
==== Front
Hip Pelvis
Hip Pelvis
Hip Pelvis
Hip & Pelvis
2287-3260
2287-3279
Korean Hip Society

39210568
10.5371/hp.2024.36.3.161
hp-36-3-161
Review Article
Evidence-based Approach for Prevention of Surgical Site Infection
https://orcid.org/0000-0002-6398-281X
Yilmaz Mehmet Kursat MD *†
https://orcid.org/0000-0002-7521-0403
Celik Nursanem MD *‡
https://orcid.org/0000-0003-3866-4657
Tarabichi Saad MD *
https://orcid.org/0009-0008-8869-7709
Abbaszadeh Ahmad MD *
https://orcid.org/0000-0002-6985-5870
Parvizi Javad MD, FRCS §
Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA*
Department of Orthopaedics and Traumatology, Istanbul Medipol University School of Medicine, Istanbul, Türkiye†
Istanbul Medipol University School of Medicine, Istanbul, Türkiye‡
International Joint Center, Acıbadem Maslak Hospital, Istanbul, Türkiye§
Correspondence to: Mehmet Kursat Yilmaz, MD https://orcid.org/0000-0002-6398-281X Rothman Orthopaedic Institute, Thomas Jefferson University, 925 Chestnut St., 5th Floor, Philadelphia, PA 19107, USA E-mail: dryilmazkursat@gmail.com
1 9 2024
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© Korean Hip Society
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Periprosthetic joint infection (PJI) is regarded as a critical factor contributing to the failure of primary and revision total joint arthroplasty (TJA). With the increasing prevalence of TJA, a significant increase in the incidence of PJI is expected. The escalating number of cases, along with the significant economic strain imposed on healthcare systems, place emphasis on the pressing need for development of effective strategies for prevention. PJI not only affects patient outcomes but also increases mortality rates, thus its prevention is a matter of vital importance. The longer-term survival rates for PJI after total hip and knee arthroplasty correspond with or are lower than those for prevalent cancers in older adults while exceeding those for other types of cancers. Because of the multifaceted nature of infection risk, a collaborative effort among healthcare professionals is essential to implementing diverse strategies for prevention. Rigorous validation of the efficacy of emerging novel preventive techniques will be required. The combined application of these strategies can minimize the risk of infection, thus their comprehensive adoption is important. Collectively, the risk of PJI could be substantially minimized by application of a multifaceted approach implementing these strategies, leading to improvement of patient outcomes and a reduced economic burden.

Periprosthetic joint infection
Total joint arthroplasty
Risk factors
Infection control
Surgical wound infection
Funding No funding to declare.
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pmcINTRODUCTION

Periprosthetic joint infection (PJI) is the most significant factor contributing to failure of primary and revision total joint arthroplasty (TJA)1). The number of TJAs is increasing daily. It is predicted that by 2060 in the United States, the volume of patients aged ≥65 years undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) will increase by 559%2). With the increasing number of TJA cases, the incidence of PJI will also increase. With estimated annual hospital spending expected to reach $1.85 billion (approximately $6 per person in the US) by 2030, PJI of the hip and knee still imposes a significant financial burden on the US healthcare system3).

The consequences of PJI can be severe. Significantly higher mortality has been reported for patients undergoing surgery for treatment of PJI compared to patients undergoing aseptic revision arthroplasty4). A study conducted by Berend et al.5) reported that the mortality rate within 90 days following a two-stage exchange surgery was 4%, while an extra 7% of patients died prior to undergoing the second stage procedure. The 5-year overall survival rates for PJI following THA and TKA are comparable to or lower than those for two of the most commonly occurring cancers in older adults in the US (prostate and breast), higher than those for other cancers6).

Some organizations have discussed the preventive practices approved by the latest clinical practice guidelines for surgical site infection (SSI) and prevention of PJI; for example, Centers for Disease Control and Prevention, International Consensus Meeting on Musculoskeletal Infection, and American Academy of Orthopedic Surgeons5,7,8). The purpose of the current study was to review and summarize the 10-step approach for prevention of PJI.

