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A Review Paper
E374 The American Journal of Orthopedics® November/December 2017 www.amjorthopedics.com
Decreasing the Incidence of Surgical-Site
Infections After Total Joint Arthroplasty
Jaydev B. Mistry, MD, Abbas Naqvi, MD, Morad Chughtai, MD, Chukwuweike Gwam, MD,
Melbin Thomas, MD, Carlos A. Higuera, MD, Michael A. Mont, MD, and Ronald E. Delanois, MD
Surgical-site infection (SSI), a potentially
devastating complication of lower extremity
total joint arthroplasty (TJA), is estimated to
occur in 1% to 2.5% of cases annually.
1
Infection
after TJA places a signicant burden on patients,
surgeons, and the healthcare system. Revision
procedures that address infection after total hip
arthroplasty (THA) are associated with more hos-
pitalizations, more operations, longer hospital stay,
and higher outpatient costs in comparison with pri-
mary THAs and revision surgeries for aseptic loos-
ening.
2
If left untreated, a SSI can go deeper into
the joint and develop into a periprosthetic infection,
which can be disastrous and costly. A peripros-
thetic joint infection study that used 20 01 to 2009
Nationwide Inpatient Sample (NIS) data found that
the cost of revision procedures increased to $560
million from $320 million, and was projected to
reach $1.62 billion by 2020.
3
Furthermore, society
incurs indirect costs as a result of patient disability
and loss of wages and productivity.
2
Therefore, the
issue of infection after TJA is even more crucial in
our cost-conscious healthcare environment.
Patient optimization, advances in surgical tech-
nique, sterile protocol, and operative procedures
have been effective in reducing bacterial counts
at incision sites and minimizing SSIs. As a result,
infection rates have leveled off after rising for a
decade.4 Although infection prevention modalities
have their differences, routine use is fundamental
and recommended by the Hospital Infection Con-
trol Practices Advisory Committee.5 Furthermore,
both the US Centers for Disease Control and Pre-
vention (CDC) and its Healthcare Infection Control
Practices Advisory Committee6,7 recently updated
their SSI prevention guidelines by incorporating
evidence-based methodology, an element missing
from earlier recommendations.
The etiologies of postoperative SSIs have been
discussed ad nauseam, but there are few reports
summarizing the literature on infection prevention
modalities. In this review, we identify and examine
SSI prevention strategies as they relate to lower
extremity TJA. Specically, we discuss the literature
on the preoperative, intraoperative, and postop-
erative actions that can be taken to reduce the
incidence of SSIs after TJA. We also highlight the
economic implications of SSIs that occur after TJA.
Abstract
Surgical-site infection (SSI) after total
joint arthroplasty (TJA) continues to
pose a challenge and place a substantial
burden on patients, surgeons, and the
healthcare system. Given the estimated
1.0% to 2.5% annual incidence of SSI after
TJA, orthopedists should be cognizant
of preventive measures that can help
optimize patient outcomes. Advances
in surgical technique, sterile protocol,
and operative procedures have been
instrumental in minimizing SSIs and may
account for the recent plateau in rising
rates. In this review, we identify and
discuss preoperative, intraoperative, and
postoperative actions that can be taken
to help reduce the incidence of SSIs, and
we highlight the economic implications of
SSIs that occur after TJA.
Authors’ Disclosure Statement: Dr. Chughtai reports that he is a paid consultant for DJ Orthopaedics, Sage Products, and Stryker. Dr. Mont reports that
he receives grants/fees from DJ Orthopaedics, Johnson & Johnson, Merz, Microport, National Institutes of Health, Ongoing Care Solutions, Orthosensor,
Pacira Pharmaceuticals, Sage Products, Stryker, TissueGene, and US Medical Innovations; he is on the editorial/governing boards of The American Acade-
my of Orthopaedic Surgeons, The American Journal of Orthopedics, Journal of Arthroplasty, Journal of Knee Surgery, Orthopedics, and Surgical Technology Inter-
national. Dr. Delanois reports that he is a paid consultant and speaker for Corin and a Maryland Orthopaedic Association board/committee member, and
he receives research support from OrthoFix Inc. and Stryker. The other authors report no actual or potential conict of interest in relation to this article.
J. B. Mistry et al
www.amjorthopedics.com November/December 2017 The American Journal of Orthopedics® E375
Methods
For this review, we performed a literature search
with PubMed, EBSCOhost, and Scopus. We looked
for reports published between the inception of each
database and July 2016. Combinations of various
search terms were used: surgical site, infection,
total joint arthroplasty, knee, hip, preoperative, intra-
operative, perioperative, postoperative, preparation,
nutrition, ventilation, antibiotic, body exhaust suit,
gloves, drain, costs, economic, and payment.
Our search identied 195 abstracts. Drs. Mistry
and Chughtai reviewed these to determine which
articles were relevant. For any uncertainties, consen-
sus was reached with the help of Dr. Delanois. Of
the 195 articles, 103 were potentially relevant, and
54 of the 103 were excluded for being not relevant
to preventing SSIs after TJA or for being written in a
language other than English. The references in the
remaining articles were assessed, and those with
potentially relevant titles were selected for abstract
review. This step provided another 35 articles. After
Table 1. Summary of Studies Reporting on Preoperative Measures to Prevent Surgical-Site Infection
Study
Patients/
Studies, N Operation Interventions Results
Preoperative
skin preparation
Hayek et al10
(198 7)
2015 Various elective
inpatient
procedures
Preparation with
chlorhexidine vs unmedicated
soap vs placebo cloth
Decreased infection rates 6 wk after
surgery with chlorhexidine (9% vs
11.7% vs 12.8%; P < .05)
Murray et al11
(20 11)
100 Shoulder
surgery
2% chlorhexidine gluconate
cloth vs standard shower
(soap & water)
Decreased positive surgical-site culture
rate with 2% chlorhexidine (66% vs
94%; P = .0008)
Darouiche et al12
(2010)
849 Various Preparation with
chlorhexidine-alcohol vs
povidone-iodine
Lower rate of SSI with chlorhexidine -
alcohol (9.5% vs 16.1%; P = .004; RR,
0.59; 95% CI, 0.41-0.85)
Zywiel et al13
(20 11)
136 TKA Advanced cutaneous
disinfection protocol vs
standard perioperative
disinfection
Lower rate of SSI in advanced protocol
group (0% vs 3%)
Kapadia et al14
(20 13)
2545 THA At-home chlorhexidine cloths
plus standard perioperative
preparation vs standard
perioperative preparation
alone
Lower incidence of SSI with at- home
chlorhexidine cloths (0.5% vs 1.7%;
P = .04)
Johnson et al15
(20 13)
2293 TKA At-home chlorhexidine cloths
plus standard perioperative
preparation vs standard
perioperative preparation
alone
Lower incidence of SSI with at- home
chlorhexidine cloths (0.6% vs 2. 2%;
P = .02)
Kapadia et al16
(2016)
554 THA , TK A Preadmission 2%
chlorhexidine gluconate–
impregnated cloths vs
preadmission soap & water
bath (standard of care)
Lower incidence of infection with
chlorhexidine (0.4% vs 2.9%; P = .049;
OR, 8.15; 95% CI, 1.01-65.6)
Continued on page E376
Take-Home Points
◾ SSIs after TJA pose a substantial burden on patients,
surgeons, and the healthcare system.
