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Roche O, Schmitz A, Lefevre M, Sirveaux F, Bonnomet F. New comprehensive score for predicting difficulties in revision total hip arthroplasty. Orthop Traumatol Surg Res 2024:103983. [PMID: 39218300 DOI: 10.1016/j.otsr.2024.103983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 04/24/2024] [Accepted: 05/07/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Revision total hip arthroplasty (THA) can be complex, and assessing possible difficulties is important to predict the operative time. No simple score for predicting difficulties has been assessed prospectively. We therefore developed an original score for the pre-operative evaluation of extraction and reconstruction difficulties. The objectives of this prospective study were to (1) assess correlations between score values and operative time, (2) determine whether the score predicted the need for revision implants and/or filling material, (3) determine whether the score predicted intra-operative and post-operative complications, and (4) evaluate the inter-observer and intra-observer reproducibility of the score. HYPOTHESIS The score is reproducible and correlates well with the operative time, thereby allowing prediction of this parameter before surgery. MATERIAL AND METHODS A prospective study of 103 revision THA procedures performed between March 2018 and August 2023 was conducted. The primary outcome was operative time and the secondary outcomes were use of a revision implant, use of filling material, and intra-operative and post-operative complications. The score was determined by four observers to allow evaluation of inter-observer agreement. Intra-observer agreement was assessed by having one of the observers determine the score a second time after inclusion of the last patient. The score has a maximum value of 20 and allows classification of the procedure as very difficult, difficult, and moderately difficult. RESULTS Mean operative time correlated with the score value: 136.0 ± 33.9 min in the very difficult group, 102.0 ± 34.8 min in the difficult group, and 75.4 ± 65.5 min in the moderately difficult group (p = 0.0002). The score predicted the use of a reinforcement ring (40 procedures: 12/17 [70%], 11/25 [44%], and 17/61 [28%] in the very difficult, difficult, and moderately difficult groups, respectively; p = 0.01) and of a long stem (20 procedures: 8/17 [47%], 7/25 [28%], and 5/61 [8%] patients in the very difficult, difficult, and moderately difficult groups, respectively; p < 0.001). The score did not predict the use of filling material (42 procedures: 10/17 [59%], 9/25 [36%], and 23/61 [37%] in the very difficult, difficult, and moderately difficult groups, respectively; p = 0.250). The score predicted both intra-operative complications (5/17 [29%], 4/25 [16%], and 4/61 [6%] procedures in the very difficult, difficult, and moderately difficult groups, respectively; p = 0.028) and post-operative complications (4/17 [23%], 0/25 [0%], and 6/61 [9%] in the very difficult, difficult, and moderately difficult groups, respectively; p = 0.15). Inter-observer agreement was strong according to Landis-Koch criteria, with kappa values ranging from 0.70 to 0.79 [0.57-0.90]. The kappa value for intra-observer agreement was 0.74 [0.63-0.85]. DISCUSSION This score predicts surgical difficulties by adding criteria to bone destruction, in contrast to widely used classifications for revision THA. Moreover, the score is reproducible and predicts the operative time, thus potentially playing an important role during pre-operative planning. LEVEL OF EVIDENCE IV; prospective observational non-comparative study.
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Affiliation(s)
- Olivier Roche
- Service de Chirurgie Orthopédique du Centre Chirurgical Émile Galle (CCEG), CHU de Nancy, France.
| | - Arthur Schmitz
- Service de Chirurgie Orthopédique du Centre Chirurgical Émile Galle (CCEG), CHU de Nancy, France
| | - Maxime Lefevre
- Service de Chirurgie Orthopédique du Centre Chirurgical Émile Galle (CCEG), CHU de Nancy, France
| | - François Sirveaux
- Service de Chirurgie Orthopédique du Centre Chirurgical Émile Galle (CCEG), CHU de Nancy, France
| | - François Bonnomet
- Service de Chirurgie Orthopédique du CHU de Strasbourg, Hôpital de Hautepierre, France
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Maher M, Ward A, Ward K, Robinson K, Mills E. Minimizing the Risk of Surgical Site Infection Following Hip Fracture Operation. Surg Infect (Larchmt) 2024. [PMID: 38958043 DOI: 10.1089/sur.2024.019] [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: 07/04/2024] Open
Abstract
Introduction: Hip fractures are the most common serious injury in the elderly, associated with disability, morbidity, and mortality. Surgical site infection (SSI) is a serious post-operative complication. This prospective cohort study outlines how our center made cumulative improvements in SSI incidence rates, reaching a 12-month average of 0.5%. Methods: All patients undergoing hip fracture operation between 2016 and 2021 were included. The primary outcome measure was confirmed SSI, according to the Public Health England definition. Results were compared with the baseline recordings by an independent SSI team in 2013. Demographic data were compared with National Hip Fracture Database records. Peri-operative infection control and wound management tactics introduced between 2014 and 2021 were collated to gain an overview care bundle. Results: Baseline recordings identified a 9.0% SSI rate in a three-month observation period. In our study, 3,138 hip fracture operative cases were completed between October 2016 and December 2021. There were 9 superficial and 32 deep infections identified, yielding an overall infection rate of 1.3%. However, when analyzing the 12-month average, there was consistent decline in SSI from the baseline 9.0% in 2013 to 0.5% in 2021 (p < 0.05). A peri-operative care bundle included pre-operative bleeding risk assessment. Intra-operatively, double preparation and draping is used for arthroplasty. Broad-spectrum antibiotic agents and tranexamic acid are administered. Meticulous hemostasis and watertight wound closure are observed. Anti-coagulated patients received negative pressure dressings. Post-operatively, a dedicated senior lead team provided daily inpatient review of patients, with urgent consultant review of all wound healing concerns. Conclusion: Patients with a hip fracture have numerous risk factors for SSI. A dedicated multi-focal tactic, adopted by a multi-disciplinary department, can yield substantial risk reduction. Each intervention is evidence based and contributes to cumulative improvement. By prioritizing infection prevention, we have minimized the need for complex infection management interventions and achieved an annual saving of £860,000 for our trust.
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Affiliation(s)
- Mark Maher
- Department of Trauma and Orthopaedic Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Alex Ward
- Department of Trauma and Orthopaedic Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Karen Ward
- Department of Trauma and Orthopaedic Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Karen Robinson
- Department of Trauma and Orthopaedic Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Edward Mills
- Department of Trauma and Orthopaedic Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
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de Haan E, Roukema GR, van Rijckevorsel VAJIM, Kuijper TM, Jong LD. Risk factors for prosthetic joint infections after hemiarthroplasty of the hip following a femoral neck fracture. Injury 2024; 55:111195. [PMID: 38039635 DOI: 10.1016/j.injury.2023.111195] [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: 05/29/2023] [Revised: 10/24/2023] [Accepted: 11/06/2023] [Indexed: 12/03/2023]
Abstract
PURPOSE The primary aim of this study was to identify risk factors and validate earlier reported risk factors for Prosthetic Joint Infection (PJI) after hemiarthroplasty. The secondary aim was to assess peri‑operative clinical outcomes, adverse events and mortality rates in PJI patients after hemiarthroplasty. METHODS A prospective hip fracture database was used to obtain data for this observational cohort study. Patients who underwent hemiarthroplasty between 2011 and 2021 were included. A PJI was diagnosed by the Musculoskeletal Infection Society criteria. Univariable and multivariable analyses were performed to identify factors highly associated with a PJI. RESULTS In total, 2044 patients were analysed of which 72 patients (3.5 %) developed PJI. The multivariable analysis showed that Body Mass Index (BMI) >30 (OR2.84, P = 0.020), operating time of <45 min (OR=2.80, P = 0.002), occurrence of haematoma (OR=6.24, P<0.001), decreasing level of hemoglobin (OR=1.62, P = 0.001) and re-operation for luxation (OR=9.25, P<0.001) were significant independent prognostic risk factors for development of PJI after hemiarthroplasty. Diabetes Mellitus (OR=0.34, P = 0.018) and >20 hemiarthroplasties performed by the surgeon in the previous year (OR=0.33, P = 0.019) were prognostic protective factors. In patients with PJI, 40 % (n = 29) died within one year after surgery, compared with 27 % (n = 538) in patients without PJI (OR=1.80, P = 0.017). CONCLUSION Independent significant prognostic factors highly associated with PJI after hemiarthroplasty were BMI >30, operating time of <45, decreasing level of hemoglobin, occurrence of haematoma and re-operation for luxation. Diabetes Mellitus and >20 hemiarthroplasties performed by the surgeon in the previous year were prognostic protective factors for the development of PJI. PJI was associated with significantly higher 1-year all-cause mortality.