OPTIMIZATION OF HOST RISK FACTORS

Prior to undergoing joint replacement surgery, collection of detailed information regarding the patient’s medical history and overall health is essential to ensure appropriate preoperative assessment and care. Several factors can play a critical role in minimizing the risk of PJI, including postoperative glycemia control, management of immunosuppression, appropriate management of obesity, malnutrition, metabolic syndrome, preoperative anemia, and smoking cessation9). Smoking, including its primary component nicotine, has been linked to microvascular constriction and reduced supply of oxygen to tissues10). In a comprehensive national database study, Duchman et al.11) reported an elevated risk of SSI among both current and former smokers, and the rate of wound complications was higher for current smokers compared to former smokers. In addition, preoperative evaluation of vitamin D levels, screening for urinary tract infection, and dental hygiene examinations can contribute to reducing the rates of PJI. Vitamin D deficiency is more common in the US population and studies have demonstrated that low levels of vitamin D can increase the risk of PJI. Preoperative optimization of serum vitamin D should be considered. A higher risk of infection has been reported for patients with uncontrolled diabetes12). Hemoglobin A1c (HbA1c) is used for long-term glycemic control and HbA1c should be less than seven12). In addition, recent studies have demonstrated the accuracy of fructosamine, a glycemic marker, in prediction of adverse outcomes following THA13).

REDUCING BIOBURDEN

SSI, a commonly encountered complication following surgery, is characterized by infection at the incision site. It imposes a significant burden on both patients and healthcare systems, contributing to extended hospital stays, increased utilization of healthcare resources, and increased healthcare costs. Use of antiseptic solutions such as chlorhexidine or povidone-iodine is preferred in the effort to avoid SSI. Although both solutions are effective in reducing occurrence of surgical infections, compared with aqueous iodine in any type of surgery, 2.0%-2.5% chlorhexidine in alcohol showed the highest efficacy. Guidelines on prevention of SSIs published by the World Health Organization (WHO), the UK National Institute for Health and Care Excellence (NICE), and the US Centers for Disease Control and Prevention (CDC) have provided contrasting recommendations regarding surgical skin preparation. NICE and WHO support the use of chlorhexidine in alcohol, while the CDC has suggested the use of any type of alcohol-based solution. A study by Jalalzadeh et al.14) recommended the use of 2.0%-2.5% chlorhexidine in alcohol as an effective preoperative skin preparation for any type of surgery. If this concentration is not available, alternatives such as 0.5% or 4.0% chlorhexidine in alcohol may be used. Hair removal, another aspect of surgical site preparation, can potentially increase the occurrence of SSIs, thus hair removal should be minimized when necessary9,12,14,15).

In addition, nasal colonization by Staphylococcus aureus has been associated with an increased risk of SSIs. And a few studies have also reported that eradicating the pathogen may be helpful in reducing the rate of infection16).

UTILIZATION OF PERIOPERATIVE ANTIBIOTIC PROPHYLAXIS

Despite limited supporting evidence, CDC guidelines recommend administration of a single preoperative dose for patients undergoing TJA16). In addition, according to a study conducted by Christensen et al.17), no difference in occurrence of acute PJI, superficial infections, reoperations. or overall complications was observed between the 24-hour antibiotic prophylaxis group and the single-dose antibiotic prophylaxis group. In contrast, compared with patients receiving single-dose antibiotic prophylaxis, patients receiving 24-hour antibiotic prophylaxis had significantly longer lengths of stay, longer operative time, and elevated body mass index, and were more likely to have undergone a bilateral procedure. Regarding antibiotic use, intravenous administration of the first generation of cephalosporin within 30 to 60 minutes before incision as a single and weight-adjusted dose is recommended18,19). Prior to the guideline updates, an allergic reaction to penicillin involving skin lesions or local swelling was categorized as a severe allergy, for which clindamycin or vancomycin was recommended as second-line prophylaxis. However, the updated guidelines have excluded skin lesions and local swelling, thereby redefining what constitutes a severe allergy20). In addition, considering the high rates of Staphylococcal resistance to clindamycin, the updated guidelines now recommend streamlining the use of vancomycin as the sole option for second-line prophylaxis21).

