Prevention of Periprosthetic Joint Infection Following Total Knee Arthroplasty (TKA)

Periprosthetic joint infection (PJI) |

 is one of the most feared and distressing complications following total knee arthroplasty (TKA). Despite efforts to prevent infection, literature reports an incidence rate of 0.2–1.5% after primary TKA and approximately 0.6–4% after revision TKA.



Once an infection occurs, the prognosis deteriorates significantly, often preventing a full return to the previous state. Patients frequently require multiple revision surgeries and prolonged antibiotic therapy, leading to substantial physical and financial burdens for both patients and healthcare providers. Therefore, a thorough preoperative evaluation, meticulous surgical planning, and adherence to treatment principles are essential to minimize infection risks.



This article provides a literature review on methods to prevent infections following TKA.





1. Preoperative Patient Evaluation and Management




A comprehensive preoperative assessment is the first step in infection prevention. Several patient-related factors increase the risk of infection:

  • Obesity: Weight reduction is recommended for excessively obese patients.

  • Diabetes and Malnutrition: Uncontrolled diabetes (HbA1c > 7.0) or poor nutritional status should be managed before surgery to improve safety.

  • Smoking and Alcohol Consumption: Smoking should be ceased at least 4–6 weeks before surgery, and alcohol should be avoided due to its negative effects on circulatory and immune function.

  • Local Wound Issues: A history of knee fractures or prior open surgeries increases the risk of infection, necessitating careful evaluation and management.

  • Rheumatoid Arthritis and Immunosuppressants: Rheumatoid arthritis increases postoperative infection risks. Disease-modifying antirheumatic drugs (DMARDs) such as glucocorticoids, cyclophosphamide, methotrexate, interferon-gamma (IFN-γ), and tumor necrosis factor-alpha (TNF-α) inhibitors should be carefully managed.

  • Serological Markers: Elevated ESR, CRP, and IL-6 levels significantly increase the risk of PJI. Surgery should be postponed if these markers are elevated.

Additionally, approximately 30% of the general population tests positive for Staphylococcus aureus in nasal swabs. While some studies suggest nasal decolonization with mupirocin ointment before surgery, the role of colonization in increasing infection risk remains controversial.



2. Preoperative Intraarticular injection



In recent years, intra-articular injections have been frequently used for treating knee osteoarthritis. These injections provide short-term symptom relief, making them attractive to both physicians and patients. However, injections have no proven chondroprotective effects and only provide analgesia. The American Academy of Orthopaedic Surgeons (AAOS) guidelines specifically recommended against intra-articular injections before TKA due to increased PJI risks.

  • Richardson et al. reported a 53% increase in infection rates in patients who received hyaluronic acid injections within three months before TKA.

  • Multiple studies recommend delaying TKA by 3–12 months if the patient received intra-articular steroid injections before surgery.

  • Advanced osteoarthritis patients with severe pain should not be denied surgery solely due to prior injections. However, given that infection risks increase with the number and timing of injections, it is advisable to manage symptoms with oral medications rather than injections if TKA is anticipated within 1–2 years.

  • I strongly recommend against performing TKA within 6 months following intraarticular injection.



3. Preoperative Preparation

  • Preoperative Bathing: The effectiveness of chlorhexidine gluconate baths in reducing infections remains inconclusive.

  • Hair Removal: Clipping is preferred over shaving to reduce infection risks.

  • Sterilization of Surgical Instruments and Operating Room: Surface disinfectants and ultraviolet (UV-C) light should be used for thorough sterilization.

  • Laminar Airflow Systems: While designed to reduce stagnant air over the surgical field, their effectiveness in preventing infections is debated.

  • Maintaining Body Temperature: Keeping the patient warm with warm air blankets helps prevent surgical site infections but requires careful handling to avoid dust contamination.





4. Surgical Hand Antisepsis




Surgical hand antisepsis reduces pathogen transmission. Effective hand scrubbing should involve at least two minutes of mechanical friction with an antiseptic solution. Common antiseptics include:

  • Povidone-Iodine: Broad-spectrum antimicrobial but requires prolonged application and may cause skin irritation.

  • 4% Chlorhexidine: More effective at reducing bacterial load and has longer residual effects with lower irritation.

  • Avagard: A combination of 1% chlorhexidine gluconate and 61% ethyl alcohol with a moisturizer, offering prolonged antimicrobial effects with minimal skin irritation.



5. Perioperative Antibiotic Prophylaxis




  • Antibiotics should be administered within 60 minutes before skin incision and 10 minutes before tourniquet inflation.

  • Bacterial growth increases exponentially within the first six postoperative hours; maintaining low bacterial levels during this period is crucial.

