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Paper of the week: Tranexamic Acid Is Associated With Reduced Periprosthetic Joint Infection After Primary Total Joint Arthroplasty.

Paper of the week: Tranexamic Acid Is Associated With Reduced Periprosthetic Joint Infection After Primary Total Joint Arthroplasty. Yazdi H, Klement MR, Hammad M, Inoue D, Xu C, Goswami K, Parvizi J. J Arthroplasty. 2019 Oct 22. pii: S0883-5403(19)31006-X. doi: 10.1016/j.arth.2019.10.029.

Summary by Dr Sreeram Penna

In this retrospective study researchers analyzed the relation between utilization of intravenous tranexamic acid (TXA) in primary total joint arthroplasty and incidence of periprosthetic joint infection (PJI). Final cohort included 6340 patients. Of these patients 3683 received TXA prior to arthroplasty and 2657 did not receive it.  Both hip and knee arthroplasty patients were included in the study. The preliminary analyses showed that patients receiving TXA were younger, more likely to be female, had a lower BMI and comorbidities, and undergoing THA.  Incidence of PJI in patients receiving TXA was 1.6% and 3.4% in those who did not receive the TXA prior to surgery.

On further analysis after controlling for confounding variables, multivariate analysis showed that administration of TXA (OR 0.68) was associated with lower rate of PJI. TXA use was also shown to be more effective in nonanemic patients (OR 0.52) and patients undergoing hip arthroplasty (OR 0.50). In conclusion this study shows overall beneficial effect of TXA in reducing PJI infection following primary arthroplasty.

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Paper of the week: No effect of vancomycin powder to prevent infection in primary total knee arthroplasty: a retrospective review of 976 cases

Paper of the week: No effect of vancomycin powder to prevent infection in primary total knee arthroplasty: a retrospective review of 976 cases. Yavuz IA, Oken OF, Yildirim AO, Inci F, Ceyhan E, Gurhan U. Knee Surg Sports Traumatol Arthrosc. 2019 Nov 14. doi: 10.1007/s00167-019-05778-8.

Summary and editorial by Dr Marjan Wouthuyzen-Bakker

In this paper of the week, Yavuz et al. studied the efficacy of vancomycin powder (VP) in preventing PJI after primary total knee arthroplasty. The authors compared 474 patients treated with local VP with a retrospective cohort of 502 control patients, without any other changes made in prevention measurements during the studied period. The minimal follow-up in both groups was 2 years. VP did not reduce the overall PJI rate (PJI rate 0.84% in the VP group vs 0.99% in the control group, P 0.54). In addition, no difference was observed for early or late infections.

Until now, the potential of VP in reducing post-operative infections is primarily demonstrated in spine surgery. Some studies report a reduction of infections in arthroplasties [1-2], but because other prevention measurements apart from the VP were applied in these studies also, the effect of VP per se cannot be made. The current study showed no effect of VP in primary knee arthroplasties. However, a potential limitation of the study was the use of a hemovac drain for 24h after surgery. Although the drains were clamped for the first 4 postoperative hours, its application could have reduced the efficacy of local antibiotics, as acknowledged by the authors themselves also.

References

  1. Whiteside LA. Prophylactic peri-operative local antibiotic irrigation. Bone Joint J 2016; 98-B:23-26.
  2. Winkler C, Dennison J, Wooldridge A et al. Do local antibiotics reduce periprosthetic joint infections? A retrospective review of 744 cases. J Clin Orthop Trauma 2018; 9:34-39.
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Paper of the week: Propidium monoazide-polymerase chain reaction for detection of residual periprosthetic joint infection in two-stage revision.

Paper of the week: Propidium monoazide-polymerase chain reaction for detection of residual periprosthetic joint infection in two-stage revision. Askar M, Sajid M, Nassif Y, Ashraf W, Scammell B, Bayston R. Mol Biol Rep. 2019 Oct 5. doi: 10.1007/s11033-019-05092-z.

Summary by Dr Sreeram Penna

In this study, researchers compare the efficacy of propidium monoazide-polymerase chain reaction (PMA-PCR or Viability PCR) for detecting residual periprosthetic joint infection in two-stage revision to a traditional polymerase chain reaction (PCR) and cultures. According to the authors, pre-treatment of propidium monoazide improves efficacy PCR testing by binding to residual DNA and RNA from the sample. Also, propidium monoazide does not cross the bacterial cell membrane and therefore, does not affect DNA from viable bacteria. Based on these actions authors postulate that by inhibiting residual DNA from both dead bacteria and human DNA in a sample using propidium monoazide, the overall efficacy of PCR in diagnosing infection is increased.

Cohort consists of 60 episodes of care in 58 patients. 14 of these episodes were considered infected using Muskulo Skeletal Infection Society criteria. The PCR assay done included only genus-specific primers for staphylococci and enterococci and species-specific primers for Cutibacterium acnes. Results showed that sensitivity of culture, PCR, and PMA-PCR were 50%, 71%, and 79%, respectively, and specificities were 98%, 72%, and 89%, respectively. Authors note that the increase in sensitivity of PMA-PCR compared to traditional PCR is due to the removal of large quantities of residual free-floating human DNA present in the sample by PMA.

In conclusion, PMA-PCR is better than traditional PCR with increased specificity and sensitivity. However, further research with broader PCR panel, including all possible bacteria causing PJI and larger sample size is needed.

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ICM Document Update: Volume 1 of Português (Brasil) translation available online

Volume 1 of Português (Brasil) translation available online at the following link.  Volume 1 is composed of Parts I (General Assembly) and Part II (Hip and Knee), with 553 pages plus the Prologue.

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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.

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.