ArticlePDF Available

Rate of surface contamination in the operating suite during revision total joint arthroplasty

Authors:

Abstract

Background This study estimated operating room surface contamination rates during aseptic vs septic total joint arthroplasty and evaluated the similarity between clinically infecting organisms and those isolated from contaminated surfaces. Methods Patients undergoing total hip and knee revision arthroplasties were identified, and surface and tissue samples were collected. Cases were classified aseptic or septic based on Musculoskeletal Infection Society criteria for prosthetic joint infection. Positive surface cultures were compared with intraoperative tissue cultures. Positive cultures were speciated and tested for antimicrobial sensitivity. Results Samples were collected from 31 aseptic and 18 septic cases. Patients had similar demographics and time to explantation. Surface contamination rates for septic revisions were greater than those for aseptic revisions (77% vs 13%). During septic revisions, when intraoperative tissue cultures were positive, the surgical field was contaminated in 14 of 15 cases. The kappa correlation statistic for positive surgical cultures matching the surface sample was 0.9 (95% confidence interval: 0.78-1). Conclusions Septic revisions had a significantly higher rate of surgical field contamination than aseptic revisions. Cultures suggest that bacteria contaminating the septic revision surgical field likely originated from the infected joint. Although this observation seems obvious, it is an important piece of information when discussing best practices during a single-stage exchange revision. Further clinical studies will demonstrate the use of a preparation and reset period during a single-stage revision to remove contaminated surfaces.
Original research
Rate of surface contamination in the operating suite during revision
total joint arthroplasty
Matthew J. Dietz, MD
a
,
*
, Phillip A. Bostian, MD
a
, Emily P. Ernest, BS
a
,
Adam E. Klein, MD
a
, P. Rocco LaSala, MD
b
, Benjamin M. Frye, MD
a
, Brock A. Lindsey, MD
a
a
Department of Orthopaedics, Health Sciences Center, WVU School of Medicine, Morgantown, WV, USA
b
Department of Pathology, Health Sciences Center, WVU School of Medicine, Morgantown, WV, USA
article info
Article history:
Received 1 August 2018
Received in revised form
14 September 2018
Accepted 17 September 2018
Available online 29 October 2018
Keywords:
Total joint revision
Contamination
Prosthetic joint infection
abstract
Background: This study estimated operating room surface contamination rates during aseptic vs septic
total joint arthroplasty and evaluated the similarity between clinically infecting organisms and those
isolated from contaminated surfaces.
Methods: Patients undergoing total hip and knee revision arthroplasties were identied, and surface and
tissue samples were collected. Cases were classied aseptic or septic based on Musculoskeletal Infection
Society criteria for prosthetic joint infection. Positive surface cultures were compared with intraoperative
tissue cultures. Positive cultures were speciated and tested for antimicrobial sensitivity.
Results: Samples were collected from 31 aseptic and 18 septic cases. Patients had similar demographics
and time to explantation. Surface contamination rates for septic revisions were greater than those for
aseptic revisions (77% vs 13%). During septic revisions, when intraoperative tissue cultures were positive,
the surgical eld was contaminated in 14 of 15 cases. The kappa correlation statistic for positive surgical
cultures matching the surface sample was 0.9 (95% condence interval: 0.78-1).
Conclusions: Septic revisions had a signicantly higher rate of surgical eld contamination than aseptic
revisions. Cultures suggest that bacteria contaminating the septic revision surgical eld likely originated
from the infected joint. Although this observation seems obvious, it is an important piece of information
when discussing best practices during a single-stage exchange revision. Further clinical studies will
demonstrate the use of a preparation and reset period during a single-stage revision to remove
contaminated surfaces.
©2018 The Authors. Published by Elsevier Inc. on behalf of The American Association of Hip and Knee
Surgeons. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
Introduction
Prosthetic joint infection (PJI) is a well-recognized complication
of hip and knee arthroplasty procedures and occurs in 0.7%-2.4% of
cases [1,2]; it is projected that it will account for $1.6 billion in
health-care costs by the year 2020 [1]. Currently, management of
PJI, which may include irrigation and debridement with retention
of components in acute PJI, has a substantial risk (64%; range, 11%-
84%) of infection relapse [3-6]. Alternatively, management by two-
stage exchange may yield greaterlikelihood of infection control but
is associated with an increased morbidity and mortality [4,7,8]. The
benecial effect of two-stage exchange on infection control and
survivorship has been addressed by Berend et al. among others, in
which factoring the mortality of patients postoperatively brings the
success rate to approximately 75% [4,9]. These studies support an
increased focus on single-stage exchanges as highlighted by Had-
dad et al. and Jiranek et al. [10,11]. Evaluation of the single-stage
exchange as a treatment for PJI has highlighted the need for strict
patient-selection criteria [11-13]. Adherence to these criteria and
good surgical technique have led to reported successes equivalent
or near equivalent to those of the two-stage exchange with less
cost, decreased morbidity, and improved function [3,14,15]. Haddad
described the preparation and reset period as the time after
One or more of the authors of this paper have disclosed potential or pertinent
conicts of interest, which may include receipt of payment, either direct or indirect,
institutional support, or association with an entity in the biomedical eld which
may be perceived to have potential conict of interest with this work. For full
disclosure statements refer to https://doi.org/10.1016/j.artd.2018.09.007.