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Affiliation(s)
- Eveline de Haan
- Surgery Department, Maasstad Hospital, 3007 AC Rotterdam, the Netherlands; Surgery Department, Franciscus Gasthuis en Vlietland, 3045 PM Rotterdam, the Netherlands.
| | - Gert R Roukema
- Surgery Department, Maasstad Hospital, 3007 AC Rotterdam, the Netherlands
| | | | - T Martijn Kuijper
- Maasstad Academy, Maasstad Hospital, 3079 DZ Rotterdam, the Netherlands
| | - Louis de Jong
- Surgery Department, Maasstad Hospital, 3007 AC Rotterdam, the Netherlands
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Du P, Guo J, Zhu Y, Cui Y, Li J, Feng Z, Hou Z, Zhang Y. Incidence and risk factors associated with postoperative surgical site infection in younger adults with hip fractures: a case-control study. INTERNATIONAL ORTHOPAEDICS 2022; 46:2953-2962. [PMID: 36222882 DOI: 10.1007/s00264-022-05607-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/05/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE Hip fracture is associated with high morbidity and mortality. The most common complication after hip fracture is surgical site infection (SSI). The goal was to investigate risks associated with SSI in young adults who underwent surgery for hip fractures. METHODS We conducted a case-control study enrolling 1243 patients from Jan 2015 to Dec 2019. This study investigated the multifaceted factors including demographics, lifestyles, comorbidities, surgical variables, and laboratory test results. Patients were divided into the case group (developed SSI) and control group (not developed SSI). Univariate analyses and multivariate logistic regression analyses were used to identify the risk factors independently associated with SSI. RESULTS A total of 25 patients including 16 (1.8%) in femoral neck fracture and nine (2.5%) in intertrochanteric fracture developed SSI post-operatively, with an accumulated incidence rate of 2.0%. Among them, four cases (1.6%) were deep SSI and 21 cases (98.4%) were superficial SSI. In most cases, Staphylococcus aureus caused the infections. Diabetes mellitus (OR 4.05, 95%CI: 1.08-15.23, P = 0.038), cerebrovascular disease (OR 3.71, 95%CI: 1.14-12.03, P = 0.029), heart disease (OR 6.23, 95%CI: 1.81-21.48, P = 0.004), and operative time (OR 1.01, 95%CI: 1.01-1.02, P = 0.002) in femoral neck fractures while ALP (> upper limit) (OR 33.39, 95%CI: 2.21-504.89, P = 0.011) and CK (> upper limit) (OR 40.97, 95%CI: 1.70-989.31, P = 0.022) in intertrochanteric fractures were found to be significantly associated with SSI. CONCLUSION Targeted pre-operative management, depending on the patients' fracture type and risk factors, should be developed to reduce post-operative SSI rates of younger adults with hip fracture.
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Affiliation(s)
- Pei Du
- Department of Infection Control and Prevention, The Third Hospital of Hebei Medical University, Shijiazhuang, China
- Department of Epidemiology and Statistics, Hebei Key Laboratory of Environment and Human Health, School of Public Health, Hebei Medical University, Shijiazhuang, China
| | - Junfei Guo
- Department of Orthopaedics Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China
- Orthopaedic Institute of Hebei Province, Shijiazhuang, China
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China
| | - Yanbin Zhu
- Department of Orthopaedics Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China
- Orthopaedic Institute of Hebei Province, Shijiazhuang, China
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China
| | - Yi Cui
- Department of Infection Control and Prevention, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jianmei Li
- Department of Infection Control and Prevention, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhongjun Feng
- Department of Infection Control and Prevention, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhiyong Hou
- Department of Orthopaedics Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China.
- Orthopaedic Institute of Hebei Province, Shijiazhuang, China.
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China.
- NHC Key Laboratory of Intelligent Orthopaedic Equipment, Shijiazhuang, China.
| | - Yingze Zhang
- Department of Orthopaedics Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China.
- Orthopaedic Institute of Hebei Province, Shijiazhuang, China.
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China.
- NHC Key Laboratory of Intelligent Orthopaedic Equipment, Shijiazhuang, China.
- Chinese Academy of Engineering, Beijing, China.
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Erichsen Andersson A, Gillespie BM, Karlsson M, Malchau H, Nellgård B, Wikström E, Rogmark C, Tillander J. Reduction of early surgical site and other care related infections in 3553 hip fracture patients: lessons learned from the 5-year Safe Hands project. Antimicrob Resist Infect Control 2022; 11:113. [PMID: 36064457 PMCID: PMC9444111 DOI: 10.1186/s13756-022-01153-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 08/25/2022] [Indexed: 11/23/2022] Open
Abstract
Background Surgical site infection (SSI) after acute hip fracture surgery is a devastating complication associated with increased suffering and mortality. The aim of the study was to investigate early SSI, sepsis, pneumonia and urinary tract infections over five years, before and after the implementation of the Safe Hands project. Methods This was a single-centre observational study with a 5-year longitudinal design, investigating the effects of an infection-prevention intervention targeting the clinical care pathway of individuals with acute hip fracture. Statistical analyses were based on routinely collected patient outcome data comprising 3553 patients. The study conforms to the criteria of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). Results The incidence of early SSIs decreased from 2.5% in years 1–2 to 1.1% in years 4–5. Similar results were observed for sepsis (2.7% to 1.3%) and urinary tract infections (14.2% to 4.2%). The multivariable regression results suggest that, for every observed year, the odds of early SSIs decreased. Male gender, procedure time, sepsis and preoperative skin damage increased the odds significantly.
Conclusions Our preventive bundle, based on partnership between researchers, managers and clinicians and a strong commitment to change from the involved professions, appear to be effective in reducing the frequency of potentially devastating SSIs and other hospital acquired infections after hip fracture surgery. The use of external and internal facilitators was crucial to enable individual and organisational learning and overcoming barriers to improvements.
Trial registration: Clinical Trials.gov ID: NCT02983136 Registered 6 December 2016—Retrospectively registered.
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Surgical site infection prevention through bundled interventions in hip replacement surgery: A systematic review. Int J Surg 2021; 95:106149. [PMID: 34687953 DOI: 10.1016/j.ijsu.2021.106149] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/30/2021] [Accepted: 10/18/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Bundles have shown to improve patient outcomes in several settings. Surgical site infections (SSIs) following joint replacement surgery are associated with severe outcomes. We aimed to determine the effectiveness of non-pathogen specific bundled interventions in reducing SSIs after hip arthroplasty procedures. MATERIALS AND METHODS A systematic review and meta-analysis were conducted according to the PRISMA statement guidelines (PROSPERO registration number CRD42020203031). PubMed, Embase and Cochrane databases were searched for studies evaluating SSI prevention bundles in hip replacement surgery, excluding studies evaluating pathogen-specific bundles. Records were independently screened by two authors. The primary outcome was the SSI rate in intervention and control groups or before and after bundle implementation. Secondary outcomes of interest were bundle compliance and the number and type of bundle components. A meta-analysis was conducted using raw data, by calculating pooled relative risk (RR) SSI estimates to assess the impact of bundled interventions on SSI reduction. RESULTS Eleven studies were included in the qualitative review and four studies comprising over 20 000 patients were included in the quantitative synthesis. All included studies found bundles were associated with reduced SSI rates. The pooled RR estimated from the fixed-effects model was 0.76 (95% confidence interval 0.61-0.96, p 0.022) with 49.8% heterogeneity. CONCLUSIONS Results support the effectiveness of non-pathogen specific bundled interventions in preventing SSIs following hip arthroplasty. A "core" group of evidence-based elements for bundle development were identified.
