Aim. Debridement, Antibiotics, Irrigation, and implant Retention (DAIR) is a surgical treatment protocol suitable for some patients with fracture related infection (FRI). Clinically relevant pre-clinical models of DAIR are scarce and none have been developed in large animals. Therefore, this project aimed to develop a large animal model for FRI including a DAIR approach and compare outcomes after 2 or 5 weeks of infection. Method. Swiss Alpine sheep (n=8), (2–6 years, 50–80 kg) were included in this study. This study was approved by cantonal Ethical authorities in Chur, Switzerland. A 2 mm osteotomy was created in the tibia and fixed with a 10-hole 5.5 mm steel plate. Subsequently, 2.5 mL of saline solution containing 10. 6. CFU/mL of Staphylococcus aureus MSSA (ATCC 25923) was added over the plate. Sheep were observed for 2 (n=3) or 5 weeks (n=5) until revision surgery, during which visibly infected or necrotic tissues were removed, and the wound flushed with saline. All samples were collected for bacterial quantification. After revision surgery, the sheep were treated systemically for 2 weeks with flucloxacillin and for 4 weeks with rifampicin and cotrimoxazole. After 2 further weeks off antibiotics, the animals were euthanized. Bacteriological culture was performed at the end of the study. Bone cores were isolated from the osteotomy site and processed for Giemsa & Eosin and Brown and Brenn staining. A radiographical examination was performed every second week. Results. Bacteriological evaluation of the retrieved samples during revision surgery showed no significant difference between the 2 vs 5 weeks infection periods in term of total CFU counts. At the end of the study, radiographical examination showed callus formation over the osteotomy site in both groups, although the osteotomy was not completely healed in either group. At euthanasia, the 2 weeks infection group showed a higher soft tissue burden compared to the 5 weeks group, whereby the infection in the 5 weeks group was primarily located in the bone and bone marrow. Conclusions. The large animal model of FRI and DAIR was successfully established. Bacteriological outcomes highlight that the increasing duration of the infection does not change the outcome but the location of the infection from a predominantly soft tissue infection to a deeper bone and intramedullary (IM) channel infection. The debridement of the IM channel could potentially reduce the infection burden by eliminating those bacteria not easily reached by systemic antibiotics, though is not practical using conventional techniques

Aim. Irrigation and debridement with an irrigation solution are essential components of the surgical management of acute and chronic periprosthetic joint infection (PJI). Nevertheless, there is a lack of agreement regarding the most effective solution to use. The aim of the study was to perform a systematic review and meta-analysis of the current literature concerning the efficacy of different irrigation solutions over bacterial biofilm. Method. This study was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Network meta-analysis (PRISMA-NMA) checklist for systematic reviews and meta-analyses. A comprehensive literature search of PubMed, Cochrane Library, Web of Science and Scopus databases from inception to September 1, 2023. We combined terms related to PJI, biofilm and irrigation solutions studied in vitro. We performed a network meta-analysis to analyze which irrigation solution achieved a higher reduction of colony forming units (CFU) after specific exposure times, always with a maximum of five minutes, replicating intraoperative conditions. Effect-size was summarized with logarithmic response ratio (logRR) and 95% confidence intervals (95% CI). The rank probability for each treatment was calculated using the p-scores. Results. We screened 233 potential sources. Following deduplication, screening and full-text review, four studies with ten irrigation solutions for different duration of exposures were included, always less than five minutes, replicating intraoperative conditions. Solutions were studied over mature biofilms of most frequent bacteria grown over metal, bone cement or polyethylene surfaces. The highest effect was achieved with povidone iodine 10% during 5 minutes (logRR: −12.02; 95% CI: −14.04, −9.99). The best ranked solutions were povidone iodine 10% during five, three and one minute (respective p-scores: 0.977, 0.932, 0.887) and its combination with hydrogen peroxide for 3 minutes (p-score: 0.836). Povidone iodine 0.3% acting for 5 minutes completed the top 5 best ranked solutions in this study (p-score: 0.761). We assumed that there were no inconsistencies in our network because after examining both scenarios, with and without inconsistencies, the results were not significantly different. Conclusions. Our results show that 10% povidone-iodine is the best antiseptic solution when studied in vitro in the context of prosthetic joint infection. However, the included studies did not evaluate the possible cytotoxic effects of these solutions. This should also be taken into account before choosing the most appropriate antiseptic solution

