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. 2018 Jan 15;2018:9136208. doi: 10.1155/2018/9136208

Temporal Change of Interleukin-6, C-Reactive Protein, and Skin Temperature after Total Knee Arthroplasty Using Triclosan-Coated Sutures

Shih-Jie Lin 1, Fu-Chun Chang 1, Tsan-Wen Huang 1,2,✉, Kuo-Ti Peng 1,2, Hsin Nung Shih 2,3,4, Mel S Lee 2,5,✉
PMCID: PMC5820568  PMID: 29568771

Abstract

The risk of surgical site infections (SSIs) after total knee arthroplasty (TKA) can never be eliminated. Antimicrobial sutures containing triclosan have been used to decrease SSIs, but whether triclosan-coated sutures are effective with TKA is unclear. Between 2011 and 2012, 102 patients randomly assigned to a triclosan or a control group were prospectively assessed. The incidence of SSI within 3 months of surgery, length of hospital stay, pain scale, functional scores, wound condition, and serum inflammatory markers during hospitalization and within 3 months postoperatively were compared. At the final follow-up, there were 2 patients with superficial infections (3.9%) in the control group but none in the triclosan group. Lower serum IL-6 was detected in the triclosan group at 4 weeks and 3 months. The local skin temperature of the knees—recorded at 3 months using infrared thermography—was lower in the triclosan group than in the control group. More precise analytical measurements are needed to investigate local and systemic complications, especially in the early subclinical stage. This prospective, randomized, open-label clinical trial is in the public registry: ClinicalTrials.gov (NCT02533492).

1. Introduction

The risk of complications after total knee arthroplasty (TKA) can never be eliminated because of the risk of surgical site infections (SSIs) [1]. Although the reported incidence of a periprosthetic joint infection (PJI) after TKA is only about 1–3% [1–4], complications such as prolonged wound drainage are associated with a 17–50% incidence of SSI after arthroplasty [5–8].

PJI has devastating effects on patients and healthcare systems. When a PJI is established, it typically requires removal of the prosthesis, extensive debridement, prolonged antibiotic treatment, and reimplantation. However, the reinfection rate associated with reimplantation for a PJI is significantly higher than for those without infections, and this, in turn, is associated with a longer hospital stay, increased risk of comorbidities, and a major economic burden [9–12]. Measures to reduce the incidence of infections are extensively implemented in clinical practice [13]. Triclosan is an antibacterial and antifungal agent that has been widely used in humans for more than 30 years [14]. Triclosan-coated sutures reduce wound complications related to bacterial infections in animal studies and in abdominal, gastrointestinal, and coronary bypass surgery [15–22]. However, its efficacy in preventing post-TKA infections has not been previously investigated.

In this prospective randomized double-blind study, we investigated whether triclosan-coated sutures prevent SSIs after TKA surgery by lowering the risk of local bacterial infection. The primary outcome measure was the incidence of SSIs, and the secondary outcome measures were inflammatory markers (CRP: C-reactive protein; ESR: erythrocyte sedimentation rate; IL-6: interleukin 6), local wound temperature and conditions, and functional scores at given in-hospital and postoperative time points.

2. Materials and Methods

2.1. Study Design

This prospective double-blind randomized controlled trial is registered at ClinicalTrials.gov (NCT02533492). The Institutional Review Board of Chang Gung Memorial Hospital approved the study protocol (IRB: 101-0352C). All study participants provided written informed consent.

2.2. Inclusion and Exclusion Criteria

The inclusion criteria were men and women aged 55–85, diagnosed with degenerative osteoarthritis of the knee, and not having previously undergone surgery to the index knee. Patients with inflammatory arthritis—rheumatoid arthritis, ankylosing spondylitis, infectious arthritis, systemic lupus erythematosus, and psoriatic arthritis—were excluded. Other exclusion criteria were a history of cancer within 5 years before the initial study screening, osteogenesis imperfecta, Paget's disease, neurovascular disease of the lower extremities, liver cirrhosis, an aspartate aminotransferase or alanine aminotransferase level more than twice the maximum normal value at screening, coagulopathy, serum creatinine lower than 35 ml/min at screening, having undergone hemodialysis for renal failure, peripheral arterial occlusive disease, a preoperative international normalized ratio over 1.5 at screening, an American Society of Anesthesiologists physical classification system score over 3, or an immunocompromised condition.