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Zhang BF. A commentary on "surgical site infection prevention through bundled interventions in hip replacement surgery: A systematic review" (Int J Surg 2021; 106149). Int J Surg 2021; 95:106159. [PMID: 34737102 DOI: 10.1016/j.ijsu.2021.106159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 01/10/2023]
Affiliation(s)
- Bin-Fei Zhang
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Beilin District, Xi'an, Shaanxi Province, China
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Canbek U, Dibek E, Akgun U, Col B, Canbek TD, Aydogan NH, Usmanov N, Kasap M, Akpinar G. Analysis of the fluid biochemistry in patients with prolonged wound drainage after hip hemiarthroplasty. Injury 2021; 52:918-925. [PMID: 33059924 DOI: 10.1016/j.injury.2020.10.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/04/2020] [Accepted: 10/06/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The origin and content of prolonged wound drainage (PWD) after arthroplasty remain uncertain. In this study, we performed the biochemical, biological and advanced proteomic analysis of the drainage fluid collected from PWD patients following hip hemiarthroplasty (HA). METHODS Data of 28 patients who developed PWD after HA were prospectively analyzed. After examining the biochemical content of the drainage fluid collected on postoperative day 6, to find out if the drainage fluid was transudate or exudate, it was compared with the patient's serum values according to the Light criteria. Subsequently, biological and proteomic analyzes of both drainage fluid and serum were performed. The similarities and differences in terms of protein concentrations, protein identities were examined. In the drainage fluid, we analyzed lymph-specific proteins. RESULTS 16 patients with PWD were male (61.1%), 12 were female (38.9%), and the mean age of all patients was 79.64 ± 8.44 (65-95). Biochemical test results of the drainage fluid / serum were as follows: Total protein: 2.1 / 5.2 g/dl, albumin: 1.3 / 3.1 g/dl, lactate dehydrogenase (LDH): 121/324 U/l, cholesterol: 28/160 mg/dl, triglyceride: 37/122 mg/dl, sodium (Na): 140/ 140mg/dl, potassium (K): 4.1/ 4.1 mg/dl. pH of the drainage fluid was 7.6. According to these biochemical values, drainage fluid was classified as transudate. As a result of protein identification, fibrinogen beta chain, keratin type 1, creatine kinase M-type protein were detected in drainage fluid. Subsequent western analysis revealed that, gliseraldehyde-3-phosphate dehydrogenase (GAPDH) and beta actin antibody were detected in the drainage fluid but not in serum. CONCLUSION Despite the similarity in serum and transudative PWD fluid in terms of biochemical content, we found that when we carried out further proteomic analysis, PWD contains lymph-specific proteins. Unlike PWD, these proteins were not determined in serum. PWD fluid can be also called as lymphorrhea. PWD fluid with abundant proteins may also provide an appropriate environment for the growth of microorganisms.
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Affiliation(s)
- Umut Canbek
- Mugla Sitki Kocman University, Faculty of Medicine, Department of Orthopaedics and Traumatology Mugla, Turkey.
| | - Esra Dibek
- Mugla Sıtkı Koçman University, Faculty of Science, Department of Biology, Mugla, Turkey
| | - Ulas Akgun
- Mugla Sitki Kocman University, Faculty of Medicine, Department of Orthopaedics and Traumatology Mugla, Turkey
| | - Bekir Col
- Mugla Sıtkı Koçman University, Faculty of Science, Department of Biology, Mugla, Turkey
| | - Tugba Dubektas Canbek
- Mugla Sitki Kocman University Training and Research Hospital, Department of Internal Medicine, Mugla, Turkey
| | - Nevres Hurriyet Aydogan
- Mugla Sitki Kocman University, Faculty of Medicine, Department of Orthopaedics and Traumatology Mugla, Turkey
| | - Nosirzhon Usmanov
- Mugla Sitki Kocman University, Faculty of Medicine, Department of Orthopaedics and Traumatology Mugla, Turkey
| | - Murat Kasap
- Kocaeli University, Medical School Department of Medical Biology, Kocaeli, Turkey
| | - Gurler Akpinar
- Kocaeli University, Medical School Department of Medical Biology, Kocaeli, Turkey
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Lok CC, Alexander CPH, Wah HY, Ho FJC. The application of evidence-based bundle approach to reduce surgical site infection in geriatric hip fracture patients: A single centre experience. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2020. [DOI: 10.1177/2210491720928486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Surgical site infection (SSI) is associated with increased morbidity and mortality, prolongation on length of hospital stay and cost of community healthcare. In 2010 and 2012, our centre experienced an unexpectedly high rate of SSI in geriatric hip fracture patients with hemiarthroplasty done. A multifaceted intervention programme – ‘bundle approach’ – consisting of preoperative microbiological screening, perioperative measures and postoperative wound care was implemented. Method: Preoperative methicillin-resistant Staphylococcus aureus (MRSA) screening was implemented. Intravenous vancomycin was given as prophylactic antibiotic of choice in those patients with positive MRSA screening. All patients will be bathed with chlorhexidine lotion 1 day before operation or on the day of operation. Standardized protocol of surgical site disinfection was implemented: a stringent first stage povidone-iodine disinfection, second stage waterproof extremity draping and sterile plastic sheet wrapping of non-surgical region and third stage ChloraPrep, followed by circumferential iodophor-impregnated plastic adhesive drape (‘Ioban’) covering the hip and thigh region. The surgical wound was dressed with Aquacel adhesive tape after wound closure. Results: The total numbers of infected cases were 17 from 2008 to 2012 and 9 from 2013 to 2018 (first quarter). The rates of infection were 7.02% from 2008 to 2012 and 3.16% from 2013 to 2018 (first quarter). There was a statistically significant reduction in the number of infected cases of hemiarthroplasty after the implementation of bundle approach ( p = 0.0411). Discussion: The bundle approach showed to achieve an effective and sustained decrease in SSI for the geriatric hip fracture patients.
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Affiliation(s)
- Chow Chun Lok
- Department of Orthopaedics and Traumatology, North District Hospital, HKSAR
| | - Chan Pak Hin Alexander
- Department of Orthopaedics and Traumatology, Alice Ho Miu Ling Nethersole Hospital, HKSAR
| | - Hung Yuk Wah
- Department of Orthopaedics and Traumatology, Alice Ho Miu Ling Nethersole Hospital, HKSAR
| | - Fan Jason Chi Ho
- Department of Orthopaedics and Traumatology, Alice Ho Miu Ling Nethersole Hospital, HKSAR
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Liu X, Dong Z, Li J, Feng Y, Cao G, Song X, Yang J. Factors affecting the incidence of surgical site infection after geriatric hip fracture surgery: a retrospective multicenter study. J Orthop Surg Res 2019; 14:382. [PMID: 31752900 PMCID: PMC6873468 DOI: 10.1186/s13018-019-1449-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 10/31/2019] [Indexed: 12/26/2022] Open
Abstract
Background Geriatric hip fracture is a common type of osteoporotic fracture with high mortality and disability; surgical site infection (SSI) can be a devastating complication of this injury. By far, only a few studies identified easily remediable factors to reduce infection rates following hip fracture and less researches have focused on geriatric patients. The objective of this study was to identify potentially modifiable factors associated with SSI following geriatric hip fracture surgery. Methods This retrospective, multicenter study involves three level I hospitals. A total of 1240 patients (60 years or older) underwent hip surgery with complete data were recruited between January 2016 and June 2018. Demographics information, medications and additional comorbidities, operation-related variables, and laboratory indexes were extracted and analyzed. Receiver operating characteristic (ROC) analysis was performed to detect the optimum cut-off value for quantitative data. Univariate and multivariate logistic analysis model were performed respectively to identify the independent predictors. Results Ninety-four (7.58%) patients developed SSI in this study, and 76 (6.13%) had superficial infection, while 18 (1.45%) were diagnosed with deep infection. Results of univariate and multivariate analysis showed age > 79 years (OR, 2.60; p < 0.001), BMI > 26.6 kg/m2 (OR, 2.97; p < 0.001), operating time > 107 min (OR, 2.18; p = 0.001), and ALB < 41.6 g/L (OR, 2.01; p = 0.005) were associated with an increased incidence of SSI; drainage use (OR, 0.57; p = 0.007) could reduce the incidence of wound infection for patients after geriatric hip fracture. Conclusion Accurate modifiable variables, operating time > 107 min, serum albumin < 41.6 g/L, BMI > 26.6 kg/m2, and age > 79 years could be applied to distinguish geriatric patients with high-risk of postoperative surgical site infection.
