1. PREVENTING INFECTION IN ORTHOPAEDIC SURGERY
Dr Parag Sancheti
FRCS(Ed), MS (ORTHO), MCh (U.K),
F.ASIF (SWISS), DNB (ORTHO)
Pune , India
KENYA ORTHOPAEDIC ASSOCIATION ANNUAL MEETING
23nd June 2016
BOMA INN , Eldoret

2. INTRODUCTION
Infection in Orthopaedic Surgery is the most disastrous complication of an otherwise successful surgical procedure.
Continues to pose a challenge to the orthopaedic community.
Leucocyte esterase: sensitivity 87-90%, specificity: %

3. RISK FACTORS FOR INFECTION
history of previous surgery, recent hospitalization
Presence of active local cutaneous, subcutaneous, or deep tissue infection
poorly controlled DM (glucose> 200 mg/L or HbA1C>7%)
Malnutrition & morbid obesity (BMI>40 Kg/m2)
active liver disease & chronic renal disease
Leucocyte esterase: sensitivity 87-90%, specificity: %

4. RISK FACTORS FOR INFECTION
excessive smoking , excessive alcohol consumption & intravenous drug abuse
extended stay in a rehabilitation facility
post-traumatic arthritis, inflammatory arthropathy
severe immunodeficiency.

5. PREVENTION IS BETTER THAN CURE

6. PREVENTION OF SURGICAL SITE INFECTION
PRE OPERATIVE SKIN CLEANSING
CHG with Alcohol based solution
lower rate of MRSA colonization in the hospital setting.
Darouiche RO, Wall MJ, Jr., Itani KM, et al. Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. N Engl J Med. 2010;362(1):18-26.

7. PREVENTION OF SURGICAL SITE INFECTION
Hair removal
Clipping done close to the time of surgery
Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev. 2011(11):CD

8. PREVENTION OF SURGICAL SITE INFECTION
Anti septic hand wash
2-3 minutes of 4 % CHG or 7.5 % POVIDONE IODINE hand wash followed by Alcohol based solution application
WHO (2009). WHO Guidelines on hand hygiene in health care

9. PREVENTION OF SURGICAL SITE INFECTION
MRSA / MSSA SCREENING
universal screening NOT recommended
Decolonisation with MUPIROCIN ointment reduces Surgical site infection
Pre operative skin cleansing with CHG + Alcohol based solution reduces rate of MRSA colonization in the hospital setting
Perl TM, Golub JE. New approaches to reduce Staphylococcus aureus nosocomial infection rates: treating S. aureus nasal carriage. Ann Pharmacother. 1998;32(1):S7-16.

10. PREVENTION OF SURGICAL SITE INFECTION
Peri operative antibiotics
A first or second-generation cephalosporin ( cefazolin or cefuroxime)
one hour prior to surgical incision
two hours for vancomycin and fluoroquinolones.
not to be administered for greater than 24 hours after surgery.
Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Am J Surg. 2005;189(4):
Turano A. New clinical data on the prophylaxis of infections in abdominal, gynecologic, and urologic surgery. Multicenter Study Group. Am J Surg. 1992;164(4A Suppl):16S-20S..

11. PREVENTION OF SURGICAL SITE INFECTION
Sterile operative environment
Minimal traffic
UV sterilization lights adjuvant to conventional cleaning
Avoid prolonged surgical time
Disposable impervious drapes & gowns
Iodine impregnated incise draping

12. PERIPROSTHETIC JOINT INFECTION
DIAGNOSIS OF INFECTION
PERIPROSTHETIC JOINT INFECTION
Findings suggestive on physical examination:
Wound dehiscence, or
Joint warmth, redness, or swelling
Plain Radiographic signs :
Signs of loosening. (within 5 years)
Subperiosteal elevation, or
Transcortical sinus tracts.
It is important to note that plain radiographs are generally normal in the setting of INFECTION.

13. DIAGNOSIS OF INFECTION
THRESHOLD FOR SERUM MARKERS IN ACUTE PJI
[< 6 Weeks]
ESR : Not Useful
CRP : > 100 Mg/L
Synovial WBC Count : > 10,000Cells/μL,
Synovial PMN% : > 90%
Synovial CRP: > 6.6 Mg /L
Synovial leucocyte esterase : ++
Synovial alpha Defensin: > 5.2 mg/L 
Alpha defensin: sensitivity & specificity: 100 %

14. DIAGNOSIS OF INFECTION
THRESHOLD FOR SERUM MARKERS IN CHRONIC
PJI [ > 6 weeks]
ESR > 30 mm/hr,
CRP > 10 mg/L,
Synovial WBC count > 3,000 cells /μL
Synovial PMN% > 80%.
Synovial CRP: > 2.5 Mg /L

15. Algorithm for diagnosis of Periprosthetic joint infection
Discharging sinus

19. Thank You… All Delegates & Members of KOA. Prof Lawerence Ndegwa Gakuu
Prof Lectary Kilbor Lelei
Dr Johnson Murila
Dr James Kigera
Dr Akhil Fazaal
All Delegates & Members of KOA.
Thank You…

20. History of Surgical infection
Joseph Lister
Postoperative infection rate
(7-9%)
Postoperative infection is the saddest
of all complications…’
Infection in Orthopaedic surgery
-Salvati et al, JBJS, – 2.6%
-Thornhill et al, JBJS, – 1.6%
-Hansen & Rand, CORR, 1999 – 2.5%

21. MANAGING INFECTION Is it a problem? Where does it come from?
What turns contamination into infection?
How do you diagnose it?
How do you treat it?
How do you prevent it?