We present the first systematic review conducted by the UK Defence Medical Services in conjunction with the Cochrane Collaboration. Irrigation fluids are used to remove contamination during the surgical treatment of traumatic wounds in order to prevent infection. This review aims to determine whether there is evidence that one wound irrigation fluid is superior to another at reducing infection. A pre-published methodology was used and two reviewers independently assessed the search results. The search produced 917 studies, of which three met the inclusion criteria. All were studies in open fractures, incorporating a total of 2,903 patients. Each RCT involved a distinct comparison, precluding meta-analysis: i) sterile saline vs. distilled/boiled water; ii) antibiotic solution vs. soap solution; iii) saline vs. soap solution. The odds ratios of infection following irrigation with various fluids was as follows: i) saline vs. distilled or boiled water 0.25 (95%CI 0.08–0.73); ii) antibiotic solution vs. soap 1.42 (95%CI 0.82–2.46); iii) saline vs. soap solution 1.00 (95%CI 0.80–1.26). These results suggest that neither soap nor antibiotic solution is superior to saline and that saline is inferior to distilled or boiled water

Historical perspective: Irrigation and debridement (I&D) with modular exchange has historically been the recommended treatment for acute post-operative periprosthetic joint infection (PJI), and acute hematogenous PJI. The theory supporting this practice was that because the bacterial glycocalyx had not yet formed by these early time points, by simply debriding the intra-articular bacterial load and exchanging the modular parts, one could potentially eradicate the infection, retain the prior components, and minimise morbidity to the patient. More recently, literature is coming out suggesting that this may not necessarily be the case. The vast majority of published research on the outcomes following I&D for treatment of PJI has focused on either cohorts of total knee arthroplasty patients or combined cohorts of total hip and knee patients. For this reason, it is difficult to tease out the differential success rate of periprosthetic hip vs. knee infections. Sherrell et al. performed a systematic review of the existing literature and created a table detailing the failure rates for various published articles on I&D for periprosthetic TKA infection. Since it is the glycocalyx that has been thought to be the reason for treatment failure of many cases of PJI treated with I&D, many authors have implicated staphylococcal species as a predictor of a negative outcome with failure rates ranging from 30–35%. Methicillin resistant organisms have been shown to be particularly difficult to eradicate with an isolated I&D, with a 72–84% failure rate at 2 year follow-up. Interestingly, a recent study by Odum et al. suggests that neither the infecting microbe, nor the antibiotic resistance profile of the organism, as has been classically thought, actually predicts success of I&D. Previous reports have indicated that the ability of I&D to control infection is related to the duration of symptoms and its timing relative to the index surgery. However, more recent literature is coming out to support the contrary. Koyonos et al. reviewed the outcomes of a series of 138 cases of PJI treated with I&D based on acuity of infection and concluded that an I&D has a limited role in controlling PJI regardless of acuity. Intuitively, the physical health of the host/patient should influence the success of I&D for treatment of PJI. Several authors have shown that an immunocompromised state is a predictor of treatment failure. Furthermore, Azzam et al. reported that patients with a higher American Society of Anesthesia (ASA) score, a proxy of severity of medical comorbidities, had a significantly higher failure rate. Although potentially appealing due to relative ease of execution and minimal surgical morbidity, the ability to successfully eradicate infection with an arthroscopic procedure may be compromised. Given the inability to perform a radical surgical debridement, nor exchange modular components, arthroscopic debridement should be used with extreme reservation in any case of PJI, regardless of the host, nature of the infecting organism, or acuity of infection. I&D as a conservative, less morbid alternative to two-stage exchange - There is a growing body of literature to suggest that an I&D with modular component exchange may not be the benign, less morbid alternative to the ‘gold standard’ two-stage exchange arthroplasty. In fact, Fehring et al. has reported that the success of a two-stage antibiotic spacer exchange arthroplasty may be compromised by an initial I&D. They found that patients who were initially treated with an I&D only had a 66% chance of eradicating infection following a two-stage exchange arthroplasty, in contrast to historical reports of 80–90% success

