The Effect of Antiseptics in the Prophylaxis of Infection in Orthopaedic Surgery

Abstract

Introduction Over the past decade, the incidence of revision arthroplasty has increased substantially. One of the main reasons for revision arthroplasty is periprosthetic joint infection, often resulting in multiple surgical interventions with variable success and poor clinical outcome. Intraoperative wound irrigation has been proposed to reduce bacterial contamination and thus the risk of periprosthetic infection. However, there is currently no widely accepted recommendation for the use of topical antiseptics within the operative setting for primary implantation. We performed a systematic review of studies pertaining to the use of intraoperative topical antiseptics and their effectiveness in preventing infection of orthopaedic implants.

Materials and Methods A comprehensive literature search including MEDLINE (PubMed), Cochrane Library, and Current Contents Medicine (CCMED-Medpilot) was performed according to a standardised protocol.

Results Overall, 1905 articles were initially assessed. Four studies met the inclusion criteria and remained for further analysis, comprising two prospective cohort studies using retrospective control groups (evidence level II – III) and two randomised controlled trials (evidence level I). 0.35% Povidone-iodine (PVP-I) was used in three of these studies and a solution of 6.25% PVP-I and 6.25%-hydrogen peroxide (H₂O₂) in one study for intraoperative wound irrigation. There was a clear trend in all studies suggesting that intraoperative topical antiseptics are effective in preventing periprosthetic infection.

Conclusion Although no clear regimen can be recommended, the available literature indicates that the use of intraoperative topical antiseptics is of clinical relevance in preventing infection of orthopaedic implants. Further randomised controlled trials are recommended.

Zusammenfassung

Hintergrund Trotz steigender Revisionsoperationen nach Hüft- und Knie-TEP-Implantationen, dadurch zunehmenden Kosten für das Gesundheitswesen und häufiger auftretenden multiresistenten Bakterien ist zur prophylaktischen intraoperativen Anwendung topischer Antiseptika zur Verhinderung periprothetischer Infektionen wenig bekannt. Ziel dieser Studie ist die Suche und statistische Aufarbeitung (Metaanalyse) existierender Studien über die Wirksamkeit und Sicherheit intraoperativ-prophylaktischer Antiseptika-Spülungen nicht infizierter Wunden während endoprothetischer Operationen.

Material und Methode Hierzu erfolgte eine umfassende Literaturrecherche als elektronische Suche nach festem Protokoll über MEDLINE (PubMed), Cochrane Library und Current Contents Medicine (CCMED-Medpilot).

Ergebnisse insgesamt wurden zunächst 1905 erfasst, nach Anwendung des Protokolls mit Ein- und Ausschlusskriterien blieben nur 4 relevante Studien. Zwei dieser eingeschlossenen Studien sind prospektive Kohortenstudien mit retrospektiver Kontrollgruppe mit Evidenzlevel II bis III. Die 2 weiteren Studien sind randomisierte kontrollierte Studien mit Evidenzlevel I. Drei der 4 Studien untersuchten PVP-Iod als Antiseptikum zur intraoperativen Wundspülung, wohingegen die vierte Studie ein Gemisch aus PVP-Iod und H2O2 verwendete. Keiner der Studien beinhaltet eine Placebo-Kontrolle. Alle 4 Untersuchungen zeigen insgesamt einen klaren Trend, der die prophylaktische Wirkung lokaler topischer Antiseptika zur Vermeidung periprothetischer Infektionen hervorhebt.

Schlussfolgerung Lokal topische Antiseptika könnten eine wichtige Bedeutung in der Behandlung und Prophylaxe periprothetischer Infektionen erlangen. Weitere „well designed random controlled“ Studien, besonders unter Einbeziehung geeignet erscheinender Antiseptika mit günstigem Biokompatibilitäts-Index wie Octenidin oder Polihexanid sind notwendig.

Key words

periprosthetic infection - prophylaxis - topical irrigation - intraoperative wound irrigation - antiseptics

Schlüsselwörter

periprothetische Infektion - Prophylaxe - intraoperative Wundspülung - topische Spülung - Antiseptika

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