Antibiotic prophylaxis for wound infections in total joint arthroplasty: A SYSTEMATIC REVIEW
Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK. The Bone & Joint Journal
(Impact Factor: 3.31).
07/2008; 90(7):915-9. DOI: 10.1302/0301-620X.90B7.20498
We reviewed systematically the published evidence on the effectiveness of antibiotic prophylaxis for the reduction of wound infection in patients undergoing total hip and total knee replacement. Publications were identified using the Cochrane Library, MEDLINE, EMBASE and CINAHL databases. We also contacted authors to identify unpublished trials. We included randomised controlled trials which compared any prophylaxis with none, the administration of systemic antibiotics with that of those in cement, cephalosporins with glycopeptides, cephalosporins with penicillin-derivatives, and second-generation with first-generation cephalosporins. A total of 26 studies (11 343 participants) met the inclusion criteria. Methodological quality was variable. In a meta-analysis of seven studies (3065 participants) antibiotic prophylaxis reduced the absolute risk of wound infection by 8% and the relative risk by 81% compared with no prophylaxis (p < 0.00001). No other comparison showed a significant difference in clinical effect. Antibiotic prophylaxis should be routine in joint replacement but the choice of agent should be made on the basis of cost and local availability.
Available from: Petteri Sjögren
- "In addition, enhanced surgical techniques minimizing blood loss, thereby avoiding the need for (allogeneic) blood transfusions and eliminating postoperative hematoma, reduce the risks for SSI. Optimizing the patients by addressing risk factors associated with SSI (such as smoking, malnutrition, diabetes, infections and conditions that compromise the immunological defence systems) in combination with the timely distribution of antibiotic prophylaxis and to maintain perioperative normothermia can significantly improve postoperative outcomes (AlBuhairn et al., 2008; Lindstrom et al., 2008). "
Available from: Ian Carluke
- "Prophylactic parenteral antibiotics prophylaxis at the start of trial was Gentamicin (4.5 mg/kg) and this was changed to Gentamicin (3 mg/kg) and Teicoplanin (400 mg) in February 2009  in line with our trust prophylaxis for primary joint replacement. On the initiation of the study the latest systematic review stated there was insufficient evidence to suggest that there was a significant difference in the efficacy of cephalosporin’s compared with that of teicoplanin or penicillin-derivatives, or that a particular generation of cephalosporin’s was more effective than another . Antibiotics were given as a single dose, within 30 minutes of induction. "
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187,000 hip and knee joint replacements are performed every year in the National Health Service (NHS). One of the commonest complications is surgical site infection (SSI), and this represents a significant burden in terms of patient morbidity, mortality and cost to health services around the world. The aim of this randomised controlled trial (RCT) is to determine if the addition of triclosan coated sutures to a standard regimen can reduce the rate of SSI after total knee replacement (TKR) and total hip replacement (THR).
2400 patients due to undergo a total hip or knee replacement are being recruited into this two-centre RCT. Participants are recruited before surgery and randomised to either standard care or intervention group. Participants, outcome assessors and statistician are blind to treatment allocation throughout the study. The intervention consists of triclosan coated sutures vs. standard non-coated sutures. The primary outcome is the Health protection Agency (HPA) defined superficial surgical site infection at 30 days. Secondary outcomes include HPA defined deep surgical site infection at 12 months, length of hospital stay, critical care stay, and payer costs.
To date there are no orthopaedic randomised controlled trials on this scale assessing the effectiveness of a surgical intervention, particularly those that can be translated across the surgical specialities. The results from this trial will inform evidence-based recommendations for suture selection in the management of patients undergoing total hip or knee replacement. If triclosan coated sutures are found to be an effective intervention, implementation into clinical practice could improve long-term outcomes for patients undergoing hip and knee replacement.
Current Controlled Trials ISRCTN 17807356.
Available from: Giandomenico Logroscino
- "Researchers are aggressively pursuing strategies to deliver antibiotics locally to the site of injury/surgery. The most common biodegradable polymer/antibiotic combination is PLGA scaffolds loaded with antibiotics such as ciprofloxin, gentamycin, and vancomycin [165, 166]. PLGA scaffolds have demonstrated successful sustained local delivery of these antibiotics for up to 20 or more days in vitro and in preclinical animal models [141, 142, 167–169]. "
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ABSTRACT: Bone substitutes are being increasingly used in surgery as over two millions bone grafting procedures are performed worldwide per year. Autografts still represent the gold standard for bone substitution, though the morbidity and the inherent limited availability are the main limitations. Allografts, i.e. banked bone, are osteoconductive and weakly osteoinductive, though there are still concerns about the residual infective risks, costs and donor availability issues. As an alternative, xenograft substitutes are cheap, but their use provided contrasting results, so far. Ceramic-based synthetic bone substitutes are alternatively based on hydroxyapatite (HA) and tricalcium phosphates, and are widely used in the clinical practice. Indeed, despite being completely resorbable and weaker than cortical bone, they have exhaustively proved to be effective. Biomimetic HAs are the evolution of traditional HA and contains ions (carbonates, Si, Sr, Fl, Mg) that mimic natural HA (biomimetic HA). Injectable cements represent another evolution, enabling mininvasive techniques. Bone morphogenetic proteins (namely BMP2 and 7) are the only bone inducing growth factors approved for human use in spine surgery and for the treatment of tibial nonunion. Demineralized bone matrix and platelet rich plasma did not prove to be effective and their use as bone substitutes remains controversial. Experimental cell-based approaches are considered the best suitable emerging strategies in several regenerative medicine application, including bone regeneration. In some cases, cells have been used as bioactive vehicles delivering osteoinductive genes locally to achieve bone regeneration. In particular, mesenchymal stem cells have been widely exploited for this purpose, being multipotent cells capable of efficient osteogenic potential. Here we intend to review and update the alternative available techniques used for bone fusion, along with some hints on the advancements achieved through the experimental research in this field.
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