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Chen KH, Rojas Lievano J, Velasquez Garcia AR, Nishikawa H, Chaney GK, Sanchez-Sotelo J, Morrey ME, O'Driscoll SW. Complications of antibiotic cement spacers used for elbow infections. J Shoulder Elbow Surg 2024; 33:1624-1632. [PMID: 38599456 DOI: 10.1016/j.jse.2024.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 02/05/2024] [Accepted: 02/17/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Antibiotic cement spacers have been widely used in the treatment of joint infections. There are no commercially available antibiotic spacers for the elbow. Instead, they are typically fashioned by the surgeon at the time of surgery using cement alone or a combination of cement with sutures, Steinmann pins, external fixator components, or elbow arthroplasty components. There is no consensus regarding the ideal elbow antibiotic spacer and no previous studies have examined the complications associated with these handmade implants in relation to their unique structural design. METHODS We retrospectively reviewed 55 patients who had 78 static antibiotic cement spacers implanted between January 1998 and February 2021 as part of a 2-stage treatment plan for infection of an elbow arthroplasty, other elbow surgery, or primary elbow infection. Several antibiotic spacer structures were used during the study period. For analysis purposes, the spacers were classified into linked and unlinked spacers based on whether there was a linking mechanism between the humerus and the ulna. Complications related to these spacers that occurred either during the implantation, between implantation and removal, or during removal were recorded and analyzed from chart review and follow-up x rays. Reoperations due to spacer-related complications were also recorded. RESULTS Among the 55 patients (78 spacers), there were 23 complications, including 17 minor and 6 major complications. The most common complication of unlinked spacers (intramedullary [IM] dowels, beads and cap spacer) was spacer displacement. Other complications included IM dowel fracture and difficulty locating beads during spacer removal. The major complications of linked cement spacers included two periprosthetic humerus fractures after internal external fixator cement spacers and re-operation due to breakage and displacement of one bushing cement spacer. The major complications of unlinked cement spacers included two reoperations due to IM dowel displacement and one reoperation due to displacement of beads. Among patients who had removal of all components and those with native joints, there was no statistically significant difference between internal external fixator cement spacers and unlinked cement spacers in minor complication rates (30% vs. 16%, P = .16), major complication rates (7% vs. 8%, P = .85) and reoperation rates (0% vs. 8%, P = .12). CONCLUSIONS Static handmade antibiotic elbow spacers have unique complications related to their structural designs. The most common complication of linked and nonlinked cement spacers were failure of the linking mechanism and displacement, respectively. Surgeons should keep in mind the possible complications of different structures of cement spacers when choosing 1 antibiotic spacer structure over another.
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Affiliation(s)
- Kun-Hui Chen
- Department of Orthopedics, Mayo Clinic, Rochester, MN, USA; Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jorge Rojas Lievano
- Department of Orthopedics, Mayo Clinic, Rochester, MN, USA; Department of Orthopedics and Traumatology, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Ausberto R Velasquez Garcia
- Department of Orthopedics, Mayo Clinic, Rochester, MN, USA; Department of Orthopedic Surgery, Clinica Universidad de los Andes, Santiago, Chile
| | - Hiroki Nishikawa
- Department of Orthopedics, Mayo Clinic, Rochester, MN, USA; Department of Orthopaedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Grace K Chaney
- Department of Orthopedics, Mayo Clinic, Rochester, MN, USA
| | | | - Mark E Morrey
- Department of Orthopedics, Mayo Clinic, Rochester, MN, USA
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Kruszewski A, Piszczatowski S, Piekarczyk P, Cieślik P, Kwiatkowski K. Weak Points of Double-Plate Stabilization Used in the Treatment of Distal Humerus Fracture through Finite Element Analysis. J Clin Med 2024; 13:1034. [PMID: 38398347 PMCID: PMC10888649 DOI: 10.3390/jcm13041034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/31/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Multi-comminuted, intra-articular fractures of the distal humerus still pose a challenge to modern orthopedics due to unsatisfactory treatment results and a high percentage (over 50%) of postoperative complications. When surgical treatment is chosen, such fractures are fixed using two plates with locking screws, which can be used in three spatial configurations: either parallel or one of two perpendicular variants (posterolateral and posteromedial). The evaluation of the fracture healing conditions for these plate configurations is unambiguous. The contradictions between the conclusions of biomechanical studies and clinical observations were the motivation to undertake a more in-depth biomechanical analysis aiming to indicate the weak points of two-plate fracture stabilization. METHODS Research was conducted using the finite element method based on an experimentally validated model. Three variants of distal humerus fracture (Y, λ, and H) were fixed using three different plate configurations (parallel, posterolateral, and posteromedial), and they were analyzed under six loading conditions, covering the whole range of flexion in the elbow joint (0-145°). A joint reaction force equal to 150 N was assumed, which corresponds with holding a weight of 1 kg in the hand. The biomechanical conditions of bone union were assessed based on the interfragmentary movement (IFM) and using criteria formulated by Steiner et al. Results: The IFMs were established for particular regions of all of the analyzed types of fracture, with distinction to the normal and tangential components. In general, the tangential component of IFM was greater than normal. A strong influence of the elbow joint's angular position on the IFM was observed, with excessive values occurring for flexion angles greater than 90°. In most cases, the smallest IFM values were obtained for the parallel plaiting, while the greatest values were obtained for the posteromedial plating. Based on IFM values, fracture healing conditions in particular cases (fracture type, plate configuration, loading condition, and fracture gap localization) were classified into one of four groups: optimal bone union (OPT), probable union (PU), probable non-union (PNU), and non-union (NU). CONCLUSIONS No plating configuration is able to ensure distal humerus fracture union when the full elbow flexion is allowed while holding a weight of 1 kg in the hand. However, flexion in the range of 0-90° with such loadings is acceptable when using parallel plating, which is a positive finding in the context of the early rehabilitation process. In general, parallel plating ensures better conditions for fracture healing than perpendicular plate configurations, especially the posteromedial version.
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Affiliation(s)
- Artur Kruszewski
- Faculty of Mechanical Engineering, Institute of Biomedical Engineering, Bialystok University of Technology, 45A Wiejska Street, 15-351 Bialystok, Poland;
| | - Szczepan Piszczatowski
- Faculty of Mechanical Engineering, Institute of Biomedical Engineering, Bialystok University of Technology, 45A Wiejska Street, 15-351 Bialystok, Poland;
| | - Piotr Piekarczyk
- Department of Traumatology and Orthopedics, Military Institute of Medicine—National Research Institute, 128 Szaserów Street, 04-141 Warsaw, Poland; (P.P.); (P.C.); (K.K.)
| | - Piotr Cieślik
- Department of Traumatology and Orthopedics, Military Institute of Medicine—National Research Institute, 128 Szaserów Street, 04-141 Warsaw, Poland; (P.P.); (P.C.); (K.K.)
| | - Krzysztof Kwiatkowski
- Department of Traumatology and Orthopedics, Military Institute of Medicine—National Research Institute, 128 Szaserów Street, 04-141 Warsaw, Poland; (P.P.); (P.C.); (K.K.)
