A meta-analysis of risk factors for non-superficial surgical site infection following spinal surgery

Glycemic laboratory values are associated with increased length of stay and 90-day revision risk following surgical management of adult spinal deformity

BACKGROUND CONTEXT

Diabetes mellitus (DM) is a common comorbidity among patients undergoing spinal fusion for adult spinal deformity (ASD) surgery. An elevated Hemoglobin A1c (HbA1c) and elevated postoperative glucose have been shown to increase the risk of complications following spine and other orthopedic surgeries; however, data is limited for ASD.

PURPOSE

To investigate glycemic control and ASD surgery to inform surgical decision making, medical optimization, and patient education.

STUDY DESIGN/SETTING

Retrospective cohort.

PATIENT SAMPLE

Total of 106 adult patients undergoing surgical correction for ASD with an HbA1c drawn within 6 months preoperatively or 2 weeks postoperatively and valid plasma glucose levels throughout postoperative hospital stay.

OUTCOME MEASURES

Length of stay, 90-day wound complication, 90-day readmission, 90-day revision.

METHODS

All patients undergoing spinal fusion of seven or more levels between 2021 and 2023 at two large academic medical centers were identified using institutional data acquisition software. Medical charts were then manually reviewed to obtain and confirm demographic, laboratory, and surgical characteristics and outcomes. Laboratory characteristics included preoperative HbA1c, mean postoperative glucose (PG), and maximum PG. Surgical characteristics and outcomes included procedure time, estimated blood loss (EBL), length of inpatient stay (LOS), transfusion requirement, 90-day complications, 90-day revision, and 90-day readmission. Bivariate analysis was performed followed by simple and multiple regression analysis. Odds ratios were established relative to the laboratory threshold values informed by receiver operating characteristics.

RESULTS

Of 872 original procedures identified, 106 patients (12.2%) were adults with preoperative HbA1c and postoperative plasma glucose measurements who underwent surgery for a diagnosis of ASD. Median patient age was 67 years (IQR 59-72 years), 59 (55.7%) were female, and 96 (90.6%) were of Caucasian race. Median LOS was 7 days (IQR 5-10 years) and median HbA1c was 5.9% (IQR 5.3%-6.5%). Higher preoperative HbA1c was correlated with increased LOS (R=0.22, p=.023). The odds ratio for patients requiring extended LOS was 2.49 (95% CI 1.06-5.86, p=.034) for those with HbA1c ≥6.3%. Multiple regression analysis of LOS identified HbA1c [B= 1.51 (95% CI 0.32-2.70), p=.013] as a positive predictor of LOS and mean PG [B= -0.05 (95% CI -0.10 to (-0.01)), p=.019] as a weakly negative predictor of LOS. Upon simple logistic regression, the odds ratio for 90-day revision was 1.81 (95% CI 1.02-3.19, p=.042) for every unit increase in HbA1c. Patients with mean PG ≥165 mg/dL [OR=5.76 (95% CI 1.28-26.01), p=.024] were at increased risk for 90-day revision. Glycemic laboratory values do not seem to predict 90-day wound complications or 90-day readmission following surgery for ASD.

CONCLUSION

Elevated preoperative HbA1c is associated with increased LOS and risk for revision within 90 days of ASD surgery. Postoperative hyperglycemia is also associated with increased 90-day revision risk. To our knowledge, this study is the first to evaluate HbA1c and outcomes following ASD surgery. These findings can be leveraged to inform preoperative medical optimization and highlight the importance of glycemic control in ASD patients undergoing corrective surgical intervention.

Inadequate soft tissue coverage and bone loss/comminution are the typical risk factors of surgical site infection in open fractures of the hand: A nomogram prediction model

BACKGROUND

Different from other parts of long bone fractures, surgical site infections (SSI) often occurs in open fractures of the hand (OFH) due to the anatomical characteristics and injury mechanisms. Our aim of the study is to investigate the particular risk factors of SSI after emergency surgery in OFH and develop a prediction nomogram model.

METHODS

In our traumatic center, patients with OFH not less than 18 years old were retrieved between October 2020 and April 2024. We excluded patients with other fractures, non-traumatic fractures or surgery before admission. The data of these patients were processed by univariate and multivariate analysis using SPSS (24.0) in order to identify the independent risk factors for SSI. Based on the predictors, the nomogram was constructed and validated by R software (R 4.1.0).

RESULTS

The incidence of SSI was 6.96% (43/618). Body mass index (BMI), albumin (ALB), neutrophils (NEU), inadequate soft tissue coverage, and bone loss/comminution were identified as the independent risk factors of post-operative SSI in OFH and enrolled in the prediction nomogram model. The nomogram exhibited a high level of discrimination, with an area under the curve of 0.856 (95%CI 0.790-0.921) in the training group and 0.931 (95%CI 0.848-1.000) in the test group. Hosmer-Lemeshow (H-L) test revealed optimal consistency between the probability of prediction model and the actual probability (training group: X2 = 5.706, P = 0.680; test group: X2 = 3.886, P = 0.867). The calibration curve of both groups demonstrated excellent consistency. Decision curve analysis (DCA) showed favorable applicability of the prediction model.

CONCLUSIONS

Inadequate soft tissue coverage, serum ALB level, NEU level, bone loss/comminution and BMI were the independent risk factors for post-operative SSI in OFH. The nomogram of this predictors can be used as an effective tool to predict SSI risk in OFH.

