Periprosthetic Joint Infection.pptx

Periprosthetic Joint Infection
R2 Topic Review

Outline
 Definition
 Epidemiology and microbiology
 Pathogenesis
 Clinical manifestation
 Diagnosis
 Treatment and follow-up
 Preventive measures

Definition
At least one criterion required:
1. Presence of a sinus tract communicating
with the prosthetic joint
2. Presence of purulence without another
known etiology surrounding the
prosthesis
3. Acute inflammation consistent with
infection at histopathologic examination
of periprosthetic tissue (>5 granulocytes
per HPF as average in 10 HPFs)
4. Elevated leukocyte count in the synovial
fluid or predominance of neutrophil, or
both
5. Growth of identical microorganism in at
least 2 intraoperative cultures or
combination of preoperative aspiration
and intraoperative cultures in case of a
low-virulence microorganism. In case of
a virulent microorganism, growth in a
single specimen from synovial fluid or
periprosthetic tissue, or both, and/or
sonication fluid may also represent
periprosthetic joint infection.
Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 9th ed. 2019

Infection
Hip and knee (%)
Hip (%) Knee (%)
Shoulder
(%)
Elbow (%)
All time
period
Early
infection
Staphylococcus aureus 27 38 13 23 18 42
Coagulase-negative
Staphylococcus
27 22 30 23 41 41
Streptococcus species 8 4 6 6 4 4
Enterococcus species 3 10 2 2 3 0
Aerobic Gram-negative bacilli 9 24 7 5 10 7
Anerobic bacteria 4 3 9 5
Proprionibacterium acnes 24 1
Other anaerobes 3 0
Culture negative 14 10 7 11 15 5
Polymicrobial 15 31 14 12 16 3
Other 3
Common causes of prosthetic joint infection
A Tande and R Patel. Clinical Microbiology Reviews. 2014

Staphylococcus aureus
 Infection occurs at all time periods after implantation
 Early-onset infection
 Concomitant bacteremia occurs in 10-60% of cases with PJI
Coagulase-negative Staphylococcus
 S. epidermidis (most frequently identified of this group), S.
simulans, S. caprae, S. lugdunensis
 Early-onset and delayed- or late- onset infection
 S. lugdunensis is capable of causing severe systemic and local
infections similar to those caused by S. aureus

Streptococcus
 <10% of PJI. Most common streptococci to cause PJI: group
B and G streptococci
 Acute-onset with at least half of patients presenting with
fever and systemic symptoms
 Among GBS PJI, up to 50% of patients may be bacteremic at
the time of PJI symptom onset
 Patients with PJI caused by group G streptococci often have
remote sites of infection, such as cellulitis
Enterococcus
 Rare
 Often as part of polymicrobial infections
 Among patients with monomicrobial enterococcal PJI, the majority of the patients
presented late after arthroplasty implantation with a prolonged duration of
symptoms, compatible with the less virulent nature of enterococci

Aerobic Gram-negative bacilli
 More common in early-onset PJI
 E. coli, P. aeruginosa, non-E.coli
Enterobacteriacaea
Proprionibacterium acnes
 Relatively-low virulence, anaerobic, Gram-positive bacillus
 Typically inoculate at the time of surgery
 More frequent for shoulder arthroplasties than other joints; presumably related
to the proximity to the axilla
 Very indolent clinical course
 Pain is often the only manifestation of infection

Other anaerobic bacteria
 Clostridium species, Bacteriodes fragilis,
Peptostreptococcus species, Actinomyces
species
 As part of polymicrobial infection (except for
Actinomyces)
 Clostridium PJI typically occurs in patients
with underlying gastrointestinal disease
 Peptostreptococcus species are associated
with periodontal disease

Incidence of
periprosthetic
joint infection
1-2%
Hip and knee
arthroplasty
60-70%
Occurs in the first 2 years
1%
Shoulder
arthroplasty
3.3%
Elbow
arthroplasty

Risk factors
 Diabetes mellitus
 Obesity
 Rheumatoid arthritis
 Immunosuppressive
therapy
 Other comorbidities:
congestive heart failure,
COPD, peripheral
vascular disease,
malignancy
Patient characteristics
 Complexity and
duration of procedure
 Wound complications
(delayed healing,
persistent dehiscence,
hematoma, seroma,
wet wound after being
dry)
Surgery-related risks Other risks
 Urinary tract infection
in the post operative
period
Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 9th ed. 2019

