Prevention of infection in orthopaedic joint replacement.
Abstract: Infection of a prosthetic joint is a significant adverse event, affecting the patient, the surgical team, and consuming hospital resources. The patient faces multiple operations, a prolonged hospital stay and a more challenging period of rehabilitation. The surgeon must perform longer and more technically demanding revision operations in order to remove the infected prosthesis, increasing the burden on hospital resources. It has been estimated that that the cost of managing an infected total hip replacement (THR) is four times greater than for a primary procedure (Dreghorn & Hamblen 1989). The personal cost to the patient must also be emphasised.
Subject: Joint replacement (Complications and side effects)
Surgical wound infections (Prevention)
Surgical wound infections (Risk factors)
Perioperative care (Methods)
Authors: Lindsay, William
Bigsby, Ewan
Bannister, Gordon
Pub Date: 06/01/2011
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2011 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: June, 2011 Source Volume: 21 Source Issue: 6
Accession Number: 272168021
Full Text: In his original series of THRs in 1964, Charnley reported post operative surgical site infection rates of 9.5% (Charnley 1964). Implementation of measures to reduce infection risk including: ventilation systems, theatre clothing, antibiotic prophylaxis and surgical technique, have significantly reduced infection rates. A combination of clean air, occlusive clothing and antibiotic prophylaxis reduced the deep infection rate after THR and total knee replacement (TKR) from 3.4% to 0.06% (Lidwell et al 1982). A 2005 UK study found a 3.1% incidence of surgical site infection following THR, with each event resulting in a mean increase in length of stay of 11.5 days and an increased cost of -3,542 (Coello et al 2005).

A foreign body within a joint increases the risk of infection. While 10,000 organisms are needed to infect a normal marrow cavity in an experimental model, only 50 are needed to cause an infection of a cemented THR (Southwood et al 1985). Even in a laminar flow ultraclean air theatre 29% of gloves, 14.5% of light handles, and 18% of gowns are contaminated by the end of the procedure (Hamilton & Jamieson 2008).

Prevention of Infection

The majority of prosthetic joints become infected from direct contamination of the surgical site, either during the operation or during wound healing, or much less frequently through haematogenous spread of bacteria from distant sites. A number of aspects are of importance perioperatively and can be considered as patient, theatre environment, theatre staff, and surgical factors.

Patient factors

Cessation of smoking, tight diabetic control (Vannini et al 1984) and stopping immunosuppressant drugs such as methotrexate and steroids (Bridges et al 1991) all reduce the risk of infection. The evidence on body mass index (BMI) is conflicting. In one study patients with a BMI greater that 35.5 were 2.5 times more likely to develop an infection than the control group (Jenkins et al. 2008). However, significantly malnourished patients are seven times more likely to develop a wound complication (Greene et al 1991).

Infection secondary to haematogenous spread is less common than direct local contamination, however its avoidance remains important. While there is no clear evidence to show that perioperative urinary tract infection (UTI) increases the risk of prosthetic joint infection (Koulouvaris 2009), given the presumed risk most surgeons withhold elective surgery until a UTI is treated. This is also true for other focal infections such as dental abscesses.

Postoperative urinary catheterisation is required to relieve urine retention and to aid in fluid balance monitoring and occurs in up to 62% of patients undergoing hip and knee arthroplasty (Walts et al 1985). Some surgeons are concerned that catheterisation increases the risk of post-operative surgical site infection. Wroblewski and Del Sel (1980) reported that of 195 patients who required catheterisation, 6.2% developed a deep implant sepsis, considerably higher than a similar uncatheterised group in a previous study which had a deep infection rate of 0.5%. However, in a randomised controlled trial no significant difference between infection rates of catheterised and uncatheterised groups was found (Michelson et al 1988). Furthermore, in a retrospective study of 949 hemiarthroplasties there was no significant difference in the rate of wound infection between patients who had and had not been catheterised (Cumming & Parker 2007). In a larger study of 2,621 hip arthroplasties, all of whom had urinary catheters placed pre-operatively or immediately post-operatively, only 23 (0.9%) developed a UTI and three developed a wound infection (0.11%) within three months of surgery. None of this group developed a postoperative UTI (Sharrock & Finerty 2005). Overall there is no strong evidence that urinary catheterisation results in higher rates of infection.

Theatre environment Air filtration systems

There is an association between bacterial counts in theatre air and the numbers of bacteria isolated from surgical wounds (Lidwell et al 1983).