*Corresponding author. Department of Orthopaedics, Health Sciences Center e
West Virginia University School of Medicine, PO Box 9196, Morgantown, WV 26506
9196, USA. Tel.: þ1 304 285 7444.
E-mail address: mdietz@hsc.wvu.edu
Contents lists available at ScienceDirect
Arthroplasty Today
journal homepage: http://www.arthroplastytoday.org/
https://doi.org/10.1016/j.artd.2018.09.007
2352-3441/©2018 The Authors. Published by Elsevier Inc. on behalf of The American Association of Hip and Knee Surgeons. This is an open access article under the CC BY-NC-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Arthroplasty Today 5 (2019) 96e99
thorough debridement and explantation of infected implant ma-
terial when the wound is packed with betadine-soaked sponges
and the wound edges temporarily approximated. The complete
cleaning or change of surgical rooms is then undertaken with sur-
geons and assistant(s) changing into clean scrubs, new instruments
being opened, and the patient being reprepped and redraped
before the reimplantation of the nal implants [11]. This step re-
quires additional time for the patient under anesthesia and can add
expense to an already costly surgery.
The main aim of this study was to estimate the rate of operative
surface contamination during aseptic vs septic total hip and knee
revision arthroplasties. Secondary aims were to evaluate the simi-
larity between clinically infecting organisms and those isolated
from the contaminated surfaces. Our hypothesis was that septic
revisions would demonstrate higher contamination rates than
aseptic revisions; although this may seem obvious, we are unaware
of any published studies on this topic.
Material and methods
After obtaining institutional review board approval, we prospec-
tively identied consecutive patients undergoing total hip or knee
revision arthroplasties from October 2014 to July 2016. All surgeries
were performed in oneuniversity-based hospitalpractice among four
fellowship-trained orthopedic surgeons. Intraoperative tissue sam-
ples were excised witha scalpel from veseparate areas, placed into a
sterile container, and processed by the clinical microbiology labora-
tory as per the standard of care. After specimen collection, revisions
were classied as either aseptic or septic according to the criteria
outlined by the Musculoskeletal Infection Society at that time (cur-
rent minorcriteria have since been altered to exclude the presence of
purulence and include leukocyte esterase changes in the synovial
uid.). Septic revisions were those that either had a sinus tract
communicating with the prosthesis, a pathogen isolated by preop-
erative or intraoperative culture from two separate tissue or uid
samples obtained from the affected prosthetic joint, or four of the
followingsix criteria:(1) elevated erythrocytesedimentation rate and
C-reactive protein (erythrocyte sedimentation rate >30 mm/h; C-
reactive protein >10 mg/L), (2) elevated synovial uid white blood
cell count (>3000 cells/
m
L), (3) elevated synovial uid neutrophil
percentage (>65%), (4) presence of purulence in the affected joint, (5)
isolation of a microorganism in a single periprosthetic tissue or uid
culture, or (6) >5 neutrophils per high-powered eld in ve high-
powered elds observed at 400 magnication [16].
Aseptic revisions and septic revisions with an identied infect-
ing organism received antibiotics before incision. Antibiotics were
held in septic revisions until intraoperative cultures were obtained.
Once all implanted components had been removed, ve operating
room surface samples were obtained in a consistent manner using
sponges hydrated with neutralizing buffer (3M, St. Paul, MN).
Sample-site acquisition was standardized by the sampling techni-
cian for each case and included surgeons gloves, front of surgeons
gown, light handles, drapes, and scalpel handle. After sample pro-
curement, each case was managed per routine care as determined
by the attending surgeon. Sponges were processed immediately
after sample attainment by placing them into 50 mL of brain heart
infusion broth (Becton Dickinson, Franklin Lakes, NJ) within a
sterile bag and stomaching with a Seward Stomacher 80 (Seward,
Bohemia, NY) at 256 rotations per minute for 10 minutes. The
samples were kept refrigerated overnight, plated on 5% sheeps
blood agar plates, and incubated at 37
C for 48 hours. A plate was
considered positive if it contained greater than two colony-forming
units after 48 hours of incubation. All unique colony morphotypes
were identied to genus or species level by matrix-assisted laser
desorption ionization time of ight mass spectrometry (Vitek MS;
Biom
erieux, Durham, NC) using manufacturer-recommended pro-
tocols. Standard quality-control testing for all identication and
antimicrobial susceptibility testing procedures were veried as
acceptable and were performed by a routine automated method
(Vitek2 GN81 and GP67 cards, Biom
erieux) and/or by manual
Kirby-Bauer disk diffusion on Mueller Hinton media with break-
points and interpretive criteria derived from Clinical Laboratory
Standards Institute recommendations (M-100 S26). Contaminated
surfaces in the same case with conrmed similar species were only
tested for susceptibilities once.
Statistical analysis
A pilot study demonstrated an average aseptic contamination
rate of 20% (n ¼15 surfaces) and an 80% contamination rate (n ¼15
surfaces) in the septic group. With a presumed culture-negative
rate of 20% in the septic revisions, a sample population of at least
13 patients would provide 10 culture-positive septic revisions. The
collection of at least 23 aseptic cases would provide type II error of
less than 0.2 (power ¼0.8). An analysis of continuous variables was
performed with Studentst-test. The Fisher exact test was used due
to smaller sample size to compare contamination rates between
groups. The degree of correlation was quantied by kappa statistic.
