The Prevention of Periprosthetic Joint Infections

Fatih Küçükdurmaz*, Javad Parvizi
Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA

Article Metrics

CrossRef Citations:
Total Statistics:

Full-Text HTML Views: 527
Abstract HTML Views: 280
PDF Downloads: 130
ePub Downloads: 94
Total Views/Downloads: 1031
Unique Statistics:

Full-Text HTML Views: 375
Abstract HTML Views: 196
PDF Downloads: 101
ePub Downloads: 70
Total Views/Downloads: 742

© Küçükdurmaz and Parvizi; Licensee Bentham Open

open-access license: This is an open access article licensed under the terms of the Creative Commons Attribution-Non-Commercial 4.0 International Public License (CC BY-NC 4.0) (, which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.

* Address correspondence to this author at the 125 South 9th Street, Suite #1000, Philadelphia, PA 19107, USA; Tel: 267-339-3736; Fax: 267-339-3696; E-mails:,


Periprosthetic joint infection (PJI) following total joint arthroplasty (TJA) adversely affects patient quality of life and health status, and places a huge financial burden on the health care. The first step in combating this complication is prevention, which may include implementation of strategies during the preoperative, intraoperative, or postoperative period. Optimization of the patient with appreciation of the modifiable and non-modifiable factors is crucial. Preoperative optimization involves medical optimization of patients with comorbidities such as diabetes, anemia, malnutrition and other conditions that may predispose the patient to PJI. Among the intraoperative strategies, administration of appropriate and timely antibiotics, blood conservation, gentle soft tissue handling, and expeditious surgery in an ultra clean operating room are among the most effective strategies. During the postoperative period, all efforts should be made to minimize ingress or proliferation of bacteria at the site of the index arthroplasty from draining the wound and hematoma formation. Although the important role of some preventative measures is known, further research is needed to evaluate the role of unproven measures that are currently employed and to devise further strategies for prevention of this feared complication.

Keywords: Periprosthetic joint infection, Prevention, Total hip arthroplasty, Total knee arthroplasty.


Total joint arthroplasty (TJA) is currently the most successful surgical procedure for improving patient quality of life. However, there are still unsolved problem in TJA, one of the most devastating after TJA is periprosthetic joint infection (PJI). The treatment of PJI often requires multiple surgical procedures and is associated with increased complications and morbidity as well as increased costs. As the volume of primary and revision TJA increases, the burden of treatment is becoming a major economical and public health issue [1].

Therefore, the prevention of PJI through implementation of effective strategies should be a priority. Several modifiable factors may influence the outcome of TJA. Identification of risk factors is important so that resources can be focused more effectively and greater attempts at risk reduction can be pursued [2]. In this review, the current evidence for the optimization of patient and surgery-related modifiable risk factors are assessed in the preoperative, intraoperative and postoperative periods.


Infection Screening

The presence of any local or systemic infection is considered to be a contraindication for elective joint arthroplasty [3]. The infection may exist in the urinary tract, skin, nails as well as the oral cavity [4]. Also the anterior nares can be a site of reservoir for Staphylococcus aureus.

The cost effectiveness of routine dental or urinary screening before an arthroplasty has been questioned. Although all infections should be treated before TJA is performed, no relationship has been demonstrated between routine dental clearance and PJI incidence [5, 6]. Due to the lack of evidence regarding dental pathology as a source of PJI, only high-risk patients (such as tobacco and narcotic users, and patients who have not had a dental visit within the past 12 months) should be screened preoperatively for dental infection [7]. On the other hand, high-level nasal carriage of S. aureus is an important risk factor for subsequent surgical site infection (SSI) [8, 9]. Males, obese patients, a history of a cerebrovascular accident, multiple hospital admissions, and having a pet at home have been associated with nasal carriage of S. aureus [10]. Empirical use of mupirocin ointment without screening is shown to be a simple, safe, cost-effective [11] and associated with a decreased incidence of SSI [12, 13]. On the other hand, there are concerns regarding the development of resistance to mupirocin in the setting of routine use [14].

Smoking and Alcohol Use

Patients who smoke were found to have increased postoperative complications compared to non-smokers [15, 16]. In different studies, former and current smokers were found to have a 24% to 43% and 32% to 56% higher risk of postoperative complications after TJA, respectively [17, 18]. Complication rates increased proportionally with the amount of smoking. Although there is no consensus on the definition of heavy smoking, it is stated that smoking more than one pack per day is significantly associated with development of PJI and other postoperative complications [19]. The optimal time for cessation of smoking is not known, but at least 4 to 8 weeks prior to surgery is recommended [20-22].

Alcohol consumption is related to increased risks of postoperative morbidity and mortality [23, 24]. Alcohol cessation or a reduction in consumption four weeks prior to surgery is effective in reducing the risk of developing postoperative complications. [2, 25]

Diabetes Mellitus (DM)

Regardless of the diabetes type, patients with uncontrolled DM exhibit a significantly increased risk of postoperative complications following TJA [26]. Thus, preoperative optimization of patients with a fasting glucose level < 200 mg/L and HbA1C levels <7% after arthroplasty is extremely important in minimizing postoperative complications [27]. Stress-induced hyperglycemia is activated by the hypothalamic-pituitary axis in up to two thirds of non-DM patients following surgery and this increases the risk of 30-day mortality in comparison to patients with well-controlled diabetes [28-30].

