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272
F. Da Rin de Lorenzo and J. Parvizi
bacterial development, due to the loss of skin
integrity, is reduced to a minimum
• The skin must be wet and soapy before shaving Wet hairs cut better than dry ones and do
not y away everywhere, moreover, skin
lesions are prevented
• The areas dened by the protocols or requested
by the surgeon must be shaved. If there are no
indications in this regard, a broad shave is applied
which includes the area to be operated on
• Shave the hair in the direction of growth, not
against it
• Don’t rush to complete the procedure, so as
not to create skin lesions.
• While shaving, pull and atten the skin in
accordance with the direction of shaving and
not against it
• When shaving is complete, rinse the skin gently Do not rub the skin vigorously so as not to
further, abrade the skin
• Only disposable razors must be used
• Always report skin lesions caused by
trichotomy
• Always wash your hands after the procedure
Another very important preventative point is
antibacterial prophylaxis [54–59] which must be
done upon anesthetic induction: A rst or secondgeneration cephalosporin (cefazolin or cefuroxime) must be administered for routine surgical
preoperative prophylaxis. Semi-synthetic penicillin, such as cloxacillin or oxacillin may be
used as an appropriate alternative.
Vancomycin should be considered for patients
who are current MRSA carriers or have anaphylactic allergy to penicillins. It should be taken
into consideration in the case of high-risk
patients, such as:
• Patients in regions with a high prevalence of
MRSA
• Institutionalized patients (nursing home residents, dialysis patients, and those who have
been in intensive care).
• Health workers.
• Patients with a high probability of
contamination.
In other cases, its use as prophylaxis must be
absolutely avoided. The preoperative dose of
antibiotics must be administered within an hour
of the surgical incision; this can be extended to
2 hours for vancomycin and uoroquinolones,
because, especially for vancomycin, the infusion
must occur slowly.
Post-operative antibiotics should not be
administered for more than 24 hours after surgery. Routine prophylactic use of double administration is not recommended unless the duration
of the intervention exceeds the 2 half-lives of the
antibiotic (.g., if an antibiotic has a life of 4hours,
a dose must be added after 2hours). Preoperative
antibiotics have different pharmacokinetics based
on patient weight and therefore the dose must be
adapted to weight. The type of pre-operative antibiotic given to a patient with a previous infection
should also cover the previous infecting
organism.
In thromboembolic prophylaxis [60, 61]. The
type, dose, and duration of administration of anticoagulant drugs for prophylaxis against venous
thromboembolism inuence the incidence of
infection (SSI). In Italy, most orthopedic centers
begin subcutaneous anticoagulant treatment
12 hours before surgery. In America, it starts
6–12hours after surgery.
In both cases, they continue for about 40days.
Hand washing is a step that must be respected
as Ignác Semmelweis said “Hand washing
remains one of the most important steps in avoiding infections” [62].
The surgeon and operating room staff should
mechanically wash their hands with an antiseptic
agent for a minimum of 2minutes for the rst
surgery. A shorter period may be appropriate for
subsequent cases, paying particular attention to
the interdigital spaces and the periungual area.
There is no clear difference between various antiseptic handwashing agents [62, 63].
19.4.2 Intraoperative
The preparation of the surgical eld [64–66] is
very important and must be done very carefully.
19 Periprosthetic Joint Infection: General Aspects
273
Chlorhexidine–alcoholic is more protective
than povidone-iodine against both supercial and
deep incisional infections.
There is enough evidence to enforce the universal use of space-type suits [67, 68] with air
exhaust during prostheses, although some authors
do not consider the use of this procedure
routine.
We acknowledge the presence of studies
showing iodine-impregnated drapes adhered to
the skin [69–71] which tend to decrease bacterial
counts, but no correlation has been established
with PJI. Furthermore, the application of the
adhesive sheet must remain for the entire duration of the operation without coming off and the
incision passes through the sheet and then the
skin on the surface.
Laminar ow operating rooms [72, 73] We
believe that prosthetic surgery can be performed
in operating rooms without laminar ow. Laminar
ow chambers and other strategies that can
reduce particles in operating rooms would be
expected to reduce this burden but studies have
not shown reduced SSI in laminar ow chambers
and, in some cases, are associated with increased
rates of SSI.These are complex technologies that
must operate in strict adherence to maintenance
protocols.
Operating rooms with ultraviolet light [74,
75] With UV one would expect to lower the bac-
terial load in operating rooms, but the technology
has not been studied for this application. It could
be considered an adjuvant, but not a substitute for
conventional cleaning. There are potential risks
to staff who inadvertently left UVs running at the
start of the work day.
