Despite significant advances in orthopedic technology and surgical techniques, infection control in total joint replacements remains an area that has room to grow, surgeons say.
The percentage of infections after total joint surgery are in the single digits, and orthopedic surgeons discussed what can be done to push innovation forward.
Note: Responses were lightly edited for clarity.
Question: How has your approach to infection control in total joint replacements changed in the last five years? What will move the needle in this area in the next five years?
Cory Calendine, MD. Bone and Joint Institute of Tennessee (Franklin): The biggest shift is intellectual rather than technical.
Despite introducing and layering every prophylactic strategy we have such as chlorhexidine, decolonization, cefazolin/ancef (even in PCN allergic patients), numerous lavage options, the rate of PJI has not meaningfully declined. The infection rate is roughly 1% to 2% in primary cases and 4% to 6% in revision cases.
Attention has more recently turned back to the patient and not just their overall health status (such as diabetes and immunocompromised conditions that are known to increase risk) , but also their individual microbiome. Jarad Parvizi, MD, and many others are exploring this concept aggressively, showing that the human knee (once thought to be sterile, zero bacteria) has a distinctive native microbiome, and that certain bacterial signatures make some patients inherently more susceptible to infection. Further, Dr. Parvizi’s group described the “Trojan Horse” hypothesis, in which gut dysbiosis and intestinal permeability may allow bacteria to traverse the gut and reach the artificial implant.
We are likely maximized on the “sterile-field” concept, and hopefully the personalized microbiome concept – testing, stratification, treatment – will finally move the needle on infection rates in the years to come.
Michael Gross, MD. Union Middlesex Orthopedics (Middleton, Conn.): The current approach has evolved toward layered, risk stratified prevention, and the next five years will be defined less by new products and more by precision prophylaxis, host optimization, and targeted adjuncts.
In the last five years, the shift has been away from “one-size-fits-all” prophylaxis toward a more structured and multimodal approach tailored to patient risk. Changes include: Stronger emphasis on host optimization including glycemic control, nutritional status, obesity management and smoking cessation. Elevated hemoglobin A1c and low albumin are consistently associated with higher infections rates, and fructosamine has emerged as a more sensitive predictor of short-term glycemic status.
Intraoperative environmental refinements include povidone/iodine lavage rather than saline; reduced traffic and wound closure consistency are increasingly recognized as major determinants of outcomes. We have made a concerted effort to avoid any intra-articular corticosteroid injections within three months before shoulder replacement and knee replacement surgery. In the future, we expect to see increased tailoring of preoperative prophylaxis to specific patient risk factors. With the addition of machine learning, this tailoring should be possible on an individual basis.
Over the last five years, the major change has been less about a single “new trick” and more about reliably stacking small preventive wins. Over the next five, the biggest gains will likely come from better risk adjustment, biofilm-focused strategies, and systems that make high-reliability arthroplasty the default.
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