Managing the Patient at High Risk for Infection

    Infection remains one of the most devastating complications in total hip arthroplasty (THA). Most periprosthetic joint infections (PJI) occur via bacterial inoculation at the time of surgery; others occur via bacterial inoculation through the open wound.

    Edward McPherson, MD, FACS, from the Los Angeles Orthopaedic Institute, treats many high-risk patients in his practice. At the ICJR/South RLO course, he discussed techniques for preventing PJI.

    The first step is understanding the infection risk, based on a staging system developed by the Musculoskeletal Infection Society:

    • Host A to C (C=worst)
    • Wound I-III (III=worst)

    With this staging system, the patient’s infection risk increases if he or she has two or more of the following risk factors:

    • Smoking
    • Diabetes
    • Cirrhosis
    • Age over 80 years
    • Kidney failure

    Preventing infection in C hosts – those with multiple risk factors – includes preoperatively evaluating three major risk areas:

    • Bacterial entry portals
    • Teeth
    • Gastrointestinal tract
    • Bladder
    • Skin wounds
    • Immune wound inhibitors
    • Smoking – nicotine and cotine levels
    • Diabetes – hemoglobin A1c
    • Nutrition – albumin and prealbumin levels
    • Glucocorticoids – wean below 10 mg prednisone, if have time before surgery
    • Disease-modifying anti-rheumatic drugs (DMARDs) – controversial, but consider stopping before surgery
    • Wound draining agents
    • Antiplatelet agents (including aspirin) – stop 1 week before surgery
    • Factor 10 inhibitors – stop 1 week before surgery
    • Warfarin – – stop 1 week before surgery
    • Non-steroidal anti-inflammatory drugs (NSAIDs) – stop 1 week before surgery; celecoxib is the exception, and can be continued

    Dr. McPherson works with an intensivist who evaluates all his patients prior to surgery. This has helped him reduce postoperative complications.In the operating room, bacteria can be introduced by the surgical team. To manage bacteria in the operating room:

    • Shorten exposure time
      • Short set-up time
      • Good preoperative planning
      • Pre-induction work done offsite, such as nerve blocks and lines
      • Keep instruments/equipment covered until use
      • Efficient joint team – same people, economy of motion
    • Minimize exposure area
    • Seal off areas at risk with Ioban dressing
    • Covered non-work zones with antibiotic-soaked towels and laps
    • Eliminate bacteria
    • Filtration with laminar air flow – vertical flow systems superior
    • Ultraviolet light deactivation
    • Minimize turbulent flow
      • Keep doors shut
      • Watch number of people coming into room
    • Bacterial inoculation
    • Local wound lavage with antibiotic saline solution
    • Systemic antibiotics with local blood flow delivery
      • Antibiotics via polymethylmethacrylate (PMMA) cement

      Prophylactic antibiotics administered 30 minutes before skin incision and continued for 24 hours after surgery

    • Wound management:
    • Water-tight deep closure essential
    • Subcuticular layered closure; staples are a biofilm risk
    • Bioclusive dressing on all wounds
    • Remains on until discharge
    • Change only if saturated

    Dr. McPhearson said that surgeons need to accept the responsibility of providing the patient the best chance for an aseptic reconstruction.

    Dr. McPhearson’s presentation can be found here.