Barbed Versus Conventional Suture for Spinal Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Barbed sutures eliminate knots and may offer some advantages over conventional sutures. This meta-analysis compares clinical, surgical, and economic outcomes of barbed sutures with standard closure techniques in spinal surgery.

METHODS

We systematically searched PubMed, Embase, and Web of Science for studies comparing barbed and conventional suture for patients undergoing spinal surgery.

RESULTS

We included 6 studies in the analysis, totaling 1235 patients. There was no significant difference between the groups in relation to deep infection (risk ratio [RR] 0.65; 95% confidence interval [CI]: 0.26-1.57; I2 = 0%), hospital stay duration (mean difference [MD] -0.55; 95% CI: -1.11 to 0.01; I2 = 8%), postoperative hematoma (RR 0.35; 95% CI: 0.04-3.00; I2 = 0%), reintervention due to wound healing problems (RR 0.98; 95% CI: 0.49-1.94; I2 = 5%), superficial infection (RR 0.49; 95% CI: 0.19-1.28; I2 = 0%), total hospitalization cost (MD -440.81; 95% CI: -1118.90 to 237.29; I2 = 63%), and wound dehiscence/seroma (RR 0.81; 95% CI: 0.29-2.27; I2 = 0%). There was a significant lower operating room time (MD -15.37; 95% CI: -29.43 to -1.32; I2 = 87%) and suturing time (MD -16.17; 95% CI: -20.58 to -11.75; I2 = 91%) in the barbed suture group, beyond a significantly lower risk of total infection (RR 0.55; 95% CI: 0.31-0.98; I2 = 0%).

CONCLUSIONS

Our meta-analysis showed that barbed sutures were associated with reduced operating room time, suturing time, and infection rates. These results highlight the safety and potential efficacy of using barbed sutures.

Interleukin-6 as a critical inflammatory marker for early diagnosis of surgical site infection after spine surgery

PURPOSE

Early diagnosis of surgical site infections (SSIs) could prevent surgical revision. Inflammatory markers (IMs), such as procalcitonin (PCT), interleukin-6 (IL-6), and tumor necrosis factor α (TNF-α), seem more accurate in diagnosing SSI than C-reactive protein (CRP) and white blood cell (WBC) count. The aim was to compare the predictive values of CRP, WBC count, PCT, IL-6, and TNF-α in SSI detection.

METHODS

A total of 130 patients undergoing dorsal spondylodesis from 2019 to 2024 were enrolled in a prospective diagnostic study at a maximum care spine center. IMs were measured preoperatively and on the postoperative days (PODs) 1, 2, 3, 5, and 7. Patients with high suspicion of SSI underwent revision surgery. SSI was diagnosed when the microbiological evidence was positive. Patients were divided a posteriori into the non-infection and infection groups.

RESULTS

IMs of 118 patients (66.9 ± 13.0 years, 61.0% females) were measured. Fifteen of the 118 patients (12.7%) developed an SSI. The groups differed with respect to existing hypertension, number of instrumented segments, region of surgery, CRPPOD1,7, PCTPOD7, and IL-6POD3,5,7. Binary logistic regression for SSI detection including these parameters showed an area under the curve (AUC) of 0.88 (95% CI 0.79-0.98; P < 0.001). The main effect for SSI detection was maintained by IL-6POD7 (odds ratio = 1.13; 95% CI 1.05-1.23; P = 0.001), which itself showed an AUC of 0.86 (95% CI 0.75-0.97).

CONCLUSION

Compared to CRP, WBC count, PCT, and TNF-α, IL-6 seems to be the critical IM for the early detection of an SSI.

TRIAL REGISTRATION

drks.de: DRKS00033773, date of registration: 29.02.2024, retrospectively registered; Postoperative Markers of Inflammation in Spine Surgery (POMIS) Trial.

Effect of Obesity on Surgical Outcomes and Complication Rates in Pediatric Patients: A Comprehensive Systematic Review and Meta-Analysis

Obesity is one of the primary public health problems faced by children. The increased incidence of obesity in the pediatric population poses significant challenges during and after surgical procedures. This systematic review and meta-analysis aimed to understand to what extent obesity is to surgical complications in pediatric patients. A systematic database search of PubMed, Web of Science, Scopus, and Science Direct was performed in June 2023. According to the inclusion and exclusion criteria, two evaluators independently conducted literature screening, data extraction, and quality evaluation of the retrieved literature. The Newcastle-Ottawa Scale score was used for quality evaluation, and a meta-analysis was performed using Review Manager software 5.4.1. A total of 1,170 relevant articles were initially identified, and 20 articles were finally included for data extraction and meta-analysis. The results of the meta-analysis showed that compared with normal-weight individuals, obese pediatric patients had a higher risk of developing surgical site infection (SSI) (relative risk (RR) = 1.63; 95% confidence interval (CI) = 1.33-2.00), wound dehiscence (RR = 2.01; 95% CI = 1.24-3.23), and underwent procedures that were 11.32 minutes longer (95% CI = 5.36-17.29). There were no differences in bleeding requiring transfusion, deep venous thromboembolism, postoperative abscess rate, and length of stay. Obese pediatric patients have a higher risk of SSI and dehiscence, along with a longer operative time. The established risks in obese adults undergoing surgery suggest a similar risk for obese pediatric patients. The findings of this study hold significant implications for clinical practice, suggesting the potential for additional measures to prevent surgical complications in children.