Between June 2011 and May 2012, we screened 112 patients scheduled for a unilateral TKA at Chang Gung Memorial Hospital: 102 eligible patients were enrolled and randomly assigned to one of two equal groups of 51 (Figure 1). Group sample sizes of 51 and 51 provided 81% power to detect a difference of 4% between the null hypothesis (that both group means would be 9.0) and the alternative hypothesis (that the mean would be 13.0 with estimated group standard deviations [SDs] of 6.0 and 8.0). Significance (α) was set at 0.05 using a two-sided two-sample t-test.

Figure 1.

Figure 1

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Overview of study design in CONSORT 2010 flow diagram.

One hundred two sets of suture materials (51 sets of triclosan-coated polyglactin sutures [Vicryl Plus, Ethicon, Johnson and Johnson Medical] and 51 sets of plain polyglactin sutures) were placed into 102 separate sealed envelopes consecutively numbered from 1 to 102 based on the randomization protocol and then randomly given to the eligible patients for wound closure. During the study, the allocation of these suture materials was blinded to the patients, the clinical staff, the operating surgeons, and the independent study nurse who prospectively collected all perioperative information and outcome measures. Only the circulating nurse who opened the envelopes and the scrub nurse who handled the suture materials were not blinded, but they were not involved in evaluating the study.

2.3. Total Knee Arthroplasty

All TKA surgery used the standard medial parapatellar technique and the standard clinical pathway. Cemented knee prostheses (NexGen LPS-Flex Fixed Bearing Knee; Zimmer, Warsaw, IN) were implanted in all patients, and all patellae were resurfaced. Wound closure was done in three layers after insertion of a closed Hemovac drainage tube. The arthrotomy, fascial layer, and subcutaneous wound were closed using triclosan-coated polyglactin sutures in the triclosan group and plain polyglactin sutures in the control group. The outermost skin edge was stapled to facilitate postoperative wound assessment.

All patients were given systemic antibacterial prophylaxis (cefazolin: 1 g if body weight was <80 kg; 2 g if body weight was >80 kg) 30 to 60 minutes before the skin incision. Postoperatively, each patient was given 3 intravenous doses of cefazolin at 8-hour intervals. The wounds were photographed and assessed by the study nurse and surgeons who were blinded to and independent of the study.

2.4. Assessments

An experienced clinician, blinded to group assignment and patients' demographic data, performed all radiographic and clinical assessments.

The demographic characteristics and perioperative laboratory data of the patients were prospectively collected and registered in a database. Samples for preoperative laboratory analysis (hemoglobin, white blood cell count, platelet count, and serum creatinine) were collected on the day before surgery and analyzed using standard clinical methods. Preoperatively, skin condition (surface temperature, digital photo, and image analysis) (ATIR-M301 Infrared Thermal Imaging System, Associated Technology Corporation, Chongqing, Sichuan, PROC), inflammatory markers (CRP, ESR, and IL-6), functional scores (knee range of motion) (KSS: Knee Society Score; SF-12: Short Form 12), and pain (Visual Analogue Scale [VAS]) were assessed and recorded.

On the 1st and 3rd postoperative day during hospitalization, skin condition, functional scores, inflammatory markers, and pain were evaluated. The surgical wounds were photographed and assessed by the study nurse and surgeons who were blinded to and independent of the study.

At 2 weeks, 4 weeks, and 3 months after surgery, skin condition, functional scores, inflammatory markers, and pain were assessed and recorded (Figure 2). An additional wound image and temperature record were performed at postoperative 6 months. This is a relatively noninvasive assessment for inflammation analysis.

Figure 2.

Figure 2

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Follow-up protocol.

The primary outcome measure was the incidence of SSI within 3 months of surgery. The secondary outcome measures included length of hospital stay, pain level, functional scores, wound condition (wound drainage, extent of erythema, local heat, and skin surface temperature), and inflammatory markers during hospitalization and within 3 months postoperatively.

2.5. Statistical Analysis

An independent statistician analyzed all data. Continuous variables are presented as means and standard deviations (SDs) and categorical data as percentages and proportions. Differences between groups were analyzed using the independent t-test for continuous variables, and χ2 and Fisher's exact tests for categorical variables. For all tests, significance was set at p < 0.05 (two-tailed). SPSS 17.0 (SPSS Inc., Chicago, IL) was used for all data analyses.

3. Results

We analyzed the data from 102 patients: 26 men; 76 women; mean age: 70.7 ± 7.4 years (Table 1). There were no significant differences in demographic data between the triclosan and control groups. The triclosan group contained 15 men and 36 women (mean age: 71.3 ± 7.7 years), and the control group contained 11 men and 40 women (mean age: 70.0 ± 7.1 years). The surgical duration was significantly shorter in the triclosan group (125 ± 24 minutes versus 136 ± 34 minutes, p = 0.046) (Table 2). There were no significant differences in the length of the incision, blood loss, or 3-month postoperative wound complication rates between the two groups.