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Affiliation(s)
- Xiaopo Liu
- Third Department of Orthopaedics, Tangshan Gongren Hospital, Tangshan, Hebei, 063000, People's Republic of China.
| | - Zhijie Dong
- Department of Orthopaedic Surgery, Hebei General Hospital, Shijiazhuang, Hebei, 063000, People's Republic of China
| | - Jun Li
- Second Department of Orthopaedic Surgery, First Hospital of Hebei Medical University, Shijiazhuang, Hebei, 063000, People's Republic of China
| | - Yunbo Feng
- Third Department of Orthopaedics, Tangshan Gongren Hospital, Tangshan, Hebei, 063000, People's Republic of China
| | - Guolong Cao
- Third Department of Orthopaedics, Tangshan Gongren Hospital, Tangshan, Hebei, 063000, People's Republic of China
| | - Xin Song
- Department of Radiology, Tangshan Gongren Hospital, Tangshan, Hebei, 063000, People's Republic of China
| | - Jie Yang
- First Department of Geriatric, Tangshan Gongren Hospital, Tangshan, Hebei, 063000, People's Republic of China
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Le J, Dong Z, Liang J, Zhang K, Li Y, Cheng M, Zhao Z. Surgical site infection following traumatic orthopaedic surgeries in geriatric patients: Incidence and prognostic risk factors. Int Wound J 2019; 17:206-213. [PMID: 31730274 DOI: 10.1111/iwj.13258] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/12/2019] [Accepted: 10/15/2019] [Indexed: 12/18/2022] Open
Abstract
Geriatric population is increasing rapidly worldwide, and fragility fracture and complication following orthopaedic surgery in elderly people have now become major challenges for surgeons. Further studies are required to identify potentially modifiable factors associated with surgical site infection (SSI) in geriatric patients. This retrospective, multicenter study was conducted at four level I hospitals in China. During the 31-month study period, a total of 2341 patients (65 years or older) underwent orthopaedic surgery and complete data were recorded from September 2015 to April 2018. Demographics information, medications and additional comorbidities, surgery-related variables, and laboratory indexes were extracted and analysed. Receiver-operating characteristic analysis was performed to detect the optimum threshold of continuous variables. Independent risk factors of SSI were identified by univariate and multivariate analyses. Finally, 63 patients suffered from wound infection within the follow-up period, indicating a 2.7% incidence rate of SSI. Statistical results showed that open injury (odds ratio [OR], 9.5; 95% confidence interval [CI], 5.4-16.7), American Society of Anesthesiologists classified III-IV score (OR, 2.2; 95% CI, 1.3-3.8), surgical duration of >132 minutes (OR, 2.9; 95% CI, 1.1-5.0), serum albumin (ALB) of <36.4 mg/L (OR, 2.0; 95% CI, 1.6-3.4), and blood glucose (GLU) of >118 mg/dL (OR, 3.1; 95% CI, 1.1-5.3) were independent risk factors of postoperative SSI. With the application of sensitive and modifiable variables such as surgical duration and the levels of ALB and GLU, more geriatric patients with sub-high risk of postoperative SSI could be identified.
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Affiliation(s)
- Jinbo Le
- Department of Orthopedic Surgery, The First People's Hospital of Yichang (People's Hospital of Three Gorges University), Yichang, Hubei, China
| | - Zhijie Dong
- Department of Orthopedic Surgery, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Jie Liang
- Department of Orthopedic Surgery, The First People's Hospital of Yichang (People's Hospital of Three Gorges University), Yichang, Hubei, China
| | - Kun Zhang
- Department of Orthopedic Surgery, The First People's Hospital of Yichang (People's Hospital of Three Gorges University), Yichang, Hubei, China
| | - Yanhua Li
- Department of Orthopedic Surgery, The First People's Hospital of Yichang (People's Hospital of Three Gorges University), Yichang, Hubei, China
| | - Meijuan Cheng
- Department of Orthopedic Surgery, The First People's Hospital of Yichang (People's Hospital of Three Gorges University), Yichang, Hubei, China
| | - Zhenshuan Zhao
- Second Department of Orthopedic Surgery, First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
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Ma T, Lu K, Song L, Wang D, Ning S, Chen Z, Wu Z. Modifiable Factors as Current Smoking, Hypoalbumin, and Elevated Fasting Blood Glucose Level Increased the SSI Risk Following Elderly Hip Fracture Surgery. J INVEST SURG 2019; 33:750-758. [PMID: 30885013 DOI: 10.1080/08941939.2018.1556364] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objective: Surgical site infection (SSI) following hip fractures represents an important complication. This study aimed to investigate the incidence rate after surgery of hip fractures in the elderly and to identify the associated risk factors. Patients: Patients' demographic, injury, and surgery-related data and biochemical indexes were retrospectively reviewed and recorded during their hospitalization, between July 2015 and June 2017. After their discharge from hospital, patients were prospectively followed up at postoperative 1, 3, 6, and 12 months. SSIs were identified by review of patients' medical records and post-discharge telephone follow-up. Univariate and multivariate analyses were performed to determine the independent risk factors associated with SSI. Results: A total of 611 patients undergoing surgery for hip fractures with complete data were included for analysis. During the postoperative one year, 27 SSIs (19 superficial and 8 deep SSIs) developed, indicating the cumulative incidence of 4.4% (95%CI, 2.8-6.0%). Of them, 21 (77.8%) SSIs were detected during patients' hospitalization, and the 6 (22.2%) cases were confirmed via telephone during the post-discharge follow-up. After adjustment of multiple variables, BMI, current smoking, surgical duration, preoperative hospital stay, ASA class of III-IV, ALB <35g/L, and FBG > 110mg/dL were identified as independent risk factors for SSI. Conclusions: Three modifiable factors as smoking, preoperative ALB <35g/L, and FBG > 110mg/dL should be optimized preoperatively to reduce the SSIs. Other factors, although not modifiable, could be used for screening of at-risk patients, patient risk stratification, or for counseling of patients.
