A Predictive Score for Determining Risk of Surgical Site Infection After Orthopaedic Trauma Surgery

Risk factors for infection in severe open tibial shaft fractures

OBJECTIVE

To evaluate risk factors for infection in severe open tibial shaft fractures.

METHODS

A secondary analysis of a multicenter prospective study investigated internal versus external fixation of severe open tibia fractures at 20 US Level I trauma centers. Adult patients, aged <65 years, with a Gustilo-Anderson Type IIIB or severe IIIA metaphyseal or diaphyseal tibia fracture were included. All fractures underwent definitive fixation with either a modern ring external fixator, intramedullary device, and/or plate. Fourteen variables previously identified as risk factors for infection were included in the analysis. Deep surgical site infection was defined as an infection treated with surgical debridement within 1 year of index surgery.

RESULTS

The study cohort included 430 patients. Deep surgical site infection requiring reoperation occurred in 108 (25 %) patients. The final model identified four risk factors for infection: age >40 years (OR, 2.00; 95 % CI, 1.3-3.1), Gustilo-Anderson Type IIIB (OR, 1.80; 95 % CI, 1.1-3.0), embedded wound contamination (OR, 1.69; 95 % CI, 1.1-2.7), and wound length (OR, 1.02/cm; 95 % CI, 1.0-1.05). The model performed poorly at distinguishing infected from uninfected patients (Area Under the Curve=0.57; 95 % CI, 0.51-0.63).

CONCLUSIONS

Surgeons can now counsel patients with these risk factors that they are at a markedly higher risk of infection. The identification of these risk factors may direct future research aimed at mitigating the risk of deep surgical site infection in this patient population.

Timing of Fracture Fixation in Ankle Fracture-Dislocations

Ankle fracture-dislocations may require delayed internal fixation. Our aim was to compare acute open reduction and internal fixation (ORIF) with delayed ORIF, using external fixation or cast splint in ankle fracture-dislocations. Factors that affect the rates of re-operation and Surgical site infection (SSI) were identified. In this retrospective cohort study, patients were included with open and closed ankle fracture-dislocations treated with ORIF from two large peripheral hospitals and one academic center in the Netherlands. This study included 447 patients with an ankle fracture-dislocation. In the multivariate analysis, the difference between surgery <48 hours compared to bridging with cast or external fixation had no significant influence on unscheduled re-operation or SSI. Higher body mass index (BMI) and open fractures had a significant positive correlation with re-operation while diabetes mellitus (DM) and open fractures correlated with SSI. In patients with open fractures, there was also no significant difference in outcome between acute or delayed internal fixation. We suggest that it is safe to perform primary ORIF on all dislocated ankle fractures if the soft tissue injury allows surgery within 48 hours. When significant swelling is present, patients with well-reduced fractures and with no soft tissue injury could be treated safely with a cast until delayed ORIF is possible.Level of Evidence: Therapeutic level 2B (retrospective cohort study).

External Validation of a Predictive Score for Fracture-Related Infections in Orthopedic Trauma Surgery

BACKGROUND

The purpose of this study was to externally validate a predictive score for fracture-related infections, establishing generalizability for absolute and relative risk of infection in the setting of orthopedic fracture surgery.

MATERIALS AND METHODS

This was a retrospective, case-control study performed at a level I academic trauma center that included 147 patients with fracture-related infection in the study group and 300 control patients. We analyzed the same 8 independent predictors of fracture-related infection cited by a previous study. We then used the area under the receiver operating characteristics curve (AUC) to compare the derivation and validation cohorts. The validation and derivation cohorts were then compared by grouping patients into 4 strata of Wise score groups. This allowed for comparison of AUC and risk of fracture-related infection in our institution with those in the previously studied institution.

RESULTS

The resulting data yielded an AUC (0.74) nearly identical to that of the previously studied institution. It was also found that the relative risk of infection correlated with the Wise score in the same way the initial model did with the absolute risks being similar.

CONCLUSION

The previous predictive model was externally validated and shown to be generalizable to a different patient population. The relative risk of a fracture-related infection can be determined using this scoring model preoperatively with the goal of aiding in patient counseling and surgical decision-making, giving a quantitative value to patient risk factors. [Orthopedics. 2024;47(5):e268-e272.].

