Prophylactic Antibiotics Prior to Hand Surgery in Patients with Prosthetic Joints

Abstract

Background: To determine the prevalence of prosthetic joint infections (PJIs) after elective clean hand surgery in order to determine whether prophylactic antibiotics are warranted in patients who have previously undergone total joint arthroplasty (TJA). Methods: All patients undergoing elective clean hand surgery between 2012 and 2018 were retrospectively cross-referenced with patients who had previously undergone a TJA at the same urban academic medical center. Inclusion criteria were any patients who underwent clean hand surgery during the study period who were an adult between the ages of 30 and 90, had a previous TJA, and did not have a previous history of a PJI. All charts were reviewed to collect data on patient demographics, co-morbidities, the type of TJA and hand surgery performed, whether prophylactic antibiotics were used prior to the hand surgery, and whether a PJI occurred within 3 months of the hand surgery. Results: Total of 331 patients (181 females and 150 males) were identified over the 6-year period that met inclusion criteria. In total, 13% of the patients received prophylactic antibiotics prior to their hand surgery and 87% had not. Only 1 case of a PJI occurred within 3 months of a hand surgery. No relationship was identified between the PJI and the hand surgery, nor the need for preoperative antibiotic prophylaxis. Conclusions: Incidence of PJI after clean hand surgery is very low. We do not recommend the routine use of antibiotic prophylaxis in patients undergoing clean elective hand surgery with a history of prior TJA in order to prophylax against a PJI.

Introduction

Antibiotic prophylaxis has been found to be effective in reducing the rates of infections across many orthopedic procedures, including spine surgeries, ¹ knee and shoulder arthroscopy, ² fracture fixation, ³ and total joint arthroplasty (TJA) of the hip and knee. ⁴ However, the benefit of using antibiotic prophylaxis in procedures involving the upper extremity is less clear. Recent studies examining postoperative infection rates in clean procedures of the hand have questioned the necessity of antibiotic prophylaxis. A study by Bykowski et al ⁵ involving 8850 patients found the rate of surgical site infections (SSIs) after elective clean hand surgery to be 0.35%, and that this rate was unaffected by the implementation of antibiotic prophylaxis. A systematic review of 4 randomized controlled trials by Metcalfe et al ⁶ found no evidence that antibiotic prophylaxis reduced the risk of SSI or osteomyelitis following open distal phalanx fractures. Other studies by Platt and Page ⁷ and Harness et al ⁸ have also shown infections rates to be independent of antibiotic prophylaxis in elective procedures of the hand and carpal tunnel releases (CTRs), respectively.

Similarly, the role of antibiotic prophylaxis before hand surgery has also not been established for patients with a history of TJA in order to avoid prosthetic joint infections (PJIs). Moreover, the role of antibiotic prophylaxis even before dental procedures has become controversial. LaPorte et al ⁹ showed that 6% of late infections following total hip arthroplasty were strongly associated with recent dental procedures, and the authors suspected that the joints were hematogenously seeded as a result of transient bacteremia. Currently, the American Dental Association recommends against antibiotic prophylaxis in patients with prosthetic joint implants based on systematic review data that failed to demonstrate an association between dental procedures and PJIs. ¹⁰ This guideline has been supported by subsequent studies such as Kao et al, ¹¹ which demonstrated that the rates of PJIs are unaffected by both dental procedures and antibiotic prophylaxis in patients with hip and knee replacements.

Although multiple studies^6-8 have largely argued against the use of prophylactic antibiotics during elective hand surgery and others have recommended against their use prior to dental procedures,^10,11 the possibility of transient bacteremia during elective hand surgery causes the question to persist regarding patients with a previous TJA given the significant morbidity associated with potential secondary PJIs. However, limited evidence exists to guide the use of antibiotic prophylaxis before hand surgery relative to the risk of PJIs after TJA. Our study goal was to retrospectively determine the incidence of PJIs after elective clean hand surgery at an urban academic medical center in order to determine whether prophylactic antibiotics are warranted in patients who have previously undergone TJA.

Materials and Methods

After institutional review board approval was obtained, all patients undergoing hand surgery between 2012 and 2018 were cross-referenced with patients who had previously undergone a TJA at the same institution (see Tables 1 and 2).

Table 1.

Number of Total Joint Arthroplasty Procedures Performed.