Statistical signicance was set at P<.05. A statistical analysis was
performed with JMP statistical software (SAS, Cary, NC).
Results
Patients undergoing revision for aseptic vs septic PJI were of
similar sex, age, and body mass index, although the septic group
had a slightly increased American Society of Anesthesiologists
classication score with a mean difference of 0.35 (95% condence
interval [CI] [0.01-0.69]; P¼.045) (Table 1). The time to explanta-
tion was seven minutes longer in the aseptic group (mean ¼54.6
min, time to explantation in septic group, 47.3), but the difference
was not signicant (95% CI: 8.5 to 23 minutes, P¼.36). All patients
were classied as aseptic or septic revision before the surgery with
the exception of one presumed aseptic patient who had 3 on 5
prosthetic tissue cultures positive for bacteria; therefore, this case
was recategorized as a septic revision.
There were no positive clinical cultures among aseptic revisions.
However, 15 of 18 septic revision cases returned with positive
periprosthetic tissue cultures; the remaining three lacked positive
tissue cultures but met the criteria of infection and were treated as
such (Table 2). The contamination rate among aseptic revisions was
13% (4/31 cases) (95% CI: 5%-29%) with 3% (5/155 surfaces) (95% CI:
1.2%-7.5%) of total sampled surfaces positive for contaminants. By
contrast, the contamination rate for septic revisions was 78% (14/
18) (95% CI: 54%-92%) with 50% (45/90) (95% CI: 40%-60%) of total
sampled surfaces positive for contaminants, which was signi-
cantly higher than those for aseptic revisions (P<.001).
Table 1
Characteristics of patients by aseptic vs septic revision.
Demographic variable Aseptic revisions Septic revisions Pvalue
n3118
Number of females 15 10 .77
Age (y) 62.16 64.72 .48
BMI (kg/m
2
) 33.64 34.29 .80
ASA class (1-4) 2.71 (þ0.53) 3.06 (þ0.64) .045
Time to explanation (min) 54.62 (±28.93) 47.25 (±21.99) .36
Total knee revisions 19 12 .77
Total hip revisions 12 6
ASA, American Society of Anesthesiologists; BMI, body mass index.
M.J. Dietz et al. / Arthroplasty Today 5 (2019) 96e99 97
Furthermore, the mean number of contamination-positive samples
per case among aseptic cases (0.16, range: 0-2) was signicantly
less than that for septic cases (2.5, range: 0-5) (P<.0001). Drapes
were the most frequently contaminated surface in both aseptic and
septic revisions (Table 3).
Comparison of surface culture contaminants with isolates
recovered by tissue culture for the 15 culture-positive septic revi-
sion cases revealed 14 matches (93%) (95% CI: [66, >99%]) to the
species level compared with the 0% (0/31) correlation seen in
aseptic revisions (P<.0001). In comparison, only 33% (95% CI: 6%-
79%) of the culture-negative septic revisions exhibited contami-
nation (P¼.56). Also, the kappa correlation statistic for positive
surgical cultures matching the surface sample was 0.9 (95% CI:
0.78-1). One septic revision case had a positive tissue culture, but
no organisms were isolated as contaminants; the patient had been
on intravenous antibiotics for several days for the treatment of a
concurrent discitis before obtaining intraoperative cultures from
the joint. The percent of positive surgical cultures matching the
contaminating organism was 93% (13/14) (95% CI: 66, >99%). Or-
ganisms identied as surface contaminants are listed in Table 4.
Similarly, comparison of antimicrobial susceptibility data between
organisms recovered from septic revision tissue cultures and those
from corresponding operative surface cultures demonstrated
identical proles in 34 of 34 instances (100%).
Discussion
In this prospective consecutive series of hip and knee revision
arthroplasties, septic revisions had a signicantly higher rate of
surgical eld contamination than aseptic revisions. Although it may
seem obvious that septic revisions would lead to more contami-
nation of the operative surfaces, this study is the rst published
nding to support this assumption. The bacteria found as con-
taminants on the surgical surfaces originated from the infected
joint based on matching tissue and surface cultures.
A limitation of this study was the assumption that the antibiotic
susceptibility prole was a surrogate for identication of matched
organism pairs. Although not as precise as molecular strain analysis
techniques (eg, pulse-eld gel electrophoresis or multilocus
sequence typing), the high degree of correlation between each
tissue culture and surface contaminate isolate is of concern and
indicates contamination of the eld and operating room by the
infecting organism. We would emphasize that association of a
contaminated eld does not provide conclusive evidence for risk of
further infection. Although this study provides support that sur-
faces during a revision PJI often become contaminated, this report
does not provide evidence of the impact of contamination on
outcomes of these patients. Dening the actual clinical benetofan
intervention aimed at reducing contamination such as a prepara-
tion and reset period during a single-stage surgery will ultimately
require longer prospective studies with infection-free survival.
This study demonstrated a contamination rate of 13% in aseptic
revisions at an average explant time of 54 minutes, which is similar
to other reported rates of contamination during the course of surgery
[17-19]. Bible et al. described a 9.5% overall contamination rate when
comparing covered (2%) to uncovered (16.7%) implant trays [17].