BEING GENTLE ON SOFT TISSUE

Failure during any step in the reprocessing of surgical instruments is associated with a higher risk of microorganism transmission. Gloving is crucial for safeguarding both the surgeon and the patient against blood-borne viruses and preventing contamination of the surgical wound by skin flora22). In addition, wound infections pose a challenge for physicians, and selection of suture material can play a crucial role in preventing infection. However, objective data guiding selection of materials are limited. Sutures, which act as foreign bodies, harbor bacteria, increasing the risk of infection. While they can promote tissue healing and limit contamination, the choice of suture material can influence resistance to infection23).

PERFORMING SURGERY AS RAPIDLY AS POSSIBLE

Operative time is a significant factor affecting SSI. In general, longer surgical operation time can result in extended tissue exposure, increased fatigue, and technical errors among the surgical team, as well as reduced systemic defenses of the body24). One study demonstrated that the duration of surgery was a significant risk factor for development of SSIs. Employment of strategies to reduce the duration of surgical operations can be a practical approach to reducing the rate of SSIs25). A recent study26) also reported an association of procedure time with increased risk of SSI. Competence of support staff during performance of operations may affect procedure time and this can be improved. Preoperative planning can also be helpful in reducing the time spent on decision making during surgery and in predicting materials requirements27). This may include employment of strategies such as the adoption of novel technologies that may be helpful in the effort to enhance operative efficiency, utilization of specialized care teams, and preventing overwork or fatigue among operating staff. Administration of additional doses of antibiotics is a generally accepted approach, in cases when the duration of surgery is prolonged and blood loss is high28).

ADOPTING STRATEGIES FOR OPTIMAL CONTROL OF BLOOD LOSS

The detrimental effects of allogeneic blood transfusion, both in general and specifically regarding the outcomes of TJA, have been clearly delineated through conduct of extensive research. An association of allogeneic blood transfusion with increased overall mortality and heightened risk of subsequent SSI has been consistently demonstrated. With supporting evidence from several studies, in the bilateral group, an association of the duration of surgery with a significant increase in the incidence of receiving an allogeneic transfusion has been reported. Therefore, emphasis on reducing operation time is important in order to alleviate the need for allogeneic transfusions and their associated risks29,30). The results of one study showed significant correlations between transfusion risk and several factors, including advancing age, female gender, lower body weight, preexisting anemia, longer surgical duration, exclusive use of general anesthesia, American Society of Anesthesiologists class higher than II, and undergoing revision surgery31).

Use of venous thromboembolism prophylaxis agents following TJA has become routine. However, potential side effects including bleeding should be noted. The potential for bleeding associated with the use of these agents should be an important consideration32).

ESTABLISHING A LESS CROWDED OPERATING ROOM ENVIRONMENT

An association of increased airborne bacterial counts with traffic within the operating room (OR) has been noted. The act of opening doors, which can potentially increase air and wound contamination, can contribute to colonization of bacteria. Numerous studies have reported statistically significant correlations between the frequency of door openings and elevated airborne bacterial counts33-35). Studies directly addressing nursing personnel and for implementation of interventions supporting a reduction in OR traffic due to the request for information have been conducted. Low-cost interventions such as door signage explicitly prohibiting entry by nonessential traffic or personnel and use of retractable tape as a physical barrier for OR doors have resulted in significantly increased awareness and have been helpful in addressing concern regarding OR traffic. The impact of these simple yet effective measures can prove substantial in the effort to mitigate the issue36,37).

UTILIZING AN ANTISEPTIC IRRIGATION SOLUTION

While chlorhexidine combined with alcohol is effective for preoperative skin preparation, use of povidone-iodine along with chlorhexidine for this purpose is still a common practice among many orthopedic surgeons38). The results of one study indicated that the shortest time to elimination of S. aureus and Cutibacterium acnes with no growth at any exposure time was achieved with use of 0.35% povidone-iodine39). Povidone-iodine was also effective in eliminating Staphylococcus epidermidis after 90 seconds of treatment39).

