Paper of the week: Dilute Betadine Lavage Reduces the Risk of Acute Postoperative Periprosthetic Joint Infection in Aseptic Revision Total Knee and Hip Arthroplasty: A Randomized Controlled Trial. Calkins TE, Culvern C, Nam D, Gerlinger TL, Levine BR, Sporer SM, Della Valle CJ. J Arthroplasty. 2019 Sep 12. pii: S0883-5403(19)30843-5. doi: 10.1016/j.arth.2019.09.011.

Summary by Dr Marjan Wouthuyzen-Bakker

Calkins et al. randomized 478 patients undergoing an aseptic revision of the hip or knee to receive either a 3-minute diluted betadine (povidone-iodine) lavage or normal saline lavage before wound closure. From the 457 analyzed patients, they observed an early PJI (i.e. <90 days of surgery) in 3.4% (8/234) cases lavaged with saline and in 0.4% (1/223) cases lavaged with betadine (p 0.04). There was no difference in wound complications between both groups. The authors conclude that the use of a diluted betadine lavage is a safe and effective way to reduce acute postoperative PJI in aseptic revisons of hip or knee.

Scarce data on the use of diluted betadine lavage in orthopaedic surgery is available. Two RCTs demonstrated an infection reduction when using betadine lavage in spine surgery [1-2]. However, no statistical difference was observed in an RCT performed by Kokavec et al., studying an orthopaedic population undergoing hip, femur or pelvis surgeries [3]. In joint arthroplasties, only one retrospective study has been performed in which the authors described a lower infection rate when using betadine compared to saline in a historical cohort of primary TJAs [4]. Due to this low quality evidence in orthopaedics, the WHO suggests ‘to consider the use of irrigation of the incisional wound with an aqueous povidone-iodine solution’ [5]. This paper of the week supports the use of diluted betadine lavage (0.35%) in revision arthroplasties in which the infection rate is generally much higher compared to primary arthroplasties, and adds to the much needed evidence in orthopaedic surgery on this topic.

References

1. 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.
2. 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.
3. Kokavec M and Fristáková M. Efficacy of antiseptics in the prevention of post-operative infections of the proximal femur, hip and pelvis regions in orthopedic pediatric patients. Analysis of the first results. Acta Chir Orthop Traumatol Cech. 2008;75(2):106-9.
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. WHO, Global guidelines on the prevention of surgical site infection; second edition, 2018. ISBN: 978-92-4-155047-5.