22. PREVENTION OF INFECTION
Pre-op
Intra-op
Post-op

23. Pre-operative High risk patients
Screening & decolonisation of MSSA/MRSA
Pre-op preparation- Chlorehxidine
- hair removal
Pre-existing dental/nutritional issues

24. High risk patients H/o infection in joint (Jerry et al, CORR, 1988)
Potentially modifiable
Inflammatory arthritis
Sickle cell disease
Diabetes mellitus
Renal failure
HIV – viral load
Malnutrition
Smoking/obesity
Can’t be modified
H/o infection in joint
(Jerry et al, CORR, 1988)
Steroid inj in joint
(Casper et al,Can J Surg,2006)

25. Results of Our Screening
It keeps MRSA out of the Hospital
But MRSA is not the main problem
Patients are susceptible to MRSE
Should we screen for MRSE ?
– Why we screen for “MRSA ". S S Mohanty, P R Kay. J.Bone Joint Surg [Br]
2003;86-B: )

26. Intra-op factors Antibiotic- systemic Hand hygiene & sx site prepn
Operating room environment
- theatre traffic
- sterile technique
- sterilization

27. Pre-operative prophylaxis
Agent:
Cefazolin -1-2g, Cefuroxime- 1.5g
Allergy – Vancomycin – 1g (Prev MRSA inf)
Clindamycin- 600mg
1hr prior to incision- before torniquet inflation, Vancomycin – 2hrs before incision
Repeat dose- Sx> 4hrs/ blood loss> 1500cc
3days/1 day after removal of drain

28. ‘The higher the class of antibiotic used for prophylaxis the lower the confidence of the surgeon in his set up’

29. Antibiotic irrigant solutions
Normal saline irrigation-12-56% reduction
Broad spectrum antibacterial agent
with pulsatile lavage, used frequently
Sufficient contact time
Diluted Pov. Iodine- activity persists
whilst the colour remains

30. Post-op antibiotics
Primary Surgery: 2-3days post-op to reduce toxicity, resistance, expense (Evrard et al, Int Orthop, 1988)
Revision Surgery : (Raut et al, 1994)
- I.V. continued till C/S report available
- Orally 6wks-3m as per report
Jackson et al, CORR,2000
- Parenterally-24hrs-8wks
- Orally-Nil-8months after parenteral dose

31. Infection custom and Practice
The ritualistic procedures
Anaesthetist without mask!

32. Contamination Surgeon hand Patients skin
Air borne particles from theatre personnel
From surgical equipment
Ha’eri, G.B.; and Wiley, A.M.: Total hip replacement in a laminar flow environment with special reference to deep infections. Clinical Orthopaedics and Related Research, (148): 163-8, 1980 May.
Howarth, F.H.: Prevention of airborne infection during surgery. The Lancet, 1(8425): 386-8, 1985 Feb. 16.

33. Hand scrub Hand scrub Chlorhexidine/Pov Iodine Alcohol rubs
Brush – increases infection
(Parienti et al, JAMA, 2002)

34. Patient’s Skin (Bratzler & Hunt, Clin Inf Dis, 2006) Preparation
Shower or Bath (dirt and descale)
Use of iodine wraps debatable
Shaving (less than 30 min pre op)
-Hair removal- hair clipper/depilators
on day of surgery
(Bratzler & Hunt, Clin Inf Dis, 2006)

35. Surgical technique The Operation Length of operation Tissue necrosis
Skin edge trauma
Avoiding heamatoma

36. Theatre design Standard theatre 7.7% Air changes 10/hr 3.5%

37. -Powderless gloves- prevents granuloma
Changes in practice
Glove tip 28.7% contaminated
-Suggest that over glove is changed after skin
preparation of patient prior to starting surgery.
-Powderless gloves- prevents granuloma
& increase efficiency

38. Changes in practice Support the practice of changing
Skin knife 9.4% contaminated
Deep knife 3.4% contaminated
Support the practice of changing
blade after skin incision

39. Changes in practice Base and body of light handle 29%
Use a swab to adjust position of light then discard swab

40. Do we need them, turn off when not used ?
Changes in practice
Sucker tip 11.4% contaminated
Do we need them, turn off when not used ?

41. Post-op care Antibiotic coated sutures Drains – Increase BT ?
BT- HIV/Hepatitis
-Prolonged stay
-IV cannula
-Immunomodulation – increased infection
Wound management – antibiotic dressings

42. Take home message Be vigilant, Disciplined, Organised
Technology does not protect us
Theatre discipline
Screen for the right organisms
Understand the genetics of host and pathogens
Need to define the best therapeutic interventions

43. MESSAGE CUSTOMISE WHAT YOU HAVE HEARD IN THIS TALK
VARIATION IN PRACTISES
Country to Country
Hospital to Hospital
Surgeon to surgeon
ADOPT WHAT WORKS FOR YOU
IN YOUR HANDS
IN YOUR SET UP

44. Aristophanes B.C.
“These impossible women! How do they get around us! The poet was right: can’t live with them, or without them”

45. Infection and the Surgeon
You can’t live with it
You can’t live without it!
So we need to manage it!