Laminar flow ventilation comprises a continuous flow of highly filtered ultraclean air (UCA) of less than 10 colony-forming units per metre cubed (cfu/m3) of bacteria which is re-circulated under positive pressure into the operating field, with air contaminants generated during surgery being removed. It was pioneered by Charnley in the 1960s but its value became established following the MRC clinical trial conducted by Lidwell et al (1982) in the late 1970s which compared postoperative deep and superficial infection rates in conventional and laminar flow operating theatres. The study demonstrated that the lower airborne bacterial count (22 times) seen in laminar flow theatres was associated with a 50% reduction in infection rates. Antibiotic prophylaxis was used concurrently in some cases and although this variable was not randomised it was analysed as a secondary outcome measure. It was found to be equally as effective as laminar flow in reducing infection.

Several subsequent large trials which controlled better for the use of antibiotic prophylaxis have not demonstrated a significant difference in infection rates in theatres using traditional ventilation and laminar flow (Marotte et al 1987, Fitzgerald 1992). This has lead to the conclusion that prophylactic antibiotics may be the single most important factor in preventing infection following arthroplasty.

Ultra violet light

Ultra violet light (UVC) in theatres produces UCA and has comparable results to air filtration systems in reducing wound infection rates (Berg et al 1991). It is a less expensive alternative, but the need to protect both patient and theatre staff from this potentially harmful radiation limits its practicality.

Body exhaust suits

Body exhaust suits in conjunction with laminar flow theatres have been advocated by several authors. Lidwell et al (1982) reported a reduction in infection rates from 1.6% to 0.9% with exhaust suits but no antibiotics. The infection rate decreased further to 0.06% with the addition of antibiotics. However, body exhaust suits have the disadvantage of discomfort and expense, and modern polyester gowns and balaclava type hats produced similar reductions in bacterial shedding from theatre personnel as exhaust suits (Whyte et al 1983, Hubble et al 1996).

Theatre practice Skin preparation

Pre-operative showering with chlorhexidine wash results in 64% relative risk reduction (risk ratio 0.36, 95% CI 0.17 to 0.79) of surgical site infection (Wihlborg 1987) but a recent systematic review of trials involving over 10,000 patients found no difference between showering with chlorhexidine, soap, or with water alone (Webster & Osbourne 2007).

Preoperative hair removal at the surgical site can be a potential source of infection. Wet shaving, clipping and depilatory creams all produce less skin excoriation and subsequently fewer infections than dry shaving. Dry shaving the night before is associated with the highest risk of infection (Serodian & Reynolds 1971).

Preoperative skin cleansing of the surgical site with antiseptic solutions has been shown to reduce the incidence of surgical site infection. A recent prospective, randomized study, involving 849 patients by Darouiche et al (2010) showed that skin cleansing with chlorhexidine-alcohol is superior to cleansing with povidone-iodine for preventing surgical site infection.

Patients' jewelry

While it is clear that any jewelry within the surgical field should be removed, there is no clear evidence in the literature to guide the management of jewelry at sites outside the surgical field. Rings should be taped to a patient's fingers, to prevent loss rather than to control infection, but must be removed from the hand undergoing surgery as postoperative swelling will cause a ring to act as a tourniquet.

Theatre personnel

The number of theatre personnel should be kept to a minimum. Healthy subjects are heavily contaminated with bacteria. These organisms are scattered into the air in many ways: sneezing disperses 39,000 organisms, coughing 710, and speaking 36 organisms per minute (Lidwell et al 1982).

Clothing

Traditional cotton fabrics have an average pore size of 80 m and provide no barrier to skin squames. Modern theatre gowns made from polyester have a pore size approaching 0.2 m, which represents a 1,000 fold improvement in their efficiency as barriers to bacteria. Polyester gowns have a maximum life of 70 washing cycles and should be discarded after this time.

Face masks reduce infection rates by deflecting bacteria from the respiratory system away from the surgical field. They are 95% effective as barriers, but once they become damp, bacteria can translocate through the mask (Mitchell & Hunt 1991). Masks should therefore be changed after each case.

It has been suggested that the areas of the face left exposed by standard theatre clothing present a significant source of bacteria which can potentially contaminate the wound. While exhaust helmets offer a potential solution to this problem, it is suggested that ears should at least be covered by theatre hats, as when left exposed, particularly if pierced, they are a significant potential source of shedding and hence wound contamination (Owers et al 2004).

Handwashing

Hand washing with 4% chlorhexidine reduces contamination by 80%. The optimum duration of 'scrubbing' is two minutes and there is no benefit in washing for longer (O'Saughnessy et al 1991). Rings are associated with higher bacterial counts on the skin under and adjacent to them. When rings are removed, bacterial counts are reduced with scrubbing but remain higher than on the skin of adjacent fingers or the opposite hand (Kelsall et al 2006). Nose and ear piercings shed more bacteria when removed than left in-situ (Bartlett et al 2002).

Gloves

Twenty nine percent of gloves are contaminated after draping the patient (Lidwell et al 1982) so double gloving and glove changes after draping should be common practice.

