Importance of preventive surgical protocols.

Deep prosthetic joint infection- most dreadful complication . Best and the most effective method - prevention. Awareness , education and participation of entire surgical team critical.

Venn diagram demonstrating the dependent nature of bacteria, host factors, and wound environment on the development of infection.

Number and virulence

Status and viablity

Ability to eliminate

HANSSEN A. D. et.al. J Bone Joint Surg 1996:78:458-71

JOINT REPLACEMENT SURGERY

ELECTIVE PROPER PLANNING CALL 2 WKS PRIOR FOR PRE OP INV

Pre operative Evaluation

IDENTIFY PATIENTS WITH

Impaired host defenses Operativesites that may provide a poor wound environment Remote sources ofinfection

BLOOD INV

HB, PCV, ESR DLC TLC BLOOD GR & CROSS MATCH BLOOD SUGAR HbA1C LFT RFT BT, CT, PT, INR HIV, HBSAG

Radiology

URINE EXAMINATION

ROUTINE MICROSCOPY CULTURE

MID STREAM , CLEAN CATCH

CARDIAC EVALUATION

ECG 2 D ECHO CARDIOLOGIST OPINION IF DEEMED NECESSARY

FOCI OF INFECTION

DENTAL ( CARIES) ENT ( OM, CSOM ) LOCAL SKIN ( PSORAISIS, PREVIOUS INCISIONS, ULCERS, FOLLOCULITIS, FUNGAL INFCTIONS) PULMONARY INFECTION

P A Assessment

Essential part of pts prep before surgery Educates patient about anaesthesia Communicates actual RISK to patient Helps in allaying anxiety

Host Factors

Diabetes and obesity

Lethal Combination Infection rate was lower with drain . Risk factors for periprosthetic infection after TKA.

Clin Orthop Relat Res. 2009 Jun;467(6):1577-81. Epub 2008 Oct 8.

Stroke, UTI, ileus, post op hemorrhage, transfusions and wound infections. Higher mortality Increased length of stay .

J Bone Joint Surg Am. 2009 Jul;91(7):1621-9.

Immunocompromised States

Joint replacement uncommon in HIV+ve.

Most experience gainedinpatients with haemophilia. Deep sepsis - 18.7%primary and 36.3% for revisions. A total of 44% ofinfections resolved fully after medical and/orsurgical treatment.

Journal of Bone andJointSurgery - British Volume, Vol 83-B, Issue 7, 1050-1054

Haemophilia

High risk of failure as a result ofinfection. Most byStaphylococcus epidermidis, hematogenous - coagulation factor. Life expectancy low. Improvement in quality of life may outweigh the risk of failure.

Total KneeArthroplastyinHemophilic Arthropathy John M. Norian, BS,Michael D. Ries, MD,Susan Karp, RNandJulie Hambleton, MD

Malnutrition

Total lymphocyte count of less than 1500 cellsper cubic millimeter (1.5 x 109per liter) Albuminlevelof less than 35 grams per liter increased prevalence of wound complications.

J.Arthroplasty,6: 321-325, 1991

Smoking

Wound healing, cardiopulmonary. Postoperative intensive care, delayin discharge Wound complications ratetwice that of non-smokers.

J Bone Joint Surg Br, Mar 2003; 85-B: 178 - 181

METHOTREXATE

Can be continued. No increase in risk for perioperative infections. Discontinuing MTX - disease flare .

Grenan DM, Gray J, Loudon J, Fear S. Ann Rheum Dis. 2001 Perhala RS, Wilke WS, Clough JD, Segal AM.. Arthritis Rheum.1991

CLOPIDOGREL DISCONTINUED ATLEAST 7 DAYS PRIOR (1) INTRA-ARTICULAR STEROIDS SX TO BE POSTPONED FOR ATLEAST 3 MNTHS (2)

(1)Anaesthesia & intensive care , June 2005 (2) A. V. Papavasiliou, D. L. Isaac, R. Marimuthu, A. Skyrme , JBJS British Volume, Vol 88-B, 2006

Skin care

Shaving not recommended. Remove hair with clippers where necessary in the operating ward. Clippers- reduction in postoperative infection rates

Alexander JW, Fischer JE, Boyajian M, Palmquist J, Morris MJ. Arch Surg.1983; 118:347 -52. Balthazar ER, Colt JD, Nichols RL.. South Med J.1982; 75:799 -801.

