Effect of Postoperative Oral Antibiotics on Infections and Wound Healing Following Foot and Ankle Surgery

Minimal Incision Management of Rearfoot & Ankle Trauma

Minimally invasive surgery is gaining tremendous popularity in reconstructive foot and ankle surgery, as well as with trauma. Minimally invasive approaches have demonstrated equivalent to outcomes to traditional open incisional approaches with the added benefit of less risk for wound healing complications and surgical site infections. Advances in orthopedic hardware and surgical techniques are allowing minimal incision surgery for trauma to become more widespread. While there is a steeper learning curve to become proficient, minimally invasive surgery is likely to become the standard for most foot and ankle trauma cases.

Antibiotic administration for open reduction internal fixation of closed ankle fractures: Is one preoperative dose enough?

Although preoperative antibiotics are used routinely in ankle fracture surgery, there is considerable variability in postoperative antibiotic dosing regimens amongst surgeons. The aim of this study is to compare the rate of surgical site infection (SSI) in patients receiving one dose of preoperative antibiotics to patients who received more than one dose of antibiotics. A single-center Level I Trauma Center retrospective review of patients with isolated closed ankle fractures who underwent open reduction internal fixation over a 10-year period was performed. Demographics data and risk factors were obtained from the electronic medical record. SSI was detected using a text-mining algorithm on all postoperative clinic notes. Factors associated with the development of SSI or increased antibiotic dosing were evaluated. Eight-hundred and twenty-six patients were included in the analysis. There was no correlation between infection rate and any of the potential risk factors evaluated. Two-hundred and ninety-two patients received only one dose of antibiotics preoperatively and 534 patients received more than one antibiotic dose. The rate of SSI was not significantly different between the single-dose cohort (5.8 %) and the multi-dose cohort (3.9 %) (p=0.215). Routine use of postoperative antibiotics in open reduction internal fixation of closed ankle fractures did not decrease the rate of SSI, regardless of associated comorbidities. LEVEL OF EVIDENCE: : Level III (therapeutic retrospective cohort study).

Incidence and associated factors of surgical site infection in patients undergoing foot and ankle surgery: a 7-year cohort study

Surgical site infections (SSI) constitute 31% of all hospital-acquired conditions, with ankle and foot surgical procedures showing an incidence of SSI ranging from 0.5% to 6.5%. This study aimed to assess the incidence of both superficial and deep surgical site infections in foot and ankle surgery, along with associated factors. Conducted as a retrospective cohort study, it included 2180 patients undergoing foot and ankle surgery in a private hospital between 2014 and 2020, encompassing elective and trauma cases. Outcome variables comprised SSI, while predictor variables encompassed sex, age, diabetes mellitus, systemic arterial hypertension, smoking, American Society of Anesthesiologists (ASA) score, and body mass index. Logistic regression models were employed to identify associations between study variables. The incidence of surgical site infections stood at 4% (83/2180), comprising a rate of 2.8% (57/2180) for superficial infections and 1.2% (26/2180) for deep infections. Smoking (OR 2.9, 95%CI 1.4-5.3) and ASA score >2 (OR 3.4, 95%CI 1.2-8.4) emerged as independent factors associated with surgical site infections. The group with deep infections exhibited higher proportions of smokers (p = 0.002), systemic arterial hypertension (p = 0.018), trauma surgery (p = 0.049), and an ASA score >2 (p = 0.011). Overall infection incidence in this cohort reached 4%, with trauma cases, smoking, hypertension, and an ASA score >2 independently linked to deep infections. Surgeons should be cognizant of these risk factors when managing prophylactic antibiotic regimens for patients.

Do We Need Routine Postoperative Prophylactic Oral Antibiotics in Elective Foot and Ankle Surgery?

Background

Previous studies about antibiotic prophylaxis in foot and ankle surgery have focused on perioperative intravenous administration, with few studies reporting on the efficiency of postoperative oral antibiotics. The purpose of this study is to investigate differences in the rate of postoperative infection and wound complications between patients with and without postoperative oral antibiotics and to identify independent risk factors for these complications following foot and ankle surgeries.

Methods

A retrospective review of all elective foot and ankle surgeries with at least a 6-month follow-up was performed over a 2-year time span. Patients were divided into 2 groups based on if they received postoperative oral antibiotics. We compared the rates of postoperative infections and wound complications between the 2 groups. The surgical site, the number of Current Procedural Terminology codes, and the number of surgical incisions were also noted. Multivariable logistic regression analysis was performed to identify independent risk factors of postoperative infection and wound complications.

Results

A total of 366 patients were included in this study-240 with antibiotics and 126 without antibiotics. There was no significant difference in the rates of postoperative infection and wound complications between the 2 groups. The rate of superficial infection, deep infection, and wound complications was 1.7%, 0.8%, and 5.8% in the antibiotic group vs 3.2%, 0.0%, and 4.0% in patients without antibiotics, respectively. Multivariable logistic regression analysis identified independent risk factors of postoperative infection and wound complications as follows: smoking (OR: 4.7), male (OR: 4.0), history of neoplasm (OR: 6.7), and multiple incisions (OR: 4.1).

