JTO - September 2021

02 Sep 2021

Volume 9 Issue 3

From the Executive Editor

To quote the first two lines of a song from my youth “I’m so excited, I just can’t hide it” – international travel, F2F science and gossip, coffee and perhaps some other beverages all coming soon for a North London Orthopod.  But... after the 18 months we have just had, even I will admit to being a bit apprehensive at this next step towards my old normality.

Much of this edition of the JTO relates to a new normality and the end of old familiar concepts – the trauma clinic perhaps (page 28), revamping how we look at our waiting lists (page 32) and how we select (page 26) and educate (page 36) our trainees and ourselves.  All these articles involve leadership and Hiro and Lisa discuss the FLP and why leadership matters to all of us (page 40).

Like all our patients, we want and need to avoid complications at all costs.  The medico-legal article (page 54) reminds us that 50% of claims relate to post-operative problems and if problems do occur, Deepa Bose’s Robert Jones prize winning essay advises us not to behave like an ostrich in either burying our head in the sand or running away fast!  With this in mind, it was sobering to realise that when asked about tourniquet use and safety – a survey said that only 10% of respondents felt they had been trained in their use whilst 37% had observed a complication (page 48).  The BOAST on ‘The Safe Use of Intraoperative Tourniquets’ is published this month.

The subspecialty articles on periprosthetic infection, (page 60 onwards) give us some ‘top tips’ on avoiding complications and demonstrate that if you can’t avoid them you can deal with them – by being expert at what you do!

Two articles gave me personal pleasure: many years ago, after my first registrar presentation at a BOA meeting, Chris Colton made a particular point of coming to find me to congratulate me – perhaps simply a minor detour on his way to coffee in his mind – but to me, a major event and one that I have tried to pass onwards to the next generation of trainees. Reading his reflections on life and trauma surgery was fun! Secondly, the award of the Presidential Medal to Julia Trusler – a real star of the BOA ‘show’ and one who has made all our lives easier – a richly deserved honour and I look forward to celebrating her success with her and the team in our new offices very soon.

With the start of the new school year imminent, it is perhaps a time to look forward too – so this edition contains an article from Bob – his last as President, and from John, as incoming President. To quote another song –the “times they are a-changin”!

I hope to see many of you in Aberdeen for the BOA meeting and if you would like to help us with the work we do, why not get involved (page 8) and apply for one of the positions up for election?

Deborah Eastwood, Vice President Elect


Subspecialty Section


The orthopaedic ostrich: surgeons’ responses to complications

  1. Dindo D, Clavien PA. What is a surgical complication? World J Surg. 2008 Jun;32(6):939-41.
  2. Camino Willhuber G, Slullitel P, Taype Zamboni D, Albergo J, Terrasa S, Piuzzi N, Boretto J. Validation of a modified Clavien-Dindo Classification for postoperative complications in orthopedic surgery. Rev Fac Cien Med Univ Nac Cordoba. 2020 Aug 21;77(3):161-7.
  3. Visser A, Ubbink DT, Gouma DJ, Goslings JC. Which clinical scenarios do surgeons record as complications? A benchmarking study of seven hospitals. BMJ Open. 2015 Jun 1;5(6):e007500.
  4. Woodfield J, Deo P, Davidson A, Chen TY, van Rij A. Patient reporting of complications after surgery: what impact does documenting postoperative problems from the perspective of the patient using telephone interview and postal questionnaires have on the identification of complications after surgery? BMJ Open. 2019 Jul 9;9(7):e028561.
  5. Patel AM, Ingalls NK, Mansour MA, Sherman S, Davis AT, Chung MH. Collateral damage: the effect of patient complications on the surgeon's psyche. Surgery. 2010 Oct;148(4):824-8; discussion 828-30.
  6. Pinto A, Faiz O, Bicknell C, Vincent C. Surgical complications and their implications for surgeons' well-being. Br J Surg. 2013 Dec;100(13):1748-55.
  7. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000 Mar 18;320(7237):726-7.
  8.  Money SR. Surgical personalities, surgical burnout, and surgical happiness. J Vasc Surg. 2017 Sep;66(3):683-6.
  9. Dorsey ER, Ritzer G. The McDonaldization of Medicine. JAMA Neurol. 2016;73(1):15-6.
  10. Royal College of Surgeons England (2020). Supporting surgeons after adverse events. Available at: www.rcseng.ac.uk/standards-and-research/standards-and-guidance/good-practice-guides/supporting-surgeons-after-adverse-events.

