Dilute Betadine Lavage Before Closure for the Prevention of Acute Postoperative Deep Periprosthetic Joint Infection

doi:10.1016/j.arth.2011.03.034

The Journal of Arthroplasty

Volume 27, Issue 1, January 2012, Pages 27-30

https://doi.org/10.1016/j.arth.2011.03.034 Get rights and content

Abstract

This study evaluated the efficacy of a dilute Betadine (Purdue Pharma, Stamford, Conn) lavage in preventing early deep postoperative infection after total hip (THA) and knee (TKA) arthroplasty. A protocol of dilute Betadine lavage (0.35%) for 3 minutes was introduced to the practice of the senior author in June 2008. A total of 1862 consecutive cases (630 THA and 1232 TKA) performed before this were compared with 688 consecutive cases (274 THA and 414 TKA) after for the occurrence of periprosthetic infections within the first 90 days postoperatively. Eighteen early postoperative infections were identified before the use of dilute Betadine lavage, and 1 since (0.97% and 0.15%, respectively; P = .04). There were no significant demographic differences between the 2 groups. Betadine lavage before wound closure may be an inexpensive, effective means of reducing acute postoperative infection after total joint arthroplasty.

Section snippets

Methods

A total of 904 consecutive primary THA and 1646 consecutive primary TKA were performed by a single surgeon (CDV) between February 2002 and March 2010. These cases were retrospectively reviewed for the presence of deep postoperative infection that presented within 90 days after surgery. Infection was defined as a minimum of 2 cultures from the joint showing bacterial growth on solid media or as meeting 2 of the 3 following criteria: at least 1 culture positive for growth on solid media, gross

Results

Acute postoperative deep infection was diagnosed in 18 of 1862 total joint arthroplasties before the use of dilute Betadine lavage and in 1 of 688 total joint arthroplasties after the initiation of this protocol (0.97% compared with 0.15%; P = .04; Table 1). There were no significant differences noted between the 2 groups with regard to mean patient age, sex ratio, or primary diagnosis between the 2 groups (Table 2). Seven hips (2.6%) were a hybrid construct with a cemented femoral component

Discussion

Our results demonstrate that a 3-minute dilute Betadine lavage combined with painting of the skin with 10% Betadine before surgical closure was associated with a significant reduction in the infection rate after primary TKA and THA (0.97%-0.15%, P = .04). Although this technique has not previously been described in total joint arthroplasty, it has been studied in other surgical fields. A recent meta-analysis reviewed 15 studies with level I or II evidence evaluating the prophylactic utility of