Table 1.

Patient demographic characteristics.

Characteristic Overall Triclosan group Control group p †
(n = 102) (n = 51) (n = 51)
Gender (female) 76 36 40  
Age (years) (mean ± SD) 70.7 ± 7.4 71.3 ± 7.7 70.0 ± 7.1 0.372
Weight (kg) (mean ± SD) 67.6 ± 10.7 69.4 ± 11.5 65.9 ± 9.7 0.151
Height (cm) (mean ± SD) 154.1 ± 8.5 155.4 ± 7.7 153.0 ± 9.0 0.105
Surgery site: (left knee) 47 22 25 0.883‡
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SD: standard deviation; †independent t-test, unless otherwise stated; ‡Pearson χ2 test.

Table 2.

Perioperative variables.

Variable Triclosan group Control group p †
(n = 51) (n = 51)
Surgery duration (min) (mean ± SD) 125 ± 24 136 ± 34 0.046∗
Incision length (cm) (mean ± SD) 13.0 ± 1.3 12.8 ± 1.4 0.285
Blood loss (mL) (mean ± SD) 137.3 ± 37.2 150.0 ± 60.8 0.205
Perioperative complications 0 0  
Postoperative complications 0 2 0.495‡
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SD: standard deviation; †independent t-test, unless otherwise stated; ‡Pearson χ2 test; ∗p < 0.05.

Inflammatory markers were compared in both groups 6 times: preoperative day 0; postoperative days 1 and 3; weeks 2 and 4; month 3. There was a significantly lower level of IL-6 in the triclosan group than in the control group between week 4 (p < 0.001) and month 3 (p = 0.05) (Figures 3–5). VAS, KSS, and SF-12 scores were not significantly different except on postoperative day 1, when the VAS score of the triclosan group was higher than that of the control group (8.6 versus 8.1, p = 0.017) (Table 3). The knee skin surface temperature in both groups was compared 6 times. There were significantly lower surface temperatures in the triclosan group than in the control group in postoperative month 3 (p = 0.022) (Figure 6).

Figure 3.

Figure 3

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Serum erythrocyte sedimentation rate (ESR) levels. Plot graph showing the mean ESR levels of patients after total knee replacement with triclosan-coated polyglactin sutures (triclosan group) or with plain polyglactin sutures (control group) from preoperative period to 3-month follow-up (error bars represent SDs).

Figure 4.

Figure 4

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Serum C-reactive protein (CRP) levels. Plot graph showing the mean CRP levels of patients following total knee replacement with triclosan-coated polyglactin sutures (triclosan group) or with plain polyglactin sutures (control group) from preoperative period to 3-month follow-up (error bars represent SDs).

Figure 5.

Figure 5

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Serum IL-6 levels. Plot graph showing the mean IL-6 levels of patients following total knee replacement with triclosan-coated polyglactin sutures (triclosan group) or with plain polyglactin sutures (control group) from preoperative period to 3-month follow-up (error bars represent SDs).

Table 3.

Summary of functional parameters in triclosan group and control group.

VAS / KSS / SF-12 Triclosan group Control group p †
(n = 51) (n = 51)
Baseline (preoperative value)      
 VAS score 6.6 ± 1.7 7.0 ± 1.8 0.280
 KSS score 40.8 ± 9.8 42.4 ± 10.6 0.424
 SF-12 score 39.7 ± 18.1 40.9 ± 17.4 0.739
Postoperative day 1      
 VAS score 8.6 ± 1.0 8.1 ± 0.9 0.017∗
Postoperative day 3      
 VAS score 6.7 ± 1.0 6.4 ± 0.8 0.131
Postoperative 2 weeks      
 VAS score 5.1 ± 1.6 4.6 ± 1.5 0.104
 KSS score 45.6 ± 10.1 48.7 ± 9.7 0.126
 SF-12 score 12.2 ± 29.4 10.2 ± 22.5 0.705
Postoperative 4 weeks      
 VAS score 3.4 ± 1.5 3.4 ± 1.9 0.974
 KSS score 55.5 ± 8.8 55.1 ± 9.3 0.834
 SF-12 score 46.6 ± 33.9 49.5 ± 33.0 0.666
Postoperative 3 months      
 VAS score 1.7 ± 1.5 1.5 ± 1.5 0.447
 KSS score 61.7 ± 7.4 63.2 ± 6.2 0.279
 SF-12 score 76.7 ± 30.9 80.3 ± 24.3 0.525
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SD: standard deviation; VAS: visual analog scale; KSS: Knee Society Score; SF-12: Short Form 12; †independent t-test, unless otherwise stated;  χ2 test; ∗p < 0.05.

