Summary. A meta-analysis was performed to compare rate of SSI after application of chlorhexidine vs. iodine in total joint arthroplasty. Chlorhexidine had significantly lower odds of SSI. Introduction. Surgical site infections (SSI) are a significant source of morbidity and mortality. The optimal preoperative skin preparation in lower extremity total joint arthroplasty (TJA) remains debatable between chlorhexidine and iodine-containing solutions. This meta-analysis sought compare SSI rates between chlorhexidine cloth application the night before surgery plus povidone-iodine-alcohol (povidone-iodine) solution at surgery or only povidone-iodine at surgery. Methods. A structured literature search was performed using Web of Science, PubMed, and EMBASE databases for randomized clinical trials (RCTs) and comparative studies that evaluated preoperative chlorhexidine-gluconate versus iodine-alcohol exclusively in TJA patients. Databases were searched from database inception to January 2, 2018, and studies were included if they had specific aims and 1) compared preoperative chlorhexidine-gluconate cloths to povidone-iodine at surgery, or 2) if they compared preoperative chlorhexidine-gluconate cloths and povidone-iodine at surgery, to solely povidone-iodine at surgery. The main outcome was deep or superficial SSI at or before 1 year postoperatively. If multiple studies reported the same patient cohort, the more recent study was used. To compare the chlorhexidine versus povidone-iodine groups, pooled odds ratios (OR) and 95% confidence intervals (95% CI) were used to calculate odds of SSI. Results. Four studies involving 2,997 TJA patients were included in this meta-analysis. Three were retrospective cohort studies, and one was a RCT. One retrospective cohort study assessed chlorhexidine to povidone-iodine using a historical control. One RCT compared chlorhexidine to povidone-iodine. The remaining two studies compared chlorhexidine in addition to povidone-iodine, to only povidone-iodine. Bias analysis showed low-to-moderate quality cohort studies and one moderate-quality RCT. Chlorhexidine had significantly lower odds of SSI compared to povidone iodine (OR=0.28; 95%CI: 0.15–0.51; p<0.0001). Conclusion. Preoperative chlorhexidine-gluconate was superior at reducing SSI risk in patients who underwent lower extremity TJA, compared to povidone-iodine. This can potentially lead to decreased morbidity and lower surgical revision rates for infections. For any figures or tables, please contact authors directly

Aim. The purpose of this study was to compare the presence of P.acnes on the skin after topical pre-operative application with benzoyl peroxide (BPO) to chlorhexidine soap (CHS) and whether this also affected skin recolonization after surgical preparation and draping. Method. Forty volunteers – twenty-four men and sixteen women were randomized to pre-operative topical treatment at home with either CHS or BPO in the area of a delto-pectoral approach of their left shoulder. The right served as a control. Five skin swabs were taken in a standardized manner on different occasions: before and after topical treatment, after surgical skin preparation and sterile draping and 120 minutes after draping. A fifth sample was taken on the contralateral untreated side as a control when the patient was draped. The draping took place in an operating room with laminar air flow and skin preparation was performed for 2 minutes with 0.5% chlorhexidine solution in 70% ethanol according to the recommendations of the Swedish National Board of Health and Welfare. Bacterial colonies were then analyzed on agar plates by colony forming units (CFU) and surface characteristics. P.acnes were identified with matrix-assisted laser desorption/ionization time-of-flight (MALDI-ToF) mass spectrometry. Results. Topical treatment with BPO significantly reduced the presence of P.acnes as CFU on the skin after surgical preparation. P.acnes was found in 1/20 subjects of the BPO group, and 7/20 in the CHS-group (p<0.044). The results remained after two hours (p<0.048). Topical treatment with BPO before surgical skin preparation significantly decreased the presence of CFU (p-value 0.035). Conclusions. Topical preparation with BPO before shoulder surgery may be effective in reducing P.acnes on the skin and prevent recolonization