Liver and Kidney Disease

Patients with chronic renal and liver failure (CRF) are at risk of increased postoperative complications [31]. The mortality of patients with chronic liver failure is reported to be 15.8% in patients undergoing total hip arthroplasty (THA) [32, 33]. The risk of mortality was found correlated by the preoperative Child-Turcotte-Pugh score [33, 34]. Advanced stage of disease (Child’s B and C), INR >1.6, prolonged PT and concurrent encephalopathy were reported as poor prognostic factors. [7, 32, 33] The hemostatic balance should be corrected before surgery in order to avoid excessive bleeding or perhaps patients with advanced stage of disease should not subjected to elective arthroplasty [35, 36].

There is increased risk of infection in chronic renal failure [37-41], particularly high in patients receiving hemodialysis [41-45]. Most CRF patients may also be carriers of MRSA and should receive vancomycin as a preoperative prophylactic antibiotic [40]. Because of the higher risk of infection in patients with CRF, some authorities have advocated that femoral component fixation should be performed with antibiotic-impregnated cement. There is no evidence in the current literature to support the use of one mode of implant fixation over another in this population [40, 46, 47]. As a result, TJA in CFR patients may be considered a reliable surgical option if performed within the framework of careful multidisciplinary patient management.

Inflammatory Joint Disease (IJD)

Patients with rheumatoid arthritis (RA), juvenile inflammatory arthritis, and spondylarthropathies, such as ankylosing spondylitis and psoriatic arthritis (PA), have been identified as having a higher baseline risk of infection compared with that of the general population [48].

In addition to the immune modulating effect of the disease itself, most patients who are on disease modifying anti-rheumatic drugs (DMARDs) may be at an additional risk of developing an infection [49]. The most commonly used medications are synthetic DMARDs such as methotrexate, hydroxychloroquine, and leflunomide; corticosteroids; and biologic agents, including TNF-blocking agents. The SSI rate among RA patients was found to be two to four times higher than in those with osteoarthritis [50].

The main issue in patients with psoriasis is the presence of skin lesions. Colonization of the skin plaques with staphylococcal species and more strikingly enteric Gram-negative organisms and Bacteroides spp. has been confirmed [51]. Because of the increased risk of infection, performing elective arthroplasty in patients with active and aggressive psoriatic arthritis and skin lesions is considered inappropriate. It is agreed that incisions should not be placed through active skin lesions [52].

The appreciation of significantly higher risk of PJI in patients with IJD by using all possible pre- and postoperative prophylactic interventions may help to reduce infection rates in this high-risk group [50]. This includes proper timing of surgery, cessation of DMARDs, proper skin preparation, and antibiotic prophylaxis. The cessation of DMARDS should be performed in consultation with a rheumatologist, which can be arranged based on the specific medication, the individual patient, and the half-life of the particular medication [2]. Although there is no clear evidence, routine use of antibiotic-laden cement for fixation in IJD patients may be justified.


Preoperative anemia, usually an underestimated problem, has also been shown to be an independent risk factor for PJI, and reported to be as high as 35% [53, 54]. Efforts should be made to treat the anemia preoperatively in order to prevent postoperative complications with surgical blood loss [55]. There are some treatment options for anemia such as autologous blood donation, iron replacement, and administration of erythropoietin. Autologous blood transfusion has well known disadvantages [56, 57] whereas iron replacement, with or without erythropoietin, was found safe and efficient to reduce the risk of transfusion in patients undergoing TJA [58].


Patients with a history of extreme weight loss and poor nutritional habits are at particular risk of being malnourished. All forms of malnutrition predispose patients to SSI up to 4 times, therefore patients undergoing elective arthroplasty should be evaluated for the presence of malnutrition [59-64]. The WHO has defined the threshold limits for malnourished patient as serum total lymphocyte count <1,500 cells/mm3, a serum albumin concentration of <3.5 g/dL, low serum prealbumin, and serum transferrin levels <200 mg/dL [63, 65-67].

Obesity is considered as paradoxical malnutrition due to carbohydrate rich and protein poor diet [68, 69]. Thus, obese patients should undergo screening for the presence of malnutrition [64] Malnutrition is a modifiable risk factor, postponing the TJA is strongly recommended because patients with a body mass index [BMI] ≥40.0 kg/m2, significantly increases the risk of PJI [21]. On the other hand, rapid weight loss can result in malnutrition as well and has greater likelihood of developing a deep SSI compared with those who remained the same weight [65, 70].


Prophylactic Perioperative Antibiotics

The goal of administering preoperative antibiotics is to allow for adequate tissue concentrations above the minimal inhibitory concentrations before surgical incision [71]. First or second generation cephalosporins are recommended for routine perioperative surgical prophylaxis with the use of vancomycin or clindamycin as secondary options in patients with a penicillin allergy. Vancomycin should be reserved for patients with known colonization or infection with MRSA [72-74].