◾ While different forms of preoperative skin preparation
have shown varying outcomes after TJA, the impor-
tance of preoperative patient optimization (nutritional
status, immune function, etc) cannot be overstated.
◾ Intraoperative infection prevention measures include
cutaneous preparation, gloving, body exhaust suits,
surgical drapes, OR staff traffic and ventilation flow,
and antibiotic-loaded cement.
◾ Antibiotic prophylaxis for dental procedures in TJA
patients continues to remain a controversial issue
with conflicting recommendations.
◾ SSIs have considerable financial costs and require
increased resource utilization. Given the significant
economic burden associated with TJA infections, it is
imperative for orthopedists to establish practical and
cost-effective strategies to prevent these devastating
complications.
Decreasing the Incidence of Surgical-Site Infections After Total Joint Arthroplasty
E376 The American Journal of Orthopedics® November/December 2017 www.amjorthopedics.com
all exclusions, 48 articles remained. We discuss
these in the context of preoperative, intraoperative,
and postoperative measures and economic impact.
Results
Preoperative Measures
Skin Preparation. Preoperative skin preparation
methods include standard washing and rinsing,
antiseptic soaps, and iodine-based or chlorhexidine
gluconate-based antiseptic showers or skin cloths.
Iodine-based antiseptics are effective against a
wide range of Gram-positive and Gram-negative
bacteria, fungi, and viruses. These agents pene-
trate the cell wall, oxidize the microbial contents,
and replace those contents with free iodine mole-
cules.8 Iodophors are free iodine molecules associ-
Table 1. Summary of Studies Reporting on Preoperative Measures to Prevent Surgical-Site Infection (continued)
Study
Patients/
Studies, N Operation Interventions Results
Patient
optimization
Greene et al18
(19 91)
217 THA, TK A N/A Up to 7-fold higher rate of infection
after TJA in patients with preoperative
malnutrition (lymphocy te count of
<1500 cells/mm3 or albumin level of
<3.5 g/dL)
Alfargieny et al20
(2015)
135 THA, TK A N/A Preoperative serum albumin levels were
only nutritional biomarker predictive of
SSI (P = .011)
Sørensen23
(2 012)
Meta-
analysis of
140 cohort
studies
Various N/A Smokers had increased risk of wound
complications (OR, 2.27; 95% CI,
1.82-2.8 4), delayed wound healing and
dehiscence (OR, 2.07; 95% CI, 1.53-
2.81), and infection (OR, 1.79; 95% CI,
1.5 7-2.0 4)
Decreased incidence of SSI with
smoking cessation (OR, 0.43; 95% CI,
0.21-0.85)
Wong et al24
(2 012)
Meta-
analysis
of 25 studies
Various N/A Decreased incidence of SSI with
smoking cessation for at least 4 wk
before surgery (OR, 0.69; 95% CI, 0.5 6-
0.84)
Pugely et al25
(2015)
25,235 Primary &
rev ision TJA
N/A Increased risk of SSI with BMI >40
kg/m 2 (OR, 1.9; 95% CI, 1.3-2.9),
electrolyte disturbance (OR, 2.4; 95%
CI, 1.0- 6.0), and hypertension diagnosis
(OR, 1.5; 95% CI, 1.1-2.0)
Han & Kang26
(20 13)
115 TKA N/A Patients with hemoglobin A1c levels
>8% more likely to have wound
complication (OR, 6.07; 95% CI, 1.12-
33.0)
Hwang et al27
(2015)
462 TKA N/A Patients with hemoglobin A1c levels
>8% more likely to have SSI (OR, 6.1;
95% CI, 1.6-23.4; P = .008)
Patients with fasting blood glucose level
of ≥200 mg/dL more likely to have SSI
(OR, 9.2; 95% CI, 2.2- 38. 2; P = .038)
Moroski et al29
(2015)
289 Primar y &
rev ision TJA
Preoperative 5- day course
of intranasal mupirocin
decolonization
Reduction in MRSA (P = .0 073) and
MSSA (P = .0 341) colonization on day
of surgery
Rao et al30
(20 11)
2284 Primary &
rev ision TJA
Preoperative 5- day course
of chlorhexidine bath and
intranasal mupirocin
Reduction in SSI with implementation of
decolonization protocol (P = .009)
Abbrev iations: BM I, body mass index ; CI, con dence inter val; MRSA, met hicillin -resis tant Staphylococcus aureus; MS SA, methicillin- sensitive Staphylococcus aureus; N/A, not ap pli-
cable; OR , odds ratio; RR, rel ative risk ; SSI, surg ical- site infection; TH A, total hi p arthrop lasty; TJA , total joint arthr oplast y; TK A, total kn ee arthro plasty.
J. B. Mistry et al
www.amjorthopedics.com November/December 2017 The American Journal of Orthopedics® E377
ated with a polymer (eg, polyvinylpyrrolidone); the
iodophor povidone-iodine is bactericidal.9 Chlor-
hexidine gluconate-based solutions are effective
against many types of yeast, Gram-
positive and Gram-negative bacteria, and a wide
variety of viruses.9 Both solutions are useful.
Patients with an allergy to iodine can use chlorhex-
idine. Table 1 summarizes the studies on preopera-
tive measures for preventing SSIs.