Aim. The origin of surgical site and biomaterial-associated infection is still elusive. Microorganisms contaminating the wound may come from the air, the surgical team, or from the skin of the patient. Prior to surgery the skin of patients is disinfected, but bacteria deeper in the skin (e.g. in sweat glands or sebaceous glands), may not be reached. This study aims to assess a potential role of this intracutaneous bacterial reservoir in biomaterial-associated infection. Method. To study if cutaneous microbiota colonize the wound when released from the skin upon cutting, we isolated, quantified and identified aerobic and anaerobic bacteria from the skin of 99 patients undergoing trauma surgery, before and after skin disinfection, from the knife blades and from the wound directly after the first cut. Results. Ninety-nine percent of the patients were culture-positive before disinfection with chlorhexidine. Of these, 40% were still culture-positive after disinfection. Of these, 54% had a positive culture of the wound after the skin cut. Twenty percent of the patients with a negative culture after disinfection, nevertheless had a positive wound culture after cutting the skin. Staphylococcus epidermidis and Cutibacterium acnes were the most often cultured bacterial species. In 9%, more than 100 bacterial colonies were cultured from the wound, a dose that may cause biomaterial-associated infections. Conclusions. Bacteria residing in the skin and not eradicated by disinfection may enter the surgical wound upon cutting, resulting in contamination which may cause a biomaterial-associated infection. Use of two knifes likely reduces the risk of wound contamination

Introduction. Periprosthetic infection following lower extremity total joint arthroplasty often requires multiple surgical procedures and imposes a marked economic burden on the patient and hospital. The purpose of this study was to evaluate the incidence of surgical site infections in total joint arthroplasty patients who used an advance at-home pre-admission cutaneous preparation protocol and to compare these results to a cohort of patients who underwent standard in-hospital peri-operative preparation only. Methods. Patients scheduled for surgery were given two packets of 2% chlorhexidine gluconate-impregnated cloths, with instructions for use the evening before and morning of surgery. Records between 2007 and 2010 were reviewed to identify deep incisional and periprosthetic infections. The Centers for Disease Control and Prevention and the Musculoskeletal Infection Society definitions were used for diagnosis. Results. A significantly lower incidence of surgical site infections was found in the chlorhexidine preparation group. For total hip arthroplasty, three surgical site infections occurred in 557 patients (0.5%) of the chlorhexidine group compared to 32 of 1,901 patients (1.7%) in the control group. For total knee arthroplasty, three surgical site infections occurred in 478 patients (0.6%) who used the chlorhexidine cloths, compared to 38 surgical site infections in 1,735 patients (2.2%) in the control group. Discussion. The use of an advance pre-admission chlorhexidine protocol significantly reduced the incidence of surgical site infections in total joint arthroplasty when compared to patients who did not use this protocol. This study validates prior studies in orthopaedics suggesting this as an effective method to prevent periprosthetic infections

Hypochlorous acid (HOCl) is a potent anti-bacterial agent which could reduce periprosthetic joint infection. Early infection complications in joint replacements are often considered to be due to local contamination at the time of surgery and result in a significant socioeconomic cost. Current theatre cleaning procedures produce “clean” operating theatres which still contain bacteria (colony forming units, CFU). Reducing this bacterial load may reduce local contamination at the time of surgery. HOCl is produced naturally in the human neutrophil and has been implicated as the primary agent involved in bacterial killing during this process. In vitro research confirms its efficacy against essentially all clinically relevant bacteria. The recent advent of commercial production of HOCl, delivered as a fog, has resulted in extensive use in the food industry. Reported lack of corrosion and high anti-bacterial potency are seen as two key factors for the use of HOCl in the orthopaedic environment. Prior work by the authors comparing human cell toxicity of HOCl, chlorhexidine and iodine solutions shows favourable results. This study evaluates use of neutral HOCl applied as a dry room fog to decrease bacteria in the operating theatre environment. Using an animal operating theatre as the test site, bacterial swabs were taken from ten 100cm. 2. sample areas before standard cleaning with detergent, after standard cleaning, and again after 60 minutes exposure to HOCl fog. After standard cleaning, 6 of 10 sample sites recorded significant bacterial growth (>10 CFU/100cm. 2. ). After exposure to HOCl fog, growth in all 10 sites was below detection limits (<10 CFU/100cm. 2. ). This was repeated with specific exposure to Staphylococcus aureus and Escherichia coli. We can conclude that HOCl is effective when used as a fogging agent to reduce bacterial loading within an operating theatre environment and as such has significant potential to reduce intraoperative contamination and periprosthetic infection

