How Do We Minimize Infection?

    At ICJR’s 2nd Annual Pan Pacific Orthopaedic Congress, faculty were asked to answer the question, “How do you minimize infections after joint replacement at your institution.” Below are abstracts from 3 of the presenters.

    Craig J. Della Valle, MD

    Minimizing the risk of periprosthetic joint infection (PJI) is of interest to all surgeons performing hip and knee arthroplasty. Among the most critical factors in reducing the risk of infection are:

    • The use of pre-incisional antibiotics
    • Appropriate skin preparation with clippers (as opposed to a razor for hair removal)
      Use of an alcohol-based skin preparation

    Addressing host factors is likewise critically important, such as:

    • Obesity
    • Diabetes
    • Inflammatory arthritis
    • Renal insufficiency
    • Skin disorders
    • Patients who are otherwise immune-compromised

    If modifiable risk factors are identified, it seems a reasonable approach to delay elective surgery until they can be optimized.

    Anther factor to consider is the nutritional status of the patient. In a study of 501 consecutive revisions, we found that serological markers suggestive of malnutrition (albumin, transferrin, or total lymphocyte count) were extremely common in the revision population.

    Specifically, among patients who presented for treatment of a chronic infection, 53% (67 of 126) had at least 1 marker for malnutrition. The prevalence of serologic markers of malnutrition was lower (33%) in the group of patients undergoing revision for an aseptic reason, suggesting that malnutrition was a risk factor for septic failure (P < 0.001 and OR 2.1).

    Interestingly, malnutrition was most common among patients of normal weight, but was also common among obese patients (so-called “paradoxical” malnutrition). What was more disturbing, however, was that of those patients undergoing an aseptic revision, serum markers of malnutrition were associated with a 6 times risk of an acute postoperative infection complicating the patient’s aseptic revision.

    At our center, we also have studied the use of dilute povidone-iodine (Betadine) at the end of the case, prior to wound closure, in an attempt to decrease the load of bacteria in the wound. In a retrospective review the prevalence of acute postoperative infection was reduced from just under 1% (18/1862) to 0.15% (1 of 688; P = 0.04).

    It is critical to use sterile povidone-iodone. In addition, the dilution we use is 0.35%, made by diluting 17.5 mL of 10% povidone-iodine paint in 500 mL of normal saline.

    Although this is a retrospective review, it does suggest a benefit, and we have not seen any problems associated with the use of dilute povidone-iodine.

    Author Information

    Craig J. Della Valle, MD, is from Rush University Medical Center, Chicago, Illinois.


    1. Brown NB, Cipriano CA, Moric M, Sporer SM, Della Valle C. Dilute betadine lavage prior to closure for the prevention of acute postoperative deep periprosthetic joint infection. J Arthroplasty, 27, 27-30, 2012.
    2. Yi PH, Vann E, Frank RM, Sonn KA, Moric, Della Valle C. Is malnutrition a risk factor for septic failure and acute post-operative infection following revision total joint arthroplasty? Clin Orthop, 473;175-82, 2015.
    3. Van Meurs SJ, Gawlitta D, Heemstra KA, Poolman RW, Vogely HC, Kruyt MC. Selection of an optimal antiseptic solution for intraoperative irrigation: an in vitro study. J Bone Joint Surg Am. 2014 Feb 19;96(4):285-91. 


    Kazou Hirakawa MD; Satoshi Takayanagi, MD; and Akira Saito MD

    In general, our infection control protocol for joint replacement patients includes:

    • Shorter surgical time: 75 minutes or less for primary procedures
    • Topical and subsurface skin irrigation
    • Use of iodine skin surface dressing
    • Bleeding control during and after surgery
    • Avoidance of longer tourniquet time for total knee arthroplasty

    We compared the use of 5% topical iodine irrigation (2004-2005) with the use of 5% topical iodine irrigation plus iodine skin dressings (2006-2007) to prevent infection in primary total hip arthroplasty and found the following:

    • Topical 5% iodine irrigation
      • Subsurface skin infection: 32/650=4.9%
      • Deep infection: 3/650=0.46%
    • Topical 5% iodine irrigation & 100% iodine skin dressing
      • Subsurface skin infection: 3/740=0.41%; 92% reduction
      • Deep infection: 1/740=0.14%; 70% reduction

    Between 2004 and 2013, 20 of 4319 (0.46%) total hip arthroplasty patients had an early postoperative infection, and 6 of 4319 patients (0.14%) had an acute hematogenous infection We performed a 2-stage re-implantation for 8 total hip arthroplasty patients with deep MRSA infection using a vancomycin-impregnated hydroxyapatite block. Six of 8 were successfully treated, and 2 required a Girdlestone procedure.


    1. Willis-Owen CA, Konyves A, Martin DK.Factors affecting the incidence of infection in hip and knee replacement” Bone & Joint Journal. 2010;92-B(8)1128-33.


    Hiromasa Miura, MD, PhD

    At our institution, we combine as many practices as possible that are thought to decrease the infection rate following joint replacement. Not all of them have the highest level of evidence, and some are controversial, however, our acute infection rate in only 0.27%.

    • We do not perform hair removal.
    • We use an operating room with vertical-flow ventilation (Class 100).
    • We use face masks and 2 sets of gloves.
    • We perform perioperative skin preparation using chlorhexidine.
    • We use the combination of non-adhesive nylon draping and iodine-impregnated draping.
    • We limit the total number of people who enter the operating room.
    • We minimize opening of the operating room door because it may alter the airflow pattern in the room.
    • We perform pulsed lavage with 2 liters of sterile saline using a pulsatile irrigator.
    • We do not use antibiotic-impregnated cement in primary total knee arthroplasty.
    • We try to limit operative time to less than 1 hour.
    • We try to use an intra-articular high-dose antibiotics infusion without implant removal for deep infection of a well-fixed total knee arthroplasty implant.

    Author Information

    Hiromasa Miura, MD, PhD, is from Ehime University Graduate School of Medicine, Matsuyama, Ehime, Japan.


    1. Fukagawa S, Matsuda S, Miura H: High-dose antibiotic infusion for infected knee prosthesis without implant removal. J Orthop Sci, 15:470-6, 2010.