Movement in the operating room [76–78]
Trafc in the operating room should be kept to a
minimum. The room must be prepared with all
the elements required before the intervention. It
is forbidden to enter once the intervention has
begun. The passage of the material occurs
through “clean” routes. Use of electronic devices
and other contaminating objects in the operating
room. Portable electronic devices can be contam-
inated with bacteria, therefore it is recommended
that the use of portable electronic devices be limited to what is necessary for patient care.
Use of sterile gloves and mask [79, 80] We
recommend double gloving. We recognize the
benet of changing gloves at least every 90minutes or more frequently and the need to change
punctured gloves. Permeability appears to be
affected by exposure to methacrylate cement and
gloves should be changed after any cementation.
Use of the “mother” table [81, 82]. It is recommended that the opening times of the trays
should occur as close as possible to the start of
the surgical procedure the prevent of any delays
between the opening of the tray and the start of a
surgical procedure. We recognize a theoretical
advantage of covering trays when not in use for
long periods, and that larger covers may be disadvantageous if containers are moved from contaminated areas across the sterile eld.
19.4.2.1 Aspects ofSurgical
Management [83, 84]
• High rates of contamination have been recog-
nized in studies of scalpel blades that have
been used for skin incision and it is recom-
mended to change the scalpel blade after skin
incision [85, 86]
• It is recommended to replace the suction every
60 minutes based on studies showing high
contamination rates. The cannulae can be
introduced into the femoral canal for the time
necessary to evacuate the uids, but must not
be left in the canal, where they circulate large
quantities of ambient air and particles that can
contaminate the surgical procedure [87]
• The theoretical basis for irrigation useful for
diluting contamination and removing non-
viable tissue is recognized and a greater vol-
ume of irrigation leads to greater dilution We
recognize the advantages and disadvantages
of different methods of uid irrigation, but we
do not recommend one method over another
[88–91]
274
F. Da Rin de Lorenzo and J. Parvizi
• The use of containers lled with liquids that
are open during the surgery
• The surgical checklist protocol is supported as
benecial to patient safety, in particular as it
applies to the correct administration of antibiotic prophylaxis and gauze counts [92, 93]
• There is no evidence to demonstrate that the
Use of closed drains increases the risk of PJI
• Surgical time [94, 95] It is recognized that
rates of PJI increase directly with the duration
of surgery We recognize that some surgeries
have a signicant level and unavoidable complexity which will take longer for technicians
of the procedure
• The exaggerated detachment of the tissues
devitalizes the tissues and creates areas of
necrosis, a source of possible infections as
well as the presence of hematomas.
• The administration of tranexamic acid (TA)
[96, 97] both intravenously and topically,
reduces the amount of blood loss and allogeneic blood transfusions in prosthesis. Topical
administration of TA has no obvious advantage over intravenous administration of the
drug and both are safe. However, the topical
use of TA can be used in a certain group of
patients where the intravenous use of TA is
considered inappropriate
• The use of “disposable” material ensures better asepticity [98]
• Wound dressing at the end of surgery [99,
100]:—The use of occlusive dressings with
Hydrober alginate, Aquacell, when available, is highly recommended. The acute infection ratio between aquacell dressing is 0.44%
and standard gauze 1.7%.
• Silver-impregnated dressings have not been
shown to reduce PJIs
• In the absence of conclusive data and the wide
variability in surgical practice, no recommendation is made regarding the type of specic
suture to prevent infection, but one fact is certainly important that is, do not suture tense tissues. There are sutures added with antibiotics
on the market but to date, there are no recognized EBMs.
19.4.3 Post-operative
19.4.3.1 “Mechanical” Thromboembolic Prophylaxis [101, 102]
• Elastic stockings with graduated compression
antithrombus at the pelvis height for hip prostheses, thigh height for knee prostheses, with
compression at the ankle of approximately
18 mmHg; kept in place until the patient
resumes effective walking; They are available
in different sizes.
• Intermittent pneumatic compression (IPC)
device composed of leg warmers and compressor, which exerts intermittent sequential
compression from the calf to the thighs; it
must be used postoperatively; requires careful
positioning. The two systems are complementary and can be used in a combined manner
(elastic stockings / intermittent pneumatic
compression).
• Lift and move the patient as soon as possible.
Post-operative transfusions [103, 104], pre-
disposing factors for allogeneic blood
transfusions:
• A low preoperative hemoglobin level (7–8g/
dL) is the strongest predictor for the potential
need for allogeneic transfusions.
