After any surgery, there is a small chance of getting a surgical site infection (SSI). According to Infectious Disease Advisor, approximately 27 million surgical procedures are performed in the United States each year, with up to 5% resulting in SSI. This is because your skin is a natural barrier against external factors that can cause infections—and when this barrier is broken during a surgery, it places you at a higher risk of infection. Surgical site infections typically occur within the first 30 days after surgery, and are usually minor and superficial. However, in more serious cases, these infections can affect tissues under the skin, organs, and even surgical implants (e.g. shoulder replacement materials). Infection after shoulder replacement surgery is unusual as it may occur with the procedure yet take months before it is clearly recognized.

What’s more, patients with SSIs are more than five times more likely to be readmitted to the hospital after discharge and are 60% more likely to need admission to the intensive care unit. This is why it’s important that you not only understand how these infections happen, but also the steps you can take to lower your risk of SSIs altogether.

How do surgical site infections happen?

Surgical site infections happen through the spread of bacteria, such as Staphylococcus, Streptococcus, and Pseudomonas in most areas of the body. This bacteria can infect a surgical wound from the touch of a contaminated caregiver, through airborne pathogens, or through microorganisms that were already on or in your body during the time of the surgery that make their way into the incision. Remarkably, the most common bacteria to cause infection after shoulder surgery is Cutibacterium acnes, which is the same bacteria that is related to acne that can affect skin on your face or back.

Certain types of infection have an increased risk of occuring in a hospital setting, such as: 

• Methicillin-resistant Staphylococcus aureus infection (MRSA) – This infection can spread through touch, such as from a healthcare worker with unclean hands or a contaminated surface that came into contact with the patient during surgery.
• Vancomycin-resistant enterococcus (VRE) – This infection typically spreads when a healthcare worker touches an infected surgical instrument, surface or person and fails to properly wash their hands before touching another patient. 

Having surgery in a hospital carries a higher risk of infection as compared to the same procedure done at an ambulatory service center (ASC). In a 2009 study of surgeries completed in hospital, SSIs occurred in approximately 2% of surgical procedures, while a 2013 study of surgeries done on an outpatient basis in a multi-specialty ASC showed a decreased rate of SSIs at 0.81%. The rate of infection fell even lower at single specialty ASCs to just 0.38%.

Who is at the highest risk for surgical site infections?

There are many factors that increase the risk of an SSI. These include:

• Diabetes;
• Tobacco use;
• Obesity; 
• Compromised immune systems;
• Poor nutritional status; and
• Existing medical conditions and diseases. 

Additionally, patients who are very old or very young are at a higher SSI risk. Having a surgery that lasts longer than two hours also increases the odds, as does the length of a patient’s hospital stay. Fortunately, a skilled surgeon like Dr. Romeo can complete most elbow and shoulder surgeries in less than two hours in an ambulatory surgery center environment.

How to prevent surgical site infections

There are many factors that increase the risk of an SSI. As such, the most effective prevention strategy involves steps taken before, during, and after surgery. 

Before Surgery

Before surgery, tell your doctor about any health problems you have. Tobacco use increases your chances for infection, so Dr. Romeo will ask you to quit smoking for at least 4 weeks before surgery to mitigate this risk as well as the risks of anesthesia due to smoking.  Also, avoid shaving the area where you will be having surgery, as this can irritate the skin and make it easier to develop an infection. If hair removal is necessary at the site of surgery, it is best to let the surgical team perform this task on the day of surgery.

In addition, since the most common infection around the shoulder is C. acnes, you will be asked to wash the area of the surgical incision for two mornings before and the morning of surgery with a cleaning solution that includes benzoyl peroxide.  Over-the-counter skin cleansers are available at pharmacies and other stores that have skin care products.

One hour before surgery, you will receive intravenous antibiotics to help protect the surgical site during the procedure. You will receive one more dosage of the antibiotic after the procedure.  Please make sure you let Dr. Romeo and his team know if you have allergies to antibiotics, or any medications.

During Surgery

During surgery, Dr. Romeo does everything possible to prevent infection. All operating room staff thoroughly wash their hands and arms up to their elbows with an antiseptic agent. They wear special hair covers, masks, gowns and gloves during surgery to keep the surgery area clean. The skin around the surgery site is also cleaned with a special germ-killing soap, as well as hydrogen peroxide which targets the C. anes bacteria. During open shoulder surgery, once the reconstruction or replacement is completed, your surgical site will be irrigated with a diluted betadine solution, followed by the application of an antibiotic powder to the surgical site which has the ability to kill the most common bacteria associated with surgical infections. Rest assured that every precaution is taken to keep you safe and the surgical field sterile.

After Surgery

Keep it clean

After surgery, you want to do everything possible to keep the surgical area clean and dry. Anyone visiting you—including healthcare workers, friends, and family—should thoroughly clean their hands with soap and water or an alcohol-based rub. No one should touch your wound or dressings unless given instructions by your doctor to do so. 

Finish your antibiotics

After surgery you may be started on antibiotics by your doctor if there is some concern of a higher risk of infection, such as a history of previous surgery for shoulder replacement. It is extremely important to finish all of the prescribed antibiotics, even if you feel better. In a recent study, patients who took all their antibiotics had an SSI rate of 3.3% (24 of 718 patients), while those which were non-compliant had a rate of 8.1% (5 of 62). 

Take care of your incision

Carefully follow any instructions from your doctor on how to properly care for your incision after surgery. These include:

• Call your doctor if you notice redness, swelling, heat, pain, tenderness, or drainage from the surgical incision (note, some watery drainage from the small incisions used for arthroscopic surgery is normal for the first 24 hours);
• Attend all post-operative appointments to get your incision checked;
• Keep your incision and your surroundings as sterile as possible while changing dressings; and
• Keep your incision dry at all times. 
• If you have any questions about the way your incision is healing, you should take a picture of your shoulder incision with your smartphone, send the picture, then call the office for advice.

Maintain good nutrition

Good nutrition is also an essential part of preventing an SSI, so embrace your leafy greens and foods with good protein content! Eating high quality foods before and after your surgery will boost your nutrition and lower your risk of inflammation. If you’re not sure where to start, there are new companies selling special nutritional supplement kits that are started before surgery and continue a short time after surgery.

While the risk of developing an SSI cannot be completely eliminated, there are many ways to lower your risk. Dr. Romeo has decades of experience preventing surgical site infections and will take every possible precaution. 

If you have any concerns prior to surgery, Dr. Romeo and his team will be happy to discuss them and prepare you for a successful elbow or shoulder surgery.