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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. 2020 Feb;35(2):538-543.e1. doi:10.1016/j.arth.2019.09.011. Epub 2019 Sep 12. PubMed PMID: 31575448.

Summary by Karan Goswami MD and Javad Parvizi MD FRCS

The use of intraoperative irrigation is an important component of infection prevention. Two recent clinical practice guidelines issued by the World Health Organization (WHO) and Centers for Disease Control (CDC) recommend the use of prophylactic incisional wound irrigation with an aqueous povidone-iodine solution for prevention of SSI [1–3]. However, these guidelines are largely based on non-orthopedic data from general surgery, urology and cardiac surgery. Prior work in the orthopedic literature is largely limited to spinal surgery and mostly retrospective in nature [4–6].

Calkins et al. present a randomized controlled trial (RCT) exploring whether dilute betadine lavage compared to normal saline lavage reduces the rate of acute postoperative PJI. Their total cohort included 457 patients undergoing aseptic revision TKA and THA. The intervention group received a 3-minute 0.35% dilute betadine lavage before wound closure (n=223), while the control arm received normal saline irrigation only (n=234). The primary outcome measure was PJI within 90 days of surgery defined by MSIS criteria [7]. A significant reduction in the acute PJI rate was noted between the dilute betadine group and saline group (0.4% vs. 2.4%; p=0.038). The authors appropriately acknowledge certain limitations of the study – including a low event rate and not reaching full power – due to an ethical obligation to halt enrollment, in view of statistical significance between groups at interim analysis. Nonetheless, this is the first level 1 RCT in the arthroplasty literature investigating the utility of dilute betadine irrigation. The study concludes that dilute betadine irrigation before wound closure is a safe and effective measure for acute PJI risk reduction.

References

  1. Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg 2017;152:784–91. https://doi.org/10.1001/jamasurg.2017.0904.
  2. Global Guidelines for the Prevention of Surgical Site Infection. World Health Organization; 2017.
  3. Allegranzi B, Zayed B, Bischoff P, Kubilay NZ, Jonge S de, Vries F de, et al. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis 2016;16:e288–303. https://doi.org/10.1016/S1473-3099(16)30402-9.
  4. Brown NM, Cipriano CA, Moric M, Sporer SM, Della Valle CJ. Dilute betadine lavage before closure for the prevention of acute postoperative deep periprosthetic joint infection. J Arthroplasty 2012;27:27–30. https://doi.org/10.1016/j.arth.2011.03.034.
  5. Cheng M-T, Chang M-C, Wang S-T, Yu W-K, Liu C-L, Chen T-H. Efficacy of dilute betadine solution irrigation in the prevention of postoperative infection of spinal surgery. Spine 2005;30:1689–93.
  6. Chang F-Y, Chang M-C, Wang S-T, Yu W-K, Liu C-L, Chen T-H. Can povidone-iodine solution be used safely in a spinal surgery? Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 2006;15:1005–14. https://doi.org/10.1007/s00586-005-0975-6.
  7. Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ, et al. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop 2011;469:2992–4. https://doi.org/10.1007/s11999-011-2102-9.

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