The Rothman Institute at Thomas Jefferson University
Prosthetic joint infection (PJI) is a calamitous complication with high morbidity and substantial cost. The reported incidence is low but it is probably underestimated due to the difficulty in diagnosis. PJI has challenged the orthopaedic community for several years and despite all the advances in this field, it is still a real concern with immense impact on patients, and the healthcare system. Eradication of infection can be very difficult. Therefore, prevention remains the ultimate goal. The medical community has executed many practices with the intention to prevent infection and treat it effectively when it encounters. Numerous factors can predispose patients to PJI. Identifying the host risk factors, patients’ health modification, proper wound care, and optimizing operative room environment remain some of the core fundamental steps that can help minimizing the overall incidence of infection. In this review we have summarized the effective prevention strategies along with the recommendations of a recent International Consensus Meeting on Surgical Site and Periprosthetic Joint Infection.
Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780–5.
Bozic KJ, Kurtz SM, Lau E, Ong K, Chiu V, Vail TP, et al. The Epidemiology of Revision Total Knee Arthroplasty in the United States.Clin Orthop Relat Res. 2010;468(1):45-51.
Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am. 2009;91(1):128-33.
Clohisy JC, Calvert G, Tull F, McDonald D, Maloney WJ. Reasons for revision hip surgery: a retrospective review. Clin Orthop Relat Res. 2004;(429):188-92.
Vessely MB, Whaley AL, Harmsen WS, Schleck CD, Berry DJ. The Chitranjan Ranawat Award: Long-term survivorship and failure modes of 1000 cemented condylar total knee arthroplasties.Clin Orthop Relat Res. 2006;452:28-34.
Della Valle C, Parvizi J, Bauer TW, Dicesare PE, Evans RP, Segreti J, et al. Diagnosis of periprosthetic joint infections of the hip and knee. J Am Acad Orthop Surg. 2010;18(12):760-70.
Parvizi J, Adeli B, Zmistowski B, Restrepo C, Greenwald AS. Management of periprosthetic joint infection: the current knowledge: AAOS exhibit selection. J Bone Joint Surg Am. 2012;94(14):104.
Della Valle C, Parvizi J, Bauer TW, DiCesare PE, Evans RP, Segreti J, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on: the diagnosis of periprosthetic joint infections of the hip and knee. J Bone Joint Surg Am. 2011;93(14):1355-7.
Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty. 2012;27:61-5.
Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ, et al. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res. 2011;469(11):2992-4.
Proceedings of the International Consensus Meeting on Periprosthetic Joint Infection. Foreword. J Orthop Res. 2014;32:2-3.
Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. 2004;351(16):1645–54.
Fitzgerald RH Jr, Nolan DR, Ilstrup DM, Van Scoy RE, Washington JA 2nd, Coventry MB. Deep wound sepsis following total hip arthroplasty. J Bone Joint Surg Am. 1977;59(7):847–55.
Tsukayama DT, Estrada R, Gustilo RB. Infection after total hip arthroplasty. A study of the treatment of one hundred and six infections. J Bone Joint Surg Am. 1996;78(4):512-23.
Zimmerli W, Moser C. Pathogenesis and treatment concepts of orthopaedic biofilm infections. FEMS Immunol Med Microbiol. 2012;65(2):158-68.
Maderazo EG, Judson S, Pasternak H. Late infections of total joint prostheses. A review and recommendations for prevention. Clin Orthop Relat Res. 1988;(229):131-42.
Sendi P, Banderet F, Graber P, Zimmerli W. Clinical comparison between exogenous and haematogenous periprosthetic joint infections caused by Staphylococcus aureus. Clin Microbiol Infect. 2011; 17(7):1098-100.
Pulido L, Ghanem E, Joshi A, Purtill JJ, Parvizi J. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res. 2008;466(7):1710-5.
Garvin KL, Konigsberg BS. Infection following total knee arthroplasty: prevention and management. Instr Course Lect. 2012;61:411-9.