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Wang X, Gu Q, Wei W, Zi S. Surgical debridement and continuous irrigation for early surgical site infection caused by Staphylococcus aureus with a closed patella fracture surgery: A case report. Int J Surg Case Rep 2023; 113:109068. [PMID: 37988986 PMCID: PMC10667781 DOI: 10.1016/j.ijscr.2023.109068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/10/2023] [Accepted: 11/14/2023] [Indexed: 11/23/2023] Open
Abstract
INTRODUCTION Management of postoperative surgical site infection (SSI) is a huge challenge to orthopedic surgeons, and significantly impacts patients and their families due to long treatment cycles and associated discomfort experiences. PRESENTATION OF CASE A 68-year-old woman without a medical history of any comorbidities, diabetes, hypertension, allergies, or tuberculosis, was admitted to our hospital complaining of right knee pain following a fall. X-ray and CT scans revealed a closed right patella fracture. The patient underwent open reduction and internal fixation with tension band wiring and circle wire. Preoperative assessment showed normal nutritional status. Prophylactic cefazolin sodium pentahydrate was administered 30 min preoperatively and maintained for 24 h post-operation to prevent infection. The patient was discharged 3 days after the operation. However, the wound exhibited signs of infection: redness, swelling, and the presence of secretions. Outpatient dressings and oral antibiotics were prescribed but failed to control the infection, leading to rehospitalization. Surgical debridement and continuous articular irrigation were implemented to address the infection. Secretion cultures were taken to identify the causative bacteria. Levofloxacin and Rifampicin were used according to drug sensitivity tests. However, the patient experienced severe knee swelling and an iodine irritative reaction subsequently. Anti-allergic treatment and normal saline dressings were applied to alleviate swelling, pain, and skin irritation. MRI results indicated arthroedema and possible infection necessitating further surgical debridement, the patient rejected additional surgery and requested discharge. Levofloxacin and Rifampicin were used for a month to control the infection after discharge, accompanied by regular rehabilitation exercises. Fortunately, the infection was successfully managed, and knee function was satisfactorily restored. DISCUSSION SSI after patella fracture surgery can lead to a worse quality of life, serious economic burden, and psychological distress. Therefore, effective treatment methods for managing postoperative SSIs are very important. CONCLUSION Sufficient surgical debridement is vital to remove infection tissue of early SSI caused by Staphylococcus aureus with a closed patella fracture surgery. Continuous articular irrigation and sensitive antibiotics help control infection, and active rehabilitation training improves knee function recovery.
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Affiliation(s)
- Xiong Wang
- Department of Orthopedics, Shanghai Baoshan Luodian Hospital, Baoshan District, Shanghai 201908, China
| | - Qing Gu
- Department of Orthopedics, Shanghai Baoshan Luodian Hospital, Baoshan District, Shanghai 201908, China
| | - Wenqiang Wei
- Department of Orthopedics, Shanghai Baoshan Luodian Hospital, Baoshan District, Shanghai 201908, China
| | - Shuming Zi
- Department of Orthopedics, Shanghai Baoshan Luodian Hospital, Baoshan District, Shanghai 201908, China.
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Wilkinson BG, Bangura A, Burke CE, O'Connor K, Gupta J, Demyanovich HK, Healey K, O'Hara NN, Schneiderman BA, Nascone JW, O'Toole RV. A deep surgical site infection risk score for patients with open tibial shaft fractures treated with intramedullary nail. Injury 2023; 54:110965. [PMID: 37572509 DOI: 10.1016/j.injury.2023.110965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 06/09/2023] [Accepted: 07/26/2023] [Indexed: 08/14/2023]
Abstract
OBJECTIVES To identify deep infection risk factors in patients with open tibial shaft fractures and to develop a scoring algorithm to predict the baseline deep infection risk in this patient population. METHODS A retrospective cohort study conducted at a single academic trauma center identified patients with open tibial shaft fractures treated with intramedullary nail fixation from December 2006 to October 2020. The primary outcome was a deep surgical site infection requiring surgical debridement. The outcome was identified by Current Procedural Terminology codes and confirmed with a medical chart review documenting evidence of a tibial draining wound or sinus tract. RESULTS Deep surgical site infection occurred in 13% of patients (97/769). Factors that predicted deep surgical site infection were identified. Gustilo-Anderson type IIIB or IIIC was the strongest predictor with a 12-fold increase in the odds of deep infection (OR 11.8, p < 0.001). Additional factors included age >40 years (OR 1.7, p = 0.03), American Society of Anesthesiologists score ≥3 (OR 1.9, p < 0.01), Gustilo-Anderson type IIIA vs. type I or II (OR 2.8, p = 0.004), and gunshot wounds (OR 2.9, p = 0.02). The risk scoring model predicted patients who would develop an infection with an acceptable level of accuracy (AUC 0.79). The risk score categorized patients from a low probability of deep infection 2%-6% with <10 points to high risk (58%-69%) with >40 points. CONCLUSIONS This risk score model predicts deep postoperative infection in patients with open tibial shaft fractures treated with intramedullary nails. The ability to accurately estimate deep infection risk at the time of presentation might aid patient expectation management and allow clinicians to focus infection prevention strategies on the high-risk subset of this population.
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Affiliation(s)
- Brandon G Wilkinson
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, United States
| | - Abdulai Bangura
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, United States
| | - Cynthia E Burke
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, United States
| | - Katherine O'Connor
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, United States
| | - Jayesh Gupta
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, United States
| | - Haley K Demyanovich
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, United States
| | - Kathleen Healey
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, United States
| | - Nathan N O'Hara
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, United States
| | - Brian A Schneiderman
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, United States
| | - Jason W Nascone
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, United States
| | - Robert V O'Toole
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, United States.
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Morisaki S, Yoshii K, Tsuchida S, Oda R, Fuke T, Takahashi K. The role of preoperative glycemic control in decreasing surgical site infections in lower extremity fractures. J Orthop Surg Res 2023; 18:700. [PMID: 37723461 PMCID: PMC10507903 DOI: 10.1186/s13018-023-04204-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/13/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Postoperative surgical site infections (SSIs) are an important complication to prevent in surgical treatment. Patients with diabetes mellitus (DM) have a higher risk of SSIs. Preoperative glycemic control is required. For patients with orthopedic trauma, the duration of preoperative glycemic control is limited because delaying operative treatment is difficult. However, whether preoperative glycemic control would decrease the risk of SSIs in diabetic patients with lower extremity fractures is unclear. The first aim of this study was to investigate the rate of SSIs among patients with DM who had undergone preoperative glycemic control, compared with that of patients without DM. As the secondary aim, we sought to demonstrate among patients with DM whether preoperative glycemic control would affect the development of SSIs between patients with controlled DM and patients with poorly controlled DM. METHODS In this retrospective cohort study, 1510 patients treated surgically for lower extremity fractures were enrolled. Data collected were patient age, sex, body mass index, history of DM, development of SSIs, tobacco use, the presence of an open fracture, the period between the day of injury and the operation, the length of surgery, and blood glucose levels on admission and on the day before surgery. RESULTS The rate of total SSIs was 6.0% among patients with DM and 4.4% among patients without DM (p = 0.31). Multivariate logistic regression revealed a significant association between the development of SSIs and the presence of DM (odds ratio, 1.79; 95% confidence interval 1.01-3.19; p = 0.047). The results of the secondary study revealed that the rate of early SSIs was significantly higher in the poorly controlled DM group than in the controlled DM group (5.9% vs. 1.5%; p = 0.032). However, multivariate logistic regression revealed that control levels of DM were not significantly associated with the development of SSIs. CONCLUSIONS Even though patients with DM had undergone preoperative glycemic control, SSIs were significantly associated with DM, especially when the patients had poorly controlled DM. This finding suggested that continuous glycemic control is important preoperatively and postoperatively to prevent SSIs.