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. Methods. Using two in vitro breakpoint assays of Staphylococcus aureus (ATCC#25923) and Escherichia coli (ATCC#25922), we examined the efficacy of a panel of irrigation solutions containing topical antibiotics (500,000U/L Polymyxin-Bacitracin 50,000U/L; Vancomycin 1g/L; Gentamicin 80mg/L), as well as commonly used irrigation solutions (Normal saline 0.9%; Povidone-iodine 0.3%; Chlorhexidine 0.05%; Castile soap 0.45%; and Sodium hypochlorite 0.125%) following 1 minute and 3 minutes of exposure. Surviving bacteria were counted in triplicate experiments. Failure to eradicate all bacteria was considered to be “not effective” for that respective solution and exposure time. Cytotoxicity analysis in human fibroblast, osteoblast, and chrondrocyte cells exposed to each of the respective irrigation solutions was performed by visualization of cell structure, lactate dehydrogenase (LDH) activity and evaluation of vital cells. Toxicity was quantified by determination of LDH release (ELISA % absorbance; with higher percentage considered a surrogate for cytotoxicity). Descriptive statistics were used to present means and standard deviation of triplicate experimental runs. Results. Polymyxin-Bacitracin, Saline and Castile soap irrigation at both exposure times were not effective at eradicating S aureus or E coli (Figure 1). In contrast, Povidone-iodine, Chlorhexidine, and Sodium hypochlorite irrigation were effective at eradicating both S aureus and E coli. Vancomycin irrigation was effective at S aureus eradication but not against E coli, whereas Gentamicin irrigation showed partial efficacy against E coli eradication but none against S aureus. The greatest cytotoxicity was seen with Chlorhexidine (49.4% ± 1.9). This was followed by Castile soap (33.2% ±3.9), Vancomycin (9.01% ±5.1), Polymyxin-Bacitracin (8.45% ±1.5), and Gentamicin irrigation (4.72% ±2.3) (Figure 2 and Figure 3 microscopy images). Povidone-iodine and Sodium hypochlorite showed least cytotoxicity (0.05% ±0.08 and 0.11%±0.19, respectively). Similar trends were seen at both exposure times and across fibroblasts, osteoblasts and chondrocytes. Discussion. This in vitro study suggests that addition of polymyxin-bacitracin to saline irrigation solution is a futile exercise. Taken within the context of its associated expense, risk of hypersensitivity and impact upon antimicrobial resistance, our findings bring its widespread clinical usage into question. Povidone-iodine may be a more effective option, with a more favorable cytotoxicity profile than the other commonly used irrigation solutions. Clinical outcomes should be studied to determine the most effective agent, concentration, and exposure time for intraoperative irrigation

Post-surgical wound infections following total hip or knee arthroplasties can be a potentially catastrophic complication for the patient. Currently, several preventative measures exist to help combat this complication. One such method is skin disinfection with preadmission cutaneous chlorhexidine preparation. Although efficacious in reducing surgical site infections during total joint arthroplasty, orthopaedists should be aware of discrepancies between hip and knee arthroplasty. For example, Kapadia et al. performed a prospective study which evaluated the use of preadmission cutaneous chlorhexidine preparation on the reduction of surgical site infections following total hip arthroplasty; they found that there was a 3-fold higher relative risk of developing infection in patients who did not receive the chlorhexidine preparation as compared to those who did. In a similar study performed for total knee arthroplasty, the same authors founds a 6-fold higher relative risk of developing infection, which equated to double the risk as compared to total hip arthroplasty. In a study by Lewis et al. regarding timing to diagnosis of surgical site infections in post-hip and knee arthroplasties, the authors found a longer median time to diagnosis post-knee arthroplasty as compared to hip arthroplasty (25 vs. 42 days, p= <0.001). These finding suggest that orthopaedists should recognise that “A knee is not a hip” with regards to surgical site infections and should be aware of the discrepancies that exist between the two

Aim. Recent studies have indicated that the presence of P. acnes in the skin of the shoulder and around the acromion is higher than other body regions like the knee or the hip. The aim of this study was to estimate the presence of P. acnes in a real set of primary shoulder arthroplasty, after skin preparation with chlorhexidine and administration of empirical antibiotic therapy. Method. A prospective observational study involving 63 patients undergoing primary shoulder arthroplasty was designed. In all patients two skin biopsies with a 3 mm dermal punch and one subcutaneous tissue sample after surgical incision were obtained. Skin biopsies were obtained at the most anterior part of the surgical wound in case of superior approach and at the upper part in the deltopectoral approach. All patients underwent preoperative antibiotic prophylaxis with cefazolin 2g ev and skin preparation with 2% chlorhexidine alcoholic tinted before the start of surgery twice. The aerobic cultures were incubated at 37ºC for 7 days whereas the anaerobic ones incubated for 14 days. Results. A total of 63 consecutive patients who underwent shoulder arthroplasty (58 reverse shoulder arthroplasty and 5 anatomical) were analysed. 54 women and 9 men, mean age of 73.94 (SD 6.19). The indication for arthroplasty was a secondary arthropathy cuff injury in 42 cases, primary osteoarthritis in 3, acute fracture in 9 and fracture sequelae in 9. We obtained 189 tissue cultures (126 skin cultures and 63 subcutaneous) and 4 cultures were positive (2.02%) for P. acnes in 3 different patients. A first patient (female) had both positive skin cultures, the second patient (male) only had positive the subcutaneous tissue cultures and the third patient had positive also the subcutaneous tissue culture. The first patient underwent anatomical shoulder arthroplasty whereas the second and third patients underwent reverse shoulder arthroplasty. The time to grow was 15 days in first patient and 14 days in the second and third patient (mean 14.5 days). Conclusions. In a real setting of patients undergoing shoulder arthroplasty using antibiotic prophylaxis and standard preoperative skin preparation with chlorhexidine we found a low rate of positive cultures for P. acnes (2.02 %). The higher rate of P. acnes positive cultures in skin reported in previous studies may be caused by a different population study group (healthy and younger volunteers without antibiotic prophylaxis) or suboptimal culture technique (use of swaps)