Waiting for the knife – orthopaedic surgery in the time of COVID-19

1.         Iserson KV, Pesik N. Ethical resource distribution after biological, chemical, or radiological terrorism. Camb Q Healthc Ethics. 2003;12(4):455-65. doi:10.1017/s0963180103124164

2.         Rathnayake D, Clarke M. The effectiveness of different patient referral systems to shorten waiting times for elective surgeries: systematic review. BMC Health Serv Res. Feb 17 2021;21(1):155. doi:10.1186/s12913-021-06140-w

3.         Finkenstädt V. [Dealing with Waiting Times in Health Systems - An International Comparative Overview]. Gesundheitswesen. Oct 2015;77(10):768-74. doi:10.1055/s-0034-1387758

4.         The Lancet. India's COVID-19 emergency. Lancet. 05 2021;397(10286):1683. doi:10.1016/S0140-6736(21)01052-7

5.         Swan KG. Triage: the past revisited. Mil Med. Aug 1996;161(8):448-52.

6.         StatPearls. 2021.

7.         Emanuel EJ, Persad G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med. 05 2020;382(21):2049-2055. doi:10.1056/NEJMsb2005114

8.         Christian MD. Triage. Crit Care Clin. Oct 2019;35(4):575-589. doi:10.1016/j.ccc.2019.06.009

9.         Moskop JC, Iserson KV. Triage in medicine, part II: Underlying values and principles. Ann Emerg Med. Mar 2007;49(3):282-7. doi:10.1016/j.annemergmed.2006.07.012

10.       Hadorn DC, Holmes AC. The New Zealand priority criteria project. Part 1: Overview. BMJ. Jan 1997;314(7074):131-4. doi:10.1136/bmj.314.7074.131

11.       Theis JC. Clinical priority criteria in orthopaedics: a validation study using the SF36 quality of life questionnaire. Health Serv Manage Res. Feb 2004;17(1):59-61. doi:10.1258/095148404322772732

12.       Oudhoff JP, Timmermans DR, Knol DL, Bijnen AB, Van der Wal G. Prioritising patients on surgical waiting lists: a conjoint analysis study on the priority judgements of patients, surgeons, occupational physicians, and general practitioners. Soc Sci Med. May 2007;64(9):1863-75. doi:10.1016/j.socscimed.2007.01.002

13.       The Lancet Rheumatology. Too long to wait: the impact of COVID-19 on elective surgery. Lancet Rheumatol. Feb 2021;3(2):e83. doi:10.1016/S2665-9913(21)00001-1

14.       Bowers J. Waiting list behaviour and the consequences for NHS targets. Journal of the Operational Research Society. 2010/02/01 2010;61(2):246-254. doi:10.1057/jors.2008.149

15.       Soltany A, Hamouda M, Ghzawi A, et al. A scoping review of the impact of COVID-19 pandemic on surgical practice. Ann Med Surg (Lond). Sep 2020;57:24-36. doi:10.1016/j.amsu.2020.07.003

16.       Simoes J, Bhangu A, Collaborative C. Should we be re-starting elective surgery? Anaesthesia. 12 2020;75(12):1563-1565. doi:10.1111/anae.15296

17.       Coleman NL, Argenziano M, Fischkoff KN. Developing an Algorithm to Guide Resumption of Operative Activity in the COVID-19 Pandemic and Beyond. Ann Surg. 09 2020;272(3):e236-e239. doi:10.1097/SLA.0000000000004123

18.       Eibich P, Dakin HA, Price AJ, Beard D, Arden NK, Gray AM. Associations between preoperative Oxford hip and knee scores and costs and quality of life of patients undergoing primary total joint replacement in the NHS England: an observational study. BMJ Open. 04 2018;8(4):e019477. doi:10.1136/bmjopen-2017-019477

Tourniquet safety – case report and national survey: Tourniquets in Orthopaedic Practice Study (TOPS)


1.             Choudhary S, Koshy C, Ahmed J, Evans J (1998) Friction burns to thigh caused by tourniquet. Br J Plast Surg. https://doi.org/10.1054/bjps.1997.0189