Pathogens in FRI - Do bugs matter? - An analysis of FRI studies to assess your enemy

Fracture-related infection (FRI) is a devasting complication for both patients and their treating Orthopaedic surgeon that can lead to loss of limb function or even amputation. The unique and unpredictable features of FRI make its diagnosis and treatment a significant challenge. It has substantial morbidity and financial implications for patients, their families and healthcare providers. In this article, we perform an in-depth and comprehensive review of FRI through recent and seminal literature to highlight evolving definitions, diagnostic and treatment approaches, focusing on common pathogens such as Staphylococcus aureus, polymicrobial infections and multi-drug-resistant organisms (MDRO). Furthermore, multiple resistance mechanisms and adaptations for microbial survival are discussed, as well as modern evidence-based medical and surgical advancements in treatment strategies in combating FRI.

-A machine learning model to predict surgical site infection after surgery of lower extremity fractures

PURPOSE

This study aimed to develop machine learning algorithms for identifying predictive factors associated with the risk of postoperative surgical site infection in patients with lower extremity fractures.

METHODS

A machine learning analysis was conducted on a dataset comprising 1,579 patients who underwent surgical fixation for lower extremity fractures to create a predictive model for risk stratification of postoperative surgical site infection. We evaluated different clinical and demographic variables to train four machine learning models (neural networks, boosted generalised linear model, naïve bayes, and penalised discriminant analysis). Performance was measured by the area under the curve score, Youdon's index and Brier score. A multivariate adaptive regression splines (MARS) was used to optimise predictor selection.

RESULTS

The final model consisted of five predictors. (1) Operating room time, (2) ankle region, (3) open injury, (4) body mass index, and (5) age. The best-performing machine learning algorithm demonstrated a promising predictive performance, with an area under the ROC curve, Youdon's index, and Brier score of 77.8%, 62.5%, and 5.1%-5.6%, respectively.

CONCLUSION

The proposed predictive model not only assists surgeons in determining high-risk factors for surgical site infections but also empowers patients to closely monitor these factors and take proactive measures to prevent complications. Furthermore, by considering the identified predictors, this model can serve as a reference for implementing preventive measures and reducing postoperative complications, ultimately enhancing patient outcomes. However, further investigations involving larger datasets and external validations are required to confirm the reliability and applicability of our model.

Predicting Which Species of Bacteria Will Cause an Infection After Fracture Surgery

The aim of this study was to develop and validate risk prediction models for deep surgical site infection (SSI) caused by specific bacterial pathogens after fracture fixation. A retrospective case-control study was conducted at a level I trauma center. Fifteen candidate predictors of the bacterial pathogens in deep SSI were evaluated to develop models of bacterial risk. The study included 441 patients with orthopedic trauma with deep SSI after fracture fixation and 576 control patients. The main outcome measurement was deep SSI cultures positive for methicillin-sensitive Staphylococcus aureus (MSSA), methicillin-resistant S aureus (MRSA), gram-negative rods (GNRs), anaerobes, or polymicrobial infection within 1 year of injury. Prognostic models were developed for five bacterial pathogen outcomes. Mean area under the curve ranged from 0.70 (GNRs) to 0.74 (polymicrobial). Strong predictors of MRSA were American Society of Anesthesiologists (ASA) classification of III or greater (odds ratio [OR], 3.4; 95% CI, 1.6-8.0) and time to fixation greater than 7 days (OR, 3.4; 95% CI, 1.9-5.9). Gustilo type III fracture was the strongest predictor of MSSA (OR, 2.5; 95% CI, 1.6-3.9) and GNRs (OR, 3.4; 95% CI, 2.3-5.0). ASA classification of III or greater was the strongest predictor of polymicrobial infection (OR, 5.9; 95% CI, 2.7-15.5) and was associated with increased odds of GNRs (OR, 2.7; 95% CI, 1.5-5.5). Our models predict the risk of MRSA, MSSA, GNR, anaerobe, and polymicrobial infections in patients with fractures. The models might allow for modification of preoperative antibiotic selection based on the particular pathogen posing greatest risk for this patient population. [Orthopedics. 2024;47(1):e19-e25.].

A deep surgical site infection risk score for patients with open tibial shaft fractures treated with intramedullary nail

OBJECTIVES

To identify deep infection risk factors in patients with open tibial shaft fractures and to develop a scoring algorithm to predict the baseline deep infection risk in this patient population.