Figure 6.

Figure 6

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Skin surface temperature. Plot graph showing the mean skin surface temperature levels of patients following total knee replacement with triclosan-coated polyglactin sutures (triclosan group) or with plain polyglactin sutures (control group) from preoperative period to 6-month follow-up (error bars represent SDs).

There were 2 cases of superficial surgical site infections (SSIs) in the control group (Table 2). Wound cultures showed that case 1 was positive for Klebsiella pneumoniae and case 2 was negative. Both cases were managed with parenteral antibiotics for 1 week (oxacillin and gentamicin for case 1; cefazolin for case 2) and then with oral antibiotics at home for another week. Both cases resolved without further complications. The infection rate was 0% in the triclosan group and 3.9% in the control group (p = 0.495). No deep SSIs were found in either group.

4. Discussion

We analyzed the efficacy of triclosan-coated sutures for reducing SSIs and preventing deep PJIs after TKA by rigorously evaluating wounds, measuring inflammatory markers, monitoring skin temperature, and assessing functional outcomes. However, because there were only two superficial SSIs in the control group and none in the triclosan group, we were unable to arrive at any conclusions about their protective efficacy against SSIs.

Some studies [23–25] have reported significantly lower wound complication rates with triclosan-coated sutures than with conventional sutures in digestive tract surgery, open vein harvesting of coronary artery bypass surgery, colorectal surgery, and hepatobiliary surgery. Hoshino et al. [26] reported a lower incidence of SSIs in Class II (clean-contaminated) surgical wounds closed with triclosan-coated sutures. Other studies [27–29], however, have reported comparable wound complication rates in head and neck surgery and general pediatric surgical procedures [27–29]. Our review of the literature showed that no similar clinical trials have compared triclosan-coated sutures with conventional sutures in TKA. In our prospective double-blind randomized controlled trial, we restricted our enrolled patients to those with degenerative osteoarthritis of the knee who had not previously undergone surgery to the index knee. Confounding factors might have been reduced because all our patients were treated by the same experienced surgeon, with the same prostheses, with the same surgical technique, and with the same treatment protocol. In addition, patients with conditions that might alter or compromise immune systems were excluded. In the present study, however, we found no significant differences in the efficacy of reducing SSIs in TKA. TKA is a Class I (clean) surgery; thus, the benefits of triclosan-coated sutures to combat microorganisms might not be demonstrated.

CRP, ESR, and IL-6 inflammation levels were analyzed as surrogates for systemic reactions; However, except for IL-6 from 4 postoperative weeks to 3 months, they were not significantly different between the triclosan and control groups. ESR and CRP are reasonably sensitive and acceptably specific post-TKA diagnostic markers for PJI in a selected group of patients [30]. However, plasma levels of these acute-phase proteins might be confounded by intraoperative tissue trauma and physiological inflammation when used to detect early subclinical infections. IL-6 induces and regulates the acute phase of inflammation, which might make it more rapid and sensitive. IL-6 levels peak within 6–12 hours after major surgery and then return to baseline levels within 48–72 postoperative hours [31–35]. We also found that IL-6 levels rapidly declined by the third postoperative day, which is consistent with other reports [36–39]. However, IL-6 in our triclosan group fell to lower than baseline levels at 2 weeks, 4 weeks, and 3 months. But in the control group, IL-6 remained at about baseline level during the follow-up.

This temporal pattern of serum IL-6 was interesting. Studies [40–42] have reported that triclosan causes human health and environmental problems, and the manufacturer announced that, from 2015, triclosan would be phased out of their baby and beauty products. Although we found no significant advantage of the triclosan-coated sutures on lowering the incidence of SSIs after TKA, we hypothesize that the triclosan in the sutures at least prevented an increase in IL-6 levels. This requires confirmation in future studies, however.

There were no significant differences in the mean global or regional surface temperature of the operated knee between the triclosan and control groups during the 6-month follow-up. As with the analysis of early postoperative subclinical inflammation in primary TKA [36, 39, 43], surface temperature changes mirrored the levels of serologic inflammatory markers. It may also have been confounded and masked by the abovementioned factors. Therefore, a more sensitive analytical tool might be necessary to investigate differences in surface temperature and other early-stage subclinical wound complications.