The timing of administration is one of the most important discussions, ranging from 30 minutes to two hours before the incision [75-77]. In current literature, most of the authors recommend to use within one hour of surgical incision for cephalosporins and can be extended to two hours for vancomycin and fluoroquinolones [74]. In patients with large blood volume loss (>2000 cc) or high volume of fluid resuscitation (>2000cc), and surgery times that last more than two half-lives of the prophylactic agent, an additional intraoperative dose of antibiotics is necessary [78].

In order to avoid under dosing of the preoperative prophylactic antibiotic dose adjustment for antibiotics is recommended, and in this regard, the routine dose of cefazolin should be doubled in patients more than 80 kg [79-82].

Air Quality

There are two main routes for contamination of the wound during TJA:

  1. Direct contamination by airborne particles, approximately
  2. Indirect contamination

30% and 70% of all contaminations are measured to become by these routes, respectively [85-87].

Although laminar flow and space suits are one of the most popular methods, the evidence seems not consistent in the literature. Some registry data does not confirm the reduced infection rates with the use of laminar flow ORs and space suits [88]. Moreover, some studies have shown that the incidence of PJI was higher when the surgery was performed in a laminar flow room or while space suits were worn by personnel [89-91]. Therefore, the efficacy of laminar flow in reducing PJI remains unproven.

The use of ultraviolet lighting was found to be correlated with reduced rates of PJI, however, the exposure hazards were 6 to 28 times greater than the recommended limits which also effects the orthopedic operating room personnel [92, 93]. Because of these safety concerns, there are recommendations against the routine use of UV lights in the OR [94-96].

One of the most important strategy to improve the air quality is to reduce the room traffic as the number of people in the room increases the air currents and subsequently reduce the quality of the air [87]. Also, a direct correlation between the activity level of OR personnel and bacterial counts in the OR air was shown [97, 98]. Therefore, minimizing the number of personnel in the OR, using a sub-sterile hallway for entry, storing the implants in the room are likely to help improve the air quality in the OR environment.

Skin Preparation

A bath with chlorhexidine soap and to sleep in clean garments and bedding one night before surgery appears to be a simple and cost-effective method to reduce PJI rates [52, 83]. A whole body disinfection was significantly superior compared with local washing or no washing at all [84, 99]. Hair clipping on the morning of surgery as opposed to shaving lowers the rate of SSI because a razor may cause superficial skin abrasions and results an increase in colonization of bacteria at the incision site [100]. Only hair around the incision should be removed [101].

There is no consensus as to use whether chlorhexidine gluconate (CHG) or povidone-iodine provides superior preoperative skin antisepsis [102-104]. On the other hand, alcohol-containing products are found to be more effective due to their rapid antimicrobial action [105]. Therefore, whichever agent is chosen, either CHG or iodine-based antiseptics, it is suggested that they should be used in combination with alcohol [52].

Surgical Team

Hospital and surgeon volume are also believed to influence SSI rates. The high-volume surgeons have less SSI rates possibly due to improved surgical skills and a more efficient protocol to minimize the risk of PJI [106]. The type of hospital is also a factor that have influence on revision rates; non-teaching hospitals are found to have a higher risk of SSI [107].

Blood Management

Numerous studies have shown that allogeneic blood transfusion increases the risk of SSI through the mechanism of immunomodulation [108]. Moreover, rates of SSI and lower and upper respiratory tract infections were significantly increased after elective TJA in patients receiving allogeneic blood transfusion compared with patients who did not receive blood transfusion [109]. On the other hand, the role of autologous transfusion in the risk of developing SSI and PJI remains inconclusive. Taken together, much effort should be exercised before the surgery in order to decrease the need for any type of blood product transfusion.

Wound Closure

There are various methods of wound closure including staples, skin adhesives, barbed sutures, however, none of these methods have an overall superiority over another. Livesey et al. found closure with staples quicker and less expensive compared with skin adhesives, without significant complications [110, 113]. TKA and THA may differ in some aspects in regards to closure methods, it was reported that skin adhesives are not appropriate for TKA because of the risk of failure during the early rehabilitation [111, 114]. Although the use of barbed sutures provide advantages in terms of time and cost some studies found increased the frequency and severity of wound complications [112, 113, 115, 116]. The use of monofilament sutures are recommended because they are less susceptible to bacterial growth [114, 117].

There is ample evidence to suggest that routine use of surgical drains during TJA may not be necessary. The tips of the drains are showed to be contaminated in many studies from 41% to 54% [110, 111, 115, 116]. Theoretically, the contamination of drain tips may lead to infection, on the other hand, these results were not correlated with a subsequent PJI rates [117].

After closure of the wound the wound dressing should be placed in the theater under sterile conditions, kept in place for a few days without a need for changes, allow for range of motion without causing skin stretching and blistering, and the dressing should be occlusive which may result in lower rates of SSI [118-120].