There is no doubt that peri-prosthetic joint infection (PJI) is one the most terrible complications of joint arthroplasty. There has been a surge of interest in PJI in recent years as this problem moves to be the last frontier in joint arthroplasty. There are a number of strategies employed for prevention of PJI. Irrigation of the surgical site with various irrigation solutions is one such strategy as it helps reduce bioburden in the wound and reduce the potential for subsequent infection. Although the irrigation solution may work by dilution phenomenon alone, some believe that bactericidal or bacteriostatic agents may be added to the irrigation solution to increase its efficacy. Addition of antibiotics (Abx) to the irrigation solution stems from the same reasoning. There are a number of serious issues related to the addition of Abx to the irrigation solution or in fact, for pouring into the wound (like the vancomycin powder). Efficacy: There are no randomised prospective studies to demonstrate that addition of Abx to the irrigation solution improves “kill”. To do such a study would be logistically challenging. Basic science studies and other clinical studies with a small number of patients have failed to prove the efficacy of Abx in the irrigation solution. In fact, I would argue that the use of agents like dilute betadine is much more likely to be effective in reduction of bioburden without having many of the issues related to the use of Abx in irrigation solution. Emergence of Resistance: Some may argue what would one lose by adding Abx to the wound or the irrigation solution. The modern society is facing an emerging catastrophe. Antimicrobial Resistance (AMR), if it persists, will kill more people than cancer by the year 2050. Annually 1000s of patients die of ESKAPE or AMR related issues. A recent task force convened by the British government produced a report about AMR which is sobering. The main finding of the task force was that continued liberal use of Abx will lead to further escalation of the AMR crisis that threatens the modern society. The guidelines by the CDC, that are about to be published, will discourage clinicians from pouring Abx into wounds and asks clinicians to exercise Abx stewardship. Expense: There are costs associated with the use of Abx in any circumstance including their addition to irrigation solution. With over 1 million joint arthroplasties being done in the US alone, this cost can be substantial. Hypersensitivity reactions: The use of Abx is not without problems. There have been a few fatalities associated with the use of Abx in patients with recognised and possibly unrecognised hypersensitivity to antibiotics

Aim

This study aims to evaluate the effectiveness of a pre-formulated irrigation solution¹ (containing ethanol, acetic acid, sodium acetate, benzalkonium chloride, and sterile water) compared to saline solution in managing acute periprosthetic joint infections (A-PJI) during Debridement, Antibiotic, and Implant Retention (DAIR) surgeries. The primary objective is to assess the healing rate using this solution¹ versus saline in A-PJI patients, with “cure” defined by a set of criteria including no recurrence, wound issues, or need for ongoing suppressive antibiotics after 1 year. Principio del formularioFinal del formulario

Aim

The efficacy of various irrigation solutions in removing microbial contamination of a surgical wound and reducing the rate of subsequent surgical site infection (SSI), has been demonstrated extensively. However, it is not known if irrigation solutions have any activity against established biofilm. This issue is pertinent as successful management of patients with periprosthetic joint infection (PJI) includes the ability to remove biofilm established on the surface of implants and necrotic tissues. The purpose of this study was to evaluate the efficacy of various irrigation solutions in eradicating established biofilm, as opposed to planktonic bacteria, in a validated in vitro model.

Introduction

The use of irrigation solution during surgical procedures is a common and effective practice in reduction of bioburden and the risk of subsequent infection. The optimal irrigation solution to accomplish this feat remains unknown. Many surgeons commonly add topical antibiotics to irrigation solutions assuming this has topical effect and eliminates bacteria. The latter reasoning has never been proven. In fact a few prior studies suggest addition of antibiotics to irrigation solution confers no added benefit. Furthermore, this practice adds to cost, has the potential for anaphylactic reactions, and may also contribute to the emergence of antimicrobial resistance. We therefore sought to compare the antimicrobial efficacy and cytotoxicity of irrigation solution containing polymyxin-bacitracin versus other commonly used irrigation solutions.

