MANAGEMENT FACTORIALS IN THA
Strategies for the prevention of periprosthetic joint infection
B. Adeli, J. Parvizi From Rothman Institute, Philadelphia, Pennsylvania, United States
B. Adeli, BA, Research and Aministrative Coordinator J. Parvizi, MD, FRCS, Orthopaedic Surgeon, Director of Joint Research Rothman Institute, 925 Chestnut Street, Philadelphia, Pennsylvania 19107, USA. Correspondence should be sent to J. Parvizi; e-mail:
[email protected] ©2012 British Editorial Society of Bone and Joint Surgery doi:10.1302/0301-620X.94B11. 30833 $2.00 J Bone Joint Surg Br 2012;94-B, Supple A:42–6.
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Periprosthetic joint infection (PJI) is a devastating complication which can follow a total joint arthroplasty (TJA). Although rare, this ongoing threat undermines the success of TJA, a historically reputable procedure. It has haunted the orthopedic community for decades and several ongoing studies have provided insights and new approaches to effectively battle this multilayered problem.
It is reported that periprosthetic joint infection (PJI) currently plagues a small yet significant number of all elective total hip (THA) and total knee arthroplasties (TKA).1,2 PJI remains the number one reason for failure in TKAs afflicting 1% to 4% of them. A total of 5.6% of these cases undergo a future revision reoperation. Similarly, PJI is the third leading complication following total hip arthroplasty procedures affecting 1% of all THAs. A revision operation is required in 3.2% of this population. Berbari et al3 showed over a course of 22 years that 1.8% of patients developed a PJI with the majority of cases 41% occurring after two years of the primary operation. This is in fact a problem because as life expectancy increases, the number of procedures can reasonably be expected to increase as well. With an additional number of elective arthroplasties performed each year, it is fair to expect an increase in the number of PJI cases resulting from these procedures as well. In fact, projections show that by 2030 the number of patients receiving a primary total joint arthroplasties (TJAs) will be around 3.5 million. This is a 673% increase compared with 2005. Specifically, studies have projected an increase of over 600% in the number of TKA procedures that will occur over the next few decades, while the number of primary THAs performed will increase 174% to 572 000 annually.4,5 This equates to over 4 million primary TJAs annually just in the USA. Subsequently, the number of revisions is also expected to rise, with revisions for PJI approximated at over 35 000 cases each year.4 Studies evaluating the rates of infection over the past decades have indicated that the incidence of infection is on the rise in the United States. The associated costs in preventing and
treating a periprosthethic joint infection confirm that it is also a huge financial burden in healthcare management. The cost of revision surgery for infection is $60 000 more than that of a mechanical revision However, the financial burdens are insignificant compared with the amount of psychological stress and turmoil faced by healthcare management, including both treating physician and patient facing the threat of PJI. This complication begins with a causative organism, a pathogen with varying and complex characteristics that will seed around the implant and begin to multiply. The organism can cause an acute, delayed, or chronic infection, classified based on the time of onset of the symptoms following the primary arthroplasty procedure. At our institution we found the highest incidence of PJI, 56%, was due to chronic infections, 31% from acute infections, and 13% were acute hematogenous infections.6,7 The challenges we face in the management of PJI are in the following three areas: prevention, diagnosis, and treatment. Each sector diverges into sub-categories which allow us to better understand, control and successfully manage each risk factor which contributes to the development of PJI. The first important step in the management of this complication is prevention, and it requires precise measures to effectively eradicate or reduce any risk factors which increase the chances of a post-operative infection.
