"Recommendations for periprosthetic joint infections (PJI) prevention: the European Knee Associates (EKA)-International Committee American Association of Hip and Knee Surgeons (AAHKS)-Arthroplasty Society in Asia (ASIA) survey of members".

ABSTRACT

PURPOSE: Periprosthetic joint infections (PJIs) represent a devastating consequence of total joint arthroplasty. The European Knee Associates (EKA), the American Association of Hip and Knee Surgeons (AAHKS) International Committee, and the Arthroplasty Society in Asia (ASIA) board members were interested in quantifying differences in arthroplasty surgeons' use of various PJI prevention measures to provide clinical recommendations to reduce PJI incidence. METHODS: A prospective Microsoft Forms online survey was distributed among EKA, AAHKS International Committee, and ASIA members and their affiliated arthroplasty surgeons. The survey consisted of 20 single and multiple response questions focused on PJI prevention strategies at three perioperative periods preoperatively, intraoperatively, and postoperatively. RESULTS: Three hundred and ninety-four arthroplasty surgeons from 6 different continents completed the survey. Preoperative (A) PJI Risk Stratification 40.6% routinely set thresholds (e.g., BMI, HgbA1C) to be met to qualify for surgery, 36.5% only review past medical history; 9.1% use machine learning to personalize PJI risk; (B) BMI limit 36% no limit; 15.4% BMI < 35; 30.9% BMI < 40; 17.2% BMI < 45; (C) Nutritional status 55.3% do not screen; among those who screen their patients (44.7%), albumin is the single most used marker (86.3%); (D) Hyperglycemia/Diabetes 83.3% check this comorbidity; 88.1% use HgbA1C as single best screening test; (E) MRSA nasal colonization 63.7% do not test; 28.9% test all patients; 7.4% test selectively. Intraoperative (A) Antibiotic prophylaxis in high-risk patients 43.4% use single antibiotic for 24 h; 21.3% use double antibiotic for 24 h; 14.2% use single/double antibiotic for 7 days postoperatively; (B) Skin-cleansing 68.7% at home (45.6% chlorhexidine sponge; 11.9% clippers); (C) Intraoperative skin disinfection 46.9% single chlorhexidine; 25% double chlorhexidine-povidone-iodine;15.4% single povidone-iodine; (D) Tranexamic acid (TXA) to reduce bleeding/SSI 96% yes (51% double IV dose, 35.2% single IV dose, 23.6% intra-articular injection); (E) Surgical suction drain 52% do not use drains; 19.7% use a drain < 24 h; (F) Intra-articular lavage 64.9% use only saline; 28.1% use dilute povidone-iodine; (G) Antibiotic local delivery to prevent PJI 82.4% use antibiotic-added cement. Postoperative (A) Routine monitoring of PJI serologic markers 42% only in symptomatic patients; 34.2% do not; 20.8% in all patients; (B) Serologic markers to rule in/out PJI 95.9% CRP; 71% SEDRATE; 60.6% WBC; (C) Synovial fluid test to rule in/out PJI 79.6% culture/sensitivity; 69.5% WBC count; 31.4% CRP. CONCLUSIONS: This survey demonstrated that notable differences still exist in the application of PJI preventive measures across different geographic areas Optimizing the patient preoperatively and applying multimodal intraoperative strategies represent newer, clinically relevant steps in the effort to reduce the burden of PJI. More uniform guidelines still need to be produced from international scientific societies in order facilitate a more comprehensive approach to this devastating complication. LEVEL OF EVIDENCE IV.