Joint procedure	Number	CPT Code
Total knee replacement	176	27447
Total hip replacement	112	27130
Total shoulder replacement	39	23472
Total ankle replacement	4	27702

Note. CPT = current procedural terminology.

Table 2.

Number of Elective Hand Surgery Procedures Performed.

Hand procedure	Number
Carpal tunnel release	206
Finger tendon sheath incision	38
Trigger finger release	29
First dorsal compartment tenosynovectomy of the wrist	11
Cubital tunnel release	6
De Quervian’s release	6
A1 pulley release	4
Thumb basal joint arthroplasty	4
Ulnar nerve transposition	4
Finger flexor tenosynovectomy	3
Wrist first dorsal compartment release	3
Distal radius and bridge plate removal	2
Guyon’s canal release	2
Hand extensor digital quinti tendon tenosynovectomy	2
Radical tenosynovectomy of the fourth dorsal compartment of the wrist	2
Thumb metacarpophalangeal joint arthrodeses	2
Flexor carpi ulnaris release	1
ORIF of open distal radius and ulnar fracture	1
Tenosynovectomy of the flexor digitorum profundus tendon	1
Thumb carpometacarpal interposition arthroplasty	1
Thumb trapezectomy	1
Wrist arthoscopic subtotal synovectomy	1

Note. ORIF = open reduction internal fixation.

Inclusion criteria were any patients who underwent clean hand surgery, defined as a procedure performed with no indication of a local infection at the time of surgery, during the study period who: (1) were an adult between the ages of 30 to 90; (2) had a previous TJ; and (3) did not have a previous history of a PJI. A PJI was determined to be potentially due to the elective hand surgery if it occurred within 3 months of the hand surgery procedure. All patients who met the inclusion criteria had their charts reviewed to collect data on their demographics, co-morbidities, the type of TJA, and hand surgery performed, and whether prophylactic antibiotics were used prior to the hand surgery. Co-morbidities studied included a history of diabetes, cancer, and smoking. The primary goal of the study was completed by determining the overall incidence of PJIs in patients undergoing elective hand surgery in our population.

The indication for hand surgery and the surgical technique used was not randomized. The choice for antibiotic prophylaxis was not standardized and based on surgeon discretion. A prestudy power analysis yielded that at least 50 cases in either the with and without preoperative antibiotic group would be needed to determine a difference of at least 2 PJI cases..

Results

A total of 6137 total cases were reviewed. A total of 331 patients (181 females and 150 males) with an average age of 73 years (range: 47-97) were identified over the 6-year period that met our inclusion criteria of undergoing a clean hand surgery after a prior TJA. Overall, 43 patients (13.0%) had received prophylactic antibiotics prior to their hand surgery while there were 288 cases without prophylactic antibiotics. There were a total of 3 cases of PJIs identified after elective hand surgery; however, 2 occurred outside the study period and 1 experienced direct traumatic inoculation. None of the patients who would later develop the 3 PJIs that occurred over our study period received preoperative antibiotics.

Of the 3 PJIs that were identified, only 1 occurred within 3 months of a hand surgery, with the other 2 PJIs both occurring approximately 30 months after their elective hand surgery. The 1 PJI case that occurred within 3 months of an elective hand surgery occurred 7 weeks after the elective hand surgery. Specifically, this patient had undergone a total knee arthroplasty 8 months before undergoing a CTR. Approximately 7 weeks postoperative to the CTR surgery, the patient fell on his prosthetic knee, ruptured his quadriceps tendon, and incurred a superficial abrasion. The patient then developed a PJI of his knee TJA a few days later requiring admission, surgical washout with maintenance of the prosthesis, and then staged quadriceps tendon repair. His infection was determined to be due to methicillin-sensitive Staphylococcus aureus. The patient underwent medical management with 6 months of antibiotic treatment under the supervision of an Infectious Disease specialist without re-operation and with maintenance of his initial prosthesis. The PJI was ultimately ascribed to the traumatic knee injury rather than the hand surgery performed 7 weeks previously. Therefore, there were essentially no cases of PJI related to a hand surgery occurring with 3 months post-operatively directly related to the hand surgery.

Discussion

Approximately 1% to 7% of TJA procedures are complicated by PJI, and the procedure itself carries with it the life-long risk of late infections that can result from hematogenous seeding from any systemic infection. ¹² Upper extremity surgery has the theoretical potential to also cause transient bacteremia that can then hematogenously seed the prosthetic joints of these patients.

