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PEARLS & PITFALLS – SURGICAL TECHNIQUE

Prophylactic Antibiotics In the evaluation of surgical site infection outbreak, Babcock

for Arthroscopic Surgery – et al found the main causes of infection to be intra articular
steroid injection and preoperative skin shaving with a razor.

To Give or Not To Give?
They also found that a single scrub nurse was associated
with 75% of the “coagulase negative” positive cultures cases.

In addition, patient-related variables cannot be fully controlled

Noam Reshef, MD,
by the surgeon, even though these must be properly
addressed. Kirchhof et al recommended a list of risk factors that
Orthopedic Sports Surgeon, increases a patient’s risk for infection. Underlying malignancy,
Orthopedic Sports Service,
rheumatoid arthritis, nicotine abuse, immunodeficiency, renal
Department of Orthopedic Surgery, dialysis, liver cirrhosis, obesity, increased age, uncontrolled
Ziv Medical Center, Tzfat, ISRAEL
diabetes and immunosuppression related to medication are
all considered risk factors. The type of arthroscopy is also

considered an important variable. Although not evidence-
based, arthroscopy for cruciate ligament reconstruction or

Arthroscopic procedures are extremely common in the world rotator cuff repair are considered longer cases and are known
of orthopedic surgery while the actual rate of associated to have an increased risk of infection due to implant usage.
infections is considered fairly low. Studies show that infection
The issue of the increased costs due to the usage of
rates for ambulatory arthroscopic procedures range from
0.13% to 5.7%, depending on which is the operated joint. prophylaxis is also a point to consider. However, one must
bear in mind that the costs of prolonged hospitalization,
However, no consensus currently exists on whether the expensive antibiotics and recurrent surgery due to septic
use of prophylactic antibiotic in arthroscopic procedures is
arthritis are much higher than the cost of a single dose of
efficacious.
simple antibiotics. The most common cause of joint infection

The AAOS considers infection prevention a major point of is Staphylococcus species, both gram positive and gram
interest, and published guidelines for prophylactic antibiotics negative. As with total joint replacement, a single dose of
in total joint replacement exist. This is currently not the
Cefazolin or Clindamycin (if cephalosporin allergy is known)
case for arthroscopic surgeries. Recent studies showed is considered sufficient, while another dose should be given if
substantial bacterial adherence to different types of synthetic
surgery time extends beyond 3–4 hours.
sutures commonly used for rotator cuff repair. Despite the
lack of evidence-based literature or society guidelines, and The use of antibiotics does not come without possible
considering the fairly small rates of infection reported with complications and raises the risks of allergic reaction and

arthroscopic procedures, the question regarding whether to diarrhea, with or without the relationship to Clostridium
use prophylactic antibiotics prior to arthroscopic cases seems Difficile. Though infection rates currently appear to be low, a
joint infection following arthroscopic surgery is a devastating
more relevant than ever.
outcome, both for the patient and the surgeon. After dealing
As aforementioned, the body of literature discussing this topic with the infection, the subjective outcome scores tend to be
is currently not substantial. Mehta et al found an infection
lower than for patients with an uneventful post op course.
rate of 3.4% in arthroscopic shoulder procedures. Ferkel et
al reported 8 superficial infections and 2 deep infections in In summary, whether to give prophylactic antibiotics is not yet
their first 612 ankle arthroscopy cases. According to these an evidence-based decision. The surgeon should consider his

authors, both deep infections appeared to correlate with patient’s risk factors, his familiarity with the surgical facility he is
the lack of prophylactic antibiotics. Oak et al reported rates operating in and its ability to maintain the envelope of sterility,

of 0.01% – 0.2% infection in hip arthroscopy, attributing this and to always evaluate his own personal sterile technique.
low rate to meticulous preparation and draping and the use Prolonged and complicated cases, cases with implant usage

of preoperative antibiotics. At the same time, Bert et al, in a and patients with co morbidities are all good reasons for
retrospective comparative study showed that the infection preoperative antibiotic prophylaxis. For the remainder of
rate for simple knee arthroscopy ranged from 0.15% with patients, a single dose of Cefazolin or Clindamycin will not

prophylactic antibiotic treatment compared to 0.16% without substantially increase the overall expenses. Additionally, it will
the use of antibiotics.
give the surgeon an extra precautionary measure to avoid

Another factor to consider is the “envelope of sterility”, defined accidental sterility problems and thus decrease the risk of
infection, as well as peace of mind.
as. The “envelope of sterility” in the operating theater should
remain unbroken, especially if no antibiotic prophylaxis is
administered. The surgeon can control several variables in

the OR. These include proper scrubbing technique, personal
sterile technique and case length. Unfortunately, the surgeon

cannot control poor surgical instrument sterility or infected
ventilator or ventilation tubes. Therefore, the surgeon should

always consider an accidental breakage in the envelope
of sterility.

ISAKOS NEWSLETTER 2013: Volume II 37