Davis et al. described 63% of cases as having some level of contam-
ination [20]. However, many of the recommendations (eg, removing
gloves after initial preparation) are now routinely used by surgeons
to mitigate against contamination. We note that the length of time
before sampling was not different between the aseptic and septic
groups. In reviewing the literature, the duration of surgery has been
demonstrated to increase contamination rates. Dalstrom et al.
demonstrated a 15% contamination rate at one hour increasing to
30% at 4 hours [18,21].Ritteretal.founda35-foldincreaseincolony-
forming units per hour in a room with ve people compared with an
undisturbed room [22,23]. Although others have found no relation-
ship between time and rates of contamination, [19,20] we felt it
important to consider this potentially confounding variable. In 13% of
our aseptic cases with contamination, most organisms isolated from
surfaces were not typical of PJIs (the single exception being Staphy-
lococcus epidermidis). The only difference we found in baseline
characteristics was a slightly elevated American Society of Anes-
thesiologists score in the septic group, which one might expect from
a patient population presenting as more acutely ill.
We did nd a signicantly higher rate of contamination in the
septic cases. This percentage is even higher when excluding spec-
imens that had no culturable organisms (culture-negative cases)
from clinical specimens. These three cases met Musculoskeletal
Infection Society criteria despite sterile intraoperative and/or pre-
operative cultures. We speculate that the inability to recover or-
ganisms from surface sites for these three cases may have been due
Table 2
Characteristics of aseptic vs septic revisions: contamination rates and degree of correlation to the infection organism identied in the surgical cultures.
Recorded results Aseptic revisions Septic revisions Pvalue
n3118
Positive clinical cultures 0 15 <.001
Positive cases with surface contamination 13% (4/31) [95% CI: 5%-29%] 78% (14/18) [95% CI: 54, 92%] <.001
Contamination rate excluding culture-negative cases 13% (4/31) [95% CI: 5, 29%] 93% (14/15) [95% CI: 66%-100%] <.0001
Percent correlation surgical culture and positive sample 0 93% (13/14) [95% CI: 66%-100%] <.0003
Average number of positive samples per case 0.16 (0-2) 2.50 (0-5) <.0001
A case was considered contaminated if one of the surfaces sampled had a positive culture (2 colony-forming units/plate).
Table 3
Number of positive samples per surface for aseptic and septic revisions.
Number of positive samples per surface
a
Aseptic
revisions
Septic
revisions
Pvalue
Gloves 0 11 <.001
Gown 1 9 <.001
Scalpel handle 1 6 <.0037
Light handle 1 6 <.0037
Drapes 2 13 <.001
a
Each surface was sampled once during each case. Multiple surfaces could be
positive in one case.
Table 4
Highlights the organisms presenting as contaminants from the sampled surfaces.
Contaminant present
Aseptic cases Septic cases
a
Staphylococcus haemolyticus
Staphylococcus epidermidis
Corynebacterium
aurimucosum
Enterococcus faecalis
Paenibacillus species
Methicillin-resistant Staphylococcus aureus
Methicillin-sensitive Staphylococcus aureus
Escherichia coli
Methicillin-resistant Staphylococcus epidermidis
Methicillin-sensitive Staphylococcus epidermidis
Serratia marcescens
Staphylococcus lugdunensis
a
All contaminants listed were also found on intraoperative tissue cultures.
M.J. Dietz et al. / Arthroplasty Today 5 (2019) 96e9998
to the fastidious nature of the organism(s), which also likely
hampered their recovery from clinical samples. We also found that
the average number of surfaces contaminated during a septic case
vs an aseptic case was signicantly different.
The drapes were the most frequently contaminated surface,
followed by the surgeons gloves, surgeons gown, and then scalpel
handles and lights. Prior reports demonstrate a contamination rate
of 0%-14.5% for light handles [20,24], 9% for scalpel blades [20], 14%-
57% for gloves [20,25], 6%-48% for gowns [20]. These rates were not
witnessed in our aseptic revisions, but similar rates were observed
in the septic revisions.
This study supports our hypothesis that septic revisions would
have higher contamination rates than aseptic revisions. Although
this observation seems somewhat obvious, it is an important piece of
information in a discussion of the use of a preparation and reset
period during a single-stage exchange. Currently, only expert-level
opinion (level V evidence) exists to support the removal of drapes
and proceeding with total repreparation of the room, all operating
room personnel, and the patient during a single-stage exchange [21].
This step prolongs the anesthetic time for the patient and increases
the expense of the surgery from a materials standpoint; however, it
is thought to be a necessary step for the success of this procedure.
Therefore, the recommendation of Haddad et al. and Jiranek
et al. for the wholesale exchange of all operating room materials
and for all personnel to change their scrubs while the wound re-
mains temporarily closed merits consideration [10-12,21]. How-
ever, further prospective collection of data is required to
denitively support this practice.
Conclusions
Septic revision arthroplasties had a signicantly higher rate of
surgical eld contamination than aseptic revisions. Bacteria
contaminating the surgical eld of septic revisions most often
originated from the infected joint itself, based on the matching of
surface cultures and tissue cultures. These results may support the
practice of exchanging gowns, gloves, drapes, and instruments after
prosthesis explantation during septic revisions to eliminate
contaminated surfaces and reduce bacterial presence at the time of
reimplantation. This topic needs to be studied further in a pro-
spective manner with follow-up with longer term outcomes.