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The outcomes of acute periprosthetic joint infection following unicompartmental knee replacement managed with early debridement, Antibiotics, and implant retention
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Periprosthetic joint infection (PJI) following unicompartmental knee replacement (UKR) is an uncommon, yet serious, complication. There is a paucity of evidence regarding the effectiveness of Debridement-Antibiotics-and-Implant-Retention (DAIR) in this setting. The aim of this study is to investigate the effectiveness of DAIR for acute UKR PJI.
Between 2006 and 2019, 5195 UKR were performed at our institution. Over this period, sixteen patients underwent DAIR for early, acute PJI. All patients met MSIS PJI diagnostic criteria. The median age at DAIR was 67 years (range 40–73) and 12 patients were male (75.0%). The median time to DAIR was 24 days (range 6–60). Patients were followed up for a median of 6.5 years (range1.4–10.5) following DAIR.
0.3% (16/5195) of UKR in our institution had a DAIR within 3 months. 15 of 16 patients (93.8%) were culture positive, with the most common organism MSSA (n = 8, 50.0%). Patients were treated with an organism-specific intravenous antibiotic regime for a median of 6 weeks, followed by oral antibiotics for a median duration of 6 months. The Kaplan-Meier survivor estimate for revision for PJI was 57% (95%CI: 28–78%) at five years, and survivor estimate for all cause revision 52% (95%CI: 25–74%).The median Oxford Knee Score for patients with a viable implant at final follow-up was 45 points (range 39–46).
Early, acute PJI after UKR is rare. DAIR had a moderate success rate, with infection-free survivorship of 57% at 5 years. Those successfully treated with DAIR had excellent functional outcome and implant survival.
Effect of Commercially Available Wound Irrigation Solutions on Uninfected Host Tissue in a Murine Model
2024, Arthroplasty Today
Commercially available irrigation solutions are used to reduce bacterial contamination and prevent surgical site infections. However, the effect of these solutions on the healing capacity of tissue has not been well-established. The purpose of this study was to investigate the effects of 5 commercially available irrigation solutions on host tissue in a murine model.
There were 5 treatment groups: bacitracin, Clorpactin, Irrisept, Prontosan, Bactisure, and normal saline control. The irrigation solutions were applied to the wound for 30 seconds or 1 minute, as per the manufacturer’s instructions, and then washed with normal saline. Mice were sacrificed at 3 days and 10 days. The tissue was examined histologically for inflammation, edema, granulation tissue formation, and re-epithelialization. Granulation tissue formation and re-epithelialization were surrogates for effective wound healing.
All of the irrigation solutions had negative effects on host tissue in the acute phase. The inflammation and edema were improved in the later phase (10 days). Recovery and healing of the open wounds were observed for all groups at 10 days. The antiseptic irrigation solutions had similar cytotoxic effects on host tissue at 3 days and did not have delayed or compromised wound healing at 10 days when compared to normal saline control.
Single short-duration use of these commercially available antiseptic irrigation solutions appears to be safe in an uninfected wound. Data from this study will provide surgeons with useful information regarding the safety of using antiseptic wound irrigation solutions intraoperatively for prevention of surgical site infections.
A systematic review and meta-analysis comparing intrawound vancomycin powder and povidone iodine lavage in the prevention of periprosthetic joint infection of hip and knee arthroplasties
2024, Journal of Orthopaedic Science
Focus on reviewing a vigorous research effort to improve the safety profile of vancomycin powder (VP) and its optimal dose in reducing periprosthetic joint infection (PJI) is the need of the hour. This systematic review and meta-analysis attempt to explore the ongoing use of VP and VP + povidone iodine (PI) lavage to prevent PJI of hip/knee arthroplasties and highlights its challenges among the orthopedic community about the existence of the major organism and its frequency in total joint arthroplasty (TJA) patients.
We searched PubMed/MEDLINE, EMBASE databases regarding the outcomes of vancomycin powder (VP) and VP + povidone iodine (PI) combination in preventing periprosthetic joint infection of hip and knee arthroplasties.
In 5 of 7 studies, the combination of vancomycin powder (VP) and povidone iodine (PI) lavage have shown a lower risk of periprosthetic joint infection (PJI) in acute and high-risk hip and knee arthroplasties patients, with less or without serious adverse events and readmissions; while four of seven studies using VP-only found increasing rates of PJI in primary total knee arthroplasty and partial hip replacement in elderly patients with comorbidities, and significantly causes aseptic wound complications compared to the control group.
Intra-articular vancomycin powder (VP) and povidone iodine (PI) lavage showed a significant reduction of periprosthetic joint infection in primary and revision total joint arthroplasty. Before its widespread use in clinical settings, prospective randomized studies and, most importantly, its long-term efficacy and safety are recommended.
Is Topical Vancomycin an Option? A Randomized Controlled Trial to Determine the Safety of the Topical Use of Vancomycin Powder in Preventing Postoperative Infections in Total Knee Arthroplasty, as Compared With Standard Postoperative Antibiotics
2023, Journal of Arthroplasty
The demand for total knee arthroplasties (TKAs) is expected to rise in the coming decades, increasing the burden of periprosthetic joint infections (PJIs). The use of intrawound vancomycin powder (VP) has proven to be effective in reducing the incidence of PJIs after spinal surgery. That said, its effectiveness in TKA remains unclear. This trial aims to examine the efficacy of intrawound vancomycin powder first versus standard postoperative antibiotics in preventing PJIs after TKA.
This study was a double-blinded, noninferiority, randomized controlled trial. All participants received standard preoperative intravenous (IV) antibiotics (Cefazolin/Vancomycin) within 60 minutes of skin incision. Patients in the treatment group received 1 gram of VP applied intraoperatively by the orthopedic surgeon (500 mg directly on the prosthesis, 500 mg above the closed joint capsule). These patients did not receive postoperative antibiotics. Patients in the control group received standard postoperative IV antibiotics. The primary outcome was the incidence of acute surgical site infection within 42 days of procedure.
There were 80 patients randomized to the treatment group and 85 patients randomized to the control. Groups were matched with respect to baseline characteristics, including average age (66 versus 64), BMI (35.7 versus 33.4), and diabetics (16 versus 13). The trial was halted at 1 year as a significantly greater proportion (P = .03) of patients in the treatment group (n = 3, 3.75%) were diagnosed with PJIs compared to the control (n = 0).
Our trial demonstrated the intrawound application of VP to be inferior to standard postoperative IV antibiotics in reducing the incidence of PJIs after TKA.
Evaluation of the role of povidone‑iodine in the prevention of surgical site infections
2023, Surgery Open Science
The occurrence of surgical site infections (SSIs) is associated with increased risk of mortality, development of other infections, and the need for reintervention, posing a significant health burden. The aim of this review was to examine the current data and guidelines around the use of antiseptic povidone‑iodine (PVP-I) for the prevention of SSIs at each stage of surgical intervention.
A literature search for selected key words was performed using PubMed. Additional papers were identified based on author expertise.
Scientific evidence demonstrates that PVP-I can be used at every stage of surgical intervention: preoperative, intraoperative, and postoperative. PVP-I is one of the most widely used antiseptics on healthy skin and mucous membranes for preoperative surgical site preparation and is associated with a low SSI rate. For intraoperative irrigation, aqueous PVP-I is the recommended agent and has been demonstrated to decrease SSIs in a range of surgical settings, and for postoperative wound healing, there is a growing body of evidence to support the use of PVP-I.
There is a need for more stringent study designs in clinical trials to enable meaningful comparisons between antiseptic agents, particularly for preoperative skin preparation. The use of a single agent (PVP-I) at each stage of surgical intervention could potentially provide advantages, including economic benefits, over agents that can only be used at discrete stages of the surgical procedure.
Evidence supports the use of PVP-I at all stages of surgical intervention, from preoperative measures (including skin preparation, preoperative washing, and nasal decolonization) to intraoperative irrigation, through to postoperative wound management. However, there is a need for more stringent study designs in clinical trials to enable meaningful comparisons between antiseptic agents, particularly for preoperative skin preparation.
Prevention Techniques Have Had Minimal Impact on the Population Rate of Prosthetic Joint Infection for Primary Total Hip and Knee Arthroplasty: A National Database Study
2023, Journal of Arthroplasty
Several studies over the years have offered modalities that may greatly decrease the rate of periprosthetic joint infection when implemented. As a result, one would expect a drastic decrease in infection rate among the implementing population with its widespread use. The purpose of this study was to assess whether there exists a decrease in infection rate over time, after accounting for available confounding variables, within a large national database.
A large national database from 2005 to 2019 was queried for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). In total, 221,416 THAs and 354,049 TKAs were performed over the study period. Differences in 30-day infection rate were assessed with time and available preoperative risk factors using multinominal logistic regressions.
Rate of infection overall trended downward for both THA and TKA. After accounting for confounding variables, odds of THA infection marginally decreased over time (odds ratio 0.968 [0.952-0.985], P < .0001), while the odds of a TKA infection marginally increased with time (odds ratio 1.037 [1.020-1.054], P < .0001).
Individual peer-reviewed publications have presented infection control modalities demonstrating dramatic decreases in infection rate while analysis at a population level shows almost no changes in infection rate over a 15-year time period. This study supports continued investigation for influential modalities in preventing periprosthetic joint infection and care in patient selection for primary hip and knee arthroplasty.