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. Method. Established biofilms of Staphylococcus aureus and Escherichia coli were exposed to different irrigation solutions that included Polymyxin 500,000U/L plus bacitracin 50,000U/L, Vancomycin 1g/L, Gentamicin 80mg/L, Normal saline 0.9%, off-the-shelf Betadine 0.3%, Chlorhexidine 0.05%, Benzalkonium 1.3g/L, Sodium hypochlorite 0.125%, and Povidone-iodine 0.5%. Each experiment was conducted in a 96-well microtiter plate with a peg lid and standardized per the MBEC assay manufacturer's protocol. Following 2 minutes of solution exposure to the irrigation solution, residual biofilms were recovered by sonication. Outcome measures for antibiofilm efficacy were residual colony forming units (CFU) and optical density (690nm). Experiments were conducted in 24 replicates and the observations recorded by two blinded observers. Statistical analysis involved t-tests with Bonferonni adjustment. Results. Povidone-iodine 0.5%, Betadine 0.3%, Benzalkonium 1.3g/L, and Sodium hypochlorite 0.125% were significantly more efficacious against S.aureus biofilm versus all other solutions (p<0.001). Against E.coli biofilm, Povidone-iodine-0.5%, Benzalkonium-1.3g/L and Sodium hypochlorite-0.125% were also most effective compared to other irrigation solutions (p<0.001). Polymyxin-bacitracin, Gentamicin, Vancomycin, and Saline solutions had minimal activity against both E.coli and S.aureus biofilms (p<0.001). Similar trends were observed using both experimental endpoints (CFU and Turbidity) and both investigators (interrater reliability; r=0.99). Conclusion. This in vitro study observed that topical antibiotic solutions do not have any activity against established biofilms. Irrigations solutions containing adequate amount of povidone-iodine, betadine, sodium hypochlorite, and benzalkonium appear to have activity against established biofilm by gram positive and gram negative organisms. The use of these irrigation solutions may need to be considered in patients with established PJI

Extremity injury and complications such as wound infection remain a significant problem for the military. This study investigates the anti-microbial efficacy of four dressings used in militarily relevant complex extremity injury. Under general anaesthesia, the flexor carpi ulnaris of 24 New Zealand White rabbits was exposed to a high-energy impact and then inoculated with 10. 6. colony forming units of Staphylococcus aureus. Dressings: gauze soaked in saline, Chlorhexidine, Betadine or Acticoat¯, were randomised and applied 3 hours post injury, to replicate casualty evacuation. Once recovered, animals were checked at least twice daily and body temperature recorded. Analgesia was administered once a day. At 48hrs animals were culled, the muscle harvested and analyzed by a blinded investigator. Group sizes of 6 were required to detect a statistically significant effect of a mean one log reduction in bacterial counts at 48 hours. No dressing gave a significant reduction in bacterial counts at 48 hours. A paired t-test of contamination versus recovered dose gave p values of 0.903, 0.648, 0.396 and 0.336 for saline, Acticoat¯, chlorhexidine and iodine respectively. Contamination dose between groups compared using ANOVA showed no significant difference (p=0.566). Recovered bacterial loads between groups revealed no significant difference (p=0.280). This study indicates that over a 48 hour period, dressings with reported anti-bacterial properties offer no advantage over saline soaked gauze in reducing the bacterial burden in a contaminated soft tissue injury. Future work will extend the study temporally and introduce multiple contaminants