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Affiliation(s)
- Shinsuke Morisaki
- Department of Orthopaedics, Saiseikai Shiga Hospital, Ohashi 2-4-1, Ritto, Shiga, 520-3046, Japan.
| | - Kengo Yoshii
- Department of Mathematics and Statistics in Medical Sciences, Kyoto Prefectural University of Medicine, Shimogamo Hangi-tyo Sakyo-ku 1-5, Kyoto, 606-0823, Japan
| | - Shinji Tsuchida
- Department of Orthopaedics, Kyoto Prefectural University of Medicine, Kawaramachi Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Ryo Oda
- Department of Orthopaedics, Kyoto Prefectural University of Medicine, Kawaramachi Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Tomoya Fuke
- Department of Diabetes and Endocrinology, Saiseikai Shiga Hospital, Ohashi 2-4-1, Ritto, Shiga, 520-3046, Japan
| | - Kenji Takahashi
- Department of Orthopaedics, Kyoto Prefectural University of Medicine, Kawaramachi Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
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Sugiura S, Shimura H, Fujita K, Ogawa T, Nimura A. Comparison of ceftriaxone and cefazolin as prophylactic antibiotics for surgical site infection in orthopedic upper extremity surgery: The nationwide shortage of cefazolin in March 2019. J Orthop Sci 2023; 28:1018-1022. [PMID: 36089431 DOI: 10.1016/j.jos.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/22/2022] [Accepted: 08/08/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Due to the nationwide supply shortage of cefazolin in March 2019 in Japan, ceftriaxone was used as an alternative prophylaxis antibiotic agent. This retrospective study was designed to investigate the impact of cefazolin and ceftriaxone as a prophylactic antibiotic agent for surgical site infection (SSI) in orthopedic upper extremity surgery. METHODS We used cefazolin for antibiotic prophylaxis to prevent SSI before March 2019. Because of cefazolin shortage, ceftriaxone was used as an alternative agent in our hospital. From April 2014 to May 2021, 2493 upper extremity surgeries were reviewed. The exclusion criteria in this study were as follows: patients aged under 16 years, those with an open wound, those with infectious diseases, those who underwent trigger finger surgery, and those who underwent percutaneous pinning surgery. The incidence of deep SSI was evaluated according to the Centers for Disease Control and Prevention guidelines. RESULTS Among the 2493 eligible cases, 1674 were included in this study. In the cefazolin group, 1140 cases were included, whereas, in the ceftriaxone group, 534 cases were included. No significant differences in the demographic data of the patients were observed between the two groups. The incidence of deep SSI was 0.08% (1/1140 cases) in the cefazolin group and 1.1% (6/534 cases) in the ceftriaxone group, with a significant difference between the two groups (odds ratio, 12.9; p = 0.005). CONCLUSIONS This study indicated that the use of ceftriaxone instead of cefazolin after upper extremity surgery increases the risk of deep SSI.
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Affiliation(s)
- Sara Sugiura
- Department of Orthopedic Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Haruhiko Shimura
- Department of Orthopedic Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan.
| | - Koji Fujita
- Department of Functional Joint Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takahisa Ogawa
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akimoto Nimura
- Department of Functional Joint Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Hockmann J, Ott N, Leschinger T, Müller LP, Hackl M. [Clinical results of total elbow arthroplasty after treatment failure for Monteggia-like injuries]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:700-705. [PMID: 37270731 PMCID: PMC10450013 DOI: 10.1007/s00113-023-01335-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Monteggia-like fractures (MLF) are complex injuries with high complication rates and frequently unsatisfying clinical results. Total elbow arthroplasty (TEA) represents the only option to salvage the functional requirements in some patients with pronounced posttraumatic arthropathy. This case series provides clinical results of TEA following failed treatment of MLF. METHODS All patients who underwent TEA from 2017 to 2022 for failed treatment of MLF were retrospectively included in this study. Complications and revisions before and after TEA and functional results, measured by the Broberg/Morrey score, were evaluated. RESULTS In this study 9 patients with a mean age of 68 (±7; 54-79) years were included. The mean follow-up was 12 (±9; 2-27) months. The main reasons leading to posttraumatic arthropathy were chronic infections (44.4%), bony instability due to coronoid deficiency (33.3%) or a combined coronoid and radial head deficiency (22.2%) and non-union of the proximal ulna with radial head necrosis (11.1%). The mean number of surgical revisions between primary fixation and TEA was 2.7 (±1.8; 0-6). The revision rate following TEA was 44%. The mean Broberg/Morrey score at the time of the latest follow-up was 83 (±10; 71-97) points. CONCLUSION Chronic infection and coronoid deficiency are the main reasons for posttraumatic arthropathy after MLF leading to TEA. While the overall clinical results are satisfying, the indications should be reserved for selected cases due to high revision rates.
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Affiliation(s)
- Jan Hockmann
- Universität zu Köln, Medizinische Fakultät und Uniklinik Köln, Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Kerpener Straße 62, 50937, Köln, Deutschland.
| | - Nadine Ott
- Universität zu Köln, Medizinische Fakultät und Uniklinik Köln, Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Kerpener Straße 62, 50937, Köln, Deutschland
| | - Tim Leschinger
- Universität zu Köln, Medizinische Fakultät und Uniklinik Köln, Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Kerpener Straße 62, 50937, Köln, Deutschland
| | - Lars Peter Müller
- Universität zu Köln, Medizinische Fakultät und Uniklinik Köln, Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Kerpener Straße 62, 50937, Köln, Deutschland
| | - Michael Hackl
- Universität zu Köln, Medizinische Fakultät und Uniklinik Köln, Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Kerpener Straße 62, 50937, Köln, Deutschland
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González CVS, Carvalho EOD, Galvão NS, Nogueira PC, Santos VLCDG. Prevalence of complicated surgical wounds and related factors among adults hospitalized in public hospitals. Rev Esc Enferm USP 2022; 56:e20210477. [PMID: 35926076 DOI: 10.1590/1980-220x-reeusp-2021-0477en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 05/04/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To estimate the prevalence of complicated surgical wounds and its related factors in hospitalized adults. METHOD In this cross-sectional study, information from 251 patients hospitalized in seven public hospitals in Manaus, Brazil, and at risk of suffering surgical site complications after undergoing surgery was analyzed. Data were collected via interviews, physical examinations, and a medical record review from March to June 2015. Prevalence rate was estimated as the ratio between individuals with complications and patients at risk. To explore associated variables, individuals with and without complications were compared via 5% significant logistic regression and bivariate analyses. This study was approved by a research ethics committee. RESULTS Overall, 15 patients (6%) showed complicated surgical wounds. General hospitalization (p < 0.003), presence of ecchymosis, (p < 0.001), and men (p = 0.047) increased patients' probability of developing complications in 13.9, 10.1, and 8.2 times, respectively. CONCLUSION Assessing the prevalence of complicated surgical wounds and its associated factors in adults contributes to their epidemiological understanding, highlighting prevention targets and making data available for scientific comparisons.
