Prosthetic Joint Infections: What Is the Real Science behind Going Back to Betadine in Wounds?

The incidence of osteoarthritis affecting the hip and knee joints is increasing every year. As the number of primary arthroplasties increases, so does the number of people affected by prosthetic joint infection (PJI). Approximately 1 to 2 percent of joint arthroplasty patients experience PJI. These outcomes create economic and social burdens that can be felt across the healthcare system. Currently, 15 percent of hip revisions and 25 percent of knee revisions are due to PJIs. Prekumar et al estimate that by 2030, the economic cost for PJIs will total $1.85 billion in the United States.

Intraoperative irrigation of the surgical site can decrease the risk of infection. It can be performed with normal saline with or without antibiotic, chlorhexidine gluconate, hydrogen peroxide, sodium hypochlorite, various antibiotic solutions, and Betadine (diluted povidone-iodine). However, there are no clear data about the most effective irrigation solution, concentration, or duration of intraoperative irrigation.

Betadine is an inexpensive antiseptic solution commonly used to reduce surgical site infections. It is a complex of polyvinyl polyvidone iodine ions. The release of iodine molecules interacts with and denatures pathogen membranes, nucleotides, fatty acids, and proteins. This occurs in a
concentration-dependent manner. Betadine used as a skin disinfectant demonstrates decreasing bacterial concentrations. It has effects on methicillin-resistant Staphylococcus aureus (MRSA), Staphylococcus epidermidis, Pseudomonas, and Escherichia coli. In a retrospective study, Brown et al reported a significant decrease in postoperative infection with use of 0.35 percent Betadine for wound irrigation following final prosthetic implantation. In a randomized, controlled trial comparing Betadine to saline, Calkins et al noticed decreased deep postoperative infections for aseptic revision arthroplasties. On the other hand, Hernandez et al did not find any significant difference in postoperative infection in patients with 0.25 percent Betadine irrigation.

The optimal concentration, duration, and tissue cytotoxicity of Betadine irrigation are still debatable. Although 0.35 percent is the most frequently used concentration, the ideal concentration is not well established. In an in vitro study, Cichos et al reported that the minimum inhibitory concentration of Betadine was 0.63 percent and that all bacteria were eliminated on immediate contact. A retrospective study by Zvi et al showed no difference in rates of all-cause revision or PJI with 0.3 percent Betadine versus 0.54 percent Betadine irrigation. No adverse intraoperative events occurred with 0.54 percent Betadine irrigation.

Three minutes was the most frequently reported irrigation time in clinical studies. Cichos et al reported elimination of bacteria on immediate contact at 0.63 percent Betadine concentration. In an in vitro study, Christopher et al examined minimum effective irrigation time for betadine at 15, 30, 60, 90, and 120 seconds. Betadine eradicated all bacterial growth after 90 seconds of treatment. In regard to tissue cytotoxicity, the ideal solution is minimally cytotoxic at its minimal bactericidal concentration. Kaysinger et al first reported in vitro toxic effects on fibroblasts and osteoblasts with effects on fracture union, fusion, and wound healing. Von Keudell et al reported that concentrations >0.35 percent and time >1 minute caused microscopic damage to bovine chondrocytes, indicating that Betadine is time and concentration dependent. Tissue cytotoxicity is reported to be minimal at 0.3 percent concentration.

In conclusion, Betadine is both an efficacious and safe antiseptic solution. The concerns with tissue toxicity with in vitro studies have not been shown to have any adverse events in clinical trials. The cytotoxic effects on articular cartilage noted by Keudell et al are essentially negated during arthroplasty, as cartilage is not retained and the damage to surrounding tissues can be minimized with a dilute solution of Betadine. Chang et al and Cheng et al demonstrated a reduction in postoperative infections with minimal complications during spine operations. Brown et al and Calkins et al have exhibited the effectiveness of Betadine during primary and revision arthroplasty. The inexpensive cost of Betadine makes it a viable solution to incorporate into protocols. Whether one uses commercially available povidone-iodine (BD Surgiphor) or non-sterile packaged Betadine, the effects on infection prevention are likely the same. The use of dilute Betadine lavage before wound closure could be an important adjunct in reducing infections in total joint arthroplasties.

