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Prevention of Surgical Site Infection in Total Joint Arthroplasty: An International Tertiary Care Center Survey

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HSS Journal ®



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.

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No grant funding was used to support this project. We would like to acknowledge all the International Society of Orthopedic Centers members who participated in the survey.


Conflict of Interest:

Katharina Merollini, PhD, Benjamin F. Ricciardi, MD and Annette W-Dahl, PhD have declared that they have no conflict of interest. Mathias P. Bostrom, MD is a paid consultant to Smith and Nephew, received grant support, is a board member of the Orthopedic Research Society and HSS Journal, outside the work. Lars Lidgren, MD owns stock/stock options in Orthocell and Bone support, is a board member of International Society of Orthopedic Centers (ISOC) and European Bone and Joint Infection Society, outside the work. Jonas Ranstam, MD receives personal fees from Medtronic Inc. for publication committee membership, is a deputy editor for Osteoarthritis Cartilage, and a board member for OARSI, outside the work.

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Correspondence to Benjamin F. Ricciardi MD.

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Level of Evidence: Level I: (Guidelines) and Level V Survey (Expert Consensus). See the Guidelines for Authors for a complete description of levels of evidence.

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Ricciardi, B.F., Bostrom, M.P., Lidgren, L. et al. Prevention of Surgical Site Infection in Total Joint Arthroplasty: An International Tertiary Care Center Survey. HSS Jrnl 10, 45–51 (2014).

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