• The use of general anesthesia.
• A higher Charlson comorbidity index (> 3).
• Female sex.
• The duration of the operation.
Allogeneic blood transfusions are associated
with an increased risk of SSI / HAI The role of
autologous transfusions in the risk of SSI/HAI
remains inconclusive.
When to remove drains [105, 106]: There is
no conclusive evidence for the optimal time for
drain removal (recommended, however, no later
than 24hours).
Another important point, for which many surgeons and companies are working, is to put the
prosthesis that is implanted in a defense condi-
19 Periprosthetic Joint Infection: General Aspects
275
tion against the germ. This position arises from
the fact that having seen that the biolm forms in
the rst hours after the operation it was thought
that at that moment in the bone-prosthesis contact, there must be something that ghts the
infection at a high concentration in the case of
antibiotics. Instead in other cases, it is the product, such as silver which cannot be in directly
contact with the bone to act as an antibacterial or
bone added with antibiotic Or, as in the case of
the Japanese experience, a disinfectant such as
iodine added to the prosthesis. And nally, a gel
is added with a targeted antibiotic, for staphylococcus or for any germ responsible for other outbreaks which is spread directly on the prosthesis
at the time of implantation. Obviously, all these
systems can also be used in the treatment of periprosthetic infections in the two stages, not only
as prevention in the rst installation.
19.4.3.2 Prostheses Cemented
withtheUse ofCement
Added withAntibiotics
[107–115]
Polymethylmethacrylate (PMMA) has been
known since the 1930s and is better known by the
commercial name of “Plexiglass or Perspex®”.
In the beginning, the material was used mainly
for the construction of safety glass but in the
1930s both an English company, ICI, and a
German researcher, Otto Roehm, proposed its use
for the creation of dental prostheses. In 1941
after the Battle of Britain (August-September
1940), RAF doctors noticed that plexiglass inclu-
sions in the skin and eyes of pilots did not induce
granulomas In 1941 PMMA was used to ll bone
defects in the skull J Charnley He began using
PMMA to x the femoral prosthetic component
(in its experience, at a follow up of 15 years, a
survival of the prosthetic implants equal to 85%)
was observed and began the modern history of
“bone cement” [116]. The use of cement (PMMA)
was later resumed to x knee prostheses (Mc
Keever, Guston). The characteristics seen can
create some problems such as the high temperature during the polymerization phase which can
create necrosis of the bone tissue, at the bonecement interface. Furthermore, a fall in arterial
pressure and an increase in central venous pressure have been demonstrated, not due to embolic
phenomena. No evident allergic phenomena, at
least until the compound is stable.
The use of antibiotic cement was introduced
in 1970 by Buchholtz and Engelbrecht [110]
Using gentamicin sulphate. But why use cement
with antibiotics in the rst implant? Bone cement
in the Australian Arthroplasty Registry had a
lower rate of revision due to infection when antibiotic cement was used (0.67%) than when
cement was used (0.91%) without antibiotics
(AOANJRR 2009) The effect of antibiotic-treated
cement has been studied most thoroughly in primary hip replacement, where there was convincing evidence of a reduced number of infections
compared to antibiotic-free cement (Figs. 19.5
and 19.6) [112, 113] The microbiology in infected
knee in previous reports from the SKAR, the
cumulative revision rate (CRR) due to infection
has been shown to have decreased from 27% during 1976–1985 to 11% during 1986–2000 [117].
Microbiology in infected knee arthroplasties in
previous SKAR reports has shown that the cumulative revision rate (CRR) decreased from 2.7%
in 1976–1985 to 1.1% during 1986–2000 due to
infection.
The release time of the antibiotic (Fig.19.3)
and the biomechanical capacity of antibioticadmixed industrial cement (Fig.19.7).
Another element to consider is the porosity of
the cement after the elimination of the antibiotic
but the new pre-packaged cement already added
with antibiotic have overcome this problem by
giving a mechanical sealing capacity equal to
cement without antibiotic (around 800 hectopascal). It is useful for the composition of the cement
itself and for its porosity that the preparation
takes place under vacuum in such a way as to
eliminate all the possible air (Fig.19.8).