Prosthetic joint infections (PJI) are amongst the most feared postoperative complication of total joint replacement (TJR). PJIs are associated with significant morbidity ranging from functional impairment to amputation. Staphylococcus aureus (S. aureus) is one of the most common causative organisms involved in PJI. More than one quarter of the general population are S. aureus carriers, and carrier status has been shown to increase the risk of developing surgical site infections including PJIs. Decolonization of S. aureus carriers prior to surgery has demonstrated promising results in general surgery, however, solid evidence supporting decolonization in orthopaedic patients is lacking. We aimed to seek further evidence supporting pre-operative screening and S. aureus decolonization in patients undergoing primary or revision hip and knee TJR. A quasi-experimental quality improvement study was conducted to compare the 5-year baseline rates of deep PJIs to a one-year screening and decolonization intervention period. All consecutive patients who underwent primary or revision TJR at one tertiary care hospital in Hamilton, ON, Canada were included in both study periods. Nasal and throat screening for S. aureus carriage of all eligible TJR patients in the preoperative clinic was implemented as standard of care. Patients who tested positive were contacted and provided with details on the S. aureus decolonization protocol. Decolonization included a standardized treatment protocol of 2% intranasal mupirocin twice daily for five days prior to surgery date (excluding day of surgery), and chlorhexidine gluconate wipes (2%) to be used once daily for 4 days prior to surgery date and on the morning of surgery. Regardless of the colonization status at the visit in the preoperative clinic, all patients were re-swabbed on the day of surgery. Primary outcome of interest was the rate of deep PJI as per CDC/NHSN at one-year postoperative follow-up. Secondary outcomes included rate of deep PJIs due to S. aureus, adherence to the decolonization protocol, proportion of S. aureus carriers successfully decolonized, and the proportion of patients deemed as non-carriers following preoperative swab subsequently identified as carriers on the day of surgery. A total of 8,505 patients were included in the 5-year control group, and 1,883 during the intervention period, of which 424 (22.5%) were identified as S. aureus carriers. The deep PJI rate was similar in the two groups, 0.4% (7/1,883) in the intervention group and 0.5% (42/8,505) in the control group (OR 0.75, 95%CI 0.34–1.67, p=0.58). More importantly, we found a significant reduction in PJI due to S. aureus to only one case in the intervention period (0.05%) as compared to 29 cases (0.3%) in the historic control (OR 0.15, 95%CI 0.004–0.94, p=0.0376). We found a significant reduction in PJIs due to S. aureus by decolonizing S. aureus carriers prior to surgery. However, no significant difference in overall infection rates was observed. In conclusion, routine implementation of active screening for S. aureus and decolonization of carriers before TJR is feasible and helps to reduce PJI due to S. aureus

Infection prevention in shoulder arthroplasty is an evolving challenge as further understanding of the pathogens becomes available. Infection rates for reverse TSA is higher than anatomic TSA. Standard decolonization protocols from our hip and knee colleagues has decreased the acute post-operative infection risk to less than 1%. By identifying at risk populations anti-MRSA precautions including intranasal antibiotics and anti-bacterial soaps for pre-surgical skin preparation have reduced the incidence of staphylococcus infections. The emerging understanding of propionibacterium acnes (P. acnes) as a primary pathogen in late shoulder periprosthetic joint infection (PJI) has led to new recommendations including pre-operative skin cleansing with 5% benzoyl peroxide to reduce infection risk. Pre-operative IV antibiotic is recommended and chlorhexidine skin prep for surgery. In the operating room, the concern is the surgeon's exposure to skin and sebaceous glands where P. acnes is prevalent. After skin incision the surgeon should use a new blade for deep incision. Application of vancomycin powder to the subcutaneous tissue may be beneficial after incision to treat potential contamination from the incision through skin. Glove change prior to handling implants and thorough irrigation before implantation is prudent. The role of antibiotic loaded bone cement for infection prevention remains unproven. Topical vancomycin powder at closure is a low cost option and has shown benefit in spine surgery but efficacy is unproven in the shoulder. Silver impregnated wound dressings may also prevent infection and are a convenient option for patient care with regards to bathing. Preventing infections in shoulder arthroplasty, particularly P. acnes, remains a challenge. A significant number of revision TSAs are found to have positive cultures for P. acnes creating a significant burden for patients and surgeons