ENSURING PROPER CLEANING OF IMPLANTS AND INSTRUMENTS

Sterilization of implants and instruments during all steps of an operation is essential in preventing infection40). Several methods can be used for sterilization, including heat (steam), dry heat, radiation, ethylene oxide gas, vaporized hydrogen peroxide, and other sterilization methods (chlorine dioxide gas, vaporized peracetic acid, nitrogen dioxide, etc.)41). Based on the rates of microbiological contamination, changing gloves after draping, prior to handling implants, and whenever visible perforation is detected is recommended. Considering the correlation between the duration of surgery and increasing rates of microbiological contamination, changing gloves at least once per hour is advisable, unless there are other compelling reasons to do so42). Over time, increasing contamination can affect all types of implant materials. Taking simple precautions, such as covering the implant set, can reduce the risk of contamination43).

OPTIMIZING WOUND CARE

Wound healing is an important factor in prevention of PJI. Recently, use of innovative surgical bandages, such as hydro fiber absorbent dressings, as an effort to minimize medication requirements while promoting enhanced wound healing and preventing infiltration of external bacterial into the wound site has been increasingly recommended44,45). According to Lung et al.46), the efficacy of chlorhexidine gluconate is comparable to that of dilute betadine in preventing PJI, while also reducing the incidence of superficial drainage and wound complications that necessitate unplanned visits to the emergency department during the acute postoperative period. The suture should fulfill its intended purpose while minimizing adverse reactions as well as the risk of infection, ensuring sufficient duration of effectiveness and strength. However, a suture with greater strength or high tensile strength is not considered universally superior due to the required increase in suture thickness and the potential for unintended tissue constriction, which could potentially exacerbate the inflammatory response47).

CONCLUSION

Prevention of SSI and PJI is more important than diagnosis and treatment. The more PJIs that can be prevented, the greater the reduction of the economic and mental burden inflicted by PJI on the state and patients. Given the multifactorial nature of infection risk, mobilization of all healthcare professionals toward prevention through use of a variety of strategies is essential. In addition, with the continued introduction of novel preventive methods in this sphere, confirming the reliability of these strategies remains critical. Combined application of these individually important strategies can minimize the risk of infection.

Conflict of Interest

Javad Parvizi has been a deputy editor since January 2021, but had no role in the decision to publish this article. No other potential conflict of interest relevant to this article was reported.
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References