  • First- or second-generation cephalosporins are recommended.

  • Guidelines recommend discontinuing antibiotics after 24 hours postoperatively, but in practice, administration for up to 48 hours may be considered for high-risk patients.




6. Intraoperative Infection Prevention



  • Skin Preparation: Povidone-iodine and chlorhexidine-alcohol are both effective, though chlorhexidine-alcohol acts faster and has longer residual effects.

  • Sterile Drape Use: Plastic adhesive drapes do not significantly reduce infection risks, but some surgeons use them to minimize flora migration.

  • Double Gloving: Reduces glove puncture rates, which occur in up to 30% of surgeries. All my surgical team change gloves before inserting and fixating real implants. 

  • Implant Fixation: Antibiotic-loaded bone cement improves both infection prevention and implant survival rates.

  • Pulsed Lavage: Cleansing the bone surface before implant insertion enhances cement penetration and reduces infection risks.

  • Betadine Irrigation: A 0.35% diluted betadine solution before wound closure can effectively lower infection rates.

  • Surgical Duration: Every additional 15 minutes of surgery increases infection risks by 9%; a 2-hour 30-minute cutoff is recommended. My TKA procedures last no longer than 90 minutes (skin-to-skin), since I believe that the duration of operation is a strong contributing factor for PJI.



7. Postoperative Infection Prevention

  • Dental and Urological Procedures: Prophylactic antibiotics may be considered before these procedures to prevent transient bacteremia.

  • Blood Transfusion: Increases infection risk by over 2.1 times. Effective hemostasis and tranexamic acid administration should be considered to minimize transfusion needs. I do not perform simultaneous bilateral TKA, nor performing consecutive TKA within a week or two to minimize the risk of transfusion.

  • Wound Healing: Advanced dressings with hydrofiber absorbents help prevent external contamination and manage wound exudate.

  • Hematoma and Drainage Management: Persistent wound drainage increases infection risks. Adjusting anticoagulant doses or surgical evacuation may be necessary. I don't use hemovac in most case.







Conclusion

Despite meticulous preventive measures, infections can still occur. Fortunately, I have not encountered a PJI in my TKA patients. However, the risk is always present, requiring continuous vigilance.

PJI can be categorized into acute (within three months) and chronic infections. Chronic infections are usually hematogenous and unrelated to surgical procedures, while acute infections are more dependent on preoperative patient factors, intraoperative techniques, and postoperative care.

Adhering to these evidence-based principles can significantly reduce the risk of PJI and improve surgical outcomes in TKA patients.






References


1. 조우신, 염윤석, 안지현. 조우신의 무릎의 인공관절술. 제4판. 영창출판사. 2022.

2. Allegranzi B, Bischoff P, de Jonge S et al. New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect. Dis. 2016 16 e276–e287. 10.1016/S1473-3099(16)30398-X

3. American Academy of Orthopaedic Surgeons Diagnosis and Prevention of Periprosthetic Joint Infections Evidence-Based Clinical Practice Guideline. Published March 11, 2019.

4. Gehrke T, Alijanipour P, Parvizi J. The management of an infected total knee arthroplasty. Bone Joint J. 2015 Oct;97-B(10 Suppl A):20-9. doi: 10.1302/0301-620X.97B10.36475. PMID: 26430083.

5. Parvizi J, Gehrke T, Chen AF. Proceedings of the International Consensus on Periprosthetic Joint Infection. Bone Joint J 2013;95-B:1450-1452.

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7. Richardson SS, Schairer WW, Sculco TP, Sculco PK. Comparison of Infection Risk with Corticosteroid or Hyaluronic Acid Injection Prior to Total Knee Arthroplasty. J Bone Joint Surg Am. 2019;101:112-8

8. Sandhu SS, Lowry JC, Morton ME, Reuben SF. Antibiotic prophylaxis, dental treatment and arthroplasty: time to explode a myth. J Bone Joint Surg Br. 1997 Jul;79(4):521-2. doi: 10.1302/0301-620x.79b4.7867. PMID: 9250728.

9. Vijaysegaran P, Knibbs LD, Morawska L et al. Surgical Space Suits Increase Particle and Microbiological Emission Rates in a Simulated Surgical Environment. J Arthroplasty. 2018 May;33(5):1524-1529.

10. Webster J, Alghamdi A. Use of plastic adhesive drapes during surgery for preventing surgical site infection. Cochrane Database Syst Rev 2013;1:CD006353







Hyo Yeol Lee, MD., PhD.

Department of Orthopaedic Surgery (Knee Surgery and Sports Medicine)

Chungbuk National University Hospital







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