The functional outcomes of the patients in the present study improved in both groups; however, there were no important significant differences between the groups throughout the 3-month postoperative follow-up. Thus, using triclosan-coated sutures to close the wounds of primary TKAs had no significant effect on postoperative clinical outcomes or knee inflammation. Soft-tissue damage during the surgery induced far greater synovial inflammation than what the relatively small amount of triclosan in the antibacterial sutures could counteract.

This study has some strengths. All patients were followed up completely, and comprehensive serological tests, wounds, infrared thermography, and functional outcomes were assessed. The prospective double-blind randomized design of this study also allowed us to independently assess the results of using triclosan-coated sutures on post-TKA surgical wounds.

This study also has some limitations. First, the sample was not large enough to demonstrate the superiority of triclosan-coated sutures in preventing SSIs in TKA. This specific sample size was chosen to attain an 80% power of analysis based on the reported incidence of SSIs after TKA [1–4]. A much larger sample seems to be needed if the occurrence of PJI is taken as the endpoint of analysis; however, it might be unethical not to use antimicrobial sutures to test the hypothesis. Instead, we conducted a noninferiority study, after IRB approval, to investigate whether triclosan-coated sutures lower the incidence of SSI and do not elicit more local or systemic adverse reactions than conventional sutures do. Early detection of surgical site infections or even periprosthetic joint infections is still one of the most challenging issues in the field of joint arthroplasty. Various measurements that were potential factors for detection should be investigated and documented. In this study, we used ESR, CRP, and IL-6 as well as surface temperature to test the efficacy of antibacterial sutures. Our data suggested that triclosan-coated sutures prevented an increase in IL-6 levels. In addition, the local skin temperature of the knees was lower in the triclosan group than in the control group at postoperative 3 months. Our study provided the information of IL-6 and surface temperature in the primary total knee arthroplasty, while the literature is sparse on this topic. Second, the rigorous follow-up of the patients might have raised patient awareness about their wound conditions. Most importantly, we believed that using PJI as the endpoint of analysis by avoiding the use of a theoretically better material was unethical. Fortunately, none of our patients developed a PJI. Whether a less strict follow-up in naïve patients would result in more wound complications is unknown. Third, the definition of superficial surgical site infection is limited to skin involvement only. Other surgical site infections are more serious and can involve tissues under the skin, organs, or implanted material. The measurements we used in the present study are indeed not convincing to discriminate these complications, especially, subcutaneous fatty tissue necrosis. Further fundamental studies to discriminate SSI, subcutaneous fatty necrosis, or even early PJI using tools such as thermal imaging system or even thermal-sensitive dressing should be considered.

5. Conclusion

Triclosan-coated sutures did not cause adverse local or systemic reactions: similar changes in serial inflammatory response occurred in both groups. Furthermore, falling levels of IL-6 imply that triclosan-coated sutures had a positive effect on postoperative knee inflammation. A more sensitive analytical measurement tool is needed to investigate local and systemic complications, especially in the early subclinical stage.

Acknowledgments

The authors would like to thank Miss Yu-Shuan Lin for her assistance in data collection and statistical analyses.

Contributor Information

Tsan-Wen Huang, Email: b8601081@cgmh.org.tw.

Mel S. Lee, Email: bone@doctor.com.

Ethical Approval

The Institutional Review Board of Chang Gung Memorial Hospital approved the study protocol (IRB: 101-0352C), which adhered to the Declaration of Helsinki.

Conflicts of Interest

All authors state that they have no conflicts of interest.