276
Infection-free survival (%)
99.6
99.3
99.0
98.7
Years postoperativety
Fig. 19.5 A study
conducted on 42,250
patients who underwent
total hip and knee
replacement surgery
from 1987 to 2007in
Norway demonstrated
that the combination of
venous antibiotics and
antibiotic-treated cement
signicantly reduced the
incidence of infection in
primary prostheses [112]
99.9
Antibiotic-impregnated
cement (C),
F. Da Rin de Lorenzo and J. Parvizi
Both intravenous antibiotic prophylaxis and
antibiotic-impregnated cement (SC)
SC
C
S
Intravenous antibiotic
prophylaxis (S)
19.4.4 Characteristics ofAntibiotics
toBeAssociated withCement
(Fig.19.9)
• Stable at heat from 50 to 150°C
• Prolonged stability at 37°C
• Soluble in water
• Available in powder
• Non-toxic or allergic
• Must not attach to molecules of cement
• Small volume
• Low inuence on the mechanical properties of
the cement
• Maximum spectrum of action
• Bactericidal action
• Activity at small doses (low MIC and MBC)
Finally, the cost of each single pack of antibi-
otic cement varies from $284 to $349; each TKA
requires at least two packs. Considering approximately 250,000 cases per year of TKA, the routine
use of ABLC for prophylactic purposes in primary
implant prostheses in this country is expected to
add a cost of approximately $75 million per year.
This price justies it by lowering the infection
rate given the costs of an infected prosthesis.
No antibiotic
prophylaxis (None),
024681012
None
At this point, it is useless to make a comparison with how much it costs to treat an infected
prosthesis where in addition to the real cost
already quantied at the beginning of the chapter
there are all the social costs, the prolonged use of
antibiotics.
All this serves to clearly reduce the possibility
of an infection.
19.4.5 Bone Chips Impregnated
withAntibiotics (Figs.19.10,
19.11, and19.12) [118]
In the rst implants with bone loss, bone granules
impregnated with antibiotics can be used as
lling.
Bone allograft as an antibiotic carrier.
Vancomycin 10 times more concentrated than
cement.
High local concentration and prolonged release.
Bone granules of an average size of 5 mm
impregnated with antibiotic (Osteomyin®).
Refrigerated homo-bone grafts immersed in
rifampicin release antibiotic, on site, at thera-
peutic levels for 3weeks.
14
19 Periprosthetic Joint Infection: General Aspects
277
Fig. 19.6 Use of cement in rst implant prosthesis with
or without antibiotics (Norwegian registry) by site (femur,
tibia and patella) from 1994 to 2009. Furthermore, we
know that the biolm begins to form in the rst few hours
and therefore the release of antibiotics must occur in the
rst 24hours [112]
278
MICROGR:/HOUR
5000
TIME
0900
100
PALACOS®R+G COPAL®G+C
Compressive strength [MPa]
100
3000
Fig. 19.7 Release time, in hours, of the
antibiotic. In the rst 24 hours there is a
peak with the maximum concentration of
antibiotic which then gradually decreases
1000
100
10
1
0.1
0100 200 300
F. Da Rin de Lorenzo and J. Parvizi
CMW
Palacos R
Simplex
500
400
600700
80
90
80
70
60
50
40
30
20
10
0
92.0
78.7
Compressive strength Bending strength E-modulus
90
80
70
60
50
40
30
Bending strength [MPa]
20
10
0
Fig. 19.8 COPAL® G*C: (gentamycin and clindamycin), PALACOS (R) R+G (gentamycin): mechanical
properties (compressive strength, bending strength and
2700
2626
2500
69.0
60.3
Standard value (ISO Standard 5833)
E-modulus [MPa]
2000
1500
1000
500
0
e-modolus). A red line indicates the standard value
according to ISO Standard 5833
19 Periprosthetic Joint Infection: General Aspects
279
Antibiotic group
Aminoglvcoside
Aminoglvcoside
Cephalosporin, 1
Cephalosporin, 2
Cephalosporin, 3
Cephalosporin, 4
Cephalosporin, 5
Fluorquinolone
Glycopeptide
Lincosamide
Macrolide
Polymyvin
-lactams
-lactamase
-lactamase inhibitor
Oxazolidinones
Carbapenem
Lipopeptide
st
nd
rd
th
th
gen.
gen.
gen.
gen.
gen.