Acknowledgments
This work was supported by a Faculty Senate Research Grant
from West Virginia University. The sponsor had no role in the study
design; collection, analysis or interpretation of the data; the writing
of the manuscript; or the decision to submit the article for publi-
cation (Research and Scholarship Advancement (RSA) Grant, West
Virginia).
In addition, the research reported in this publication was sup-
ported by the National Institutes of Health under Award Number
5u54GM104942-03. The content is solely the responsibility of the
authors and does not necessarily represent the ofcial views of the
National Institutes of Health.
References
[1] Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of peri-
prosthetic joint infection in the United States. J Arthroplasty 2012;27(8
Suppl):61.
[2] Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ. The
impact of surgical-site infections following orthopedic surgery at a commu-
nity hospital and a university hospital: adverse quality of life, excess length of
stay, and extra cost. Infect Control Hosp Epidemiol 2002;23(4):183.
[3] Bauer T, Piriou P, Lhotellier L, Leclerc P, Mamoudy P, Lortat-Jacob A. Results of
reimplantation for infected total knee arthroplasty: 107 cases. Rev Chir
Orthop Reparatrice Appar Mot 2006;92(7):692.
[4] Berend KR, Lombardi Jr AV, Morris MJ, Bergeson AG, Adams JB, Sneller MA.
Two-stage treatment of hip periprosthetic joint infection is associated with a
high rate of infection control but high mortality. Clin Orthop Relat Res
2013;471(2):510.
[5] Odum SM, Fehring TK, Lombardi AV, et al. Irrigation and debridement for
periprosthetic infections: does the organism matter? J Arthroplasty 2011;26(6
Suppl):114.
[6] Fehring TK, Odum SM, Berend KR, et al. Failure of irrigation and debridement
for early postoperative periprosthetic infection. Clin Orthop Relat Res
2013;471(1):250.
[7] Haleem AA, Berry DJ, Hanssen AD. Mid-term to long-term followup of two-
stage reimplantation for infected total knee arthroplasty. Clin Orthop Relat
Res 2004;428(428):35.
[8] Choi HR, Beecher B, Bedair H. Mortality after septic versus aseptic revision
total hip arthroplasty: a matched-cohort study. J Arthroplasty 2013;28(8
Suppl):56.
[9] Cochran AR, Ong KL, Lau E, Mont MA, Malkani AL. Risk of reinfection after
treatment of infected total knee arthroplasty. J Arthroplasty 2016;31(9 Suppl):
156.
[10] Jiranek WA, Waligora AC, Hess SR, Golladay GL. Surgical treatment of pros-
thetic joint infections of the hip and knee: changing paradigms?
J Arthroplasty 2015;30(6):912.
[11] Haddad FS, Sukeik M, Alazzawi S. Is single-stage revision according to a strict
protocol effective in treatment of chronic knee arthroplasty infections? Clin
Orthop Relat Res 2015;473(1):8.
[12] Rudelli S, Uip D, Honda E, Lima AL. One-stage revision of infected total hip
arthroplasty with bone graft. J Arthroplasty 2008;23(8):1165.
[13] Callaghan JJ, Katz RP, Johnston RC. One-stage revision surgery of the
infected hip. A minimum 10-year followup study. Clin Orthop Relat Res
1999;369:139.
[14] Greidanus NV, Peterson RC, Masri BA, Garbuz DS. Quality of life outcomes in
revision versus primary total knee arthroplasty. J Arthroplasty 2011;26(4):
615.
[15] Vanhegan IS, Morgan-Jones R, Barrett DS, Haddad FS. Developing a strategy to
treat established infection in total knee replacement: a review of the latest
evidence and clinical practice. J Bone Joint Surg Br 2012;94(7):875.
[16] Parvizi J, Zmistowski B, Berbari EF, et al. New denition for periprosthetic joint
infection: from the workgroup of the musculoskeletal infection society. Clin
Orthop Relat Res 2011;469(11):2992.
[17] Bible JE, O'Neill KR, Crosby CG, Schoenecker JG, McGirt MJ, Devin CJ. Implant
contamination during spine surgery. Spine J 2013;13(6):637.
[18] Dalstrom DJ, Venkatarayappa I, Manternach AL, Palcic MS, Heyse BA,
Prayson MJ. Time-dependent contamination of opened sterile operating-room
trays. J Bone Joint Surg Am 2008;90(5):1022.
[19] Li CH, Yew AY, Kimball JA, McBride DQ, Wang JC, Lu DC. Comparison of
operating eld sterility in open versus minimally invasive microdiscectomies
of the lumbar spine. Surg Neurol Int 2013;4(Suppl 5):S295.
[20] Davis N, Curry A, Gambhir AK, et al. Intraoperative bacterial contamination in
operations for joint replacement. J Bone Joint Surg Br 1999;81(5):886.
[21] Gulhane S, Vanhegan IS, Haddad FS. Single stage revision: regaining mo-
mentum. J Bone Joint Surg Br 2012;94(11 Suppl A):120.
[22] Ritter MA, French ML, Hart JB. Microbiological studies in a horizontal wall-less
laminar air-ow operating room during actual surgery. Clin Orthop Relat Res
1973;97(97):16.
[23] Ritter MA. Surgical wound environment. Clin Orthop Relat Res
1984;190(190):11.