Conclusion

Our results suggest that routine postoperative prophylactic oral antibiotics are not needed following elective foot and ankle surgeries. However, certain risk factors may increase the risk for postoperative infection and wound complications in foot and ankle surgery.

Level of Evidence

Level III, case-control study.

The impact of wound pH on the antibacterial properties of Medical Grade Honey when applied to bacterial isolates present in common foot and ankle wounds. An in vitro study

BACKGROUND

Diabetic foot ulcers (DFUs) and post-surgical wound infections are amongst the most troublesome complications of diabetes and following foot and ankle surgery (FAS) respectively. Both have significant psychosocial and financial burden for both patients and the healthcare system. FAS has been reported to have higher than average post-surgical infections when compared to other orthopaedic subspecialties. Evidence also indicates that patients with diabetes and other co morbidities undergoing FAS are at a much greater risk of developing surgical site infections (SSIs). With the growing challenges of antibiotic resistance and the increasingly high numbers of resilient bacteria to said antibiotics, the need for alternative antimicrobial therapies has become critical.

AIM

The aim of this study was to investigate the use of medical grade honey (MGH) when altered to environments typically present in foot and ankle wounds including DFUs and post-surgical wounds (pH6-8).

METHODS

MGH (Activon) was altered to pH 6, 7 and 8 and experimental inoculums of Pseudomonas aeruginosa (NCTC10782), Escherichia coli, (NCTC10418), Staphylococcus aureus (NCTC10655) and Staphylococcus epidermidis (NCTC 5955) were transferred into each pH adjusted MGH and TSB solution and the positive and negative controls.

RESULTS

MGH adjusted to various pH values had the ability to reduce bacteria cell survival in all pH variations for all bacteria tested, with the most bacterial reduction/elimination noted for Staphylococcus epidermidis. No correlations were noted among the pH environments investigated and the colony counts, for which there were small amounts of bacteria survived.

CONCLUSION

This research would indicate that the antibacterial properties of honey remains the same regardless of the pH environment. MGH could therefore potentially be considered for use on non-infected foot and ankle wounds to reduce the bacterial bioburden, the risk of infections and ultimately to improve healing outcomes.

Postoperative Infection and Revision Surgery Rates in Foot and Ankle Surgery Without Routine Prescription of Prophylactic Antibiotics

INTRODUCTION

Surgical site infections (SSIs) are associated with patient morbidity and increased healthcare costs. Limited literature in foot and ankle surgery provides guidance about routine administration of postoperative antibiotic prophylaxis. The purpose of this study was to examine the incidence and revision surgery rates of SSI in outpatient foot and ankle surgeries in patients not receiving oral postoperative antibiotic prophylaxis.

METHODS

A retrospective review of all outpatient surgeries (n = 1517) conducted by a single surgeon in a tertiary referral academic center was conducted through electronic medical records. Incidence of SSI, revision surgery rate, and associated risk factors were determined. The median follow-up was 6 months.

RESULTS

Postoperative infection occurred in 2.9% (n = 44) of the surgeries conducted, with 0.9% of patients (n = 14) requiring return to the operating room. Thirty patients (2.0%) were diagnosed with simple superficial infections, which resolved with local wound care and oral antibiotics. Diabetes (adjusted odds ratio, 2.09; 95% confidence interval, 1.00 to 4.38; P = 0.049) and increasing age (adjusted odds ratio, 1.02; 95% confidence interval, 1.00 to 1.04; P = 0.016) were significantly associated with postoperative infection.

DISCUSSION

This study demonstrated low postoperative infection and revision surgery rates without the routine prescription of prophylactic postoperative antibiotics. Increasing age and diabetes are signficant risk factors for developing a postoperative infection.

A Case Series Evaluating Postoperative Complications of Foot and Ankle Surgeries in Adult Patients With Neuromuscular Disease

Background

Patients with neuromuscular diseases such as cerebral palsy (CP) are living longer because of advances in medicine, yielding a larger number of adult patients that could benefit from corrective surgery. However, some surgeons are hesitant to offer surgery to these patients because of concern for postoperative complications. A paucity of literature exists that describes complications in patients undergoing foot and ankle surgery for neuromuscular diseases. The primary study outcome was to identify the postoperative complication rates associated with foot and ankle surgery in adult patients with neuromuscular disease.

Methods

The charts of patients with neuromuscular diseases who had foot and ankle surgery by the senior author at a single institution from March 2010 to March 2020 were reviewed. Patient charts were reviewed for demographic data, medical history and diagnoses, and surgical treatment information. Only patients' index procedures with the senior author were evaluated for surgical data. Patient charts were assessed to determine the presence or absence of a postoperative complication following an index procedure.

