Prévalence et facteurs de risque de l’infection postopératoire en chirurgie orthopédique pédiatrique

Prevalence of surgical wound infection and related factors in patients after long bone surgery: A systematic review and meta-analysis

The goal of this systematic review and meta-analysis is to provide an overview of the prevalence of surgical wound infection and related factors in patients after long bone surgery. A comprehensive, systematic search was conducted in different international electronic databases, such as Scopus, PubMed, Web of Science and Persian electronic databases such as Iranmedex and Scientific Information Database using keywords extracted from Medical Subject Headings such as "Prevalence", "Surgical wound infection", "Surgical site infection" and "Orthopedics" from the earliest to the May 1, 2023. The appraisal tool for cross-sectional studies (AXIS tool) evaluates the quality of the included studies. A total of 71 854 patients undergoing long bone surgery participated in 12 studies. The pooled prevalence of surgical wound infection in patients who underwent long bone surgery reported in the 12 studies was 3.3% (95% CI: 1.5%-7.2%; I2  = 99.39%; p < 0.001). The pooled prevalence of surgical wound infection in male and female patients who underwent long bone surgery was 4.6% (95% CI: 1.7%-11.7%; p < 0.001; I2  = 99.34%) and 2.6% (95% CI: 1.0%-6.3%; I2  = 98.84%; p < 0.001), respectively. The pooled prevalence of surgical wound infection in patients with femur surgery sites reported in nine studies was 3.7% (95% CI: 2.1-6.4%; I2  = 93.43%; p < 0.001). The pooled prevalence of surgical wound infection in open and close fractures was 16.4% (95% CI: 8.2%-30.2%; I2  = 95.83%; p < 0.001) and 2.9% (95% CI: 1.5%-5.5%; I2  = 96.40%; p < 0.001), respectively. The pooled prevalence of surgical wound infection in patients with diabetes mellitus (DM), hypertension (HTN) and cardiovascular disease (CVD) was 4.6% (95% CI: 2.3%-8.9%; I2  = 81.50%; p < 0.001), 2.7% (95% CI: 1.2%-6.0%; I2  = 83.82%; p < 0.001) and 3.0% (95% CI: 1.4%-6.4%; I2  = 69.12%; p = 0.006), respectively. In general, the different prevalence of surgical wound infection in patients undergoing surgical treatment after long bone fracture may be caused by underlying factors (gender and co-morbidity) and fracture-related factors (surgery site and type of fracture).

Distal Femur Growth Modification Surgery Is Associated With Higher Surgical Wound Complication Rate

BACKGROUND

Orthopaedic wound complications are often associated with extensive surgeries and patient medical conditions. However, we noticed wound complications in minor growth modification surgeries in children, including guided growth and epiphysiodesis. Herein, we report the complication rate and risk factors associated with pediatric growth modification surgeries.

METHODS

This retrospective study reviewed surgical wound complications in 622 pediatric orthopaedic patients who underwent growth modification surgeries (418 children) or osteotomies (204 children) in the lower extremities in a single center between 2007 and 2019. The grades II and III complications assessed using the modified Clavien-Dindo-Sink complication classification system were compared between growth modification and osteotomy. Risk factors for complications, including the type of surgery, age, body mass index, neuromuscular disease, operation time, surgical sites per patient, surgical location, and implant types, were analyzed using the logistic regression.

RESULTS

The complication rate was 6.9% per patient and 3.6% per surgical site (29 sites in 29 patients comprising 21 grade II and 8 grade III) in the growth modification group, which was >1.0% per patient and 0.6% per site in the osteotomy group (2 sites in 2 patients comprising 2 grade III infections; P =0.001). Among 418 patients with 797 surgical sites in the growth modification group, wound complications were associated with surgical location (5.2% at distal femur vs. 1.0% at proximal tibia, P =0.002) and implant type (0.5% using transphyseal screw vs. 4.3-10.5% using plates or staples, P =0.011).

CONCLUSION

Surgical wound complication was associated with growth modification surgeries using plates or staples at the distal femur. Our results alert orthopaedic surgeons to this minor but unneglectable problem. Transphyseal screws may be the implant of choice for guided growth and epiphysiodesis at the distal femur in older children, considering the lower risks of wound complication.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Surgical Antibiotic Prophylaxis in Children Undergoing Surgery: A Systematic Review and Meta-Analysis

Background: To establish the role of surgical antibiotic prophylaxis (SAP) in the prevention of surgical site infection (SSI) in children undergoing surgery. Design: A systematic review and meta-analysis of six databases: MEDLINE (PubMed), EMBASE, CINAHL Plus, Cochrane Library, Web of Science, and Scopus. Study Selection: Included studies (irrespective of design) compared outcomes in children undergoing surgery, aged 0 to 21 years who received SAP with those who did not, with SSI as an outcome, using the U.S. Centers for Disease Control and Prevention (CDC) definitions for SSI. Data Extraction: Two independent reviewers applied eligibility criteria, assessed the risk of bias, and extracted data. Results: A total of six randomized control trials and 26 observational studies including 202,593 surgical procedures among 202,405 participants were included in the review. The pooled odds ratio of SSI was 1.20; (95% confidence interval [CI], 0.91-1.58) comparing those receiving SAP with those not receiving SAP, with moderate heterogeneity in effect size between studies (τ² = 0.246; χ² = 69.75; p < 0.001; I² = 57.0%). There was insufficient data on many factors known to be associated with SSI, such as cost, length of stay, re-admission, and re-operation; it was therefore not possible to perform subanalyses on these. Conclusions: This review and metanalysis did not find a preventive action of SAP against SSI, and our results suggest that SAP should not be used in surgical wound class (SWC) I procedures in children. However, considering the poor quality of included studies, the principal message of this study is in highlighting the absence of quality data to drive evidence-based decision-making in SSI prevention in children, and in advocating for more research in this field.