[24] Hussein JR, Villar RN, Gray AJ, Farrington M. Use of light handles in the
laminar ow operating theatreis it a cause of bacterial concern? Ann R Coll
Surg Engl 2001;83(5):353.
[25] Eckersley JR, Williamson DM. Glove punctures in an orthopaedic trauma unit.
Injury 1990;21(3):177.
M.J. Dietz et al. / Arthroplasty Today 5 (2019) 96e99 99
... In our study, surgical lights, with 10.24% (21/205) of the contaminated samples, has the lowest bacterial load rate among level 1 cases. In the survey of [12], the extent of microbial contamination in people who have undergone arthroplasty surgery due to knee inflammation was investigated using the tissue culture technique. Moreover, the bacterial load of many items such as surgeon gloves, surgical gowns (front surface), and surgical light handles was checked. ...
Article
Full-text available
Introduction:In this descriptive cross-sectional study, we have made our attemptto recognize the highest microbial contamination in operating rooms (OR),which could have a strikingcorrelation with increasing duration of hospitalization or probability of death. Material & Methods:Totally 3909 samples of surgical equipmenthave been sampled from the various surgical fieldfrom Aug to Oct 2020. The specimens were obtained in the morning shift,and all the bacteria which had more than 50,000 CFU are noticed as pathogenic microorganism. Eventually,we classified the cases into 4 levels in terms of hygiene and sterility,as mentioned in the text. Results:Among all the specimens, the highest contamination rate wasrelated to Sandbags, O2& CO2tank, Toilet slippers, ORs desk,and Tourniquets,respectively. Overall,ten species of bacteria have been detected,and also Staphylococcus aureus, E. coli,and Bacillus subtilis were the most commonly transmitted infectious pathogens in the OR ward. Conclusion:According to our findings, it is recommended that adequate cleaning should be done regularly, at least 3 timesa week.To improve disinfection methods,we can also increase equipment contact with detergents.
... 50,51 It has been recognized that preventing bacterial recolonization of the implant surface after in situ biofilm treatment is key to reduce reinfection rates. [50][51][52] To our best knowledge, there has been no report of a method that eradicates established biofilm on implants in situ and at the same time coats the implant in situ with antimicrobial agents to prevent reinfection. ...
Article
Full-text available
Purpose: The aim of this study was to investigate a new method of in situ biofilm treatment for infected prostheses that remove bacterial biofilm and prevent reinfection through the use of an immobilizing agent in combination with the actions of biofilm-lysing enzymes and bactericidal antimicrobials. Methods: We investigated the combination of self-immobilization chemistry of dopamine with a biofilm-lysing enzyme, α-amylase (Am), and an antimicrobial agent, silver nitrate (Ag), to treat model Staphylococcus aureus (S. aureus) biofilms formed on titanium. The efficacy of biofilm removal and bacterial treatment was analyzed by crystal violet, colony-forming unit assays, confocal laser scanning microscopy, and scanning electron microscopy (SEM). To confirm the in situ coating of the titanium surface with antimicrobial Ag as a strategy to prevent bacterial recolonization, SEM in secondary electron mode (SE), backscatter electron mode, (BSE) and energy-dispersive spectroscopy (EDX) were used. The antimicrobial activity of the coated surface was evaluated by optical density measurement and colony-forming unit assays. Results: Polydopamine (PDA)-assisted treatment showed approximately a 2 log reduction in recoverable CFU and a 15% increase in biofilm removal efficacy compared to treatments that had only Am or Ag. More importantly, PDA-assisted treatment was found to immobilize Ag on the surface after the treatment, rendering them resistant to bacterial recolonization. Conclusion: Our in vitro findings suggested that this PDA-assisted treatment and the surface immobilization-enhanced treatment concept could be promising in the development of advanced treatment for implant retention surgery for an infected prosthesis.
