Vacuum drainage of groin wounds after vascular surgery: a controlled trial

Efficacy of Strategies Intended to Prevent Surgical Site Infection After Lower Limb Revascularization Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

The objective of this study is to evaluate the efficacy of strategies intended to prevent surgical site infection (SSI) after lower limb revascularization surgery.

BACKGROUND

SSIs are common, costly complications of lower limb revascularization surgery associated with significant morbidity and mortality.

METHODS

We searched MEDLINE, EMBASE, CENTRAL, and Evidence-Based Medicine Reviews (inception to April 28, 2022). Two investigators independently screened abstracts and full-text articles, extracted data, and assessed the risk of bias. We included randomized controlled trials (RCTs) that evaluated strategies intended to prevent SSI after lower limb revascularization surgery for peripheral artery disease. We used random-effects models to pool data and GRADE to assess certainty.

RESULTS

Among 6258 identified citations, we included 26 RCTs (n=4752 patients) that evaluated 12 strategies to prevent SSI. Preincision antibiotics [risk ratio (RR)=0.25; 95% CI, 0.11-0.57; n=4 studies; I2 statistic=7.1%; high certainty] and incisional negative-pressure wound therapy (iNPWT) (RR=0.54; 95% CI, 0.38-0.78; n=5 studies; I2 statistic=7.2%; high certainty) reduced pooled risk of early (≤30 days) SSI. iNPWT also reduced the risk of longer-term (>30 days) SSI (pooled-RR=0.44; 95% CI, 0.26-0.73; n=2 studies; I2 =0%; low certainty). Strategies with uncertain effects on risk of SSI included preincision ultrasound vein mapping (RR=0.58; 95% CI, 0.33-1.01; n=1 study); transverse groin incisions (RR=0.33; 95% CI, 0.097-1.15; n=1 study), antibiotic-bonded prosthetic bypass grafts (RR=0.74; 95% CI, 0.44-1.25; n=1 study; n=257 patients), and postoperative oxygen administration (RR=0.66; 95% CI, 0.42-1.03; n=1 study) (low certainty for all).

CONCLUSIONS

Preincision antibiotics and iNPWT reduce the risk of early SSI after lower limb revascularization surgery. Confirmatory trials are required to determine whether other promising strategies also reduce SSI risk.

How to Prevent Surgical Site Infection in Vascular Surgery: A Review of the Evidence

BACKGROUND

This review aims to identify and review the current evidence for preventing postoperative surgical site infections in abdominal aortic aneurysm surgery or infrainguinal arterial surgery.

METHODS

Extended literature review of clinical trials that examined the prevention of postoperative surgical site infections in abdominal aortic aneurysm or infrainguinal arterial surgery. Searches were conducted on Ovid MEDLINE (1950 - 13 March 2020) using key terms for vascular surgery, surgical site infections and specific preventative techniques. Articles were included if they discussed a relationship between a preventative technique and surgical site infections in abdominal aortic aneurysm or infrainguinal arterial surgery. The GRADE guidelines were used to assess the quality of evidence.

RESULTS

21 techniques and 81 studies were included. Prophylactic antibiotics and negative pressure wound therapy have a high quality of evidence for the prevention of surgical site infections in abdominal aortic aneurysm or infrainguinal arterial surgery. A moderate quality evidence base was identified for gentamicin containing collagen implant (confined to high surgical site infection risk centers). Currently, there is a low or very low quality of evidence to suggest a reduction in the surgical site infection rate for combination therapy, glycaemic control, Methicillin-resistant Staphylococcus aureus screening and absorbable suture. Evidence suggests no beneficial effect for nutritional supplementation, chlorhexidine bath, hair removal therapy, Staphylococcus aureus nasal eradication, cyanoacrylate microsealant, silver grafts, rifampicin bonded grafts, triclosan coated suture and postoperative wound drains. Endoscopic saphenous vein harvest may reduce surgical site infection rate (very low quality of evidence) but may lower long-term patency. Autologous vein grafts may increase surgical site infections (very low quality of evidence) but may provide better long-term patency rates in above-knee infrainguinal bypass surgery. There was no identified evidence for perioperative normothermia, electrosurgical bipolar vessel sealer or Dermabond and Tegaderm for surgical site infection prevention in vascular surgery.

