Intraoperative Irrigation and Topical Antibiotic Use Fail to Reduce Early Periprosthetic Joint Infection Rates: A Michigan Arthroplasty Registry Collaborative Quality Initiative Study

Abstract

Background

Periprosthetic joint infections remain a major complication in total joint arthroplasty. Tremendous efforts made intraoperatively to prevent periprosthetic joint infection during primary procedures include antiseptics or antibiotics in irrigation solutions. This study analyzed the incidence of postoperative infection in relation to use of irrigation solutions and antibiotic powder.

Methods

We reviewed primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) cases from the Michigan Arthroplasty Registry Collaborative Quality Initiative between January 2019 and December 2022. Data on irrigation solutions were categorized by those containing antibiotics, chlorhexidine-gluconate, povidone-iodine, or other substances, compared to normal saline. Logistic regression analyses were conducted, adjusting for various factors such as age, body mass index, sex, American Society of Anesthesiologists score, smoking, and more. There were 67,871 THA and 105,963 TKA cases analyzed, with an overall infection rate of 0.6% (confidence interval: 0.6 to 0.7, n = 420) for THA and 0.4% (0.36 to 0.43, n = 419) for TKA within 90 days postsurgery.

Results

There were statistical differences between the use of normal saline alone versus other irrigation solutions in THA, including povidone and others. For TKA, there was a statistically significant difference with lower infection rates using normal saline alone than multiple types, chlorhexidine-gluconate, and povidone. Notably, the use of nonsaline irrigation increased over the study period.

Conclusions

There was no reduction in 90-day infection rates for primary THA or TKA with irrigation additives. Higher infection rates were noted with povidone than saline for THA and TKA, potentially due to selection bias or local adverse tissue effects. Topical powders did not improve infection control. While irrigation is strongly recommended in all patients having TKA or THA, multiple irrigation solutions were not correlated with lower infection rates, suggesting importance of patient selection and optimization over irrigation type.