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Affiliation(s)
- Tianxiao Ma
- Department of Orthopaedic Surgery, The General Hospital of Jizhong Energy Xingtai Mining Group, Xingtai, Hebei, P. R China
| | - Kaosheng Lu
- Department of Orthopaedic Surgery, The General Hospital of Jizhong Energy Xingtai Mining Group, Xingtai, Hebei, P. R China
| | - Lihua Song
- Department of Orthopaedic Surgery, The General Hospital of Jizhong Energy Xingtai Mining Group, Xingtai, Hebei, P. R China
| | - Dongyue Wang
- Department of Orthopaedic Surgery, The General Hospital of Jizhong Energy Xingtai Mining Group, Xingtai, Hebei, P. R China
| | - Shenghua Ning
- Department of Orthopaedic Surgery, The General Hospital of Jizhong Energy Xingtai Mining Group, Xingtai, Hebei, P. R China
| | - Ziqi Chen
- Department of Orthopaedic Surgery, The General Hospital of Jizhong Energy Xingtai Mining Group, Xingtai, Hebei, P. R China
| | - Zhanyong Wu
- Department of Orthopaedic Surgery, The General Hospital of Jizhong Energy Xingtai Mining Group, Xingtai, Hebei, P. R China
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Implementation strategies to reduce surgical site infections: A systematic review. Infect Control Hosp Epidemiol 2019; 40:287-300. [PMID: 30786946 DOI: 10.1017/ice.2018.355] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) portend high patient morbidity and mortality. Although evidence-based clinical interventions can reduce SSIs, they are not reliably delivered in practice, and data are limited on the best approach to improve adherence. OBJECTIVE To summarize implementation strategies aimed at improving adherence to evidence-based interventions that reduce SSIs. DESIGN Systematic reviewMethods:We searched PubMed, Embase, CINAHL, the Cochrane Library, the WHO Regional databases, AFROLIB, and Africa-Wide for studies published between January 1990 and December 2015. The Effective Practice and Organization Care (EPOC) criteria were used to identify an acceptable-quality study design. We used structured forms to extract data on implementation strategies and grouped them into an implementation model called the "Four Es" framework (ie, engage, educate, execute, and evaluate). RESULTS In total, 125 studies met our inclusion criteria, but only 8 studies met the EPOC criteria, which limited our ability to identify best practices. Most studies used multifaceted strategies to improve adherence with evidence-based interventions. Engagement strategies included multidisciplinary work and strong leadership involvement. Education strategies included various approaches to introduce evidence-based practices to clinicians and patients. Execution strategies standardized the interventions into simple tasks to facilitate uptake. Evaluation strategies assessed adherence with evidence-based interventions and patient outcomes, providing feedback of performance to providers. CONCLUSIONS Multifaceted implementation strategies represent the most common approach to facilitating the adoption of evidence-based practices. We believe that this summary of implementation strategies complements existing clinical guidelines and may accelerate efforts to reduce SSIs.
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Longer duration of operative time enhances healing metabolites and improves patient outcome after Achilles tendon rupture surgery. Knee Surg Sports Traumatol Arthrosc 2018; 26. [PMID: 28638971 PMCID: PMC6061452 DOI: 10.1007/s00167-017-4606-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE The relationship between the duration of operative time (DOT), healing response and patient outcome has not been previously investigated. An enhanced healing response related to DOT may potentiate repair processes, especially in hypovascular and sparsely metabolized musculoskeletal tissues such as tendons. This study aimed to investigate the association between DOT and the metabolic healing response, patient-reported outcome and the rate of post-operative complications after acute Achilles tendon injury. METHODS Observational cohort, cross-sectional study with observers blinded to patient grouping. A total of two-hundred and fifty-six prospectively randomized patients (210 men, 46 women; mean age 41 years) with an acute total Achilles tendon rupture all operated on with uniform anaesthetic and surgical technique were retrospectively assessed. At 2 weeks post-operatively, six metabolites were quantified using microdialysis. At 3, 6 and 12 months, patient-reported pain, walking ability and physical activity were examined using self-reported questionnaires, Achilles tendon total rupture score, foot and ankle outcome score and physical activity scale. At 12 months, functional outcome was assessed using the heel-rise test. Complications, such as deep venous thrombosis, infections and re-operations, were recorded throughout the study. RESULTS Patients who underwent longer DOT exhibited higher levels of glutamate (p = 0.026) and glycerol (p = 0.023) at 2 weeks. At the 1-year follow-up, longer DOT was associated with significantly less loss in physical activity (p = 0.003), less pain (p = 0.009), less walking limitations (p = 0.022) and better functional outcome (p = 0.014). DOT did not significantly correlate with the rate of adverse events, such as deep venous thrombosis, infections or re-ruptures. Higher glutamate levels were associated with less loss in physical activity (p = 0.017). All correlations were confirmed by multiple linear regressions taking confounding factors into consideration. CONCLUSION The results from this study suggest a previously unknown mechanism, increased metabolic response associated with longer DOT, which may improve patient outcome after Achilles tendon rupture surgery. Allowing for a higher amount of traumatized tissue, as reflected by up-regulation of glycerol in patients with longer DOT, may prove to be an important surgical tip for stimulation of repair of hypometabolic soft tissue injuries, such as Achilles tendon ruptures. LEVEL OF EVIDENCE II.
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Solomkin JS, Mazuski J, Blanchard JC, Itani KMF, Ricks P, Dellinger EP, Allen G, Kelz R, Reinke CE, Berríos-Torres SI. Introduction to the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee Guideline for the Prevention of Surgical Site Infections. Surg Infect (Larchmt) 2017; 18:385-393. [PMID: 28541804 DOI: 10.1089/sur.2017.075] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Surgical site infection (SSI) is a common type of health-care-associated infection (HAI) and adds considerably to the individual, social, and economic costs of surgical treatment. This document serves to introduce the updated Guideline for the Prevention of SSI from the Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC). The Core section of the guideline addresses issues relevant to multiple surgical specialties and procedures. The second procedure-specific section focuses on a high-volume, high-burden procedure: Prosthetic joint arthroplasty. While many elements of the 1999 guideline remain current, others warrant updating to incorporate new knowledge and changes in the patient population, operative techniques, emerging pathogens, and guideline development methodology.
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Affiliation(s)
- Joseph S Solomkin
- 1 Department of Surgery, Division of Trauma/Critical Care, University of Cincinnati College of Medicine , Cincinnati, Ohio
| | - John Mazuski
- 2 Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine , St. Louis, Missouri
| | - Joan C Blanchard
- 3 Association of periOperative Registered Nurses, Inc. , Denver, Colorado
| | | | - Philip Ricks
- 5 Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention , Atlanta, Georgia
| | - E Patchen Dellinger
- 6 Department of Surgery, Division of General Surgery, University of Washington , Seattle, Washington
| | - George Allen
- 7 SUNY Downstate Medical Center and SUNY College of Health Related Professions , Brooklyn, New York
| | - Rachel Kelz
- 8 Department of Surgery, Hospital of the University of Pennsylvania , Philadelphia, Pennsylvania
| | - Caroline E Reinke
- 8 Department of Surgery, Hospital of the University of Pennsylvania , Philadelphia, Pennsylvania
| | - Sandra I Berríos-Torres
- 5 Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention , Atlanta, Georgia
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de Jong L, Klem TMAL, Kuijper TM, Roukema GR. Factors affecting the rate of surgical site infection in patients after hemiarthroplasty of the hip following a fracture of the neck of the femur. Bone Joint J 2017; 99-B:1088-1094. [PMID: 28768787 DOI: 10.1302/0301-620x.99b8.bjj-2016-1119.r1] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 03/22/2017] [Indexed: 02/06/2023]
Abstract
AIMS Surgical site infection can be a devastating complication of hemiarthroplasty of the hip, when performed in elderly patients with a displaced fracture of the femoral neck. It results in a prolonged stay in hospital, a poor outcome and increased costs. Many studies have identified risk and prognostic factors for deep infection. However, most have combined the rates of infection following total hip arthroplasty and internal fixation as well as hemiarthroplasty, despite the fact that they are different entities. The aim of this study was to clarify the risk and prognostic factors causing deep infection after hemiarthroplasty alone. PATIENTS AND METHODS Data were extracted from a prospective hip fracture database and completed by retrospective review of the hospital records. A total of 916 patients undergoing a hemiarthroplasty in two level II trauma teaching hospitals between 01 January 2011 and 01 May 2016 were included. We analysed the potential peri-operative risk factors with univariable and multivariable logistic regression analysis. RESULTS A total of 92 patients (10%) had a surgical site infection, and 44 (4.9%) developed a deep infection. After univariable analyses, the multivariable model showed that the level of experience of the surgeon measured by the number of hemiarthroplasties performed per year was a significant prognostic factor (odds ratio (OR) 0.93, p = 0.042) for the development of an infection. Secondly, the development of a haematoma (OR 9.6, p < 0.001), a re-operation (OR 4.7, p = 0.004) and an operating time of < 45 mins (OR 5.1, p = 0.002) or > 90 mins (OR 2.7, p = 0.034) were also significant factors. CONCLUSION There was a significant association between the experience of the surgeon and the rate of deep infection. Secondly, a haematoma, a re-operation and both shorter and longer operating times were associated with an increased risk of deep infection after hemiarthroplasty. No association was found between deep infection and the anatomical approach, the time when surgery was undertaken and the use of a drain. Cite this article: Bone Joint J 2017;99-B:1088-94.