CONCLUSIONS

Prophylactic antibiotics and postoperative negative pressure wound therapy are effective in the prevention of postoperative surgical site infection in abdominal aortic aneurysm or infrainguinal arterial surgery. There exists a significant risk of bias in the literature for many preventative techniques and further studies are required to investigate the efficacy of gentamicin containing collagen implant, and specific combination therapies.

Algorithmic approach to the lymphatic leak after vascular reconstruction: a systematic review

Background

To date, there are no consensus guidelines for management of lymphatic leak in groin vascular reconstruction patients. The goal of this study is to review the relevant literature to determine alternatives for treatment and to design an evidence-based algorithm to minimize cost and morbidity and maximize efficacy.

Methods

A systematic review of the literature was conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Two independent reviewers applied agreed-upon inclusion and exclusion criteria to eligible records. Studies that included patients who underwent groin dissection for oncologic diagnoses and level 5 data were excluded. Interventions were then categorized by efficacy using predetermined criteria.

Results

Our search yielded 333 records, of which eight studies were included. In four studies, the success of lymphatic ligation ranged from 75% to 100%, with average days to resolution ranging from 0 to 9. Conservative management in the form of elevation, compression, and bedrest may prolong time to resolution of lymphatic leak (14–24 days) and therefore cost.

Conclusions

The majority of patients should be offered early operative intervention in the form of lymphatic ligation with or without a primary muscle flap. If the patient is not an operative candidate, a trial of conservative management should be attempted before other nonsurgical interventions.

A review of the postoperative lymphatic leakage

Lymphatic complications are rare, but well-known phenomena, and have been described by many researchers. However, many diagnoses of lymphatic complications are found confusing due to different definition. A literature search in Pubmed was performed for studies postoperative lympatic complications. These complications divided into two parts: lymphatic leakage and lymphatic stasis. This review is about lymphatic leakage, especially, postoperative lymphatic leakage due to the injury of lymphatic channels in surgical procedures. According to polytrophic consequences, many types of postoperative lymphatic leakage have been presented, including lymph ascites, lymphocele, lymphorrhea, lymphatic fistula, chylous ascites, chylothorax, chyloretroperitoneum and chylorrhea. In this review, we focus on the definition, incidence and treatment about most of these forms of lymphatic complications to depict a comprehensive view of postoperative lymphatic leakage. We hold the idea that the method of treatment should be individual and personal according to manifestation and tolerance of patient. Meanwhile, conservative treatment is suitable and should be considered first.

Wound drainage for lower limb arterial surgery

BACKGROUND

Drains are often used in leg wounds after vascular surgery procedures despite uncertainty regarding their benefits. Drains are placed with the aim of reducing the incidence and size of blood or fluid collections. Conversely, drains may predispose patients to infection and may prolong hospitalisation. Surgeons need robust data regarding the effects of drains on complications following lower limb arterial surgery.

OBJECTIVES

To determine whether routine placement of wound drains results in fewer complications following lower limb arterial surgery than no drains.

SEARCH METHODS

In June 2016 we searched: the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. We also searched clinical trial registries for ongoing studies.There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We considered randomized controlled trials (RCTs) that evaluated the use of any type of drain in lower limb arterial surgery.

DATA COLLECTION AND ANALYSIS

Two authors independently determined study eligibility, extracted data and performed an assessment of bias. An effort was made to contact authors for missing data. The methods and results of each eligible study were summarised and we planned to pool data in meta-analyses when it was considered appropriate, based upon clinical and statistical homogeneity.