2.          Savvidis E, Parsch K (1999) Prolonged transitory paralysis after pneumatic tourniquet use on the upper arm

3.          Noordin S, McEwen JA, Kragh JF, et al (2009) Surgical tourniquets in orthopaedics. J. Bone Jt. Surg. - Ser. A

4.          KLENERMAN L (1962) The tourniquet in surgery. J Bone Joint Surg Br. https://doi.org/10.1302/0301-620x.44b4.937

5.          Blackbourne LH, Mabry R, Sebesta J, Holcomb JB (2008) Joseph Lister, noncompressible arterial hemorrhage, and the next generation of “tourniquets”? US Army Med Dep J

6.          McEwen JA (1981) Complications of and improvements in pneumatic tourniquets used in surgery. Med Instrum

7.          (2018) Guidelines for Best Practices for Safe Use of Pneumatic Tourniquets. Technol Assoc Surg

8.          Bogdan Y, Helfet DL (2018) Use of Tourniquets in Limb Trauma Surgery. Orthop. Clin. North Am.

9.          Tredwell SJ, Wilmink M, Inkpen K, McEwen JA (2001) Pediatric tourniquets: Analysis of cuff and limb interface, current practice, and guidelines for use. J Pediatr Orthop. https://doi.org/10.1097/00004694-200109000-00023

10.        (2007) Recommended practices for the use of the pneumatic tourniquet in the perioperative practice setting. AORN J. https://doi.org/10.1016/j.aorn.2007.09.004

11.        Sadri A, Braithwaite IJ, Abdlu-Jabar HB, Sarraf KM (2010) Understanding of intra-operative tourniquets amongst orthopaedic surgeons and theatre staff - A questionnaire study. Ann R Coll Surg Engl. https://doi.org/10.1308/003588410X1251883644060.


Appendix - Tourniquets in Orthopaedic Practice Study (TOPS) – A National Survey


The Bone and Joint Infection Registry (BAJIR) and its role in supporting the Bone and Joint Infection MDT in our Institution

  1. https://bajir.org/for-professionals/ (accessed 07.06.21 10:00)
  2. https://bajirdotorg.files.wordpress.com/2020/10/annual-report-2020-1.pdf Financial Support (accessed 07.06.21 10:07)
  3. Parvizi MD, Gehrke MD. Definition of periprosthetic joint infection. Volume 29, Issue, 7, pages:1331, July 2014 DOI: 10.1016/j.arth.2014.03.009
  4. Douglas R. Osmon, Elie F. Berbari, Anthony R. Berendt, Daniel Lew, Werner Zimmerli, James M. Steckelberg, Nalini Rao, Arlen Hanssen, Walter R. Wilson, Diagnosis and Management of Prosthetic Joint Infection: Clinical Practice Guidelines by the Infectious Diseases Society of America, Clinical Infectious Diseases, Volume 56, Issue 1, 1 January 2013, Pages e1–e25, https://doi.org/10.1093/cid/cis803
  5. Parvizi J, Tan TL, Goswami K, Higuera C, Della Valle C, Chen AF, Shohat N. The 2018 definition of periprosthetic hip and knee infection: an evidence-based and validated criteria. The Journal of arthroplasty. 2018 May 1;33(5):1309-14.
  6. McNally M, Sousa R, Wouthuyzen-Bakker M, Chen AF, Soriano A, Vogely HC, Clauss M, Higuera CA, Trebše R. The EBJIS definition of periprosthetic joint infection: a practical guide for clinicians. The Bone & Joint Journal. 2021 Jan 1;103(1):18-25.
  7. Metsemakers WJ, Morgenstern M, McNally MA, Moriarty TF, McFadyen I, Scarborough M, Athanasou NA, Ochsner PE, Kuehl R, Raschke M, Borens O, Xie Z, Velkes S, Hungerer S, Kates SL, Zalavras C, Giannoudis PV, Richards RG, Verhofstad MHJ. Fracture-related infection: A consensus on definition from an international expert group. Injury. 2018 Mar;49(3):505-510. doi: 10.1016/j.injury.2017.08.040. Epub 2017 Aug 24. PMID: 28867644.
  8. British Orthoapedic Association (BOA) Revision Total Knee Replacement Surgical Practice Guidelines 2020;27.
  9. British Orthoapedic Association (BOA) Investigation and Management of Prosthetic Joint Infection in Knee Replacement 2020;27.
  10. British Orthoapedic Association (BOA) Investigation and Management of Patients with Problematic Knee Replacements 2020;27.
  11. https://bajirdotorg.files.wordpress.com/2020/02/national-bajir-eq5d-v02.20.pdf (accessed 07.06.21 10:34)