Prevention is the most critical step in decreasing rates of PJI. A patient with high risk factors will ultimately compromise the healing process, allowing bacteria to settle and replicate in the surgical field. Defining the risks preoperatively and optimizing the patient is the most effective strategy for the prevention of PJI. Implementation of a comprehensive, standardized, evidence-based perioperative protocol should be the first step to battle this frustrating and challenging complication. A protocol can be instituted on either an institutional or national basis. Clarification of the most common risk factors for the patient population is critical for taking further steps. Ongoing research for prevention of PJI, such as vaccination or smart implants, is promising; however, further improvements in prevention practices are warranted before these methods can be clinically applied.


Part of this article has been previously published in “Hip Sepsis and the Prevention of Perioperative Infections, Diagnosis and Management of Hip Disease pp 249-271, DOI 10.1007/978-3-319-19905-4_12


JP is an equity owner in CD Diagnostics, a company that is involved in developing molecular biomarker for diagnosis of PJI. JP is also a paid consultant to various companies that are involved in development of novel techniques for management of PJI.


Declared none.


[1] Parvizi J, Kucukdurmaz F. Hip Sepsis and the Prevention of Periprosthetic Joint Infections Diagnosis and Management of Hip Disease: Biological Bases of Clinical Care. Springer 2015; pp. 249-71.
[2] Maoz G, Phillips M, Bosco J, et al. The Otto Aufranc Award: Modifiable versus nonmodifiable risk factors for infection after hip arthroplasty. Clin Orthop Relat Res 2015; 473(2): 453-9.
[3] Aggarwal VK, Tischler EH, Lautenbach C, et al. Mitigation and education. J Orthop Res 2014; 32(Suppl. 1): S16-25.
[4] Bartzokas CA, Johnson R, Jane M, Martin MV, Pearce PK, Saw Y. Relation between mouth and haematogenous infection in total joint replacements. BMJ 1994; 309(6953): 506-8.
[5] Young H, Hirsh J, Hammerberg EM, Price CS. Dental disease and periprosthetic joint infection. J Bone Joint Surg Am 2014; 96(2): 162-8.
[6] Barrington JW, Barrington TA. What is the true incidence of dental pathology in the total joint arthroplasty population? J Arthroplasty 2011; 26(6)(Suppl.): 88-91.
[7] Tokarski AT, Patel RG, Parvizi J, Deirmengian GK. Dental clearance prior to elective arthroplasty may not be needed for everyone. J Arthroplasty 2014; 29(9): 1729-32.
[8] Kalmeijer MD, van Nieuwland-Bollen E, Bogaers-Hofman D, de Baere GA. Nasal carriage of Staphylococcus aureus is a major risk factor for surgical-site infections in orthopedic surgery. Infect Control Hosp Epidemiol 2000; 21(5): 319-23.
[9] Schweizer M, Perencevich E, McDanel J, et al. Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: systematic review and meta-analysis. BMJ 2013; 346: f2743.
[10] Herwaldt LA, Cullen JJ, French P, et al. Preoperative risk factors for nasal carriage of Staphylococcus aureus. Infect Control Hosp Epidemiol 2004; 25(6): 481-4.
[11] Courville XF, Tomek IM, Kirkland KB, Birhle M, Kantor SR, Finlayson SR. Cost-effectiveness of preoperative nasal mupirocin treatment in preventing surgical site infection in patients undergoing total hip and knee arthroplasty: a cost-effectiveness analysis. Infect Control Hosp Epidemiol 2012; 33(2): 152-9.
[12] Chen AF, Heyl AE, Xu PZ, Rao N, Klatt BA. Preoperative decolonization effective at reducing staphylococcal colonization in total joint arthroplasty patients. J Arthroplasty 2013; 28(8)(Suppl.): 18-20.
[13] Ridenour G, Lampen R, Federspiel J, Kritchevsky S, Wong E, Climo M. Selective use of intranasal mupirocin and chlorhexidine bathing and the incidence of methicillin-resistant Staphylococcus aureus colonization and infection among intensive care unit patients. Infect Control Hosp Epidemiol 2007; 28(10): 1155-61.
[14] Economedes DM, Deirmengian GK, Deirmengian CA. Staphylococcus aureus colonization among arthroplasty patients previously treated by a decolonization protocol: a pilot study. Clin Orthop Relat Res 2013; 471(10): 3128-32.
[15] Wong J, Abrishami A, El Beheiry H, et al. Topical application of tranexamic acid reduces postoperative blood loss in total knee arthroplasty: a randomized, controlled trial. J Bone Joint Surg Am 2010; 92(15): 2503-13.
[16] Møller AM, Villebro N, Pedersen T, Tønnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet 2002; 359(9301): 114-7.