MAIN RESULTS

We identified three eligible trials involving a total of 222 participants with 333 groin wounds. Suction drainage was compared with no drainage in all studies. Two studies were parallel-group, randomized controlled trials, and one was a split-body, randomized controlled trial. Trial settings were not clearly described. Patients undergoing bypass and endarterectomy procedures were included, but none of the studies provided details on the severity of the underlying arterial disease.We deemed all of the studies to be at a high risk of bias in three or more domains of the 'Risk of bias' assessment and overall the evidence was of very low quality. Two out of three studies had unit of analysis errors (with multiple wounds within patients analysed as independent) and it was not possible to judge the appropriateness of the analysis of the third. Meta-analysis was not appropriate, firstly because of clinical heterogeneity, and secondly because we were not able to adjust for the analysis errors in the individual trials. One trial yielded data on surgical site infections (SSI; the primary outcome of the review): there was no clear difference between drained and non-drained wounds for SSI (risk ratio 1.33; 95% confidence interval 0.30 to 5.94; 50 participants with bilateral groin wounds; very low quality evidence). It was not possible to evaluate any other outcomes from this trial. The results from the other two studies are unreliable because of analysis errors and reporting omissions.

AUTHORS' CONCLUSIONS

The data upon which to base practice in this area are limited and prone to biases. Complete uncertainty remains regarding the potential benefits and harms associated with the use of wound drains in lower limb arterial surgery due to the small number of completed studies and weaknesses in their design and conduct. Higher quality evidence is needed to inform clinical decision making. To our knowledge, no trials on this topic are currently active.

Management of Infected Early Postoperative Lymph Leak in the Groin

Lymph leak from a groin incision following vascular procedures on the fem oral vessels can be a difficult postoperative management problem. Eight pa tients (of 198 undergoing vascular reconstructions involving the femoral vessels) developed 9 lymph leaks (4.5%) through the groin skin incision in the first post operative week. Three patients (38%) had a synthetic prosthesis and 5 (62%) had autogenous saphenous vein grafts. Initially, the authors treated the patients with intravenous antibiotics, bed rest, and sterile occlusive dressings. The lym phorrhea persisted in all patients, and serial cultures of the draining lymph became positive within fourteen days postoperatively. Surgical management consisted of radical debridement of the wound and rotation of a muscle flap to cover the vascular repair. The wounds were left open to granulate, then split- thickness skin grafts were applied. During a follow-up period ranging from eighteen to thirty-six months, there was no evidence of graft infection, recurrent lymph leak, or limb loss.

Although the patient population is small, the authors feel that when a lymph collection in the groin leaks through the skin incision, the incidence of infection is high. Their surgical approach seems to yield a favorable outcome in control ling the lymph leak and preventing extension of infection to the vascular recon struction.

Necessity of Surgical Site Closed Suction Drain for Pterional Craniotomy

Objective

The aim of this study was to assess the benefit of using a prophylactic surgical site closed suction drain in pterional craniotomy.

Materials and Methods

A retrospective review was conducted on 607 consecutive patients who underwent a pterional craniotomy for treatment of intracranial anterior circulation aneurysms over a 5-year period. Between January 2000 and December 2004, 607 patients were divided into two groups, those who had a prophylactic suction drain during closure of the surgical site (drain group, DG) and those who did not (non-drain group, NDG). Head computed tomography (CT) was taken routinely on postoperative day (POD) 1, 7, and 14. Patients' demographics, incidence of surgical site complications, and courses of surgical site healing which were evaluated radiologically by the thickness of the surgical site myocutaneous layer, were analyzed between DG and NDG.

Results

Patients' demographics and characteristics did not differ significantly between the two groups. The head CT showed that the degree of changes in the postoperative surgical site thickness was 148% at POD 1, 209% at POD 7, and 198% at POD 14 in DG, and 118% at POD 1, 152% at POD 7, and 158% at POD 14 in NDG compared to the preoperative value. Postoperative surgical site hematoma was 7.9% (22/274) in DG and 2.4% (8/333) in NDG.

