Current Concepts for Clean Air and Total Joint Arthroplasty: Laminar Airflow and Ultraviolet Radiation: A Systematic Review

With the trend toward pay-for-performance standards plus the increasing incidence and prevalence of periprosthetic joint infection (PJI), orthopaedic surgeons must reconsider all potential infection control measures. Both airborne and nonairborne bacterial contamination must be reduced in the operating room. Analysis of airborne bacterial reduction technologies includes evaluation of (1) the effectiveness of laminar air flow (LAF) and ultraviolet light (UVL); (2) the financial and potential health costs of each; and (3) an examination of current national and international standards, and guidelines. We systematically reviewed the literature from Ovid, PubMed (Medline), Cochrane DSR, ACP Journal Club, DARE, CCTR, CMR, HTA, NHSEED, CINAHLPLUS, and Google Scholar published until June 2010 focusing on ultraclean air, ultraviolet light, and laminar air. High-level data demonstrating substantial PJI reduction of any infection control method may not be feasible as a result of the relatively low rates of occurrence and the expense and difficulty of conducting a large enough study with adequate power. UVL has potentially unacceptable health costs and the Centers for Disease Control and Prevention (CDC) recommends against its use. European countries have standardized LAF and it is used by the majority of American joint surgeons. Both LAF and UVL reduce PJI. The absence of a high level of evidence from randomized trials is not proof of ineffectiveness. The historically high cost of LAF has decreased substantially. Only LAF has been standardized by several European countries. The CDC recommends further study of LAF but recommends UVL not be used secondary to documented potential health risks to personnel.