Preventing infection in total joint arthroplasty.

Introduction Recent projections have forecast that by the year 2030 the number of primary total knee arthroplasty procedures will increase to 3.48 million, an increase of 673% compared with 2005, and the number of primary total hip arthroplasties will increase by 174% to 572,000, with the expectant result being that over 4 million primary total joint arthroplasties will be performed in the United Stated annually'. Similarly, the number of arthroplasty revision procedures is projected to increase correspondingly. Periprosthetic joint infection is a devastating complication and is one of the leading causes of morbidity following total joint arthroplasty, with a mortality rate ranging between 2.7% and 18%" '". The average rate of periprosthetic joint infection within two years after primary hip or knee replacement is between 0.25% and 2.0%'"" ' \ Hence, a tremendous psychological and financial burden is placed on the patient and the health-care system, with the cost of treatment of each episode of periprosthetic joint infection estimated to be three to four times the cost of a primary total joint arthroplasty'"'". As the "at-risk" population pool is predicted to expand dramatically, so too will the burden of infection as recent epidemiologic studies have suggested that both the incidence and the prevalence of periprosthetic joint infection may be increasing over time in the United States" "\ Kurtz et al., using a Nationwide Inpatient Sample database, showed that, between 1990 and 2004, a nearly twofold increase was observed in the incidence of infection for both hip and knee arthroplasty in the United States". The reason for this increase is multifactorial and includes both host and agent-related factors. Improvement in the medical care of patients, especially those who may be immunocompromised, is prolonging life expectancy. In addition, patients are subject to more invasive monitoring in the perioperative period, a process that may violate the natural barrier of the skin, permitting bacterial invasion'"". Furthermore, the emergence of antibiotic-resistant strains of bacteria, such as methicillin-resistant Staphylococcus aureus (MRSA), is increasing because ofthe liberal prescription of wide-spectrum antibiotics by physicians"""". Several perioperative strategies are currently employed to decrease the incidence of infection, some of which are supported by the literature whereas others remain unproven. These strategies revolve around improving the host response and decreasing the chance of bacterial contamination in the preoperative, intraoperative, and postoperative periods'^"'. The present report wiU discuss the commonly used methods to decrease the rate ol periprosthetic joint infection at our institution and will review the available literature to support their use.