Background. Periprosthetic joint infection (PJI) is a devastating complication and interest exists in finding lower cost alternatives to current management strategies. Current strategies include a two-stage revision with placement of an antibiotic spacer and delayed placement of a new arthroplasty implant. This study aimed to show that biofilm residue can be reliably eradicated on infected implants, safely allowing re-implantation in a spacer. Methods. Strains of Staphylococcus aureus MRSA252 or Staphylococcus epidermidis RP62A were grown on cobalt-chrome discs. For each strain, discs were divided into 5 groups (5 discs each) and exposed to several sterilization and biofilm eradication treatments: (1) autoclave, (2) autoclave + sonication; (3) autoclave + saline scrub; (4) autoclave + 4% chlorhexidine (CHC) scrub; and (5) autoclave + sonication + CHC scrub. Sterilization and biofilm eradication were quantified with crystal violet assays and scanning electron microscopy (SEM). Results. Relative to non-treated controls, autoclaving alone reduced biofilm load by 33.9% and 54.7% for MRSA252 and RP62A strains, respectively. On average, the most effective sterilization and biofilm removal treatment was the combined treatment of autoclaving, sonication and CHC-scrub for MRSA252 (100%) and RP62A (99.8%). High resolution SEM revealed no cells or biofilm for this combined treatment. Conclusions. Using two commonly encountered bacterial strains in PJI, infected cobalt-chrome implants were sterilized and eradicated of residual biofilm with a combination of autoclaving, sonication and CHC scrubbing. This protocol is time efficient, can be done in the OR and provides a basis for reuse of infected implants as articulating spacers in PJI

The following checklist is derived from the “Proceedings of the International Consensus Meeting on Peri-prosthetic Joint Infection”, under the auspices of the Musculoskeletal Infection Society, August 1, 2013. It is available online at . http://www.msis-na.org/wp-content/themes/msis-temp/pdf/ism-peri-prosthetic-joint-information.pdf. . Pre-Operative: Patient Factors, AODM, Obesity, Smoking, Immunodeficiency, ASA score > 2, Prior open surgery?, MRSA history, EtOH abuse, Malnutrition, Anemia, Recurrent infections. Peri-Operative: Avoid pre-op hospitalization, Chlorhexidine scrub < 6 h pre-op, Hair removal: depilatory or clipper, Appropriate Antibiotic Prophylaxis, Cephalosporin 30–60 min pre-incision, or Vancomycin 1 hour pre-incision, Alcohol based hand emollient after antiseptic soap hand scrub, Limit OR Traffic and Talking!, Double glove, change gloves q2h, ABC bone cement: revisions, high risk patients (immunocompromised), Dilute Betadiner lavage?. Post-Operative: Careful wound closure (Sealed, dry), Sterile, impervious dressing x 24 h, Drain optional, < 48 h, Antibiotic prophylaxis x 24 h, Aggressive drainage hematomas

Aim. A previous Dutch guideline for prophylaxis of hematogenous PJI (HPJI) caused defensive medicine and incorrect own guidelines. There was a need for a better national guideline, developed cooperatively by orthopedic surgeons and dentist. Method. A committee of Dutch Orthopedic and Dental Society, performed a systematic literature review to answer the question: “Is there a difference in the risk for hematogenous infection between always or never giving antibiotic prophylaxis to patients with a joint prosthesis undergoing a dental procedure”. We included 9 papers as follows:. 1. RCT's and systematic reviews: 539 abstracts > 33 full papers > 1 paper included. 2. observational studies: 289 abstracts > 12 full papers > 5 papers. 3. reference-to-reference: 3 papers. The nine papers’ quality was scored according the GRADE method. In addition we studied in non-included literature on further information about additional questions of pathophysiology, risk factors and risk procedures. Results. No evidence was found that prophylactic antibiotics have an effect on the incidence of HPJI (Grade score: very low). We concluded from the non-included literature that:. 1. Bacteremia in dental procedures is frequent, but even more frequent in daily life. The influence of antibiotics on bacteremia is uncertain. 2. There is no evidence that in the first 2 years after implantation the risk for HPJI is increased. 3. There is no evidence that “bleeding” during dental procedures is associated with more bacteremia. 4. The relation between decreased immune status and the risk for HPJI is unclear. Also in these patients the cumulative dose of bacteremia is much higher in daily life as compared with dental procedures. 5. A risk/benefit analysis could not be made, since the data are too uncertain of effectivety of antibiotics, incidence of HPJI and of side effects of antibiotics. 6. For the same reason a cost/effectivety analysis was not possible. Even reliable data are missing about the prevalence of joint prosthesis patients. 7. There are increasing data about the relation between the oral and general health. Therefore good oral hygiene and regular dental controls is advised. 8. We could not conclude if the prophylactic use of oral Chlorhexidine prior to a dental procedure has any positive influence on HPJI incidence. Conclusions. the guideline states:. 1. there is no indication for antibiotic prophylaxis in dental procedures. 2. also not in case of decreased immunity. 3. patients should be advised to maintain good oral hygiene and have regular dental control