Pathogenesis
• Prosthetic joints are made of metal and
polymers.
• After implantation, the device is covered by
host proteins favoring bacterial adherence.
• Complement in interstitial fluid be activated
at the surface of polymeric implants, which
results in degranulation of local neutrophils.
• This interaction with wear particles,
fragments from within the joint space,
results in an impaired granulocyte function
and favors aseptic loosening of joint
prostheses.
Mandell Douglas and Bennett's principles and practice of infectious diseases 9th edition

Pathogenesis
• Implanted foreign material is highly susceptible to local infection.
• In 1957, Elek and Conen showed in human volunteers
• The minimal abscess-forming dose is 10,000-fold lower than in the absence of
foreign material.
• The route of infection can be exogenous, hematogenous, or
contiguous spread.

Pathogenesis
• Implant-associated microorganisms growing as a
biofilm are protected from phagocytosis.
• Most antibiotics do not kill adherent bacteria
despite penetration into the biofilm due to low
growth rate.
• As an exception
• Rifampin can eliminate biofilm-associated GP
• Fluoroquinolones are active against biofilms from GNB

Classification
• No unanimous classification system
• On the basis of
• The routes: exogenous or hematogenous
• The virulence of bacteria and the host response: acute or chronic
• Traditional classification:
• early <3 months
• delayed 3–24 months
• late >24 months

Classification
• In clinical practice, it is more useful to classify PJI as follows:
• Acute hematogenous PJI: duration of symptoms <3 weeks
• Early interventional PJI: <1 month after procedure
• Chronic PJI: duration of symptoms >3 weeks or >1 month after procedure

Classification
• This classification allows the DDx between PJI for appropriate treatment
• Acute hematogenous PJI: device can be retained.
• Early interventional PJI: device can be retained.
• Chronic PJI: requires removal of all hardware and bone cement

Clinical manifestations and differential
diagnosis
• Acute exogenous infection typically causes local signs of inflammation
• Acute hematogenous infection is characterized by new-onset pain,
initially without prominent local signs of infection.
• Most early (postoperative) acute infections have an exogenous origin.
• Wound dehiscence, drainage, and erythema are typical signs.
• A systemic inflammatory response syndrome may be missing.
• DDx includes wound complications such as hematoma or seroma.
• Suspicious wound needs a careful orthopedic evaluation

diagnosis
• Acute-onset PJI occurring beyond the postoperative period is
generally of hematogenous origin
• Systemic signs of inflammation are prominent.
• Profound pain at the site of the implant, although soft tissue damage is less
frequent and less obviously
• DDx includes crystal arthropathy, venous thrombosis and arterial emboli

diagnosis
• Chronic PJI can be exogenous or hematogenous.
• If the joint is infected at surgery by low-virulence organisms, infection
often manifests beyond 1 month.
• The key symptoms are chronic joint effusion, pain caused by local
inflammation or implant loosening, and, occasionally, sinus tracts.
• DDx includes mechanical failure, excessive wear debris, or allergy to
the implant material.

Diagnosis of Prosthetic joint infection
• Peripheral Blood Tests
• Imaging Procedures
• Synovial Fluid analysis
• Periprosthetic Tissue
• Sonication
• Novel Diagnostic Procedures and Molecular Diagnosis

Blood Tests
• Leukocyte counts
• poor sensitivity and low predictive values
• CRP and ESR
• Both tests have good sensitivity but poor specificity
• ⟫ 30 mm/h (ESR) and ⟫ 10 mg/L (CRP)
• sensitivities are 91% to 97% and the specificities are 70% to 78%
• Sensitivity is less for low-virulence organisms, such as C. acnes.
• Procalcitonin (PCT)has not proved helpful
• Interleukin-6 (IL-6) values above the cutoff value of 10 pg/L
• appear to have an excellent sensitivity of nearly 100% to predict the presence
of PJI
Werner Zimmerli and Parham Sendi ,Orthopedic Implant– Associated Infections
Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 105, 1430-1442.e3

Prosthetic Joint Infection , Clinical micro rev. April 2014 Volume 27 Number 2

Plain radiographs
• Radiographs have a low sensitivity and specificity for the diagnosis of
PJI
• Periosteal new bone formation alone was 100% specific but occurred
in only 16% of patients with PJI.
• Serial radiographs with progressively expanding lucency over several
months may also suggest PJI.