Investigation of Prosthetic Joint Infection of the Knee – The Exeter approach to this challenging condition

1.           Investigation and management of periprosthetic knee joint infection in knee replacement. 2020.

2.           Awad F, Fine N, Phillips J, Toms A. A regional DMT service for the management of  infected native and total knee replacements: development and results of an established service.  BASK; Leicester2018.

3.           Stephens MR, Lewis WG, Brewster AE, Lord I, Blackshaw GR, Hodzovic I, et al. Multidisciplinary team management is associated with improved outcomes after surgery for esophageal cancer. Dis Esophagus. 2006;19(3):164-71.

4.           Soukup T, Lamb BW, Arora S, Darzi A, Sevdalis N, Green JS. Successful strategies in implementing a multidisciplinary team working in the care of patients with cancer: an overview and synthesis of the available literature. J Multidiscip Healthc. 2018;11:49-61.

5.           Lan YT, Jiang JK, Chang SC, Yang SH, Lin CC, Lin HH, et al. Improved outcomes of colorectal cancer patients with liver metastases in the era of the multidisciplinary teams. Int J Colorectal Dis. 2016;31(2):403-11.

6.           Awad F, Fine N, Phillips J, Toms A. A regional MDT service for the management of  infected native and total knee replacements: development and results of an established service.  BASK; Leicester2018.

7.           Jenkins N, Hughes H. How I do it…. How infection doctors approach the PJI MDT. Knee. 2020;27(6):1994-7.

8.           Moore AJ, Whitehouse MR, Gooberman-Hill R, Heddington J, Beswick AD, Blom AW, et al. A UK national survey of care pathways and support offered to patients receiving revision surgery for prosthetic joint infection in the highest volume NHS orthopaedic centres. Musculoskeletal Care. 2017;15(4):379-85.

9.           Second international consensus meeting (ICM) on musculoskeletal infection  [Available from: http://icmphilly.com.

10.         Mathews JA, Kalson NS, Tarrant PM, Toms AD, group RKRPSPs. Top ten research priorities for problematic knee arthroplasty. Bone Joint J. 2020;102-B(9):1176-82.

11.         James Lind Alliance Priority Setting Partnerships  [Available from: https://www.jla.nihr.ac.uk.

12.         clinicaltrials.gov. MIKROBE Management of Infected Knee Replacements - Obtaining Best Evidence (MIKROBE).

13.         Petretta R, Phillips J, Toms A. Management of acute periprosthetic joint infection of the knee - Algorithms for the on call surgeon. Surgeon. 2017;15(2):83-92.

14.         Bajada S, Yoong AWH, Hourigan P, Koopmans PC, Phillips JRA, Toms AD. Plasma Viscosity Has a Role in the Diagnosis of Prosthetic Joint Infection After Total Knee Arthroplasty. J Arthroplasty. 2019;34(12):3035-9.

15.         Phillips JRA, Al-Mouazzen L, Morgan-Jones R, Murray JR, Porteous AJ, Toms AD. Revision knee complexity classification-RKCC: a common-sense guide for surgeons to support regional clinical networking in revision knee surgery. Knee Surg Sports Traumatol Arthrosc. 2019;27(4):1011-7.

16.         Phillips JR, Hopwood B, Stroud R, Dieppe PA, Toms AD. The characterisation of unexplained pain after knee replacement. Br J Pain. 2017;11(4):203-9.

17.         Kalson NS, Mathews JA, Miles J, Bloch BV, Price AJ, Phillips JRA, et al. Provision of revision knee surgery and calculation of the effect of a network service reconfiguration: An analysis from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. Knee. 2020;27(5):1593-600.

18.         Kalson NS, Mathews JA, Phillips JRA, Baker PN, Price AJ, Toms AD, et al. Revision knee replacement surgery in the NHS: A BASK surgical practice guideline. Knee. 2021;29:353-64.