The following checklist is derived from the “Proceedings of the International Consensus Meeting on Periprosthetic Joint Infection”, under the auspices of the Musculoskeletal Infection Society, August 1, 2013. It is available online at . http://www.msis-na.org/wp-content/themes/msis-temp/pdf/ism-periprosthetic-joint-information.pdf. . Pre-Operative: Patient Factors, AODM, Obesity, Smoking, Immunodeficiency, ASA score > 2, Prior open surgery?, MRSA history, EtOH abuse, Malnutrition, Anemia, Recurrent infections. Peri-Operative: Avoid pre-op hospitalisation, Chlorhexidine scrub < 6 h pre-op, Hair removal: depilatory or clipper, Appropriate Antibiotic Prophylaxis, Cephalosporin 30–60 min pre-incision, or Vancomycin 1 hour pre-incision, Alcohol based hand emollient after antiseptic soap hand scrub, Limit OR Traffic and Talking!, Double glove, change gloves q2h, ABC bone cement: revisions, high risk patients (immunocompromised), Dilute Betadine lavage?. Post-Operative: Careful wound closure (Sealed, dry), Sterile, impervious dressing × 24 h, Drain optional, < 48 h, Antibiotic prophylaxis × 24 h, Aggressive drainage hematomas

[Introduction]. Surgical-site-infections (SSI) prolong hospital stay, and they are leading nosocomial cause of morbidity and a source of excess cost. Recently, a waterless hand-rubbing protocol containing aqueous 1% chlorhexidine gluconate was developed before surgery, but there is no literature in orthopaedic surgery. The aim was to compare the SSI rates between waterless hand-rubbing and traditional hand-scrubbing protocol. [Materials and Methods]. STUDY 1: A total of 996 consecutive patients who underwent orthopaedic surgery between August 1, 2012 and January 31, 2014, were screened for SSI within 30 days after surgery. 500 patients from August 1, 2012 to April 1, 2013 were used by traditional hand-scrubbing, and 496 patients from June 1, 2013 to January 1, 2014 were by waterless hand-rubbing. STUDY 2: The twelve operating room staff members were randomly recruited, and the participants were assigned equally to use either a traditional hand-scrubbing protocol or a waterless hand-rubbing on 2 separate days. Washing times were recorded and microorganisms on hands were sampled on bacterial culture plates. Two days after sampling, the grown colonies were counted. [Results]. STUDY 1: SSI rates were 6 of 500 (1.2%) in the traditional hand-scrubbing protocol (2 deep and 4 superficial infecitons) and 4 of 496 (0.9%) in the waterless hand-rubbing protocol (all superficial infections). There were no significant differences. The cost for scrub liquids in one hand-wash was about $2 for traditional hand-scrubbing and less than $1 for waterless hand-rubbing. STUDY 2: Microorganism found on 4 of the 12 plates in the traditional hand-scrubbing protocol and on 0 of 12 in the waterless hand-rubbing protocol. The difference between the groups was statistically significant (p < 0.05). The consuming time for wash was 4 minutes 24 seconds in the traditional hand-scrubbing protocol and 2 minute 43 seconds in the waterless hand-rubbing protocol. [Discussion]. Waterless hand rubbing with aqueous alcoholic solution was as effective as traditional hand scrubbing with antiseptic soap in preventing SSI in orthopaedic surgery. Waterless hand rubbing with liquid aqueous alcoholic solution can be safely, quickly and cost-effectively used as an alternative to traditional hand-scrubbing

