Contamination of primary total hip replacements in standard and ultra-clean operating theaters detected by the polymerase chain reaction

Clarke, M.; Lee, Paul T. H.; Roberts, C. S.; Gray, John; Keene, G; Rushton, Neil

doi:10.1080/00016470410001394

Cited by 25 publications

(8 citation statements)

References 2 publications

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“…To be most effective, key operating theatre staff should wear body exhaust suits while working in the ultraclean environment 1 34. However, standard culture techniques by air sampling or landing ‘mode’ as a method to assess potential wound contamination do not directly correlate with wound contamination, and they are at best surrogate measures representing the degree of air contamination at the point of sampling, which might be some distance away from the implant zone 35. There was also evidence that wound contamination was greater at the end of surgery than at the beginning 35…”

Section: Discussionmentioning

confidence: 99%

Control strategies to prevent total hip replacement-related infections: a systematic review and mixed treatment comparison

et al. 2014

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ObjectiveTo synthesise the available evidence and estimate the comparative efficacy of control strategies to prevent total hip replacement (THR)-related surgical site infections (SSIs) using a mixed treatment comparison.DesignSystematic review and mixed treatment comparison.SettingHospital and other healthcare settings.ParticipantsPatients undergoing THR.Primary and secondary outcome measuresThe number of THR-related SSIs occurring following the surgical operation.Results12 studies involving 123 788 THRs and 9 infection control strategies were identified. The strategy of ‘systemic antibiotics+antibiotic-impregnated cement+conventional ventilation’ significantly reduced the risk of THR-related SSI compared with the referent strategy (no systemic antibiotics+plain cement+conventional ventilation), OR 0.13 (95% credible interval (CrI) 0.03–0.35), and had the highest probability (47–64%) and highest median rank of being the most effective strategy. There was some evidence to suggest that ‘systemic antibiotics+antibiotic-impregnated cement+laminar airflow’ could potentially increase infection risk compared with ‘systemic antibiotics+antibiotic-impregnated cement+conventional ventilation’, 1.96 (95% CrI 0.52–5.37). There was no high-quality evidence that antibiotic-impregnated cement without systemic antibiotic prophylaxis was effective in reducing infection compared with plain cement with systemic antibiotics, 1.28 (95% CrI 0.38–3.38).ConclusionsWe found no convincing evidence in favour of the use of laminar airflow over conventional ventilation for prevention of THR-related SSIs, yet laminar airflow is costly and widely used. Antibiotic-impregnated cement without systemic antibiotics may not be effective in reducing THR-related SSIs. The combination with the highest confidence for reducing SSIs was ‘systemic antibiotics+antibiotic-impregnated cement+conventional ventilation’. Our evidence synthesis underscores the need to review current guidelines based on the available evidence, and to conduct further high-quality double-blind randomised controlled trials to better inform the current clinical guidelines and practice for prevention of THR-related SSIs.

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Section: Discussionmentioning

confidence: 99%

Control strategies to prevent total hip replacement-related infections: a systematic review and mixed treatment comparison

et al. 2014

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“…Others have found that bacterial contamination of the wound in THR was not reduced with laminar-flow ventilation. 18 In order to be effective, laminar flow requires no obstructions to the path of the high flow of air. Obstructions cause eddies which in turn can produce areas of risk for increasing contamination and infection.…”

Section: Discussionmentioning

confidence: 99%

Does the use of laminar flow and space suits reduce early deep infection after total hip and knee replacement?

Hooper¹,

Rothwell

Frampton³

et al. 2011

The Journal of Bone and Joint Surgery. British volume

210

120

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We have investigated whether the use of laminar-flow theatres and space suits reduced the rate of revision for early deep infection after total hip (THR) and knee (TKR) replacement by reviewing the results of the New Zealand Joint Registry at ten years. Of the 51 485 primary THRs and 36 826 primary TKRs analysed, laminar-flow theatres were used in 35.5% and space suits in 23.5%. For THR there was a significant increase in early infection in those procedures performed with the use of a space suit compared with those without (p < 0.0001), in those carried out in a laminar-flow theatre compared with a conventional theatre (p < 0.003) and in those undertaken in a laminar-flow theatre with a space suit (p < 0.001) when compared with conventional theatres without such a suit. The results were similar for TKR with the use of a space suit (p < 0.001), in laminar-flow theatres (p < 0.019) and when space suits were used in those theatres (p < 0.001). These findings were independent of age, disease and operating time and were unchanged when the surgeons and hospital were analysed individually. The rate of revision for early deep infection has not been reduced by using laminar flow and space suits. Our results question the rationale for their increasing use in routine joint replacement, where the added cost to the health system seems to be unjustified.

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“…One possible explanation could be that the cementation per se in some way creates conditions that are conducive to the growth of bacteria following the apparently unavoidable contamination peroperatively (Davis et al 1999, Clarke et al 2004a, Maathuis et al 2005. Necrotic bone tissue around the cement, caused by cement toxicity or heat generation during curing of the cement, could be the potential growth medium.…”

Section: Discussionmentioning

confidence: 99%

“…Peroperative wound contamination during implantation of primary total hip arthroplasties (THAs) occurs in more than 30% of all operations in standard and in ultra-clean operating theaters (Davis et al 1999, Clarke et al 2004a, b, Maathuis et al 2005. Many THAs are considered to fail due to the presence of clinically unrecognized low-grade infection.…”

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confidence: 99%

Does cement increase the risk of infection in primary total hip arthroplasty? Revision rates in 56,275 cemented and uncemented primary THAs followed for 0–16 years in the Norwegian Arthroplasty Register

et al. 2006

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Introduction The cementation of a total hip prosthesis may cause bone necrosis, either by direct toxicity or by generation of heat during the polymerization process. This necrotic bone may create conditions that encourage the growth of bacteria. We compared the revision rates due to infection in primary uncemented total hip arthroplasties (THAs) with those of cemented THAs with antibiotic-loaded cement and to those of cemented THAs without antibiotic cement.Methods Data from the Norwegian Arthroplasty Register for the period 1987-2003 were used. To have comparable groups, we analyzed only primary THAs performed because of primary osteoarthrosis, and where both the acetabular and the femoral component of the prosthesis were either uncemented or cemented (n = 56,275).Results In total, 252 revisions due to infection were reported. Compared to the uncemented THAs (n = 5,259), the risk of revision due to infection for THAs without antibiotic cement (n = 15,802) was increased 1.8 times (CI 1.0-3.1; p = 0.04). No differences could be detected when compared to THAs with antibioticloaded cement (n = 35,214) (RR 1.2, CI 0.7-2.0; p = 0.5). The average operating time for uncemented THAs was 15 min less than for cemented THAs.Interpretation The risk of revision due to infection was the same for uncemented and for cemented arthroplasties with antibiotic-loaded cement, but higher for cemented arthroplasties without antibiotic cement. Our findings can be explained by reduced resistance

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Contamination of primary total hip replacements in standard and ultra-clean operating theaters detected by the polymerase chain reaction

Cited by 25 publications

References 2 publications

Control strategies to prevent total hip replacement-related infections: a systematic review and mixed treatment comparison

Control strategies to prevent total hip replacement-related infections: a systematic review and mixed treatment comparison

Does the use of laminar flow and space suits reduce early deep infection after total hip and knee replacement?

Does cement increase the risk of infection in primary total hip arthroplasty? Revision rates in 56,275 cemented and uncemented primary THAs followed for 0–16 years in the Norwegian Arthroplasty Register

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