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: The Conflict of Interest statement associated with this article can be found at doi:10.1016/j.arth.2011.03.034.

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Dilute Betadine Lavage Before Closure for the Prevention of Acute Postoperative Deep Periprosthetic Joint Infection

Abstract

Section snippets

Methods

Results

Discussion

J Hosp Infect

J Hosp Infect

J Hosp Infect

J Arthroplasty

J Hosp Infect

J Arthroplasty

J Hosp Infect

J Arthroplasty

J Arthroplasty

Risk factors for infection after knee arthroplasty. A register-based analysis of 43,149 cases

J Bone Joint Surg Am

Infection in total knee replacement: a retrospective review of 6489 total knee replacements

Clin Orthop Relat Res

Periprosthetic joint infection: the incidence, timing, and predisposing factors

Clin Orthop Relat Res

Risk factors associated with acute hip prosthetic joint infections and outcome of treatment with a rifampinbased regimen

Acta Orthop

The incidence of deep prosthetic infections in a specialist orthopaedic hospital: a 15-year prospective survey

J Bone Joint Surg Br

Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030

J Bone Joint Surg Am

The efficacy and risks of using povidone-iodine irrigation to prevent surgical site infection: an evidence-based review

Can J Surg

Efficacy of dilute Betadine solution irrigation in the prevention of postoperative infection of spinal surgery

Spine (Phila Pa 1976)

Anti-biofilm activity of sub-inhibitory povidone-iodine concentrations against Staphylococcus epidermidis and Staphylococcus aureus

J Orthop Res

In vitro efficacy of povidone-iodine solution and cream against methicillin-resistant Staphylococcus aureus

Postgrad Med J

Bactericidal activity of antiseptics against methicillin-resistant Staphylococcus aureus

J Clin Microbiol

Antimicrobial effectiveness of povidone-iodine and consequences for new application areas

Dermatology