Prevention Methodologies Against Infection After Total Joint Arthroplasty

Bhaveen H. Kapadia; Aaron J. Johnson; Kimona Issa; Qais Naziri; Jacqueline A. Daley; Michael A. Mont


Curr Orthop Pract. 2012;23(6):533-539. 

In This Article

Abstract and Introduction


Surgical site infections after lower extremity total joint arthroplasty procedures remain a substantial economic burden to the patient, the treating institution, and the healthcare system. The complexity of these surgical procedures creates the potential for various patient-related or surgery-related risk factors for infection. Although there is much literature regarding the use of many preventative methods, a consensus regarding the true efficacy and application of such practices generally is not available. In this review, we evaluated selected preventative measures including: the Centers for Disease Control and Prevention recommendations, skin preparation techniques, surgical draping techniques, operative dress, operating room ventilation, hair removal techniques, as well as operating room traffic control. Our literature review consisted of searching PubMed, EMBASE, Ovid, and other relevant orthopaedic journal databases. Preference was given to randomized-controlled trials, data from national registries, and meta-analyses within the past 5 years written in the English language. After reviewing the available literature, we present the authors' current preferred infection prevention methodology and protocol.


Currently there are approximately 658,000 primary joint arthroplasties performed annually in the United States.[1] This number is expected to increase to approximately 4 million by the year 2030. Although rare, many modes of failure are possible and can result in revision procedures. It is estimated that there are approximately 80,000 annual total joint revision procedures for failures in the United States alone.[1] Among these failures, the most disastrous remains surgical site infections.[2,3] Infections after total hip and knee arthroplasty are estimated to range from 0.9–2.5% annually.[4] Up to 25% of revisions estimated annually are caused by surgical site infections, which potentially are preventable complications.[5] In general, revisions impose significant health and economic burdens to the patient and healthcare system.[6,7] Surgical site infections often are not adequately treated with a single procedure, with many requiring multiple operations because of the difficultly in eradicating pathogens associated with prosthetic devices.[3,8]

Consequently, many healthcare institutions have implemented preoperative infection preventative measures and protocols.[9] Classifying surgical site infection risk factors as either patient-related or surgery-related allows for a more targeted interventional protocol. Factors related to the patient include comorbidities such as diabetes mellitus,[7] immunocompromising illnesses,[10] obesity,[7] cigarette smoking,[11] and personal hygiene practices.[12] Factors related to the surgical procedure include the use of prophylactic antibiotics,[13] draping techniques,[14,15] operating room ventilation,12,16–18 foot traffic in and out of the operating room,[19] operating room attire (e.g. body exhaust suits[12,20]), hair removal technique (e.g. shaving or clippers[13]), and postoperative wound care.[21] Thus, there are many potential points of intervention possible to avoid surgical site infections after total joint arthroplasty.

In this report, we first reviewed the current Centers for Disease Control and Prevention recommendations, before skin preparation techniques, surgical draping technique, operative dress, operating room ventilation, hair removal techniques, and operating room traffic control. We will evaluate the various preventative methods by reviewing the literature to derive which interventions have demonstrated to be the most effective in lower extremity total joint arthroplasty procedures. Many of these practices are controversial and have conflicting data, but the unifying principles are an attempt to reduce the contaminant transmission from external sources to the patient during surgery. We also will derive the current preferred infection prevention protocol used at the authors' institution.