References

  • 1.Jämsen E., Varonen M., Huhtala H., et al. Incidence of Prosthetic Joint Infections After Primary Knee Arthroplasty. The Journal of Arthroplasty. 2010;25(1):87–92. doi: 10.1016/j.arth.2008.10.013. [DOI] [PubMed] [Google Scholar]
  • 2.Peersman G., Laskin R., Davis J., Peterson M. The Insall award paper: infection in total knee replacement: a retrospective review of 6489 total knee replacements. Clinical Orthopaedics and Related Research. 2001;(392):15–23. [PubMed] [Google Scholar]
  • 3.Phillips J. E., Crane T. P., Noy M., Elliott T. S. J., Grimer R. J. The incidence of deep prosthetic infections in a specialist orthopaedic hospital: a 15-year prospective survey. The Journal of Bone & Joint Surgery—British Volume. 2006;88(7):943–948. doi: 10.1302/0301-620x.88b7.17150. [DOI] [PubMed] [Google Scholar]
  • 4.Huotari K., Lyytikäinen O. Impact of postdischarge surveillance on the rate of surgical site infection after orthopedic surgery. Infection Control and Hospital Epidemiology. 2006;27(12):1324–1329. doi: 10.1086/509840. [DOI] [PubMed] [Google Scholar]
  • 5.Weiss A.-P. C., Krackow K. A. Persistent wound drainage after primary total knee arthroplasty. The Journal of Arthroplasty. 1993;8(3):285–289. doi: 10.1016/S0883-5403(06)80091-4. [DOI] [PubMed] [Google Scholar]
  • 6.Jämsen E., Huhtala H., Puolakka T., Moilanen T. Risk factors for infection after knee arthroplasty a register-based analysis of 43,149 cases. The Journal of Bone & Joint Surgery. 2009;91(1):38–47. doi: 10.2106/jbjs.g.01686. [DOI] [PubMed] [Google Scholar]
  • 7.Patel V. P., Walsh M., Sehgal B., Preston C., DeWal H., Di Cesare P. E. Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty. The Journal of Bone and Joint Surgery—American Volume. 2007;89(1):33–38. doi: 10.2106/jbjs.f.00163. [DOI] [PubMed] [Google Scholar]
  • 8.Vince K. G., Abdeen A. Wound problems in total knee arthroplasty. Clinical Orthopaedics and Related Research. 2006;(452):88–90. doi: 10.1097/01.blo.0000238821.71271.cc. [DOI] [PubMed] [Google Scholar]
  • 9.Kirkland K. B., Briggs J. P., Trivette S. L., Wilkinson W. E., Sexton D. J. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infection Control and Hospital Epidemiology. 1999;20(11):725–730. doi: 10.1086/501572. [DOI] [PubMed] [Google Scholar]
  • 10.Garrido-Gómez J., Arrabal-Polo M. A., Girón-Prieto M. S., Cabello-Salas J., Torres-Barroso J., Parra-Ruiz J. Descriptive analysis of the economic costs of periprosthetic joint infection of the knee for the public health system of Andalusia. The Journal of Arthroplasty. 2013;28(7):1057–1060. doi: 10.1016/j.arth.2013.02.012. [DOI] [PubMed] [Google Scholar]
  • 11.Kapadia B. H., McElroy M. J., Issa K., Johnson A. J., Bozic K. J., Mont M. A. The economic impact of periprosthetic infections following total knee arthroplasty at a specialized tertiary-care center. The Journal of Arthroplasty. 2014;29(5):929–932. doi: 10.1016/j.arth.2013.09.017. [DOI] [PubMed] [Google Scholar]
  • 12.Kurtz S. M., Lau E., Watson H., Schmier J. K., Parvizi J. Economic burden of periprosthetic joint infection in the United States. The Journal of Arthroplasty. 2012;27(8, supplement 1):61.e1–65.e1. doi: 10.1016/j.arth.2012.02.022. [DOI] [PubMed] [Google Scholar]
  • 13.Illingworth K. D., Mihalko W. M., Parvizi J., et al. How to minimize infection and thereby maximize patient outcomes in total joint arthroplasty: a multicenter approach: AAOS exhibit selection. The Journal of Bone & Joint Surgery. 2013;95(8):p. e50. doi: 10.2106/JBJS.L.00596. [DOI] [PubMed] [Google Scholar]
  • 14.Barbolt T. A. Chemistry and safety of triclosan, and its use as an antimicrobial coating on coated VICRYL. Plus antibacterial suture (Coated polyglactin 910 suture with triclosan) Surgical Infections. 2002;3(1):S-45–S-53. doi: 10.1089/sur.2002.3.s1-45. [DOI] [PubMed] [Google Scholar]
  • 15.Marco F., Vallez R., Gonzalez P., Ortega L., De La Lama J., Lopez-Duran L. Study of the efficacy of Coated Vicryl Plus® antibacterial suture in an animal model of orthopedic surgery. Surgical Infections. 2007;8(3):359–365. doi: 10.1089/sur.2006.013. [DOI] [PubMed] [Google Scholar]