Bozic KJ, Lau E, Kurtz S, Ong K, Berry DJ. Patient-related risk factors for postoperative mortality and periprosthetic joint infection in medicare patients undergoing TKA. Clin Orthop Relat Res. 2012; 470(1):130-7.
Malinzak RA, Ritter MA, Berend ME, Meding JB, Olberding EM, Davis KE. Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates. J Arthroplasty. 2009;24:84-8.
Fletcher N, Sofianos D, Berkes MB, Obremskey WT. Prevention of perioperative infection. J Bone Joint Surg Am. 2007;89(7):1605-18.
Buller LT, Sabry FY, Easton RW, Klika AK, Barsoum WK. The preoperative prediction of success following irrigation and debridement with polyethylene exchange for hip and knee prosthetic joint infections. J Arthroplasty. 2012;27(6):857-64.
Jämsen E, Huhtala H, Puolakka T, Moilanen T. Risk factors for infection after knee arthroplasty. A register-based analysis of 43,149 cases. J Bone Joint Surg Am. 2009;91(1):38-47.
Jämsen E, Nevalainen P, Eskelinen A, Huotari K, Kalliovalkama J, Moilanen T. Obesity, diabetes, and preoperative hyperglycemia as predictors of periprosthetic joint infection: a single-center analysis of 7181 primary hip and knee replacements for osteoarthritis. J Bone Joint Surg Am. 2012; 94(14):101.
Lai K, Bohm ER, Burnell C, Hedden DR. Presence of medical comorbidities in patients with infected primary hip or knee arthroplasties. J Arthroplasty. 2007;22(5):651-6.
Marchant MH Jr, Viens NA, Cook C, Vail TP, Bolognesi MP. The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. J Bone Joint Surg Am. 2009; 91(7):1621-9.
Mraovic B, Suh D, Jacovides C, Parvizi J. Perioperative hyperglycemia and postoperative infection after lower limb arthroplasty. J Diabetes Sci Technol. 2011;5(2):412-8.
Kamal T, Conway RM, Littlejohn I, Ricketts D. The role of a multidisciplinary pre-assessment clinic in reducing mortality after complex orthopaedic surgery. Ann R Coll Surg Engl. 2011;93(2):149-51.
Aggarwal VK, Tischler EH, Lautenbach C, Williams GR, Abboud JA, Altena M, et al. Mitigation and Education. J Arthroplasty. 2014;29(2):19–25.
Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control. 1999;27(2):97–132; quiz 133–4; discussion 96.
Rao N, Cannella B, Crossett LS, Yates AJ Jr, McGough R 3rd. A preoperative decolonization protocol for staphylococcus aureus prevents orthopaedic infections. Clin Orthop Relat Res. 2008;466(6):1343-8.
Bleasdale SC, Trick WE, Gonzalez IM, Lyles RD, Hayden MK, Weinstein RA. Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients. Arch Intern Med. 2007;167(19):2073-9.
Climo MW, Sepkowitz KA, Zuccotti G, Fraser VJ, Warren DK, Perl TM, et al. The effect of daily bathing with chlorhexidine on the acquisition of methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and healthcare-associated bloodstream infections: results of a quasi-experimental multicenter trial. Crit Care Med. 2009;37(6):1858-65.
Rao N, Cannella BA, Crossett LS, Yates AJ Jr, McGough RL 3rd, Hamilton CW. Preoperative screening/decolonization for Staphylococcus aureus to prevent orthopedic surgical site infection: prospective cohort study with 2-year follow-up. J Arthroplasty. 2011;26(8):1501-7.
Darouiche RO, Wall MJ Jr, Itani KMF, Otterson MF, Webb AL, Carrick MM, et al. Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. N Engl J Med. 2010;362(1):18–26.
Hidron AI, Edwards JR, Patel J, Horan TC, Sievert DM, Pollock DA, et al. NHSN annual update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006-2007. Infect Control Hosp Epidemiol. 2008; 29(11):996-1011.
Ramos N, Skeete F, Haas JP, Hutzler L, Slover J, Phillips M, et al. Surgical site infection prevention initiative - patient attitude and compliance. Bull NYU Hosp Jt Dis. 2011;69(4):312-5.