There is no shortage of evidence of the efcacy
of these antiseptics in minimizing the incidence of
SSIs. Hayek and colleagues10 prospectively ana-
lyzed use of different preoperative skin preparation
methods in 2015 patients. Six weeks after surgery,
the infection rate was signicantly lower with use
of chlorhexidine than with use of an unmedicated
bar of soap or placebo cloth (9% vs 11.7% and
12.8%, respectively; P < .05). In a study of 100
patients, Murray and colleagues11 found the overall
bacterial culture rate was signicantly lower for
those who used a 2% chlorhexidine gluconate
cloth before shoulder surgery than for those who
took a standard shower with soap (66% vs 94%;
P = .0008). Darouiche and colleagues12 found the
overall SSI rate was signicantly lower for 409 sur-
gical patients prepared with chlorhexidine-alcohol
than for 440 prepared with povidone-iodine (9.5%
vs 16.1%; P = .004; relative risk [RR], 0.59; 95%
condence interval [CI], 0.41-0.85).
Chlorhexidine gluconate-impregnated cloths
have also had promising results, which may be at-
tributed to general ease of use and potentially im-
proved patient adherence. Zywiel and colleagues13
reported no SSIs in 136 patients who used these
cloths at home before total knee arthroplasty (TKA)
and 21 SSIs (3.0%) in 711 patients who did not
use the cloths. In a study of 2545 THA patients, Ka-
padia and colleagues14 noted a signicantly lower
incidence of SSIs with at-home preoperative use
of chlorhexidine cloths than with only in-hospital
perioperative skin preparation (0.5% vs 1.7%; P =
.04). In 2293 TKAs, Johnson and colleagues15 simi-
larly found a lower incidence of SSIs with at-home
preoperative use of chlorhexidine cloths (0.6% vs
2.2%; P = .02). In another prospective, random-
ized trial, Kapadia and colleagues16 compared 275
patients who used chlorhexidine cloths the night
before and the morning of lower extremity TJA sur-
gery with 279 patients who underwent standard-
of-care preparation (preadmission bathing with
antibacterial soap and water). The chlorhexidine
cohort had a lower overall incidence of infection
(0.4% vs 2.9%; P = .049), and the standard-of-care
cohort had a stronger association with infection
(odds ratio [OR], 8.15; 95% CI, 1.01-65.6).
Patient Optimization. Poor nutritional status may
compromise immune function, potentially result-
ing in delayed healing, increased risk of infection,
and, ultimately, negative postoperative outcomes.
Malnutrition can be diagnosed on the basis of a
prealbumin level of <15 mg/dL (normal, 15-30 mg/
dL), a serum albumin level of <3.4 g/dL (normal,
3.4-5.4 g/dL), or a total lymphocyte count under
1200 cells/μL (normal, 3900-10,000 cells/μL).17- 19
Greene and colleagues18 found that patients with
preoperative malnutrition had up to a 7-fold higher
rate of infection after TJA. In a study of 135 THAs
and TKAs, Alfargieny and colleagues20 found preop-
erative serum albumin was the only nutritional bio-
marker predictive of SSI (P = .011). Furthermore,
patients who take immunomodulating medications
(eg, for inammatory arthropathies) should tempo-
rarily discontinue them before surgery in order to
lower their risk of infection.21
Smoking is well established as a major risk fac-
tor for poor outcomes after surgery. It is postulated
that the vasoconstrictive effects of nicotine and
the hypoxic effects of carbon monoxide contrib-
ute to poor wound healing.22 In a meta-analysis
of 4 studies, Sørensen23 found smokers were at
increased risk for wound complications (OR, 2.27;
95% CI, 1.82-2.84), delayed wound healing and
dehiscence (OR, 2.07; 95% CI, 1.53-2.81), and
infection (OR, 1.79; 95% CI, 1.57-2.04). Moreover,
smoking cessation decreased the incidence of
SSIs (OR, 0.43; 95% CI, 0.21-0.85). A meta-
analysis by Wong and colleagues24 revealed an
inection point for improved outcomes in patients
who abstained from smoking for at least 4 weeks
before surgery. Risk of infection was lower for
these patients than for current smokers (OR, 0.69;
95% CI, 0.56-0.84).
Other comorbidities contribute to SSIs as well.
In their analysis of American College of Surgeons
National Surgical Quality Improvement Program
registry data on 25,235 patients who underwent
primary and revision lower extremity TJA, Pugely
and colleagues25 found that, in the primary TJA
cohort, body mass index (BMI) of >40 kg/m2 (OR,
1.9; 95% CI, 1.3-2.9), electrolyte disturbance (OR,
2.4; 95% CI, 1.0-6.0), and hypertension diagnosis
(OR, 1.5; 95% CI, 1.1-2.0) increased the risk of SSI
within 30 days. Furthermore, diabetes mellitus de-
lays collagen synthesis, impairs lymphocyte func-
tion, and impairs wound healing, which may lead
to poor recovery and higher risk of infection.26 In a
Decreasing the Incidence of Surgical-Site Infections After Total Joint Arthroplasty
E378 The American Journal of Orthopedics® November/December 2017 www.amjorthopedics.com
study of 167 TKAs performed in 115 patients with
type 2 diabetes mellitus, Han and Kang26 found
that wound complications were 6 times more
likely in those with hemoglobin A1c (HbA1c) levels
higher than 8% than in those with lower HbA1c
levels (OR, 6.07; 95% CI, 1.12-33.0). In a similar
study of 462 patients with diabetes, Hwang and
colleagues27 found a higher likelihood of supercial
SSIs in patients with HbA1c levels >8% (OR, 6.1;
95% CI, 1.6-23.4; P = .008). This association was
also found in patients with a fasting blood glucose
level of >200 mg/dL (OR, 9.2; 95% CI, 2.2-38.2;
P = .038).
Methicillin-resistant Staphylococcus aureus
(MRSA) is thought to account for 10% to 25% of
all periprosthetic infections in the United States.28
Nasal colonization by this pathogen increases the
risk for SSIs; however, decolonization protocols
have proved useful in decreasing the rates of colo-
nization. Moroski and colleagues29 assessed the ef-
cacy of a preoperative 5-day course of intranasal
mupirocin in 289 primary or revision TJA patients.
Before surgery, 12 patients had positive MRSA
cultures, and 44 had positive methicillin-sensitive
S aureus (MSSA) cultures. On day of surgery, a sig-
nicant reduction in MRSA (P = .0073) and MSSA
(P = .0341) colonization was noted. Rao and col-
leagues30 found that the infection rate decreased
from 2.7% to 1.2% in 2284 TJA patients treated
with a decolonization protocol (P = .009).