Prevention and treatment of total joint infection is closely related to biofilm formation and concentration of antibiotics achieved in the area around the implants. Most total joint infections are caused by bacteria that enter the wound at the time of the operation. These bacteria can attach to surfaces and rapidly form biofilm that is highly resistant to antibiotics. Prophylactic antibiotics given intravenously achieve concentration of local antibiotics in the knee in response to intravenous antibiotics about 1/3 of that achieved in the serum, and the level is transient. This may be enough to treat the planktonic form of the bacteria, but far from enough to treat the biofilm. The concentration of antibiotics in the joint fluid achieved with antibiotics applied locally during surgery is 1000 times higher, and can be maintained throughout the procedure. High concentration persists in drainage fluid for 24 hours after surgery. Studies done with use of local antibiotics in spinal implant surgery indicate a major reduction in the rate of infection, and cost analysis shows remarkable monetary benefit to this effect.

Infected total joints benefit especially from direct application of antibiotics to the local area. The safety and efficacy of this protocol was evaluated in patients undergoing primary or revision TKA by measuring joint and serum levels of vancomycin following IV administration (as a prophylactic) and IA administration (as a treatment for infected TKA), and comparing the levels with each method. Therapeutic levels of vancomycin were present in the knee following IV or IA administration, but much higher levels were possible with IA administration (average of 6.8 and 9,242µg/mL, respectively). Vancomycin achieved therapeutic levels in the synovial fluid of the knee with IV administration, but clearance from the knee was rapid, suggesting that the synovial fluid concentration may be sub-therapeutic for hours before the next IV dose is given. In contrast, IA delivery of vancomycin resulted in peak levels that were thousands of times higher, and trough levels remained therapeutic for 24 hours in both the joint space and in the serum (minimum trough levels of 8.4 and 4.2µg/mL, respectively). The elimination constant (half-life) of IA-administered vancomycin was 3.1 hours.

Directly infusing antibiotics into the infected area maintains a high local concentration level while minimizing systemic toxicity. This method avoids the use of antibiotic-loaded cement and the potential for growth of antibiotic-resistant strains of bacteria. These findings support single-stage revision in cases treated with cementless revision and IA antibiotics.

Preventing and treating infection in orthopaedic implant surgery requires achieving concentrations that are above the minimal biofilm eradication concentration. This can be achieved only with direct application.

Prevention and treatment of total joint infection is closely related to biofilm formation and concentration of antibiotics achieved in the area around the implants. Most total joint infections are caused by bacteria that enter the wound at the time of the operation. These bacteria can attach to surfaces and rapidly form biofilm that is highly resistant to antibiotics. Prophylactic antibiotics given intravenously achieve concentration of local antibiotics in the knee in response to intravenous antibiotics about 1/3 of that achieved in the serum, and the level is transient. This may be enough to treat the planktonic form of the bacteria, but far from enough to treat the biofilm. The concentration of antibiotics in the joint fluid achieved with antibiotics applied locally during surgery is 1000 times higher, and can be maintained throughout the procedure. High concentration persists in drainage fluid for 24 hours after surgery. Studies done with use of local antibiotics in spinal implant surgery indicate a major reduction in the rate of infection, and cost analysis shows remarkable monetary benefit to this effect.

Infected total joints benefit especially from direct application of antibiotics to the local area. The safety and efficacy of this protocol was evaluated in patients undergoing primary or revision TKA by measuring joint and serum levels of vancomycin following IV administration (as a prophylactic) and IA administration (as a treatment for infected TKA), and comparing the levels with each method. Therapeutic levels of vancomycin were present in the knee following IV or IA administration, but much higher levels were possible with IA administration (avg. of 6.8 and 9,242 µg/mL). Vancomycin achieved therapeutic levels in the synovial fluid of the knee with IV administration, but clearance from the knee was rapid, suggesting that the synovial fluid concentration may be sub-therapeutic for hours before the next IV dose is given. In contrast, IA delivery of vancomycin resulted in peak levels that were thousands of times higher, and trough levels remained therapeutic for 24 hours in both the joint space and in the serum (minimum trough levels of 8.4 and 4.2 µg/mL, respectively). The elimination constant (half-life) of IA-administered vancomycin was 3.1 hours.