Results

In a cohort of 42 patients, females comprised 60% of the patient cohort. The average age was 35 (range, 20-69) years old. CP was the most common neuromuscular diagnosis at 52% (22 of 42) patients. Eighteen percent (11 of 60) of the index surgeries had 1 or more complication with a total of 13 complications. The overall wound complication rate was 10% (6 of 60), infection rate was 8% (5 of 60), and the nonunion rate following arthrodesis was 10% (2 of 21).

Conclusion

We conclude that foot and ankle surgery in this complex population can be done safely, with postoperative complication rates similar to the average population. Although these patients may present with unique challenges, surgeons should not forgo surgery out of concern for postoperative complications.

Level of Evidence

Level IV, retrospective cohort study at a single institution.

Efficacy of Postoperative Oral Antibiotics in Foot and Ankle Surgery

BACKGROUND

Preoperative oral antibiotic use in patients undergoing foot and ankle surgery is standard practice, but no consensus has been reached regarding the efficacy of postoperative oral antibiotics. The purpose of this study was to determine whether postoperative oral antibiotics reduce the rate of surgical site infections (SSIs) in patients, with and without comorbidities, undergoing foot and ankle surgery.

METHODS

A retrospective chart review was conducted identifying patients who underwent foot and ankle surgery by 4 fellowship-trained, foot and ankle orthopaedic surgeons between January 1, 2015, and January 1, 2019. Patients were divided into 2 groups: those who received postoperative oral antibiotics (group 1) and those who did not (group 2). Two surgeons routinely prescribed postoperative oral antibiotics, and 2 did not. Demographics, comorbidities, and procedure complexity based on surgical site and Current Procedural Terminology code were recorded from the charts. The primary outcome was postoperative infection (superficial or deep) within 6 months after surgery. Patients with antibiotic use prior to surgery, preoperative infection, or lack of follow-up >6 weeks were excluded. Multivariate logistic regression modeling was used to analyze differences in infection rate and severity.

RESULTS

Chart review identified 3631 patients, 1227 of whom did not receive postoperative oral antibiotics whereas 2394 patients did. Routine postoperative oral antibiotic use did not significantly affect postoperative infection rates or severity. However, all covariates studied (diabetes, hypertension, obesity, tobacco use, alcohol use, rheumatoid conditions, and age) influenced postoperative infection rates and severity.

CONCLUSION

The results of this study indicate that postoperative oral antibiotics are not associated with differences in infection rates or severity. We do not recommend routine use in foot and ankle surgery.

Tranexamic Acid Associated With Less Wound Complications in Ankle and Hindfoot Surgery: Level III, Retrospective Cohort Study

INTRODUCTION

The purpose of this study was to determine whether total ankle arthroplasty (TAA) and ankle/hindfoot fusion patients receiving tranexamic acid (TXA) exhibit fewer wound complications.

METHODS

A retrospective review was conducted of 212 patients (217 feet) undergoing TAA (n = 72), ankle (n = 36), tibiotalocalcaneal (n = 20), pantalar (n = 1), or hindfoot fusion (ie, subtalar = 47, double = 33, and triple = 8) between 2015 and 2020 by a fellowship-trained foot and ankle surgeon at an academic medical center. Demographics, medical history, complications, and union status were compared between TXA (n = 101) and non-TXA (n = 116) cohorts. The mean follow-up was 1.24 years (range, 0.25 to 4.68).

RESULTS

The TXA group had significantly less postoperative infections (5.9% versus 15.5%, P = 0.025). Within a subgroup analysis of ankle/hindfoot fusions, the TXA group exhibited significantly more Charcot neuroarthropathy (20.7% versus 5.7%, P = 0.006) and shorter follow-up duration (0.96 versus 1.30 years, P = 0.030); however, TXA was associated with shorter time to fusion (146 versus 202 days, P = 0.049) and fewer revision surgeries (8.6% versus 21.8%, P = 0.036). Subgroup analysis excluding feet with Charcot also demonstrated less postoperative infections (4.5% versus 14.4%, P = 0.020). Subgroup analysis of TAAs showed fewer cases of superficial infections (2.3% versus 27.6%, P = 0.002) and delayed wound healing (25.6% versus 48.3%, P = 0.047) in the TXA cohort.

DISCUSSION

TXA use in ankle/hindfoot surgery was correlated with a reduction in superficial infections and radiographic time to union. The use of TXA in TAA correlated with fewer superficial infections and cases of delayed wound healing. Thus, in addition to other areas of orthopaedics, TXA seems to be beneficial in hindfoot and ankle surgery.

DATA AVAILABILITY AND TRIAL REGISTRATION NUMBERS

All data were obtained from our institution's medical records. This study is not associated with a clinical trial.