For clean procedures of the upper extremity, low rates of post-operative infection have consistently been reported in the literature. In a study involving 2337 patients undergoing upper-extremity surgery, Kleinert et al ¹³ observed an infection rate of 1.4% and a deep infection rate of 0.3%. This is a similar result to yet another retrospective study by Hanssen et al ¹⁴ which showed an infection rate of 0.47% after CTR. Others, such as the previously mentioned study by Bykowski et al, ⁵ have shown that these already low rates of infection are unaffected by the use of prophylactic antibiotics. This assertion has been supported by other reports. Metcalfe et al ⁶ concluded the focus of open distal phalanx fracture treatment should be on irrigation and debridement rather than prophylactic antibiotic use as they found no evidence to suggest that they affected infection rates. A prospective study by Platt et al ⁷ looked at patients undergoing elective hand surgery and also observed no difference in postoperative infection rates between patients who received antibiotics and those who did not. Similarly, a 2009 multicenter retrospective review of CTR procedures found no statistically significant difference in the rate of surgical site or deep infections regardless of antibiotic prophylaxis or diabetic status. ⁸ Part of the difficulty in showing statistical significance regarding the effectiveness of prophylactic antibiotics for these procedures may be attributable to their inherently low rates of infection; however, the lack of any identifiable benefit in conjunction with the potential risks and costs associated with prophylactic antibiotic usage should call their use into question.

Despite all this, a study by Johnson et al ¹⁵ showed that nearly 20% of patients undergoing clean soft tissue hand surgery in 2015 received prophylactic antibiotics and that there had been a 73% increase in their use from 2009 to 2015. The authors concluded that if no pre- or postoperative antibiotics were given over the study period, $1.6 million in excess healthcare expenditure could have been avoided. Aside from the economic argument against their use, serious risks also accompany antibiotic usage, namely the possibility of anaphylaxis, ¹⁶ the growing problem of antibiotic resistance, ¹⁷ and the potential for Clostridium difficile infection of the gut. ¹⁸

While these studies argue against the utility of prophylactic antibiotics for clean procedures of the hand, they have not addressed specifically TJA being a risk factor for PJI following elective hand surgery nor the incidence of said infections. To the best of our knowledge, only 1 study has previously investigated this question. Zeng et al ¹⁹ looked at 275 CTR surgeries in patients who had previously undergone hip, knee, and/or shoulder TJA. The study resulted in no PJIs, regardless of antibiotic use, and furthermore showed that hand surgeon awareness of a previous TJA had no effect on the surgeons’ choice to use antibiotics. Our study reports similar findings as only 1 PJI was observed within 3 months of an elective hand surgery, with the PJI showing no direct correlation to the hand surgery but rather being traumatic in nature resulting in both an abrasion over the knee replacement and a ruptured quadriceps tendon. Moreover, our study adds to Zeng et al’s report as we provide a larger sample size, more varied hand surgical cases, and also examined a larger variety of TJAs. Overall, our data also argue against using prophylactic antibiotics to prevent PJIs in patients undergoing elective hand surgery by virtue of the low incidence of PJIs. However, like Zeng et al, we would recommend prescribing antibiotics preoperatively based on the individual patients’ history and not recommending routine preoperative antibiotic prophylaxis.

This study has several limitations. First, it is retrospective. Second, only patients who underwent both their TJA and hand surgery at our institution were available for review. Despite diligent chart review, some instances of PJI could have been overlooked if treatment was sought at another facility. Finally, the established low rate of postoperative infections for clean procedures of the hand makes it difficult to find an appreciable amount of PJIs after subsequent hand surgery without an extremely large sample size. In this analysis, our study was underpowered in that there were only 43 cases in the preoperative antibiotic group and 288 in the no- antibiotic group, rather than at least 50 patients in each group. However, there were no cases of hand surgery–related PJI in any group regardless. Moreover, without a current understanding of the potential incidence of PJI after clean hand surgery, a better power analysis is not possible.

In conclusion, the rate of PJIs after elective hand surgery in patients who had previously undergone a TJA is extremely low. Given the low incidence of PJIs within our population following elective hand surgery, we are unable to comment on possible risk factors. Regarding antibiotic prophylaxis, although underpowered, there were no cases of PJI in any group and therefore preoperative antibiotics should be administered on only a case-by-case basis and not routinely.