Conclusion

Prophylactic use of an epidural and/or subgaleal closed suction drain does not appear to be necessary for prevention of postoperative surgical site hematoma as well as for promotion of surgical site healing in pterional craniotomy.

Forearm Isosulfan blue injection in the treatment of postoperative lymphatic complications

Lymphatic leakage is an uncommon but serious complication following vascular procedures. When conservative measures fail, accurate identification and ligation of disrupted lymphatic channels is necessary to avoid recurrence. We report the case of a 52-year-old male with a left forearm lymphocele, which occurred following repair of an interosseous artery pseudoaneurysm. Successful lymphatic identification and ligation was performed using intradermal injection of Isosulphan blue dye at the time of operation.

Closed suction drainage improves clinical outcome in patients undergoing endoscopic vein harvesting for coronary artery bypass grafting

BACKGROUND

Endoscopic vein harvesting (EVH) is a widely accepted technique for coronary artery bypass grafting, with well-reported benefits. However, EVH is associated with severe hematoma formation at incision sites, resulting in postoperative pain. We hypothesized that the use of a leg wound drain at the incision site may reduce these comorbidities.

METHODS

One hundred consecutive patients were prospectively randomly allocated into two groups of 50: group 1 with leg wound drains, and group 2 without drains. Group 1 patients underwent EVH followed by closure with a size 10 high vacuum leg wound drain (20 kPa), whereas group 2 underwent EVH followed by closure without a leg wound drain. Patients were assessed for postoperative pain, wound infection, and satisfaction using validated scoring systems immediately after surgery.

RESULTS

Pain at rest (p < 0.001) and with movement (p < 0.001), incidence of hematoma (p < 0.001), and patient satisfaction (p < 0.001) were significantly improved in the drain group at days 1 to 7 and remained significant at week 6 after surgery. Interestingly, the use of antibiotics (6% versus 24%, p = 0.012) and the number of general practitioner visits (6% versus 26%, p = 0.012) were lower in the drain group compared with the no-drain group. However, there were no differences in the length of hospital stay between the two groups after surgery.

CONCLUSIONS

Our findings indicate that the use of a high vacuum leg drain after EVH for long saphenous vein is of clear therapeutic benefit in the early postoperative period. We also report that this technique may reduce antibiotic administration and general practitioner visits after patient discharge.

Efficacy of closed suction drainage in lower limb arterial surgery: a meta-analysis of published clinical trials

BACKGROUND

Suction drains are widely used in vascular surgery, despite the absence of specific evidence that they confer benefit to patients. There has been no systematic review of the available evidence, though drainage has been shown to confer no benefit, or indeed harm, across a variety of surgical disciplines. Accordingly, a systematic review and meta-analysis of the current evidence base for closed suction drainage following surgical lower limb revascularization was undertaken.

METHODS

Medline, Embase, trial registries, conference proceedings, and article reference lists were searched to identify randomized controlled trials of the use of surgical drains. The primary outcomes were wound infection, seroma/lymphocele formation, and hematoma formation. Pooled odds ratios were calculated for categorical outcomes.

RESULTS

Four trials containing 429 groin wounds were eligible for inclusion. There was no significant effect on wound infection, seroma/lymphocele formation, or hematoma formation.

CONCLUSION

Our meta-analysis suggests that no benefit is conferred by wound drainage following lower limb revascularization. The practice incurs avoidable expense and should not be routinely used.

Prevention of infection in peripheral arterial reconstruction: A systematic review and meta-analysis

OBJECTIVE

The aim of this systematic review and meta-analysis was to determine the effectiveness of perioperative strategies to prevent infection in patients undergoing peripheral arterial reconstruction.

