Prosthetic joint infections (PJIs) are a major complication of total joint arthroplasty (TJA) that can result in significant increases in patient morbidity and mortality and decreased quality of life. Infection rates after total hip arthroplasty and total knee arthroplasty are reported to be between 0.5 percent and 2 percent. Current cost estimates for the treatment of PJIs are three to four times that of the index procedure, and the projected annual healthcare costs associated with PJI by 2030 will total approximately $1.85 billion, with increases in costs mainly attributable to increases in volume. The standard of care for preventing PJIs has evolved over time and involves a combination of preoperative, intraoperative, and postoperative measures.

Preoperative measures
Preoperative risk factors for PJI include obesity, anemia, malnutrition, glycemic control, smoking, and Staphylococcus aureus colonization. Per the AAOS Clinical Practice Guideline (CPG) for the Diagnosis and Prevention of Periprosthetic Joint Infections, patients with a BMI ≥35 have a two- to six-fold increased risk of PJI. For patients with obesity, preoperative informed consent highlighting the risks and benefits associated with arthroplasty and the importance of weight management must be attempted.

Malnutrition and anemia are mutually related and potentially modifiable surgical risk factors of PJI. Malnutrition can be defined as albumin <3.5 g/dL, and or white blood cell counts of fewer than 4 cells × 10³/μL, and/or hemoglobin <12 g/dL. Anemia is defined as hemoglobin <12 g/dL in women and <13 g/dL in men. The incidence of preoperative anemia in patients undergoing orthopaedic surgeries ranges from 21 to 35 percent. According to a retrospective study conducted by Greenky et al, PJI occurred more frequently in patients with anemia compared with non-anemic patients (4.3 percent versus 2 percent, respectively; P <0.01). The overall risk of PJI is higher in anemic patients compared with non-anemic patients. Patients with chronic anemia and malnutrition should undergo preoperative optimization.

Patients should undergo preoperative nasal and throat screening for colonization or infection with methicillin-sensitive or methicillin-resistant S. aureus and extremity decolonization of carriers prior to surgery. Jeans et al demonstrated that adoption of a screening and decolonization protocol in patients scheduled to undergo TJA led to a significant reduction in PJI rate, from 1.92 percent to 1.42 percent.

Diabetes mellitus is an established risk factor for infections, yet evidence is still scarce and conflicting on how perioperative hyperglycemia and glycemic control prior to TJA modify the risk for developing PJI. As per the 2022 AAOS Surgical Management of Osteoarthritis of the Knee Evidence-Based CPG, optimization of perioperative glucose control (<126 mg/dL) after total knee arthroplasty should be attempted.

Intraoperative measures
Intraoperative measures aim to reduce the risk of contamination and inoculation during surgery. These include timely administration of perioperative antibiotic prophylaxis, control of OR traffic, irrigation of wounds, and proper wound-closure techniques.

Cefazolin is the most appropriate perioperative antibiotic prophylaxis for patients undergoing TJA. However, in patients with a true immunoglobulin E–mediated allergic reaction to penicillin (e.g., bronchospasm, urticaria, angioedema, anaphylaxis), cefazolin should be avoided. In such cases, weight-based (15 mg/kg) vancomycin may be used as an alternative prophylactic antibiotic. Postoperative first- or second-generation cephalosporins are routinely administered and continued for 24 hours at many institutions after skin closure to further limit PJI, despite limited evidence of its efficacy.

Intraoperative pre-closure irrigation of wounds with diluted Betadine, chlorhexidine, commercially available wound-irrigation solutions (e.g., Irrisept, Bactrisure), and normal saline has been used to prevent surgical site infection. Surgical site irrigation during TJA is a practice routinely done by orthopaedic surgeons to prevent PJI.

Unnecessary door openings and traffic in the OR are associated with higher risks of environmental contamination. Restricting entry into the OR is a simple, low-cost way to prevent possible contributors to PJI; it decreases unnecessary disruptions, controls OR traffic, and reduces bacterial load.

Microbial contamination of sterile surgical gloves increases with longer surgeries. Double gloving is recommended in all orthopaedic surgeries to limit contamination of surgical site wounds. The current recommendation is to change the entire team’s outer glove prior to applying the cutaneous adhesive drape; prior to incision; and following bone preparation, prosthesis reduction, and cementing.

