The Effect of Irrigation Fluid on Periprosthetic Joint Infection in Total Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis

Abstract

Introduction Rates of osteoarthritis and total joint arthroplasty (TJA) are on the rise globally. Periprosthetic joint infection (PJI) is the most devastating complication of TJA. A number of different intraoperative interventions have been proposed in an effort to reduce infection rates, including antibiotic cements, local antibiotic powder, and various irrigation solutions. The evidence on the importance of irrigation solutions is limited but has gained prominence recently, including the publication of a large randomized controlled trial (RCT). Thus, the purpose of this study was to evaluate the effectiveness of various irrigation solutions and pressures at reducing the rates of PJI. Methods A systematic review was performed using the electronic databases MEDLINE, Embase, and Web of Science. All records were screened in duplicate. Data collected included basic study characteristics, the details of the intervention and comparison solutions, if applicable, and rates of superficial and deep infection. A meta-analysis of comparative studies was performed to assess for consistency and potential direction of effect. Results A total of ten studies were included, of which one was an RCT, eight were retrospective cohorts, and one was a case series. In total, there were 29,630 TJAs in 29,596 patients. The mean age ranged from 61 to 80 years. Six studies compared povidone-iodine (Betadine®) to normal saline, two studies compared chlorhexidine to saline, one study compared "triple prophylaxis" to standard practice, and one study used gentamicin but had no comparison group. The pooled risk ratio for deep infection in studies using Betadine® compared to saline was 0.62 (95% confidence interval [CI]: 0.33-1.19), while for chlorhexidine it was 0.74 (95%CI: 0.33-1.65).

Stability analysis of tranexamic acid in the presence of various antiseptic solutions

“…Consequently, the utilization of these antiseptic irrigation agents has become increasingly common in both the primary and revision setting. However, to date, there is no consensus regarding the optimal irrigation solution for the prevention and management of PJI 25,26 …”

“…However, to date, there is no consensus regarding the optimal irrigation solution for the prevention and management of PJI. 25,26 The data presented in the current study should be interpreted within the appropriate context. While these data suggest TXA may degrade in the presence of sodium hypochlorite when administered topically, the vast majority of TXA is administered intravenously in the setting of TJA.…”

Antiseptic Irrigation Solutions Used in Total Joint Arthroplasty

“…Only 1 randomized study was included. There was a pooled risk ratio for deep infection of 0.62 for povidone-iodine and 0.74 for chlorhexidine compared with saline solution, but wide confidence intervals and substantial heterogeneity limited the applicability and validity of these results 65 . One of the difficulties in identifying the ideal irrigation fluid is that the relative infrequency of PJI makes detecting differences challenging.…”

“…Unfortunately, the ideal solutions have not been determined for TJA. Arguably, povidone-iodine and chlorhexidine have the most literature support and are frequently utilized 17,19,27,65,66 . With the adoption of modern irrigation solutions, some solutions, including Dakin’s solution and hydrogen peroxide, have fallen out of favor because they may cause additional cytotoxicity to tissues, which may be less pronounced with other irrigants 5,67,68 .…”

Morphology of the rat knee joint after intraarticular injection of hydroxymethyl-quinoxaline dioxide

“…Microorganisms resistant to most antibiotics and antiseptics have emerged, the ways of transmission and their persistence in the body are transforming. Antiseptics with different properties have been developed and used [4,5,6,7]. However, microbial strains with the ability to survive despite the effects of antibiotics and antiseptics are spreading.…”