1 Jafari SM Coyle C Mortazavi SM Sharkey PF Parvizi J 2010 Revision hip arthroplasty: infection is the most common cause of failure Clin Orthop Relat Res 468 2046 51 https://doi.org/10.1007/s11999-010-1251-6 10.1007/s11999-010-1251-6 20195808
2 Shichman I Roof M Askew N 2023 Projections and epidemiology of primary hip and knee arthroplasty in Medicare patients to 2040-2060 JB JS Open Access 8 e22.00112 https://doi.org/10.2106/JBJS.OA.22.00112 10.2106/JBJS.OA.22.00112 36864906
3 Premkumar A Kolin DA Farley KX 2021 Projected economic burden of periprosthetic joint infection of the hip and knee in the United States J Arthroplasty 36 1484 9.e3 https://doi.org/10.1016/j.arth.2020.12.005 10.1016/j.arth.2020.12.005 33422392
4 Zmistowski B Karam JA Durinka JB Casper DS Parvizi J 2013 Periprosthetic joint infection increases the risk of one-year mortality J Bone Joint Surg Am 95 2177 84 https://doi.org/10.2106/JBJS.L.00789 10.2106/JBJS.L.00789 24352771
5 Berend KR Lombardi AV Jr Morris MJ Bergeson AG Adams JB Sneller MA 2013 Two-stage treatment of hip periprosthetic joint infection is associated with a high rate of infection control but high mortality Clin Orthop Relat Res 471 510 8 https://doi.org/10.1007/s11999-012-2595-x 10.1007/s11999-012-2595-x 22983683
6 Kurtz SM Lau EC Son MS Chang ET Zimmerli W Parvizi J 2018 Are we winning or losing the battle with periprosthetic joint infection: trends in periprosthetic joint infection and mortality risk for the Medicare population J Arthroplasty 33 3238 45 https://doi.org/10.1016/j.arth.2018.05.042 10.1016/j.arth.2018.05.042 29914821
7 Jiranek W Kigera JWM Klatt BA 2019 General assembly, prevention, host risk mitigation - general factors: proceedings of international consensus on orthopedic infections J Arthroplasty 34 2S S43 8 https://doi.org/10.1016/j.arth.2018.09.052 10.1016/j.arth.2018.09.052 30348564
8 Tubb CC Polkowksi GG Krause B 2020 Diagnosis and Prevention of Periprosthetic Joint Infections J Am Acad Orthop Surg 28 e340 8 https://doi.org/10.5435/JAAOS-D-19-00405 10.5435/JAAOS-D-19-00405 31972719
9 Wang K Li W Liu H Yang Y Lv L 2021 Progress in prevention, diagnosis, and treatment of periprosthetic joint infection Evid Based Complement Alternat Med 2021 3023047 https://doi.org/10.1155/2021/3023047 10.1155/2021/3023047 33542741
10 Møller AM Pedersen T Villebro N Munksgaard A 2003 Effect of smoking on early complications after elective orthopaedic surgery J Bone Joint Surg Br 85 178 81 https://doi.org/10.1302/0301-620x.85b2.13717 10.1302/0301-620X.85B2.13717 12678348
11 Duchman KR Gao Y Pugely AJ Martin CT Noiseux NO Callaghan JJ 2015 The effect of smoking on short-term complications following total hip and knee arthroplasty J Bone Joint Surg Am 97 1049 58 https://doi.org/10.2106/JBJS.N.01016 10.2106/JBJS.N.01016 26135071
12 Alamanda VK Springer BD 2018 Perioperative and modifiable risk factors for periprosthetic joint infections (PJI) and recommended guidelines Curr Rev Musculoskelet Med 11 325 31 https://doi.org/10.1007/s12178-018-9494-z 10.1007/s12178-018-9494-z 29869135
13 Shohat N Goswami K Breckenridge L 2021 Fructosamine is a valuable marker for glycemic control and predicting adverse outcomes following total hip arthroplasty: a prospective multi-institutional investigation Sci Rep 11 2227 https://doi.org/10.1038/s41598-021-81803-6 10.1038/s41598-021-81803-6 33500515
14 Jalalzadeh H Groenen H Buis DR 2022 Efficacy of different preoperative skin antiseptics on the incidence of surgical site infections: a systematic review, GRADE assessment, and network meta-analysis Lancet Microbe 3 e762 71 https://doi.org/10.1016/S2666-5247(22)00187-2 10.1016/S2666-5247(22)00187-2 35985350
15 Webster J Osborne S 2015 Preoperative bathing or showering with skin antiseptics to prevent surgical site infection Cochrane Database Syst Rev 2015 CD004985 https://doi.org/10.1002/14651858.CD004985.pub5 10.1002/14651858.CD004985.pub5 25927093