METHODS

All randomized controlled trials (RCTs) evaluating measures intended to reduce or prevent infection in arterial surgery were identified through searches of the Cochrane Peripheral Vascular Diseases Group specialized trials register, the Cochrane Central Register of Controlled Trials (CENTRAL), and reference lists of relevant articles. Two authors independently selected and assessed the quality of included trials. Relative risk (RR) was used as a measure of effect for each dichotomous outcome.

RESULTS

The study included 34 RCTs. Of these, 22 were trials of prophylactic systemic antibiotics, 3 of rifampicin-bonded grafts, 3 of preoperative skin antisepsis, 2 of suction wound drainage, 2 of minimally invasive in situ bypass techniques, and individual trials of intraoperative glove change and wound closure techniques. Wound infection or early graft infection outcomes were recorded in all trials. Only two trials, both of rifampicin bonding, followed up graft infection outcomes to 2 years. Prophylactic systemic antibiotics reduced the risk of wound infection (RR, 0.25; 95% confidence interval [CI], 0.17 to 0.38) and early graft infection in a fixed-effect model (RR, 0.31; 95% CI, 0.11 to 0.85, P = .02). Antibiotic prophylaxis for >24 hours appeared to be of no added benefit (RR, 1.28; 95% CI, 0.82 to 1.98). There was no evidence that prophylactic rifampicin bonding to Dacron grafts reduced graft infection at 1 month (RR, 0.63; 95% CI, 0.27 to 1.49), or 2 years (RR, 1.05; 95% CI, 0.46 to 2.40). There was no evidence of a beneficial or detrimental effect on rates of wound infection with suction groin wound drainage (RR, 0.96; 95% CI, 0.50 to 1.86) or from preoperative bathing with antiseptic agents compared with unmedicated bathing (RR, 0.97; 95% CI, 0.70 to 1.36).

CONCLUSIONS

There is clear evidence of the benefit of prophylactic broad-spectrum antibiotics for vascular reconstruction. Many other interventions intended to reduce the risk of infection in arterial reconstruction lack evidence of effectiveness.

Prevention of infection in arterial reconstruction

BACKGROUND

Arterial reconstructions with prosthetic graft materials or vein are susceptible to infection with a resultant high patient mortality and risk of limb loss. To reduce the risk of infection effective perioperative measures are essential.

OBJECTIVES

To determine the effectiveness of perioperative strategies to prevent infection in patients undergoing peripheral arterial reconstruction.

SEARCH STRATEGY

We searched the Cochrane Peripheral Vascular Diseases Group trials register (last searched May 2006) and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched Issue 2, 2006), and reference lists of relevant articles.

SELECTION CRITERIA

All randomised controlled trials (RCTs) evaluating measures intended to reduce or prevent infection in arterial surgery.

DATA COLLECTION AND ANALYSIS

AS and PSE independently selected and assessed the quality of included trials. Relative risk was used as a measure of effect for each dichotomous outcome.

MAIN RESULTS

Thirty-five RCTs were included. Of these, 23 were trials of prophylactic systemic antibiotics, three of rifampicin-bonded grafts, three of preoperative skin antisepsis, two of suction wound drainage, two of minimally invasive in situ bypass techniques, and individual trials of intraoperative glove change and wound closure techniques. Wound infection or early graft infection outcomes were recorded in all trials. Only two trials, both of rifampicin bonding, followed up graft infection outcomes to two years. Trials of antibiotics versus placebo were of highest quality with six double-blind studies of the ten included. Prophylactic systemic antibiotics reduced the risk of wound infection (Relative Risk (RR) 0.25, 95% Confidence Interval (CI) 0.17 to 0.38) and early graft infection in a fixed-effect model (RR 0.31, 95% CI 0.11 to 0.85, P = 0.02). Antibiotic prophylaxis for greater than 24 hours appears to be of no added benefit (RR 1.28, 95% CI 0.82 to 1.98). There was no evidence that prophylactic rifampicin bonding to dacron grafts reduced graft infection at either one month (RR 0.63, 95% CI 0.27 to 1.49) or two years (RR 1.05, 95% CI 0.46 to 2.40). There was no evidence of a beneficial or detrimental effect on rates of wound infection with suction groin-wound drainage (RR 0.96 95% CI 0.50 to 1.86) or of any benefit from a preoperative bathing or shower regimen with antiseptic agents over unmedicated bathing (RR 0.97, 95% CI 0.70 to 1.36).