Intraoperative Measures
Cutaneous Preparation. The solutions used in
perioperative skin preparation are similar to those
used preoperatively: povidone-iodine, alcohol,
and chlorhexidine. The efcacy of these prepara-
tions varies. Table 2 summarizes the studies on
intraoperative measures for preventing SSIs. In a
prospective study, Saltzman and colleagues31 ran-
domly assigned 150 shoulder arthroplasty patients
to one of 3 preparations: 0.75% iodine scrub with
1% iodine paint (Povidone-Iodine; Tyco Healthcare
Group), 0.7% iodophor with 74% iodine povacrylex
(DuraPrep; 3M Health Care), or chlorhexidine
gluconate with 70% isopropyl alcohol (ChloraPrep;
Enturia). All patients had their skin area prepared
and swabbed for culture before incision. Although
no one in any group developed a SSI, patients in
the chlorhexidine group had the lowest overall
incidence of positive skin cultures. That incidence
(7%) and the incidence of patients in the iodophor
group (19%) were signicantly lower than that of
patients in the iodine group (31%) (P < .001 for
both). Conversely, another study32 found a higher
likelihood of SSI with chlorhexidine than with
povidone-iodine (OR, 4.75; 95% CI, 1.42-15.92; P
= .012). This nding is controversial, but the body
of evidence led the CDC to recommend use of
an alcohol-based solution for preoperative skin
preparation.6
The literature also highlights the importance of
technique in incision-site preparation. In a prospec-
tive study, Morrison and colleagues33 randomly
assigned 600 primary TJA patients to either (1) use
of alcohol and povidone-iodine before draping, with
additional preparation with iodine povacrylex (Du-
raPrep) and isopropyl alcohol before application of
the nal drape (300-patient intervention group) or
(2) only use of alcohol and povidone-iodine before
draping (300-patient control group). At the nal
follow-up, the incidence of SSI was signicantly
lower in the intervention group than in the control
group (1.8% vs 6.5%; P = .015). In another study
that assessed perioperative skin preparation meth-
ods, Brown and colleagues34 found that airborne
bacteria levels in operating rooms were >4 times
higher with patients whose legs were prepared by
a scrubbed, gowned leg-holder than with patients
whose legs were prepared by an unscrubbed,
ungowned leg-holder (P = .0001).
Hair Removal. Although removing hair from
surgical sites is common practice, the literature
advocating it varies. A large comprehensive review
35
revealed no increased risk of SSI with removing vs
not removing hair (RR, 1.65; 95% CI, 0.85-3.19). On
the other hand, some hair removal methods may
affect the incidence of infection. For example, use
of electric hair clippers is presumed to reduce the
risk of SSIs, whereas traditional razors may compro-
mise the epidermal barriers and create a pathway
for bacterial colonization.
5,36,37
In the aforementioned
review,
35
SSIs were more than twice as likely to
occur with hair removed by shaving than with hair
removed by electric clippers (RR, 2.02; 95% CI,
1.21-3.36). Cruse and Foord
38
found a higher rate of
SSIs with hair removed by shaving than with hair re-
moved by clipping (2.3% vs 1.7%). Most surgeons
agree that, if given the choice, they would remove
hair with electric clippers rather than razors.
Gloves. Almost all orthopedists double their
gloves for TJA cases. Over several studies, the
incidence of glove perforation during orthopedic
procedures has ranged from 3.6% to 26%,39-41
depending on the operating room personnel and
glove layering studied. Orthopedists must know
this startling nding, as surgical glove perforation
J. B. Mistry et al
www.amjorthopedics.com November/December 2017 The American Journal of Orthopedics® E379
is associated with an increase in the rate of SSIs,
from 1.7% to 5.7%.38 Carter and colleagues42
found the highest risk of glove perforation occurs
when double-gloved attending surgeons, adult
reconstruction fellows, and registered nurses ini-
tially assist during primary and revision TJA. In their
study, outer and inner glove layers were perforated
2.5% of the time. All outer-layer perforations were
noticed, but inner-layer perforations went unno-
ticed 81% of the time, which poses a potential
hazard for both patients and healthcare personnel.
In addition, there was a signicant increase in the
incidence of glove perforations for attending sur-
geons during revision TJA vs primar y TJA (8.9% vs
3.7%; P = .04). This nding may be expected given
the complexity of revision procedures, the pres-
ence of sharp bony and metal edges, and the lon-
ger operative times. Giving more attention to glove
perforations during arthroplasties may mitigate the
risk of SSI. As soon as a perforation is noticed, the
glove should be removed and replaced.
Body Exhaust Suits. Early TJAs had infection
Table 2. Summary of Studies Reporting on Intraoperative Measures to Prevent Surgical-Site Infection
Study
Patients/
Studies, N Operation Interventions/Endpoints Results
Perioperative
skin preparation
Saltzman et al31
(2009)
150 TSA Preparation with iodine vs
iodophor vs chlorhexidine
gluconate
Lower incidence of positive skin cultures
with chlorhexidine gluconate or iodophor
preparation vs iodine preparation (P <
.001 for both)
Carroll et al32
(2014)
964 THA, TKA 0.5% chlorhexidine vs 1%
iodine
Increased likelihood of SSI with
chlorhexidine preparation (OR, 4.75;
95% CI, 1.42-15.92; P = .012)
Morrison et al33
(2016)
600 Primary TJA Skin preparation before
draping and additional
preparation before application
of final drape vs skin
preparation only before
draping
Reduced incidence of SSI with repeat
skin preparation (1.8% vs 6.5%;
P = .015)
Brown et al34
(199 6)
29 THA, TKA Unscrubbed, ungowned leg-