Ultrasonography
• Ultrasonography is helpful in cases with joint effusion that cannot be
clinically diagnosed and where guidance for joint aspiration is
necessary.

Computed tomography (CT)
• Allows detection of soft tissue infection (abscesses, sinus tracts),
prosthetic loosening, and bone erosion
• this technique is more often used to estimate the extent of an
infection than to determine whether or not an infection is present
• The indication for magnetic resonance imaging (MRI) is similar to that
for CT

Radionuclide imaging
• signs of infection are visible before anatomic changes
• The three-phase bone scan using a bone-seeking tracer (e.g.,
technetium 99m–labeled methylene diphosphonate [99mTc-MDP]) is
sensitive for detecting infection but poor specificity
• Bone remodeling and hence marker uptake is increased for at least 1
year after implantation
• Heterotopic ossification and aseptic loosening also increase tracer
uptake

Positron Emission Tomography
• plays an important role in the detection of malignant tumors
• F-fluorodeoxyglucose (FDG) accumulates in cells such as neutrophils
and is intracellularly phosphorylated to a stable molecule.
• Therefore accumulation occurs in not only tumors but also
inflammatory foci
• FDG-PET has good and spec for the detection of PJIs
• PET cannot be recommended for routine clinical practice

In general, the majority of patients with
suspected PJI do not need an advanced
imaging modality to make the diagnosis
of PJI.
However, for selected patients for whom
further imaging is warranted, careful
selection among the available tests is
necessary. The cost, additional
information that might be gained from the
test, and time from the start of the test to
the availability of results should be
considered when making this decision.

Synovial Fluid Cell Counts
• Threshold is much lower than for septic native joint arthritis
• no uniformly accepted precise cutoff value
• It should be noted that there were small number of the patients with
inflammatory joint disease, so these results should be confirmed in
larger studies.
• In summary, leukocyte and differential counts are key parameters for
the diagnosis of PJI, especially in patients with negative culture.

Synovial Fluid Culture
• Conventional microbiologic cultures
• moderate sensitivity of approximately 85%
• specificity > 95%
• Do not stratify whether the fluid was obtained by puncture,
arthroscopy, or open surgery
• A negative culture result does not exclude PJI
• The sample sensitivity can be improved by use of polymerase chain
reaction (PCR) or by culturing synovial fluid in blood culture flasks

Periprosthetic Tissue
• Preoperative periprosthetic tissue biopsy
• Intraoperative periprosthetic tissue Gram staining
• Intraoperative periprosthetic tissue culture.
• Cultures obtained by using swabs
• Histological analysis of periprosthetic tissue

Preoperative periprosthetic tissue biopsy
• Lack of demonstrated superiority and the additional expense and
possible complications of the involved procedure
• Large study comparing preoperative synovial fluid aspiration and
tissue biopsy with hip arthroplasty found that aspiration was more
accurate
Preoperative biopsy is not routinely recommended

Intraoperative periprosthetic tissue Gram
staining
• very low sensitivity and offers little additional information
• the poor test characteristics of tissue Gram staining, and the
numerous other available preoperative tests,
Tissue Gram staining is not routinely recommended

Tissue Gram staining is not routinely recommended

Intraoperative Samples for Culture
• Swab cultures
• lower sensitivity than cultures from periprosthetic tissue and synovial fluid
• Culturing synovial fluid and periprosthetic tissue has the best
accuracy
• For the diagnosis of PJI, at least three specimens should be obtained
• The greatest accuracy is
• four specimens processed with conventional culture and three specimens
cultured in blood culture bottles
• Recent investigations have reported an incubation time of up to 10
days

Intraoperative Samples for Culture
Submission of single tissue specimens for culture is not recommended
Culture using aerobic and anaerobic conditions
should be performed in all cases
Both aerobic and anaerobic cultures should be incubated for 13
days
However, a single positive culture may be important,
especially when virulent organisms (such as S. aureus,
beta-hemolytic streptococci, or aerobic Gram- negative
bacilli) are isolated or when the same organism is found in
a different specimen type, such as synovial or sonicate
fluid
Collection of swabs for culture is not recommended