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Affiliation(s)
- L de Jong
- Maasstad Hospital, Maasstadweg 21, 3079 DZ Rotterdam, The Netherlands
| | - T M A L Klem
- Franciscus Hospital, Kleiweg 500, 3045 PM Rotterdam, The Netherlands
| | - T M Kuijper
- Maasstad Hospital, Maasstadweg 21, 3079 DZ Rotterdam, The Netherlands
| | - G R Roukema
- Maasstad Hospital, Maasstadweg 21, 3079 DZ Rotterdam, The Netherlands
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Bert F, Giacomelli S, Amprino V, Pieve G, Ceresetti D, Testa M, Zotti CM. The "bundle" approach to reduce the surgical site infection rate. J Eval Clin Pract 2017; 23:642-647. [PMID: 28145067 DOI: 10.1111/jep.12694] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/25/2016] [Accepted: 11/25/2016] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES In Italy, since 2008, the surveillance of surgical site infections (SSIs) has been conducted following ECDC recommendations, according to the protocol of the National System of Surveillance of Surgical Site Infections. In 2009, in Piedmont region, where the study was conducted, it was introduced a survey of a "bundle" for every patient under SSIs surveillance. The bundle includes 5 items: infection risk index calculation, preoperative shower, trichotomy, antibiotic prophylaxis, and body temperature control. The aim of this study is the evaluation of the incidence rate of the SSIs in relation to the implementation of the bundle from January 1st to December 31st, 2012. METHOD This study is an observational study (retrospective cohort). The regional surveillance system collected 3314 surgical operations during the year 2012 from 37 hospitals. The represented surgical categories were hip prosthetic surgery (HPRO: 1992 cases) and colon surgery (COLO: 1322 cases). The bundle was implemented in 1114 and 671 operations, respectively. Univariate and multivariate analysis were conducted stratifying the sample for hip surgery and colorectal surgery, with the purpose to identify an association between the implementation of the bundle and a decrease of the rate of SSIs. RESULTS From the analysis, the bundle resulted as a protective factor for the infection risk in colon surgery (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.38-0.78). The main risk factors were American Society of Anesthesiologists score ≥ 3 (OR, 1.57; 95% CI, 1.10-2.24) and contamination class ≥ 3 (OR, 2.02; 95% CI, 1.37-2.97). In the hip surgery, the application of the bundle was not statistically associated to a decrease of the risk of infection. CONCLUSION The use of surgical bundle seems to reduce significantly the SSIs rate in the colon surgery.
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Affiliation(s)
- Fabrizio Bert
- Department of Public Health Sciences and Pediatrics, University of Turin, Turin, Italy
| | - Sebastian Giacomelli
- Department of Public Health Sciences and Pediatrics, University of Turin, Turin, Italy
| | - Viola Amprino
- Department of Public Health Sciences and Pediatrics, University of Turin, Turin, Italy
| | - Giulio Pieve
- Department of Public Health Sciences and Pediatrics, University of Turin, Turin, Italy
| | - Daniela Ceresetti
- Department of Public Health Sciences and Pediatrics, University of Turin, Turin, Italy
| | - Marco Testa
- Department of Public Health Sciences and Pediatrics, University of Turin, Turin, Italy
| | - Carla M Zotti
- Department of Public Health Sciences and Pediatrics, University of Turin, Turin, Italy
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Fisher A, Srikusalanukul W, Fisher L, Smith P. The Neutrophil to Lymphocyte Ratio on Admission and Short-Term Outcomes in Orthogeriatric Patients. Int J Med Sci 2016; 13:588-602. [PMID: 27499691 PMCID: PMC4974907 DOI: 10.7150/ijms.15445] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 06/15/2016] [Indexed: 12/18/2022] Open
Abstract
AIM To investigate the association of the neutrophil to lymphocyte ratio (NLR) at admission with presence of fracture, comorbid conditions, and its prognostic value for short-term outcomes in orthogeriatric patients. METHODS On 415 consecutive patients (mean age 78.8 ±8.7[SD] years, 281 women, 255 with a non-vertebral bone fracture, including 167 with a hip fracture, HF) admitted to the Department of Orthopaedic Surgery at the Canberra hospital (2010 - 2011) data on clinical and laboratory characteristics were collected prospectively. The validation dataset included 294 consecutive patients (mean age 82.1 ± 8.0 years, 72.1% women) with HF. RESULTS Multivariate regression revealed four variables, presence of HF, hypoalbuminaemia (<33g/L), anaemia (<120g/L) and hyperparathyroidism (PTH>6.8 pmol/L), as independent determinants of admission NLR≥5.1. There was a dose-graded relationship between presence of fracture, especially HF, postoperative complications and levels of NLR categorized as tertiles. Compared to patients with NLR<5.1(first tertile), patients with NLR 5.1-8.5 (second tertile) had a 1.8-, 3.1-, 2.6-, and 2.5-fold higher risk for presence of any fracture, HF, developing postoperative myocardial injury (troponin I rise) and a high inflammatory response/infection (CRP>100mg/L after the 3rd postoperative day), respectively, while in subjects with NLR>8.5 (third tertile) these risks were 2.6-, 4.9-, 5.9- and 4.5-times higher, respectively; subjects with NLR>8.5 had a 9.7 times higher chance of dying in the hospital compared to patients with NLR 5.1-8.5; the NLR retained its significance on multivariate analyses. The NLR ≥5.1 predicted postoperative myocardial injury with an area under the curve (AUC) of 0.626, CRP>100mg/L with AUC of 0.631 and the NLR >8.5 predicted in-hospital mortality with an AUC of 0.793, showing moderately high sensitivity (86.7%, 80% and 90%, respectively) and negative predictive value (92.9%, 71.2%, 99.6%, respectively), but low specificity. Admission NLR was superior to other, except hypoalbuminaemia, prognostic markers; combined use of both NLR≥5.1 and albumin<33g/L only moderately increased the accuracy of prediction. The validation study confirmed the prognostic value of the admission NLR. CONCLUSIONS In orthogeriatric patients, high NLR on admission is an independent indicator of fracture presence, a significant risk factor and moderate predictor of postoperative myocardial injury, high inflammatory response/infection and in-hospital death.
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Affiliation(s)
- Alexander Fisher
- Department of Geriatric Medicine, The Canberra Hospital, Canberra, ACT, Australia; Department of Orthopaedic Surgery, The Canberra Hospital, Canberra, ACT, Australia; Australian National University Medical School, Canberra, ACT, Australia
| | | | - Leon Fisher
- Department of Gastroenterology, The Canberra Hospital, Canberra, ACT, Australia
| | - Paul Smith
- Department of Orthopaedic Surgery, The Canberra Hospital, Canberra, ACT, Australia; Australian National University Medical School, Canberra, ACT, Australia
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What are the risk factors for post-operative infection after hip hemiarthroplasty? Systematic review of literature. INTERNATIONAL ORTHOPAEDICS 2015; 40:1843-8. [DOI: 10.1007/s00264-015-3033-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 11/01/2015] [Indexed: 12/21/2022]
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Leaper DJ, Tanner J, Kiernan M, Assadian O, Edmiston CE. Surgical site infection: poor compliance with guidelines and care bundles. Int Wound J 2015; 12:357-62. [PMID: 24612792 PMCID: PMC7950697 DOI: 10.1111/iwj.12243] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 01/27/2014] [Indexed: 11/28/2022] Open
Abstract
Surgical site infections (SSIs) are probably the most preventable of the health care-associated infections. Despite the widespread international introduction of level I evidence-based guidelines for the prevention of SSIs, such as that of the National Institute for Clinical Excellence (NICE) in the UK and the surgical care improvement project (SCIP) of the USA, SSI rates have not measurably fallen. The care bundle approach is an accepted method of packaging best, evidence-based measures into routine care for all patients and, common to many guidelines for the prevention of SSI, includes methods for preoperative removal of hair (where appropriate), rational antibiotic prophylaxis, avoidance of perioperative hypothermia, management of perioperative blood glucose and effective skin preparation. Reasons for poor compliance with care bundles are not clear and have not matched the wide uptake and perceived benefit of the WHO 'Safe Surgery Saves Lives' checklist. Recommendations include the need for further research and continuous updating of guidelines; comprehensive surveillance, using validated definitions that facilitate benchmarking of anonymised surgeon-specific SSI rates; assurance that incorporation of checklists and care bundles has taken place; the development of effective communication strategies for all health care providers and those who commission services and comprehensive information for patients.
