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Volume 03 / Issue 03 / September 2015
Page 50
JTO Peer-Reviewed Articles
Prevention of
Ramsay Refaie, Simon Jameson and Mike Reed
The Basis of the
Periprosthetic joint infection (PJI) can be a catastrophic When Charnley wrote about complication fol owing joint replacement surgery. The financial prosthetic joint infection in 1969 he stated there was "still costs and morbidity associated with PJI are wel established1-3 uncertainty as to how often with evidence now emerging that PJI is an independent risk a wound is infected in the operating room and how often factor for mortality4. Prevention is better than cure and whilst an at a later date during the healing exhaustive list is beyond the scope of this article we wil discuss of the wound"5. This same uncertainty still persists to this some offbeat tactics to consider in practice.
day. Contaminants may arise from the patient's skin, from the surgical personnel or from the surgical instrumentation itself 6, 7. It is likely that almost all surgical wounds are contaminated because skin preparation at the time of surgery will only decontaminate the skin surface and bacteria will remain in deeper layers of the skin8. Whilst it is also possible for infection to seed to the implant in haematogenous spread or so called "metastatic infection"9 this occurs less frequently. Gram-positive organisms are the most commonly reported with Staphylococcus aureus accounting for over a third of reported PJIs in England and Wales10. Broadly speaking prevention strategies target modifiable patient factors and peri-operative factors; these are summarised in Table 1. Many of these tactics are presented at open events with The Quality Improvement in Ramsay Refaie Simon Jameson Surgical Teams initiative11. Volume 03 / Issue 03 / September 2015
Page 51
2015 British Orthopaedic Association Journal of Trauma and Orthopaedics: Volume 03, Issue 03, pages 50-52
Title: Prevention of Periprosthetic Joint Infection Authors: Ramsay Refaie, Simon Jameson and Mike Reed Risk Factor
Proven strategies and
5% (p<0.001) in patients undergoing some food for thought
hip and knee arthroplasty17. Smoking cessation should be considered for al patients.
• Disease-modifying anti-rheumatic drugs MSSA screening and
(DMARDs) including methotrexate should be Patient warming
discussed with the prescriber • Peri-operative steroids are general y not required Methicil in Resistant Pre warming of patients before • Balance the risks and benefits of stopping anti- Staphylococcus aureus (MRSA) theatre is a proven strategy for TNF – stop at 3-5 half-lives pre-operatively, restart is the emotive "superbug" that preventing hypothermia intra- after wound healing and no evidence of infection every patient seems to fear. operatively and in recovery18, 19. Indeed MRSA infections have A large RCT from the UK published • Dietician input to encourage weight loss been shown to have significantly in the Lancet showed that pre • Adjust peri-operative antibiotic doses appropriately higher treatment costs than other warming reduced the risk of infection • In super-obese consider bariatric surgery prior to causal organisms of PJI12. MRSA by around 65% in clean surgery20. joint replacement surgery screening is now wel established Despite this pre warming is stil not • Consider a smoking cessation programme across the NHS with positive widely adopted in UK centres. results prompting decolonisation • Screening based on local guidelines, and prior to surgery. However, nasal Intra-operative warming is widely decolonise prior to surgery carriage of Methicil in sensitive performed but the method of Methicil in Sensitive organisms (MSSA) also confers intra-operative patient warming an increased risk of PJI. Carriage may also alter the risk of infection is common ( 20%)13 and during clean air surgery21. decolonisation presents us with Randomised studies have an easy "high yield" strategy in demonstrated that the popular the fight against PJI. A large, forced air warming devices interact Patient preparation • Shower on day of surgery randomised, placebo control ed with laminar air flow currents in • If hair removal required, use electric clippers on multi-centre trial published in the such a way that non-filtered air can New England Journal of Medicine be drawn from outside the clean • Avoid oil-based skin moisturisers in 2010 showed that decolonisation air canopy into the wound area22, 23. of MSSA carriers with mupirocin Our own switch to the alternative • Prophylactic antibiotics should be given as early nasal ointment and chlorhexidine conductive fabric warming led as possible in the anaesthetic room soap prior to orthopaedic and to a significant decrease in deep • If cementation is required, antibiotic-impregnated cardiothoracic surgery reduced infection rates22. These concepts cement should be used their risk of MSSA SSI by almost are best demonstrated in high • There is little consensus or evidence for which 60% from 7.7% to 3.4%13. This definition video ( antibiotic prophylaxis strategy has also been shown to be • Use laminar flow where possible cost effective14. Despite this, many • Keep theatre door opening to a minimum centres stil do not routinely screen Laminar flow and lights