Prevention of PJI Preventative measures are absolutely necessary to decrease the overall rate of PJI following TKA and THA procedures. These strategies are best understood and employed when risk factors are divided and tackled on three fronts: THE JOURNAL OF BONE AND JOINT SURGERY
STRATEGIES FOR THE PREVENTION OF PERIPROSTHETIC JOINT INFECTION
host, operating room environment, and surgical variables. It is important to determine the risks within each category in order to develop adequate, successful preventative approaches. Furthermore, while some strategies are strongly supported throughout the literature, others may lack sufficient evidence despite their effectiveness. It is possible that doing away with some strategies may even be best as their use contributes very little in the prevention of PJI. Nonetheless, familiarity with these contributing factors which most undermine the success of a TJA is paramount. In order to implement an effective strategy for the prevention of PJI, a review of the current literature evaluating all associated risk factors for infection is required. The first category involves risk factors related to the host, such as comorbidities that may increase the risk of subsequent complications. Suitable measures involve screening and optimisation of the patients prior to surgery. A successful first screening occurs during clinical visits. The second category which contains variables that may elevate the risk of PJI, is the operating room environment. A critical evaluation of this peri-operative arena as well as involved personnel is necessary to ensure a successful operation. The third category in the prevention of PJI involves the potential risk factors related to the surgery such as: skin preparation, antibiotic prophylaxis, use of antibiotic-laden bone cement, and a thorough post operative evaluation along with follow-up care.7
The host The successful screening and optimisation of the patient is the first important strategy in the prevention of PJI. Thorough pre-operative tests and evaluations are necessary to detect any host risk factors that may compromise outcome. However, due to a scarcity of prospective studies on PJI, debates on the legitimacy of risk factors and predisposing comorbidities currently surround this topic. Implementation of some preventative strategies coupled with diligent monitoring of high risk patients, properly identified preoperatively during a clinical visit, may reduce the chance of a post-operative PJI. Host or patient related risk factors can be further divided by the specific screening methods used. Ultimately, this can reveal an overall picture of the patient’s health prior to surgery and can associate a certain likelihood of that particular patient developing post-operative complications. Appropriate and thorough screenings are divided into the following three categories: 1. Questionnaires containing the patient’s background medical history along with previous diagnoses, medications, and social/behavioral factors. 2. Clinical signs or symptoms observed by the clinician. 3. Results of pre-operative testing (i.e. serology, urinalysis, etc). The combination of all three categories reveals necessary information needed to develop and implement a specific and individualized strategy for patient optimisation. VOL. 94-B, No. 11, NOVEMBER 2012
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Early on, there needs to be a thorough evaluation of the patient’s medical history. This will reveal any underlying conditions, comorbidities, and medications which may be controlled and closely monitored prior to and during an operation. For example, patients with rheumatoid arthritis are at a greater risk of developing a post-operative PJI, mainly due to the immunosuppressive disease modifying medications taken to control the condition.7 It is important here to notice if the patient has taken any systemic steroids for an extended period of time as that will also increase the risk of PJI. Some studies indicate that patients who have a malignancy in the past five years, are at an increased risk of developing a PJI. Optimising host health through nutritional evaluations is also a very important step at this stage. Obese patients, or those with a BMI > 20% of their ideal weight, are also at a greater risk of developing an infection. A referral to a cardiologist for a pre-operative evaluation is important since some patients with a history of myocardial infarctions, atrial fibrillation, or anticoagulant use have a higher chance of developing a post-operative hematoma and PJI. In fact, hematomas are one of the strongest indications of a PJI. Therefore, absolutely no aggressive anticoagulation should be given to these higher risk patients.8,9 After the patient medical history is complete, a thorough clinical evaluation should be conducted in office. For example, any ulceration or neuropathy detected means the patient is not a good candidate for elective arthroplasty. Furthermore, any skin problems or vascular insufficiencies, commonly detected in smokers, are indications that the patient is at a greater risk of a post-operative PJI. These patients should complete a smoking cessation program prior to their operation.7 The third important category to evaluate for patient related risk factors is the results of pre-operative blood tests. Elevated glucose levels may reveal uncontrolled diabetes, and these patients should not be operated on at all.3,8-11 High INR levels point to a higher chance of intra-operative bleeding and hematoma formation. Also, low albumin levels may reveal malnutrition.12 Interestingly, obese patients are more likely to have malnourishment, so called paradoxical malnutrition.13,14 These are all important variables that should be monitored prior to an operation. Blood test should show that hemoglobin A1C levels are normal as anemia is an additional a risk factor for infection. Patients with chronic renal insufficiency should have normal creatinine values before the operation as well. Finally, it is important to make sure that the patient has no other underlying infections, such as a urinary tract infection, before the elective arthroplasty.6,14 These patients should be optimised by eradication of the infection prior to surgery via appropriate antibiotic therapy. Although the issue surrounding the requirement of a pre-operative dental clearance is debated, it is another method used to detect active infections. Studies have shown that patients undergoing a TKA are at a significantly higher risk of developing a PJI than those receiving a THA.6,8,9 Before operating, the clinician must
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decide if the patient is a good candidate for a TKA specifically. Then based on a patient’s overall health, the surgeon can then decide if the patient is a candidate for a bilateral procedure, generally reserved for low risk patients.6 Healthy patients are not be a high risk of needing allogenic transfusions or longer hospital stays which both elevate the risk of a post-operative PJI as well. There are a few important points to consider in addition to these suggested host optimisation strategies. MRSA decolonisation is recommended in order to optimise the host prior to an operation.7 One study indicated that each medical condition was estimated at increasing the risk of PJI by 35%.15 Therefore, quantifying the overall health of a patient using indices such as the Charlson Comorbidity Index or ASA values is important. An ASA > 3 is a significant risk factor for post-operative PJI.10 Therefore, all patients should be thoroughly screened and optimised prior to surgery.
