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

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]. Sincemost 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].