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Infection Rate in Total Shoulder Replacement: Best Practices – Chlorhexidine, Iodophor Incise Drapes and Antibiotic Cement.

Kevin Roth, M.D.

Deep infection of primary total shoulder arthroplasty (TSA) is a rare but potentially devastating complication. The reported prevalence in the literature ranges from 0% to 15.4%. Although patient factors generally remain non-modifiable, certain intraoperative precautions may help minimize the risk of infection. Three effective modifications reported in the literature include 1) chlorhexadine scrub, 2) occlusive incise drape and 3) the use of antibiotic cement. Currently, antibiotic cement is approved for use following hip and knee infection, however, the use in primary TSA has not been established. This is the first study of its kind to report infection rates following the use of these measures.

A retrospective review of all TSA performed between 1999 -2009 was carried out. A total of 311 primary TSAs were included in this study. In 2006, the senior author changed his anti-sepsis protocol in primary TSAs to include chlorhexidine scrub, occlusive iodophor incise drapes, and antibiotic impregnated cement. This provided a comparative analysis of infection rates prior to and following implementation of the above. Previous non-arthroplasty surgery was not an exclusion criterion. Demographic data, operative information and post-operative follow up were included. The presence or absence of a post-operative infection was recorded. Group A included 153 primary TSA which were performed with Betadine scrub, iodophor strips at the drape edges, and plain cement. Group B included 158 primary TSA which were performed using chlorhexidine scrub, complete occlusive iodophor drape, and antibiotic impregnated cement.

Demographic data was similar between groups. There were a total of nine shoulders (5.9%) in Group A that developed a deep infection. In Group B, there was only one shoulder (0.6%) deep infection. There was a difference in operative time between Group A and Group B, but no difference in operative time between those patients in Group A that developed an infection and those that did not develop an infection.

There was an 11-fold decrease in the rate of infection following the implementation of chlorohexidine scrub, antibiotic cement and occlusive draping. There was no statistically significant difference between Groups A and B in terms of age or sex, and no difference in operative time between those who developed and infection and those who did not within Group A. These findings corroborate outcomes seen in other areas of the literature, and support the hypothesis that in combination, these measures are efficacious in the prevention of deep peri-prosthetic infection in primary total shoulder arthroplasty.