The use of prophylactic antibiotics in treatment of fingertip amputation: a randomized prospective trial

Fingertip injuries: Does administration of antibiotics give benefits? A double-blind randomized controlled trial

PURPOSE

Adequate debridement and defect closure is an important treatment in fingertip injuries in addition to administration of antibiotic. However, administration of anitibiotics remains controversial whether it necessary for fingertip injuries that have been treated with adequate debridement and defect closure. The goal of study is to assess the differences of infection rate between subgroups with administration of antibiotics and without antibiotic in FTI treated by debridement and simple defect closure.

METHODS

The study design was a double-blind randomized clinical trial. Data collection was carried out at Cipto Mangunkusumo General Hospital, Jakarta and Tangerang Regency Hospital, Banten, in July 2022-February 2023. The target population of this study were adult patients with Fingertip injuries that treated by debridement and simple defect closures with antibiotics administration and without antibiotic. Infection was assessed at day-7, 14, and 21 follow-up.

RESULTS

There were 31 FTI subjects with 41 fingers affected. The number of male subjects was 27 people and female subjects 4 people. The most affected finger was the little finger (12 fingers, 30.8%), with most type of Allen classification was type IV (18 fingers, 43.90%), most procedure performed was primary suture (24 fingers, 58.54%). 15 subjects randomized to antibiotic group and 16 subjects to no-antibiotic group. There was 1 subject of antibiotic group and 1 subject of no-antibiotic group has infection. There are no significant differences between two groups.

CONCLUSION

There were no significant differences of infection rate between antibiotics administration and without antibiotic in FTI cases that treated by debridement and simple defect closures.

Antibiotic Prophylaxis in the Management of Distal Fingertip Amputation and Crush Injury

Purpose

We sought to investigate the role of prophylactic antibiotics for distal fingertip crush injury or transphalangeal amputation treated outside of an operating room and better understand the factors that contribute to antibiotic-prescribing decisions. We hypothesized that prophylactic antibiotics do not meaningfully reduce the incidence of infection and that antibiotics are prescribed in a predictable way.

Methods

This is a retrospective review of all patients treated in a MedStar-affiliated emergency department or urgent care for nonsurgical distal fingertip trauma in 2019. Patient demographics, comorbidities, injury characteristics, interventions, and follow-up details were recorded. Exclusion criteria included signs of infection at the time of presentation, minor injuries not requiring intervention, bite wounds, one-time intravenous antibiotic administration without oral course, and surgical intervention. Outcomes included infection and interventions at follow-up. Chi-square analysis was performed, comparing antibiotic and no-antibiotic groups. A stepwise binomial regression was used to evaluate for variables predictive of antibiotic prescription.

Results

We identified eight infections in 323 patients included in the study (2.5% incidence of infection). There was no statistically significant difference in the incidence of infection between patients treated with antibiotics (2.7%) and those who did not receive antibiotics (2.2%). However, due to the low incidence of infections, we were likely underpowered for this analysis. We also created a model to predict antibiotic prescribing, which achieved an area under the receiver operating characteristic curve of 0.86 (P < .0001) based on age, bleeding disorders, depressive disorders, open wound status, amputation, fractures, and encounter type.

Conclusions

The low incidence of infection (2.5%) and lack of a meaningful difference between the groups call into question prophylactic antibiotic prescribing after these distal fingertip injuries. Our model does predict provider prescribing habits, identifying areas for potential practice pattern change.

Type of study/level of evidence

Therapeutic III.

APPLICABILITY OF RANDOMIZED TRIALS IN HAND SURGERY: SURVEY STUDY

OBJECTIVE

To assess the applicability of randomized clinical trials and whether certain factors (surgeon experience/journal impact factor) influence their applicability.

METHODS

In this survey study we used the Pubmed/Medline database to select 32 consecutive randomized clinical trials published between 2013 and 2015, involving hand surgery (high/low impact). These studies were independently assessed by 20 hand surgeons (with more or less than 10 years of practice) who answered 4 questions regarding their applicability. Agreement was assessed using Cohen's kappa and comparison of proportions via chi-square statistics. P-value <5% constituted statistical significance.

RESULTS

A total of 640 evaluations were produced, generating 2560 responses. A weak correlation was observed between less and more experienced respondents (kappa <0.2; range 0.119-0.179). Applicability between the least and most experienced respondents was similar (p = 0.424 and p = 0.70). Stratification by journal impact factor showed no greater propensity of applicability (p = 0.29) for any of the groups.

CONCLUSIONS

Low agreement was found between the respondents for the applicability of the randomized studies. Surgeon experience and journal impact do not seem to influence this decision. Level of Evidence II, Prospective comparative study.

Management of partial fingertip amputation in adults: Operative and non operative treatment

BACKGROUND

Hand and finger injuries account for approximately 4.8 million visits to emergency departments each year. These injuries can cause a great deal of distress for both patients and providers and are often initially encountered in urgent care clinics, community hospitals, and level one trauma centers. Tip amputation injuries vary widely in mechanism, ranging from sharp lacerations to crush injuries that present with varying degrees of contamination. The severity of damage to soft tissue, bone, arteries and nerves is dependent upon the mechanism and guides treatment decision-making. The management algorithm can oftentimes be complex, as a wide variety of providers, including orthopedists, general surgeons, plastic surgeons and emergency physicians, may care for these injuries, depending on location and local culture. We review the common mechanisms for tip amputation and the optimal treatment in adults, based on the severity of the injury, degree of wound contamination, and the facilities available to the provider.

METHODS

Pubmed was searched using text words for articles related to management of fingertip injuries in adults. Bibliographies of matching articles were searched for additional relevant articles, which were then also reviewed. 107 articles were reviewed in total, and 61 were deemed relevant for inclusion. All clinical studies and reviews were included. Particular attention was paid to articles published within the past 15 years.

RESULTS

In the United States, up to 90% of fingertip amputations are treated with non-replant techniques. In comparison, the majority of amputations in Asian countries are replanted due to moral values and importance of body integrity. Tip amputation injuries can be managed with local debridement, complex reconstruction, or simply with irrigation and application of a sterile dressing.

CONCLUSION

In the United States, most fingertip amputations in adults are treated with non-replant techniques. However, the precise management of a fingertip injury in adults depends on the degree of injury itself, and a number of operative and non-operative techniques may be successfully employed.

BEST-PRACTICE GUIDELINES FOR FIELD-BASED SURGERY AND ANESTHESIA ON FREE-RANGING WILDLIFE. II. SURGERY

The principles of surgical asepsis apply to field surgeries with few exceptions. The minimum level for performance of surgeries in the field on free-ranging animals should be the same as for domestic animals undergoing surgery in animal hospitals. Surgeries in the field are typically done as part of research and management projects and usually involve a combination of biologists and veterinarians with the possibility of conflicts in scientific cultures. This article outlines a minimum standard of care for field surgeries and will serve as a resource for Institutional Animal Care and Use Committees and biologists and veterinarians planning projects that involve surgeries on free-ranging wildlife in field conditions.