Proper wound-closure techniques are essential in preventing prolonged postoperative wound drainage (>5 days) and the increased risk of PJI. Barbed monofilament suture provides a more watertight seal and allows a more cosmetic closure. The use of silver-impregnated dressings following closure has been shown to significantly decrease wound complications with a four-fold decrease in the rate of PJI.

Postoperative measures
Postoperative care is critical in preventing PJIs. Interventions include routine postoperative follow-up and early detection and management of infections through patient education on the signs and symptoms of infection, such as fever, erythema, swelling, and drainage from the surgical wound site.

The use of prophylactic antibiotics for patients undergoing dental procedures remains controversial. AAOS and the American Dental Association recommend that physicians discontinue the practice of routine antibiotic prophylaxis for routine dental care due to limited evidence in efficacy of preventing PJI. However, a recent International Consensus Meeting on surgical site infection and PJI recommended that prophylactic antibiotics prior to dental procedures should be based on individual risk factors and the complexity of dental procedures.

PJIs are a serious postoperative complication with significant morbidity, mortality, and increased economic burden on our healthcare system. Preoperative optimization is essential in addressing modifiable risk factors. Timely administration of perioperative antibiotic prophylaxis, irrigation of wounds, and proper wound-closure techniques have all demonstrated significant reduction in PJI risk. Prophylactic antibiotics after the initial perioperative course and routine prophylactic antibiotics for dental procedures remain controversial. Further research on strategies in PJI prevention may provide better insights on how to reduce infection following orthopaedic surgeries.

Mohammed K. Alsarraj, MD, is an orthopaedic surgery resident at the Michigan State University–McLaren Health Care program in Flint, Michigan.

Nathanael Adams, MD, is an orthopaedic surgery resident at the Michigan State University–McLaren Health Care program in Flint, Michigan.

Ajay Srivastava, MD, FAAOS, is director of the orthopaedic surgery residency program at McLaren Flint and an adult reconstruction orthopaedic surgeon at McLaren Flint and Hurley Medical Center.

References

1. Premkumar A, Kolin DA, Farley KX, et al: Projected economic burden of periprosthetic joint infection of the hip and knee in the United States. J Arthroplasty 2021;36(5):1484-9.e3.
2. Maradit Kremers H, Lewallen LW, Mabry TM, et al: Diabetes mellitus, hyperglycemia, hemoglobin A1C and the risk of prosthetic joint infections in total hip and knee arthroplasty. J Arthroplasty 2015;30(3):439-43.
3. Higuera C, Parvizi J: AAOS Clinical Practice Guideline: Diagnosis of Periprosthetic Joint Infections in Hip and Knee. In: Parvizi J, Kerr GJ, Glynn A, Higuera CA (Eds.), Periprosthetic Joint Infection: Practical Management Guide (1st ed.). Jaypee Brothers Medical Publishing; 2013:177-84.
4. Shohat N, Parvizi J: Prevention of periprosthetic joint infection: examining the recent guidelines. J Arthroplasty 2017;32(7):2040-6.
5. Ryan SP, Kildow BJ, Tan TL, et al; American Association of Hip and Knee Surgeons Research Committee: Is there a difference in infection risk between single and multiple doses of prophylactic antibiotics? A meta-analysis. Clin Orthop Relat Res 2019;477(7):1577-90.
6. Aboltins CA, Berdal JE, Casas F, et al: Hip and Knee Section, Prevention, Antimicrobials (Systemic): Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019;34(2S):S279-88.
7. Kheir MM, Dilley JE, Ziemba-Davis M, et al: The AAHKS Clinical Research Award: extended oral antibiotics prevent periprosthetic joint infection in high-risk cases: 3855 patients with 1-year follow-up. J Arthroplasty 2021;36(7S):S18-25.
8. Jevsevar DS, Abt E: The new AAOS-ADA Clinical Practice Guideline on Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures. J Am Acad Orthop Surg 2013;21(3):195-7.
9. Rezapoor M, Parvizi J: Prevention of periprosthetic joint infection. J Arthroplasty 2015;30(6):902-7.
10. Hansen E, Belden K, Silibovsky R, et al: Perioperative antibiotics. J Arthroplasty 2014;29(2 Suppl):29-48.