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Affiliation(s)
- Carol Viviana Serna González
- Universidade de São Paulo, Escola de Enfermagem, Programa de Pós-Graduação em Enfermagem na Saúde do Adulto, São Paulo, SP, Brazil
| | | | | | - Paula Cristina Nogueira
- Universidade de São Paulo, Escola de Enfermagem, Departamento de Enfermagem Médico-Cirúrgica, São Paulo, SP, Brazil
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SAITO T, UEHARA T, NAKAHARA R, SHIMAMURA Y, NAKAO A, OZAKI T. Risk Factors for Infection Following Operative Treatment of Traumatic Upper Extremity Amputation Injury. J Hand Surg Asian Pac Vol 2022; 27:691-697. [DOI: 10.1142/s2424835522500709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Identification of the risk factors for surgical site infection (SSI) can be a straightforward and cost-effective measure to reduce or prevent the occurrence of SSI. However, there are no studies that revealed risk factors for SSI for traumatic upper extremity amputation. The aim of this study is to investigate the risk factors that promote SSI after surgery for traumatic upper extremity amputation using a large nationwide database. Methods: We used data from the Japan Trauma Data Bank. Diagnoses were defined using the Abbreviated Injury Scale code. We applied multivariate logistic regression to evaluate the infection risk factor. We chose age, sex, vital signs, cause and type of trauma, concomitant injury, diabetes, amputation level, Glasgow coma scale, Injury Severity Score (ISS) and blood transfusion within 24 hours following hospital arrival as confounders. Receiver operating characteristic (ROC) curve analysis was adopted to identify thresholds for change in infection risk. We also applied propensity score (PS) matching to adjust for confounding factors that may affect the outcome. Results: A total of 1,150 patients (967 males, 183 females) had traumatic upper extremity amputation. The mean patient age was 46.5 years. A total of 21 patients (1.8%) suffered from SSI. ISS, blood transfusion, systolic blood pressure (BP) and the upper extremity amputation except for finger were identified as the independent significant risk factors for SSI occurrence by the multivariate analysis (p < 0.05, p < 0.005, p < 0.05 and p < 0.005, respectively). ROC modelling revealed that patients with ISS of over 9 or systolic BP of over 160 had a risk for SSI. After PS matching, the patients with blood transfusion or systolic BP of over 160 had a significantly higher risk of infection (OR 9.0; p = 0.01 and OR 7.0; p = 0.03, respectively). Conclusions: In treating patients with these risk factors, we must be especially careful in performing thorough debridement and wound care. Level of Evidence: Level II (Therapeutic)
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Affiliation(s)
- Taichi SAITO
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Takenori UEHARA
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, Okayama, Japan
| | - Ryuichi NAKAHARA
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Yasunori SHIMAMURA
- Department of Sports Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Atsunori NAKAO
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, Okayama, Japan
| | - Toshifumi OZAKI
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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Hovis JP, Moore-Lotridge SN, Mansour A, Gibson BH, Weikert DR, Desai MJ, Gebhart SS, Schoenecker JG, Lee DH. Sterility of Miniature C-arm Fluoroscopy in Hand and Upper Extremity Surgery. J Hand Microsurg 2022; 14:153-159. [PMID: 35983289 PMCID: PMC9381171 DOI: 10.1055/s-0040-1714434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Previous studies have demonstrated that sterile equipment is frequently contaminated intraoperatively, yet the incidence of miniature c-arm (MCA) contamination in hand and upper extremity surgery is unclear. To examine this incidence, a prospective study of MCA sterility in hand and upper extremity cases was performed in a hospital main operating room (MOR) ( n = 13) or an ambulatory surgery center operating room (AOR) ( n = 16) at a single tertiary care center. Case length, MCA usage parameters, and sterility of the MCA through the case were examined. We found that MOR surgical times trended toward significance ( p = 0.055) and that MOR MCAs had significantly more contamination prior to draping than AOR MCAs ( p < 0.001). In MORs and AORs, 46.2 and 37.5% of MCAs respectively were contaminated intraoperatively. In MORs and AORs, 85.7 and 80% of noncontaminated cases, respectively, used the above hand- table technique, while 50 and 83.3% of contaminated MOR and AOR cases, respectively, used a below hand-table technique. Similar CPT codes were noted in both settings. Thus, a high-rate of MCA intraoperative contamination occurs in both settings. MCA placement below the hand-table may impact intraoperative contamination, even to distant MCA areas. Regular sterilization of equipment and awareness of these possible risk factors could lower bacterial burden.
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Affiliation(s)
- James P. Hovis
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Stephanie N. Moore-Lotridge
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Ashton Mansour
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Breanne H.Y. Gibson
- Department of Pharmacology, Vanderbilt University, Robinson Research, Nashville, Tennessee, United States
| | - Douglas R. Weikert
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Mihir J. Desai
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Sandra S. Gebhart
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Jonathan G. Schoenecker
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
- Department of Pharmacology, Vanderbilt University, Robinson Research, Nashville, Tennessee, United States
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Donald H. Lee
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
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11
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Are deep infections that present before and after 90 days from orthopaedic trauma different? An analysis of the validity of the recent change in CDC criteria for infections. Injury 2022; 53:912-918. [PMID: 34732287 DOI: 10.1016/j.injury.2021.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 10/13/2021] [Accepted: 10/18/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND In 2016, the Centers for Disease Control and Prevention (CDC) changed the time frame for their definition of deep surgical site infection (SSI) from within 1 year to within 90 days of surgery. We hypothesized that a substantial number of infections in patients who have undergone fracture fixation present beyond 90 days and that there are patient or injury factors that can predict who is more likely to present with SSI after 90 days. METHODS A retrospective review yielded 452 deep SSI after fracture fixation. These patients were divided into two groups-those infected within 90 days of surgery and those infected beyond 90 days . Data were collected on risk factors for infection. Univariate and multiple logistic regression analyses were performed to compare the two groups. A randomly selected control group was used to build infection prediction models for both outcomes. The two outcomes were then modelled against each other to determine whether differences in predictors for early versus late infection exist. RESULTS Of the 452 infections, 144 occurred beyond 90 days (32% [95% CI, 28%-36%]). No statistically significant patient factors were found in multivariable analysis between the early and late infection groups. The need for flap coverage was the only injury characteristic that differed significantly between groups, with patients in the late infection group more likely to have needed a flap. When modelled against the control group and directly comparing the two models, predictors for early infection include male sex and fractures of the pelvis, acetabulum, or hip, whereas predictors of late infection include hepatitis C and/or human immunodeficiency virus (HIV) and admission to the intensive care unit (ICU). CONCLUSION Use of the recent CDC definition will underestimate the rate of actual postoperative infections when applied to orthopaedic trauma patients. Hepatitis C and/or HIV and ICU admission are predictors of late infection, whereas male sex and pelvis, acetabulum, or hip fractures are predictors of early infection. Patients who receive flap coverage may be more likely to present with late infection.