METHODS

A retrospective cohort study conducted at a single academic trauma center identified patients with open tibial shaft fractures treated with intramedullary nail fixation from December 2006 to October 2020. The primary outcome was a deep surgical site infection requiring surgical debridement. The outcome was identified by Current Procedural Terminology codes and confirmed with a medical chart review documenting evidence of a tibial draining wound or sinus tract.

RESULTS

Deep surgical site infection occurred in 13% of patients (97/769). Factors that predicted deep surgical site infection were identified. Gustilo-Anderson type IIIB or IIIC was the strongest predictor with a 12-fold increase in the odds of deep infection (OR 11.8, p < 0.001). Additional factors included age >40 years (OR 1.7, p = 0.03), American Society of Anesthesiologists score ≥3 (OR 1.9, p < 0.01), Gustilo-Anderson type IIIA vs. type I or II (OR 2.8, p = 0.004), and gunshot wounds (OR 2.9, p = 0.02). The risk scoring model predicted patients who would develop an infection with an acceptable level of accuracy (AUC 0.79). The risk score categorized patients from a low probability of deep infection 2%-6% with <10 points to high risk (58%-69%) with >40 points.

CONCLUSIONS

This risk score model predicts deep postoperative infection in patients with open tibial shaft fractures treated with intramedullary nails. The ability to accurately estimate deep infection risk at the time of presentation might aid patient expectation management and allow clinicians to focus infection prevention strategies on the high-risk subset of this population.

Factors Associated With 30-Day Morbidity and Mortality Following the Surgical Treatment of Olecranon Fractures

The objective of this study was to identify factors independently associated with complications, hospital readmission, reoperation, and death in the 30-day period after surgical treatment of isolated olecranon fractures. A retrospective case-control study was performed using the National Surgical Quality Improvement Program database by querying the Current Procedural Terminology code for patients who underwent surgical treatment of isolated olecranon fractures from 2011 to 2020. A total of 4404 patients were included. The main study outcomes were 30-day medical or wound complications, hospital readmission, reoperation, and death. A bivariate screen was performed for explanatory variables associated with our outcome variables, and variables with P<.1 in the bivariate screen were included in multivariable regression models. Of the 4404 patients in our cohort, 29 patients (0.7%) developed medical or wound complications, 157 patients (3.6%) were readmitted, 123 patients (2.8%) underwent reoperation, and 12 patients (0.3%) died during the 30-day postoperative period. Multivariable logistic regression analysis showed that older age, smoking, bleeding disorders, and higher American Society of Anesthesiologists classification were associated with readmission; that older age, bleeding disorders, and higher American Society of Anesthesiologists classification were associated with reoperation; and that bleeding disorders were associated with mortality. No identifiable factors were independently associated with medical or wound complications. In this National Surgical Quality Improvement Program database study of olecranon fractures treated surgically during a recent 10-year period, we identified demographic and comorbid factors independently associated with 30-day postoperative readmission, reoperation, and mortality. Our findings are relevant for preoperative risk stratification and counseling. [Orthopedics. 2023;46(5):e310-e316.].

Trends in microbiological epidemiology of orthopedic infections: a large retrospective study from 2008 to 2021

BACKGROUND

This study assessed the distribution characteristics of pathogens isolated from cases of orthopedic infections and focused on the antimicrobial susceptibility of the main pathogens.

METHODS

This retrospective study involved patients with orthopedic infection in a tertiary medical center located in Shanghai, China, from 2008 to 2021.Pathogen information and the basic information of patients were identified from clinical microbiology laboratory data and the institutional medical record system.

RESULTS

In total, the pathogen information of 2821 patients were enrolled in the study. S. aureus (37.71%) was the main causative pathogen responsible for orthopedic infection. Gender, pathogens distribution and polymicrobial infection rates were significantly different (P < 0.05) among patients with different orthopedic infection diseases.The trends in the distribution of pathogens in the total cohort, implant-related infection group (Group A), non-implant-related infection group (Group B), and the sub-group of cases with arthroplasty showed significant linear changes over time. And the polymicrobial infection rates of the total cohort (from 17.17% to 11.00%), Group B(from 24.35% to 14.47%), and the sub-group of cases with internal fixation (from 10.58% to 4.87%) decreased significantly. The antimicrobial susceptibility showed changing trends with time for some main pathogens, especially for S.aureus and Enterobacter spp.

CONCLUSIONS

Our research indicated that the pathogen distribution and antimicrobial susceptibility in orthopedic infections changed over time. And the distribution of pathogens varied significantly among different types of orthopedic infectious diseases. These findings may serve as a reference for prophylaxis and empirical treatment strategies of orthopedic infection.

