The implementation of dilute betadine lavage before wound closure in total joint replacement operations reduced post-op infection rates from 0.97% to 0.15%, according to a 2011 study of more than 2,000 surgeries.
Nicholas Michael Brown, MD, discussed his team’s results at the 2011 Annual Meeting of the American Academy of Orthopedic Surgeons. Brown said although joint infection is rare following total joint replacement, when it does occur it can have harrowing physical, mental, and psychological effects.
Before implementing dilute betadine lavage, surgeons used a variety of techniques to address the incision before closure, including aseptic techniques, prophylactic antibiotics, and laminary air flow. All of these processes helped reduce post-op infection rates, but doctors continued to look for ways to improve.
New Solution
In 2008, Craig J. Della Valle, MD, senior surgeon on Brown’s medical team, began addressing total joint replacement incisions with the dilute betadine lavage for 3 minutes prior to closing the wound. Brown said the solution was made by adding 17.5 ml of 10% povidone-iodine to 500 cc of basic saline, which resulted in a 0.35% dilution.
“[The betadine] was followed by cleansing with 1L of normal saline pulse lavage … and then finally painting the skin with the 10% povidone-iodine solution from the swab sticks prior to the final closure,” Brown said. “This was in addition to the standard protocol, which all patients in the series received that included prophylactic antibiotics prior to the incision and for 24 hours postoperatively.”
Before switching to dilute betadine lavage, researchers examined 1,862 consecutive cases involving total knee or hip replacements. They then compared their results to 688 consecutive cases where dilute betadine lavage was used to address a wound before closure.
Research Results
Brown and his team examined the post-op infection rates of each procedure and saw a significant reduction in infection rates for those patients who were treated with dilute betadine lavage.
“What we saw was a 0.97% infection rate prior to the use of betadine and a 0.15% infection rate after the onset of betadine usage,” he said. “This was statistically significant.”
There were 18 acute post-op infections out of the 1,862 cases treated without the solution, but only one such case in the 688 cases were dilute betadine lavage was administered.
“In conclusion, we saw that betadine is safe,” Brown concluded. “It has minimal toxicity to human tissue when it is dilute, it is inexpensive — about a dollar per packet — it is easy to use and, at least in our study, we found it to be effective as we saw a statistically significant decrease in acute postoperative infections. Given the retrospective nature of the study, however, we do interpret these results with caution and have initiated a prospective study to try to confirm these results.”
Dr. Silverman Comments
It has been the standard to thoroughly cleanse wounds before closure post-op. I was always told during my schooling that “the solution to pollution is dilution.” It appears that improved solutions can further our quest to prevent infections.
For the last several years I have been working with saline solutions mixed with antibiotics. Early last decade, articles started being published that supported irrigation with soap mixed with saline as the best option. However, with further study, the soap mix didn’t fare as well as hoped.
Now, betadine (a strong bacteria killing agent) seems to be favored. Spine surgeons are switching to it, and two recent articles from surgeons who specialize in total joint replacement have identified a phenomenal drop in infections following surgery in which a dilute betadine solution was used.
Although the information is helpful, it can hardly be considered “new.” Betadine as means of diminishing peri-operative infections was used decades ago. The earliest studies demonstrating the potential benefits of dilute betadine irrigation in surgery date to 1977. It was first noted in General Surgery and Urology, and many other specialties have noted this effect over the last 35 years.
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