Reducing the Risk: Periprosthetic Joint Infection Prevention

By Don Sadler

Total joint arthroplasty (TJA) is one of the most common elective surgeries in the U.S. today. It has been shown to improve physical health, lessen pain and depression, and lead to a higher quality of life among patients. Long-term revision-free survivorship exceeds 90% at 10 years.

Between 2000 and 2019, the number of primary total hip arthroplasties (THAs) increased by 150% while the number of primary total knee arthroplasties (TKAs) increased by 170%. These surgeries are projected to skyrocket over the next two-plus decades to nearly 720,000 THAs and more than 1.2 million TKAs by 2040. Many have now moved into an ambulatory setting with same-day and next-day discharge for patients becoming increasingly common options.

Infection Rates Are Rising

Despite efforts to lower infection rates, the number of periprosthetic joint infections (PJIs) is on the rise. PJIs now occur in 0.5-1.5% of all primary total hip and knee arthroplasties and in 3-10% of revision surgeries. 

PJIs are a major cause of failure affecting total joint arthroplasties. There’s a five-year mortality rate of over 20% associated with hip and knee PJIs, which is projected to result in an economic burden of $1.85 billion by 2030.

“Prosthetic joint infections have large clinical and economic implications,” says Ilda B. Molloy, M.D., M.S., the at the Yale University School of Medicine Department of Orthopaedics & Rehabilitation. “They’re costly to patients, society and the overall healthcare system.”

“We know there are negative implications for any patient who ends up with a complication or infection after total joint arthroplasty,” says Lee E. Rubin, M.D., FAAOS, FAAHKS, FAOA, associate professor at the Yale University School of Medicine Department of Orthopaedics & Rehabilitation. “So, we’re doing everything we can to try to prevent these infections.”

“Periprosthetic joint infections can lead to a wide range of problems for patients,” says Karen deKay, MSN, RN, CNOR, CIC, EBP-C, FAPIC, senior perioperative practice specialist at the Association of periOperative Registered Nurses (AORN).

“These infections can lead to prolonged hospitalizations, which can contribute to higher costs, time away from family and work, and greater potential for additional complications such as other hospital acquired infections, venous thromboembolism, and even death,” says deKay. “Additional surgery may also be necessary for wound debridement or removal and replacement of a prosthetic device.”

A Comprehensive Infection Prevention Strategy

Yale New Haven Health (YNHH) has created a series of steps and interventions to form a comprehensive PJI prevention strategy. 

“If there are deviations from a step, someone will catch it,” says Rubin. “It’s critical to have multiple eyes watching every step. I believe that every institution should have this kind of strategy to make it less likely that a step will be missed.”

One example is YNHH’s antibiotic administration protocol that dictates what antibiotic should be used, the concentration patients should receive and under what circumstances a different antibiotic should be given. 

“We have all of this mapped out so there’s very little guessing that goes on,” says Rubin. “It’s all standardized and based on evidence and national guidelines.”

According to Molloy, YNHH uses nurse navigation for pre-op risk assessment and patient optimization to identify host risk factors prior to surgery. “We’ve developed an Ortho Risk Score that factors in the patient’s health history and risk factors that might influence complications or readmissions,” she says. “This helps us select which patients are good candidates to go home or have a short stay after surgery. We really have to be careful when choosing these patients.”

“We’re trying to carefully match the needs of patients to what we can do in the OR before we even get there,” says Rubin. 

The YNHH PJI prevention strategy includes the following guidelines for proper use:

Surgical helmets

• Do not walk around the OR with the helmet and battery turned on and blowing air.
• Clip in the battery immediately when scrubbing in.
• Do not reach under the chin to scratch your nose.
• Do not touch the top or rear of the helmet.

Surgical gowns

• Unfurl the gown completely before it is donned.
• Cover cuffs and bottom gloves with top gloves at all times.
• Tie the gown tightly to minimize rear opening and exposure.
• Use toga-type gowns or vests to eliminate rear openings to reduce risk of inadvertent contamination.

Surgical tables

• Minimize contamination from any passersby such as students, observers and sales reps.
• If a surgical case is delayed after setup, cover open kits with a blue towel and cover the table with a large sheet to minimize the risk of passive contamination.
• Drape surgical sites meticulously to reduce the risk of inadvertent contamination.

Surgical basins

• Use dry basins instead of wet basins to minimize contamination risk.
• If a wet basin is used, place a betadine packet in the sterile water to lower contamination risks.

Sterile Betadine for TJA 

Molloy and Rubin stress the importance of using betadine during TJA procedures. 

“When we talk to periop audiences, my impression is that many of them are not seeing betadine used in the OR for TJAs,” says Molloy. “For us, this is a standard of care and there’s a lot of data to support this practice.”

For example, surgeons at Rush Medical Center in Chicago compared 1,862 consecutive TJA cases before adoption of a betadine protocol with 688 consecutive TJA cases after adoption of the protocol. The betadine protocol reduced the PJI rate from 0.97% to 0.15%. For revision cases, the betadine protocol reduced the PJI rate from 3.4% to 0.4%.

“The data is pretty convincing,” says Rubin. “A betadine wash is a very inexpensive intervention that has a huge potential impact. The cost is about one dollar, compared to possibly $60,000 to $80,000 to treat infection cases.” 

The YNHH protocol uses 22.5mL of sterile 10% betadine diluted in 500mL normal saline. For betadine allergic patients, YNHH uses pre-packaged sterile 0.05% CHG (Irrisept).

