement of blood calcium level and histological examination of the joint were performed to rule out hypocalcemia and arthrofibrosis after EDTA irrigation.

RESULTS

With S. aureus inoculation, EDTA irrigation resulted in fewer culture-positive joints than normal saline (37% [11 of 30] versus 70% [21 of 30]; p = 0.019), benzalkonium chloride (83% [25 of 30]; p < 0.001), and povidone iodine (83% [25 of 30]; p < 0.001) irrigation. Likewise, infection rates for implant inoculation with E. coli were also lower in the EDTA irrigation group (13% [four of 30]) than in the normal saline (60% [18 of 30]; p < 0.001), benzalkonium chloride (77% [23 of 30]; p < 0.001), and povidone iodine (80% [24 of 30]; p < 0.001) groups. Between normal saline control and EDTA, there were no differences in cell viability in chondrocytes (normal saline: 98% ± 18%; EDTA: 105% ± 18%; p = 0.127), osteoblasts (normal saline: 102 ± 19%, EDTA: 103 ± 14%; p = 0.835), and synovial fibroblasts (normal saline: 101% ± 21%, EDTA: 110% ± 13%; p = 0.073). EDTA irrigation did not result in hypocalcemia (before irrigation: 2.21 ± 0.32 mmol/L, after irrigation: 2.23 ± 0.34 mmol/L; p = 0.822); and we observed no arthrofibrosis in 30 histologic samples.

CONCLUSIONS

In a rat model of a bacteria-contaminated intra-articular implants, intraoperative irrigation with 1 mmol/L of an EDTA solution was superior to normal saline, 0.03% benzalkonium chloride, and 0.3% povidone iodine in preventing surgical-site infection and caused no adverse effects including death of resident cells, arthrofibrosis, and hypocalcemia. Future studies should seek to replicate our findings in other animal models, perhaps such as dog and goat.

CLINICAL RELEVANCE

If other animal models substantiate the efficacy and safety of the EDTA solution, clinical trials would be warranted to determine whether the use of an EDTA irrigation solution might reduce the risk of periprosthetic joint infections in patients compared with traditional irrigation solutions.

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.