Superficial wound infection does not cause inferior clinical outcome after TKA

Methylene Blue Infiltration As a Method for Distinguishing Superficial and Deep Infections

BACKGROUND

There are no established objective methods to reliably differentiate between superficial and deep infection in the setting of total hip arthroplasty. We employed a technique of distinguishing superficial and deep infections by infiltrating methylene blue to a prosthetic hip during infection workup to determine its effectiveness and to characterize its utility in defining the joint cavity where deep debridement is required.

METHODS

An analysis was conducted on 35 patients who preoperatively received an injection of methylene blue under radiological guidance to their total hip arthroplasty. Where established periprosthetic joint infection (PJI) criteria were not met, without signs of methylene blue beyond the deep fascia, the infection was considered superficial, and debridement remained superficial to the deep fascia. Where diagnosis of PJI was confirmed preoperatively or the presence of methylene blue in the wound cavity confirmed deep contamination, the prosthesis was addressed with methylene blue staining defining the joint cavity as a guide for debridement.

RESULTS

There were 11 patients who had no methylene blue extrusion into the superficial compartment and did not meet PJI criteria. Eight patients failed to meet PJI criteria preoperatively, but had extrusion of methylene blue, confirming a deep infection intraoperatively. There were 16 patients who met PJI criteria preoperatively with methylene blue acting as a visual guide to the joint space.

CONCLUSION

Infiltrating methylene blue in a prosthetic hip is useful in differentiating between superficial or deep infections where PJI workup is indeterminate. Where deep infection is present, its utility in defining the joint cavity may be advantageous.

Impact of surgical-site infection on health utility values: a meta-analysis

BACKGROUND

Surgical-site infections (SSIs) are recognized as negatively affecting patient quality of life. No meta-analysis of SSI utility values is available in the literature to inform estimates of this burden and investment decisions in prevention.

METHODS

A systematic search of PubMed, MEDLINE, CINAHL, and the National Health Service Economic Evaluation Database was performed in April 2022 in accordance with PROSPERO registration CRD 42021262633. Studies were included where quality-of-life data were gathered from adults undergoing surgery, and such data were presented for those with and without an SSI at similar time points. Two researchers undertook data extraction and quality appraisal independently, with a third as arbiter. Utility values were converted to EuroQol 5D (EQ-5D™) estimates. Meta-analyses were conducted using a random-effects model across all relevant studies, with subgroup analyses on type and timing of the SSI.

RESULTS

In total, 15 studies with 2817 patients met the inclusion criteria. Six studies across seven time points were used in the meta-analysis. The pooled mean difference in EQ-5D™ utility in all studies combined was -0.08 (95 per cent c.i. -0.11 to -0.05; prediction interval -0.16 to -0.01; I2 = 40 per cent). The mean difference in EQ-5D™ utility associated with deep SSI was -0.10 (95 per cent c.i. -0.14 to -0.06; I2 = 0 per cent) and the mean difference in EQ-5D™ utility persisted over time.

CONCLUSION

The present study provides the first synthesized estimate of SSI burden over the short and long term. EQ-5D™ utility estimates for a range of SSIs are essential for infection prevention planning and future economic modelling.

Impact of Incisional Surgical Site Infections on Quality of Life and Patient Satisfaction after General Surgery: A Case Controlled Study

Background: Most incisional surgical site infections (ISSI) are now diagnosed after discharge from hospital. In this context, it is important to document the impact ISSI has on our patients. Patients and Methods: Our surgical department sent a validated questionnaire to patients after they had been discharged. This documented incision problems, the 36-Item Short Form Health (SF-36) qualify of life questionnaire, and a patient satisfaction survey (PSS). We retrospectively reviewed records for 115 patients with an ISSI and 115 matched controls with no documented complications. Patient demographics and outcomes were collected. Differences in physical component summary (PCS) score and mental component summary (MCS) score and the PSS score were compared. Results: A majority (87%) of ISSIs were diagnosed after discharge from hospital. There were no differences in demographics, the American Society of Anaesthesiologists grade, or length of stay (LOS) between groups. Two months after surgery, ISSI was associated with lower post-operative SF-36 scores. The PCS was 42.9 (95% confidence interval [CI], 41.3-44.8) for ISSI cases and 47.0 (95% CI, 45.1-48.7) for controls (p ≤ 0.001). The MCS was 45.8 (95% CI, 43.7-47.9) and 50.2 (95% CI, 48.0-52.3), respectively (p = 0.01). Patients had less vitality, increased pain, and a reduction in physical activities and roles. The PSS score was 82.5 (95% CI, 79.6-85.4) in the control group and 74.1 (95% CI, 71.1-77.0) in the ISSI group (p < 0.001). Patients with ISSI reported worse satisfaction ratings with the quality of information received (p = 0.005) and their satisfaction with surgery (p < 0.001). Conclusions: Incisional surgical site infection was correlated with lower quality of life and PSS scores for up to two months after surgery. Prospective studies with pre-operative and post-operative quality of life are required to confirm causality.

