J Korean Med Sci.  2024 Apr;39(15):e147. 10.3346/jkms.2024.39.e147.

Comprehensive Guidance for the Prevention of Periprosthetic Joint Infection After Total Joint Arthroplasty and Pitfalls in the Prevention

• Parvizi J
• Cha Y
• Chisari E
• Kim K
• Koo KH

• KMID: 2555475
• DOI: http://doi.org/10.3346/jkms.2024.39.e147

Abstract

Total joint arthroplasty (TJA) is a surgical procedure, in which parts of damaged joints are removed and replaced with a prosthesis. The main indication of TJA is osteoarthritis, and the volume of TJA is rising annually along with the increase of aged population. Hip and knee are the most common joints, in which TJAs are performed. The TJA prosthesis is composed of metal, plastic, or ceramic device. Even though TJA is the most successful treatment for end-stage osteoarthritis, it is associated with various complications, and periprosthetic joint infection (PJI) is the most serious complication after TJA. With the increasing volume of TJAs, there is a simultaneous rise in the incidence of PJI. Contamination of the surgical wound and the adherence of bacteria to the surface of prosthetic component represent the initial step in the pathogenesis of PJI. The main sources of the contamination are 1) patient's own flora, 2) droplets in the operation room air, and 3) surgical gloves and instruments. Even though modern techniques have markedly reduced the degree of contamination, TJAs cannot be done in completely germ-free conditions and some degree of contamination is inevitable in all surgical procedures. However, not all contamination leads to PJI. It develops when the burden of contamination exceeds the immune threshold or the colony forming units (CFUs) and various factors contribute to a decrease in the CFU level. Surgeons should be aware of the germ burden/CFU concept and should monitor sources of contamination to maintain the germ burden below the CFU to prevent PJI.

Keyword

Total Joint Arthroplasty; Periprosthetic Joint Infection; Contamination; Germ Burden; Prevention

Figure

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  Fig. 1 CFU and germ burden. In uneventful total joint arthroplasties, the germ burden on the surface of implant is below CFU, and PJI does not occur. However, when germ burden is higher than CFU, PJI occurs. The weakening of the host's immune system can decrease the level of the CFU, while substantial exposure to microorganisms capable of causing PJI can increase the germ-burden beyond the CFU threshold.CFU = colony forming unit, PJI = periprosthetic joint infection.

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  Fig. 2 All objects along the steam of air flow can shed particulates. The astral lamp, its lever and handle should be kept clean.

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  Fig. 3 Additional scrub vest with head sealing. (A) Surgical gown can be contaminated during skin preparation and draping. Thus, it is recommended to wear additional extra-gown after draping. (B) During surgery, surgical staffs’ heads are located at the steam of laminar air flow. Thus, it is necessary to completely seal off hairs and ears of surgical staffs. We recommend wearing additional non-woven helmet cap. The individual depicted has granted consent for their inclusion in this paper’s figure.

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  Fig. 4 Surgical gown and sleeve. (A) Surgical gown is made of non-woven fabric, which is not completely waterproof. It is simply water-resistant for a while. It becomes soaked in prolonged wet and high-pressure condition (dark lines). (B) We recommend the use of additional non-fabric sleeve.

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