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12
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González CVS, Carvalho EOD, Galvão NS, Nogueira PC, Santos VLCDG. Prevalência de ferida operatória complicada e fatores associados em adultos internados em hospitais públicos. Rev Esc Enferm USP 2022. [DOI: 10.1590/1980-220x-reeusp-2021-0477pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
RESUMO Objetivo: Estimar a prevalência de Ferida Operatória Complicada e seus fatores associados, em adultos hospitalizados. Método: Estudo transversal, aprovado por comitê de ética. Foram analisadas informações de 251 pacientes submetidos à cirurgia e com risco de complicação do sítio cirúrgico, internados em sete hospitais públicos em Manaus (Brasil); cujos dados foram coletados por meio de entrevista, exame físico e revisão de prontuários, no período de março a junho de 2015. A taxa de prevalência foi calculada como a razão entre os indivíduos com complicação e os pacientes em risco. Para exploração de variáveis associadas, foram comparados indivíduos com e sem complicação por meio de análises bivariadas e regressão logística, com significância de 5%. Resultados: 15 pacientes (6%) apresentaram ferida operatória complicada. A presença de equimose (p < 0,001), ajustada pelo sexo masculino (p = 0,047) e a internação na clínica geral (p < 0,003) aumentaram a probabilidade de desenvolver a complicação em 10,1; 8,2 e 13,9 vezes, respectivamente. Conclusão A identificação da prevalência da ferida operatória complicada em adultos e seus fatores associados contribuem para a sua compreensão epidemiológica, destacando alvos de prevenção e disponibilizando dados para comparação científica.
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Smolle MA, Leitner L, Böhler N, Seibert FJ, Glehr M, Leithner A. Fracture, nonunion and postoperative infection risk in the smoking orthopaedic patient: a systematic review and meta-analysis. EFORT Open Rev 2021; 6:1006-1019. [PMID: 34909221 PMCID: PMC8631245 DOI: 10.1302/2058-5241.6.210058] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
This systematic review and meta-analysis aimed to analyse negative effects of smoking in orthopaedic and trauma patients. A PubMed search was carried out for studies published until July 2020 regarding effects of smoking on fracture risk, nonunion, infection after orthopaedic surgery, and persisting nonunion after scaphoid nonunion surgery. Random effects models calculated for outcome parameters, and relative risks (RR) with 95% confidence intervals are provided. No adjustments for covariates were made. Heterogeneity was assessed with Higgins’ I2, publication bias with Harbord’s p (Hp), sensitivity analysis performed on funnel plots and quality of studies was analysed using the Newcastle-Ottawa Scale. Of 3362 retrieved entries, 69 were included in the final analysis. Unadjusted RR for smokers to develop vertebral (six studies, seven entries; RR: 1.61; p = 0.008; I2 = 89.4%), hip (11 studies, 15 entries; RR: 1.28; p = 0.007; I2 = 84.1%), and other fractures (eight studies, 10 entries; RR: 1.75; p = 0.019; I2 = 89.3%) was significantly higher. Postoperative infection risk was generally higher for smokers (21 studies; RR: 2.20; p < 0.001; I2 = 58.9%), and remained upon subgroup analysis for elective spinal (two studies; RR: 4.38; p < 0.001; I2 = 0.0%) and fracture surgery (19 studies; RR: 2.10; p < 0.001; I2 = 58.5%). Nonunion risk after orthopaedic (eight studies; RR: 2.15; p < 0.001; I2 = 35.9%) and fracture surgery (11 studies; RR: 1.85; p < 0.001; I2 = 39.9%) was significantly higher for smokers, as was persisting nonunion risk after surgery for scaphoid nonunion (five studies; RR: 3.52; p < 0.001; I2 = 0.0%). Sensitivity analysis for each model reduced heterogeneity whilst maintaining significance (all I2 < 20.0%). Smoking has a deleterious impact on fracture incidence, and (subsequent) development of nonunions and postoperative infections.
Cite this article: EFORT Open Rev 2021;6:1006-1019. DOI: 10.1302/2058-5241.6.210058
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Affiliation(s)
- Maria Anna Smolle
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Lukas Leitner
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Nikolaus Böhler
- Department for Orthopedics and Traumatology, Kepler University Hospital GmbH, Linz, Austria
| | - Franz-Josef Seibert
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Mathias Glehr
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Andreas Leithner
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
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Lans J, Notermans BJ, Germawi L, Lee H, Jupiter JB, Chen NC. Factors Associated With Reoperation After Silicone Proximal Interphalangeal Joint Arthroplasty. Hand (N Y) 2021; 16:461-466. [PMID: 31387388 PMCID: PMC8283101 DOI: 10.1177/1558944719864453] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Silicone proximal interphalangeal (PIP) joint arthroplasty has a high revision rate. It has been suggested that persistent ulnar deviation and joint instability influence the durability of PIP silicone arthroplasties. The goal of this study was to evaluate what factors are associated with reoperation after silicone PIP arthroplasty. Methods: We retrospectively evaluated all adult patients who underwent PIP silicone arthroplasty between 2002 and 2016 at one institutional system for inflammatory-, posttraumatic-, and primary degenerative arthritis. After manual chart review, we included 91 patients who underwent 114 arthroplasties. Fingers operated included 14 index, 41 middle, 38 ring, and 21 small fingers. Results: The overall reoperation rate was 14% (n = 16). Non-Caucasian race (P = .040), smoking (P = .022) and PIP silicone arthroplasty for post-traumatic osteoarthritis (P = .021) were associated with reoperation. The 1-, 5- and 10-year implant survival rates were 87%, 85%, and 85%, respectively. Conclusion: Caution should be exercised when considering PIP silicone arthroplasty of the index finger or in patients with post-traumatic osteoarthritis. It may be worthwhile addressing smoking behavior before pursuing silicone PIP arthroplasty.