The operating room Once the host is optimised and the patient has received pre-operative clearance for a TJA, there are several strategies related to the operating room environment which can be implemented to ensure sterility and order throughout the operation. A clean operating room environment is paramount to the success of an operation and in the prevention of post-operative infection. To thoroughly assess the operating room setting and risk factors associated with PJI, the following three categories were created: 1) risk factors centered around the quality of air in the operating room; 2) risk factors associated with healthcare personnel involved; 3) risk factors related to the patient undergoing the operation. There is one very important factor which must be discussed first as it relates to all three categories and poses a significant risk if not properly monitored and that is the frequency of traffic into and out of an operating room during surgery. Monitoring personnel the operating room traffic is a critical step towards the prevention of post-operative PJI. It is vital to not only regulate personnel allowed within the operating room and sterile area, but it is equally important to monitor the number of times individuals enter and leave throughout an operation.16-18 People shed up to 10 000 bacteria per minute, men being a greater source of bacteria than women. It is obvious then, that individuals are sources of bacteria in the operating room. Therefore, bacteria transfer from visitors and operating room personnel, be it nurses or surgeons, is inevitable. However, a conscious effort to minimise or prevent intra-operative traffic is a critical step towards the prevention of PJI. As previously mentioned, the first category of risk factors is related to air quality within the operating room. As modern operating rooms have air filters, particles are removed and the room is ventilated. Although the success of vertical versus horizontal laminar airflow systems on surgical site infections (SSI) has been debated in the past, emerging data indicates the importance of laminar airflow in the operating
room in the prevention of PJI.19-22 Dharan et al19 indicate the importance of not only using a vertical laminar airflow, but also knowing the filter size and personnel responsible for its routine maintenance. This concept goes hand-inhand with control of operating room traffic since an open door equates to a 30 second disruption of that laminar airflow in the room. Optimising the air quality in an operating room is an important strategy which can minimise the risk of post-operative infection. The second category of risk factors associated with an operating room is related to preventative measures taken by healthcare personnel involved in the operation. Strategies focusing on the use of gloves and body exhaust systems do much to not only minimise the risk of PJI for the patient, but also to protect those performing or assisting with the surgery. As recommended by the CDC, it is worth reiterating that hand-washing still remains a frontline strategy towards minimising the transfer of bacteria into the operating room and to the patient. Furthermore, we recommend the use of three sets of gloves, where the outer set is changed following draping. Gloves have a 33% contamination rate, half of which occur during the draping process. Additionally, gloves often get perforated, sometimes unbeknownst to operating room personnel. Because surgical gloves are a source of contamination, double gloving is a must during TJA to reduce the perforation of inner gloves. Changing at regular intervals can decrease incidence of bacterial contamination. Therefore, it is important to change gloves throughout a TJA, especially if the surgical time extends beyond three hours or if an obvious puncture in the gloves is seen.23,24 Outer surgical cutting gloves are also recommended, especially in cases involving a high risk patient groups, such as those with HIV. In addition to gloving strategies, the use of body exhaust systems can minimise the risk of post-operative PJI.25 Despite the lack of Level I evidence, the use of a personal protection system is recommended by our institution as it reduces bacterial count and prevents fallout from personnel onto an open wound. The third category of risk factors in the operating room involves the patient. Skin preparation is very important and should begin at the patient’s home. In the operating room however, alcohol must be part of the skin preparation in addition to the chosen preparation agent.26 However, skin can re-colonize bacteria after this step.27,28 Therefore, draping to minimise the risk of re-colonization after skin has been prepped is recommended.29-32 Although there is no Level I evidence for this, the use of some sort of an adhesive drape can be an additional preventative measure. Though evidence on the effects of laminar airflow, protective suits and the size and volume of the operating room on PJI rates varies, research has shown that wound contamination often occurs during surgery and a majority of the time by direct fallout or contact with a contaminated glove or an instrument. Since the primary source of bacteria in CCJR SUPPLEMENT TO THE JOURNAL OF BONE AND JOINT SURGERY
STRATEGIES FOR THE PREVENTION OF PERIPROSTHETIC JOINT INFECTION
the operating room is related to the personnel, following the suggested preventative strategies is important in the successful management of PJI.