  • 16.Rothenburger S., Spangler D., Bhende S., Burkley D. In vitro antimicrobial evaluation of coated VICRYL∗ plus antibacterial suture (coated polyglactin 910 with triclosan) using zone of inhibitation assays. Surgical Infections. 2002;3:79–87. doi: 10.1089/sur.2002.3.s1-79. doi: 10.1089/sur.2002.3.s1-79. [DOI] [PubMed] [Google Scholar]
  • 17.Storch M. L., Rothenburger S. J., Jacinto G. Experimental efficacy study of coated VICRYL plus antibacterial suture in in Guinea pigs challenged with Staphylococcus aureus. Surgical Infections. 2004;5(3):281–288. doi: 10.1089/sur.2004.5.281. [DOI] [PubMed] [Google Scholar]
  • 18.Gómez-Alonso A., García-Criado F. J., Parreño-Manchado F. C., et al. Study of the efficacy of Coated VICRYL Plus® Antibacterial suture (coated Polyglactin 910 suture with Triclosan) in two animal models of general surgery. Infection. 2007;54(1):82–88. doi: 10.1016/j.jinf.2006.01.008. [DOI] [PubMed] [Google Scholar]
  • 19.Picó R. B., Jiménez L. A., Sánchez M. C., et al. Prospective study comparing the incidence of wound infection following appendectomy for acute appendicitis in children: conventional treatment versus using reabsorbable antibacterial suture or gentamicin-impregnated collagen fleeces. Cirugía pediátrica : organo oficial de la Sociedad Española de Cirugía Pediátrica. 2008;21(4):199–202. [PubMed] [Google Scholar]
  • 20.Suárez Grau J. M., de Toro Crespo M., Docobo Durántez F., Rublo Cheves C., Martín Cartes J. A., Docobo Pérez F. Prevention of surgical infection using reabsorbable antibacterial suture (Vicryl Plus) versus reabsorbable conventional suture in hernioplasty. An experimental study in animals. Cirugía Española. 2007;81(6):324–329. doi: 10.1016/S0009-739X(07)71331-3. [DOI] [PubMed] [Google Scholar]
  • 21.Justinger C., Moussavian M. R., Schlueter C., Kopp B., Kollmar O., Schilling M. K. Antibiotic coating of abdominal closure sutures and wound infection. Surgery. 2009;145(3):330–334. doi: 10.1016/j.surg.2008.11.007. [DOI] [PubMed] [Google Scholar]
  • 22.Storch M., Perry L. C., Davidson J. M., Ward J. J. A 28-day study of the effect of coated VICRYL∗ plus antibacterial suture (coated polyglactin 910 suture with triclosan) on wound healing in guinea pig linear incisional skin wounds. Surgical Infections. 2002;3(1):S-89–S-98. doi: 10.1089/sur.2002.3.s1-89. [DOI] [PubMed] [Google Scholar]
  • 23.Rašić Ž., Schwarz D., Adam V. N., et al. Efficacy of antimicrobial triclosan-coated polyglactin 910 (Vicryl Plus) suture for closure of the abdominal wall after colorectal surgery. Collegium Antropologicum. 2011;35(2):439–443. [PubMed] [Google Scholar]
  • 24.Thimour-Bergström L., Roman-Emanuel C., Scherstén H., Friberg Ö., Gudbjartsson T., Jeppsson A. Triclosan-coated sutures reduce surgical site infection after open vein harvesting in coronary artery bypass grafting patients: A randomized controlled trial. European Journal of Cardio-Thoracic Surgery. 2013;44(5):931–938. doi: 10.1093/ejcts/ezt063.ezt063 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Justinger C., Schuld J., Sperling J., Kollmar O., Richter S., Schilling M. K. Triclosan-coated sutures reduce wound infections after hepatobiliary surgery-a prospective non-randomized clinical pathway driven study. Langenbeck's Archives of Surgery. 2011;396(6):845–850. doi: 10.1007/s00423-011-0786-7. [DOI] [PubMed] [Google Scholar]
  • 26.Hoshino S., Yoshida Y., Tanimura S., Yamauchi Y., Noritomi T., Yamashita Y. A study of the efficacy of antibacterial sutures for surgical site infection: A retrospective controlled trial. International Surgery. 2013;98(2):129–132. doi: 10.9738/CC179. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Seim B. E., Tonnessen T., Woldbaek P. R. Triclosan-coated sutures do not reduce leg wound infections after coronary artery bypass grafting. Interactive CardioVascular and Thoracic Surgery. 2012;15(3):411–415. doi: 10.1093/icvts/ivs266. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Chen S. Y., Chen T. M., Dai N. T., et al. Do antibacterial-coated sutures reduce wound infection in head and neck cancer reconstruction? European Journal of Surgical Oncology. 2011;37(4):300–304. doi: 10.1016/j.ejso.2011.01.015. [DOI] [PubMed] [Google Scholar]
  • 29.Ford H. R., Jones P., Gaines B., Reblock K., Simpkins D. L. Intraoperative handling and wound healing: Controlled clinical trial comparing coated Vicryl® plus antibacterial suture (coated polyglactin 910 suture with triclosan) with coated Vicryl® suture (coated polyglactin 910 suture) Surgical Infections. 2005;6(3):313–321. doi: 10.1089/sur.2005.6.313. [DOI] [PubMed] [Google Scholar]