AUTHORS' CONCLUSIONS

There is clear evidence of the benefits of prophylactic broad spectrum antibiotics. Many other interventions intended to reduce the risk of infection in arterial reconstruction lack evidence of effectiveness.

The Value of Suction Wound Drain after Carotid and Femoral Artery Surgery: A Randomised Trial Using Duplex Assessment of the Volume of Post-operative Haematoma

BACKGROUND

The use of vacuum suction drains after carotid endarterectomy (CEA) and groin dissection for arterial reconstruction surgery remains controversial. A large multicentre prospective randomised trial would be needed to show any difference if clinical end points (infection and haematoma) are used. Therefore, we conducted a study to evaluate the value of wound drainage using accurate duplex measurement of haematoma expecting a 25% difference in volume between drained and non-drained wounds.

PATIENTS AND METHODS

Seventy consecutive patients undergoing CEA and 73 patients who underwent 106 groins dissection were separately and blindly randomised into two groups: group (a) with wound drain and group (b) without wound drain. A duplex scan was carried out post-operatively to document the presence and volume of any wound haematoma.

RESULTS

The majority of wounds did not show any evidence of collections. 1. In the CEA patients duplex scan revealed wound haematoma in 8 patients with a median volume of 25 ml (5-65) in group (a) in comparison to 7 wound haematomas 31 ml (3-72) in group (b). Median suction drain drainage was 42 ml (10-120) when used. There was no significant difference between the two groups. Three patients 4.3% (two from the drain group) underwent evacuation of haematoma post-operatively.2. In the groin dissection patients most of the documented collections were trivial. Ultrasound scans showed 21 collections (20%), of these 7 (34%) were in group (a) and 14 (66%) were in group (b). There was no significant difference in wound collections between the two groups (p = 0.28). Only 5 collections (75%) exceeded 10 ml, three of them were in the drain group. One patient (1%), who did not have a drain, developed a wound collection, which needed re-exploration. When a drain was used the median drainage was 64.5 ml (range 10-220).

CONCLUSION

These results based on accurate measurement of wound collection suggest that there is no benefit in terms of reduction of the volume of haematoma on wound drainage after CEA or arterial reconstruction surgery involving the groin. A selective policy of use of drainage is therefore recommended.

Intraoperative use of isosulfan blue in the treatment of persistent lymphatic leaks

BACKGROUND

Lymphatic leaks are a major source of morbidity after lower extremity vascular surgery. We determined the ability of isosulfan blue (Lymphazurin) use to identify and help ligate offending lymphatics, and compared postoperative complication rates and length of stay versus nonoperative therapy alone.

METHODS

From January 1993 through March 2002, we identified 15 patients with lymphatic leaks. The first group consisted of 5 patients treated nonoperatively. The second group was 10 patients (11 explorations) treated operatively aided by isosulfan blue, after a trial of nonoperative therapy.

RESULTS

Isosulfan blue identified the leak in 10 of 11 cases. Mean drainage time for the nonoperative group was 47.6 days versus 1.8 days for the operative group (P = 0.036). Within the operative group, the mean drainage time during their initial conservative treatment phase was 15 days versus 1.8 days after surgery (P < 0.01). Complications were significantly less in the operative group (P < 0.05). Postoperative length of stay was a mean of 4.7 days versus 8.1 days for nonoperative patients (P = not significant).

CONCLUSIONS

Intraoperative isosulfan blue use accurately identifies disrupted lymphatic channels and helps ensure definitive ligation. This simple procedure is associated with fewer complications, and a trend toward shorter hospital stay.