Morel-Lavallee lesions and number of surgeries for associated injuries predict surgical site infection risk following pelvic ring injury osteosynthesis

We examined the incidence and causative factors of surgical site infection (SSI) following osteosynthesis for pelvic ring injury by reviewing the data of 97 consecutive patients with pelvic ring injuries treated between 2014 and 2019. Osteosyntheses, including internal or external skeletal fixation with plates or screws, were performed based on fracture type and patient's condition. Fractures were treated surgically, with a 36 months minimum follow-up period. Eight (8.2%) patients experienced SSI. The most common causative pathogen was Staphylococcus aureus. Patients with SSI had significantly worse functional outcomes at 3, 6, 12, 24, and 36 months than those without. For patients with SSI, the average Merle d'Aubigné and Majeed scores at 3, 6, 12, 24, and 36 months after injury were 2.4, 4.1, 8.0, 11.0, and 11.3, and 25.5, 32.1, 47.9, 61.9, and 63.3, respectively. Patients with SSI had a higher likelihood of undergoing staged operations (50.0 vs. 13.5%, p = 0.02), more surgeries for associated injuries (6.3% vs. 2.5%, p = 0.04), higher likelihood of Morel-Lavallee lesions (50.0% vs. 5.6%, p = 0.002), higher incidence of diversional colostomy (37.5% vs. 9.0%, p = 0.05), and longer intensive care unit stay (11.1 vs. 3.9 days, p = 0.001) than those without. The contributing factors for SSI were Morel-Lavallee lesions (odds ratio [OR] 4.55, 95% confidence interval [95% CI] 3.34-50.0) and other surgeries for associated injuries (OR 2.37, 95% CI 1.07-5.28). Patients with SSI after osteosynthesis for pelvic ring injuries may have worse short-term functional outcomes.

Antibiotic-Loaded Coatings to Reduce Fracture-Related Infections: Retrospective Case Series of Patients with Increased Infectious Risk

Local antibiotic delivery strategies have been increasingly employed for the prevention of fracture-related infections (FRIs). The aim of this study is to evaluate the efficacy and safety of antibiotic-coated implants in the prevention of FRIs after surgical treatment in patients with increased infectious risk. A retrospective observational study has been conducted on patients with upper and lower limb fractures treated with internal fixation or prosthetic replacements, using a gentamicin coated nail (CN) and/or antibiotic-loaded hydrogel applied to the implant of choice (ALH). The study included 37 patients (20 M, 17 F), with a mean age of 63 years. The mean estimated preoperative infectious risk score was 6.4%. ALH was used in 27 cases, tibial CNs were implanted in 4 cases, and both were employed in 6 cases. The antibiotics used locally were gentamicin in 72.97% of cases (27 patients) and a combination of gentamicin + vancomycin in 27.03% of cases (10 patients). Mean follow-up was 32 months. Only one case (2.94%) showed onset of FRI at 5 months after surgery. Local antibiotic prophylaxis by coating resulted in a reduction in the incidence FRI, as compared to the estimated preoperative risk. The use of ALH allows for the choice of antibiotic; however, the application of antibiotics seems more nonuniform when applied to a nail.

Fracture-Related infection - the role of the surgeon and surgery in prevention and treatment

Fracture-related infection (FRI) is a complication that impacts care costs, quality of life, and patient function. Great strides have been made in the last decade to obtain a common language for definition and diagnosis with the contribution of the Fracture-Related Infection Consensus. Although FRI treatment requires the participation of clinical specialists in infectious diseases for the management of antibiotics, it is necessary to understand that this complication is an eminently surgical pathology. The orthopedic surgeon must play a leadership role in the prevention and treatment of this complex disease. In this review, the most relevant aspects of prevention are updated, and a strategy for a sequential and comprehensive approach to the patient with this complication is presented.

Incidence and risk factors for surgical site infection following volar locking plating (VLP) of unstable distal radius fracture (DRF)

PURPOSE

Volar locking plating (VLP) is the mainstay of treatment for distal radius fracture (DRF) but may be compromised by postoperative surgical site infection (SSI). This study aimed to identify the incidence and the risk factors for SSI following VLP of DRF.