[17] Singh JA. Smoking and outcomes after knee and hip arthroplasty: a systematic review. J Rheumatol 2011; 38(9): 1824-34.
[18] Sadr Azodi O, Bellocco R, Eriksson K, Adami J. The impact of tobacco use and body mass index on the length of stay in hospital and the risk of post-operative complications among patients undergoing total hip replacement. J Bone Joint Surg Br 2006; 88(10): 1316-20.
[19] Alijanipour P, Heller S, Parvizi J. Prevention of periprosthetic joint infection: what are the effective strategies? J Knee Surg 2014; 27(4): 251-8.
[20] Mills E, Eyawo O, Lockhart I, Kelly S, Wu P, Ebbert JO. Smoking cessation reduces postoperative complications: a systematic review and meta-analysis. Am J Med 2011; 124(2): 144-154.e8.
[21] Everhart JS, Altneu E, Calhoun JH. Medical comorbidities are independent preoperative risk factors for surgical infection after total joint arthroplasty. Clin Orthop Relat Res 2013; 471(10): 3112-9.
[22] Sadr Azodi O, Bellocco R, Eriksson K, Adami J. The impact of tobacco use and body mass index on the length of stay in hospital and the risk of post-operative complications among patients undergoing total hip replacement. J Bone Joint Surg Br 2006; 88(10): 1316-20.
[23] Bradley KA, Williams EC, Achtmeyer CE, et al. Measuring performance of brief alcohol counseling in medical settings:a review of the options and lessons from the Veterans Affairs (VA) health care system. Subst Abus 2007; 28(4): 133-49.
[24] Litaker D, Locala J, Franco K, Bronson DL, Tannous Z. Preoperative risk factors for postoperative delirium. Gen Hosp Psychiatry 2001; 23(2): 84-9.
[25] Tonnesen H, Rosenberg J, Nielsen HJ, et al. Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: randomised controlled trial. BMJ 1999; 318(7194): 1311-6.
[26] Marchant MH Jr, Viens NA, Cook C, Vail TP, Bolognesi MP. The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. J Bone Joint Surg Am 2009; 91(7): 1621-9.
[27] Dronge AS, Perkal MF, Kancir S, Concato J, Aslan M, Rosenthal RA. Long-term glycemic control and postoperative infectious complications. Arch Surg 2006; 141(4): 375-80.
[28] Kiran RP, Turina M, Hammel J, Fazio V. The clinical significance of an elevated postoperative glucose value in nondiabetic patients after colorectal surgery: evidence for the need for tight glucose control? Ann Surg 2013; 258(4): 599-604.
[29] Kotagal M, Symons RG, Hirsch IB, et al. Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes. Ann Surg 2015; 261(1): 97-103.
[30] Frisch A, Chandra P, Smiley D, et al. Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery. Diabetes Care 2010; 33(8): 1783-8.
[31] Ziser A, Plevak DJ, Wiesner RH, Rakela J, Offord KP, Brown DL. Morbidity and mortality in cirrhotic patients undergoing anesthesia and surgery. Anesthesiology 1999; 90(1): 42-53.
[32] Rice HE, OKeefe GE, Helton WS, Johansen K. Morbid prognostic features in patients with chronic liver failure undergoing nonhepatic surgery. Arch Surg 1997; 132(8): 880-4.
[33] Cohen SM, Te HS, Levitsky J. Operative risk of total hip and knee arthroplasty in cirrhotic patients. J Arthroplasty 2005; 20(4): 460-6.
[34] Garrison RN, Cryer HM, Howard DA, Polk HC Jr. Clarification of risk factors for abdominal operations in patients with hepatic cirrhosis. Ann Surg 1984; 199(6): 648-55.
[35] Hsieh P-H, Ueng SW, Lee MS, Shih H-N, Huang K-C. Prosthetic hip infection in patients with liver cirrhosis: an outcome analysis. Int J Infect Dis 2010; 14(12): e1054-9.
[36] Moon Y-W, Kim Y-S, Kwon S-Y, Kim S-Y, Lim S-J, Park Y-S. Perioperative risk of hip arthroplasty in patients with cirrhotic liver disease. J Korean Med Sci 2007; 22(2): 223-6.
[37] Li W-C, Shih C-H, Ueng SW, Shih H-N, Lee MS, Hsieh P-H. Uncemented total hip arthroplasty in chronic hemodialysis patients. Acta Orthop 2010; 81(2): 178-82.
[38] Nagoya S, Nagao M, Takada J, Kuwabara H, Kaya M, Yamashita T. Efficacy of cementless total hip arthroplasty in patients on long-term hemodialysis. J Arthroplasty 2005; 20(1): 66-71.
[39] Devlin VJ, Einhorn TA, Gordon SL, Alvarez EV, Butt KM. Total hip arthroplasty after renal transplantation. Long-term follow-up study and assessment of metabolic bone status. J Arthroplasty 1988; 3(3): 205-13.
[40] Nowicki P, Chaudhary H. Total hip replacement in renal transplant patients. J Bone Joint Surg Br 2007; 89(12): 1561-6.
[41] Shrader MW, Schall D, Parvizi J, McCarthy JT, Lewallen DG. Total hip arthroplasty in patients with renal failure: a comparison between transplant and dialysis patients. J Arthroplasty 2006; 21(3): 324-9.
