But i switched to chlorhexidine-alcohol prep, iodine-impregnated drapes, and meticulous layered closure with a nylon running subcuticular in July, and my 90-day SSI rate after primary TKA fell from 1.2% to 0.3% over 84 cases. With sealed dressings kept 7 days and tighter glucose control, incisions are consistently dry and pristine — anyone else seeing similar gains from small, precise changes?
tighter glucose control, incisions are consistently dry and pristine — anyone else seeing similar gains Same here — standardizing a PACU insulin protocol (target 110–[redacted]/dL for the first 24 h) cut superficial drainage and nudged our 90-day SSI under 0.5%; small caveat: dexamethasone spikes it, so we preempt with a little basal insulin — have you tweaked steroid use?
My take: I’d lean toward the simplest next step and see if it changes anything this week — if not, you’ve got a clear case to escalate. What would block you from trying that?
One tweak that moved the needle for me was a 0.35% dilute povidone‑iodine soak for about 3 minutes after implant and before final closure — since adding it, early drainage has been rare. I also make the team wait for “full dry time” on the CHG‑alcohol prep before draping; when we rush it, we see more edge blistering. Small caveat: vancomycin powder didn’t help in my TKAs, so I dropped it; CDC SSI guidance is a good baseline: https://www.cdc.gov/infectioncontrol/guidelines/ssi/index.html.
We saw a similar drop after adding universal nasal decolonization — mupirocin BID x5 days plus CHG wipes started at the pre-op visit; over about 120 primaries, 90‑day SSI fell from about 1% to about 0.4%. Only caveat is compliance; if they show up late, we’ll use day-of 5% povidone‑iodine nasal swabs — @jporter4, are you screening or going “universal”?
Switching to incisional negative pressure therapy just for higher-risk TKAs (BMI >40, insulin-dependent DM, smokers) made the biggest difference for me; early drainage fell off and the wounds look calmer, and the key is a meticulous seal (‘no wrinkles under the foam’). Minor caveat: I’ve seen a couple edge blisters if the drape overlaps the popliteal crease, so I trim it short.
Right before that ‘meticulous layered closure,’ we switch to a clean closing tray, change gloves, and drop a fresh drape; since adding it, we’ve seen fewer weepy wounds and fewer superficial positives. It’s not sexy — more like swapping to a fresh cutting board — but it helps, though it does add a couple minutes and an extra tray.
Tightened up peri‑op antibiotic dosing — weight‑based cefazolin (3 g if >120 kg) with a redose when cases cross 3 hours — nudged our TKA SSI rate down too; not glamorous, but it works. For true beta‑lactam allergy, clinda alone underperforms so I add a single low‑dose gent (watch the kidneys), and @davis_jay76’s decolonization pairs nicely — are you redosing on longer cases?
Quick win for us was enforcing a full 3‑minute dry time after the chlorhexidine‑alcohol before the iodine drape, @OP… When we rushed it, , we got edge blistering and occasional weepers; ‘let it dry’ + a thin skin‑prep ring kept the 7‑day dressing pristine. Small downside is the extra minute when turnover’s tight, but it’s been worth it — are you timing the dry before you drop the drape?
We started releasing the tourniquet before final closure, took a 2‑minute hemostasis timeout, and added topical TXA (1 g in [redacted]) — post‑op ooze dropped and, like your 7‑day sealed dressings, the incisions stayed dry, @OP. The only annoyance is it adds a couple minutes, but I’ll take that over dressing changes; quick overview if helpful: topical tranexamic acid total knee arthroplasty - Search Results - PubMed.