16 Iannotti F Prati P Fidanza A 2020 Prevention of Periprosthetic Joint Infection (PJI): a clinical practice protocol in high-risk patients Trop Med Infect Dis 5 186 https://doi.org/10.3390/tropicalmed5040186 10.3390/tropicalmed5040186 33322463
17 Christensen DD Moschetti WE Brown MG Lucas AP Jevsevar DS Fillingham YA 2021 Perioperative antibiotic prophylaxis: single and 24-hour antibiotic dosages are equally effective at preventing periprosthetic joint infection in total joint arthroplasty J Arthroplasty 36 7S S308 13 https://doi.org/10.1016/j.arth.2021.02.037 10.1016/j.arth.2021.02.037 33712358
18 Aboltins CA Berdal JE Casas F 2019 Hip and knee section, prevention, antimicrobials (systemic): proceedings of international consensus on orthopedic infections J Arthroplasty 34 2S S279 88 https://doi.org/10.1016/j.arth.2018.09.012 10.1016/j.arth.2018.09.012 30348572
19 Hehl J Jones D Stohler S Clinical practice guideline surgical site infection prevention National Association of Orthopaedic Nurses 2021
20 Alamanda VK Springer BD 2019 The prevention of infection: 12 modifiable risk factors Bone Joint J 101-B 1_Supple_A 3 9 https://doi.org/10.1302/0301-620X.101B1.BJJ-2018-0233.R1 10.1302/0301-620X.101B1.BJJ-2018-0233.R1 30648488
21 Jones R Quartuccio KS Stern JL Heintz EV Pillinger KE Myers TG 2021 Antibiotic stewardship interventions improve choice of antibiotic prophylaxis in total joint arthroplasty in patients with reported penicillin allergies Clin Orthop Relat Res 479 1484 94 https://doi.org/10.1097/CORR.0000000000001739 10.1097/CORR.0000000000001739 33856366
22 Bali RK Bonanthaya K Panneerselvam E Manuel S Kumar VV Rai A Operating room protocols and infection control Oral and maxillofacial surgery for the clinician Springer Nature 2021 173 94 10.1007/978-981-15-1346-6_9
23 Masini BD Stinner DJ Waterman SM Wenke JC 2011 Bacterial adherence to suture materials J Surg Educ 68 101 4 https://doi.org/10.1016/j.jsurg.2010.09.015 10.1016/j.jsurg.2010.09.015 21338964
24 Ercole FF Franco LM Macieira TG Wenceslau LC de Resende HI Chianca TC 2011 Risk of surgical site infection in patients undergoing orthopedic surgery Rev Lat Am Enfermagem 19 1362 8 https://doi.org/10.1590/s0104-11692011000600012 10.1590/S0104-11692011000600012 22249670
25 Li GQ Guo FF Ou Y Dong GW Zhou W 2013 Epidemiology and outcomes of surgical site infections following orthopedic surgery Am J Infect Control 41 1268 71 https://doi.org/10.1016/j.ajic.2013.03.305 10.1016/j.ajic.2013.03.305 23890741
26 Simon S Hollenbeck B 2022 Risk factors for surgical site infections in knee and hip arthroplasty patients Am J Infect Control 50 214 6 https://doi.org/10.1016/j.ajic.2021.11.006 10.1016/j.ajic.2021.11.006 34793889
27 Cheng H Chen BP Soleas IM Ferko NC Cameron CG Hinoul P 2017 Prolonged operative duration increases risk of surgical site infections: a systematic review Surg Infect (Larchmt) 18 722 35 https://doi.org/10.1089/sur.2017.089 10.1089/sur.2017.089 28832271
28 Hanssen AD Osmon DR The use of prophylactic antimicrobial agents during and after hip arthroplasty Clin Orthop Relat Res 1999 369 124 38 https://doi.org/10.1097/00003086-199912000-00013 10.1097/00003086-199912000-00013 10611867
29 Pedersen AB Mehnert F Overgaard S Johnsen SP 2009 Allogeneic blood transfusion and prognosis following total hip replacement: a population-based follow up study BMC Musculoskelet Disord 10 167 https://doi.org/10.1186/1471-2474-10-167 10.1186/1471-2474-10-167 20040083
30 Ross D Erkocak O Rasouli MR Parvizi J 2019 Operative time directly correlates with blood loss and need for blood transfusion in total joint arthroplasty Arch Bone Jt Surg 7 229 34 https://doi.org/10.22038/ABJS.2019.28534.1736 10.22038/ABJS.2019.28534.1736 31312679
31 Rashiq S Finegan BA 2006 The effect of spinal anesthesia on blood transfusion rate in total joint arthroplasty Can J Surg 49 391 6 17234066