METHODS

This retrospective study identified consecutive patients who underwent VLP for closed unstable DRFs in our institution between January 2015 and June 2021. Postoperative SSI was identified by inquiring the medical records, the follow-up records or the readmission medical records for treatment of SSI. The potential factors for SSI were extracted from the medical records. Univariate and multivariate logistic regression analyses were performed to identify the independent factors.

RESULTS

There were 930 patients included, and 34 had an SSI, representing an incidence of 3.7% (95% CI 2.4-4.9%). Patients with an SSI had threefold extended hospitalization stay (44.1 ± 38.2 versus 14.4 ± 12.5 days) as did those without. In univariate analysis, 18 variables were tested to be statistically different between SSI and non-SSI group. In multivariate analysis, 6 factors were identified as independently associated with SSI, including sex (male vs. female, OR 3.5, p = 0.014), ASA (III and IV vs. I, OR 3.2, p = 0.031), smoking (yes vs. no, OR 2.4, p = 0.015), bone grafting (OR 4.0, p = 0.007), surgeon volume (low vs. high, OR 2.7, p 0.011) and operation at night-time (vs. day-time, OR 7.8, p < 0.001).

CONCLUSION

The postoperative SSI of VLP of DRF was not uncommon, and the factors identified in this study, especially those modifiable, would help identify individual SSI risk, target clinical surveillance and inform patient counseling.

Is the timing of fixation associated with fracture-related infection among tibial plateau fracture patients with compartment syndrome? A multicenter retrospective cohort study of 729 patients

BACKGROUND

Tibial plateau fractures with an ipsilateral compartment syndrome are a clinical challenge with limited guidance regarding the best time to perform open reduction and internal fixation (ORIF) relative to fasciotomy wound closure. This study aimed to determine if the risk of fracture-related infection (FRI) differs based on the timing of tibial plateau ORIF relative to closure of ipsilateral fasciotomy wounds.

METHODS

A retrospective cohort study identified patients with tibial plateau fractures and an ipsilateral compartment syndrome treated with 4-compartment fasciotomy at 22 US trauma centers from 2009 to 2019. The primary outcome measure was FRI requiring operative debridement after ORIF. The ORIF timing relative to fasciotomy closure was categorized as ORIF before, at the same time as, or after fasciotomy closure. Bayesian hierarchical regression models with a neutral prior were used to determine the association between timing of ORIF and infection. The posterior probability of treatment benefit for ORIF was also determined for the three timings of ORIF relative to fasciotomy closure.

RESULTS

Of the 729 patients who underwent ORIF of their tibial plateau fracture, 143 (19.6%) subsequently developed a FRI requiring operative treatment. Patients sustaining infections were: 21.0% of those with ORIF before (43 of 205), 15.9% at the same time as (37 of 232), and 21.6% after fasciotomy wound closure (63 of 292). ORIF at the same time as fasciotomy closure demonstrated a 91% probability of being superior to before closure (RR, 0.75; 95% CrI, 0.38 to 1.10). ORIF after fasciotomy closure had a lower likelihood (45%) of a superior outcome than before closure (RR, 1.02; 95% CrI; 0.64 to 1.39).

CONCLUSION

Data from this multicenter cohort confirms previous reports of a high FRI risk in patients with a tibial plateau fracture and ipsilateral compartment syndrome. Our results suggest that ORIF at the time of fasciotomy closure has the highest probability of treatment benefit, but that infection was common with all three timings of ORIF in this difficult clinical situation.

A pragmatic randomized trial evaluating pre-operative aqueous antiseptic skin solutions in open fractures (Aqueous-PREP): statistical analysis plan

BACKGROUND

Approximately 1 in 10 patients with a surgically treated open fracture will develop a surgical site infection. The Aqueous-PREP trial will investigate the effect of 10% povidone-iodine versus 4% chlorhexidine in aqueous antiseptic solutions in reducing infections after open fracture surgery. The study protocol was published in April 2020.

METHODS AND DESIGN

The Aqueous-PREP trial is a pragmatic, multicenter, open-label, randomized multiple period cluster crossover trial. Each participating cluster is randomly assigned in a 1:1 ratio to provide 1 of the 2 study interventions on all eligible patients during a study period. The intervention periods are 2 months in length. After completing a 2-month period, the participating cluster crosses over to the alternative intervention. We plan to enroll a minimum of 1540 patients at 14 sites.