Prevention of postoperative wound haematomas and hyperperfusion following carotid endarterectomy

OBJECTIVE

To study the incidence of wound haematomas and hyperperfusion following carotid endarterectomy and the effect of changes in perioperative management.

METHODS

We undertook a prospective audit of the postoperative outcome of 300 consecutive carotid endarterectomies performed for a symptomatic stenosis of the internal carotid artery, under the care of a single consultant.

RESULTS

audit of the first 100 operations between 1990-93 resulted in 4 changes to clinical practice. These included the use of Dacron instead of vein because of 3 vein patch blowouts, invasive postoperative monitoring of blood pressure, and the use of intravenous beta-blockers to control hypertension, because of 4 hyperperfusion injuries. The use of 10F suction drains was discontinued, because they did not prevent 8 wound haematomas. The results of the second 100 cases between 1994-97 and the third 100 cases between 1998-2000 confirmed no further hyperperfusion injuries or patch blowouts (p =0.01 and 0.04 respectively). Larger 14F suction drains were reintroduced for the third series because of thirteen haematomas in the second series (p =0.09). Only 4 haematomas occurred in the third series ( p =0.05). The need for beta-blockers fell in the third series due to the introduction of local anaesthesia (p =0.0001).

CONCLUSION

The use of Dacron patches and postoperative control of hypertension has reduced the incidence of haemorrhage and hyperperfusion after carotid endarterectomy. Larger suction drains may also help.

Efficacy of surgical wound drainage in orthopaedic trauma patients: a randomized prospective trial

OBJECTIVE

To study the efficacy of closed suction drainage in clean nonemergent surgical fracture fixation or bone grafting on the extremities or pelvis.

DESIGN

A prospective randomized trial.

SETTING

The orthopaedic trauma service of a Level I trauma hospital.

PATIENTS

Patients were older than age eighteen years and undergoing clean nonemergent surgical fracture fixation or bone grafting procedures on the extremities (excluding hands and feet) or pelvis.

INTERVENTION

The application of a surgical drain.

MAIN OUTCOME MEASUREMENTS

Wound drainage, edema, hematoma and erythema, dehiscence, infection, and need for surgery or readmission were followed for six weeks. A univariate analysis with Student's t test for continuous variables and chi-squared analysis for all categorical data were used, with a p value of < or = 0.05 considered statistically significant.

RESULTS

A total of 202 patients were randomized to 102 patients with no drain and 100 patients with a drain. There was no significant difference between the groups with regard to injury severity, systemic disease, age, body weight, physical status, or estimated blood loss. There was no significant difference between the drain and no-drain groups in any of the parameters evaluated.

CONCLUSION

There is no significant difference between drained and nondrained wounds in clean, nonurgent orthopaedic trauma surgery. It appears that drainage systems can be safely eliminated in this group.

Vacuum requirement in closed surgical drainage of the head and neck

Prophylactic vacuum drainage of surgical wounds is a controversial issue, but is acknowledged to be important in head and neck surgery. A study was undertaken to identify the ideal surgical drain. The results indicate that the low vacuum systems are inefficient, and should not be used in situations where tissue swelling may compromise the airway.

Prosthetic vascular graft infection

The aetiology, diagnosis and management of prosthetic vascular graft infection are reviewed. The importance of contamination at the time of surgery as the crucial aetiological factor is highlighted. Staphylococcus epidermidis is the causative organism in over 50 per cent of cases and the reasons for this are explored. Sound surgical technique, use of prophylactic antibiotics and the avoidance of a groin incision are emphasized as the most important factors in prevention of graft infection. Difficulties of diagnosis are highlighted and the diagnostic role of various imaging methods is assessed. Graft excision with extra-anatomic revascularization is presented as the conventional surgical solution, while the roles of less radical surgical solutions and non-operative management are discussed.