[42] Tannenbaum DA, Matthews LS, Grady-Benson JC. Infection around joint replacements in patients who have a renal or liver transplantation. J Bone Joint Surg Am 1997; 79(1): 36-43.
[43] Radford PJ, Doran A, Greatorex RA, Rushton N. Total hip replacement in the renal transplant recipient. J Bone Joint Surg Br 1989; 71(3): 456-9.
[44] Sakalkale DP, Hozack WJ, Rothman RH. Total hip arthroplasty in patients on long-term renal dialysis. J Arthroplasty 1999; 14(5): 571-5.
[45] Lieberman JR, Fuchs MD, Haas SB, et al. Hip arthroplasty in patients with chronic renal failure. J Arthroplasty 1995; 10(2): 191-5.
[46] Alpert B, Waddell JP, Morton J, Bear RA. Cementless total hip arthroplasty in renal transplant patients. Clin Orthop Relat Res 1992; (284): 164-9.
[47] Orwin JF, Fisher RC, Wiedel JD. Use of the uncemented bipolar endoprosthesis for the treatment of steroid-induced osteonecrosis of the hip in renal transplantation patients. J Arthroplasty 1991; 6(1): 1-9.
[48] Doran MF, Crowson CS, Pond GR, OFallon WM, Gabriel SE. Frequency of infection in patients with rheumatoid arthritis compared with controls: a population-based study. Arthritis Rheum 2002; 46(9): 2287-93.
[49] Bernatsky S, Hudson M, Suissa S. Anti-rheumatic drug use and risk of serious infections in rheumatoid arthritis. Rheumatology (Oxford) 2007; 46(7): 1157-60.
[50] Bongartz T, Halligan CS, Osmon DR, et al. Incidence and risk factors of prosthetic joint infection after total hip or knee replacement in patients with rheumatoid arthritis. Arthritis Rheum 2008; 59(12): 1713-20.
[51] Brook I. Secondary bacterial infections complicating skin lesions. J Med Microbiol 2002; 51(10): 808-12.
[52] Tokarski AT, Blaha D, Mont MA, et al. Perioperative skin preparation. J Orthop Res 2014; 32(Suppl. 1): S26-30.
[53] Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, Welch RB. An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am 1999; 81(1): 2-10.
[54] Greenky M, Gandhi K, Pulido L, Restrepo C, Parvizi J. Preoperative anemia in total joint arthroplasty: is it associated with periprosthetic joint infection? Clin Orthop Relat Res 2012; 470(10): 2695-701.
[55] Keating EM, Ritter MA. Transfusion options in total joint arthroplasty. J Arthroplasty 2002; 17(4)(Suppl. 1): 125-8.
[56] Forgie MA, Wells PS, Laupacis A, Fergusson D. Preoperative autologous donation decreases allogeneic transfusion but increases exposure to all red blood cell transfusion: results of a meta-analysis. Arch Intern Med 1998; 158(6): 610-6.
[57] Stramer SL, Dodd RY. Transfusion-transmitted emerging infectious diseases: 30 years of challenges and progress. Transfusion 2013; 53(10 Pt 2): 2375-83.
[58] Feagan BG, Wong CJ, Kirkley A, et al. Erythropoietin with iron supplementation to prevent allogeneic blood transfusion in total hip joint arthroplasty. A randomized, controlled trial. Ann Intern Med 2000; 133(11): 845-54.
[59] World Health Organization. Nutrition. 2014. Available at:
[60] Rai J, Gill SS, Kumar BR. The influence of preoperative nutritional status in wound healing after replacement arthroplasty. Orthopedics 2002; 25(4): 417-21.
[61] Seibert DJ. Pathophysiology of surgical site infection in total hip arthroplasty. Am J Infect Control 1999; 27(6): 536-42.
[62] Greene KA, Wilde AH, Stulberg BN. Preoperative nutritional status of total joint patients. Relationship to postoperative wound complications. J Arthroplasty 1991; 6(4): 321-5.
[63] Jaberi FM, Parvizi J, Haytmanek CT, Joshi A, Purtill J. Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty. Clin Orthop Relat Res 2008; 466(6): 1368-71.
[64] Huang R, Greenky M, Kerr GJ, Austin MS, Parvizi J. The effect of malnutrition on patients undergoing elective joint arthroplasty. J Arthroplasty 2013; 28(8)(Suppl.): 21-4.
[65] Cross MB, Yi PH, Thomas CF, Garcia J, Della Valle CJ. Evaluation of malnutrition in orthopaedic surgery. J Am Acad Orthop Surg 2014; 22(3): 193-9.
[66] Puskarich CL, Nelson CL, Nusbickel FR, Stroope HF. The use of two nutritional indicators in identifying long bone fracture patients who do and do not develop infections. J Orthop Res 1990; 8(6): 799-803.
[67] Guo JJ, Yang H, Qian H, Huang L, Guo Z, Tang T. The effects of different nutritional measurements on delayed wound healing after hip fracture in the elderly. J Surg Res 2010; 159(1): 503-8.
[68] Batsis JA, Naessens JM, Keegan MT, Huddleston PM, Wagie AE, Huddleston JM. Body mass index and the impact on hospital resource use in patients undergoing total knee arthroplasty. J Arthroplasty 2010; 25(8): 1250-7.e1.