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Affiliation(s)
- David J Leaper
- School of Applied Sciences, University of Huddersfield, Huddersfield, UK
| | - Judith Tanner
- Clinical Nursing Research, DeMontfort University, Leicester, UK
| | - Martin Kiernan
- Prevention and Control of Infection, Southport and Ormskirk Hospitals NHS Trust, Southport, UK
| | - Ojan Assadian
- Department of Hospital Hygiene, Medical University of Vienna, Vienna, Austria
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Kulacoglu H. Hernia, mesh, and topical antibiotics, especially gentamycin: seeking the evidence for the perfect outcome…. Front Surg 2015; 1:53. [PMID: 25699259 PMCID: PMC4315908 DOI: 10.3389/fsurg.2014.00053] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 12/27/2014] [Indexed: 11/20/2022] Open
Abstract
Inguinal hernia repair is a clean surgical procedure and surgical site infection (SSI) rate is generally below 2%. Antibiotic prophylaxis is not routinely recommended, but it may be a good choice for institutions with high rates of wound infection (>5%). Typical prophylaxis is the intravenous application of first or second-generation cephalosporins before the skin incision. However, SSI rate remains more than 2% in many centers in spite of intravenous antibiotic prophylaxis. Even a 1% SSI rate may be unacceptable for the surgeons who specifically deal with hernia surgery. A hernia center targets to be a center of excellence not only in respect of recurrence rate but also for other postoperative outcomes, therefore a further measure is required for an excellent result regarding infection control. Topical gentamycin application in combination with preoperative single-dose intravenous antibiotic may be a useful to obtain this perfect outcome. Data about this subject are not complete and high-grade evidence has not been cumulated yet. Prospective randomized controlled trials can make our knowledge more solid about this subject and help the surgeons who seek perfect outcome regarding infection control in inguinal hernia surgery.
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Affiliation(s)
- Hakan Kulacoglu
- Department of Surgery, Recep Tayyip Erdoğan University , Rize , Turkey
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The longitudinal assessment of osteomyelitis development by molecular imaging in a rabbit model. BIOMED RESEARCH INTERNATIONAL 2014; 2014:424652. [PMID: 25295260 PMCID: PMC4177738 DOI: 10.1155/2014/424652] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 08/22/2014] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Osteomyelitis is a severe orthopaedic complication which is difficult to diagnose and treat. Previous experimental studies mainly focussed on evaluating osteomyelitis in the presence of an implant or used a sclerosing agent to promote infection onset. In contrast, we focused on the longitudinal assessment of a nonimplant related osteomyelitis. METHODS An intramedullary tibial infection with S. aureus was established in NZW rabbits. Clinical and haematological infection status was evaluated weekly, combined with X-ray radiographs, biweekly injections of calcium binding fluorophores, and postmortem micro-CT. The development of the infection was assessed by micro-PET at consecutive time points using 18F-FDG as an infection tracer. RESULTS The intramedullary contamination of the rabbit tibia resulted in an osteomyelitis. Haematological parameters confirmed infection in mainly the first postoperative weeks (CRP at the first 5 postoperative weeks, leucocyte differentiation at the second and sixth postoperative weeks, and ESR on the second postoperative week only), while micro-PET was able to detect the infection from the first post-operative week onward until the end of the study. CONCLUSIONS This study shows that osteomyelitis in the rabbit can be induced without use of an implant or sclerosing agent. The sequential follow-up indicates that the diagnostic value of each infection parameter is time point dependant. Furthermore, from all parameters used, the diagnostic value of 18F-FDG micro-PET is the most versatile to assess the presence of an orthopaedic infection in this model.
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Ferreri I, Lopes V, Calderon V. S, Tavares C, Cavaleiro A, Carvalho S. Study of the effect of the silver content on the structural and mechanical behavior of Ag–ZrCN coatings for orthopedic prostheses. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2014; 42:782-90. [DOI: 10.1016/j.msec.2014.06.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 05/16/2014] [Accepted: 06/10/2014] [Indexed: 10/25/2022]
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Odekerken JCE, Brans BT, Welting TJM, Walenkamp GHIM. (18)F-FDG microPET imaging differentiates between septic and aseptic wound healing after orthopedic implant placement: a longitudinal study of an implant osteomyelitis in the rabbit tibia. Acta Orthop 2014; 85:305-13. [PMID: 24673540 PMCID: PMC4062800 DOI: 10.3109/17453674.2014.900894] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND PURPOSE (18)F-FDG PET is a widely used tool for molecular imaging of oncological, cardiovascular, and neurological disorders. We evaluated (18)F-FDG microPET as an implant osteomyelitis imaging tool using a Staphylococcus aureus-induced peroperative implant infection in rabbits. METHODS Intramedullary titanium nails were implanted in contaminated and uncontaminated (control) proximal right tibiae of rabbits. Tibiae were quantitatively assessed with microPET for (18)F-FDG uptake before and sequentially at 1, 3, and 6 weeks after surgery. Tracer uptake was assessed in soft tissue and bone in both treatment groups with an additional comparison between the operated and unoperated limb. MicroPET analysis was combined with radiographic assessment and complementary histology of the tibiae. RESULTS At the first postoperative week, the (18)F-FDG uptake in the contaminated implant group was significantly higher than the preoperative measurement, without a significant difference between the contaminated and uncontaminated tibiae. From the third postoperative week onward, (18)F-FDG uptake allowed discrimination between osteomyelitis and postoperative aseptic bone healing, as well as quantification of the infection at distinct locations around the implant. INTERPRETATION (18)F-FDG-based microPET imaging allows differentiation between deep infection and undisturbed wound healing after implantation of a titanium intramedullary nail in this rabbit model. Furthermore, our results indicate that (18)F-FDG PET may provide a tool in human clinical diagnostics and for the evaluation of antimicrobial strategies in animal models of orthopedic implant infection.