Intraoperative Samples for Histopathology
• Histopathologic specimens are difficult to interpret because varies
among different experts
• Many experts accept 5 or more neutrophils per HPF in ×40
magnification as a positive indicator for PJI
• Frozen sections use in centers with experienced pathologists
• The comparison between culture results and histopathologic findings
helps to differentiate between contamination and infection
While this meta-analysis did not provide pooled sensitivity and specificity, these likelihood
ratios suggest that frozen-section analysis is helpful to confirm or support the diagnosis of PJI
in patients with an intermediate pretest probability of PJI. However, for the same patient with
an intermediate pretest probability, the absence of acute inflammation will only modestly
lower the posttest probability of PJI, and further data to exclude PJI would be necessary. For
a patient with a low pretest probability of PJI, a negative frozen-section result may be

Periprosthetic Tissue
• Preoperative periprosthetic tissue biopsy
• Intraoperative periprosthetic tissue Gram staining
• Intraoperative periprosthetic tissue culture
• Cultures obtained by using swabs
• Histological analysis of periprosthetic tissue

Sonication
• Allows detection of
microorganisms in
biofilms
currently recommended protocol for sonication of explanted joint
prostheses

Novel Diagnostic Procedures
• α-Defensin is an antimicrobial peptide that is released by neutrophils and
natural killer cells in response to inflammation.
• The result is not influenced by prior antibiotics, but metallosis is a potential
source of false-positive results.
• rapid detection of α-defensin in synovial fluid had a limited sensitivity of
67% and 69%, respectively.
• it has been shown that the sensitivity of leukocyte count is higher than that
of the qualitative α-defensin test (86% vs. 54%; P < .001)
• A strip test for detecting leukocyte esterase has also been used
intraoperatively but has low sensitivity and gives false-positive results in
bloody specimens

Molecular Diagnostics
• broad-range PCR or specific multiplex PCR
• In pt pretreated with antibiotics
• the sensitivity of broad-spectrum PCR is higher than that of culture, but still
only about 70%.
• it does not give information about the susceptibility of the
microorganism with a few exceptions (e.g., mecA gene for methicillin
resistance, rpoB gene for rifampin resistance)
• in a recent study the sensitivity of a multiplex PCR in sonication fluid
was not better than that of sonicate culture (53% vs. 58%)

Treatment of choice
• Debridement and implant retention
• Debridement, antibiotics and implant retention (DAIR)
• One-stage exchange
• Two-stage exchange
• Permanent resection
• Amputation

Antibiotic of choice
• IV route is preferred
• Choice of antibiotic depend on culture and tissue penetration
• Empirical in severe case should be cover MRSA and aerobic gram
negative pathogen
W. Zimmerli, P. Sendi (2019) 'Orthopedic implant-associated infections', in John E. Bennett, et al. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. : Elsevier, pp. 1430-42.

Rifampicin
• Excellent activity on susceptible biofilm staphylococci
• No clinical study prove using rifampicin in other gram-positive or
gram-negative
• Always combine with another drug for prevention of emergence of
resistance
• Start only in dry wound due to risk of superinfection from skin
microbiome

Debridement, antibiotics and implant retention
(DAIR)
• Fulfill condition
• Acute infection < 3 weeks
• Stable implant
• Pathogen susceptible to biofilm-active antimicrobial agent
• No sinus tract and no periprosthetic abscess
Osmon, D. R., et al. (2012). Diagnosis and Management of Prosthetic Joint Infection: Clinical Practice Guidelines by the Infectious Diseases Society of America. Clinical Infectious Diseases, 56(1), e1–e25.
Tande AJ, et al. Management of Prosthetic joint infection. Infect Dis Clin North Am 2017; 31:237.

One-stage exchange
• Consider in
• Good soft tissue envelop
• Pathogen that is susceptible to oral antimicrobial agent with bioavailability
and activity on biofilms

One-stage exchange
• Success rate of 1 stage exchange is
similar to 2 stage exchange and
superior to DAIR  study in THA
• High risk of failure if bone grafting can’t
use ATB impregnated bone cement
Lange J, et al. Chronic infections in hip arthroplasties: comparing risk of reinfection following one-stage and two-stage revision: a sys- tematic review and meta-analysis. Clin Epidemiol 2012;4:57–73.
Fulfilled condition

Two-stage exchange
• Remove all of the implant  reimplant new device
• Concept : difficult-to-treat microorganism must be completely eradicated
• After removal : antibiotic-impregnated spacer is insert to achieve stability, allow
mobility, prevent shrinking of joint space, produce high concentration of
antibiotics

Two-stage exchange
• Short interval
• IV antibiotic 2-3 weeks before reimplantation
• Except in difficult-to-treat microorganism
• No sampling during implantation
• Post-op antibiotic is necessary