32 Choi YS Kim TW Chang MJ Kang SB Chang CB 2022 Enhanced recovery after surgery for major orthopedic surgery: a narrative review Knee Surg Relat Res 34 8 https://doi.org/10.1186/s43019-022-00137-3 10.1186/s43019-022-00137-3 35193701
33 Alizo G Onayemi A Sciarretta JD Davis JM 2019 Operating room foot traffic: a risk factor for surgical site infections Surg Infect (Larchmt) 20 146 50 https://doi.org/10.1089/sur.2018.248 10.1089/sur.2018.248 30648925
34 Lansing SS Moley JP McGrath MS Stoodley P Chaudhari AMW Quatman CE 2021 High number of door openings increases the bacterial load of the operating room Surg Infect (Larchmt) 22 684 9 https://doi.org/10.1089/sur.2020.361 10.1089/sur.2020.361 33370210
35 Panahi P Stroh M Casper DS Parvizi J Austin MS 2012 Operating room traffic is a major concern during total joint arthroplasty Clin Orthop Relat Res 470 2690 4 https://doi.org/10.1007/s11999-012-2252-4 10.1007/s11999-012-2252-4 22302655
36 Buckner L Lacy J Young K Dishman D 2022 Decreasing foot traffic in the orthopedic operating room: a narrative review of the literature J Patient Saf 18 e414 23 https://doi.org/10.1097/PTS.0000000000000833 10.1097/PTS.0000000000000833 33871413
37 Osborn NS Hoehmann CL McCormack R Owens J 2020 Operating room traffic in total joint arthroplasty: one simple measure toward solving a complex problem JB JS Open Access 5 e20.00015 https://doi.org/10.2106/JBJS.OA.20.00015 10.2106/JBJS.OA.20.00015 32803103
38 Mastrocola M Matziolis G Böhle S Lindemann C Schlattmann P Eijer H 2021 Meta-analysis of the efficacy of preoperative skin preparation with alcoholic chlorhexidine compared to povidone iodine in orthopedic surgery Sci Rep 11 18634 https://doi.org/10.1038/s41598-021-97838-8 10.1038/s41598-021-97838-8 34545135
39 Christopher ZK Tran CP Vernon BL Spangehl MJ 2022 What is the duration of irrigation? An in vitro study of the minimum exposure time to eradicate bacteria with irrigation solutions J Arthroplasty 37 385 9.e2 https://doi.org/10.1016/j.arth.2021.10.013 10.1016/j.arth.2021.10.013 34740788
40 Spiegel C Nogler M Coraça-Huber DC 2022 Sterilization procedures for titanium alloy surfaces leads to higher expression of biofilm-related Staphylococcus aureus genes Antibiotics (Basel) 11 1647 https://doi.org/10.3390/antibiotics11111647 10.3390/antibiotics11111647 36421291
41 U.S. Food and Drug Administration (FDA) Sterilization for medical devices FDA 2023
42 Kim K Zhu M Munro JT Young SW 2019 Glove change to reduce the risk of surgical site infection or prosthetic joint infection in arthroplasty surgeries: a systematic review ANZ J Surg 89 1009 15 https://doi.org/10.1111/ans.14936 10.1111/ans.14936 30497094
43 Menekse G Kuscu F Suntur BM 2015 Evaluation of the time-dependent contamination of spinal implants: prospective randomized trial Spine (Phila Pa 1976) 40 1247 51 https://doi.org/10.1097/BRS.0000000000000944 10.1097/BRS.0000000000000944 25929209
44 Ratto N Arrigoni C Rosso F 2017 Total knee arthroplasty and infection: how surgeons can reduce the risks EFORT Open Rev 1 339 44 https://doi.org/10.1302/2058-5241.1.000032 10.1302/2058-5241.1.000032 28461965
45 Cai J Karam JA Parvizi J Smith EB Sharkey PF 2014 Aquacel surgical dressing reduces the rate of acute PJI following total joint arthroplasty: a case-control study J Arthroplasty 29 1098 100 https://doi.org/10.1016/j.arth.2013.11.012 10.1016/j.arth.2013.11.012 24405622
46 Lung BE Le R Callan K 2022 Chlorhexidine gluconate lavage during total joint arthroplasty may improve wound healing compared to dilute betadine J Exp Orthop 9 67 https://doi.org/10.1186/s40634-022-00503-w 10.1186/s40634-022-00503-w 35819733
47 Pacer E Griffin DW Anderson AB Tintle SM Potter BK 2020 Suture and needle characteristics in orthopaedic surgery JBJS Rev 8 e19.00133 https://doi.org/10.2106/JBJS.RVW.19.00133 10.2106/JBJS.RVW.19.00133 32649161