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Affiliation(s)
| | - Bo J.W. Notermans
- Radboud UMC, Nijmegen, The Netherlands,Bo J.W. Notermans, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands.
| | | | - Hang Lee
- Massachusetts General Hospital, Boston, USA
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15
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The Impact of Smoking on Early Postoperative Complications in Hand Surgery. J Hand Surg Am 2021; 46:336.e1-336.e11. [PMID: 32868099 DOI: 10.1016/j.jhsa.2020.07.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 05/25/2020] [Accepted: 07/21/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Smoking is a prevalent modifiable risk factor that has been associated with adverse postoperative outcomes across numerous surgical specialties. We examined the impact of smoking on 30-day complications in patients undergoing hand surgery procedures. METHODS The American College of Surgeons National Surgical Quality Improvement Program data sets were queried for patients who underwent common hand surgery procedures from 2011 to 2016. Cohorts were divided into smoking and nonsmoking and compared in terms of demographic characteristics, comorbidities, and postoperative complications. Multivariable logistic regression models were used to control for demographic characteristics and comorbidities in assessing the association between smoking and postoperative infections as well as other major and minor complications. RESULTS We identified a cohort of 48,370 patients in the National Surgical Quality Improvement Program who underwent certain outpatient and inpatient hospital facility-based hand surgery procedures from 2011 to 2016. Up to 22% of these patients reported active smoking. Compared with nonsmokers, smokers were more likely to be younger and male and to have a lower body mass index. In addition, they were more likely to have a higher American Society of Anesthesiologists classification and to report dyspnea and chronic obstructive pulmonary disease. Multivariable logistic regression identified an independent association between smoking and major complications. Smoking was not significantly associated with minor complications. When regrouped by complication type, smoking was associated with infectious and wound healing complications. In subgroup analysis, smokers undergoing elective hand surgery had increased odds of wound healing complications but not major, minor, or infectious complications. CONCLUSIONS Smokers may be at a significantly higher odds of certain complications compared with nonsmokers. For patients undergoing the elective procedures evaluated in this study, perioperative smoking may increase the risk of wound-healing complications. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.
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16
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Teitelbaum JI, Grasse C, Quan D, Abi Hachem R, Goldstein BJ, Hua X, Jang DW. General Complications after Endoscopic Sinus Surgery in Smokers: A 2005-2016 NSQIP Analysis. Ann Otol Rhinol Laryngol 2020; 130:350-355. [PMID: 32819161 DOI: 10.1177/0003489420952481] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Exposure to cigarette smoke has been associated with a higher incidence of postoperative complications across a variety of surgical specialties. However, it is unclear if smoking increases this risk after endoscopic sinus surgery (ESS). Because complication rates after ESS are relatively low, a large national database allows for a statistically meaningful study of this topic. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) dataset from 2005 to 2016 was analyzed. Patients who underwent ESS were identified. Thirty-day postoperative complication rates between smokers and nonsmokers were compared. Complications included infection, thromboembolic events, reintubation, readmission, acute renal failure, and cardiovascular events. RESULTS 921 patients who underwent ESS were identified. 182 (20%) were smokers and 739 (80%) were nonsmokers. 609 patients underwent outpatient ESS, while 312 patients underwent inpatient ESS. A total of 12 patients experienced postoperative surgical site infections involving the deeper tissues beyond the wound (organ/space SSI). On univariate analysis, smoking was associated with a higher incidence of organ/space SSI (P = .0067) and pulmonary embolism (P = .0321) after ESS. On multivariate logistic regression, smoking was associated with increased odds (4.495, 1.11- 8.17, P = .0347) of organ/space SSI after ESS. CONCLUSIONS This study demonstrates an association between exposure to cigarette smoke and potentially serious surgical site infections in the 30-day postoperative period after ESS. Our findings may help when counseling smokers who are considering ESS. Further study is required to understand the nature of these infections and ways to prevent them.Level of Evidence: 2c ("health outcomes").
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Affiliation(s)
- Jordan I Teitelbaum
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, NC, USA
| | - Catie Grasse
- Department of Computer Science, Duke University, Durham, NC, USA
| | - Dennis Quan
- Department of Computer Science, Duke University, Durham, NC, USA
| | - Ralph Abi Hachem
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, NC, USA
| | - Bradley J Goldstein
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, NC, USA
| | - Xiaoyang Hua
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, NC, USA
| | - David W Jang
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, NC, USA
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Forget V, Fauconnier J, Boisset S, Pavese P, Vermorel C, Bosson JL, Saragaglia D, Tonetti J, Mallaret MR, Landelle C. Risk factors for Staphylococcus aureus surgical site infections after orthopaedic and trauma surgery in a French university hospital. Int J Hyg Environ Health 2020; 229:113585. [PMID: 32781428 DOI: 10.1016/j.ijheh.2020.113585] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 05/14/2020] [Accepted: 06/08/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Surgical site infections (SSI) after orthopaedic surgery are responsible for reduced quality of life, increased length of hospital stay and costs. The most commonly identified organism is Staphylococcus aureus but risk factors for S. aureus SSI are not well-known. The aim of this study was to evaluate the incidence rate trend of S. aureus SSI over the years and risk factors of these infections in a French University Hospital. METHODS SSI rates were expressed as cumulative incidence rates per year. A case-control study nested within a prospective cohort of patients undergoing orthopaedic or trauma surgery from January 1st, 2012 to April 30th, 2015 was performed. Cases were patients with S. aureus SSI; controls were patients without SSI. Risk factors of S. aureus SSI were identified by univariate and multivariable analysis. RESULTS Of 7438 interventions, 50 (0.7%) S. aureus SSI were identified, without significant increase by years. A total of 46 S. aureus SSI was matched to 91 controls. Risk factors for S. aureus SSI were smoking (odds-ratio (OR) = 8.4, 95%CI 1.2-59.6) and National Nosocomial Infections Surveillance System score (NNISS) ≥1 (OR = 5.8, 95%CI 1.8-19.1). Having 1 or 2 preoperative antiseptic showers (OR = 0.3, 95%CI 0.1-0.7) was a protective factor. CONCLUSION The rate of S. aureus SSI is not negligible after orthopaedic and trauma surgery. It seems imperative to strengthen smoking cessation recommendations, and to recall the importance of preoperative antiseptic showers. Systematic screening and decolonization for S. aureus carriage before orthopaedic and trauma surgery could be a means to prevent these infections.
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Affiliation(s)
| | - Jérôme Fauconnier
- Univ Grenoble Alpes, CNRS, Grenoble INP, TIMC-IMAG, Grenoble, France; Medical Information, Public Health Department, Grenoble Alpes University Hospital, Grenoble, France
| | - Sandrine Boisset
- Bacteriology Laboratory, Grenoble Alpes University Hospital, Grenoble, France
| | - Patricia Pavese
- Infectious Diseases Unit, Grenoble Alpes University Hospital, Grenoble, France
| | - Céline Vermorel
- Univ Grenoble Alpes, CNRS, Grenoble INP, TIMC-IMAG, Grenoble, France
| | - Jean-Luc Bosson
- Univ Grenoble Alpes, CNRS, Grenoble INP, TIMC-IMAG, Grenoble, France
| | - Dominique Saragaglia
- Department of Osteoarthritis and Sport Surgery, South Teaching Hospital, Grenoble Alpes University Hospital, Grenoble, France
| | - Jérôme Tonetti
- Department of Orthopaedic Surgery, Grenoble Alpes University Hospital, Grenoble, France
| | - Marie-Reine Mallaret
- Univ Grenoble Alpes, CNRS, Grenoble INP, TIMC-IMAG, Grenoble, France; Infection Control Unit, Public Health Department, Grenoble Alpes University Hospital, Grenoble, France
| | - Caroline Landelle
- Univ Grenoble Alpes, CNRS, Grenoble INP, TIMC-IMAG, Grenoble, France; Infection Control Unit, Public Health Department, Grenoble Alpes University Hospital, Grenoble, France.
