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AAOS Now

Published 5/1/2012
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Andrew R. Hsu, MD

Looking at the Past to Improve the Present

Dilute povidone-iodine lavage to prevent infection in orthopaedic procedures

Perioperative infections after orthopaedic procedures can be devastating complications for patients, families, and physicians. The morbidity from surgical site infections includes pain, loss of function, increased hospitalization, prolonged rehabilitation, and higher rates of reoperation.

Research has shown that certain orthopaedic procedures—such as revision total knee arthroplasty, ankle fusion, and subtalar fusion—carry a significantly greater risk of infection than other operations. Foot and ankle surgeries in particular have been shown to have higher infection rates compared with procedures on other body parts.

The resource allocation and financial costs of treating perioperative infections in orthopaedic surgery can often rise to 3 to 13 times more than the cost of the index procedure. Therefore, effective, low-cost, safe, and easy-to-adapt methods of preventing perioperative infection after orthopaedic procedures are needed.

Several advances—including aseptic technique, preoperative antibiotics, pulsatile lavage, laminar flow, isolation suites, antibiotic-impregnated cement, and ultraviolet light—have been employed to reduce orthopaedic surgical infections. However, these methods have varying results and, depending on institution resources, may not always be available.

Use of chlorhexidine-alcohol (2 percent chlorhexidine gluconate, 70 percent isopropyl alcohol) skin preparation has been shown to significantly decrease superficial and deep-incision infections after surgery compared with povidone-iodine. However, no differences in the rates of organ-space infections have been found.

Povidone-iodine (Betadine®, Purdue Pharma LP, Stamford, Conn.) is a widely used antiseptic for skin, mucous membranes, and wound care that has bactericidal activity against multiple pathogens including methicillin-resistant Staphylococcus aureus (MRSA). Laboratory studies have shown that a dilute Betadine solution of 0.5 percent to 4 percent is the most effective agent against MRSA and with minimal cytotoxic effects on healthy tissues.

A prospective study conducted in 2005 examined the effect of a dilute 3.5 percent Betadine 3-minute lavage on the incidence of postoperative spine infections. When compared with saline lavage alone, the Betadine lavage significantly decreased the infection rate without adverse effects on clinical outcomes. Recently, a research group led by Craig Della Valle, MD, demonstrated that a 3-minute, 0.35 percent Betadine lavage significantly lowered the rate of acute postoperative infection after total hip and knee arthroplasty—from 0.97 percent to 0.15 percent in a group of 2,550 patients.

Although these two studies in the orthopaedic spine and joint arthroplasty literature show promising results with the use of dilute Betadine wound irrigation in orthopaedic surgery, an analysis of the general surgical literature reveals that povidone-iodine concentrations of 0.35 percent to 10 percent have previously been shown to significantly decrease rates of postoperative infections in general, cardiovascular, and urologic surgery as well. The earliest studies demonstrating the potential benefits of dilute povidone-iodine irrigation in general and urologic surgery date to 1977, with subsequent studies in additional specialties showing similar findings over the next three decades.

With the increased attention on developing new methods and technologies to reduce perioperative infections, simple, cost-effective solutions may be found by exploring research in other specialties that may be applied to orthopaedic surgery. The example of dilute Betadine lavage and its potential benefits in preventing orthopaedic infections underscores the importance of multidisciplinary collaboration in modern medicine to foster creative and innovative solutions to challenging problems.

Overall, lavage with a dilute Betadine solution prior to wound closure may be an effective, simple, rapid, and low-cost method of preventing perioperative infection that should be investigated across a broad array of orthopaedic procedures. Prospective, randomized trials in multiple orthopaedic specialties are therefore warranted to improve future patient care and clinical outcomes.

Disclosures: Dr. Hsu—no conflicts.

Andrew R. Hsu, MD, is a PGY-3 orthopaedic resident at Rush University Medical Center, Chicago. He can be reached at andyhsu1@gmail.com

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