[69] Namba RS, Paxton L, Fithian DC, Stone ML. Obesity and perioperative morbidity in total hip and total knee arthroplasty patients. J Arthroplasty 2005; 20(7)(Suppl. 3): 46-50.
[70] Inacio MC, Kritz-Silverstein D, Raman R, et al. The risk of surgical site infection and re-admission in obese patients undergoing total joint replacement who lose weight before surgery and keep it off post-operatively. Bone Joint J 2014; 96-B(5): 629-35.
[71] Forse RA, Karam B, MacLean LD, Christou NV. Antibiotic prophylaxis for surgery in morbidly obese patients. Surgery 1989; 106(4): 750-6.
[72] Neu HC. Cephalosporin antibiotics as applied in surgery of bones and joints. Clin Orthop Relat Res 1984; (190): 50-64.
[73] The American Academy of Orthopaedic Surgeons. Recommendations for the use of intravenous antibiotic prophylaxis in primary total joint arthroplasty. 2013. Available at:
[74] Hansen E, Belden K, Silibovsky R, et al. Perioperative antibiotics. J Orthop Res 2014; 32(Suppl. 1): S31-59.
[75] Steinberg JP, Braun BI, Hellinger WC, et al. Timing of antimicrobial prophylaxis and the risk of surgical site infections: results from the Trial to Reduce Antimicrobial Prophylaxis Errors. Ann Surg 2009; 250(1): 10-6.
[76] Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992; 326(5): 281-6.
[77] Weber WP, Marti WR, Zwahlen M, et al. The timing of surgical antimicrobial prophylaxis. Ann Surg 2008; 247(6): 918-26.
[78] Zanetti G, Giardina R, Platt R. Intraoperative redosing of cefazolin and risk for surgical site infection in cardiac surgery. Emerg Infect Dis 2001; 7(5): 828-31.
[79] Brogden RN, Peters DH. Teicoplanin. A reappraisal of its antimicrobial activity, pharmacokinetic properties and therapeutic efficacy. Drugs 1994; 47(5): 823-54.
[80] Rybak MJ, Lomaestro BM, Rotschafer JC, et al. Vancomycin therapeutic guidelines: a summary of consensus recommendations from the infectious diseases Society of America, the American Society of Health-System Pharmacists, and the Society of Infectious Diseases Pharmacists. Clin Infect Dis 2009; 49(3): 325-7.
[81] Traynor AM, Nafziger AN, Bertino JS Jr. Aminoglycoside dosing weight correction factors for patients of various body sizes. Antimicrob Agents Chemother 1995; 39(2): 545-8.
[82] Prokuski L. Prophylactic antibiotics in orthopaedic surgery. J Am Acad Orthop Surg 2008; 16(5): 283-93.
[83] Johnson AJ, Daley JA, Zywiel MG, Delanois RE, Mont MA. Preoperative chlorhexidine preparation and the incidence of surgical site infections after hip arthroplasty. J Arthroplasty 2010; 25(6)(Suppl.): 98-102.
[84] Wihlborg O. The effect of washing with chlorhexidine soap on wound infection rate in general surgery. A controlled clinical study. Ann Chir Gynaecol 1987; 76(5): 263-5.
[85] Persson M, van der Linden J. Wound ventilation with ultraclean air for prevention of direct airborne contamination during surgery. Infect Control Hosp Epidemiol 2004; 25(4): 297-301.
[86] Edmiston CE Jr, Seabrook GR, Cambria RA, et al. Molecular epidemiology of microbial contamination in the operating room environment: Is there a risk for infection? Surgery 2005; 138(4): 573-9.
[87] Malinzak RA, Ritter MA. Postoperative wound infection: 35 years of experience. Orthopedics 2006; 29(9): 797-8.
[88] Hooper GJ, Rothwell AG, Frampton C, Wyatt MC. Does the use of laminar flow and space suits reduce early deep infection after total hip and knee replacement?: the ten-year results of the New Zealand Joint Registry. J Bone Joint Surg Br 2011; 93(1): 85-90.
[89] Brandt C, Hott U, Sohr D, Daschner F, Gastmeier P, Rüden H. Operating room ventilation with laminar airflow shows no protective effect on the surgical site infection rate in orthopedic and abdominal surgery. Ann Surg 2008; 248(5): 695-700.
[90] Kapadia BH, Pivec R, Johnson AJ, et al. Infection prevention methodologies for lower extremity total joint arthroplasty. Expert Rev Med Devices 2013; 10(2): 215-24.
[91] Hooper GJ, Rothwell AG, Frampton C, Wyatt MC. Does the use of laminar flow and space suits reduce early deep infection after total hip and knee replacement?: the ten-year results of the New Zealand Joint Registry. J Bone Joint Surg Br 2011; 93(1): 85-90.
[92] Ritter MA, Olberding EM, Malinzak RA. Ultraviolet lighting during orthopaedic surgery and the rate of infection. J Bone Joint Surg Am 2007; 89(9): 1935-40.
[93] Sylvain D, Tapp L. UV-C Exposure and Health Effects in Surgical Suite Personnel. Heal Hazard Eval Rep. 2009 May. Available at:
[94] Sehulster L, Chinn RY. Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep 2003; 52(RR-10): 1-42.
[95] Salassa TE, Swiontkowski MF. Surgical attire and the operating room: role in infection prevention. J Bone Joint Surg Am 2014; 96(17): 1485-92.
[96] Evans RP. Current concepts for clean air and total joint arthroplasty: laminar airflow and ultraviolet radiation: a systematic review. Clin Orthop Relat Res 2011; 469(4): 945-53.
[97] Andersson BM, Lidgren L, Schalén C, Steen A. Contamination of irrigation solutions in an operating theatre. Infect Control 1984; 5(7): 339-41.
[98] Quraishi ZA, Blais FX, Sottile WS, Adler LM. Movement of personnel and wound contamination. AORN J 1983; 38(1): 146-147, 150-156.
[99] Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev 2011; 11(11): CD004122.
[100] Alexander JW, Fischer JE, Boyajian M, Palmquist J, Morris MJ. The influence of hair-removal methods on wound infections. Arch Surg 1983; 118(3): 347-52.
[101] Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Am J Infect Control 1999; 27(2): 97-132.
[102] Darouiche RO, Wall MJ Jr, Itani KM, et al. Chlorhexidine-Alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 2010; 362(1): 18-26.
[103] Swenson BR, Hedrick TL, Metzger R, Bonatti H, Pruett TL, Sawyer RG. Effects of preoperative skin preparation on postoperative wound infection rates: a prospective study of 3 skin preparation protocols. Infect Control Hosp Epidemiol 2009; 30(10): 964-71.
[104] Sistla SC, Prabhu G, Sistla S, Sadasivan J. Minimizing wound contamination in a clean surgery: comparison of chlorhexidine-ethanol and povidone-iodine. Chemotherapy 2010; 56(4): 261-7.
[105] Dumville JC, McFarlane E, Edwards P, Lipp A, Holmes A. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database Syst Rev 2013; 3(3): CD003949.
[106] Urquhart DM, Hanna FS, Brennan SL, et al. Incidence and risk factors for deep surgical site infection after primary total hip arthroplasty: a systematic review. J Arthroplasty 2010; 25(8): 1216-22.e1, 3.
[107] Manley M, Ong K, Lau E, Kurtz SM. Effect of volume on total hip arthroplasty revision rates in the United States Medicare population. J Bone Joint Surg Am 2008; 90(11): 2446-51.
[108] Bloch EM, Jackman RP, Lee TH, Busch MP. Transfusion-associated microchimerism: the hybrid within. Transfus Med Rev 2013; 27(1): 10-20.
[109] Friedman R, Homering M, Holberg G, Berkowitz SD. Allogeneic blood transfusions and postoperative infections after total hip or knee arthroplasty. J Bone Joint Surg Am 2014; 96(4): 272-8.
[110] Livesey C, Wylde V, Descamps S, et al. Skin closure after total hip replacement: a randomised controlled trial of skin adhesive versus surgical staples. J Bone Joint Surg Br 2009; 91(6): 725-9.
[111] Khan RJ, Fick D, Yao F, et al. A comparison of three methods of wound closure following arthroplasty: a prospective, randomised, controlled trial. J Bone Joint Surg Br 2006; 88(2): 238-42.
[112] Ting NT, Moric MM, Della Valle CJ, Levine BR. Use of knotless suture for closure of total hip and knee arthroplasties: a prospective, randomized clinical trial. J Arthroplasty 2012; 27(10): 1783-8.
[113] Smith EL, DiSegna ST, Shukla PY, Matzkin EG. Barbed versus traditional sutures: closure time, cost, and wound related outcomes in total joint arthroplasty. J Arthroplasty 2014; 29(2): 283-7.
[114] Alijanipour P, Karam J, Llinás A, et al. Operative environment. J Orthop Res 2014; 32(Suppl. 1): S60-80.
[115] Robinson AH, Drew S, Anderson J, Bentley G, Ridgway GL. Suction tip contamination in the ultraclean-air operating theatre. Ann R Coll Surg Engl 1993; 75(4): 254-6.
[116] Strange-Vognsen HH, Klareskov B. Bacteriologic contamination of suction tips during hip arthroplasty. Acta Orthop Scand 1988; 59(4): 410-1.
[117] Parker MJ, Livingstone V, Clifton R, McKee A. Closed suction surgical wound drainage after orthopaedic surgery. Cochrane Database Syst Rev 2007; 3(3): CD001825.
[118] Hopper GP, Deakin AH, Crane EO, Clarke JV. Enhancing patient recovery following lower limb arthroplasty with a modern wound dressing: a prospective, comparative audit. J Wound Care 2012; 21(4): 200-3.
[119] Abuzakuk TM, Coward P, Shenava Y, Kumar VS, Skinner JA. The management of wounds following primary lower limb arthroplasty: a prospective, randomised study comparing hydrofibre and central pad dressings. Int Wound J 2006; 3(2): 133-7.
[120] Ghanem E, Heppert V, Spangehl M, et al. Wound management. J Orthop Res 2014; 32(Suppl. 1): S108-19.