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Surgical Site Infection After Open Upper Extremity Fracture and the Effect of Urgent Operative Intervention. J Orthop Trauma 2020; 34:258-262. [PMID: 31738238 DOI: 10.1097/bot.0000000000001700] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To identify which factors are predictive of surgical site infection in upper extremity fractures, and to assess whether the timing of operative debridement influences infection risk. DESIGN Retrospective database review. SETTING Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. PATIENTS Patients in the NSQIP database with fractures involving the upper extremity. INTERVENTION Surgical management of upper extremity fracture, including operative debridement for open injuries. MAIN OUTCOME MEASUREMENTS Surgical site infection, including both superficial and deep infections. RESULTS A total of 22,578 patients were identified, including 1298 patients with open injuries (5.7% of total). The overall wound infection rate was 0.79%. Patients with open injuries were found to have a higher incidence of infection compared with those with closed injuries (1.7% vs. 0.7%, P < 0.001). Independent risk factors for 30-day infection included open fracture diagnosis, obesity, smoking, and American Society of Anesthesiolgists class >2 (all P < 0.05). Of patients with open fractures, 79.7% were taken expediently to the operating room. The rate of infection did not differ based on whether surgery was performed expediently or not (1.8% vs. 1.1%, P = 0.431). CONCLUSIONS Based on an analysis of the NSQIP database, the overall risk of surgical site infection following intervention for open or closed upper extremity fractures remains low. Risk factors for infection include open injury, obesity, and cigarette smoking. There was no difference in the infection rate based on the urgency of operative debridement. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Wang JH, Du JY, Tu LA, Brown CC, Chepla K, Bafus BT. A Comparison of 30-Day Perioperative Complications for Open Operative Care of Distal Upper-Extremity Fractures Treated by Orthopedic Versus Plastic Surgeons: A Study of the National Surgical Quality Improvement (NSQIP) Database. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2020; 2:84-89. [PMID: 35415479 PMCID: PMC8991454 DOI: 10.1016/j.jhsg.2020.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 01/29/2020] [Indexed: 11/16/2022] Open
Affiliation(s)
- Joanne H. Wang
- Department of Orthopedics, University Hospitals/Cleveland Medical Center, Cleveland, OH
- Corresponding author: Joanne H. Wang, MD, Department of Orthopedics, University Hospitals/Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106.
| | - Jerry Y. Du
- Department of Orthopedics, University Hospitals/Cleveland Medical Center, Cleveland, OH
| | - Leigh-Anne Tu
- Department of Orthopedics, University Hospitals/Cleveland Medical Center, Cleveland, OH
| | - Corina C. Brown
- Department of Orthopedics, University Hospitals/Cleveland Medical Center, Cleveland, OH
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21
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Jiang N, Wang BW, Chai YM, Wu XB, Tang PF, Zhang YZ, Yu B. Chinese expert consensus on diagnosis and treatment of infection after fracture fixation. Injury 2019; 50:1952-1958. [PMID: 31445830 DOI: 10.1016/j.injury.2019.08.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Currently, accurate diagnosis and successful treatment of infection after fracture fixation (IAFF) still impose great challenges. According to the onset of infection symptoms after implantation, IAFF is classified as early infection (<2 weeks), delayed infection (2∼10 weeks) and late infection (>10 weeks). Confirmation of IAFF should be supported by histopathological tests of intraoperative specimens which confirm infection, cultures from at least two suspected infection sites which reveal the same pathogen, a definite sinus or fistula which connects directly the bone or the implant, and purulent drainage from the wound or presence of pus during surgery. Diagnosis of IAFF is built on comprehensive assessment of medical history, clinical signs and symptoms of the patient, and imaging and laboratory tests. The gold standard of diagnosis is histopathological tests. Treatment of IAFF consists of radical debridement, adequate irrigation, implant handling, systematic and local antibiotics, reconstruction of osseous and/or soft tissue defects, and functional rehabilitation of an affected limb. Early accurate diagnosis and appropriate treatment of IAFF play a key role in increasing the cure rate, reducing infection recurrence and disability risk, restoring limb function and improving quality of life of the patient.
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Affiliation(s)
- Nan Jiang
- Department of Orthopaedics & Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Bo-Wei Wang
- Department of Orthopaedics & Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Yi-Min Chai
- Department of Orthopaedics, The Sixth People's Hospital of Shanghai Jiao Tong University, Shanghai, PR China
| | - Xin-Bao Wu
- Department of Orthopaedics & Traumatology, Beijing Jishuitan Hospital, Beijing, PR China.
| | - Pei-Fu Tang
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, PR China.
| | - Ying-Ze Zhang
- Department of Orthopaedics, The Third Hospital of Hebei Medical University, Shijiazhuang, PR China.
| | - Bin Yu
- Department of Orthopaedics & Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China.
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Abstract
OBJECTIVES To determine factors predictive of postoperative surgical site infection (SSI) after fracture fixation and create a prediction score for risk of infection at time of initial treatment. DESIGN Retrospective cohort study. SETTING Level I trauma center. PATIENTS/PARTICIPANTS Study group, 311 patients with deep SSI; control group, 608 patients. INTERVENTION We evaluated 27 factors theorized to be associated with postoperative infection. Bivariate and multiple logistic regression analyses were used to build a prediction model. A composite score reflecting risk of SSI was then created. MAIN OUTCOME MEASURES Risk of postoperative infection. RESULTS The final model consisted of 8 independent predictors: (1) male sex, (2) obesity (body mass index ≥ 30) (3) diabetes, (4) alcohol abuse, (5) fracture region, (6) Gustilo-Anderson type III open fracture, (7) methicillin-resistant Staphylococcus aureus nasal swab testing (not tested or positive result), and (8) American Society of Anesthesiologists classification. Risk strata were well correlated with observed proportion of SSI and resulted in a percent risk of infection of 1% for ≤3 points, 6% for 4-5 points, 11% for 6 to 8-9 points, and 41% for ≥10 points. CONCLUSION The proposed postoperative infection prediction model might be able to determine which patients have fractures at higher risk of infection and provides an estimate of the percent risk of infection before fixation. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Schmitt D, Rodts M, Davis B, Summers H, Bernstein M, Lack W. Standardized practice is associated with low rate of surgical site infection in orthopaedic trauma. J Clin Orthop Trauma 2019; 10:S95-S99. [PMID: 31695267 PMCID: PMC6823722 DOI: 10.1016/j.jcot.2018.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 09/17/2018] [Accepted: 12/29/2018] [Indexed: 11/22/2022] Open
Affiliation(s)
- Daniel Schmitt
- Department of Orthopaedic Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Megan Rodts
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Benjamin Davis
- Department of Orthopaedic Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Hobie Summers
- Department of Orthopaedic Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Mitchell Bernstein
- Department of Surgery and Pediatric Surgery, McGill University Health Centre, Montréal, Québec, Canada
| | - William Lack
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, WA, USA
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Garcia DR, Deckey D, Haglin JM, Emanuel T, Mayfield C, Eltorai AE, Spake CS, Jarrell JD, Born CT. Commonly Encountered Skin Biome-Derived Pathogens after Orthopedic Surgery. Surg Infect (Larchmt) 2019; 20:341-350. [DOI: 10.1089/sur.2018.161] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Dioscaris R. Garcia