Article
Full-text available
Background: The increasing number of patients experiencing periprosthetic total knee arthroplasty (TKA) infections and the cost of treating them suggest that we seek alternatives to two-stage revision. Single-stage revision is a potential alternative to the standard two-stage procedure because it involves only one surgical procedure, so if it is comparably effective, it would be associated with less patient morbidity and lower cost. Questions/purposes: We compared (1) the degree to which our protocol of a highly selective single-stage revision approach achieved infection control compared with a two-stage revision approach to TKA infections; and (2) Knee Society scores and radiographic evidence of implant fixation between the single-stage and two-stage patients who were treated for more complicated infections. Methods: Between 2004 and 2009, we treated 102 patients for chronic TKA infections, of whom 28 (27%) were treated using a single-stage approach and 74 (73%) were treated using a two-stage approach. All patients were available for followup at a minimum of 3 years (mean, 6.5 years; range, 3-9 years). The indications for using a single-stage approach were minimal/moderate bone loss, the absence of immunocompromise, healthy soft tissues, and a known organism with known sensitivities for which appropriate antibiotics are available. Participants included 38 men and 64 women with a mean age of 65 years (range, 45-87 years). We used the Musculoskeletal Infection Society definition of periprosthetic joint infection to confirm infection control at the last followup appointment. Radiographs were evaluated for signs of loosening, and patients completed Knee Society Scores for clinical evaluation. Results: None of the patients in the single-stage revision group developed recurrence of infection, and five patients (93%) in the two-stage revision group developed reinfection (p=0.16). Patients treated with a single-stage approach had higher Knee Society scores than did patients treated with the two-stage approach (88 versus 76, p<0.001). However, radiographic findings showed a well-fixed prosthesis in all patients with no evidence of loosening at last followup in either group. Conclusions: Our data provide preliminary support to the use of a single-stage approach in highly selected patients with chronically infected TKAs as an alternative to a two-stage procedure. However, larger, multicenter, prospective trials are called for to validate our findings. Level of evidence: Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
Article
Full-text available
Postoperative wound infection is a preventable risk that can lead to significant adverse outcomes and increased cost of care. Minimally invasive surgeries (MIS) have been found to have lower rates of postoperative infection compared with the traditional approach. To assess if the reported difference is related to intraoperative contamination or to other factors, we assessed the surgical field for sterility. We compared 10 MIS versus 10 traditional microdiscectomies. Swabs of the operating field were obtained before and after the procedure from multiple sites in the operating room. Positive and negative controls were taken of the skin immediately before and after preparation of the incision site. All swabs were plated out on Columbia blood agar plates and grown for 48 hours. Colony counting was performed to determine growth. There was no statistically significant difference in the colony counts of swab sites in traditional microdiscectomies compared with MIS microdiscectomies. There was no significant contamination of the operating field using either approach. In this prospective study, we found that there was no significant difference in bacterial counts in swabs of operative sites in either traditional or MIS microdiscectomies, suggesting that the decreased rate of postoperative infection in the reported literature for MIS cases may be related to other factors, such as patient selection and/or postoperative care.
Article
Full-text available
This review summarises the opinions and conclusions reached from a symposium on infected total knee replacement (TKR) held at the British Association of Surgery of the Knee (BASK) annual meeting in 2011. The National Joint Registry for England and Wales reported 5082 revision TKRs in 2010, of which 1157 (23%) were caused by infection. The diagnosis of infection beyond the acute post-operative stage relies on the identification of the causative organism by aspiration and analysis of material obtained at arthroscopy. Ideal treatment then involves a two-stage surgical procedure with extensive debridement and washout, followed by antibiotics. An articulating or non-articulating drug-eluting cement spacer is used prior to implantation of the revision prosthesis, guided by the serum level of inflammatory markers. The use of a single-stage revision is gaining popularity and we would advocate its use in certain patients where the causative organism is known, no sinuses are present, the patient is not immunocompromised, and there is no radiological evidence of component loosening or osteitis. It is our opinion that single-stage revision produces high-quality reproducible results and will soon achieve the same widespread acceptance as it does in infected hip arthroplasty.
Article
All surgical operations have the potential for contamination, and the equipment used can harbour bacteria. We collected samples from 100 elective primary hip and knee arthroplasties. These showed rates of contamination of 11.4% for the sucker tips, 14.5% for light handles, 9.4% for skin blades and 3.2% for the inside blades used during surgery; 28.7% of gloves used for preparation were also contaminated. Of the samples taken from the collection bags used during hip arthroplasty, 20% grew bacteria, which represents a significant microbial reservoir. Also, 17% of theatre gowns were contaminated at the end of the operation. Contamination was found in 10% of the needles used during closure of the fascia. Overall, 76% of the organisms grown were coagulase-negative staphylococcus. A total of 63% of operations showed contamination in the field of operation. Some changes in practice are suggested. Follow-up for a minimum of two years revealed one deep infection but the organism was not identified as a contaminant. These data provide a baseline for studying the bacteriology of the surgery of revision arthroplasty.
Article
Background: The purpose of this study was to determine the incidence of subsequent reinfections after initial treatment of an infected total knee arthroplasty, identify risk factors leading to reinfection, and compare results among the varying treatment modalities. Methods: A total of 1,493,924 primary TKA patients were identified from the Medicare data between October 1, 2005, and December 31, 2011. Patients who encountered periprosthetic joint infection (PJI) after TKA were identified using International Classification of Diseases, Ninth Revision, Clinical Modification code 996.66. The risk of subsequent PJI was stratified based on the first-line treatment and compared between the various first-line treatment groups. Results: A total of 16,622 patients (1.1%) were diagnosed with PJI. The Kaplan-Meier risk of PJI was 0.77% at 1 year and 1.58% at 6 years. Age (P < .001), Charlson score (P < .001), hospital control (P < .001), race (P = .036), census region (P = .031), gender (P < .001) were identified as risk factors for PJI. Of the PJI patients, 20.8% (n = 2806) were treated with incision and drainage (I&D), 15.9% (n = 2150) treated with I&D and liner exchange, 22.7% (n = 3069) treated with 1-stage revision, 39.7% (n = 5364) treated with 2-stage revision, and 0.98% (n = 132) treated with amputation. After first-line treatment, 26% of patients with PJI had a subsequent PJI. Patients undergoing I&D as a first-line treatment had the highest risk of reinfection, with risks of 28.2% at 1 year and 43.2% at 6 years. One-stage revision patients had 33.9% greater adjusted risk of reinfection than 2-stage revision patients (P < .001). Conclusion: Two-stage reimplantation, despite 19% recurrence, had the highest success rate. Given the higher failure rates of I&D and single-stage revisions, guidelines need to be established for their specific indications.
