Preventing Periprosthetic Joint Infection

Javad Parvizi, Kevin McCoy
US Musculoskeletal Review, 2011;6(1):8-10
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Abstract

Total joint arthroplasty (TJA) is one of the most commonly performed orthopaedic operations today. While extremely successful in the majority of cases, perhaps the most feared complication of TJA is periprosthetic joint infection (PJI). PJI causes a substantial burden to the patient as well as a great economic strain to the healthcare system. It is imperative that orthopaedic surgeons take every step possible in order to minimize the chance of PJI. Topics requiring attention include: host optimization, skin decontamination, use of prophylactic antibiotics, the operating room environment, surgical set up and technique, and post-operative care. Pre-operative methicillin-resistant Staphylococcus aureus (MRSA) screening and decolonization has been receiving much research interest and could become a popular step in preventing PJI in the future. While there has been a substantial decline in the incidence of PJI, it is likely to remain an important problem in orthopaedics.
Keywords
Total joint arthroplasty, periprosthetic joint infection, prevention
Disclosure The authors have no conflicts of interest to declare.
Received: May 06, 2011 Accepted July 07, 2011
Correspondence: Javad Parvizi, MD, FRCS, Department of Orthopaedic Surgery, Rothman Institute of Orthopaedics, Thomas Jefferson University Hospital, 925 Chestnut St, Philadelphia, PA 19107. E: parvj@aol.com

Total joint arthroplasty (TJA) is one of the most commonly performed orthopaedic operations today. There were over 600,000 performed in the US in 2003, and that number is thought to now be over 1,000,000 per year.1

While extremely successful in the majority of patients, TJA is not without the risk for complications. Perhaps the most devastating is periprosthetic joint infection (PJI), seen in 1–2% of arthroplasties.2 Infection is the most common reason for revision knee arthroplasty,3–6 which inflicts a substantial burden on the patient and a great economic strain to the healthcare system.7–10

Undoubtedly, the best way to decrease the burden of infection is to prevent the infection from occurring. One of the most critical steps in prevention is recognition of the fact that most infections arise from contamination intraoperatively. Hence, multiple steps can be taken to minimize the chance of contamination throughout TJA surgery. By remaining cognizant of possible sources of contamination and taking all necessary precautions, the orthopaedic surgeon can minimize the chances of PJI after TJA. This article aims to share strategies for preventing PJI, including some of the authors’ own practices. It concludes with some exciting areas of research on the horizon.

Prevention Strategies
Host Optimization
Multiple associations and risk factors are known for PJI, including but not limited to: systemic malignancy, prior joint arthroplasty, rheumatoid arthritis, skin ulcers, obesity, recurrent urinary tract infections (UTIs), use of oral corticosteroids or immunosuppressive therapy, poor nutrition, hypokalemia, diabetes, and history of smoking.11–13 It is of utmost importance to optimize the factors that can be controlled prior to joint arthroplasty. This includes resolution of any possible nidus of infection such as superficial skin infections, ulcerations, periodontal disease, or existing UTI. In addition, our institution requires smoking cessation prior to surgery, as the effects of smoking on wound healing and infection are well-known.14

While is it known that diabetics are more prone to PJI, it is unclear if steps can be taken to decrease this risk. Is the infectious risk due to the long-term effects of hyperglycemia or to the more acute effects of perioperative hyperglycemia? Studies in other surgical disciplines are beginning to point towards the latter, with improved outcomes being obtained through strict control of perioperative blood glucose.15,16 In one study, tight glucose control was shown to decrease deep sternal wound infection rates in diabetics to the rates of non-diabetics in a cohort of diabetic patients undergoing cardiac surgery.15 This is an area that certainly warrants future investigation, specifically in joint arthroplasty patients. Regardless, it is clear that perioperative diabetic management is beneficial.

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