The surgical ward

Avoid preoperative stay in the ward Clean environment to protect from colonization with bacteria from infected patients.

SKIN ANTISEPSIS

MICROSHIELD : 2.5% CHLORHEXIDINE + 75% ETHANOL STERLIUM : PROPANOL 10% BETADINE : Povidone-iodine BACTOSCRUB : 4% CHORHEXIDINE GLUCONATE

Povidone-iodine may impair wound-healing

Toxic to fibroblasts and keratinocytes (1)

Not be used for preparation of open wounds or on postoperative dressings (2)

(1) Cooper ML, Laxer JA, Hansbrough JF.. J Trauma.1991; 31:775 -84. (2) Kramer SA.. J Vasc Nurs.1999; 17:17 -23.

Surgeon scrub

Chlorhexidine gluconate achieved significantly (p < 0.01) greater adjusted mean log bacterial count reductions than did povidone-iodine at all sampling times.

Aly R, Maibach HI. Am J Infect Control. 1988;16:173 -7.

Povidone-iodine and chlorhexidine gluconate have equal efficacy in decreasing the initial bacterial contamination of the skin of a patient or surgeon Chlorhexidine gluconate longer effect, less toxic in open wounds and causes less skin irritation with prolonged use (1)

(1) Grabsch EA, Mitchell DJ, Hooper J, Turnidge JD.. ANZ J Surg.2004; 74:769 72.

During draping, leg should be held by a scrubbed & gowned member of the team. Bacterial air counts have been shown to be 4.4 times higher during draping using unscrubbed, ungowned leg holder

Brown AR, Taylor GJ, J bone Joint Surg Br 1996;78:92

Occlusive Drapes

Ioban : Prevents penetration & lateral migration of bacteria, reduce wound contamination as measured by positive cultures of specimens obtained from the skin

Plastic adhesive drapes can avulse or harm thin, friable skin

Levy JH, Nagle DM, Curling PE, Waller JL, Kopel M, Tobia V. Crit Care Med.1988 Geelhoed GW, Sharpe K, Simon GL. Surg Gynecol Obstet. 1983

DISPOSABLE NON WOVEN CLOTHING

Spun laced fibre Bacteria tend to get entrapped within the fibres Open structure so air circulation not impended Single use & expensive

Wraparound gowns and synthetic gowns

Decreases the number of colony-forming units compared with that associated with the use of cotton gowns or operating room clothing

Hubble MJ, Weale AE, Perez JV, Bowker KE, MacGowan AP, Bannister GC. .J Hosp Infect. 1996

GLOVES

Gloves perforation during orthopaedics procedure 40 %. So double gloving. Gloves exclusively for draping are most likely to be contaminated. So routine changing of outer gloves after draping is advisable

James Howard & Arlen Hanssen. Journal of Arthroplasty 2007; 22

Avoid repetitive touching of surgical gown with gloves because bacteria invariably progress to surface of gown

James Howard & Arlen Hanssen. Journal of Arthroplasty 2007; 22

Surgical site infection decreased by

Control of perioperative glucose levels especially in patients with diabetes. Maximizing patient oxygenation in the first twenty-four hours perioperatively Normothermia in the perioperative period

Latham R, Lancaster AD, Covington JF, Pirolo JS, Thomas CS. Infect Control Hosp Epidemiol. 2001

DRAINS

Clamping

drains intermittently intotal knee arthroplasty results in significantly less external blood loss

No change in morbidity or mortality.

This study was a level 1 therapeutic study

ANZ J Surg. 2007 May;77(5):333-5. Drain clamping in knee arthroplasty, a randomized controlled trial.