holder vs scrubbed, gowned
leg-holder during preparation
Airborne bacteria levels >4 times higher
with unscrubbed, ungowned leg-holder
(P = .0001)
Hair removal Tanner et al35
(2006)
Review of
11 studies
Various Removal of hair from surgical
site
No increased risk of SSI with hair
removal vs no hair removal (RR, 1.65;
95% CI, 0.8 5- 3.19)
Increased risk of S SI with shaving vs
use of electrical clippers (RR, 2.02; 95%
CI, 1.21-3.36)
Cruse & Foord38
(1973 )
23,649
surgical
wounds
Various Hair removal by shaving vs
hair removal with electric
clippers
Higher rate of SSI with shaving vs use
of electric clippers (2.3% vs 1.7%)
Gloves and body
exhaust suits
Carter et al42
(2 012)
3863
gloves
Primary and
rev ision TJA
Incidence of glove perforation Higher incidence of glove perforation
with revision vs primary TJA (8.9% vs
3.7%; P = .04)
Hooper et al47
(20 11)
8 8 ,3 11 THA, TKA Body exhaust suits Increase in early revision THA for deep
infection with use of body exhaust suits
(0.186% vs 0.06 4%; P < .0001)
Increase in early revision TK A for deep
infection with use of body exhaust suits
(0.24 3% vs 0.09 8%; P < .0001)
Miner et al48
(2007)
8288 TKA Body exhaust suits No difference in risk of SSI with use of
body exhaust suits (RR, 0.75; 95% CI,
0. 34-1.62)
Continued on page E380
Decreasing the Incidence of Surgical-Site Infections After Total Joint Arthroplasty
E380 The American Journal of Orthopedics® November/December 2017 www.amjorthopedics.com
Table 2. Summary of Studies Reporting on Intraoperative Measures to Prevent Surgical-Site Infection (continued)
Study
Patients/
Studies, N Operation Interventions/Endpoints Results
Surgical drapes Blom et al50
(2000)
N/A N/A 7 different surgical drapes Increased bacterial penetration with
woven cloth drapes vs nonwoven
disposable drapes
Blom et al51
(2002)
N/A N/A Effect of different wetting
agents on bacterial
penetration and growth with
reusable polyester/cotton
surgical drapes
Enhanced bacterial penetration rate and
heavy grow th (>100,000 colony-forming
units) after 30 minutes with drapes wet
with blood or normal saline
Fairclough
et al52
(198 6)
235 Hip surgery
requiring implant
Povidone-iodine preparation
vs iodophor-impregnated
adhesive drape
Surgical-site bacterial contamination
reduced from 15% to 1.6% with
iodophor-impregnated drape
Webster &
Alghamdi53
(2007)
4195 Various Adhesive drapes with/
without antimicrobial
properties vs no drapes
No reduced risk of SSI with iodine-
impregnated drapes (RR, 1.03; 9 5% CI,
0.06 -1.66; P = .89)
Increased risk of infection with overall
use of adhesive draping (RR, 1.23; 95%
CI, 1.0 2-1.4 8; P = .03)
Ventilation flow Evans54
(20 11)
Review of
48 studies
Various TJAs Laminar vs nonlaminar
airflow
Laminar airflow can decrease bacterial
count in air and wound
Lidwell et al46
(198 2)
8055 TKA Laminar vs nonlaminar
airflow
Lower incidence of SSI with laminar-
airflow operating rooms (0.6% vs 2.3%;
P < .0 01)
Miner et al48
(2007)
8288 TKA Laminar vs nonlaminar
airflow
No difference in risk of SSI with laminar-
airflow operating rooms (RR, 1.57; 95%
CI, 0.75-3.31)
Hooper et al47
(20 11)
8 8 ,3 11 THA, TKA Laminar vs nonlaminar
airflow
Increased incidence of early infections
with laminar air flow for both TK A
(0.193% vs 0.100%; P = .019) and THA
(0.148% vs 0.061%; P < .0 01)
Staff traffic
volume
Lynch et al55
(2009)
28 Various Frequency of opening
operating room door
Door may remain open for up to 20
minutes per case
Young &
O’Regan56
(2010)
46 Cardiac Frequency of opening
operating room door
Door is open for almost 10.7% of each
hour
Pryor &
Messmer57
(199 8)
2864 Various Personnel in operating room SSI rate of 6.27% with >17 people
entering vs 1.52% with <9 people
entering
Antibiotic
prophylaxis
Gorenoi et al60
(2010)
Review of
10 studies
TKA Antibiotic prophylaxis vs no
prophylaxis
Antibiotic prophylaxis is highly effective,
but a particular antibiotic could not be
recommended
AlBuhairan
et al61
(2008)
Review of
26 studies
TJA Antibiotic prophylaxis vs no
prophylaxis
8% reduction in absolute risk of wound
infection and 81% reduction in RR with
antibiotic prophylaxis (P < .00001)
Antibiotic-loaded
bone cement
Parvizi et al64
(2008)
Meta-
analysis of
19 studies
THA ALBC vs regular bone
cement
Decreased infection rate with ALBC
(1.2% vs 2.3%)
Namba et al65
(2009)
22,889 TKA ALBC vs regular bone
cement
Higher incidence of deep infection with
ALBC (1.4% vs 0.7%; P = .002)
Zhou et al66
(2015)
Meta-
analysis of
5 studies
TKA ALBC vs regular bone
cement
No difference in incidence of deep SSI
(1.32% vs 1.89%; RR, 0.75; 95% CI,
0.43-1. 3 3; P = .33)
Abbrev iations: A LBC, ant ibiotic -lade n bone ceme nt; CI, con dence interval; N /A, not ap plicabl e; OR, odd s ratio; RR, re lative ris k; SSI, su rgical -site infec tion; TH A, total hi p arthro -
plast y; TJA, total j oint arth roplast y; TK A, total k nee arthr oplast y; TSA , total shou lder arth roplast y.
J. B. Mistry et al
www.amjorthopedics.com November/December 2017 The American Journal of Orthopedics® E381
rates approaching 10%.43 Bacterial-laden particles
shed from surgical staff were postulated to be the
cause,44,45 and this idea prompted the development
of new technology, such as body exhaust suits,
which have demonstrated up to a 20-fold reduction
in airborne bacterial contamination and decreased
incidence of deep infection, from 1% to 0.1%,
as compared with conventional surgical attire.46
However, the efcacy of these suits was recently
challenged. Hooper and colleagues47 assessed
>88,000 TJA cases in the New Zealand Joint Regis-
try and found a signicant increase in early revision
THA for deep infection with vs without use of body
exhaust suits (0.186% vs 0.064%; P < .0001).