19.         Salar O, Phillips J, Porter R. Diagnosis of knee prosthetic joint infection; aspiration and biopsy. Knee. 2021;30:249-53.

20.         Kalson NS, Mathews JA, Toms AD, Murray JRD, Group BRKW. Clinical prioritisation of revision knee surgical procedures: BASK working group consensus document. Knee. 2021;28:57-63.

Top 10 tips to avoid periprosthetic joint infection

  1. Sloan M, Premkumar A, Sheth NP. Projected Volume of Primary Total Joint Arthroplasty in the U.S., 2014 to 2030: The Journal of Bone and Joint Surgery 2018;100:1455–60.
  2. Koh CK, Zeng I, Ravi S, Zhu M, Vince KG, Young SW. Periprosthetic Joint Infection Is the Main Cause of Failure for Modern Knee Arthroplasty: An Analysis of 11,134 Knees. Clin Orthop Relat Res 2017;475:2194–201.
  3. American Academy of Orthopaedic Surgeons. American Academy of Orthopaedic Surgeons Clinical Practice Guideline on the Diagnosis and Prevention of Periprosthetic Joint Infections. AAOS Quality & Practice Resources n.d. www.aaos.org/contentassets/9a006edd608c468ba066624defca5502/pji-clinicalpractice-guideline-final-9-18-19-.pdf (accessed November 30, 2020).
  4. Parvizi J, Tan TL, Goswami K, Higuera C, Della Valle C, Chen AF, et al. The 2018 Definition of Periprosthetic Hip and Knee Infection: An Evidence-Based and Validated Criteria. The Journal of Arthroplasty 2018;33:1309-1314.e2.
  5. Jiranek W, Kigera JWM, Klatt BA, Küçükdurmaz F, Lieberman J, Moser C, et al. General Assembly, Prevention, Host Risk Mitigation - General Factors: Proceedings of International Consensus on Orthopedic Infections. The Journal of Arthroplasty 2019;34:S43–8.
  6. Cizmic Z, Feng JE, Huang R, Iorio R, Komnos G, Kunutsor SK, et al. Hip and Knee Section, Prevention, Host Related: Proceedings of International Consensus on Orthopedic Infections. The Journal of Arthroplasty 2019;34:S255–70.
  7. Shohat N, Goswami K, Tarabichi M, Sterbis E, Tan TL, Parvizi J. All Patients Should Be Screened for Diabetes Before Total Joint Arthroplasty. The Journal of Arthroplasty 2018;33:2057–61.
  8. Capozzi JD, Lepkowsky ER, Callari MM, Jordan ET, Koenig JA, Sirounian GH. The Prevalence of Diabetes Mellitus and Routine Hemoglobin A1c Screening in Elective Total Joint Arthroplasty Patients. The Journal of Arthroplasty 2017;32:304–8.
  9. Shohat N, Muhsen K, Gilat R, Rondon AJ, Chen AF, Parvizi J. Inadequate Glycemic Control Is Associated With Increased Surgical Site Infection in Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. The Journal of Arthroplasty 2018;33:2312-2321.e3.
  10. Shohat N, Tarabichi M, Tan TL, Goswami K, Kheir M, Malkani AL, et al. 2019 John Insall Award: Fructosamine is a better glycaemic marker compared with glycated haemoglobin (HbA1C) in predicting adverse outcomes following total knee arthroplasty: a prospective multicentre study. The Bone & Joint Journal 2019;101-B:3–9.
  11. Shohat N, Goswami K, Breckenridge L, Held MB, Malkani AL, Shah RP, et al. Fructosamine is a valuable marker for glycaemic control and predicting adverse outcomes following total hip arthroplasty: a prospective multi-institutional investigation. Sci Rep 2021;11:2227.
  12. Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg 2017;152:784.
  13. Kapadia BH, Elmallah RK, Mont MA. A Randomized, Clinical Trial of Preadmission Chlorhexidine Skin Preparation for Lower Extremity Total Joint Arthroplasty. The Journal of Arthroplasty 2016;31:2856–61.
  14. Kapadia BH, Issa K, McElroy MJ, Pivec R, Daley JA, Mont MA. Advance pre-operative chlorhexidine preparation reduces periprosthetic infections following total joint arthroplasty. Seminars in Arthroplasty 2013;24:83–6.