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Affiliation(s)
- Jim C E Odekerken
- Laboratory for Experimental Orthopaedics, Department of Orthopaedic Surgery, CAPHRI School for Public Health and Primary Care
| | - Boudewijn T Brans
- Department of Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherlands.
| | - Tim J M Welting
- Laboratory for Experimental Orthopaedics, Department of Orthopaedic Surgery, CAPHRI School for Public Health and Primary Care
| | - Geert H I M Walenkamp
- Laboratory for Experimental Orthopaedics, Department of Orthopaedic Surgery, CAPHRI School for Public Health and Primary Care
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del Toro MD, Nieto I, Guerrero F, Corzo J, del Arco A, Palomino J, Nuño E, Lomas JM, Natera C, Fajardo JM, Delgado J, Torres-Tortosa M, Romero A, Martín-Rico P, Muniain MÁ, Rodríguez-Baño J. Are hip hemiarthroplasty and total hip arthroplasty infections different entities? The importance of hip fractures. Eur J Clin Microbiol Infect Dis 2014; 33:1439-48. [PMID: 24671411 DOI: 10.1007/s10096-014-2091-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 03/09/2014] [Indexed: 01/21/2023]
Abstract
Hip hemiarthroplasty (HHA) and total hip arthroplasty (THA) infections are usually considered as one entity; however, they may show important differences. We analyze these differences, as well as predictors of treatment failure (TF) and poor functional status among patients with prosthetic hip infections (PHIs). A multicenter cohort study of consecutive patients with PHIs was performed. The main outcome variable was TF after the first surgical treatment performed to treat the infection. Multivariate analysis was used to identify predictors of TF. A total of 127 patients with PHI were included (43 HHA, 84 THA). Patients with HHA infections were more frequently women (88% vs. 54%; p < 0.001), had comorbidities (86% vs. 67%, p = 0.02), and were older (median age 79 vs. 65 years, p < 0.001), and the reason for arthroplasty was more frequently a fracture (100% vs. 18%, p < 0.001). Failure of initial treatment and crude mortality were more frequent among HHA patients (44% vs. 23%, p = 0.01 and 28% vs. 7%, p = 0.001, respectively). However, HHA was not associated with TF in the multivariate analysis when hip fracture was considered; thus, variables independently associated with TF were hip fracture, inadequate surgical management, prosthesis retention, and higher C-reactive protein level. Failure of the first surgical treatment was associated with poorer functional status. HHA and THA infections showed significant differences in epidemiology, clinical features, and outcome. Although patients with HHA infections had a higher risk of TF, this was related to the reason for hip implant: a hip fracture. Success of the initial management of infection is a predictor of better clinical and functional outcome.
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Affiliation(s)
- M D del Toro
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Avda. Dr. Fedriani 3, 41009, Sevilla, Spain,
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Takigawa N, Moriuchi H, Abe M, Yasui K, Eshiro H, Kinoshita M. Complications and fixation techniques of trochanteric fractures with the TARGON(®) PF. Injury 2014; 45 Suppl 1:S44-8. [PMID: 24252573 DOI: 10.1016/j.injury.2013.10.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The purpose of this study was to analyse clinical results of elderly patients with trochanteric fractures that were treated with use of TARGON(®) PF nail. Overall, 494 patients (113 males) were available for this study. On the basis of Jensen classification, there were 76 cases in type I, 164 cases in type II, 70 in type III, 129 in type IV and 55 in type V. (1) Sliding amount of lag screw in relation to the Jensen classification, (2) sliding amount of lag screw according to the Ikuta's classification that categorises the reduction in lateral view in three, Subtype A, Subtype N and Subtype P, (3) sliding amount of lag screw in correlation between Jensen classification and Ikuta's classification and (4) postoperative complications (9 cases; 1.7%) were assessed. Cut-out and back-out cases were seen in 6 cases (1.1%), and these severe complications were evaluated in details. In correlation between Jensen classification and Ikuta's classification, the excessive sliding of lag screw was prominent with the Subtype P, which was preoperatively in Jensen type III or V. Cut-out or back-out cases were caused either from (1) Subtype P that were preoperatively Jensen types III or V, or from (2) the fracture where there was bony defect anteriorly. Therefore, special care must be taken for these types.
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Affiliation(s)
- Naohide Takigawa
- Department of Orthopaedic Surgery, Nishinomiya Kyoritsu Neurosurgical Hospital, Japan.
| | - Hiromitsu Moriuchi
- Department of Orthopaedic Surgery, Nishinomiya Kyoritsu Neurosurgical Hospital, Japan
| | - Muneki Abe
- Department of Orthopaedic Surgery, Nishinomiya Kyoritsu Neurosurgical Hospital, Japan
| | - Kenji Yasui
- Department of Orthopaedic Surgery, Nishinomiya Kyoritsu Neurosurgical Hospital, Japan
| | - Hisako Eshiro
- Department of Orthopaedic Surgery, Nishinomiya Kyoritsu Neurosurgical Hospital, Japan
| | - Mitsuo Kinoshita
- Department of Orthopaedic Surgery, Nishinomiya Kyoritsu Neurosurgical Hospital, Japan
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Periprosthetic bone loss following hemiarthroplasty: a comparison between cemented and cementless hip prosthesis. Injury 2013; 44 Suppl 3:S62-6. [PMID: 24060022 DOI: 10.1016/s0020-1383(13)70201-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The aim of this prospective randomized clinical study was to evaluate the magnitude of bone mineral changes as well as the clinical results after cemented and cementless haemiarthroplasty (HA) for femoral neck fracture. The study was comprised of 60 patients (mean age 85.2 years); 30 of them underwent cemented HA and 30 cementless HA. All patients underwent osteodensitometry for the purpose of Bone Mineral Density (BMD) evaluation. BMD was measured with dual-energy X-ray absorptiometry test (DEXA scans), which was scheduled at 1 month, 6 months and 1 year after surgery. BMD was evaluated at each of the seven Gruen zones. Harris Hip Score (HHS) at 3 months, 6 months and 12 months was used for evaluation of functional outcome. No difference was found between the two groups of patients in terms hospital stay, morbidity and mortality. The procedure took longer time in group A (cemented HA) compared to group B (cementless HA) (79.03 ± 3.59 vs 68.02 ± 5.97 minutes; p = 0.00). The Harris hip score averaged 76.97 ± 7.49 one year after surgery. At each follow - up examination the HHS was significantly higher in patients with cemented HA. We noted a trend of less intensive BMD reduction in all Gruen zones in group A compared to group B. However, the difference in BMD reduction between these two groups was significant only in zones 2, 3 and 4. Our results support the view that cemented hemiarthroplasty should be used for the management of displaced femoral neck fractures providing better functional outcomes and lower periprosthetic bone loss.
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Andersson AE, Bergh I, Karlsson J, Eriksson BI, Nilsson K. The application of evidence-based measures to reduce surgical site infections during orthopedic surgery - report of a single-center experience in Sweden. Patient Saf Surg 2012; 6:11. [PMID: 22697808 PMCID: PMC3495663 DOI: 10.1186/1754-9493-6-11] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 05/28/2012] [Indexed: 01/01/2023] Open
Abstract
Background Current knowledge suggests that, by applying evidence-based measures relating to the correct use of prophylactic antibiotics, perioperative normothermia, urinary tract catheterization and hand hygiene, important contributions can be made to reducing the risk of postoperative infections and device-related infections. The aim of this study was to explore and describe the application of intraoperative evidence-based measures, designed to reduce the risk of infection. In addition, we aimed to investigate whether the type of surgery, i.e. total joint arthroplasty compared with tibia and femur/hip fracture surgery, affected the use of protective measures. Method Data on the clinical application of evidence-based measures were collected structurally on site during 69 consecutively included operations involving fracture surgery (n = 35) and total joint arthroplasties (n = 34) using a pre-tested observation form. For observations in relation to hand disinfection, a modified version of the World Health Organization hand hygiene observation method was used. Results In all, only 29 patients (49%) of 59 received prophylaxis within the recommended time span. The differences in the timing of prophylactic antibiotics between total joint arthroplasty and fracture surgery were significant, i.e. a more accurate timing was implemented in patients undergoing total joint arthroplasty (p = 0.02). Eighteen (53%) of the patients undergoing total joint arthroplasty were actively treated with a forced-air warming system. The corresponding number for fracture surgery was 12 (34%) (p = 0.04). Observations of 254 opportunities for hand hygiene revealed an overall adherence rate of 10.3% to hand disinfection guidelines. Conclusions The results showed that the utilization of evidence-based measures to reduce infections in clinical practice is not sufficient and there are unjustifiable differences in care depending on the type of surgery. The poor adherence to hand hygiene precautions in the operating room is a serious problem for patient safety and further studies should focus on resolving this problem. The WHO Safe Surgery checklist “time out” worked as an important reminder, but is not per se a guarantee of safety; it is the way we act in response to mistakes or lapses that finally matters.
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Affiliation(s)
- Annette Erichsen Andersson
- University of Gothenburg, The Sahlgrenska Academy, Institute of Health and Care Sciences, Gothenburg, Sweden.
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