Tokarski AT, Blaha D, Mont MA, Sancheti P, Cardona L, Cotacio GL, et al. Perioperative skin preparation. J Arthroplasty. 2014;29:26–8.
Fogelberg EV, Zitzmann EK, Stinchfield FE. Prophylactic penicillin in orthopaedic surgery. J Bone Joint Surg Am. 1970;52(1):95-8.
Pavel A, Smith RL, Ballard A, Larsen IJ. Prophylactic antibiotics in clean orthopaedic surgery. J Bone Joint Surg Am. 1974;56(4):777–82.
Meehan J, Jamali AA, Nguyen H. Prophylactic antibiotics in hip and knee arthroplasty. J Bone Joint Surg Am. 2009;91(10):2480-90.
Mauerhan DR, Nelson CL, Smith DL, Fitzgerald RH Jr, Slama TG, Petty RW, et al. Prophylaxis against infection in total joint arthroplasty. One day of cefuroxime compared with three days of cefazolin. J Bone Joint Surg Am. 1994;76(1):39–45.
Van Kasteren MEE, Manniën J, Ott A, Kullberg B-J, de Boer AS, Gyssens IC. Antibiotic prophylaxis and the risk of surgical site infections following total hip arthroplasty: timely administration is the most important factor. Clin Infect Dis. 2007;44(7):921-7.
Hansen E, Belden K, Silibovsky R, Vogt M, Arnold WV, Bicanic G, et al. Perioperative antibiotics. J Arthroplasty. 2014;29(2 Suppl):29–48.
Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev. 2011;(11):CD004122.
Lee J, Singletary R, Schmader K, Anderson DJ, Bolognesi M, Kaye KS. Surgical site infection in the elderly following orthopaedic surgery. Risk factors and outcomes. J Bone Joint Surg Am. 2006; 88(8):1705-12.
Prokuski L. Prophylactic antibiotics in orthopaedic surgery. J Am Acad Orthop Surg. 2008;16(5):283-93.
Von Eiff C, Becker K, Machka K, Stammer H, Peters G. Nasal carriage as a source of Staphylococcus aureus bacteremia. Study Group. N Engl J Med. 2001; 344(1):11-6.
Edwards PS, Lipp A, Holmes A. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database Syst Rev. 2004;(3):CD003949.
Ostrander RV, Brage ME, Botte MJ. Bacterial skin contamination after surgical preparation in foot and ankle surgery. Clin Orthop Relat Res. 2003;(406):246-52.
Keblish DJ, Zurakowski D, Wilson MG, Chiodo CP. Preoperative skin preparation of the foot and ankle: bristles and alcohol are better. J Bone Joint Surg Am. 2005;87(5):986-92.
Ostrander RV, Botte MJ, Brage ME. Efficacy of surgical preparation solutions in foot and ankle surgery. J Bone Joint Surg Am. 2005;87(5):980-5.
Tanner J, Swarbrook S, Stuart J. Surgical hand antisepsis to reduce surgical site infection. Cochrane Database Syst Rev. 2008;(1):CD004288.
Larson EL, Butz AM, Gullette DL, Laughon BA. Alcohol for surgical scrubbing? Infect Control Hosp Epidemiol. 1990;11(3):139-43.
Katthagen BD, Zamani P, Jung W. Effect of surgical draping on bacterial contamination in the surgical field. Z Orthop Ihre Grenzgeb. 1992 ;130(3):230-5.
French ML, Eitzen HE, Ritter MA. The plastic surgical adhesive drape: an evaluation of its efficacy as a microbial barrier. Ann Surg. 1976;184(1):46–50.
Johnston DH, Fairclough JA, Brown EM, Morris R. Rate of bacterial recolonization of the skin after preparation: four methods compared. Br J Surg. 1987; 74(1):64.
Blom AW, Gozzard C, Heal J, Bowker K, Estela CM. Bacterial strike-through of re-usable surgical drapes: the effect of different wetting agents. J Hosp Infect. 2002;52(1):52-5.
