CORR Insights®: Is Elective Soft Tissue Hand Surgery Associated with Periprosthetic Joint Infection after Total Joint Arthroplasty?

Where Are We Now?

In the United States, it is believed that the overutilization of antibiotics has resulted in an increased incidence of drug resistance and led to the creation of pathogens that are resistant to multiple antibiotics [11]. Recently, the Centers for Disease Control and Prevention (CDC) changed its recommendation for prophylaxis for clean, single incision surgeries, including total joint replacement from three doses to a single preoperative dose of antibiotics [4]. The need for prophylaxis in orthopaedic surgery has also been a topic of debate. Although in the past, the American Academy of Orthopaedic Surgeons (AAOS) has recommended surgeons consider prophylactic antibiotics for patients with a total joint arthroplasty undergoing a procedure that could cause bacteremia, more recently the AAOS (in conjunction with the American Dental Association [ADA]) released a guideline that suggested that most patients do not need prophylactic antibiotics before undergoing dental procedures [3]. However, no recommendations cover other routine procedures, including soft-tissue hand surgery. The current study by Li and colleagues [8] seeks to provide evidence to help fill this gap.

Preoperative antibiotics are theorized to prevent transient bacteremia, the postulated mechanism of PJI in total joint arthroplasty patients undergoing routine procedures [12]. Several studies have argued that surgical procedures such as dental extractions and colonoscopies with biopsies can introduce small amounts of bacteria into the bloodstream, which could then seed a hip or knee implant [7, 10]. However, the patients most susceptible to bacteremia often are immunocompromised, or have active malignancies or other comorbid conditions (like poorly controlled diabetes) that could render them susceptible to infections [10]. Since most patients don’t have these problems, and since this sort of hematogenous seeding is believed to be extremely rare among patients without them, the current AAOS/ADA recommendation suggests that most patients do not benefit from prophylactic antibiotics in advance of dental procedures, and that in aggregate, the use of prophylactic antibiotics in those patients can cause more harm than good [10].

Despite the lack of current evidence for prophylaxis and the AAOS/ADA statement, many orthopaedic surgeons still prescribe antibiotics to all TJA patients before routine procedures that might induce PJI, with the goal of preventing PJI [6]. One concern with this practice is that it may lead to the prescription of antibiotics that might be unnecessary; this can cause complications like Clostridium difficile colitis and antibiotic resistance. C difficile is a serious complication that can result in death in patients with orthopaedic conditions [5].

In their study, Li and colleagues demonstrated that prophylactic antibiotic use was not correlated with a decreased risk of PJI, as has been shown by several other studies [1, 12].

Where Do We Need to Go?

While there is an official statement from the AAOS and the ADA on antibiotic use in dental procedures [3], there is no analogous joint statement with other academic societies, such as the American Urologic Association (AUA) and the American Heart Association (AHA), regarding prophylaxis in other outpatient procedures. Many countries take their cue from the AAOS guidelines, and I believe it is important to establish a precedent in the debate of prophylaxis for minor procedures following TJA.

The AUA guidelines for prophylaxis recommend that patients < 2 years out from a total joint arthroplasty who are undergoing a urologic procedure with an increased risk of bacteremia should receive preoperative antibiotics [2]. The guideline does leave room for consideration of antibiotics to reduce the risk of other infections, but has clear criteria for at risk orthopaedic patients. Prophylaxis is not routinely indicated for urologic patients with total joint replacements, or orthopedic pins, plates or screws. Recommendations such as this are favorable in my opinion, as they provide a treatment plan most orthopedists and urologists can potentially agree upon.

In contrast, there is no such guideline from the AHA for orthopedic patients undergoing cardiovascular procedures. The AHA updated their guidelines regarding antibiotic prophylaxis in 2017, after a review of the literature suggested that antibiotic prophylaxis to prevent infective endocarditis (IE) did not completely prevent bacteremia, especially in high-risk dental procedures. As such, their guidelines recommend prophylaxis for patients undergoing dental procedures with an increased risk of developing IE and experiencing adverse outcomes, but do not recommend IE prophylaxis for gastrointestinal or genitourinary procedures [9]. Additionally, there is no mention of recommendations for patients with IE undergoing total joint arthroplasty, once again leaving the decision for preoperative antibiotics up to the orthopaedic surgeon. It is my opinion that clearer guidelines are needed to inform both cardiologists and orthopedists of the optimal prophylactic regimen for orthopedic patients undergoing cardiovascular procedures.

Although there are some societal recommendations for prophylaxis of orthopedic patients undergoing other procedures, more information and guidance may be necessary. Based on current evidence, I am in agreement with the AAOS/ADA guidelines, as well as the AUA guidelines, and feel we need more recommendations like these. The study by Li and colleagues [8] has demonstrated that infections occur in soft tissue hand surgery regardless of prophylaxis and additional procedures. Further analysis is needed in order to clearly determine whether this finding holds true across other outpatient procedures. Once we have evidence that helps answer the question of prophylactic antibiotics in these procedures, it is my hope that the AAOS will partner with more organizations to develop understandable better guidelines to protect orthopedic patients from adverse outcomes.

How Do We Get There?

Future studies using large databases (similar to that of Li and colleagues [8]]) might seek to determine whether dental manipulations, colonoscopy, and urological interventions are similar to or different from one another in terms of the risk of subsequent PJI. Related to this, it would be important to know whether different kinds of arthroplasty—such as that of the knee, hip, and shoulder—are differentially vulnerable to PJI following interventions that can produce bacteremia.

While it is difficult and impractical to conduct randomized control trials for patients with infections, it is possible to explore the implications of antibiotic prophylaxis on routine procedures following TJA utilizing large national databases and registries. Accurate analysis of an uncommon complication such as PJI is what researchers like me live for, in the hopes that our findings help with the management and treatment of infected patients. The current study by Li and colleagues [8] has done this, and although their results are unconventional, I believe more studies should be conducted using large datasets to make more definitive recommendations with regard to antibiotic prophylaxis. The current AAOS guidelines provide a good baseline to work with, but they can always be reassessed and improved upon.