What Surgeons Can Do Perioperatively to Prevent Infections
Bryan D. Springer, from OrthoCarolina Hip & Knee Center in Charlotte, North Carolina, has written and lectured extensively on patient risk factors – such as obesity, diabetes, and smoking – that can be modified preoperatively to reduce the risk of infection following total joint arthroplasty.
But, he acknowledges, surgeons can’t always depend on patients to modify their behavior enough to reduce the risk, despite education and referrals to medical services that can help them, for example, lose weight or stop smoking.
That’s why it’s so important, Dr. Springer told attendees at the 7th Annual ICJR South Hip & Knee Course, for surgeons to understand the intraoperative and postoperative measures they can control to prevent infections. These include:
- Preoperative antibiotics
- Skin preparation
- Surgical site irrigation
- Wound closure and dressings
- Postoperative antibiotics
A first-generation cephalosporin remains the top choice for antibiotic prophylaxis in primary total joint arthroplasty patients, Dr. Springer said. They’re cost-effective, have good tissue penetration, and provide gram-negative and gram-positive coverage.
Correct dosing based on weight is essential:
- 1 gram per dose for patients weighing less than 80 kg (although some surgeons have abandoned this dose and now start at 2 grams)
- 2 grams per dose for patients weighing more than 80 kg
- 3 grams per dose for patients weighing more than 120 kg
The number of doses to be given is controversial, Dr. Springer said, but until definitive data are available, he and his colleagues at OrthoCarolina will continue to view 3 perioperative doses as the standard of care for antibiotic prophylaxis.
Patients scheduled for total joint arthroplasty should be advised to shower or bathe (full body) at least the night before the operative day with either soap or an antiseptic agent. However, the optimal antiseptic agent has not been defined.
In the operating room, an alcohol-based solution should be used for preoperative painting. There is no direct evidence to favor chlorhexidine gluconate over iodophors, Dr. Springer said, with both having positives and negatives. [1,2] The key point, he said, is that the solution should have an alcohol base.
Surgical Site Irrigation
A number of irrigation solutions are available:
- Chlorhexidine gluconate
- Hydrogen peroxide
- Acetic acid
- Castille soap
- Dakin’s solution
- Antibiotic irrigation
The first 3 in this list are the most commonly used irrigation solutions, with the best clinical data available for the use of povidone-iodine in preventing surgical site infection. However, as with skin preparations, it is still unclear with irrigation is the optimum choice.
Wound Closure and Wound Dressings
The type of wound closure is controversial: Dr. Springer contends that the skill of the person closing the wound is more important than what is used for wound closure. He noted that an interesting study of blood flow to the skin from Mayo Clinic showed that running subcutaneous sutures facilitate significantly better wound perfusion and significantly less mean perfusion impairment than staples. 
Dr. Springer said the choice of wound dressing is another controversial area: There is no direct evidence for the benefits of occlusive dressings. The benefit, he said, is that they act as a barrier between the wound and the environment, thus promoting healing.
In a recently published study, patients took oral antibiotics for 7 days after total joint arthroplasty, which resulted in a lower 90-day periprosthetic joint infection rate. Not all of the study authors’ patients participated in this protocol. Instead, it was reserved for specific high-risk patients:
- BMI of 35 of more
- Diabetes mellitus
- Active smoker
- Chronic kidney disease
- Autoimmune disease
- Nasal colonization with MRSA or MSSA
If surgeons were to adopt an extended antibiotic prophylaxis protocol, this might be the right approach, Dr. Springer said. It allows for good antibiotic stewardship while addressing the needs of high-risk patients.
Click the image above to watch Dr. Springer’s presentation and hear more about intraoperative and postoperative prevention of infection in total joint arthroplasty patients.
Disclosures: Dr. Springer has no disclosures relevant to this presentation.
- Ostrander RV, Botte MJ, Brage ME. Efficacy of surgical preparation solutions in foot and ankle surgery. J Bone Joint Surg Am 2005;87(5):980-985.
- Markatos K, Kaseta M, Nikolaou VS. Preoperative skin preparation and draping in modern total joint arthroplasty: current evidence. Surg Infect (Larchmt). 2015;15(3):221-225.
- Wyles C, Jacobson SR, Houdek MT, et al. The Chitranjan Ranawat Award: Running subcuticular closure enables the most robust perfusion after TKA: a randomized clinical trial. Clin Orthop Relat Res. 2016;474(1):47-56.
- Inabathula A, Dilley JE, Ziemba-Davis M, et al. Extended oral antibiotic prophylaxis in high-risk patients substantially reduces primary total hip and knee arthroplasty 90-day infection rate. J Bone Joint Surg Am. 2018;100(24):2103-2109.