The incidence of revision TKAs for deep infections
with use of these suits was similar (0.243% vs
0.098%; P < .001). Many of the surgeons sur-
veyed indicated their peripheral vision was limited
by the suits, which may contribute to sterile eld
contamination. By contrast, Miner and colleagues48
were unable to determine an increased risk of SSI
with use of body exhaust suits (RR, 0.75; 95% CI,
0.34-1.62), though there was a trend toward more
infections without suits. Moreover, these suits are
effective in reducing mean air bacterial counts (P =
.014), but it is not known if this method correlates
with mean wound bacterial counts (r = –.011) and
therefore increases the risk of SSI.49
Surgical Drapes. Surgical draping, including
cloths, iodine-impregnated materials, and woven
or unwoven materials, is the standard of care
worldwide. The particular draping technique usually
varies by surgeon. Plastic drapes are better barriers
than cloth drapes, as found in a study by Blom and
colleagues
50
: Bacterial growth rates were almost 10
times higher with use of wet woven cloth drapes
than with plastic surgical drapes. These ndings
were supported in another, similar study by Blom
and colleagues
51
: Wetting drapes with blood or
normal saline enhanced bacterial penetration. In ad-
dition, wetting drapes with chlorhexidine or iodine
reduced but did not eliminate bacterial penetra-
tion. Fairclough and colleagues
52
emphasized that
iodine-impregnated drapes reduced surgical-site
bacterial contamination from 15% to 1.6%. Howev-
er, a Cochrane review
53
found these drapes had no
effect on the SSI rate (RR, 1.03; 95% CI, 0.06-1.66;
P = .89), though the risk of infection was slightly
higher with adhesive draping than with no drape
(RR, 1.23; 95% CI, 1.02-1.48; P = .03).
Ventilation Flow. Laminar-airow systems are
widely used to prevent SSIs after TJA.
Horizontal-ow and vertical-ow ventilation provides
and maintains ultra-clean air in the operating room.
Evans54 found the bacterial counts in the air and
the wound were lower with laminar airow than
without this airow. The amount of airborne bac-
terial colony-forming units and dust large enough
to carry bacteria was reduced to 1 or 2 particles
more than 2 μm/m3 with use of a typical laminar-
airow system. In comparing 3922 TKA patients in
laminar-airow operating rooms with 4133 patients
in conventional rooms, Lidwell and colleagues46
found a signicantly lower incidence of SSIs in
patients in laminar-airow operating rooms (0.6%
vs 2.3%; P < .001).
Conversely, Miner and colleagues48 did not nd
a lower risk of SSI with laminar-airow systems
(RR, 1.57; 95% CI, 0.75-3.31). In addition, in their
analysis of >88,000 cases from the New Zealand
Joint Registry, Hooper and colleagues47 found
that the incidence of early infections was higher
with laminar-airow systems than with standard
airow systems for both TKA (0.193% vs 0.100%;
P = .019) and THA (0.148% vs 0.061%; P < .001).
They postulated that vertically oriented airow may
have transmitted contaminated particles into the
surgical sites. Additional evidence may be needed
to resolve these conicting ndings and determine
whether clean-air practices provide signicant
clinical benet in the operating room.
Staff Trafc Volume. When staff enters or exits
the operating room or makes extra movements
during a procedure, airow near the wound is dis-
turbed and no longer able to remove sufcient air-
borne pathogens from the sterile eld. The laminar-
airow pattern may be disrupted each time the
operating room doors open and close, potentially
allowing airborne pathogens to be introduced
near the patient. Lynch and colleagues55 found the
operating room door opened almost 50 times per
hour, and it took about 20 seconds to close each
time. As a result, the door may remain open for up
to 20 minutes per case, causing substantial airow
disruption and potentially ineffective removal of
airborne bacterial particles. Similarly, Young and
O’Regan56 found the operating room door opened
about 19 times per hour and took 20 seconds to
close each time. The theater door was open an
estimated 10.7% of each hour of sterile procedure.
Presence of more staff also increases airborne
bacterial counts. Pryor and Messmer57 evaluated a
cohort of 2864 patients to determine the effect of
number of personnel in the operating theater on
the incidence of SSIs. Infection rates were 6.27%
with >17 different people entering the room and
Decreasing the Incidence of Surgical-Site Infections After Total Joint Arthroplasty
E382 The American Journal of Orthopedics® November/December 2017 www.amjorthopedics.com
1.52% with <9 different people entering the room.
Restricting the number of people in the room may
be one of the easiest and most efcient ways to
prevent SSI.
Systemic Antibiotic Prophylaxis. Perioperative
antibiotic use is vital in minimizing the risk of
infection after TJA. The Surgical Care Improvement
Project recommended beginning the rst anti-
microbial dose either within 60 minutes before
surgical incision (for cephalosporin) or within 2
hours before incision (for vancomycin) and dis-
continuing the prophylactic antimicrobial agents
within 24 hours after surgery ends.58,59 However,
Gorenoi and colleagues60 were unable to recom-
mend a way to select particular antibiotics, as they
found no difference in the effectiveness of various
antibiotic agents used in TKA. A systematic review
by AlBuhairan and colleagues61 revealed that anti-
biotic prophylaxis (vs no prophylaxis) reduced the
absolute risk of a SSI by 8% and the relative risk
by 81% (P < 0.0001). These ndings are supported
by evidence of the efcacy of perioperative antibi-
otics in reducing the incidence of SSI.62,63 Antibiotic
regimens should be based on susceptibility and
availability, depending on hospital prevalence of
infections. Even more, patients should receive pro-
phylaxis in a timely manner. Finally, bacteriostatic
antibiotics (vancomycin) should not be used on
their own for preoperative prophylaxis.
Antibiotic Cement. Antibiotic-loaded bone ce-
ment (ALBC), which locally releases antimicrobials
in high concentration, is often used in revision joint
arthroplasty, but use in primary joint arthroplasty
remains controversial. In a study of THA patients,
Parvizi and colleagues64 found infection rates of
1.2% with 2.3% with and without use of ALBC,
respectively. Other studies have had opposing
results. Namba and colleagues65 evaluated 22,889
primary TKAs, 2030 (8.9%) of which used ALBC.
The incidence of deep infection was signicantly
higher with ALBC than with regular bone cement
(1.4% vs 0.7%; P = .002). In addition, a meta-
analysis of >6500 primary TKA patients, by Zhou
and colleagues,66 revealed no signicant difference
in the incidence of deep SSIs with use of ALBC vs
regular cement (1.32% vs 1.89%; RR, 0.75; 95%
CI, 0.43-1.33; P = .33). More evidence is needed
to determine the efcacy of ALBC in primary TJA.
International Consensus Meeting on Periprosthetic
Joint Infection participants recommended use of
ALBC in high-risk patients, including patients who
are obese or immunosuppressed or have diabetes
or a prior history of infection.67
Postoperative Measures
Antibiotic Prophylaxis. The American Academy of
Orthopaedic Surgeons (AAOS) and the American
Dental Association (ADA) have suggestions for
antibiotic prophylaxis for patients at increased risk
for infection. As of 2015, the ADA no longer rec-
ommends antibiotic prophylaxis for patients with
prosthetic joint implants,68 whereas the AAOS con-
siders all patients with TJA to be at risk.69 For TJA
patients, the AAOS recommends administering
antibiotic prophylaxis at least 1 hour before a den-
tal procedure and discontinuing it within 24 hours
after the procedure ends.69 Single preoperative
doses are acceptable for outpatient procedures.70
Table 3 summarizes the studies that reported on
postoperative measures for preventing SSI.