  15. Kapadia BH, Johnson AJ, Daley JA, Issa K, Mont MA. Pre-admission Cutaneous Chlorhexidine Preparation Reduces Surgical Site Infections In Total Hip Arthroplasty. The Journal of Arthroplasty 2013;28:490–3.
  16. Peel TN, Dowsey MM, Buising KL, Cheng AC, Choong PFM. Chlorhexidine–alcohol versus iodine–alcohol for surgical site skin preparation in an elective arthroplasty (ACAISA) study: a cluster randomized controlled trial. Clinical Microbiology and Infection 2019;25:1239–45.
  17. Garvin KL, Hanssen AD. Infection after total hip arthroplasty. Past, present, and future. J Bone Joint Surg Am 1995;77:1576–88.
  18. Blumenthal KG, Ryan EE, Li Y, Lee H, Kuhlen JL, Shenoy ES. The Impact of a Reported Penicillin Allergy on Surgical Site Infection Risk. Clinical Infectious Diseases 2018;66:329–36.
  19. Aboltins CA, Berdal JE, Casas F, Corona PS, Cuellar D, Ferrari MC, et al. Hip and Knee Section, Prevention, Antimicrobials (Systemic): Proceedings of International Consensus on Orthopedic Infections. The Journal of Arthroplasty 2019;34:S279–88.
  20. Sakoulas G, Geriak M, Nizet V. Is a Reported Penicillin Allergy Sufficient Grounds to Forgo the Multidimensional Antimicrobial Benefits of β-Lactam Antibiotics? Clinical Infectious Diseases 2018;68:157–64.
  21. Coleman DT, Stone CA, Wei W-Q, Phillips EJ. Penicillin allergy labels drive perioperative prophylactic antibiotic selection in orthopedic procedures. The Journal of Allergy and Clinical Immunology: In Practice 2020:S2213219820307121.
  22. Wyles CC, Hevesi M, Osmon DR, Park MA, Habermann EB, Lewallen DG, et al. 2019 John Charnley Award: Increased risk of prosthetic joint infection following primary total knee and hip arthroplasty with the use of alternative antibiotics to cefazolin: the value of allergy testing for antibiotic prophylaxis. The Bone & Joint Journal 2019;101-B:9–15.
  23. Stone AH, Kelmer G, MacDonald JH, Clance MR, King PJ. The Impact of Patient-Reported Penicillin Allergy on Risk for Surgical Site Infection in Total Joint Arthroplasty: Journal of the American Academy of Orthopaedic Surgeons 2019;27:854–60.
  24. Ponce B, Raines BT, Reed RD, Vick C, Richman J, Hawn M. Surgical Site Infection After Arthroplasty: Comparative Effectiveness of Prophylactic Antibiotics. The Journal of Bone and Joint Surgery 2014;96:970–7.
  25. Tan TL, Springer BD, Ruder JA, Ruffolo MR, Chen AF. Is Vancomycin-only Prophylaxis for Patients With Penicillin Allergy Associated With Increased Risk of Infection After Arthroplasty?: Clinical Orthopaedics and Related Research 2016;474:1601–6.
  26. Macy E, Blumenthal KG. Are Cephalosporins Safe for Use in Penicillin Allergy without Prior Allergy Evaluation? The Journal of Allergy and Clinical Immunology: In Practice 2018;6:82–9.
  27. Courtney MP, Melnic CM, Zimmer Z, Anari J, Lee G-C. Addition of Vancomycin to Cefazolin Prophylaxis Is Associated With Acute Kidney Injury After Primary Joint Arthroplasty. Clinical Orthopaedics & Related Research 2015;473:2197–203.
  28. Altemeier WA. Manual on control of infection in surgical patients. Lippincott Williams & Wilkins; 1984.
  29. Wang Q, Goswami K, Shohat N, Aalirezaie A, Manrique J, Parvizi J. Longer Operative Time Results in a Higher Rate of Subsequent Periprosthetic Joint Infection in Patients Undergoing Primary Joint Arthroplasty. The Journal of Arthroplasty 2019;34:947–53.
  30. Howorth FH. Prevention of airborne infection during surgery. The Lancet 1985;325:386–8.
  31. Haridas M, Malangoni MA. Predictive factors for surgical site infection in general surgery. Surgery 2008;144:496–503.
