Courtesy: Dr. Javad Parvizi , Dr Ashok Shyam, Ortho TV
Periprosthetic Joint Infections (PJI): Prevention and Risk Management
Overview
- Prevention of infection in orthopaedic procedures is a major priority
- Complete elimination of infection risk is not possible due to:
- Normal skin flora
- Variable patient immunity
- Bacterial behavior differences
Key Concept
- Even a small number of microorganisms can cause infection
- Focus is on risk reduction at multiple stages
Risk Assessment
Factors Influencing Infection Risk
- Patient-related
- Procedure-related
- Microbiological factors
Classification of Risk Factors
- Modifiable vs non-modifiable
- Controlled vs uncontrolled
Preoperative Risk Factors
1. Patient-Related Factors
- High BMI (especially >40 kg/m²)
- Smoking
- Alcohol use
- Diabetes / poor glycaemic control
- Malnutrition (low serum albumin)
- Both underweight and obesity increase risk
- Chronic medical conditions
2. Metabolic and Systemic Factors
- Poor glycaemic control —- increased infection risk
- Target:
- Fasting glucose <200 mg/dL
- Intensive perioperative glucose control recommended
3. Other Medical Conditions
- Liver disease (especially uncontrolled hepatitis)
- Controlled Human Immunodeficiency Virus (HIV):
- Comparable risk if well managed
- Mental health conditions:
- Depression
- Anxiety
4. Medication and Injection-Related Factors
- Chronic opioid use
- Intra-articular steroid injections:
- May increase infection risk
- Safe interval unclear
5. Local and Nutritional Factors
- Active skin infections — must be treated
- Malnutrition — optimize if possible
Preoperative Screening and Optimization
1. Dental Health
- Routine screening — not required for all
- Evaluate if:
- Poor oral hygiene
- Bleeding gums
- Recent dental procedures
2. Urinary Tract Infection
- Routine screening — not recommended
- Symptomatic patients:
- Evaluate and treat
3. Bacterial Carrier Status
- Routine screening — not universal
- Known resistant organisms:
- Tailored antibiotic coverage
Decolonization
- Antiseptic protocols may be used
Preoperative Preparation
Skin Preparation
- Alcohol-based antiseptic solutions recommended
- Preoperative antiseptic cleansing beneficial
Hair Removal
- Only if necessary
- Use clippers (not razors)
- Perform immediately before surgery
Antibiotic Prophylaxis
Preferred Antibiotic
- First-generation cephalosporin
Key Principles
- Dose adjusted for weight
- Administer within 1 hour before incision
High-Risk Patients
- Additional antibiotics may be required
Intraoperative Measures
Operating Room Environment
- Adequate ventilation essential
- No definitive superiority of airflow systems
Temperature Management
- Maintain normothermia
- Warming systems are safe
Wound Care
- Antiseptic irrigation reduces infection risk
- Short exposure of antiseptic solutions before closure
Postoperative Management
Dressings
- Occlusive dressings preferred
- Keep in place for several days
Antibiotics
- Short-duration prophylaxis
- Avoid prolonged use in uncomplicated cases
Urinary Catheters
- Avoid unless necessary
Wound Monitoring
- Persistent drainage >1 week:
- Requires evaluation
- May need intervention
Additional Considerations
- Thromboprophylaxis
- Multidisciplinary care improves outcomes
Key Messages
- Infection prevention requires a multifactorial approach
- Optimize patient risk factors before surgery
- Appropriate:
- Antibiotics
- Surgical technique
- Wound care
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