Prevention of Surgical Site Infection in Total Joint Arthroplasty: An International Tertiary Care Center Survey
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.Get Access
Prevention strategies are critical to reduce infection rates in total joint arthroplasty (TJA), but evidence-based consensus guidelines on prevention of surgical site infection (SSI) remain heterogeneous and do not necessarily represent this particular patient population.
What infection prevention measures are recommended by consensus evidence-based guidelines for prevention of periprosthetic joint infection? How do these recommendations compare to expert consensus on infection prevention strategies from orthopedic surgeons from the largest international tertiary referral centers for TJA?
Patients and Methods
A review of consensus guidelines was undertaken as described by Merollini et al. Four clinical guidelines met inclusion criteria: Centers for Disease Control and Prevention's, British Orthopedic Association, National Institute of Clinical Excellence's, and National Health and Medical Research Council's (NHMRC). Twenty-eight recommendations from these guidelines were used to create an evidence-based survey of infection prevention strategies that was administered to 28 orthopedic surgeons from members of the International Society of Orthopedic Centers. The results between existing consensus guidelines and expert opinion were then compared.
Recommended strategies in the guidelines such as prophylactic antibiotics, preoperative skin preparation of patients and staff, and sterile surgical attire were considered critically or significantly important by the surveyed surgeons. Additional strategies such as ultraclean air/laminar flow, antibiotic cement, wound irrigation, and preoperative blood glucose control were also considered highly important by surveyed surgeons, but were not recommended or not uniformly addressed in existing guidelines on SSI prevention.
Current evidence-based guidelines are incomplete and evidence should be updated specifically to address patient needs undergoing TJA.
- Adams AL, Paxton EW, Wang JQ, et al. Surgical outcomes of total knee replacement according to diabetes status and glycemic control, 2001 to 2009. J Bone Joint Surg Am. 2013; 95(6): 481-7. CrossRef
- Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am. 2009; 91(1): 128-33. CrossRef
- Bozic KJ, Kurtz SM, Lau E, et al. The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop Relat Res. 2010; 468(1): 45-51. CrossRef
- Bozic KJ, Lau E, Kurtz S, et al. Patient-related risk factors for periprosthetic joint infection and postoperative mortality following total hip arthroplasty in Medicare patients. J Bone Joint Surg Am. 2012; 94(9): 794-800.
- British Orthopaedic Association. Primary total hip replacement: a guide to good practice. London: British Orthopaedic Association; 2006.
- Chiu FY, Lin CF, Chen CM, Lo WH, Chaung TY. Cefuroxime-impregnated cement at primary total knee arthroplasty in diabetes mellitus. A prospective, randomized study. J Bone Joint Surg Br. 2001; 83(5): 691-5. CrossRef
- Cummins JS, Tomek IM, Kantor SR, Furnes O, Engesaeter LB, Finlayson SR. Cost-effectiveness of antibiotic-impregnated bone cement used in primary total hip arthroplasty. J Bone Joint Surg Am. 2009; 91(3): 634-41. CrossRef
- Dale H, Fenstad AM, Hallan G, et al. Increasing risk of prosthetic joint infection after total hip arthroplasty. Acta Orthop. 2012; 83(5): 449-58. CrossRef
- Dale H, Hallan G, Espehaug B, Havelin LI, Engesæter LB. Increasing risk of revision due to deep infection after hip Arthroplasty. Acta Orthop. 2009; 80: 6,639-45. CrossRef
- Danish Knee Arthroplasty register. Annual report 2010. Available: http://www.knee.dk/groups/dkr/pdf/DKRreportEnglish2010.pdf. Accessed: 4/21/2013.
- Dean NC, Bateman KA, Donnelly SM, Silver MP, Snow GL, Hale D. Improved clinical outcomes with utilization of a community-acquired pneumonia guideline. Chest. 2006; 130(3): 794-9. CrossRef
- Espehaug B, Engesaeter LB, Vollset SE, Havelin LI, Langeland N. Antibiotic prophylaxis in total hip arthroplasty. Review of 10,905 primary cemented total hip replacements reported to the Norwegian Arthroplasty Register, 1987 to 1995. J Bone Joint Surg Br. 1997; 79: 590-595. 1987. CrossRef
- Everhart JS, Altneu E, Calhoun JH. Medical comorbidities are independent preoperative risk factors for surgical infection after total joint arthroplasty. Clin Orthop Relat Res 2013;471:3112–3119.