Surgical factors Surgical factors involve pre-operative, intra-operative, and post-operative variables that when closely managed can decrease the overall risk of a PJI. A post-operative surgical site infection, a longer hospital stay, and bilateral procedures are the most common risk factors associated with PJI in an elective arthroplasty6. There is plenty of evidence in support of skin preparation as a means of preventing PJI. Skin prep actually beings in a patient’s home, where betadyne showers or chlorohexadine wipes can be used prior to surgery.33 To further minimise the risk of SSI, hair removal from the incision site using clippers now occurs immediately prior to surgery, before the patient enters the operating room.34 Intra-operatively, the surgical site is further decontaminated while the patient is started on prophylactic perioperative antibiotics. It is important to note that healthcare workers are also at risk of being carriers of MRSA, and successful screening is important in this population as well. One of the most effective agents in the prevention of PJI and SSI is administration of the appropriate and timely perioperative antibiotics. Perhaps the strongest evidence which exists today is in support of antibiotic administration prior to surgery.35-40 This is especially important due to the risk of resistant organisms. Not only are these cases more complicated for both surgeon and patient, there is also a higher cost for treatment of infections with resistant organisms. Infections involving methicillin resistant strains have a mean cost of $107 264 per case versus $68 053 for treatment of PJI in cases involving susceptible strains.41-42 Based on the Center for Disease Control (CDC) recommendations, intravenous antibiotics need to be administered about one hour prior to surgery, and the dose needs to be repeated if the time extends beyond two to three hours or if the patient has had significant blood loss. Presently, second generation cephalosporin appears to be one of the most effective antibiotics for the prevention of PJI as they have excellent tissue activity against the majority of organisms, including gram-positive cocci.8,37,38 They have a long half-life and good tissue penetration. However, these antibiotics will not be an option in patients that are MRSA carriers, those with a remote recent history of MRSA, and patients who may have a severe penicillin allergy. Administration of vancomycin is a fair alternative to consider for these patients.7 To minimise the risk of infection, avoid allogenic blood transfusion as patients receiving them are 2.1 times more likely to get a PJI.6,43-45 Transfusion mediated modulation of the immune system by allogenic blood and the storage lesion of transfused RBCs, impair microcirculation and oxygen delivery at the site of a surgical wound. At our institution, autogenous pre-operative donations are not recommended. VOL. 94-B, No. 11, NOVEMBER 2012
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Finally, a few other surgical factors should be considered to minimize the overall risk of infection. Changing of the scalpel is a procedure that should be abandoned as little evidence exists to support the need for a different surgical blade.46-49 Addition of antibiotic to irrigation solution is currently not supported by any evidence in the literature.7 However, we currently use polyyxin B and bacitracin and believe that antibiotic impregnated irrigation solutions have a role in minimising infections during an operation. This is one area that should be carefully considered as contaminations occur in the basin or at the suction tip, which means changing it regularly may be useful.50-53 Lastly, although it is not approved by the FDA, there are numerous studies, mainly in Europe, indicating that the use of antibiotic cement is protective against septic and aseptic failures in TKA procedures.8,54-57 There are important strategies to consider during the immediate post-operative period as well. Strategies implemented during the immediate post-operative period involve treatment of a draining wound and antibiotic administration with immediate dental procedures following an arthroplasty. Drainage, hematoma, and necrosis are important problems that are sometimes encountered during this time period. It is extremely important to aggressively treat these cases early when they are detected7. Since hematomas are associated with the use of anticoagulation medications, gentle distribution and use of these is recommended in high risk patient populations. Currently, there is no evidence indicating the use of a drain for or against PJI specifically, though one study shows that hematoma formation is higher when drains are employed.6
Conclusion Based on current literature, strategies should be organised and implemented as stringent pre-operative protocols in order to minimise risk factors and effectively prevent PJI. Ultimately, the success of a surgical procedure demands a sterile operating room, clean personnel and practices, and a healthy host who will have a full and quick recovery resulting in a pain-free, functional joint. A high risk host will ultimately compromise the healing process, allowing bacteria to seed and replicate, especially when the body is most vulnerable as it is with high risk patients who have multiple underlying comorbidities and will not heal fully after an operation, providing a better environment for complications such as PJI. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. This paper is based on a study which was presented at the Winter 2011 Current Concepts in Joint Replacement meeting in Orlando, Florida, 7th – 10th December.
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