Introduction: Despite exhaustive prophylactic measures, intra-operative contamination still occurs following cemented arthroplasty. We undertook a prospective study to identify the incidence of intra-operative deep wound contamination in cemented joint arthroplasty. Furthermore, we assessed the medium term incidence (at 4 years) of wound contamination in this patient cohort.

Materials & Methods: A total of 82 consecutive patients admitted for elective cemented arthroplasty were enrolled in the study over a 6 month period. Standard medical and dental work up was performed prior to admission to assess fitness for surgery. Pre-operative wound site preparation included Hibitane showers and painting and draping of the operative site in both the anaesthetic room and theatre. All cases were undertaken in an ultra-clean laminar airflow theatre and the surgical team wore isolation suits in all cases. Standard swabs from skin incision and deep in the wound were sent in addition to the blades and suction tip used. Cultures were typed by morphology and identified by standard techniques. A control swab was sent from all cases to exclude contamination occurring in the laboratory setting.

Results: A total of 82 patients were included in the study. Mean patient age was 67.4 years (36–85 years). Of the 82 procedures performed, 59 were total hip replacements and 23 total knee replacements. Five procedures were performed for revision arthroplasty (1 knee and 4 hips). 19 of the 82 cases (23%) examined grew contamination organisms with S. epidermidis being the commonest organism (16). In 16 cases a single specimen demonstrated contamination. 2 patients had 2 contaminated specimens and 1 had 3 contaminated specimens. No significant correlation between the duration of the case, number of personnel in theatre, or the seniority of the operating surgeon was demonstrated. On medium term follow up (mean 49.6 months, 95% CI 3.2 months) no patient had developed clinical evidence of infection.

Conclusion: We noted a high incidence of intra-operative contamination of cemented arthroplasties despite standard prophylaxis. However, this was not reflected by a similar rate of post-operative infection. This may be due to a small bacterial innoculum in each case or possibly may be due to the therapeutic effect of peri-operative intra-venous antibiotic prophylaxis.

Introduction: Since the introduction of joint arthroplasty major advances including the introduction of laminar airflow, have been made in reducing infection to current rates of 1 to 2%. Nonetheless infection remains a devastating complication, with major implications in terms of patient suffering, duration of hospital stay and financial burden. We undertook a study to examine the incidence of bacterial wound contamination occurring in the intra-operative period.

Materials and Methods: All patients admitted to our unit for elective hip and knee arthroplasty were entered into the study. On arrival in theatre a skin swab was taken. The patient was then prepared and draped in the anaesthetic room before final draping by the surgical team in the operating theatre. All procedures were performed in theatres equipped with laminar airflow, and all surgical personnel wore isolator suits. During the course of the procedure swabs were taken from the anterior aspect of the femur at 30-minute intervals. In addition the skin and inside blades and the suction tip were harvested at the end of the procedure. All samples were then sent for culture. Patient data including age, comorbid conditions and history of previous surgery were noted on a standardised pro forma. In addition, operative data including duration of the procedure, operating surgeon and type of drape and skin preparation used were noted.

Results: 65 patients have been examined to date. An incidence of contamination of 14% has been noted (9 patients) with the skin blade and suction tip being the most common source of contaminating organisms. Staphylococcus epidermis was cultured in 5 cases, with Gram negative organisms being cultured in the remaining samples. In all 9 cases only small numbers of organisms were identified. None of the patients with positive cultures developed clinical signs of deep or superficial wound sepsis, and all had an uncomplicated postoperative course.

Conclusions: While low levels of contamination are unavoidable in theatre, it is important that strict discipline be maintained in order to minimise this risk. In particular, careful attention to patient skin preparation, the use of prophylactic antibiotics and minimising use of the suction tubing help decrease contamination rates.