  • 30.Ghanem E., Antoci V., Jr., Pulido L., Joshi A., Hozack W., Parvizi J. The use of receiver operating characteristics analysis in determining erythrocyte sedimentation rate and C-reactive protein levels in diagnosing periprosthetic infection prior to revision total hip arthroplasty. International Journal of Infectious Diseases. 2009;13(6):444–449. doi: 10.1016/j.ijid.2009.02.017. [DOI] [PubMed] [Google Scholar]
  • 31.Kragsbjerg P., Holmberg H., Vikerfors T. Serum concentrations of interleukin-6, tumour necrosis factor-α, and C-reactive protein in patients undergoing major operations. European Journal of Surgery-Acta Chirurgica. 1995;161(1):17–22. [PubMed] [Google Scholar]
  • 32.Heinrich P. C., Castell J. V., Andus T. Interleukin-6 and the acute phase response. Biochemical Journal. 1990;265(3):621–636. doi: 10.1042/bj2650621. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Wirtz D. C., Heller K.-D., Miltner O., Zilkens K.-W., Wolff J. M. Interleukin-6: a potential inflammatory marker after total joint replacement. International Orthopaedics. 2000;24(4):194–196. doi: 10.1007/s002640000136. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Berbari E., Mabry T., Tsaras G., et al. Inflammatory blood laboratory levels as markers of prosthetic joint infection: a systematic review and meta-analysis. The Journal of Bone & Joint Surgery. 2010;92(11):2102–2109. doi: 10.2106/JBJS.I.01199. [DOI] [PubMed] [Google Scholar]
  • 35.Bottner F., Wegner A., Winkelmann W., Becker K., Erren M., Götze C. Interleukin-6, procalcitonin and TNF-α: markers of peri-prosthetic infection following total joint replacement. The Journal of Bone & Joint Surgery (British Volume) 2007;89(1):94–99. doi: 10.1302/0301-620X.89B1.17485. [DOI] [PubMed] [Google Scholar]
  • 36.Tanavalee A., Honsawek S., Rojpornpradit T., Sakdinakiattikoon M., Ngarmukos S. Inflammation related to synovectomy during total knee replacement in patients with primary osteoarthritis: a prospective, randomised study. The Journal of Bone and Joint Surgery (British Volume) 2011;93(8):1065–1070. doi: 10.1302/0301-620X.93B8.26719. [DOI] [PubMed] [Google Scholar]
  • 37.Minetto M. A., Oprandi G., Saba L., et al. Serum interleukin-6 response to elective total hip replacement surgery. International Orthopaedics. 2006;30(3):172–176. doi: 10.1007/s00264-006-0073-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38.Park K. K., Kim T. K., Chang C. B., Yoon S. W., Park K. U. Normative temporal values of CRP and ESR in unilateral and staged bilateral TKA. Clinical Orthopaedics and Related Research. 2008;466(1):179–188. doi: 10.1007/s11999-007-0001-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Honsawek S., Deepaisarnsakul B., Tanavalee A., et al. Erratum to: Relationship of serum IL-6, C-reactive protein, erythrocyte sedimentation rate, and knee skin temperature after total knee arthroplasty: a prospective study. International Orthopaedics. 2011:p. 1. doi: 10.1007/s00264-011-1320-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 40.Dinwiddie M. T., Terry P. D., Chen J. Recent evidence regarding triclosan and cancer risk. International Journal of Environmental Research and Public Health. 2014;11(2):2209–2217. doi: 10.3390/ijerph110202209. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Halden R. U. On the need and speed of regulating triclosan and triclocarban in the United States. Environmental Science & Technology. 2014;48(7):3603–3611. doi: 10.1021/es500495p. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Park I., Zhang N., Ogunyoku T. A., Young T. M., Scow K. M. Effects of Triclosan and biosolids on microbial community composition in an agricultural soil. Water Environment Research. 2013;85(12):2237–2242. doi: 10.2175/106143012X13560205144335. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Mehra A., Langkamer V. G., Day A., Harris S., Spencer R. F. C reactive protein and skin temperature post total knee replacement. The Knee. 2005;12(4):297–300. doi: 10.1016/j.knee.2004.09.005. [DOI] [PubMed] [Google Scholar]

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