[Epidemiological and bacteriological features of surgical site infections (ISO) in the Division of Surgery at the Niamey National Hospital (HNN)]

Ce travail à consister à étudier les aspects épidémiologiques et bactériologiques des souches bactériennes isolées au cours des infections du site opératoire (ISO) à l'Hôpital National de Niamey. Nous avions mené une étude rétrospective, et descriptive sur une période de 24 mois. Toutes les souches isolées à partir de prélèvements bactériologiques effectués chez les patients présentant une infection du site opératoire ont été identifiées et testés aux antibiotiques selon les méthodes classiques conventionnelles. Les analyses bactériologiques ont permis d'isoler 126 souches bactériennes avec une prédominance de S.aureus (n=39, 31%) suivi d'Escherichia coli (n = 29, 23%) et de Pseudomonas aeruginosa (n=12, 9,5%). Les souches d'Escherichia coli étaient sensibles à 100% à l'imipenème. Elles ont montré des résistances marquées à l'ampicilline, l'amoxicilline, l'acide-clavulanique et la ticarcilline. Elles présentaient des résistances variables aux aminosides (62% à la gentamycine, et 78% à l'amikacine), et aux fluoroquinolones (acide nalidixique 74%, pefloxacine 33%, l'ofloxacine 69%, ciprofloxacine 61%). L'ensemble des isolats d'entérobactéries étaient sensibles à l'imipénème. Les souches de S.aureus avaient montré des résistances à la Pénicilline G (88,6%) et à l'oxacilline (83%). Elles avaient montré aussi des résistances de 37% et 57% respectivement à la vancomycine et teicoplanine. Par contre, elles étaient sensibles à la lincomycine et aux aminosides testés. Compte tenu de ces résultats, nous pensons qu'il faudra améliorer les protocoles d'antibioprophylaxie et d'antibiothérapie probabiliste dans les services chirurgicaux. Aussi, mener des études périodiques de surveillances des ISO.

Clinical outcome of posteromedial versus posteromedial-lateral release for clubfoot

Although the Ponseti serial casting method is the gold standard for the management of clubfoot, surgical correction remains the best option for resistant cases. Therefore, we compared posteromedial and posteromedial-lateral surgical approaches for the correction of resistant clubfoot. Between 2007 and 2013, 68 patients with idiopathic nonsyndromic resistant clubfoot, who were admitted to our referral institute, were enrolled in our study. The patients were divided into two groups. The patients in group 1 (33 cases of clubfoot) underwent posteromedial release with a single incision and those in group 2 (35 cases of clubfoot) underwent posteromedial-lateral release by two separate incisions. The severity of deformity was classified according to the Dimeglio classification. After the operations, all patients were followed up and surgical results as well as acute and chronic complications were evaluated. The patients were followed up for a mean of 43 months, and at the last follow-up visit, the Dimeglio scores in groups 1 and 2 were 4.8±3.8 and 3.3±2.6, respectively (P=0.04). Outcomes improved in both groups significantly. Although group 2 had more severe deformity, compared with group 1 at the baseline, the final outcome was better in this group. Heel varus and equinus was corrected more appropriately in group 2. Complications such as navicular dorsal subluxation and valgus overcorrection were less common in group 2. In cases of resistant clubfoot, it appears that a posteromedial-lateral approach with two separate incisions not only provides a better correction but is also associated with a lower complication rate in comparison with the single-incision posteromedial approach.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Surgical site infection rates and risk factors in orthopedic pediatric patients in Madrid, Spain

BACKGROUND

The objective of the study is to study surgical site infection (SSI) rates and risk factors in a pediatric population.

METHODS

We conducted a prospective cohort study to estimate the SSI rate at a national pediatric referral center, covering all patients managed at the Orthopedic Surgery Department of the Niño Jesús Children's University Teaching Hospital from January 2010 through December 2012. Risk factors and antibiotic prophylaxis were monitored. A comparison between Spanish and US data was performed, with a breakdown by National Nosocomial Infection Surveillance risk indices. We also conducted a comparative study of SSI rates from 2010 to 2012 to assess the impact of the epidemiologic surveillance system.

RESULTS

The study population of 1079 patients had a SSI rate of 2.8%. SSI rates were calculated for spinal fusion and other musculoskeletal procedures according to the National Nosocomial Infection Surveillance risk index. In the case of other musculoskeletal procedures, our SSI rates were 0.8 times lower than the overall Spanish rate, but higher than US rates for all risk categories. For spinal fusion procedures, our SSI rates were 1.2 times higher than the Spanish rates and 3.5 times higher than National Nosocomial Infection Surveillance rates. This latter finding should be interpreted with caution because it was based on a small sample. The multivariate analysis indicated that the only predictive factors of SSI were American Society of Anesthesiologists score and age.

CONCLUSIONS

The surveillance program showed that for clean procedures, SSI incidence decreased from 4% in 2010 to 3.2% in 2011 and to 2.4% in 2012.