RESULTS

The primary outcome is surgical site infection guided by the Centers for Disease Control and Prevention's National Healthcare Safety Network reporting criteria (2017). All participants' surgical site infection surveillance period will end 30 days after definitive fracture management surgery for superficial infections and 90 days after definitive fracture management surgery for deep incisional or organ/space infections [1]. The secondary outcome is an unplanned fracture-related reoperation within 12 months of the fracture.

CONCLUSION

This manuscript serves as the formal statistical analysis plan (version 1.0) for the Aqueous-PREP trial. The statistical analysis plan was completed on February 28, 2022.

A Four-Probiotic Regime to Reduce Surgical Site Infections in Multi-Trauma Patients

Investigations that focused on the protective role of probiotics against Surgical Site Infections (SSI) in multiple-trauma (MT) patients are generally few, probably due to the complexity of the concept of trauma. We aimed to assess the efficacy of a four-probiotic regime to reduce the incidence of SSI in MT patients, with a brain injury included. MT patients, being intubated and expected to require mechanical ventilation for >10 days, were randomly allocated into placebo (n = 50) or probiotic treatment (n = 53) comprising Lactobacillus acidophilus LA-5 (1.75 × 109 cfu), Lactiplantibacillus plantarum UBLP-40 (0.5 × 109 cfu), Bifidobacterium animalis subsp. lactis BB-12 (1.75 × 109 cfu), and Saccharomycesboulardii Unique-28 (1.5 × 109 cfu) in sachets. All patients received two sachets of placebo or probiotics twice/day for 15 days and were followed-up for 30 days. The operations were classified as neurosurgical, thoracostomies, laparotomies, orthopedics, and others; then, the SSI and the isolated pathogen were registered. A total of 23 (46.0%) and 13 (24.5%) infectious insults in 89 (50 placebo patients) and 88 (53 probiotics-treated) operations (p = 0.022) were recorded, the majority of them relating to osteosynthesis—17 and 8, respectively. The most commonly identified pathogens were Staphylococcus aureus and Acinetobacter baumannii. Our results support published evidence that the prophylactic administration of probiotics in MT patients exerts a positive effect on the incidence of SSI.

Are deep infections that present before and after 90 days from orthopaedic trauma different? An analysis of the validity of the recent change in CDC criteria for infections

BACKGROUND

In 2016, the Centers for Disease Control and Prevention (CDC) changed the time frame for their definition of deep surgical site infection (SSI) from within 1 year to within 90 days of surgery. We hypothesized that a substantial number of infections in patients who have undergone fracture fixation present beyond 90 days and that there are patient or injury factors that can predict who is more likely to present with SSI after 90 days.

METHODS

A retrospective review yielded 452 deep SSI after fracture fixation. These patients were divided into two groups-those infected within 90 days of surgery and those infected beyond 90 days . Data were collected on risk factors for infection. Univariate and multiple logistic regression analyses were performed to compare the two groups. A randomly selected control group was used to build infection prediction models for both outcomes. The two outcomes were then modelled against each other to determine whether differences in predictors for early versus late infection exist.

RESULTS

Of the 452 infections, 144 occurred beyond 90 days (32% [95% CI, 28%-36%]). No statistically significant patient factors were found in multivariable analysis between the early and late infection groups. The need for flap coverage was the only injury characteristic that differed significantly between groups, with patients in the late infection group more likely to have needed a flap. When modelled against the control group and directly comparing the two models, predictors for early infection include male sex and fractures of the pelvis, acetabulum, or hip, whereas predictors of late infection include hepatitis C and/or human immunodeficiency virus (HIV) and admission to the intensive care unit (ICU).

CONCLUSION

Use of the recent CDC definition will underestimate the rate of actual postoperative infections when applied to orthopaedic trauma patients. Hepatitis C and/or HIV and ICU admission are predictors of late infection, whereas male sex and pelvis, acetabulum, or hip fractures are predictors of early infection. Patients who receive flap coverage may be more likely to present with late infection.

