ICJR REWIND: Povidone-Iodine Irrigation as a Safe and Effective Measure to Prevent SSIs

    In ICJR REWIND, we will periodically republish past articles that were of great interest to the orthopaedic community. This article, originally published on July 12, 2018, describes research from The Rothman Institute that examined the effectiveness of 3 intraoperative interventions implemented to reduce the incidence of surgical site infections in total knee arthroplasty patients. Dr. Matthew Austin discusses the findings.

    A surgical site infection (SSI) after total knee arthroplasty (TKA) can result in significant patient morbidity and increased institutional costs. Fortunately, there are intraoperative measures the surgical team can implement to reduce the risk of an SSI. The question is, how effective are these measures in decreasing the number of SSIs? And, are any of them more effective than others?

    Those were the questions surgeons from The Rothman Institute sought to answer in an investigation comparing the effectiveness of 3 intraoperative measures – use of dilute povidone-iodine (Betadine) irrigation, subcuticular monofilament suture instead of skin staples, and occlusive dressings – that were introduced over the last decade at their institution to prevent SSIs.

    Their findings were presented at the 2018 Annual Meeting of the American Academy of Orthopaedic Surgeons in New Orleans.

    They examined outcomes of 10,949 consecutive primary TKAs performed by 4 Rothman surgeons between 2006 and 2017. The interventions mentioned above were introduced in a step-wise manner and implemented heterogeneously during that period to reduce the incidence of SSIs. Additional interventions included prophylactic antibiotics for all patients and use of either antibiotic-eluting bone cement or topical intra-wound antibiotics.

    Using the definition of SSI from the Centers for Disease Control and Prevention, the researchers identified all SSIs that occurred within 90 days of surgery in this patient cohort. They also recorded gender, BMI, ASA score, length of hospitalization (adjusted for year), year of surgery, and individual surgeon for the statistical analysis.

    They found that, based on univariate analysis, only the use of povidone-iodine irrigation significantly reduced SSIs (odds ratio [OR] 0.38, 95% CI 0.15 – 0.96). Use of a monofilament suture (OR 1.2, 95% CI 0.31-4.5) and use of an occlusive dressing (OR 0.64, 95% CI 0.15-2.7) were not significantly associated with a decrease in SSIs.

    “While multiple measures contribute to SSI prevention, dilute povidone-iodine irrigation appears to have played the greatest individual role in reducing the incidence of SSI following TKA within our study,” said Matthew S. Austin, MD, one of the study authors. “Dilute povidone-iodine irrigation is safe, efficacious and cost-effective at $0.31 per case. Our experience over the last decade supports the addition of povidone-iodine irrigation to your armamentarium.”

    Dr. Austin noted that most studies on the use of povidone-iodine irrigation to reduce SSIs come from the spinal and abdominal surgery literature, with relatively limited data from retrospective studies in primary total joint arthroplasty. “Our findings specifically validate the utility of povidone-iodine irrigation within the context of total knee arthroplasty, which although not surprising, adds to the current body of evidence,” he said.

    “Furthermore, our data are consistent with the recently released guidelines from the CDC on the prevention of surgical site infection, which provide a Category II recommendation for the use of intraoperative aqueous iodophor irrigation.”

    In addition, studies in total joint arthroplasty typically combine SSIs in TKA and total hip arthroplasty (THA) patients. The study from The Rothman Institute does not do this, focusing solely on SSIs in TKA patients. Dr. Austin said their data showed a higher SSI rate in TKA patients than in THA patient. Combining data from both patient cohorts could have “affected our multivariate model and potentially skewed our analysis. We therefore focused on a generating a more homogeneous joint-specific cohort and scientifically rigorous analysis,” he said.

    Povidone-iodine irrigation was introduced at The Rothman Institute in 2012 following publication of a study by Brown et al [1] highlighting its use as a way to reduce acute deep infections following total joint arthroplasty. But it’s up to the surgeons whether they want to use it.

    “While SSI preventive measures ultimately remain each individual surgeon’s decision at our institution, we have seen an increased routine usage of povidone-iodine irrigation since collation of our work,” Dr. Austin said. “The authors of the study are using each of the preventive interventions discussed, and we foresee more surgeons using these as evidence accumulates.​”


    Fleischman A, Restrepo C, Goswami K, Parvizi J, Austin M. A Decade of Protocol Developments for Surgical Site Infection Prevention: Intraoperative Betadine Irrigation Prevails (Paper 124). Presented at the 2018 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 6-10, 2018, New Orleans, Louisiana.


    Dr. Fleischman, Dr. Restrepo, and Dr. Goswami have no disclosures for this study. Dr. Parvizi has disclosed that he has stock or stock options in Alphaeon, Ceribell, Cross Current Business Intelligence, Hip Innovation Technology, Intellijoint, Invisible Sentinel, Joint Purification Systems, MDValuate, MedAp, MicroGenDx, Parvizi Surgical Innovations, Physician Recommended Nutriceuticals, and PRN-Veterinary; that he is a paid consultant for CeramTec, ConvaTec, Ethicon, Heron, Tenor, TissueGene, and Zimmer Biomet; and that he receives royalties from, is a paid consultant to, and has stock or stock options in Corentec. Dr. Austin has disclosed that he is a paid consultant for Corin USA, Link Orthopaedics, and Stryker and that he receives royalties and research from and is a paid consultant for Zimmer Biomet.


    1. Brown NM, Cipriano CA, Moric M, Sporer SM, Della Valle CJ. Dilute betadine lavage before closure for the prevention of acute postoperative deep periprosthetic joint infection. J Arthroplasty. 2012 Jan;27(1):27-30. doi: 10.1016/j.arth.2011.03.034. Epub 2011 May 8.