The use of 2-octyl cyanoacrylate as an adjuvant to wound closure in total knee arthroplasty

PURPOSE

The efficacy of the use of 2-octyl cyanoacrylate (OCA) as an adjuvant to wound closure in preventing wound complications after total knee arthroplasty (TKA) is rarely reported. This study was aimed to determine whether the use of OCA as a supplement to conventional wound closure reduces the incidence of wound complications following TKA.

PATIENTS AND METHODS

This retrospective study reviewed 1106 consecutive patients who underwent TKA for symptomatic end-stage osteoarthritis (OA) between 2012 and 2017. The first 562 patients who did not receive OCA were grouped into the Control group, and the subsequent 544 patients who received OCA as an adjuvant to wound closure were grouped into the OCA group. All patients were followed up for at least 2 years. The main outcome was the development of operative site complications, including aseptic and infectious complications. Aseptic wound complications were wound leakage, hematoma, wound dehiscence and delayed wound healing, and infectious complication was mainly referred to the superficial infection.

RESULTS

No significant difference with regard to hematoma was observed between groups (3.0% vs. 3.7%, P = 0.617, φ = - 0.02). The incidences were significantly higher in the Control group versus the OCA group in regard to wound leakage (9.4% vs. 2.0%, P = 0.000, φ = 0.16), wound dehiscence (5.7% vs. 1.3%, P = 0.000, φ = 0.12), delayed wound healing (4.4% vs. 1.5%, P = 0.004, φ = 0.09) and superficial infection (2.0% vs. 0.4%, P = 0.022, φ = 0.07). No serious adverse events (AEs) occurred.

CONCLUSIONS

The present study showed that the addition of OCA reduced the incidence of wound leakage, wound dehiscence, delayed wound healing and superficial infection after TKA compared to conventional wound closure. Based on the outcomes above, we decide to use OCA routinely for wound closure after TKA.

LEVEL OF EVIDENCE

III, retrospective, cohort study.

Low post-arthroplasty infection rate is possible in developing countries: long-term experience of local vancomycin use in Iran

Background

Utilizing intrawound vancomycin powder in TKA surgery has yielded rather contrasting results in the current literature. Furthermore, CDC criteria, although effective in general, are not specifically designed for post-TKA infections. Here, we present a 7-year experience of vancomycin use in primary TKA in a high-volume tertiary knee center in Iran. Also, new criteria are proposed to detect suspected superficial post-TKA infections.

Methods

This is a retrospective analysis of primary total knee arthroplasties performed in a tertiary knee center, from March 2007 to December 2018, by a single senior knee surgeon. All patients with follow-up periods of less than 1 year were excluded from the study. Since March 2011, all patients received vancomycin (powder, 1 g) before water-tight closure of the joint capsule. A comparison was made between this group and historical control subjects (operated from March 2007 to March 2011).

Results

Altogether, 2024 patients were included in the study. The vancomycin and the control groups included 1710 and 314 cases respectively. Patients were mostly women (male to female ratio, 1 to 4), with a mean age of 65.20 (SD = 10.83) years. In the vancomycin group, the rate of suspected SII (1.87%) and PJI (0.41%) was significantly lower than the control group (P = 0.002).

Conclusions

Our experience shows that application of local vancomycin during TKA surgery could be a reasonable infection prevention measure, although prospective randomized studies are required to evaluate its efficacy.