Ferdinando Iannotti1, Paolo Prati2, Andrea Fidanza3, Raffaele Iorio1, Andrea Ferretti1, Daniel Pèrez Prieto4, Nanne Kort5, Bruno Violante6, Gennaro Pipino7, Alfredo Schiavone Panni8, Michael Hirschmann9, Marco Mugnaini10, Pier Francesco Indelli3. 1. Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome, 00185 Rome, Italy. 2. ASST Bergamo Ovest, 24047 Ospedale Treviglio, Italy. 3. Department of Orthopaedic Surgery and Bioengineering, Stanford University School of Medicine, Stanford, CA 94305, USA. 4. Department of Orthopaedic Surgery, Hospital del Mar, Universitat Autònoma de Barcelona, 08003 Barcelona, Spain. 5. CortoClinics, 5482 Schijndel, The Netherlands. 6. Orthopaedic Department, Istituto Clinico Sant'Ambrogio IRCCS Galeazzi, 20161 Milan, Italy. 7. Ospedali Privati Riuniti Villa Regina, 40136 Bologna, Italy. 8. Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy. 9. Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, (Bruderholz, Liestal, Laufen), 4101 Bruderholz, Switzerland. 10. Division of Orthopaedic Surgery, Ospedale Santa Maria Annunziata Asl Toscana Centro, 50012 Firenze, Italy.
Abstract
Background: Periprosthetic joint infection (PJI) represents 25% of failed total knee arthroplasties (TKA). The European Knee Associates (EKA) formed a transatlantic panel of experts to perform a literature review examining patient-related risk factors with the objective of producing perioperative recommendations in PJI high-risk patients. Methods: Multiple databases (Pubmed/MEDLINE, EMBASE, Scopus, Cochrane Library) and recommendations on TKA PJI prevention measures from the International Consensus Meetings on PJI from the AAOS and AAHKS were reviewed. This represents a Level IV study. Results: Strong evidence was found on poor glycemic control, obesity, malnutrition, and smoking being all associated with increased rates of PJI. In the preoperative period, patient optimization is key: BMI < 35, diet optimization, Hemoglobin A1c < 7.5, Fructosamine < 292 mmol/L, smoking cessation, and MRSA nasal screening all showed strong evidence on reducing PJI risk. Intraoperatively, a weight-based antibiotic prophylaxis, accurate fluid resuscitation, betadine and chlorhexidine dual skin preparation, diluted povidone iodine solution irrigation, tranexamic acid administration, and monofilament barbed triclosan-coated sutures for soft tissues closure all represented effective prevention measures. In the postoperative period, failure to reach normalization of ESR, CRP, D-dimer, and IL-6 six weeks postoperatively suggested early PJI. Conclusion: The current recommendations from this group of experts, based on published evidence, support risk stratification to identify high-risk patients requiring implementation of perioperative measures to reduce postoperative PJI.
Background: Periprosthetic joint infection (PJI) represents 25% of failed total knee arthroplasties (TKA). The European Knee Associates (EKA) formed a transatlantic panel of experts to perform a literature review examining patient-related risk factors with the objective of producing perioperative recommendations in PJI high-risk patients. Methods: Multiple databases (Pubmed/MEDLINE, EMBASE, Scopus, Cochrane Library) and recommendations on TKA PJI prevention measures from the International Consensus Meetings on PJI from the AAOS and AAHKS were reviewed. This represents a Level IV study. Results: Strong evidence was found on poor glycemic control, obesity, malnutrition, and smoking being all associated with increased rates of PJI. In the preoperative period, patient optimization is key: BMI < 35, diet optimization, Hemoglobin A1c < 7.5, Fructosamine < 292 mmol/L, smoking cessation, and MRSA nasal screening all showed strong evidence on reducing PJI risk. Intraoperatively, a weight-based antibiotic prophylaxis, accurate fluid resuscitation, betadine and chlorhexidine dual skin preparation, diluted povidone iodine solution irrigation, tranexamic acid administration, and monofilament barbed triclosan-coated sutures for soft tissues closure all represented effective prevention measures. In the postoperative period, failure to reach normalization of ESR, CRP, D-dimer, and IL-6 six weeks postoperatively suggested early PJI. Conclusion: The current recommendations from this group of experts, based on published evidence, support risk stratification to identify high-risk patients requiring implementation of perioperative measures to reduce postoperative PJI.
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