Article
In this paper we make the case for the use of single-stage revision for infected knee arthroplasty.
Article
Prosthetic joint infection (PJI) of the hip and knee remains one of the most common and feared arthroplasty complications. The impact and cost of PJI is significant, both to the patient and to the health care system. Recent reports of results of different treatment strategies have led many surgeons to modify their approach to management of PJI. This paper will explore apparent paradigm shifts, both to indications and technique, including the importance of waiting for bacterial identification, the decreasing role for irrigation and debridement (I&D) with retention of components, the increased utilization of single stage revision, and conversely a decreasing role for two-stage exchange. Strategies for treating drug-resistant organisms and management of failed treatment will also be examined. Copyright © 2015. Published by Elsevier Inc.
Article
Mortality rates after revision total hip arthroplasty (THA) for periprosthetic sepsis were investigated in 93 patients and compared to 93 patients, matched for age, gender, year of surgery, who underwent revision for aseptic failures. The mortality rate was 33% (31/93) in the septic group and 22% (20/93) in the aseptic group at 5 and 6year follow-up, respectively (P=0.10). Patients in the septic group died on average 6years earlier (74 versus 80yrs; P<0.05) than those in the aseptic group. Charlson Comorbidity Index (CCI) was an independent predictor of mortality among the both groups (P<0.05), while age (P<0.01) was a predictor of mortality only in the aseptic group. While revision THA for sepsis alone did not predict increased mortality, a 33% mortality rate at five years in patients with an average age of 66years and earlier death by 6years compared to aseptic revisions is alarming.
Article
Background context: Postoperative spine infections have been reported to occur in 1% to 15% of patients and subsequently lead to significant morbidity and cost, with an elevated risk for instrumented cases. Every effort should be made to minimize the risk of intraoperative wound contamination. Consequently, certain practices are followed in the operating room to prevent contamination, many of which are not evidence based. Conversely, certain objects believed to be sterile are frequently overlooked as potential sources of contamination. Purpose: To assess to what degree contamination of spinal implants occurs during spine surgery and evaluate whether coverage of implants alters the rate of contamination. Study design: Prospective study. Study sample: This study included 105 consecutive noninfection surgical cases performed by a single spine surgeon that required the use of instrumentation. Outcome measure: Spinal implant contamination. Methods: Cases were randomized to have all implant trays either remain uncovered (n=54) or covered (n=51) with sterile surgical towels on opening until implants were required for the case. After the last implant was placed, a sterile culture swab was used to obtain a sample from all open implants that had been present at the start of the case. The paper outer wraps of the implant trays were sampled in each case as a positive control, and an additional 105 swabs were capped immediately after they were opened to obtain negative controls. Swab samples were assessed for bacterial growth on 5% sheep blood Columbia agar plates. Of note, only departmental funding was used and no applicable financial relationships exist with any author. Results: No growth was observed on any of the 105 negative controls, whereas 99.1% of positive controls demonstrated obvious contamination. Cultures from implant samples demonstrated a 9.5% overall rate of contamination with 2.0% (n=1) of covered implants versus 16.7% (n=9) of uncovered implants demonstrating contamination. Length of time implant trays were open before sample collection; implant type (plate, rods, vs. polyetheretherketone), number of scrubbed personnel, and number of implants used were all not found to be significantly associated with implant contamination (p>.05). However, coverage of implants was found to significantly reduce the implant contamination rate (p=.016). Conclusions: The contamination of sterile implants during spine surgery was found to occur. However, this contamination was independent of the amount of time the implant trays remained open. Coverage of implants significantly reduces this contamination. Therefore, no matter the expected duration of a case, implant coverage is a simple modifiable way to reduce the risk of intraoperative wound contamination and potentially reduce postoperative infections.
Article
Background: Periprosthetic infection after total hip arthroplasty (THA) is a devastating complication. Reported rates of infection control range from 80% to 95% but mortality rates associated with treatment of infected THA are also substantial and we suspect underreported. Questions/purposes: For patients selected for two-stage treatment of infected THA we therefore determined (1) mortality; (2) rate of reimplantation; and (3) rate of reinfection. Methods: We identified 202 patients (205 hips) with infected primary or revision THA treated with a two-stage protocol between 1996 and 2009 in our prospectively collected practice registry. Patients underwent two-stage treatment for infection, including removal of all implants and foreign material with implantation of an antibiotic-laden cement spacer in the first stage followed by intravenous culture-specific antibiotics for a minimum of 6 weeks. Second-stage reimplantation was performed if erythrocyte sedimentation rate and C-reactive protein were trending toward normal and the wound was well healed. Thirteen patients (13 hips) were lost to followup before 24 months. The minimum followup in surviving patients was 24 months or failure (average, 53 months; range, 24-180 months). Results: Fourteen patients (7%; 14 hips) died before reimplantation and two were not candidates because of medical comorbidities. The 90-day mortality rate after the first-stage débridement was 4% (eight patients). Of the 186 patients (189 hips) who underwent reimplantation, 157 (83%) achieved control of the infection. Including all patients who underwent the first stage, survival and infection control after two-stage reimplantation was 76%. Conclusion: Two-stage treatment of deep infection in primary and revision THA is associated with substantial mortality and a substantial failure rate from both reinfection and inability to perform the second stage. Level of evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.