for MSSA. After MSSA screening • Hand wash with antiseptic surgical solution, and decolonisation was introduced Historical evidence has shown using a single-use brush or pick for the nails in one NHS joint replacement that laminar flow in combination • Before subsequent operations hands should be unit, MSSA infections reduced with antibiotic prophylaxis washed with either an alcoholic hand rub or an from 0.84% to 0.26% - the caveat reduces infection rates in joint antiseptic surgical solution being there were other infection arthroplasty24. Recently however, • Use scrub staff assisted glove donning prevention methods implemented the benefit of laminar flow has • Double glove and change gloves regularly during the time period15. come into question10, 25, 26. • Use an alcohol pre-wash fol owed by a 2% chlorhexidine-alcohol scrub solution, or alcoholic Given the fragile nature of laminar betadine. Beware of fires air flow, we wanted to investigate Smokers are at increased risk the impact of popular suspended • Maintain normothermia of wound complications and theatre lights. In a series of • Maintain normovolaemia infections16. A randomised experiments using neutral y buoyant • A higher inspired oxygen concentration peri- control ed trial from Denmark, helium bubbles we evaluated the operatively and for 6 hours post-operative may published in the Lancet, has shown efficacy of laminar flow at clearing that cessation or at least 50% particles from the operative field reduction in smoking decreased looking specifical y at the impact Table 1: Summary table of common prevention tactics
wound complications from 31% to of lights. These experiments

Volume 03 / Issue 03 / September 2015
Page 52
JTO Peer-Reviewed Articles
are best viewed in high definition orthopodresearch). Perhaps PJI is catastrophic and every unsurprisingly we found that placing feasible step should be taken to lights directly above the operative prevent this. Whilst this article is field impairs the ability of the system not exhaustive it may encourage to clear airborne particles. Figure achievable strategies to reduce 1 shows the rate at which particles the incidence of PJI. were cleared from the operative field after one minute of fil ing with Ramsay Refaie is a Specialty bubbles. No lights, a single light Trainee in the Northern Deanery. and two lights over a mannequin He is currently on an out of knee (Figure 2) were evaluated. program experience for research at This provides further evidence for Newcastle University and is looking the intuitive interactions between Figure 1: Rate of bubble clearance
at novel diagnostic biomarkers in laminar air flow currents and objects Prosthetic joint infection. within it. Based on this the lead author has joined several others who Simon Jameson is currently Robin operate without suspended theatre Ling Hip Fellow at the Princess lights for knee replacement. Hugh Elizabeth Orthopaedic Centre in Howorth and Sir John Charnley Exeter. He trained on the Northern worked closely to develop the and Glasgow Orthopaedic optimal operating environment. rotations. He is a past NJR The original greenhouse used by research fellow with an MD Charnley contained two banks of thesis focused on outcomes after lights to il uminate the operative primary hip replacement. field27. Subsequent Howorth/Charnley theatre designs contained Mike Reed is an orthopaedic banks of lights outside the laminar surgeon for Northumbria flow canopy. The theatre picture Healthcare and a Senior Lecturer Figure 2: Knee mannequin with bubbles being introduced
of Wrightington Hospital (Figure with Newcastle University. He 3) clearly shows a bank of lights Chairs the Trust's Surgical Site outside the laminar flow enclosure. Infection Prevention Programme. Whilst this approach is not for everyone, an awareness of the potential interactions with laminar flow and attempts to minimise these should be encouraged.
Targeted antibiotic
The benefits of prophylactic antibiotics are widely accepted across most surgical specialties28, 29.
References can be found online at Figure 3: Old Theatre 1 at Wrightington Hospital
Prophylaxis is however not without risks and the potential reduction or by scanning the QR Code.
in SSIs must be balanced against in elective orthopaedic surgery with higher incidence of acute the adverse effects of antibiotics. (1.7 per 1000)30. A systematic kidney injury and no change Cephalosporins, once a panacea in review reported that there is in rates of PJI32-35. Elsewhere, our prophylactic armamentarium, insufficient evidence of a gentamicin alone has also been have fallen out of favour in the UK significant difference between shown to offer no benefit in terms largely due to their association with cephalosporins, teicoplanin or of reducing CDAD36. With all this Clostridium difficile associated penicillin derivatives31. In practice, confusion a large randomised trial diarrhoea (CDAD), despite this most prophylactic regimens are is required to best protect our representing a relatively minor now based on dual therapy yet patients undergoing primary joint these are frequently associated

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