The goals of the present study are to describe the prevalence of both methicillin sensitive and resistant S.aureus carriage among elective total hip and knee arthroplasty candidates and to evaluate the real impact of preoperatively treating carriers in preventing prosthetic joint infection. Patients undergoing elective primary THA or TKA at a single institution were enrolled in a prospective randomized trial. S.aureus nasal carriage screening was performed in the outpatient setting and selected carriers underwent a 5-day preoperative treatment of nasal mupirocin and chlorhexidine bathing. All patients were followed regularly in the outpatient clinic. No patients were lost to follow-up at a minimum of one year after surgery. The main outcome of the study was the diagnosis of prosthetic joint infection occurring in the first year after surgery including all pathogens and a secondary outcome was defined as infections involving S.aureus bacteria only. From January 2010 to December 2012, 1305 total joint arthroplasties were performed and 1028 of those were screened. We observed a 22.2% (228/1028) S.aureus colonization rate and only eight patients colonized with MRSA (0.8%). Twenty five cases of prosthetic joint infections were identified with an overall infection rate of 2.4%. S.aureus was involved in 14 cases. PJI rate in S.aureus carriers was 3.9% (9/228), which was not significantly higher than the 2.0% (16/800) found among non carriers. Treated and untreated carriers infection rate also showed no significant differences – 3.4% (3/89) vs. 4.3% (6/139). Multivariable analysis substantiates ASA≥ 3 (OR=3.42, 95% CI=1.51 – 7.74) and duration of surgery above the 75th percentile (OR=2.74, 95% CI=1.22 – 6.16) as independent predictors of PJI but not S.aureus carrier state. We obtained similar results when considering infection involving S.aureus bacteria only. Of the 14 cases where S.aureus was present in PJI, only five were carriers preoperatively. Of those five cases, one was an untreated MSSA carrier that ultimately got an MRSA infection. Our results show no clear benefit in screening and decolonizing S.aureus nasal carriers before total joint arthroplasty. There seems to be a lack of causal relation between nasal S.aureus and PJI pathogen as most of S.aureus PJI seems to have an exogenous source

Aims

In the UK, the NHS generates an estimated 25 megatonnes of carbon dioxide equivalents (4% to 5% of the nation’s total carbon emissions) and produces over 500,000 tonnes of waste annually. There is limited evidence demonstrating the principles of sustainability and its benefits within orthopaedic surgery. The primary aim of this study was to analyze the environmental impact of orthopaedic surgery and the environmentally sustainable initiatives undertaken to address this. The secondary aim of this study was to describe the barriers to making sustainable changes within orthopaedic surgery.

Introduction. The purpose of this study was to introduce our perioperative prophylaxis method for infection and clarify surgical site infection rate in our patients performed total hip arthroplasty (THA). Method. Two hundred and eighty four THA (including revision 18 cases) performed by single surgeon between Oct. 2007 and Jan. 2013 were evaluated. The mean age of patients was 65.7 years old. The male to female ratio was 46 to 238. BMI was 23.6. Ninety patients (32%) were compromised host suffering from diabetes mellitus, rheumatoid arthritis, autoimmune disease, history of malignant tumor, hemodialysis or skin disease at surgical site respectively. At preoperative period, we checked decayed tooth, alveolar pyorrhea, hemorrhoids, and leg skin condition. In addition, we examined culture of nasal cavity. At the day of surgery, patient took a shower just before entering surgical room. All of THA was performed in clean room NASA class 100. Surgeons and assistant nurse put on nonwoven fabric gown, space suit and double rubber gloves. We wiped surgical site leg by gauze impregnated by 0.5% chlorhexidine alchohol to eliminate skin bacteria twice just before surgeons scrubbing hands. Surgical site was covered by povidone iodine containing drape. Surgeons or nurse changed gloves when glove was broken at each time. We cleaned surgical field by pulse washer whenever necessary. We did not use drain except for 5 revision THAs. Regarding to prophylactic antibiotics usage, we administered cefcapene pivoxil orally the day before surgery. Drip infusion antibiotics (PIPC: until Oct. 2008, CEZ: after Oct. 2008) was administered at the period of 30 min. before surgery and 4 hours after surgery in case of prolonged surgical time (4 hours >). Skin closure was performed by staple and covered by gauze until May 2010. After that, we used surgical tape and transparent water proof sheet. After finishing surgery, antibiotic was administered 8 hours interval at surgery day and 12 hours interval for additional two days. In case multi-drug resistant bacteria (MRSA, MRSE) was positive in nasal culture, we applied mupirocin ointment to nasal cavity for 3 days before surgery and administered vancomycin (from Aug. 2011) or linezolid (from 2012) for prophylactic antibiotics in perioperative period. Results. Multi-drug resistant bacteria was detected from nasal cavity in 23 patients (8%). The mean operation time was 194 min (due to education for young surgeon). Intraoperative bleeding was 598g. Length of skin incision was 13.6 cm. Intraoperative wash volume was 4500 ml. The infection rate were 0 % in early period and 0.7 % (two case) in late period respectively. One infected case was 75 years old female. Deep infection was occurred 3 years after surgery. She was administered steroid and immunosuppressive drug due to metal allergy after total knee arthroplasty. The other case was 64 years old female. Superficial infection happened 3 months after THA. The patient was suffered from collagen disease and diabetes. Conclusion. Our prophylaxis method for surgical site infection of THA achieved 0 % in early infection and 0.7% late chronic infection respectively