Permanent resection
• May be consider in nonambulatory patient, limit bone stock, poor
soft issue coverage, no antimicrobial available or prior failure

Amputation
• Should be last option
• Antimicrobial give until 24-48 hours after amputation
• If residual infected bone and soft tissue  extend 4-6 weeks antimicrobial

Culture negative Prosthetic joint infection
• Reason : preceding antimicrobial, can’t identify pathogen (insufficient
tool, unavailable method), non-infectious mimic
• Treatment plan : spectrum of preceding antimicrobial, time period
and host

Chronic oral antimicrobial suppression

Chronic oral antimicrobial suppression
• Role
• After treatment of PJI with DAIR and one-stage exchange
• Discontinuation : 4 fold increased risk of treatment failure in DAIR
• Palliative (elderly patients, no surgical treatment)
Byren I, Bejon P, Atkins BL, et al. One hundred and twelve infected arthroplasties treated with ‘DAIR’ antibiotic duration and outcome. J Antimicrob Chemother 2009; 63:1264–71.
Prendki, V., et al. (2017). Efficacy of indefinite chronic oral antimicrobial suppression for PJI in the elderly: a comparative study. International Journal of Infectious Diseases, 60, 57–60.

Treatment monitoring
• Treatment monitoring includes clinical monitoring and laboratory
monitoring.
• Laboratory monitoring is needed during prolonged administration of ATB to
monitor for adverse drug effects and to assess control of infection.
• For patients on parenteral antimicrobial therapy
• Weekly CBC and chemistries.
• Serum inflammatory markers at
• the beginning
• the ending
• the time of transition to oral suppressive therapy
• clinical suspicion for treatment failure in conjunction with clinical examination and
radiographic
• For patients on oral suppressive antimicrobial therapy
• CBC at 2, 4, 8, and 12 weeks and then every 6 to 12 months thereafter
Elie B, Larry MB, Antonia F C, Prosthetic joint infection: Treatment. Wolters Kluwer. Feb 28, 2020.

Treatment monitoring
• Persistently elevated inflammatory markers
• The first priority should be to ensure that complete debridement has been
performed. In addition, the microbiologic diagnosis and susceptibility data
should be reviewed.
• Persistently elevated inflammatory markers without an alternative
explanation 2 weeks following completion of antimicrobial therapy
should prompt workup for persistent infection.
• Patients with associated symptoms warrant repeat debridement and
additional antimicrobial therapy.
• In the absence of clinical signs consistent with persistent infection,
clinical observation may be reasonable.
Elie B, Larry MB, Antonia F C, Prosthetic joint infection: Treatment. Wolters Kluwer. Feb 28, 2020.

Prevention
vulnerable host
Poor sterile technique
Bacterial colonization
Poor surgical technique
Poor environmental
hygiene
Contaminated prosthesis
Prosthetic
joint infection

Perioperative antibiotic
• Perioperative antimicrobial prophylaxis for joint arthroplasty has been
shown to reduce the risk of surgical site infection by >80%
• antibiotic selected should reflect the antibiogram of the individual
institution
• first dose should be given within the 60 min prior to the incision
• a second intraoperative dose should be given in case of excessive
blood loss or the procedure is longer than 4 hours
• antimicrobial prophylaxis beyond 24 h postoperatively does not
appear to be beneﬁcial
Prosthetic Joint Infection. Clin Microbiol Rev. 2014 Apr;27(2):302-45.

American Academy of Orthopaedic Surgeons Guideline 2019
AASO 2019 Diagnosis and Prevention of Periprosthetic Joint Infections Clinical Practice Guideline

Antibiotic cement
• Bone cement (polymethyl methacrylate
[PMMA]) is frequently employed at the
metal-bone interface
• Various antibiotics have been
successfully mixed and used with bone
cements like Gentamycin, Erythromycin,
Cefuroxime, Vancomycin, Colistin etc.
Prosthetic Joint Infection. Clin Microbiol Rev. 2014 Apr;27(2):302-45.
Trowels and Tribulations: Review of Antimicrobial- Impregnated Bone Cements in Prosthetic Joint Surgery. Pharmacotherapy. 2017 Dec;37(12):1565-1577.

