title: A Bundle Protocol to Reduce the Incidence of Periprosthetic Joint Infections After Total Joint Arthroplasty: A Single-Center Experience.
abstract: Periprosthetic joint infection (PJI) represents a devastating complication of total hip arthroplasty (THA) or total knee arthroplasty (TKA). Modifiable patient risk factors as well as various intraoperative and postoperative variables have been associated with risk of PJI. In 2011, our institution formulated a "bundle" to optimize patient outcomes after THA and TKA. The purpose of this report is to describe the "bundle" protocol we implemented for primary THA and TKA patients and to analyze its impact on rates of PJI and readmission.
  
  
  
  Our bundle protocol for primary THA and TKA patients is conceptually organized about 3 chronological periods of patient care: preoperative, intraoperative, and postoperative. The institutional total joint database and electronic medical record were reviewed to identify all primary THAs and TKAs performed in the 2 years before and following implementation of the bundle. Rates of PJI and readmission were then calculated.
  
  
  
  Thirteen of 908 (1.43%) TKAs performed before the bundle became infected compared to only 1 of 890 (0.11%) TKAs performed after bundle implementation (P = .0016). Ten of 641 (1.56%) THAs performed before the bundle became infected, which was not statistically different from the 4 of 675 (0.59%) THAs performed after the bundle that became infected (P = .09).
  
  
  
  The bundle protocol we describe significantly reduced PJIs at our institution, which we attribute to patient selection, optimization of modifiable risk factors, and our perioperative protocol. We believe the bundle concept represents a systematic way to improve patient outcomes and increase value in total joint arthroplasty.
authors.affiliation: Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, North Carolina.
authors.forename: Matthew W
authors.initials: MW
authors.lastname: Bullock
authors.affiliation: Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, North Carolina.
authors.forename: Matthew L
authors.initials: ML
authors.lastname: Brown
authors.affiliation: Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, North Carolina.
authors.forename: Daniel N
authors.initials: DN
authors.lastname: Bracey
authors.affiliation: Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, North Carolina.
authors.forename: Maxwell K
authors.initials: MK
authors.lastname: Langfitt
authors.affiliation: Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, North Carolina.
authors.forename: John S
authors.initials: JS
authors.lastname: Shields
authors.affiliation: Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, North Carolina.
authors.forename: Jason E
authors.initials: JE
authors.lastname: Lang
mesh_terms: D001170:Arthritis, Infectious; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects*; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects*; D002985:Clinical Protocols; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D009657:North Carolina / Q000453:epidemiology; D064872:Patient Care Bundles; D010359:Patient Readmission / Q000706:statistics & numerical data; D016459:Prosthesis-Related Infections / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D012189:Retrospective Studies; D012307:Risk Factors
keywords: bundle protocol; outcomes; periprosthetic joint infection; total hip arthroplasty; total knee arthroplasty