Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Prevention of Deep Periprosthetic Joint Infection*†

Abstract

Although the prevalence of postoperative deep wound infection after total joint arthroplasty has decreased over the past few decades, it remains a feared consequence for both surgeons and patients107. Moynihan stated that “every operation in surgery is an experiment in bacteriology.”80 This statement provides remarkable insight into the seemingly variable and unpredictable nature of infection. Often, the specific mechanism and timing of bacterial delivery in a given wound is unknown, and it is usually extremely difficult to prove the exact cause of the infection in an individual situation. Despite improved outcomes of treatment for established deep periprosthetic infection, prevention remains a meaningful objective. The estimated cost of treatment67 of an infection at the site of a total hip or total knee arthroplasty exceeds $50,000. A thorough appreciation of and respect for the innumerable factors that may contribute to an infection is essential in the development of an over-all approach to prevention. The concept of an interdependent relationship among the triad of bacteria, host, and wound is helpful when considering prevention Fig. 1. Infection depends on the number and virulence of the bacteria introduced into a wound, the host's ability to eliminate these bacteria, and the status or viability of the wound environment. Within this triad, multiple variables can contribute to the deposition of bacteria into the wound, many conditions may impair the patient's ability to eliminate bacteria, and numerous vagaries of the wound milieu can facilitate the infectious process (Table I). Every variable may be influenced by the other variables within the triad. For example, the effect of a foreign body on the absolute number of bacteria required to facilitate the infectious process is well known29. Venn diagram demonstrating the dependent nature of bacteria, host factors, and wound environment on the development of …