Type of
antibiotic
Tobramycin
Gentamicin
Cefazolin
Cefuroxime
Ceftazidime
Cefotaxime
Ceftaroline
Ciprofloxacin
Vancomvcin
Clindamvcin
Erythromvcin
Colistin
Piperacillin
Aztreonam
Tazobactam
Linelozid
Meropenem
Daptomvcin
Activity Dose per 40 g
Gram-negative bacteria, such as pseudomonas
Gram-negative bacteria, such as Escherichia coli, Klebsiella, in particula
aerogynous, Also aerobic bacteria (not mandatory/optioanl anaerobic)
Gram-positive, gram-negative infections limited coverage
Reduced gram positive coverage, better gram negative coverage
Gram-negative bacteria, especially pseudomonas
Gram-negative bacteria, no activity against pseudomonas
Gram-negative bacteria, no activity against pseudomonas
Gram-negative organisms, including activity against Enterobactericiae
Gram-positive bacteria, including methicillin-resistant organisms
Gram-positive, anaerobic cocci
Cocci and aerobic gram-positive bacilli
Gram-negative
Gram-negative bacteria (particularly Pseudomonas), entrobacteria and anaerobes
Only gram-negative bacteria
Gram-negative bacteria (especially Pseudomonas), entrobacteria and anaerobes
in combination with piperacillin
Multiresistant gram-positive cocci, such as MRSA
Gram-positive and gram-negative bacteria, anaerobes, Pseudomonas
Gram-positive organisms only
r Pseudomonas
cement
(in grams)
1–4,8
0,25–4,8
1–2
1,5–2
2
2
2–4
02–3
05–4
1–2
05–1
0,24
4–8
4
0,5
1,2
0,5–4
2
Antifungal
Antifungal
Amphotericin
Voricanazole
Most fung
Most fungi
i
200
300–600 mg
Fig. 19.9 The concentration of antibiotics in 40 g of cement powder and the action capabilities of the antibiotics
against various germs
Advantages:
• No risk of damaging the bone in the search for
press-t
• Presence of local antibiotics at high doses
• Greater adherence to the antibiotic in the
cleaned bone areas
Disadvantages:
• Delayed direct loading while waiting for
osteointegration
• Possibility to add only some antibiotics
Fig. 19.10 Mixing of bone chips, from donor, with antibiotic (commercial material) but it can also be done self-made.
(© Ivyspring International Publisher. Reproduced under the
terms of the Creative Commons Attribution (CC BY-NC)
license (
See http://ivyspring.com/terms for full terms and conditions)
https://creativecommons.org/licenses/by- nc/4.0/).
280
0246
AB loaded bone graft
versus
AB loaded cement
F. Da Rin de Lorenzo and J. Parvizi
14,000
AB Carrier
Storage capacity/10cc
Availability
Release 1.day
Release 6.day
Release 100.day
Purified Bone PMMA
1g
>90%
10.000–20.000mg/l
60–130mg/l
0
0.1g
>10%
40–400mg/l
Traces
Traces
Fig. 19.11 Demonstration of the different behavior
between antibiotic-loaded bone compared to antibioticloaded cement. (© Ivyspring International Publisher.
Reproduced under the terms of the Creative Commons
12,000
10,000
8,000
6,000
4,000
2,000
0
Bone
Cement
Attribution (CC BY-NC) license (https://creativecom-
mons.org/licenses/by- nc/4.0/). See http://ivyspring.com/
terms for full terms and conditions)
Fig. 19.12 Osteointegration 6 months after removal of
an infection (creeping substitution) with resorption of the
graft and deposition of new bone. (© Ivyspring
International Publisher. Reproduced under the terms of
the Creative Commons Attribution (CC BY-NC) license
(
https://creativecommons.org/licenses/by- nc/4.0/). See
http://ivyspring.com/terms for full terms and conditions)
19 Periprosthetic Joint Infection: General Aspects
281
19.5 Coatings oftheProstheses
During theOperation
The coating is carried out in the operating room
as in the case of DAC® (Defensive Antibacterial
Coating) (Figs. 19.13, 19.14, and 19.15)
[119–123].
It consists of a gel that can be added with the
targeted antibiotic in the implantation of cementless prostheses. It is applied directly to the
prosthesis and allows the elimination of the antibiotic during the possible formation of the biolm. The experiments conducted have highlighted
that its introduction does not create a detachment
of the same, thus avoiding its protective function,
as can be seen from the example reported on a
corpse where in the end the entire contact area
between the bone and the prosthesis was covered
by the gel. Furthermore, it has a reabsorption of
approximately 24hours.
Advantages:
• Possibility of adding any antibiotic not only in
powder form
• Greater search for press-t
• Presence of local antibiotics in high doses
• Direct contact between bone—gel
(absorbable)—prosthesis
Figs. 19.13 and 19.14 The application of the covering
material can be supplemented with various antibiotics
based on the sensitivity of the germs. If an antibiogram is
not available, broad-spectrum antibiotics can be applied.
Reproduced with permission of SAGE from Ref. (courtesy C. Romanò [120]