  32. Clarke MT, Longstaff L, Edwards D, Rushton N. Tourniquet-induced wound hypoxia after total knee replacement. J Bone Joint Surg Br 2001;83:40–4.
  33. Tweed C. Prevention of surgical wound infection: prophylactic antibiotics in colorectal surgery. Journal of Wound Care 2005;14:202–5.
  34. Anis HK, Sodhi N, Klika AK, Mont MA, Barsoum WK, Higuera CA, et al. Is Operative Time a Predictor for Post-Operative Infection in Primary Total Knee Arthroplasty? The Journal of Arthroplasty 2019;34:S331–6.
  35. Maoz G, Phillips M, Bosco J, Slover J, Stachel A, Inneh I, et al. The Otto Aufranc Award: Modifiable versus Nonmodifiable Risk Factors for Infection After Hip Arthroplasty. Clinical Orthopaedics & Related Research 2015;473:453–9.
  36. Greenky M, Gandhi K, Pulido L, Restrepo C, Parvizi J. Preoperative Anemia in Total Joint Arthroplasty: Is It Associated with Periprosthetic Joint Infection? Clinical Orthopaedics & Related Research 2012;470:2695–701.
  37. Newman ET, Watters TS, Lewis JS, Jennings JM, Wellman SS, Attarian DE, et al. Impact of Perioperative Allogeneic and Autologous Blood Transfusion on Acute Wound Infection Following Total Knee and Total Hip Arthroplasty. Journal of Bone and Joint Surgery 2014;96:279–84.
  38. Fillingham YA, Ramkumar DB, Jevsevar DS, Yates AJ, Bini SA, Clarke HD, et al. Tranexamic Acid Use in Total Joint Arthroplasty: The Clinical Practice Guidelines Endorsed by the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. The Journal of Arthroplasty 2018;33:3065–9.
  39. Yazdi H, Klement MR, Hammad M, Inoue D, Xu C, Goswami K, et al. Tranexamic Acid Is Associated With Reduced Periprosthetic Joint Infection After Primary Total Joint Arthroplasty. The Journal of Arthroplasty 2020;35:840–4.
  40. Garfinkel JH, Gladnick BP, Roland N, Romness DW. Increased Incidence of Bleeding and Wound Complications With Factor-Xa Inhibitors After Total Joint Arthroplasty. The Journal of Arthroplasty 2018;33:533–6.
  41. Lindquist DE, Stewart DW, Brewster A, Waldroup C, Odle BL, Burchette JE, et al. Comparison of Postoperative Bleeding in Total Hip and Knee Arthroplasty Patients Receiving Rivaroxaban, Enoxaparin, or Aspirin for Thromboprophylaxis. Clin Appl Thromb Hemost 2018;24:1315–21.
  42. Huang R, Buckley PS, Scott B, Parvizi J, Purtill JJ. Administration of Aspirin as a Prophylaxis Agent Against Venous Thromboembolism Results in Lower Incidence of Periprosthetic Joint Infection. The Journal of Arthroplasty 2015;30:39–41.
  43. Panahi P, Stroh M, Casper DS, Parvizi J, Austin MS. Operating Room Traffic is a Major Concern During Total Joint Arthroplasty. Clinical Orthopaedics and Related Research® 2012;470:2690–4.
  44. Hamilton WG, Balkam CB, Purcell RL, Parks NL, Holdsworth JE. Operating room traffic in total joint arthroplasty: Identifying patterns and training the team to keep the door shut. American Journal of Infection Control 2018;46:633–6.
  45. Teter J, Guajardo I, Al-Rammah T, Rosson G, Perl TM, Manahan M. Assessment of operating room airflow using air particle counts and direct observation of door openings. American Journal of Infection Control 2017;45:477–82.
  46. Brown NM, Cipriano CA, Moric M, Sporer SM, Della Valle CJ. Dilute Betadine Lavage Before Closure for the Prevention of Acute Postoperative Deep Periprosthetic Joint Infection. The Journal of Arthroplasty 2012;27:27–30.
  47. Siddiqi A, Abdo ZE, Rossman SR, Kelly MA, Piuzzi NS, Higuera CA, et al. What Is the Optimal Irrigation Solution in the Management of Periprosthetic Hip and Knee Joint Infections? The Journal of Arthroplasty 2021:S0883540321005143.
  48. Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg 2017.
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