Blom A, Estela C, Bowker K, MacGowan A, Hardy JR. The passage of bacteria through surgical drapes. Ann R Coll Surg Engl. 2000;82(6):405-7.
Ritter MA, Campbell ED. Retrospective evaluation of an iodophor-incorporated antimicrobial plastic adhesive wound drape. Clin Orthop Relat Res. 1988; (228):307-8.
Jacobson C, Osmon DR, Hanssen A, Trousdale RT, Pagnano MW, Pyrek J, et al. Prevention of wound contamination using DuraPrep solution plus Ioban 2 drapes. Clin Orthop Relat Res. 2005;439:32-7.
Webster J, Alghamdi AA. Use of plastic adhesive drapes during surgery for preventing surgical site infection. Cochrane Database Syst Rev. 2007; (4):CD006353.
Alijanipour P, Karam J, Llinás A, Vince KG, Zalavras C, Austin M, et al. Operative environment. J Orthop Res. 2014;32:60-80.
Guo YP, Wong PM, Li Y, Or PPL. Is double-gloving really protective? A comparison between the glove perforation rate among perioperative nurses with single and double gloves during surgery. Am J Surg. 2012;204(2):210-5.
Tanner J, Parkinson H. Double gloving to reduce surgical cross-infection. Cochrane Database Syst Rev. 2002;(3):CD003087.
Ersozlu S, Sahin O, Ozgur AF, Akkaya T, Tuncay C. Glove punctures in major and minor orthopaedic surgery with double gloving. Acta Orthop Belg. 2007; 73(6):760-4.
Carter AH, Casper DS, Parvizi J, Austin MS. A prospective analysis of glove perforation in primary and revision total hip and total knee arthroplasty. J Arthroplasty. 2012;27(7):1271-5.
Demircay E, Unay K, Bilgili MG, Alataca G. Glove perforation in hip and knee arthroplasty.J Orthop Sci. 2010;15(6):790-4.
Sutton PM, Greene T, Howell FR. The protective effect of a cut-resistant glove liner. A prospective, randomised trial. J Bone Joint Surg Br. 1998; 80(3):411-3.
Pieper SP, Schimmele SR, Johnson JA, Harper JL. A prospective study of the efficacy of various gloving techniques in the application of Erich arch bars. J Oral Maxillofac Surg. 1995; 53(10):1174-6
Parvizi J, Saleh KJ, Ragland PS, Pour AE, Mont MA. Efficacy of antibiotic-impregnated cement in total hip replacement. Acta Orthop. 2008;79(3):335-41.
Engesaeter LB, Lie SA, Espehaug B, Furnes O, Vollset SE, Havelin LI. Antibiotic prophylaxis in total hip arthroplasty: effects of antibiotic prophylaxis systemically and in bone cement on the revision rate of 22,170 primary hip replacements followed 0-14 years in the Norwegian Arthroplasty Register. Acta Orthop Scand. 2003;74(6):644-51.
Bohm E, Zhu N, Gu J, de Guia N, Linton C, Anderson T, et al. Does adding antibiotics to cement reduce the need for early revision in total knee arthroplasty? Clin Orthop Relat Res. 2014;472(1):162-8.
Namba RS, Inacio MCS, Paxton EW. Risk factors associated with deep surgical site infections after primary total knee arthroplasty: an analysis of 56,216 knees. J Bone Joint Surg Am. 2013;95(9):775–82.
Citak M, Argenson J-N, Masri B, Kendoff D, Springer B, Alt V, et al. Spacers. J Arthroplasty. 2014;29:93–9.
Koval KJ, Rosenberg AD, Zuckerman JD, Aharonoff GB, Skovron ML, Bernstein RL, et al. Does blood transfusion increase the risk of infection after hip fracture? J Orthop Trauma. 1997;11(4):260-5; discussion 265-6.
Innerhofer P, Klingler A, Klimmer C, Fries D, Nussbaumer W. Risk for postoperative infection after transfusion of white blood cell-filtered allogeneic or autologous blood components in orthopedic patients undergoing primary arthroplasty. Transfusion. 2005; 45(1):103-10.
