The documentation of deep infection rates in joint replacement is fraught with multiple difficulties. Deep infections acquired in theatre may present late, but some later presenting deep infections are clearly haematogenous, and not related to surgical management. The effect of Ultra Clean Air on infection rates was published by Charnley in 1972 (CORR,87:167–187). The data is valuable because large numbers of THRs were performed in standard and Ultra Clean theatres, and detailed microbiology of the air was also recorded. No IV antibiotics were used, so only the effect of air quality was studied. We extracted the data on theatre type and numbers from Table 3, and numbers and intervals from surgery of deep infections from Table 7. Theatre types with 300 air changes per hour and 3.5 CFU/M. 3. were classified as Ultra Clean. A logistic regression model was used to examine the effect of theatre type and time elapsed after procedure on the probability of becoming infected. The model suggests that, controlling for time period, Ultra Clean Air is associated with a significantly lower probability of infection, with an OR of 0.30, p = 2.74 × 10. −6. The effect is larger earlier post-surgery, but it does persist. The results are best reviewed as a graphic, which shows that Ultra Clean Air clearly affects the deep infection rate for up to four years post-surgery. Ultra Clean Air reduces infection rates for up to four years post-surgery, so it is safe to assume that infections presenting after this are haematogenous. Ultra Clean Air does not eliminate early deep infection, so some early infections are not related to air quality. It is not practical to undertake widespread detailed retrospective analyses of cases. When monitoring infection rates there needs to be a balance between failing to record infections related to surgical technique and waiting many years to record low numbers of very late presenting problems. We suggest that registries should regard infections documented within three years of surgery as treatment complications. For any figures or tables, please contact the authors directly

Introduction. Superficial pin site infection is a common problem associated with external fixation, which has been extensively reported. However, the incidence and risk factors with regards to deep infection is rarely reported in the literature. In this study, we investigate and explore the incidence and risk factors of deep infection following circular frame surgery. For the purpose of this study, deep infection was defined as: persistent discharge or collection for which surgical intervention was recommended. Materials and Methods. Retrospective review of all patients whom underwent frame surgery between 1. st. of April 2015 to 1. st. April 2019 in our unit with a minimum of 1 year follow up following frame removal. We recorded patient demographics, patient risk factors, trauma or elective procedure, number of days the frame was in situ, location of infection and fracture pattern. Results. 304 patients were identified. 27 patients were excluded as they were lost to follow up or had their primary frame surgery as a treatment for infection. This provided us with 277 patients for analysis. Mean age was 47 years (range 9–89 years), the male to female ratio was 1.5:1 and 80% were trauma frames. 13 patients (4.69%) developed deep infection and all occurred in trauma patients. Of the 13 patients who developed deep infection, 4 had infection before frame removal and 9 occurred after frame removal. 8 deep infections occurred within a year of frame removal, 1 occurred between 1 and 2 years. Within the 13 frame procedures for trauma, 12 were periarticular multifragmentary fractures, 3 of which were open, and the remaining was an open diaphyseal fracture. The periarticular fractures were more likely to develop deep infection than diaphyseal fractures (p–0.033). 12 patients (out of 13) also had concurrent minimally invasive internal fixation with screws in very close proximity of the wires. Conclusions. The rate of deep infection following circular frame surgery appears to be low. Pooled, multicentre data would be required to analyse risk factors however multifragmentary, periarticular fracture and the requirement for additional internal fixation appears to be an associated factor

Aims. Deep surgical site infection (SSI) remains an unsolved problem after hip fracture. Debridement, antibiotic, and implant retention (DAIR) has become a mainstream treatment in elective periprosthetic joint infection; however, evidence for DAIR after infected hip hemiarthroplaty is limited. Methods. Patients who underwent a hemiarthroplasty between March 2007 and August 2018 were reviewed. Multivariable binary logistic regression was performed to identify and adjust for risk factors for SSI, and to identify factors predicting a successful DAIR at one year. Results. A total of 3,966 patients were identified. The overall rate of SSI was 1.7% (51 patients (1.3%) with deep SSI, and 18 (0.45%) with superficial SSI). In all, 50 patients underwent revision surgery for infection (43 with DAIR, and seven with excision arthroplasty). After adjustment for other variables, only concurrent urinary tract infection (odds ratio (OR) 2.78, 95% confidence interval (CI) 1.57 to 4.92; p < 0.001) and increasing delay to theatre for treatment of the fracture (OR 1.31 per day, 95% CI 1.12 to 1.52; p < 0.001) were predictors of developing a SSI, while a cemented arthroplasty was protective (OR 0.54, 95% CI 0.31 to 0.96; p = 0.031). In all, nine patients (20.9%) were alive at one year with a functioning hemiarthroplasty following DAIR, 20 (46.5%) required multiple surgical debridements after an initial DAIR, and 18 were converted to an excision arthroplasty due to persistent infection, with six were alive at one year. The culture of any gram-negative organism reduced success rates to 12.5% (no cases were successful with methicillin-resistant Staphylococcus aureus or Pseudomonas infection). Favourable organisms included Citrobacter and Proteus (100% cure rate). The all-cause mortality at one year after deep SSI was 55.87% versus 24.9% without deep infection. Conclusion. Deep infection remains a devastating complication regardless of the treatment strategy employed. Success rates of DAIR are poor compared to total hip arthroplasty, and should be reserved for favourable organisms in patients able to tolerate multiple surgical procedures. Cite this article: Bone Jt Open 2021;2(11):958–965

Deep infection was identified as a serious complication in the earliest days of total hip arthroplasty. It was identified that airborne contamination in conventional operating theatres was the major contributing factor. As progress was made in improving the engineering of operating theatres, airborne contamination was reduced. Detailed studies were carried out relating airborne contamination to deep infection rates. In a trial conducted by the United Kingdom Medical Research Council (MRC), it was found that the use of ultra-clean air (UCA) operating theatres was associated with a significant reduction in deep infection rates. Deep infection rates were further reduced by the use of a body exhaust system. The MRC trial also included a detailed microbiology study, which confirmed the relationship between airborne contamination and deep infection rates. Recent observational evidence from joint registries has shown that in contemporary practice, infection rates remain a problem, and may be getting worse. Registry observations have also called into question the value of “laminar flow” operating theatres. Observational evidence from joint registries provides very limited evidence on the efficacy of UCA operating theatres. Although there have been some changes in surgical practice in recent years, the conclusions of the MRC trial remain valid, and the use of UCA is essential in preventing deep infection. There is evidence that if UCA operating theatres are not used correctly, they may have poor microbiological performance. Current UCA operating theatres have limitations, and further research is required to update them and improve their microbiological performance in contemporary practice. Cite this article: Bone Joint J 2018;100-B:1264–9

Aim. In recent years, many studies on revision for infection after arthroplasty have been published. In national arthroplasty registers, revision for infection is defined as surgical debridement, with or without removal or exchange of the entire or parts of the prosthesis due to deep infection, and should be reported to the register immediately after surgery. The diagnosis of infection is made at the surgeon's discretion, based on pre- and perioperative assessment and evaluation, and is not to be corrected to the register based on peroperative bacterial cultures. Due to this lack of validation, the rate of revision for infection will only be an approximation of the true rate of periprosthetic joint infection (PJI). Our aim was to validate the reporting of infection after total hip arthroplasty, and to assess if revisions for infection actually represented true PJI. Methods. We investigated the reported revisions for infection and aseptic loosening after total hip arthroplasty from 12 hospitals, representing one region of the country, reported during the period 2010–2020. The electronic patient charts were investigated for information on surgical treatment, use of antibiotics, biochemistry and microbiology findings. PJI was defined as growth of at least two phenotypically identical microbes in perioperative tissue samples. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy were calculated. Results. 145 revisions for infection and 137 revisions for aseptic loosening were reported. Of the reported infections, there were 141/145 true positives and 4/145 false positives. Of the reported aseptic loosenings, there were 126/137 true negatives and 11/137 false negatives. This gives a positive predictive value of 0.97, negative predictive value of 0.92, sensitivity of 0.93, specificity of 0.97 and accuracy of 0.95. Interpretation. We found the reporting revision for infection after total hip arthroplasty to the national register accurate. There was high correlation between reported revision for infection and PJI. Studies on revision for infection from arthroplasty registers may therefore be considered as reliable as studies of true PJI

Deep infection is one of the most serious complications after total hip replacement (THR). The aim of this study is to evaluate the efficacy of one stage revision THR for deep infection with a long-term follow-up. One stage revision THR for deep infection was carried out in 285 joints on 274 patients by a single surgeon (BMW) between 1974 and 2001. All infected hip replacements are primarily treated with one stage revision THR at the authors’ unit unless bone stock is extremely poor. This study included a review of 162 revisions in 154 for which a minimum follow-up of five years had been done. The mean duration of follow-up was 12.3 years. Trochanteric osteotomy was done for extensive resection of infected tissue and removal of cement. Both cups and stems were revised with bone cement. Antibiotic-loaded cement was used in 152 cases (93.8%). Further antibiotics were commenced systemically for 6–12 weeks postoperatively. Failure of infection control was defined as a) reoperation for recurrent infection or b) clinically persistent infection. Infection control. One hundred and thirty eight hips (85.2%) were free of infection at the time of the latest follow-up. 1) No sinus group (N=110): Success rate was 82.7 %. 2) Sinus group (N=52): Success rate was 90.4 %. This study presents the longest follow-up with a large number of cases in revision THR for deep infection. At least, history of discharging sinus was not considered as a contraindication. The results suggested that one stage revision was an effective treatment for deep infection of hip replacement in the long term

Purpose: Currently, there is little information available concerning the outcome of patients with infection following rotator cuff repair. Therefore, the purpose of this study was to review the incidence, management and outcomes of patients with rotator cuff repair complicated with deep infection. Methods: Between 1975 and 2003, 39 cases of deep infection following rotator cuff repair were identified. The medical records and radiographs were retrospectively examined. At a mean follow-up of 8.2 years, seven patients had died and two patients had been lost to follow-up leaving 30 cases for outcome evaluation. Results: The incidence of deep infection after rotator cuff repairs that were performed at our institution was 0.43% (21 of 4886 cases). The mean interval from rotator cuff repair to the time of infection diagnosis was 49 days. ESR and C-reactive protein were elevated in only 60% and 50% of patients, respectively. Propionibacterium was the most common organism isolated, infecting 51% of cases. A mean of 3.3 surgical debridements were necessary for the eradication of infection. At final follow-up, mean active abduction was 121° and mean external rotation was 44°. The ASES score averaged 67 points and the Simple Shoulder Test score averaged 7.3 points. Conclusions: The data from this study suggests that the eradication of deep infection following rotator cuff repair is possible, however, substantial functional limitations are not unusual. Additionally, the treating surgeon should be aware of the high incidence of Propionibacterium and the importance of allowing a minimum of seven days of culture to identify this organism

This study explores the relationship between delay to surgical debridement and deep infection in a series of 364 consecutive patients with 459 open fractures treated at an academic level one trauma hospital in North America. . The mean delay to debridement for all fractures was 10.6 hours (0.6 to 111.5). There were 46 deep infections (10%). There were no infections among the 55 Gustilo-Anderson grade I open fractures. Among the grade II and III injuries, a statistically significant increase in the rate of deep infection was found for each hour of delay (OR = 1.033: 95% CI 1.01 to 1.057). This relationship shows a linear increase of 3% per hour of delay. No distinct time cut-off points were identified. Deep infection was also associated with tibial fractures (OR = 2.44: 95% CI 1.26 to 4.73), a higher Gustilo-Anderson grade (OR = 1.99: 95% CI 1.004 to 3.954), and contamination of the fracture (OR = 3.12: 95% CI 1.36 to 7.36). These individual effects are additive, which suggests that delayed debridement will have a clinically significant detrimental effect on more severe open fractures. Delayed treatment appeared safe for grade 1 open fractures. However, when the negative prognostic factors of tibial site, high grade of fracture and/or contamination are present we recommend more urgent operative debridement. . Cite this article: Bone Joint J 2014;96-B:379–84

Sixty-eight patients suffering deep infection from a consecutive series of 1746 total hip replacement operations are reviewed. The infection rate has been reduced considerably by improved technique and multiple antibiotic prophylaxis without the use of a special operation enclosure. Factors affecting deep infection are analysed and discussed

Surgical site infections (SSIs) after spinal fusion surgery increase healthcare costs, morbidity and mortality. Routine measures of obesity fail to consider site specific fat distribution. We aimed to assess the association between the spine adipose index and deep surgical site infection and determine a threshold value for spine adipose index that can assist in preoperative risk stratification in patients undergoing posterior instrumented lumbar fusion (PILF). A multicentre retrospective case-control study was completed. We reviewed patients who underwent PILF from January 1, 2010 to December 31, 2018. All patients developing a deep primary incisional or organ-space SSI within 90 days of surgery as per US Centre for Disease Control and Prevention criteria were identified. We gathered potential pre-operative and intra-operative deep infection risk factors for each patient. Spine adipose index was measured on pre-operative mid-sagittal cuts of T2 weighted MRI scans. Each measurement was repeated twice by three authors in a blinded fashion, with each series of measurement separated by a period of at least six weeks. Forty-two patients were included in final analysis, with twenty-one cases and twenty-one matched controls. The spine adipose index was significantly greater in patients developing deep SSI (p =0.029), and this relationship was maintained after adjusting for confounders (p=0.046). Risk of developing deep SSI following PILF surgery was increased 2.0-fold when the spine adipose index was ≥0.51. The spine adipose index had excellent (ICC >0.9; p <0.001) inter- and intra-observer reliabilities. The spine adipose index is a novel radiographic measure and an independent risk factor for developing deep SSI, with 0.51 being the ideal threshold value for pre-operative risk stratification in patients undergoing PILF surgery

Introduction and Aims: The aim of this study was to evaluate the efficacy of one stage revision THA for deep infection with a long-term follow-up. Method: One stage revision THA for deep infection was carried out in 273 joints on 262 patients by the senior author between 1974 and 2000. All infected hip replacements were primarily treated with one stage revision THA, regardless of microorganisms at the authors’ unit unless bone stock in the hips was too poor for implant fixation. This study included 162 revisions in 154 patients for which a minimum follow-up of five years (range 5.1 to 27.6 years; average 12.3 years) had been done. Fifty-two cases (32.1 %) had had discharging sinus by the time of revision surgery for infection. Results: One hundred and thirty eight (85.2 %) hips were free of infection at the time of the latest follow-up. Twenty cases (12.3 %) had reoperation for recurrent infection. Four hips (2.5%) maintained their implants with the evidence of infection. Twenty-two cases (13.6 %) showed radiological loosening. Thirteen cases (8.0 %) were revised again for reasons other than infection (12 for aseptic loosening and one for dislocation). Conclusion: Deep infection is one of the most serious complications after total hip arthroplasty (THA). This study presented the longest follow-up, with a large number of cases in revision THA for deep infection. The results suggested that one stage revision was an effective treatment for deep infection of hip arthroplasty

Purpose: Prophylactic use of antibiotic-laden bone cement (ALBC) has been proposed to decrease the incidence of deep infections. We asked if the use of antibiotic laden bone cement decreased the deep infection rate following primary total knee replacement (TKA) as compared to plain bone cement (PBC). Method: We surveyed 1,625 consecutive patients undergoing cemented, primary knee replacement with either ALBC or PBC. Relevant covariates including age, body mass index (BMI), gender, education, and medical comorbidity were collected. Joint pain and functional status were assessed at baseline and at 1 year follow up with the respective Western Ontario McMaster University Osteoarthritis Index (WOMAC) scores. The incidence of deep infection at 1 year follow up was recorded. Results: There were 811 (49.9%) patients in the ALBC group and 814(50.1%) in the PBC group. There were no differences in age, gender, BMI, education or comorbidity between groups at baseline (p> 0.05). We found a deep infection rate of 3.1% in the ALBC group and 2.2% in the PBC group (p=0.27). Adjusted analysis showed that ALBC was not predictive of a lower infection rate at 1 year (p=0.84). Conclusion: ALBC did not reduce the incidence of deep infection following primary TKA at 1 year follow up. Further studies are needed to define any high risk groups for which ALBC might be beneficial

Background and Purpose: The purpose of the present study was to assess the risk for revision due to deep infection for primary uncemented total hip arthroplasties (THAs) reported to the Norwegian Arthroplasty Register (NAR) over the period 1987–2007. Methods: All primary uncemented THAs reported to NAR from the period 1987–2007 were studied. Adjusted Cox regression analyses with first revision due to deep infection as the end-point were performed. Changes in the revision rate as a function of year of operation were investigated, as was impact of risk factors (gender, age, type of diagnosis, duration of surgery, operation room ventilation and systemic antibiotic prophylaxis) on risk for revision due to deep infection. Results: 14,348 primary uncemented THAs met the inclusion criteria. 97 THAs had been revised due to deep infection (5-year survival 99.56). Risk for revision due to deep infection increased through the period studied. Compared to the uncemented THAs implanted 1987–1992, the risk for revision due to infection was 1.2 times higher (95%CI 0.6–2.4, p=0.6) for those implanted 1993–1997, 1.4 times (95%CI 0.7–2.9, p=0.3) for 1998–2002, and 5.3 times (95%CI 2.6–10.7, p=< 0.001) for 2003–2007. The increase in risk for revision due to infection for primary uncemented THAs was most pronounced after the year 2000. No risk factor registered had any statistically significant impact on risk for revision due to infection in this study. Interpretation: The results of this study indicate an increase in incidence of deep infection after uncemented THAs during the period 1987–2007. Concomitant changes in confounding factors, however, complicate the interpretation of these results

Our aim was to review the efficacy of the wound vacuum-assisted closure (VAC) system in the treatment of deep infection after extensive instrumentation and fusion for spinal deformity in children and adolescents. A total of 14 patients with early deep spinal infection were treated using this technique. Of these, 12 had neuromuscular or syndromic problems. Clinical and laboratory data were reviewed. The mean follow-up was 44 months (24 to 72). All wounds healed. Two patients required plastic surgery to speed up the process. In no patient was the hardware removed and there was no loss of correction or recurrent infection. We believe that the wound VAC system is a useful tool in the armamentarium of the spinal surgeon dealing with patients susceptible to wound infections, especially those with neuromuscular diseases. It allows for the retention of the instrumentation and the maintenance of spinal correction. It is reliable and easy to use

Over the period 1990–2002, 12 patients, 3 male and 9 female, mean age 65 years (58–74), have been treated for deep infection after total knee arthroplasty (TKA). Two patients diagnosed with early and ten with late infection. Diagnosis was clinical, radiological (X-rays, 3 phase bone scan with Tc99m), laboratory (WBC, ESR, CRP) and from knee aspiration cultures. Of the inflammations, three were low grade. Eight patients had resurfacing total knee replacement, while four hinged type (Endomodel). Five of the initial arthroplasties were referred cases. Two phase revision was performed to all patients. Initially there was removal of the prothesis and extensive surgical debridement. Staphylococcus Aureus was cultured from seven arthroplasties, Staphylococcus Epidermidis from three and Pseudomonas Aeruginosa from two. After the prothesis removal, PMMA spacer with antibiotic was placed, in eleven cases molded to the shape of a TKA which permitted knee motion. A 6–8 week period of IV antibiotic therapy followed, which was based on intraoperative cultures and microbial sensitivity. Finally arthrodesis was performed in two knees, while in the other ten a new cemented TKA was place. All the patients received postsurgery antibiotics for 3–6 months. No recurrences of infection were note over a follow-up period of 8 months to 10 years, one revision was performed for a fractured femoral stem. In conclusion, two phase revision arthroplasty is proved to be an invaluable method in the treatment of deep infection after total knee arthroplasty

The objective of this study is to report the epidemiology and results of treatment of deep infection after a reverse shoulder arthroplasty. This is a multicenter retrospective study involving 457 reverse prostheses performed between 1992 and 2002. Fifteen patients (3%) (mean age 71 ± 9 years) presented with a deep infection. Eight were primary arthroplasties and seven were revision procedures. There were five associated peri-operative fractures and three early postoperative complications requiring surgical treatment. Infection was treated by debridement (n=4), prosthetic resection (n=10) or two-stage revision (n=1). The infection rate was 2% (8/363) for a primary reverse arthroplasty and 7% (7/94) for revisions. The infection was diagnosed at a mean of seventeen months (range, one to fifty-seven) post-operatively, corresponding to two acute, five sub-acute and eight chronic infections. The most common pathogen was P. acnes in six cases (40%). At a mean follow-up of thirty-four ± nineteen months, there were twelve remissions (80%) and three recurrent infections. The two acute infections (one debridement and one resection) and the eight chronic infections (seven resections and one two-stage revision) were in remission. Among the five sub-acute infections, the two resections were in remission, whereas the three debridements recurred. Overall, the ten resections were in remission with seven patients disappointed and three satisfied, a mean Constant score of thirty-one ± eight points and a mean active anterior elevation of 53 ± 15°. The two-stage exchange was in remission but remained disappointed with a Constant score of twenty-seven points and an active anterior elevation of 90°. Infection compromises the functional results of the reverse prosthesis whatever the treatment performed. Acute infections appear to be satisfactorily treated by debridement or resection. Both resection and two-stage revision can successfully treat sub-acute and chronic infection; however, debridement alone is ineffective and not recommended. There is a high rate of infection when the reverse prosthesis is used in revision arthroplasty. Prevention, by looking for such infection before surgery and by performing a two-stage procedure is recommended in the case of any uncertainty

We reviewed a series of 91 patients with deep infection of a cemented total hip arthroplasty caused by coagulase-negative staphylococci (C-NS). Of these, 72 were treated by one-stage exchange arthroplasty with a failure rate of 13% due to recurrence of infection. The other 19 patients have started or completed treatment by a two-stage exchange without failure to date. In 27 of the 91 patients multiple strains of C-NS were discovered, many being resistant to previously used antibiotics. The use of gentamicin-containing cement in the primary arthroplasty was significantly associated with the emergence of gentamicin-resistant C-NS in subsequent deep infection. Bacteriological diagnosis of such infections must take into consideration the possibility that multiple strains of the organism are involved

The aim of our study is to identify the organisms causing delayed deep infections following primary total knee arthroplasty in the current situation. We also compared the differences in outcome based on the infecting organism. We undertook a retrospective study of all the patients who presented with delayed deep infection following primary total knee replacement during a six year period between April 1998 and March 2004. We analysed the infecting organism, sensitivity of the organism to antibiotics, number of surgical procedure carried out and the outcome of the infected arthroplasty based on the infecting organism. Statistical analysis was done using Fisher’s Exact test for categorical data and Mann-Whitney U test for the non-parametric numeric data. The mean age at the time of primary arthroplasty was 69.9 years (range 46 to 92 years, SD=10.8). The mean follow-up (time since the initial knee replacement) was 77.3 months (range 27–170 months,). The mean follow-up since the last surgical procedure to treat infection was 31 months (range 14–47 months). Organisms were isolated in 27 of the 31 patients who presented with delayed deep infection. Forty-four % of the organisms isolated were multi-drug resistant with increasing incidence of Methicillin resistant Staphylococcus aureus and multi-drug resistant Staphylococcus epidermidis infections. Successful outcome following an infected total knee arthroplasty was lower compared to the previous studies where there were fewer multi-drug resistant organisms. The number of patients with satisfactory outcome is significantly lower when the organism isolated is multi-drug resistant. Patients infected by multi-drug resistant organisms undergo higher number of surgical procedures compared to patients where the organism is not multi-drug resistant. We conclude that deep infection with MRSA and Methicillin resistant Staphylococcus epidermidis are on the rise. Outcome is significantly better when the organism isolated is non resistant Staphylococcus aureus

Introduction: Bone stock and cement-bone interface in revision total hip replacement (THR) for deep infection have never been investigated in the literature, while they are known to be important for aseptic loosening. The purpose of this study was to assess preoperative bone stock and immediate postoperative cement-bone interface as factors affecting infection control and mechanical outcome after revision THR for deep infection. Methods: This study included 115 cases in which revision THR with antibiotic-loaded cement was operated for infected hip replacement by a single surgeon with minimal follow-up of five years (range 5–27 years). Preoperative bone stock was classified into four grades (Grade 0: No bone loss, Grade 1: Demarcation, Grade 2: Localized cavitation, Grade 3: Extensive bone loss). The immediate postoperative cement-bone interface was also graded into four categories (Grade A: White-out, obscure interface, Grade B: Clear line, no measurable gap, Grade C: Gap> 1mm, Grade D< 1mm). These two factors were analysed with regard to infection control and mechanical survival of implants after surgery. Results: Bone stock did not have significant influence on infection control while it affected mechanical outcome. The cement-bone interface was an affecting factor for not only the mechanical survival of implants but also the cure of infection. Discussion: There was a good chance of curing the infection even with extensive bone loss. Good cement fixation was an important factor with regard to infection control as well as the mechanical survival of implants. The results suggested that it might be important to shield the medullary space from the infected joint space with antibiotic-loaded cement

The purpose of this study was to determine whether a laminar flow operating system reduces deep infection rates in Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) and to examine the costs involved in implementing laminar flow technology. A retrospective analysis of deep infection rates in 759 patients who underwent THA and TKA was performed in one hospital prior to and after the introduction of a vertical laminar flow operating system together with the use of isolation body exhaust suits. A cost analysis was also performed on the cost of implementing laminar flow technology and the average inpatient hospital cost of managing a deep infection. A control group consisted of 387 THA and TKA performed in 2 years in a conventional operating theatre and follow up carried out to a mean of 29 months. There were 12 recorded deep infections, 3.1%. Case group consisted of 372 THA and TKA performed in 2 years after the introduction of a vertical laminar flow operating theatre together with the use of isolation body exhaust suits, with a mean follow up to 22 months. There were 4 recorded deep infections, 1.1%. A comparison of deep infection rates yielded p value 0.06. There was a strong trend toward a reduction in deep infection rate in THA and TKA performed in the laminar flow theatre with the use of isolation body exhaust suits. The economic impact of deep infection in THA and TKA is vast and the cost of implementing laminar flow technology must be weighed against the deep infection rate as well as the number of operations performed at an institution