Directly infusing antibiotics into the infected area maintains a high local concentration level while minimizing systemic toxicity. This method avoids the use of antibiotic-loaded cement and the potential for growth of antibiotic-resistant strains of bacteria. These findings support single-stage revision in cases treated with cementless revision and IA antibiotics.

Preventing and treating infection in orthopaedic implant surgery requires achieving concentrations that are above the minimal biofilm eradication concentration. This can be achieved only with direct application.

Infection is still a major problem in implant surgery. Most infections are caused by bacteria that enter the wound at the time of the operation. Although prophylactic antibiotics given intravenously have been shown to be effective if given during the correct time frame, the concentration of local antibiotics in the knee in response to intravenous antibiotics is about 1/3 that achieved in the serum, and the level is transient. The concentration of antibiotics in the joint fluid achieved with antibiotics applied locally during surgery is 1000 times higher, and can be maintained throughout the procedure. High concentration persists in drainage fluid for 24 hours after surgery.

Studies done with use of local antibiotics in spinal implant surgery indicate a major reduction in the rate of infection, and cost analysis shows a remarkable monetary benefit to this effect.

Local antibiotic irrigation during implant surgery is inexpensive, easy, and effective.

Despite long-standing dogma, a clear relationship between the timing of surgical irrigation and the development of subsequent deep infection has not been established in the literature. Traditionally, irrigation of an open fracture has been recommended within six-hours of injury based on animal studies from the 1970s, however the clinical basis for this remains unclear. Using data from a multi-centre randomized controlled trial of 2,447 open fracture patients, the primary objective of this secondary analysis is to determine if a relationship exists between timing of wound irrigation (within six hours of injury versus beyond six hours) and subsequent reoperation rate for infection or healing complications within one year for patients with open extremity fractures requiring surgical treatment.

To adjust for the influence of patient and injury characteristics on the timing of irrigation, a propensity score was developed from the data set. Propensity-adjusted regression allowed for a matched cohort analysis within the study population to determine if early irrigation put patients independently at risk for reoperation, while controlling for confounding factors. Results were reported as odds ratios (ORs), 95% Confidence Intervals (CIs), and p-values. All analyses were conducted using STATA 14 (StataCorp LP, College Station, TX, USA).

Two thousand, two hundred eighty-six of 2,447 patients randomized to the trial from 41 orthopaedic trauma centers across five countries had complete data regarding time to irrigation. Prior to matching, the patients managed with early irrigation had a higher proportion requiring reoperation for infection or healing complications (17% versus 12.8%, p=0.02), however this does not account for selection bias of more severe injuries preferentially being treated earlier. After the propensity score-matching algorithm was applied, there were 373 matched pairs of patients available for comparison. In the matched cohort, reoperation rates did not differ between early and late groups (16.1% vs 16.6%, p=0.84). When accounting for propensity matching in a logistic regression analysis, early irrigation was not associated with reoperation (OR 0.93, 95% CI 0.62 to 1.40, p=0.73).

When accounting for other variables, late irrigation does not independently increase risk of reoperation.

Infection is still a major problem in implant surgery. Most infections are caused by bacteria that enter the wound at the time of the operation. Although prophylactic antibiotics given intravenously have been shown to be effective if given during the correct time frame, the concentration of local antibiotics in the knee in response to intravenous antibiotics is about 1/3 that achieved in the serum, and the level is transient. The concentration of antibiotics in the joint fluid achieved with antibiotics applied locally during surgery is 1000 times higher, and can be maintained throughout the procedure. High concentration persists in drainage fluid for 24 hours after surgery.

Studies done with use of local antibiotics in spinal implant surgery indicate a major reduction in the rate of infection, and costs analysis shows a remarkable monetary benefit to this effect.

Local antibiotic irrigation during implant surgery is inexpensive, easy, and effective.

