Treatment of Periprosthetic Joint Infection Using Antimicrobials: Dilute Povidone-Iodine Lavage

Abstract

Periprosthetic joint infections (PJI) remain a challenge for the orthopaedic surgeon to treat and remain a leading cause of failure of both primary and revision total joint arthroplasty. Once a PJI develops, surgical treatment is generally indicated and includes an aggressive irrigation and debridement. One component of the irrigation and debridement involves the use of an antiseptic irrigating solution. In primary and revision TJA, dilute povidone-iodine lavage can be performed prior to wound closure. Approximately 17.5mL of 10% povidone-iodine is diluted with 500-1000cc of normal saline. The wound is then irrigated with the dilute povidone-iodine for 3 minutes. The dilute povidone-iodine is then thoroughly irrigated and washed out of the wound with normal saline prior to wound closure. The use of dilute povidone-iodine lavage prior to wound closure has been shown to reduce the risk of deep surgical site infection in multiple surgical specialties. In primary TJA, it has been demonstrated to reduce the risk of infection, without any associated adverse effects. It is also included in multiple protocols for the surgical treatment of PJI. Dilute povidone-iodine lavage provides a safe and inexpensive method to reduce the rate of PJI in TJA.

New Innovations in the Treatment of PJI and Biofilms—Clinical and Preclinical Topics

“…Such low cure rates are believed to occur in part due to surgeon variability in how surgical debridement is performed, but also due to current topical agents being ineffective in removing biofilm from metal and plastic implant surfaces [30]. Currently, administration of dilute betadine [31], chlorhexidine [32], and vancomycin powder [33] has all been separately advocated to improve irrigation and debridement treatment outcomes, but these effects have only been observed in retrospective case series. The limited quality of evidence and high degree of both morbidity and mortality obviate the need for novel methods of preventing and eradicating biofilm formation around artificial joint implants.…”

Perioperative Contamination of Orthopaedic Polyethylene Implants, Targeting Devices and Arthroscopes. Experts' Decision Tree and Literature Review

“…However, there are no guidelines in cases of unexpected sterility errors. Treating infection at the surgical site is a constant challenge in orthopedic surgery, and remains a leading cause of failure, with increased morbidity and mortality rates 8. Despite continued efforts in research, education and technical progress, per-operative contamination remains relatively frequent.…”

“…Due to obvious methodological limitations one can only extrapolate from non-dedicated studies. Ruder et al 8 found that lavage of the contaminated implant reduced the risk of deep surgical site infection in orthopedic surgery, when using dilute povidone- iodine lavage prior to wound closure. As this chemical has no associated adverse effects, they concluded that this method is a safe and inexpensive method to reduce the infection rate.…”

Pursuit of the ideal antiseptic irrigation solution in the management of periprosthetic joint infections

“…Similar to other antiseptic irrigation efficacy studies, the broad-spectrum effects of CHG have been highlighted in in vitro studies. CHG solutions have been shown to decrease MRSA biofilm load (Schwechter et al, 2011) and Staphylococcus epidermidis biofilm (Frisch et al, 2017) on orthopaedic implants using a titanium alloy (Ti-6Al-4V) in vitro models. Clinically, Barros et al ( 2019) noted an 89.5 % (34 out of 38) success rate using a CHG scrub brush followed by normal saline irrigation in a DAIR (12 THA, 12 TKA) protocol at 2-year follow-up.…”