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - David Deckey
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Jack M. Haglin
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Toby Emanuel
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Cory Mayfield
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Adam E.M. Eltorai
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Carole Sl Spake
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - John D. Jarrell
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Christopher T. Born
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Riedel MD, Parker A, Zheng M, Briceno J, Staffa SJ, Miller CP, Kaiser PB, Wu JS, Zurakowski D, Kwon JY. Correlation of Soft Tissue Swelling and Timing to Surgery With Acute Wound Complications for Operatively Treated Ankle and Other Lower Extremity Fractures. Foot Ankle Int 2019; 40:526-536. [PMID: 30688533 DOI: 10.1177/1071100718820352] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Considerable debate exists regarding how soft-tissue edema should influence timing of surgery for ankle and other lower extremity fractures. Assessment of swelling is subjective, and timing varies among surgeons. However, timing of surgery is one of the few modifiable factors in fracture care. Ultrasonography can objectively measure swelling and help determine optimal timing. The purposes of this study were to determine whether objective measures of swelling, timing to surgery, and patient-specific risk factors correlated with wound complications and to try to create a prediction model for postoperative wound complications based on identified modifiable and nonmodifiable risk factors. METHODS Patients with closed ankle and other lower extremity fractures requiring surgery with an uninjured, contralateral extremity were included. Demographic information and sonographic measurements on both lower extremities were obtained pre-operatively. Subjects were followed for 3 months and wound complications were documented. A predictive algorithm of independent risk factors was constructed, determining wound complication risk. Given that patients with ankle fractures made up the majority of the study cohort (75/93 or 80%), a separate statistical analysis was performed on this group. A total of 93 subjects completed the study, with 75/93 sustaining ankle fractures. RESULTS Overall wound complication rate was 18.3%. Timing to surgery showed no correlation with wound complications. A heel-pad edema index >1.4 was independently associated with wound complications. Subgroup analysis of ankle fractures demonstrated a 3.4× increase in wound complications with a heel-pad edema index >1.4. Tobacco history and BMI >25 were independent predictors of wound complications. An algorithm was established based on heel-pad edema index, BMI >25, and tobacco history. Patients with none of the 3 factors had a 3% probability of a wound complication. Patients with 1/3, 2/3 and 3/3 factors had a 12-36%, 60-86% and 96% probability of a wound complication, respectively. CONCLUSIONS Timing to surgery had no correlation with wound complications. Heel-pad edema index >1.4, BMI >25, and tobacco-use correlated with wound complications. When separately analyzing the cohort that sustained ankle fractures, the heel-pad edema index of >1.4 was still demonstrated to be predictive of wound complications corresponding to a 3.4× increase in wound complication rates (11.1% vs 37.5%). Risk of wound complications significantly increased with each factor. In patients with increased BMI and/or tobacco use, resolution of heel edema may significantly reduce wound complications in lower extremity trauma. LEVEL OF EVIDENCE Level II, prognostic, prospective cohort study.
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Affiliation(s)
- Matthew D Riedel
- 1 Harvard Medical School, Harvard Combined Orthopaedic Residency Program, Boston, MA, USA
| | - Amber Parker
- 2 Department of Orthopaedic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mingxin Zheng
- 3 Department of Radiology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jorge Briceno
- 2 Department of Orthopaedic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Steven J Staffa
- 4 Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Christopher P Miller
- 2 Department of Orthopaedic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Philip B Kaiser
- 1 Harvard Medical School, Harvard Combined Orthopaedic Residency Program, Boston, MA, USA
| | - Jim S Wu
- 3 Department of Radiology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - David Zurakowski
- 4 Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - John Y Kwon
- 2 Department of Orthopaedic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
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26
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Cuomo R, Nisi G, Brandi C, Giardino FR, Grimaldi L. Future Directions to Limit Surgical Site Infections. J INVEST SURG 2019; 33:759-761. [PMID: 31043108 DOI: 10.1080/08941939.2019.1566420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Roberto Cuomo
- Unit of Plastic Surgery, University of Siena - Santa Maria Alle Scotte Hospital - Viale Mario Bracci, Siena, Italy
| | - Giuseppe Nisi
- Unit of Plastic Surgery, University of Siena - Santa Maria Alle Scotte Hospital - Viale Mario Bracci, Siena, Italy
| | - Cesare Brandi
- Unit of Plastic Surgery, University of Siena - Santa Maria Alle Scotte Hospital - Viale Mario Bracci, Siena, Italy
| | - Francesco Ruben Giardino
- Unit of Plastic Surgery, University of Siena - Santa Maria Alle Scotte Hospital - Viale Mario Bracci, Siena, Italy
| | - Luca Grimaldi
- Unit of Plastic Surgery, University of Siena - Santa Maria Alle Scotte Hospital - Viale Mario Bracci, Siena, Italy
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27
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Cessation from Smoking Improves Innate Host Defense and Clearance of Experimentally Inoculated Nasal Staphylococcus aureus. Infect Immun 2018; 86:IAI.00912-17. [PMID: 29311241 DOI: 10.1128/iai.00912-17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 01/02/2018] [Indexed: 12/17/2022] Open
Abstract
Staphylococcus aureus nasal carriage is transient in most humans and usually benign, but dissemination of S. aureus to extranasal sites causes the majority of clinical infections, and S. aureus is a major cause of serious infections in the United States. A better understanding of innate nasal decolonization mechanisms is urgently needed, as are relevant models for studying S. aureus clearance. Here, we screened a population of healthy smokers for nasal S. aureus carriage and compared the participants' abilities to clear experimentally applied nasal S. aureus before and after completion of a smoking cessation program. We determined that cigarette smoking increases the mean nasal S. aureus load (2.6 × 104 CFU/swab) compared to the load observed in healthy nonsmokers (1.7 × 103 CFU/swab) and might increase the rate of S. aureus nasal carriage in otherwise-healthy adults: 22 of 99 smokers carried S. aureus at the screening visit, while only 4 of 30 nonsmokers screened positive during the same time period. Only 6 of 19 experimental inoculation studies in active smokers resulted in S. aureus clearance within the month of follow-up, while in the cessation group, 6 of 9 subjects cleared nasal S. aureus and carriage duration averaged 21 ± 4 days. Smoking cessation associated with enhanced expression of S. aureus-associated interleukin-1β (IL-1β) and granulocyte colony-stimulating factor (G-CSF) in nasal fluids. Participants who failed to clear S. aureus exhibited a higher nasal S. aureus load and elevated nasal interleukin-1 receptor antagonist (IL-1RA) expression at the preexperiment study visits. We conclude that smokers exhibit higher S. aureus loads than nonsmokers and that innate immune pathways, including G-CSF expression and signaling through the IL-1 axis, are important mediators of nasal S. aureus clearance.
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