• a randomized, open study, single
center of 2948 knees under went
primary total knee arthroplasty with
at least one year follow up
• all patients, preoperative intravenous
prophylactic antibiotics were
administered with 2 g of cefazolin
• compare between Simplex cement
without antibiotic with Simplex P
cement loaded with 0.5 g of
erythromycin and three million units
of colistin in 40 g of cement
The Use of Erythromycin and Colistin-Loaded Cement in Total Knee Arthroplasty Does Not Reduce the Incidence of Infection. J Bone Joint Surg Am. 2013 May 1;95(9):769-74.

The Use of Erythromycin and Colistin-Loaded Cement in Total Knee Arthroplasty Does Not Reduce the Incidence of Infection. J Bone Joint Surg Am. 2013 May 1;95(9):769-74.
• The effectiveness of the antibiotic-loaded cement probably cannot be
generalized to another antibiotic, and it is only valid if a correct systemic
antibiotic prophylaxis regimen is performed

• Meta-analysis of 5 RCTs and 5 cohorts evaluating AIBC use in reducing
infection rates
Antibiotic-impregnated Bone Cement for Preventing Infection in Patients Receiving Primary Total Hip and Knee Arthroplasty: A Meta-Analysis
Medicine (Baltimore), 98 (49), e18068

AIBC vs.
Systemic
antibiotic
Superficial
infection
deep
infection
total
infection

AIBC
vs.
plain cement
Superficial
infection
deep
infection
total
infection

Knee
arthropathy
Hip
arthropathy
deep
infection

Cefuroxime
Gentamicin
deep
infection

Antibiotic cement

Screening and nasal decolonization
• Carriage of S. aureus is a risk factor for the development of infections
in various settings
• Elimination of nasal carriage would theoretically reduce the infection
rates
• Studies in Thailand showed prevalence of MSSA nasal colonization
was 15-20%.
Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus. N Engl J Med 2010; 362:9-17.
Prevalence of nasal carriage of Staphylococcus aureus in allergic rhinitis patients and healthy controls in Thailand. Asian Pac J Allergy Immunol. 2019.

• randomized, double-blind, placebo-
controlled, multicenter trial
• mupirocin nasal ointment 2%
applied twice daily + chlorhexidine
gluconate soap for a total-body wash
for 5 days compared to identical
placebo
• immediate decolonization
significantly reduced the risk of
hospital-acquired S. aureus
infections in patients at risk

Adverse event
Outcome
no statistically significant
difference in the subgroup

Preoperative Staphylococcus aureus Screening/Decolonization Protocol Before Total Joint Arthroplasty
Results of a Small Prospective Randomized Trial. J Arthroplasty. 2016 Jan;31(1):234-9.
• randomized, single center trial of 228
identiﬁed carriers (underpower)
• patients were instructed to apply a 2%
mupirocin nasal ointment twice daily
and to bath with chlorhexidine soap
• 24 patients did not receive the
intended treatment
• Treated and untreated carriers showed
no significant difference in PJI (3.4% vs
4.4%)

Methicillin sensitive staphylococcus aureus screening and decolonisation in elective hip and knee arthroplasty. J Infect. 2018 Nov;77(5):405-409.
• a cohort of 12,911 patients
compared PJI between before and
after Pre-operative screening for
MSSA was introduced
• All patients are given Octenisan
bodywash to use for 5 days. In those
with MSSA positive are additionally
given Bactroban nasal apply.
• found a signiﬁcant decrease in the
MSSA infection rate which
predominantly in the hip
replacement group

A Randomized, Clinical Trial of Preadmission Chlorhexidine Skin Preparation for Lower Extremity Total Joint Arthroplasty. J Arthroplasty. 2016 Dec;31(12):2856-2861.
• A prospective, RCT, single center
of 582 patients undergoing hip or
knee arthroplasty
• compared 2% chlorhexidine
gluconateeimpregnated cloths to
standard-of-care antiseptic
bathing
• lower periprosthetic infection rate
was found in the chlorhexidine
cohort (0.4% vs 2.9%)

Screening and nasal decolonization

• dilute Betadine lavage of the surgical
wound before closure can decrease the
rate of postoperative infection
• small retrospective cohort (1862 cases)
showed significant decrease in the
infection rate following
implementation of the betadine lavage
protocol
• wound is soaked with 500 mL of the
dilute Betadine solution for 3 minutes,
followed by pulsatile lavage with 1 L of
0.9% NaCl
Dilute betadine lavage before closure for the prevention of acute postoperative deep periprosthetic joint infection. J Arthroplasty. 2012 Jan;27(1):27-30.

Intraoperative technical factors

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