Total knee arthroplasty and infection: how surgeons can reduce the risks

Abstract

Total joint arthroplasty (TJA) is one of the most common orthopaedic procedures. Nevertheless, several complications can lead to implant failure.Peri-prosthetic joint infections (PJI) certainly represent a significant challenge in TJA, constituting a major cause of prosthetic revision. The surgeon may have an important role in reducing the PJI rate by limiting the impact of significant risk factors associated to either the patient, the operative environment or the post-operative care.In the pre-operative period, several preventive measures may be adopted to manage reversible medical comorbidities. Other recognised pre-operative risk factors are urinary tract infections, intra-articular corticosteroid injections and nasal colonisation with Staphylococcus (S.) aureus, particularly the methicillin-resistant strain (MRSA).In the intra-operative setting, protective measures for PJI include antibiotic prophylaxis, surgical-site antisepsis and use of pre-admission chlorhexidine washing and pulsed lavage during surgery. In this setting, the use of plastic adhesive drapes and sterile stockinette, as well as using personal protection systems, do not clearly reduce the risk of infection. On the contrary, using sterile theatre light handles and splash basins as well as an increased traffic in the operating room are all associated with an increased risk for PJI.In the post-operative period, other infections causing transient bacteraemia, blood transfusion and poor wound care are considered as risk factors for PJI.Cite this article: Ratto N, Arrigoni C, Rosso F, Bruzzone M, Dettoni F, Bonasia DE, Rossi R. Total knee arthroplasty and infection: how surgeons can reduce the risks. EFORT Open Rev 2016;1: 339-344 DOI: 10.1302/2058-5241.1.000032.

A potential risk factor of total knee arthroplasty: an infected Baker’s cyst – a case report

“…Periprosthetic joint infection occurs in 0.8-1.9% of patients after TKA [6]. Periprosthetic joint infection requires a long hospital stay incurring major costs, upsetting both the clinician and patient.…”

“…Kong et al [7] reported that age, obesity, operation time, drain usage, diabetes mellitus, urinary tract infection, and rheumatoid arthritis were risk factors for periprosthetic joint infection. Ratto et al [6] reported that careful management of glucose level, general nutrition and body weight, as well as smoking cessation, reduced infection rates. However, Baker's cysts may disappear naturally after surgery and, even if they persist, no clinical manifestations are evident.…”

Skin avulsion injuries caused by the application of adhesive drapes during total knee arthroplasty

“…There are 3 main measures to minimize SSI, which include a series of preoperative, intraoperative, and postoperative measures. [ 10 , 11 ] Some medical comorbidities have been proven to be associated with increased risk of severe infection, predominantly including diabetes, obesity, rheumatoid arthritis, and immunosuppression. Particular measures must be adopted to control these comorbidities before proceeding with TJA to optimize the health of the patient and facilitate operative success.…”

An Incision Closure Bundle for Colorectal Surgery

“…Although most SSI prevention measures focus on the preoperative and intraoperative phases, the postoperative phase is also critical. Until the exudative and proliferative phases of wound healing are complete, the incisional edges are not fully sealed and the surgical incision remains vulnerable to exogenous bacterial contamination from the environment and substandard wound care . For example, lumbar spinal fusion surgery incisions may be close to the buttocks and perineum, and contamination from bedpans and commodes can pose an infection risk.…”

“…Until the exudative and proliferative phases of wound healing are complete, the incisional edges are not fully sealed and the surgical incision remains vulnerable to exogenous bacterial contamination from the environment and substandard wound care. 39,54,88 For example, lumbar spinal fusion surgery incisions may be close to the buttocks and perineum, and contamination from bedpans and commodes can pose an infection risk. Body fluids, including blood and serum, that collect in the incision can provide a rich growth medium for any contaminating organisms.…”