Infection is still a major problem in implant surgery. Most infections are caused by bacteria that enter the wound at the time of the operation. Although prophylactic antibiotics given intravenously have been shown to be effective if given during the correct time frame, the concentration of local antibiotics in the knee in response to intravenous antibiotics is about 1/3 that achieved in the serum, and the level is transient. The concentration of antibiotics in the joint fluid achieved with antibiotics applied locally during surgery is 1000 times higher, and can be maintained throughout the procedure. High concentration persists in drainage fluid for 24 hours after surgery.

Studies done with use of local antibiotics in spinal implant surgery indicate a major reduction in the rate of infection, and costs analysis shows a remarkable monetary benefit to this effect.

Local antibiotic irrigation during implant surgery is inexpensive, easy, and effective.

Infection following total hip arthroplasty (THA) represents a devastating complication and is one of the main causes for revision surgery. This complication may be treated by irrigation and debridement with head and polyethylene exchange (IDHPE) or a two-stage revision (2SR). Previous studies have reported on the eradication success rates but few have reported patient outcome scores. The purpose of this study was to report patient outcome scores for both IDHPE and 2SR and compare these to a non-infected matched cohort. We hypothesised that both cohorts would have worse outcomes than the control group, and that those who failed an initial IDHPE and required a 2SR would have a worse outcome than those treated initially with a 2SR.

A retrospective review identified 137 patients from our institutional arthroplasty database who had an infected primary THA between 1986–2013. We excluded patients with less than one-year follow-up. Mean follow-up was 60 months (12–187 months). A control cohort was identified and matched according to age and Charlton Comorbidity Index (CCI). Harris Hip Scores, Short Form 12 and WOMAC scores were compared between our control group and our infected cohort.

Sixty-eight patients were treated with a 2SR and 69 patients were treated with an IDHPE. There was a 59% success rate in eradicating the infection with an IDHPE. All of the 28 patients who failed an IDHPE later went on to a 2SR. Outcome scores for the 2SR cohort were significantly worse than the non-infected controls (p0.05). There was no difference in outcome scores when comparing our 2SR cohort to our failed IDHPE (p>0.05).

Previous studies have focused on eradication rates. However, it is important to consider patient outcome scores when deciding the best treatment. Infected patients treated with a successful IDHPE had similar outcomes to non-infected patients. Patients that failed IDHPE and went onto 2SR had similar outcomes to those that had a 2SR alone. IDHPE should still be considered in the treatment algorithm of infected THA.

Background

Open fracture wounds are well known to be associated with infection & prolonged healing. Activity in scientific research to improve wound healing has often provided variable results. This study was done to question the de facto nature of Normal Saline as best irrigant in management of such wounds and to find out a better irrigant, if so, that does exist with due consideration to the mechanism by which saline dressings act.

Aim. Irrigation is a major step during debridement surgery in the context of Prosthetic Joint Infections (PJI), but its effects on biofilms are poorly described. The present study aims at evaluating the effect of PW alone or followed by antibiotics on MSSA and MRSA biofilms grown on Ti6Al4V coupons in-vitro. Method. Strains: 1 reference (MSSA: ATCC25923; MRSA: ATCC33591) and 2 clinical MSSA and MRSA isolated from PJI. Biofilm culture: Coupons were incubated for 24h at 37°C with bacteria (starting inoculum ∼6.6Log. 10. CFU/mL in TGN [TSB + 1% glucose + 2% NaCl]), under shaking at 50rpm. Treatment: Half of the coupons were irrigated with 50mL physiological serum from 5cm using a Stryker Interpulse; the coupons were then either analysed (ControlT0 and PWT0) or reincubated for 24h in TGN or TGN containing flucloxacillin (MSSA) or vancomycin (MRSA) at MIC or 20mg/L. Analysis: Coupons were rinsed twice with PBS. Biomass was measured by crystal violet (CV) assay. CFUs were counted after recovering bacteria from coupons using sonication and TSA plating. Results. Antibiotics alone: Flucloxacillin reduced CFU and biomass for ATCC25923 and 611 but not 578 (Fig b and d). Vancomycin had no statistically significant effects on CFUs for all MRSA and only a weak effect on biomass for 676. Irrigation alone markedly reduced CFUs and biomass for all strains but had no persistent effect after 24h reincubation in TGN. PW + antibiotics: Antibiotics prevented bacterial regrowth after PW when used at their MIC and further decreased CFUs when used at 20 mg/L. Conclusions. PW alone has a transient effect on coupon colonisation by S. aureus biofilms. Vancomycin at therapeutic concentrations is ineffective and flucloxacillin has a strain-dependent effect. In combination, these treatments show synergistic effects, indicating the importance of irrigation followed by high antibiotic doses for ODRI. For any figures or tables, please contact the authors directly

