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Selected Instructional Course Lecture   |    
Perioperative Strategies for Decreasing InfectionA Comprehensive Evidence-Based Approach
Joseph A. Bosco, III, MD1; James D. Slover, MD, MS1; Janet P. Haas, RN, PhD2
1 Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York University Langone Medical Center, 301 East 17th Street, New York, NY 10003. E-mail address for J.A. Bosco III: joseph.bosco@nyumc.org. E-mail address for J.D. Slover: james.slover@nyumc.org
2 Infection Prevention and Control, Westchester Medical Center, 100 Woods Road, Macy Pavilion SW246, Valhalla, NY 10595. E-mail address: Haasj@wcmc.com
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons
Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy's Annual Meeting, will be available in March 2010 in Instructional Course Lectures, Volume 59. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726 (8 a.m.-5 p.m., Central time).

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Jan 01;92(1):232-239
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Extract

Surgical site infections associated with orthopaedic surgical procedures are devastating complications. They increase morbidity, mortality, and cost and result in outcomes that are worse than those in uninfected cases1. Decreasing the incidence of surgical site infections is not only of interest to patients and surgeons, it is also a major focus of several groups of interested parties. These range from payers, including the Centers for Medicare and Medicaid Services (CMS, Baltimore, Maryland), to institutions represented by the Surgical Care Improvement Project (SCIP), a multiple-institution partnership between major public and private health-care organizations, including the Joint Commission on Accreditation of Healthcare Organizations (Oakbrook Terrace, Illinois). Decreasing the incidence of surgical site infections is, and will continue to be, a major focus in medicine.
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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Nigel T. Brewster, MB ChB
    Posted on April 02, 2010
    Chlorhexidine Hand Wash Should Be Used in Preference to Alcohol Hand Rub
    Freeman Hospital, Newcastle upon Tyne, United Kingdom

    EDITOR’S NOTE: The authors were invited to respond to the letter, but to date, have not done so.

    To the Editor:

    In Bosco's Instructional Course Lecture on perioperative strategies for decreasing Infection (1), he bases advice on surgeons using alcohol hand rub on a research paper by Hajipour (2).

    Bosco's interpretation of the findings of Hajipour's paper is wrong.

    Hajipour showed that surgeons using alcohol handrub between cases had significantly more colony forming units on their hands at the end of the procedure than those who had used a chlorhexidine hand wash.

    Based on this study, surgeons should use a chlorhexidine hand wash between procedures in preference to an alcohol hand rub.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

    References

    1. Bosco JA 3rd, Slover JD, Haas JP. Perioperative strategies for decreasing infection: a comprehensive evidence-based approach. J Bone Joint Surg Am. 2010;92:232-9.

    2. Hajipour L, Longstaff L, Cleeve V, Brewster N, Bint D, Henman P. Hand washing rituals in trauma theatre: clean or dirty? Ann R Coll Surg Engl. 2006;88:13-5.

    Charles A. Willis-Owen
    Posted on January 31, 2010
    Duration of Surgery and Infection in Arthroplasty
    Sportsmed SA, Adelaide, Australia

    To the Editor:

    The comprehensive review by Bosco et al. (1) does not mention the role of operative duration in orthopaedic wound infections. A number of studies have shown a positive correlation between the length of surgery and the incidence of wound infection. In a retrospective study of knee arthroplasty patients, Peersman et al. showed operative times of greater than 2.5 hours were associated with a greater incidence of infection (2) and that operative time can be used as a predictive factor for those at increased risk on infection (3). Kessler et al. found that increased operative duration was associated with increased overall morbidity (encompassing infection, bleeding or thrombo-embolic events) in revision hip arthroplasty (4). In addition, the large registry based study by Ridgeway et al. had similar findings (5).

    We recently completed a prospective observational study of 5,277 hip and knee arthroplasties, (submitted for publication) which showed a strong positive correlation between increased surgical duration and postoperative wound infection.

    A number of factors can contribute to unnecessary delays during surgery such as insufficient equipment, poor planning, lack of training and inadequate assistance. In addition to all of the factors Bosco et al. mention, every attempt should be made to keep the amount of time a wound is kept open to the minimum, in order to further reduce the risk of wound infection.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References

    1. Bosco JA 3rd, Slover JD, Haas JP. Perioperative strategies for decreasing infection: a comprehensive evidence-based approach. J Bone Joint Surg Am. 2010;92:232-9.

    2. Peersman G, Laskin R, Davis J, Peterson M. Infection in total knee replacement: a retrospective review of 6489 total knee replacements. Clin Orthop Relat Res. 2001;392:15-23.

    3. Peersman G, Laskin R, Davis J, Peterson MG, Richart T. Prolonged operative time correlates with increased infection rate after total knee arthroplasty. HSS J. 2006;2:70-2.

    4. Kessler S, Kinkel S, Käfer W, Puhl W, Schochat T. Influence of operation duration on perioperative morbidity in revision total hip arthroplasty. Acta Orthop Belg. 2003;69:328-33.

    5. Ridgeway S, Wilson J, Charlet A, Kafatos G, Pearson A, Coello R. Infection of the surgical site after arthroplasty of the hip. J Bone Joint Surg Br. 2005;87:844-50.

    John Z. Edwards, MD
    Posted on January 16, 2010
    Strategies for Decreasing Infection -- Not Supported by the Evidence
    Martha Jefferson Hospital, Charlottesville, VA

    EDITOR’S NOTE: The authors were invited to respond to the letter, but to date, have not done so.

    To the Editor:

    I recently read “Perioperative Strategies for Decreasing Infection: A Comprehensive Evidence-Based Approach" by Bosco et al. in the January, 2010 volume of the Journal (1). Overall this review paper summarized many good points, however, two of the conclusions are not supported by the cited evidence.

    The authors criticize the widely used practice of flash sterilization. The cited reference (2) is an uncontrolled case series published in a nursing journal that showed a 3% rate of infection in cases where flash sterilization was performed. This is hardly the type of Level 1 evidence that should lead us to alter how we practice medicine. The cost of every hospital and surgical center buying duplicate and triplicate instruments so as to avoid needing to flash instruments would be tremendous. Would not this money be better spent on something else?

    I also take issue with the notion that chlorhexidine gluconate skin prep solution is the so-called “best practice.” Again the referenced study does not support such a broad conclusion (3). A series of skin cultures were taken immediately after skin prep with a variety of different agents. The chlorhexidine gluconate prep had the lowest rate of positive cultures, however, the study did not test the duration of the skin sterility. The rates of infection were not significantly different between the tested agents. Indeed chlorhexidine gluconate may well be the best skin prep, but until additional studies are performed, chlorhexidine gluconate cannot be called “best practice.”

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    References

    1. Bosco JA 3rd, Slover JD, Haas JP. Perioperative strategies for decreasing infection: a comprehensive evidence-based approach. J Bone Joint Surg Am. 2010;92:232-9.

    2. Leonard Y, Speroni KG, Atherton M, Corriher J. Evaluating use of flash sterilization in the OR with regard to postoperative infections. AORN J. 2006;83:672-80.

    3. Ostrander RV, Botte MJ, Brage ME. Efficacy of surgical preparation solutions in foot and ankle surgery. J Bone Joint Surg Am. 2005;87:980-5.

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