Another simple PJI prevention step is minimizing traffic in the OR. 

“If additional personnel are not needed in the OR, then they shouldn’t be in there,” says Molloy. “Opening and closing the door creates air turbulence and having more people in the OR increases the risk of contamination to the room.”

“We post signs outside the OR saying that if you need to talk to someone, call into the room instead of going in and out,” says Rubin. “This goes back to case preparation by OR techs and nurses: Ideally, everything should be on the case card and picked in advance for the OR team to minimize the need to go in and out of the room to get more supplies.”

“We also try to only use the main entry door instead of the peripheral door whenever possible,” Rubin adds. “And we have now placed sterile hand cleansers inside the OR to limit door openings and improve case efficiency.”

Wound Management Strategies

The YNHH PJI prevention strategy recommends barbed sutures for fascial closures to lessen drainage and infection risk. 

“There should be a standardized protocol for an occlusive dressing and how long it stays on the wound,” says Rubin. “We believe these are the best bet because there’s no one touching the wound or changing the dressing for the first seven days.”

Surgical centers can incorporate the application of controlled negative pressure dressings for high-risk cases (e.g., revisions and periprosthetic fractures) to accelerate debridement, with an optimum level of negative pressure around -125 mmHg. “This will result in removal of interstital fluid, decreased local edema and increased blood flow,” says Molloy.

The YNHH strategy also includes a defined protocol for the use of “extended oral” antibiotic prophylaxis that takes into account the patient’s risk factors, such as their immunocompromised status (as defined by the NIH/CDC), body mass index (over 35), aseptic revision, and whether they are known smokers or diabetics (A1C greater than 7). 

“We give these patients an extra week of oral antibiotics as this is one additional evidence-based step that can help decrease the rate of infection,” says Rubin. 

Molloy notes, however, that there is a potential risk of complications associated with extending antibiotics. “Some studies support extending antibiotics and some don’t, so there’s ongoing review and some debate about it,” she says. 

Lastly, each facility should establish a terminal room cleaning protocol. 

“Dirty infection cases should ideally be scheduled at the end of the day,” says Molloy.

‘Speak Up’ for Sterility

Both Molloy and Rubin stress the importance of all perioperative staff speaking up for sterility. “Everyone has eyes and ears and should feel empowered to speak up if they see a break in the protocol or in sterility,” says Rubin. 

“Every member of the OR team is part of the mission of achieving zero infections,” says Molloy. “Establishing good habits and practices, like the ones in our PJI prevention strategy, enables us to pursue excellence.”

As the number of total joint arthroplasties rises sharply, the importance of reducing periprosthetic joint infections also rises. “Even though we have taken all of these prevention steps, the rate of PJIs still persists,” says Molloy. “So, we have to remain vigilant.”

Molloy will represent YNHH at the International Consensus Meeting on Infection (ICM-I) in Istanbul, Turkey, in May 2025. The mission of the ICM-I is to fund research and innovation focused on reducing orthopaedic-related infections. Visit https://www.icmortho.org/aboutus to learn more about the ICM-I.

A Structured Approach to Preventing PJIs

Saad Tarabichi of the Rothman Orthopaedic Institute at Thomas Jefferson University Hospital in Philadelphia, and Javad Parvizi, CEO and founder of Parvizi Surgical Innovation, published a 10-step guide to preventing periprosthetic joint infections in 2023. The guide includes practical and effective measures to prevent PJIs:

1. Host optimization: The authors identify a number of modifiable host risk factors including diabetes, hypertension, hyperglycemia, malnutrition, immunocompromised state, high body mass index, a history of smoking, corticosteroid use and malnutrition.
2. Bioburden reduction: The rationale behind this strategy is that effective skin decontamination, along with the removal of hair near the surgical site, can cause a significant reduction in the number of bacteria. Patients undergoing TJA should also bathe with antiseptic soap in the days leading up to their procedure.
3. Perioperative antibiotic prophylaxis: This is a proven method of PJI prevention. Recent clinical practice guidelines have endorsed the use of either first- or second-generation cephalosporins as the primary method of antibiotic prophylaxis in this setting.
4. Respect for soft tissues: It’s vital to ensure that soft tissues are properly handled by instruments, not by hand and potentially contaminated gloves. Excessive tension on the skin and soft tissues should be avoided.
5. Expeditious surgery: Protracted operative time is a well-established risk factor for PJI development due to the higher chance of surgical field contamination. The authors cite research indicating that a 20-minute increase in operative time increased the risk of PJIs by as much as 25%.
6. Minimized blood loss: It’s recognized that the need for allogeneic blood transfusions increases the risk of PJIs, which makes preventing unnecessary blood loss during TJA critical.
7. Reduced OR traffic and door openings: The majority of airborne pathogens in the OR originate from members of the surgical team, so the number of surgical personnel should be kept to a minimum without compromising patient care. Also, excessive opening and closing of the OR doors can generate air currents that may increase the chances of surgical field contamination.
8. Use of an antiseptic irrigation solution: This will help ensure effective chemical and mechanical debridement of tissues. The authors note that 0.5% povidone-iodine (PVP-I) irrigation solution is the choice of their institution and many others.
9. Cleaned and sterilized implants and instruments: Validated methods of orthopedic implant and surgical device sterilization cited by the authors include radiation, ethylene oxide gas and vaporized hydrogen peroxide.
10. Proper wound closure and management: This includes application of an appropriate skin dressing. The authors recommend suturing in extension following total hip arthroplasty and suturing in 10 degrees of flexion following total knee arthroplasty.