Although recommendations exist, the actual risk
of infection resulting from dental procedures and
the role of antibiotic prophylaxis are not well de-
ned. Berbari and colleagues71 found that antibiotic
prophylaxis in high- or low-risk dental procedures
did not decrease the risk of subsequent THA
infection (OR, 0.9; 95% CI, 0.5-1.6) or TKA infec-
tion (OR, 1.2; 95% CI, 0.7-2.2). Moreover, the risk
of infection was no higher for patients who had a
prosthetic hip or knee and underwent a high- or
Table 3. Summary of Studies Reporting on Postoperative Measures to Prevent Surgical-Site Infection
Study Patients, N Operation Interventions Results
Antibiotic
prophylaxis
and drain
management
Berbari et al71
(2010)
678 THA, TKA Antibiotic prophylaxis for
dental procedures
No decreased risk of subsequent THA
infection (OR, 0.9; 95% CI, 0.5-1.6)
No decreased risk of subsequent TKA
infection (OR, 1.2; 95% CI, 0.7-2.2)
Jaberi et al74
(2008)
10,325 TH A, TK A Treatments for draining
wound to prevent
subsequent SSI
Of 300 patients (2.9%) with persistent
drainage, 8 3 (28%) required surgical
débridement
Abbrev iations: CI , conde nce inter val; OR, od ds ratio; SS I, surgic al-si te infection; T HA, total hip ar thropla sty; TK A, total knee ar throplasty.
J. B. Mistry et al
www.amjorthopedics.com November/December 2017 The American Journal of Orthopedics ® E383
low-risk dental procedure without antibiotic pro-
phylaxis (OR, 0.8; 95% CI, 0.4-1.6) than for similar
patients who did not undergo a dental procedure
(OR, 0.6; 95% CI, 0.4-1.1). Some studies highlight
the low level of evidence supporting antibiotic
prophylaxis during dental procedures.72,73 However,
there is no evidence of adverse effects of antibiotic
prophylaxis. Given the potential high risk of infec-
tion after such procedures, a more robust body of
evidence is needed to reach consensus.
Evacuation Drain Management. Prolonged use
of surgical evacuation drains may be a risk factor
for SSI. Therefore, early drain removal is para-
mount. Higher infection rates with prolonged drain
use have been found in patients with persistent
wound drainage, including malnourished, obese,
and over-anticoagulated patients. Patients with
wounds persistently draining for >1 week should
undergo supercial wound irrigation and débride-
ment. Jaberi and colleagues74 assessed 10,325 TJA
patients and found that the majority of persistent
drainage ceased within 1 week with use of less
invasive measures, including oral antibiotics and
local wound care. Furthermore, only 28% of pa-
tients with persistent drainage underwent surgical
débridement. It is unclear if this practice alone is
appropriate. Infection should always be suspected
and treated aggressively, and cultures should be
obtained from synovial uid before antibiotics are
started, unless there is an obvious supercial infec-
tion that does not require further work-up.67
Economic Impact
SSIs remain a signicant healthcare issue, and the
social and nancial costs are staggering. Without
appropriate measures in place, these complica-
tions will place a larger burden on the healthcare
system primarily as a result of longer hospital
stays, multiple procedures, and increased resource
utilization.75 Given the risk of progression to pros-
thetic joint infection, early preventive interventions
must be explored.
Several studies have addressed the economic
implications of SSIs after TJA as well as the impact
of preventive interventions (Table 4). Using the
NIS database, Kurtz and colleagues4 found that
not only were hospital stays signicantly longer
for infected (vs noninfected) knee arthroplasties
(7.6 vs 3.9 days; P < .0001), but hospital charges
were 1.52 times higher (P < .0001), and results
were similar for infected (vs noninfected) hips (9.7
vs 4.3 days; 1.76 times higher charges; P < .0001
for both). Kapadia and colleagues76 matched 21
TKA patients with periprosthetic infections with 21
noninfected TKA patients at a single institution and
found the infected patients had more readmissions
(3.6 vs 0.1; P < .0001), longer hospitalizations (5.3
vs 3.0 days; P = .0002), more days in the hospital
within 1 year of arthroplasty (23.7 vs 3.4 days;
P < .0001), and more clinic visits (6.5 vs 1.3; P <
.0001). Furthermore, the infected patients had a
signicantly higher mean annual cost of treatment
($116,383 vs $28,249; P < .0001). Performing a
Markov analysis, Slover and colleagues77 found
that the decreased incidence of infection and the
potential cost savings associated with preoperative
S aureus screening and a decolonization protocol
were able to offset the costs acquired by the
screening and decolonization protocol. Similarly,
Cummins and colleagues78 evaluated the effects
of ALBC on overall healthcare costs; if revision
surgery was the primary outcome of all infections,
use of ALBC (vs cement without antibiotics)
resulted in a cost-effectiveness ratio of $37,355 per
quality-adjusted life year. Kapadia and colleagues79
evaluated the economic impact of adding 2%
chlorhexidine gluconate-impregnated cloths to an
existing preoperative skin preparation protocol for
TKA. One percent of non-chlorhexidine patients
and 0.6% of chlorhexidine patients developed an
infection. The reduction in incidence of infection
amounted to projected net savings of almost $2.1
million per 1000 TKA patients. Nationally, annual
healthcare savings were expected to range from
$0.78 billion to $3.18 billion with implementation
of this protocol.
Improved patient selection may be an important
factor in reducing SSIs. In an analysis of 8494 joint
arthroplasties, Malinzak and colleagues80 noted
that patients with a BMI of >50 kg/m2 had an in-
creased OR of infection of 21.3 compared to those
with BMI <50 kg/m2. Wagner and colleagues81 an-
alyzed 21,361 THAs and found that, for every BMI
unit over 25 kg/m2, there was an 8% increased risk
of joint infection (P < .001). Although it is unknown
if there is an association between reduction in
preoperative BMI and reduction in postoperative
complication risk, it may still be worthwhile and
cost-effective to modify this and similar risk factors
before elective procedures.