Spahn DR. Anemia and patient blood management in hip and knee surgery: a systematic review of the literature. Anesthesiology. 2010;113(2):482-95.
Alshryda S, Sarda P, Sukeik M, Nargol A, Blenkinsopp J, Mason JM. Tranexamic acid in total knee replacement: a systematic review and meta-analysis. J Bone Joint Surg Br. 2011;93(12):1577-85.
Yang ZG, Chen WP, Wu LD. Effectiveness and safety of tranexamic acid in reducing blood loss in total knee arthroplasty: a meta-analysis. J Bone Joint Surg Am. 2012;94(13):1153-9.
Gastmeier P, Breier A-C, Brandt C. Influence of laminar airflow on prosthetic joint infections: a systematic review. J Hosp Infect. 2012;81(2):73-8.
Ong KL, Lau E, Manley M, Kurtz SM. Effect of procedure duration on total hip arthroplasty and total knee arthroplasty survivorship in the United States Medicare population. J Arthroplasty. 2008;23:127-32.
Urquhart DM, Hanna FS, Brennan SL, Wluka AE, Leder K, Cameron PA, et al. Incidence and risk factors for deep surgical site infection after primary total hip arthroplasty: a systematic review. J Arthroplasty. 2010;25(8):1216-22.
Muilwijk J, van den Hof S, Wille JC. Associations between surgical site infection risk and hospital operation volume and surgeon operation volume among hospitals in the Dutch nosocomial infection surveillance network. Infect Control Hosp Epidemiol. 2007;28(5):557-63.
Andersson AE, Bergh I, Karlsson J, Eriksson BI, Nilsson K. Traffic flow in the operating room: an explorative and descriptive study on air quality during orthopedic trauma implant surgery. Am J Infect Control. 2012;40(8):750-5.
Salvati EA, Robinson RP, Zeno SM, Koslin BL, Brause BD, Wilson PD Jr. Infection rates after 3175 total hip and total knee replacements performed with and without a horizontal unidirectional filtered air-flow system. J Bone Joint Surg Am. 1982;64(4):525-35.
Young RS, O’Regan DJ. Cardiac surgical theatre traffic: time for traffic calming measures? Interact Cardiovasc Thorac Surg. 2010;10(4):526-9.
Davis N, Curry A, Gambhir AK, Panigrahi H, Walker CR, Wilkins EG, et al. Intraoperative bacterial contamination in operations for joint replacement. J Bone Joint Surg Br. 1999;81(5):886-9.
Givissis P, Karataglis D, Antonarakos P, Symeonidis P, christodoulou A. Suction during orthopaedic surgery. How safe is the suction tip ? Acta Orthop Belg. 2008; 74(4):531-3.
Greenough CG. An investigation into contamination of operative suction. J Bone Joint Surg Br. 1986; 68(1):151-3.
Insull PJ, Hudson J. Suction tip: a potential source of infection in clean orthopaedic procedures. ANZ J Surg. 2012;82(3):185-6.
Mulcahy DM, McCormack D, McElwain JP. Intraoperative suction catheter tip contamination. J R Coll Surg Edinb. 1994;39(6):371-3.
Beldame J, Lagrave B, Lievain L, Lefebvre B, Frebourg N, Dujardin F. Surgical glove bacterial contamination and perforation during total hip arthroplasty implantation: when gloves should be changed. Orthop Traumatol Surg Res. 2012;98(4):432-40.
American Academy of Orthopedic Surgeons. AAOS clinical practice guideline: Prevention of orthopaedic implant infection in patients undergoing dental procedures [Internet]. [cited 2014 Jan 28]. Available from: http://www.aaos.org/research/guidelines/PUDP/PUDP_guideline.pdf
Chen A, Haddad F, Lachiewicz P, Bolognesi M, Cortes LE, Franceschini M, et al. Prevention of late PJI. J Arthroplasty. 2014;29:119-28.