Total Shoulder Resurfacing (TSR) provides a reliable solution for the treatment of glenohumeral arthritis. It confers a number of advantages over traditional joint replacement with stemmed humeral components, in terms of bone preservation and improved joint kinematics. This study aimed to determine if humeral reaming instruments produce a thermal insult to subchondral bone during TSR. This was tested in vivo on 13 patients (8 with rheumatoid arthritis and 5 with osteoarthritis) with a single reaming system and in vitro with three different humeral reaming systems on saw bone models. Real-time infrared thermal video imaging was used to assess the temperatures generated. Synthes Epoca instruments generated average temperatures of 40.7°. C. (SD 0.9°. C. ) in the rheumatoid group and 56.5°. C. (SD 0.87°. C. ) in the osteoarthritis group (p = 0.001). Irrigation with room temperature saline cooled the humeral head to 30°. C. (SD 1.2°. C. ). Saw bone analysis generated temperatures of 58.2°. C. (SD 0.79°. C. ) in the Synthes (Epoca) 59.9°. C. (SD 0.81°. C. ) in Biomet (Copeland) and 58.4°. C. (SD 0.88°. C. ) in the Depuy (CAP) reamers (p=0.12). Humeral reaming with power driven instruments generates considerable temperatures both in vivo and in vitro. This paper demonstrates that a significant thermal effect beyond the 47°. C. threshold needed to induce osteonecrosis is observed with humeral reamers, with little variation seen between manufacturers. Irrigation with room temperature saline cools the reamed bone to physiological levels, and should be performed regularly during this step in TSR

Background. Irrigation and débridement (I&D), often with exchange of modular polyethylene components, is commonly used to treat acute periprosthetic infection (PPI) following total joint arthroplasty. Two-stage revision, the “Gold Standard” for PPIs' is more invasive, requires more resources, creating controversy over recommended initial treatment of PPIs. This study seeks to determine the success rate of an “intent to treat” approach utilizing I&Ds with progression to two stage revisions as required. Methods. We retrospectively reviewed 5193 hip and knee joint arthroplasties performed over a 63 month period and identified 46 (20 female, 26 male, mean age 60) deep postoperative (within 365 days) infections that were initially managed with an “intention to treat and cure” I&D, with or without poly exchange. We investigated the overall success rate of this approach and the requirements for additional surgical procedures, as well other associated factors. 34 were managed with I&Ds only and 12 with two stage revisions as well. Results. Infection eradication with implant retention was accomplished in 33 patients with I&Ds alone (72%). Of these, 25 required one I&D, 6 required 2 I&Ds and 2 required 3 I&Ds. 12 had 2-stage revisions, with 7 successes, 3 failures (1 each – amputation, fusion and infection recurrence after reimplantation) and 2 refusing revision of spacers. One had fusion after I&D without attempted staged revision. Thus, overall 40 of 46 (83%) were successfully managed after beginning with an “intent to treat” I&D and 33 of 46 (72%) patients avoided any surgeries other than I&Ds, thereby minimizing their cost, pain and morbidity. Conclusions. This preliminary study, which will require further follow-up, appears to support beginning the treatment of selected acute postoperative infected arthroplasties with an initial I&D and then tailoring further treatments based on individual factors. Level of Evidence This study was a retrospective comparative study, Level III evidence. Key Words: IRRIGATION AND DEBRIDEMENT, I&D, PERIPROSTHETIC INFECTION, TWO STAGE REVISION, TOTAL HIP, TOTAL KNEE

Modifiable Risk Factors. Preoperative Screening. Preoperative Skin Cleansing. Skin Preparation. Perioperative Antibiotics. Controlling the OR Environment. Intraoperative Irrigation and Lavage. Postoperative Wound Management