This article was submitted on behalf of the AAOS Committee on Healthcare Safety.

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

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

References

1. Maradit Kremers H, Larson DR, Crowson CS, et al: Prevalence of total hip and knee replacement in the United States. J Bone Joint Surg Am 2015;97(17):1386-97.
2. Kurtz SM, Lau E, Ong K, et al: Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030. Clin Orthop Relat Res 2009;467(10):2606-12.
3. 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):1484-89.e3.
4. Brown NM, Cipriano CA, Moric M, et al: Dilute Betadine lavage before closure for the prevention of acute postoperative deep periprosthetic joint infection. J Arthroplasty 2012;27(1):27-30.
5. Siddiqi A, Abdo ZE, Rossman SR, et al: What is the optimal irrigation solution in the management of periprosthetic hip and knee joint infections? J Arthroplasty 2021;36(10):3570-83.
6. Langgartner J, Linde HJ, Lehn N, et al: Combined skin disinfection with chlorhexidine/propanol and aqueous povidone-iodine reduces bacterial colonisation of central venous catheters. Intensive Care Med 2004;30(6):1081-8.
7. Cichos KH, Andrews RM, Wolschendorf F, et al: Efficacy of intraoperative antiseptic techniques in the prevention of periprosthetic joint infection: superiority of Betadine. J Arthroplasty 2019;34(7S):S312-8.
8. Calkins TE, Culvern C, Nam D, et al: Dilute Betadine lavage reduces the risk of acute postoperative periprosthetic joint infection in aseptic revision total knee and hip arthroplasty: a randomized controlled trial. J Arthroplasty 2020;35(2):538-43.e1.
9. Hernandez NM, Hart A, Taunton MJ, et al: Use of povidone-iodine irrigation prior to wound closure in primary total hip and knee arthroplasty: an analysis of 11,738 cases. J Bone Joint Surg Am 2019;101(13):1144-50.
10. Zvi YS, Follett LY, Reddy H, et al: Non-inferiority and safety of increased povidone-iodine (Betadine) concentration for irrigation following primary total joint arthroplasty (TJA). Cureus 2024;16(2):e53453.
11. Christopher ZK, Tran CP, Vernon BL, et al: What is the duration of irrigation? An in vitro study of the minimum exposure time to eradicate bacteria with irrigation solutions. J Arthroplasty 2022;37(2):385-9.e2.
12. Goswami K, Austin MS: Intraoperative povidone-iodine irrigation for infection prevention. Arthroplast Today 2019;5(3):306-8.
13. Ruder JA, Springer BD: Treatment of periprosthetic joint infection using antimicrobials: dilute povidone-iodine lavage. J Bone Jt Infect 2017;2(1):10-4.
14. Kaysinger KK, Nicholson NC, Ramp WK, et al: Toxic effects of wound irrigation solutions on cultured tibiae and osteoblasts. J Orthop Trauma 1995;9(4):303-11.
15. von Keudell A, Canseco JA, Gomoll AH: Deleterious effects of diluted povidone-iodine on articular cartilage. J Arthroplasty 2013;28(6):918-21.
16. Romano V, Di Gennaro D, Sacco AM, et al: Cell toxicity study of antiseptic solutions containing povidone-iodine and hydrogen peroxide. Diagnostics (Basel) 2022;12(8):2021.
17. Chang FY, Chang MC, Wang ST, et al: Can povidone-iodine solution be used safely in a spinal surgery? Eur Spine J 2006;15(6):1005-14.
18. Cheng MT, Chang MC, Wang ST, et al: Efficacy of dilute Betadine solution irrigation in the prevention of postoperative infection of spinal surgery. Spine 2005;30(15):1689-93.