- Gandhi R, Razak F, Pathy R, Davey JR, Syed K, Mahomed NN. Antibiotic bone cement and the incidence of deep infection after total knee arthroplasty. J Arthroplasty. 2009; 24(7): 1015-8. CrossRef
- Hepner KA, Rowe M, Rost K, et al. The effect of adherence to practice guidelines on depression outcomes. Ann Intern Med. 2007; 147(5): 320-9. CrossRef
- Hsu C, Cheng SH. Practice guideline adherence and health care outcomes—use of prophylactic antibiotics during surgery in Taiwan. J Eval Clin Pract. 2009; 15(6): 1091-6. CrossRef
- Iorio R, Williams KM, Marcantonio AJ, Specht LM, Tilzey JF, Healy WL. Diabetes mellitus, hemoglobin A1C, and the incidence of total joint arthroplasty infection. J Arthroplasty. 2012; 27(5): 726-9.e1. CrossRef
- Jämsen E, Furnes O, Engesæter LB, et al. Prevention of deep infection in joint replacement surgery a review. Acta Orthop. 2010; 81(6): 660-666. CrossRef
- Jämsen E, Nevalainen P, Eskelinen A, Huotari K, Kalliovalkama J, Moilanen T. Obesity, diabetes, and preoperative hyperglycemia as predictors of periprosthetic joint infection: a single-center analysis of 7181 primary hip and knee replacements for osteoarthritis. J Bone Joint Surg Am. 2012; 94(14): e101. CrossRef
- Kim DH, Spencer M, Davidson SM, et al. Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery. J Bone Joint Surg Am. 2010; 92(9): 1820-6. CrossRef
- Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007; 89(4): 780-5. CrossRef
- Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty. 2012; 27(8): 61-5.e1. CrossRef
- Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. the Hospital Infection Control Practices Advisory Committee. Guideline for the prevention of surgical site infection. Infect Control Hosp Epidemiol. 1999; 20: 247-280. CrossRef
- Marchant MH Jr, Viens NA, Cook C, Vail TP, Bolognesi MP. The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. J Bone Joint Surg Am. 2009; 91(7): 1621-9. CrossRef
- Merollini KM, Zheng H, Graves N. Most relevant strategies for preventing surgical site infection after total hip arthroplasty: guideline recommendations and expert opinion. Am J Infect Control. 2013; 41(3): 221-6. CrossRef
- Merollini KM, Crawford RW, Whitehouse SL, Graves N. Surgical site infection prevention following total hip arthroplasty in Australia: a cost-effectiveness analysis. Am J Infect Control. 2013; 41: 803-809. CrossRef
- Namba RS, Chen Y, Paxton EW, Slipchenko T, Fithian DC. Outcomes of routine use of antibiotic-loaded cement in primary total knee arthroplasty. J Arthroplasty. 2009; 24(6 Suppl): 44-7. CrossRef
- Namba RS, Inacio MC, Paxton EW. Risk factors associated with surgical site infection in 30,491 primary total hip replacements. J Bone Joint Surg Br. 2012; 94(10): 1330-8. CrossRef
- Namba RS, Inacio MC, Paxton EW. Risk factors associated with deep surgical site infections after primary total knee arthroplasty: an analysis of 56,216 knees. J Bone Joint Surg Am. 2013; 95(9): 775-82. CrossRef
- National Health and Medical Research Council. Australian Guidelines for the Prevention and Control of Infection in Healthcare. Commonwealth of Australia. 2010. Available: http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cd33_infection_control_healthcare_0.pdf. Accessed: 4/19/2013.
- National Institute for Health and Clinical Excellence. Prevention and Treatment of Surgical Site Infection. October 2008. Available: http://www.nice.org.uk/nicemedia/live/11743/42378/42378.pdf. Accessed 4/19/2013.
- Rao N, Cannella B, Crossett LS, Yates AJ Jr, McGough R 3rd. A preoperative decolonization protocol for Staphylococcus aureus prevents orthopaedic infections. Clin Orthop Relat Res. 2008; 466(6): 1343-8. CrossRef
- Schrama JC, Espehaug B, Hallan G, et al. Risk of revision for infection in primary total hip and knee arthroplasty in patients with rheumatoid arthritis compared with osteoarthritis: a prospective, population-based study on 108,786 hip and knee joint arthroplasties from the Norwegian Arthroplasty Register. Arthritis Care Res (Hoboken). 2010; 62(4): 473-9. CrossRef
- Swedish Knee Arthroplasty Register Annual Report 2012. Avaliable online. http://www.knee.nko.se/english/online/uploadedFiles//117_SKAR_2012_Engl_1.0.pdf. Accessed 4/20/2013.
- Tsaras G, Osmon DR, Mabry T, et al. Incidence, secular trends, and outcomes of prosthetic joint infection: a population-based study, Olmsted County, Minnesota, 1969–2007. Infect Control Hosp Epidemiol. 2012; 33(12): 1207-12. CrossRef
- Wilcox MH, Hall J, Pike H, et al. Use of perioperative mupirocin to prevent methicillin-resistant Staphylococcus aureus (MRSA) orthopaedic surgical site infections. J Hosp Infect. 2003; 54(3): 196-201. CrossRef
- Prevention of Surgical Site Infection in Total Joint Arthroplasty: An International Tertiary Care Center Survey
HSS Journal ®
Volume 10, Issue 1 , pp 45-51
- Cover Date
- Print ISSN
- Online ISSN
- Springer US
- Additional Links
- prosthetic joint infection
- international survey
- infection prevention strategies
- Author Affiliations
- 1. Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
- 2. Department of Orthopedics Clinical Sciences Lund, Lund University, Lund, Sweden
- 3. The Swedish Knee Arthroplasty Register, Lund, Sweden
- 5. National Musculoskeletal Competence Centre, Lund, Sweden
- 4. Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia