Cost-Effective Solutions to Prevent Orthopedic Infections

The unprecedented rising cost of health­ care in the United States has been at the forefront of national debate for the past decade and represents a seri­ous threat to the infrastructure of our society. Health care costs are currently following an unsustainable growth rate and are projected to constitute 34% of the US gross domestic prod­uct by 2040. Commercial and government payers have become increasingly interested in improved resource utilization through regulation, price fixing, and assigning value levels to physician care as a means of cutting costs and improving quality of care. A key component of transitioning from a volume-driven to a value-driven model is individual surgeon accountability to make use of effective, inexpensive solutions supported by cost-effectiveness data. Groups such as the Social and Economic Value of Orthopaedic Surgery Project Team, lead by current AAOS president Dr. John R. Tongue, represent a modern, proactive approach by surgeons to take personal responsibility for reducing health care spending. However, while we often think of technological innovation as the primary means to provide improved health care solutions, these answers are often expensive and impracti­cal when applied large-scale. Recent findings in the field of perioperative infec­tions show us that we cannot forget to look at past discoveries in other medical disciplines that may offer cost-effective adaptations in orthopedic surgery.^1-3

Perioperative infections after orthopedic procedures can be devastating complications for patients, families, and physicians alike, with an enor­mous cost to the health care system. The morbidity from surgical site infec­tions includes pain, loss of function, increased hospitalization, prolonged rehabilitation, and higher rates of reoperation.⁴ Research has shown that certain orthopedic operations have a significantly greater risk of infection such as revision total knee arthroplasty, ankle fusion, and subtalar fusion.⁵ Specialty areas, such as foot and ankle surgery in particular, have been shown to have higher infection rates, compared with other procedures.⁶ The resource allocation and financial costs of treating perioperative infec­tions in orthopedic surgery can often rise 3-13 times more than the cost of the index procedure, thus mak­ing perioperative infections an ideal target for cost-effective solutions in a value-driven health care model.^7,8 There is a tremendous need for effec­tive, low-cost, safe, and easy to use methods of preventing perioperative infections after orthopedic proce­dures, and dilute Betadine lavage is an example of such a solution.

Povidone-iodine is a stable chemi­cal complex of polyvinylpyrrolidone and elemental iodine (9-12%) that was first sold in 1955 and is now one of the most widely used antiseptics for skin, mucous membranes, and wounds. Betadine is a brand name for a range of povidone-iodine topi­cal antiseptics and has been shown to have bactericidal activity against multiple pathogens, including meth­icillin-resistant Staphlococcus aure­us.⁹ It is cheap ($1), safe, fast, widely used, and easy to alter into various concentrations. The earliest study by Sindelar and Mason¹⁰ investigating the potential decreases in periopera­tive infection rates with dilute povi­done-iodine irrigation in general and urologic surgery date back as early as 1977. Since then, there have been 14 studies conducted in multiple coun­tries, involving the fields of general, cardiovascular, and urologic surgery. Many of these studies showed similar decreases in infection rates before the idea of using a dilute Betadine lavage was implemented in orthopedic sur­gery 3 decades later.¹¹

In 2005, Cheng and colleagues¹² prospectively studied the effect of a dilute 3.5% Betadine 3-minute lavage on the incidence of postoperative spine infections. They found a significant decrease in infection rate, compared with saline lavage alone, without adverse effects on clinical outcomes. Recently, a research group led by Dr. Craig Della Valle¹³ demonstrated that a 0.35% Betadine lavage for 3 minutes significantly lowered the rate of acute postoperative infection after total hip and knee arthroplasty from 0.97% to 0.15% in a group of 2550 patients.

Using inexpensive tools that cur­rently exist and applying them in new and innovative ways, represents an area of orthopedic research that should be further pursued and that may pro­vide the cost-effective solutions that the current healthcare environment demands. Parvizi² recently showed that levels of synovial C-reactive pro­tein (CRP) could help differentiate between infected and uninfected revi­sion total knee arthroplasties with a sensitivity of 70% and specificity of 100%. CRP is a relatively inexpen­sive ($15), widely used laboratory test that has been known to rise in response to acute inflammation since its discovery in 1930 by Tillett and Francis.¹⁴ The use of serum CRP has changed the management of ortho­pedic perioperative infections, and specifically, the diagnosis algorithm for periprosthetic joint infections.13 CRP represents another example of how using old tools in new ways can address both orthopedic and resource management needs. The use of intra­wound vancomycin powder ($12) to decrease postsurgical wound infec­tion in instrumented thoracolumbar fusions may also represent a cost-effective method of infection pre­vention that is applicable to other orthopedic specialties and should be explored further.³