Advances in the Prevention of Surgical Site Infection After Joint Replacement

The International Consensus Meeting (ICM) on Infection represents an ongoing, comprehensive global effort to synthesize high-quality evidence regarding musculoskeletal infection. The article by the International Consensus Meeting Executive Committee summarizes the top 10 recommendations from the third and most comprehensive ICM, which recently concluded in Istanbul, Türkiye, in 2025. Two of the recommendations reaffirm long-held clinical practice, such as the primacy of cefazolin for prophylaxis in primary arthroplasty, even in patients with a documented allergic reaction to penicillin. The delegates who researched that topic emphasized the need to increase the dose of cefazolin in patients weighing >120 kg. Additionally, the use of tranexamic acid, which is now the standard of care in arthroplasty, was deemed to be protective against periprosthetic joint infection (PJI). An interesting finding is that intraoperative dexamethasone use does not seem to increase the risk of PJI. Another topic that was discussed at the ICM, and that has been debated within the orthopaedic and medical communities, was the risk of PJI associated with various thromboprophylactic agents. The ICM delegates concluded that, among the spectrum of chemical thromboprophylactic agents, warfarin was associated with the highest risk of PJI, followed by low-molecular-weight heparins and direct oral anticoagulants, with acetylsalicylic acid (ASA) being associated with the lowest risk. The findings regarding the thromboprophylactic agents were based on retrospective data, as the randomized controlled trial (RCT) data would have been underpowered to detect a difference, given the low event rate for PJI. Although there has been a recent push toward the use of more modern, and much more expensive, surgical closure methods, the delegates found that the type of closure does not affect the risk of PJI, provided that a closure type that would sustain the tension forces on the wound is chosen. However, they found that antibiotic-impregnated sutures can reduce the risk of PJI, according to some studies, although the evidence was mixed. Also, there was a strong consensus supporting incisional negative pressure wound therapy (iNPWT) in select patients (who, in practice, are typically those at high risk), which aligns with growing RCT evidence. The delegates also concluded that the use of surgical drains does not affect the risk of surgical site infections (SSIs) but may increase blood loss and the potential need for a transfusion. The use of antibiotic-loaded cement in primary arthroplasty for the sole purpose of preventing infection has been debated, with many surgeons advocating its use and studies refuting its anticipated efficacy, and many surgeons not trusting these studies. The ICM delegates concluded that the use of antibiotic-loaded cement in primary arthroplasty does not reduce the risk of PJI, in concordance with the published studies and not surgeon opinion. However, as the authors note, the level of consensus did not uniformly track with the quality of the evidence. Even questions backed by large meta-analyses sometimes achieved only low/no consensus, which the authors reason may have been due to a lack of familiarity with the available evidence, bias, and concern about the wording of a recommendation. This underscores the reality that data alone rarely change practice; surgeon beliefs, institutional norms, and resource constraints remain potent influences. The report also illustrates an enduring problem in infection research: the rarity of PJI events limits statistical power, making even well-conducted RCTs prone to inconclusive results. The authors’ call to action was for large, collaborative, international platform trials. These trials would be difficult, costly, and larger than any orthopaedic RCTs to date. Ultimately, the ICM’s structured, transparent process and commitment to global representation make it a unique vehicle for shaping infection prevention and treatment policy. The challenge ahead lies in converting these consensus-backed recommendations into measurable reductions in PJI rates worldwide—a task requiring not only rigorous science but also deliberate strategies for knowledge translation and system-level change.

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