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Laminar airflow operating rooms: Are they needed for joint arthroplasty?
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The increasing burden and the immense financial impact of periprosthetic joint infection compel the orthopedic community to seek all potential infection control measures. Based on the teachings of Sir John Charnley and the literature from the early era of total joint arthroplasty, orthopedic surgeons are aware that an ultra-clean OR environment is critical to minimize the number of airborne particulate matters that can contaminate the wound and lead to infection of the implanted foreign material. It is known that airborne and non-airborne bacterial contaminations are the major source of infection in ORs.
The rationale behind the use of the laminar airflow (LAF) systems is the ability of LAF to reduce airborne particles and pathogens by 80%. LAF systems were first developed in the United States in 1964. Since then, they have evolved substantially during the years; from horizontal to vertical, and now vertical exponential designs. Horizontal LAFs designs create a HEPA-filtered positive pressure plane of air in a horizontal path over the surgical field. Vertical LAF create plenums from the ceiling to the floor around the surgical site. Vertical exponential design LAF air plenums have a conical shape sitting on the floor with air intake at the floor level.
Alisina Shahi
Javad Parvizi
Numerous studies have supported the use of LAF and demonstrated that it could reduce the rates of PJI. Charnley and his colleagues revealed that the use of an ultra-clean OR reduced the rate of infection by 20-fold from 9.5% to 0.5% by using a combination of a clean air system and occlusive operating gowns. On the other hand, some recent studies have demonstrated that LAF provides no benefit and can even increase the risk of surgical site infection after arthroplasty. Eight studies conducted during a span of 10 years were pooled in a recent systematic review, which concluded that LAF does not reduce the rates of periprosthetic joint infection (PJI). Furthermore, the CDC has taken no stance regarding the LAF issue.
A definitive study that could define the absolute clinical benefit of LAF has yet to be conducted, and the existing literature on this subject remains compelling. Future research is needed to determine if particulate sampling can be routinely performed in lieu of microbiologic sampling for examining the air quality of clean environments. Regardless of whether LAF has a role in reduction of PJI, it is pertinent that every effort is made to reduce the number of particulate matters in the OR by controlling the OR traffic and by using a positive ventilation system.
References:
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Charnley J, et al. Br J Surg. 1969;56:641–649.
Gastmeier P, et al. J Hosp Infect. 2012; doi:10.1016/j.jhin.2012.04.008.
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For more information:
Alisina Shahi, MD; and Javad Parvizi MD, FRCS, can be reached at the Rothman Institute, 925 Chestnut St., 5th Floor, Philadelphia, PA 19107; Shahi’s email: alisina.ir@gmail.com; Parvizi’s email: parvj@aol.com.
Disclosures: Shahi reports no relevant financial disclosures. Parvizi reports he is a consultant to Zimmer, Smith & Nephew, 3M and Convatec.