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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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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.
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Paper of the week: The 2018 new definition of periprosthetic joint infection improves the diagnostic efficiency in the Chinese population.

Paper of the week:  The 2018 new definition of periprosthetic joint infection improves the diagnostic efficiency in the Chinese population. Haitao Guan, Jun Fu, Xiang Li, Wei Chai, Libo Hao, Rui Li, Jing Zhao, and Jiying Chen. J Orthop Surg Res. 2019; 14: 151. Published online 2019 May 24. doi: 10.1186/s13018-019-1185-y

Summary by Dr Sreeram Penna

The purpose of this retrospective study was to validate the 2018 ICM criteria on Chinese patients that underwent revision for total hip arthroplasty (THA) and total knee arthroplasty (TKA) for the periprosthetic joint infection (PJI) or aseptic loosening. This study excluded patients with antibiotic-loaded cement spacer in their joint at admission, patients who had a long antibiotic history prior to surgery, and those who had multiple prior surgical procedures. Patients were classified in PJI or not using major criteria in MSIS, 2013 ICM, and 2018 ICM criteria. Researchers then compared minor criteria between the 2018 ICM definition and the 2013 ICM and IDSA criteria.

The study cohort included 98 PJI cases and 168 aseptic revision patients. Statistical analysis showed that overall sensitivity, specificity, positive predictive value, and negative predictive value of 2018 ICM criteria was 94.9%, 95.2%, 92.1%, and 96.1% respectively. For 2013 ICM criteria the results were 53.1%, 98.4%, 96.3%, and 78.8% respectively. For IDSA criteria results were 72.4%, 86.7%, 76.3% and 84.1% respectively.

Overall researchers conclude that 2018 ICM criteria are applicable in the Chinese population. Also, the 2018 ICM criteria was shown to have higher sensitivity compared to the 2013 ICM criteria and IDSA criteria for the diagnosis of PJI.

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ICM Document Update: Chinese Translation Available Online

ICM Chinese translation is available online at the following link