Market forces are becoming a larger consider-
ation in healthcare and are being driven by provider
competition.82 Treatment outcomes, quality of care,
and healthcare prices have gained attention as a
means of estimating potential costs.83 In 2011,
the Centers for Medicare & Medicaid Services
Decreasing the Incidence of Surgical-Site Infections After Total Joint Arthroplasty
E384 The American Journal of Orthopedics® November/December 2017 www.amjorthopedics.com
(CMS) advanced the Bundled Payments for Care
Improvement (BPCI) initiative, which aimed to
provide better coordinated care of higher quality
and lower cost.84 This led to development of the
Comprehensive Care for Joint Replacement (CJR)
program, which gives beneciaries exibility in
choosing services and ensures that providers
adhere to required standards. During its 5-year
test period beginning in 2016, the CJR program is
projected to save CMS $153 million.84 Under this
program, the institution where TJA is performed is
responsible for all the costs of related care from
time of surgery through 90 days after hospital dis-
charge—which is known as an “episode of care.”
If the cost incurred during an episode exceeds an
established target cost (as determined by CMS),
the hospital must repay Medicare the difference.
Conversely, if the cost of an episode is less than
the established target cost, the hospital is reward-
ed with the difference. Bundling payments for a
single episode of care in this manner is thought to
incentivize providers and hospitals to give patients
more comprehensive and coordinated care. Given
the substantial economic burden associated with
joint arthroplasty infections, it is imperative for
orthopedists to establish practical and
Table 4. Summary of Studies Reporting on Economic Impact of Surgical-Site Infection and/or Effect of Preventive
Measures
Study Patients, N Operation Endpoints Results
Kurtz et al4
(2008)
9190 THA, TKA Incidence and
costs of SSI
Greater LOS (7.6 vs 3.9 days; P < .0001) and higher hospital charges
(P < .00 01) for infected TKAs than for noninfected TKAs
Greater LOS (9.7 vs 4. 3 days; P < .0001) and higher hospital charges
(P < .00 01) for infected THAs than for noninfected THAs
Kapadia et al76
(2014)
42 TKA Readmissions,
infections, days in
hospital, number
of clinic visits,
and annual costs
for infected vs
noninfected TK As
Infected patients had more readmissions (3.6 vs 0.1; P < .0001), longer
hospitalization (5.3 vs 3.0 days; P = .00 02), more days in hospital within
1 year of arthroplasty (23.7 vs 3.4; P < .0001), and more clinic visits (6.5
vs 1. 3; P < .0001)
Higher annual costs for infected patients ($116,383 vs $28,249;
P < .0001)
Slover et al77
(20 11)
365 THA, TKA Potential costs
of decolonization
protocol
Decreased incidence of infection and potential cost savings of
preoperative Staphylococcus aureus screening and decolonization
protocol are sufficient to offset costs acquired by protocol
Cummins et al78
(2009)
N/A THA Cost-effectiveness
of use of ALBC
if revision THA
is considered
primary outcome
of all infections
Cost-effectiveness ratio of $37,355 per quality -adjusted life year with
use of ALBC vs cement without antibiotics
Kapadia et al79
(20 13)
2213 TK A Cost vs benefit
of including
chlorhexidine
protocol in
preoperative
skin preparation
protocol
Incidence of SSI reduced from 1% to 0.6%, with projected net savings
of $2.1 million per 1000 TKA patients
Malinzak et al80
(2009)
8494 THA , TKA Selection of
patients with
comorbidities
Increased odds ratio of infection (18.3; P < .0001) for patients with BMI
of >50 kg/m2 than for patients with BMI of <50 kg/m2
Patients with diabetes 3 times more likely to develop infection than
patients without diabetes (P = .0027)
Wagner et al81
(2016)
21,361 THA Association
of BMI and
postoperative
complications
8% increased risk of T HA infection for every unit of BMI >25 kg/m2
(P < .00 1)
Abbrev iations: A LBC, ant ibiotic -lade n bone ceme nt; BMI, bo dy mass ind ex; LOS, le ngth of stay ; N/A, n ot applic able; SSI , surgical -site infection; T HA, tot al hip art hroplast y; TKA,
total knee arthroplasty.
J. B. Mistry et al
www.amjorthopedics.com November/December 2017 The American Journal of Orthopedics ® E385
cost-effective strategies that can prevent these
disastrous complications.
Conclusion
SSIs are a devastating burden to patients, sur-
geons, and other healthcare providers. In recent
years, new discoveries and innovations have
helped mitigate the incidence of these complica-
tions of THA and TKA. However, the incidence of
SSIs may rise with the increasing use of TJAs and
with the development of new drug-resistant patho-
gens. In addition, the increasing number of TJAs
performed on overweight and high-risk patients
means the costs of postoperative infections will be
substantial. With new reimbursement models in
place, hospitals and providers are being held more
accountable for the care they deliver during and
after TJA. Consequently, more emphasis should be
placed on techniques that are proved to minimize
the incidence of SSIs.
Dr. Mistry is a Resident Physician, Department of
Orthopaedic Surgery, SUNY Downstate Medical Center,
Brooklyn, New York. Dr. Naqvi is a Resident Physician,
Department of Orthopaedic Surgery and Rehabilitation,
Howard University Hospital, Washington, DC. Dr. Chugh-
tai is a Resident Physician, Department of Orthopaedic
Surgery, Cleveland Clinic, Cleveland, Ohio. Dr. Gwam and
Dr. Thomas are Orthopaedic Research Fellows, Center for
Joint Preservation and Replacement, Rubin Institute for
Advanced Orthopedics, Sinai Hospital of Baltimore, Bal-
timore, Maryland. Dr. Higuera is an Attending Physician,
and Dr. Mont is Chairman, Department of Orthopaedic
Surgery, Cleveland Clinic, Cleveland, Ohio. Dr. Delanois
is Director of Hip, Knee, and Shoulder Surgery, Center
for Joint Preservation and Replacement, Rubin Institute
for Advanced Orthopedics, Sinai Hospital of Baltimore,
Baltimore, Maryland.
Address correspondence to: Ronald E. Delanois, MD,
Center for Joint Preservation and Replacement, Rubin
Institute for Advanced Orthopedics, Sinai Hospital of
Baltimore, 2401 W Belvedere Ave, Baltimore, MD 21215
(tel, 410-601-8500; fax, 410-601-8501; email, delanois@
me.com, rdelanoi@lifebridgehealth.org).
Am J Orthop. 2017;46(6):E374-E387. Copyright Frontline
Medical Communications Inc. 2017. All rights reserved.
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This paper will be judged for the Resident Writer’s Award.