The frequency of surgical site infection after glove perforation increases from 1.7% to 5.7% (Cruse & Foord 1973). During arthroplasty 50 to 67% of surgical gloves are perforated (Lankaster et al 2002), double gloving reduces this incidence by between three to nine times (Sandiford & Skinner 2009).

Surgical technique Prophylactic antibiotics

Antibiotic prophylaxis is routinely used to prevent infections in orthopaedic surgery. This is delivered in two ways: perioperative doses of antibiotics are given and antibiotic impregnated cement is used for cemented components. The effectiveness of antibiotic prophylaxis was first established by Burke's classic experiment on guinea pig skin which showed that antibiotics were most effective if given prior to the initial incision (Burke 1961). Numerous subsequent studies have supported the use of prophylactic antibiotics, with a recent large meta-analysis suggesting that antibiotic prophylaxis reduces the absolute risk of infection by 8% and the relative risk by 81% (Al Buhairian et al 2008).

A range of different antibiotics and administration regimens are used in different hospitals reflecting different local microbiology protocols. The selection of appropriate antibiotics is important. One study showed that up to 50% of wound isolates from hip arthroplasty were resistant to cefuroxime, which is commonly used for prophylaxis, and by inference resistant to other beta-lactam antibiotics (Al Maiyah et al 2005).

It is generally accepted that multiple doses are needed, as a single dose is almost certainly inadequate for bone (Bannister 2002). The initial dose of antibiotic should be given at least 15 minutes prior to inflation of the tourniquet to allow infiltration of the operative site (Bannister et al 1988).

Duration of surgery

The duration of surgery correlates with infection rate, which increases from 2.6% for procedures lasting up to one hour, to 4.9% for those between one and two hours long, to 8.5% for those lasting more than three hours (Pavel et al 1974).

Lavage

Saline pulsatile lavage significantly decreases infection rates from 15.6% to 5.5% when compared with traditional washout with jugs of saline (Hargrove et al 2006). While many surgeons advocate the use of chlorhexidine or iodine washes there is no level one evidence supporting their use and antiseptics may kill healthy cells on the wound surfaces, impairing the local immune response. However, there is in vitro evidence demonstrating that 0.05% chlorhexidine reduces wound contamination. 1% iodine is not effective and the 5% solution that is effective causes tissue toxicity (Taylor et al 1993).

Published Guidance

Specific guidance on measures to prevent infection in orthopaedic joint replacement surgery is lacking and practice is largely led by local operating polices.

The National Institute for Health and Clinical Excellence has published guidance on the prevention and treatment of surgical site infection (NICE 2008). Although not specific to joint replacement surgery, this guidance provides best practice advice on preventing surgical site infection. Of particular note, the guidance stresses the importance of postoperative wound care and involvement of specialist tissue viability services.

Guidance specific to joint replacement surgery is provided by the British Orthopaedic Association in their Guide to Good Practice (BOA 1999). The document highlights that post-operative infection is a catastrophic event. It recommends clear local protocols for sterile theatre practice and that antibiotic regimens are established in conjunction with local microbiologists. The document also states that the combination of systemic antibiotics, antibiotic-impregnated cement, ultra-clean air theatre ventilation and body exhaust suits is felt to provide the most effective infection prophylaxis.

Summary

Prosthetic joint infection is catastrophic for the patient, surgeon, and the health system. While advances in revision surgery are helping to reduce the long term impact on the patient, prevention is clearly of foremost importance. Antibiotic prophylaxis is of great importance but constitutes a Faustian pact with emerging bacterial resistance, and a wide number of barrier methods by all members of the surgical team are essential in decreasing the incidence of infection. The Health Protection Agency's recent report on the mandatory surveillance of surgical site infection in orthopaedic surgery (HPA 2010) shows a significant decline in surgical site infection rates since surveillance began in 2004. This encouraging report highlights that new preventative measures are continuing to improve results, with 1 in 100 patients developing a surgical site infection following hip prosthesis surgery, and only 1 in 200 following knee prosthesis surgery in the 154 NHS trusts surveyed in England in 2009/10.

No competing interests declared

Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication March 2011.

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Correspondence address: William Lindsay, Northern General Hospital, Herries Road, Sheffield, S5 7AU. Email: william.lindsay@sth.nhs.uk

About the authors

William Lindsay BMBCh

Trauma and Orthopaedic Surgery House Officer, Frenchay Hospital, Bristol

Ewan Bigsby MRCS, DPhil

Senior House Officer Trauma and Orthopaedic Surgery, Frenchay Hospital, Bristol

Gordon Bannister MD, MCh Orth, FRCS

Professor of Orthopaedic Surgery, Avon Orthopaedic Centre, Southmead Hospital, Bristol
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