Influence of seasonal variability on orthopedic surgical outcomes in pediatric patients: a review of surgical site infections

Surgical site infections (SSIs) are challenging, with highly variable reported rates for children undergoing orthopedic surgery. It has been shown in adults that there is seasonal variability in SSI rates, with peak incidences in the summer months. We reviewed 8766 pediatric orthopedic procedures completed at a quaternary children's hospital over a 43-month period. Data collected included: age, sex, BMI, season of procedure, cultures, and other variables related to risks and treatment of SSIs. Of 4875 male and 3891 female pediatric patients undergoing orthopedic procedures, 47 patients (0.54%) with an average age of 11.3 years (range: 2.0-18.6) developed an SSI. Average time between surgery and diagnosis was 27.7 ± 19.8 days. Sixty percent of SSI patients had a BMI in the 85th percentile or above, and 49% of SSI patients had a BMI above the 95th percentile. Thirty-eight patients had positive cultures, with most common infections being due to methicillin-sensitive Staphylococcus aureus in 11 (29%) cases, polymicrobial in 9 (24%), pseudomonas in 5 (13%), and coagulase-negative Staphylococcus in 5 (13%). SSI rate in winter (0.18%) was significantly lower than in autumn (0.77%, P = 0.006) and summer (0.69%, P = 0.02). The difference did not reach statistical significance from the infection rate in spring (0.53%, P = 0.06). Twenty-nine (62%) SSI cases were considered elective in nature, and the other 18 (38%) cases were for acute traumatic injuries. There is a significantly higher SSI rate in summer and autumn than winter for pediatric patients undergoing orthopedic surgeries. Most patients with SSIs were overweight or obese.

Admission Hyperglycemia Is a Risk Factor for Deep Surgical-Site Infection in Orthopaedic Trauma Patients

OBJECTIVES

To evaluate the association of admission blood glucose ≥200 mg/dL and surgical site infection in orthopaedic trauma surgery.

DESIGN

Retrospective, case control study.

SETTING

Academic trauma center.

PATIENTS

Four hundred sixty-five nondiabetic, noncritically ill orthopaedic trauma patients with an extremity, pelvic, or acetabular fracture and requiring open reduction and internal fixation or intramedullary nailing.

INTERVENTION

None.

MAIN OUTCOME MEASUREMENTS

Ninety-day deep surgical site infection.

RESULTS

Admission blood glucose ≥200 mg/dL was significantly associated with the primary outcome (8/128, 6.3% vs. 35/337, 1.8%; P = 0.01). Multivariable logistic regression modeling demonstrated that admission blood glucose ≥200 mg/dL was a significant risk factor for deep surgical site infections [odds ratio (OR): 4.7, 95% confidence interval (CI) 1.4-15.7], after controlling for male gender (OR: 1.8, 95% CI: 1.1-3.1), prior drug or alcohol abuse (OR: 1.9, 95% CI 0.9-4.0), open fracture (OR: 6.4, 95% CI 3.7-11.0), and fracture region (upper extremity OR: reference; pelvis/hip OR: 3.9, 95% CI 1.6-9.7; femur OR: 2.0, 95% CI 0.88-4.8; tibia/ankle OR: 3.3, 95% CI 1.7-6.2; and foot OR: 2.7, 95% CI 1.2-6.3).

CONCLUSIONS

Admission glucose ≥200 mg/dL was a significant independent risk factor for 90-day deep surgical site infections in orthopaedic trauma patients and may serve as an important marker for infection risk.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Biofilm and its implications postfracture fixation: All I need to know

Biofilm represents an organized multicellular community of bacteria having a complex 3D structure, formed by bacterial cells and their self-produced extracellular matrix. It usually attaches to any foreign body or fixation implant. It acts as a physical protective barrier of the bacteria from the penetration of antibodies, bacteriophages, granulocytes and biocides, antiseptics, and antibiotics. Biofilm-related infections will increase in the near future. This group of surgical site infections is the most difficult to diagnose, to suppress, to eradicate, and in general to manage. Multispecialty teams involved in all stages of care are an effective way to improve results and save resources and time for the benefit of patients and the health system. Significant steps have occurred recently in the prevention and development of clever tools that we can employ in this everlasting fight with the bacteria. Herein, we attempt to describe the nature and role of the "biofilm" to the specific clinical setting of surgical site infections in the field of orthopaedic trauma surgery.

Risk factors for treatment failure of fracture-related infections

OBJECTIVE

Infection after fracture fixation is a potentially devastating outcome, and surgical management is frequently unsuccessful at clearing these infections. The purpose of this study is to determine if factors can be identified that are associated with treatment failure after operative management of a deep surgical site infection.

METHODS

We retrospectively reviewed the billing system at a Level I trauma center between March 2006 and December 2015. We identified 451 patients treated for deep surgical site infection after fracture fixation at our center. A multivariate regression analysis was then performed to evaluate for factors associated with treatment failure.

