The role of surgical helmet systems in reducing infection rate: a systematic review.

BACKGROUND: Periprosthetic joint infection (PJI) is a severe complication of arthroplasty. Surgical helmet system (SHS) was introduced to reduce airborne contamination however their efficacy remains controversial. This systematic review evaluates on the role of SHS in reduction PJI, explores contamination mechanisms and the impact of design and operational factors. METHODS: A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines across PubMed, Medline and Cochrane Library databases from 1950 to 2024. Studies were included if they investigated SHS in arthroplasty and reported on infection rates, contamination or SHS performance. Data extraction focused on study design, SHS type, infection outcomes and contamination mechanisms and whether paper is supporting SHS in reducing PJI. Effective Public Health Practice Project (EPHPP) quality tool was used to assess methodological quality of each included papers. RESULTS: Twenty studies met inclusion criteria. Five large registry studies evaluated SHS effectiveness in reducing PJI, with conflicting outcomes: one showed significantly lower infection rates with SHS, while others found no difference or a potential increase in risk. Ten studies assessed contamination pathways, with several reporting higher microbial emission and wound contamination associated with SHS use. Design and operational factors significantly influenced contamination, with delayed fan activation and use of sealed or zippered gowns associated with reduced contamination levels. CONCLUSION: Evidence on SHS effectiveness in reducing PJI remains inconclusive. While modern systems may offer benefits, improper use can increase contamination. Optimized protocols including delayed fan activation, appropriate gowning techniques, and regular helmet decontamination are essential. SHS should complement, not replace, established infection prevention strategies. High-quality prospective studies are needed to define best practices for SHS implementation.