RESULTS

Mean follow-up was 2.3 years. One hundred fifty-six patients (35%) failed initial surgical management. Risk factors associated with treatment failure included initial culture results positive for polymicrobial organisms (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.0-2.4), removal of implants (OR, 1.9; 95% CI, 1.2-2.9), or Gustilo-Anderson IIIB/IIIC injury (OR, 2.0; 95% CI, 1.1-3.7). Increased body mass index and fulfilling the criteria to have a methicillin-resistant Staphylococcus aureus (MRSA) nasal swab screening showed a trend toward increased risk of failure.

CONCLUSION

Treatment failure after deep surgical site infection was relatively common. Three distinct factors (polymicrobial infection, removal of implants, and IIIB/C fracture) were associated with failure to eradicate the infection in the first series of surgeries and antibiotics. These data might help guide clinicians as they counsel patients on the risk of treatment failure and might focus efforts to improve treatment toward patients at higher risk of treatment failure.

Comparison of 3 C-Arm Draping Techniques to Prevent Far Side Contamination

OBJECTIVE

To assess the effectiveness of reducing contamination using 2 methods of C-Arm draping compared with traditional methods.

MATERIALS AND METHODS

The authors simulated an operating room using an extremity drape, commercially available C-Arm drapes, and C-Arm. A black light was placed above the field. A fluorescent powder was placed on the nonsterile portions of the field. Baseline light intensity was recorded by photo. The C-Arm was brought into the surgical field for orthogonal imaging for 15 cycles. A repeat photograph was taken to measure the increase in intensity of the fluorescent powder to assess degree of contamination. This was repeated 5 times for each configuration: standard C-Arm drape, a proprietary close-fitting drape, and a split drape secured to the far side with the split wrapped around the C-Arm receiver. Light intensity difference was measured and average change in intensity was compared.

RESULTS

Compared with standard draping, the proprietary close-fitting drape resulted in a 71.3% decrease in contamination (4.84% vs. 16.90%, P = 0.101) that trended toward significance and the split drape resulted in a 99.5% decrease (0.09% vs. 16.90%, P = 0.017) that was statistically significant.

CONCLUSION

Far side contamination can be reduced by using a split drape connecting the operative table to the C-Arm receiver, effectively "sealing off" contaminants. The proprietary close-fitting drape may also decrease contamination, but this was not statistically significant in this study. Use of the split drape technique will help prevent contamination and may ultimately lead to decreased infection risk.

Surgical Site Infections After Routine Syndesmotic Screw Removal: A Systematic Review

OBJECTIVES

To investigate the incidence of surgical site infections (SSIs) after routine removal of syndesmotic screws (SSs) placed to stabilize syndesmotic injuries.

DATA SOURCES

A systematic literature search was performed in the PubMed, Cochrane, and EMBASE databases for studies published online before February 2020, using the key words and synonyms of "syndesmotic screw" ("ankle fractures" or "syndesmotic injury") and "implant removal."

STUDY SELECTION

Studies were eligible for inclusion when they described >10 adult patients undergoing elective/scheduled removal of the SS.

DATA EXTRACTION

The 15 included articles were assessed for quality and risk of bias using the Newcastle-Ottawa Scale. Baseline characteristics of the studies, the study population, the intervention, the potential confounders, and the primary outcome (% of SSIs) were extracted using a customized extraction sheet.

DATA SYNTHESIS

The primary outcome was presented as a proportion of included patients and as a weighted mean, using inverse variance, calculated in RStudio. Furthermore, potential confounders were identified.

CONCLUSIONS

The percentage of SSIs ranged from 0% to 9.2%, with a weighted mean of 4%. The largest proportion of these infections were superficial (3%, 95% confidence interval: 2-5), compared with 2% deep infections (95% confidence interval: 1-4). These rates were comparable to those of other foot/ankle procedures indicating that the individual indication for SS removal (SSR) should be carefully considered. Future studies should focus on valid indications for SSR, the influence of prophylactic antibiotics on an SSI after SSR, and complications of retaining the SS to enable a fair benefits/risks comparison of routine versus on-demand removal of the SS.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

ReGeneraTing Agents (rgta®) technology combined with antibiotics improves outcomes for infections in the upper limb

A matrix therapy agent marketed as CACIPLIQ20® showed marked improvement in the healing rate of hand infections, including functional recovery. It can be used at both earlier and later stages to promote faster healing and prevent an adverse outcome.