Postoperative wound infections of the spine

Learning curve and complication analysis of oblique lateral interbody fusion in cases with single-segment lumbar tuberculosis: a retrospective single-center consecutive study

OBJECTIVE

Oblique lateral interbody fusion (OLIF) is becoming widely used in patients with single-segment spinal tuberculosis (STB). The learning curve and complications associated with OLIF for the treatment of STB are still unknown. This study aims to figure out the learning curve and associated complications experience of OLIF for the treatment of STB.

METHODS

Between September 2018 and August 2023, 61 STB patients underwent OLIF plus percutaneous pedicle screw fixation (PPSF) were consecutively included in this research. Cumulative sum analysis (CUSUM) was applied to establish the learning curve of OLIF and determine the cut-off case number. All cases were divided into learning and experienced groups based on the cut-off case number. Clinical characteristics and relating surgical complications were compared and analyzed between the two groups.

RESULTS

The best-fitting curve was quadratic. The fitting equation was CUSUM (min) = 95.83 + 34.16x - 0.611 x 2 (x means operation case). The cut-off operation case number was 27 cases. The presence of significant differences particularly in the duration of operation, operative blood loss, overall incidence, and severity of postoperative complications was noteworthy between the two groups.

CONCLUSION

A total of 27 cases is the minimum number to master OLIF combined with PPSF for the treatment of patients with single-segment STB. When surgeons master this operation, the operative time, operative blood loss, overall incidence, and severity of postoperative complications will improve.

Negative pressure wound therapy in the management of postoperative spinal wound infections: a systematic review

INTRODUCTION

Postoperative wound infection after spinal surgery might be a challenge to manage. A wide range of procedures have been described for managing infected spinal wounds. An increasingly common procedure in the management of surgical site infections (SSI) is negative pressure wound therapy (NPWT), also known as vacuum-assisted closure. As there is a paucity of clear clinical advice the present investigation aims to update current evidence on the use of NPWT to manage postoperative SSI occurring after instrumented spine surgery.

METHODS

This systematic review was conducted according to the preferred reporting Items for systematic reviews and meta-analyses: the 2020 PRISMA statement. In January 2024, the following databases were accessed: PubMed, Web of Science, and Google Scholar. No time constraint was set for the search. All the clinical studies investigating the unique use of NPWT in treating postoperative spinal wound infections were accessed.

RESULTS

A total of 381 patients were included in the present study. Of them 52.5% (200 of 381 patients) were women. The mean age was 52.2 ± 15.2 years. The average length of the NPWT was 21.2 days (range 7-90 days).

CONCLUSION

NPWT could be a valuable adjuvant therapy for the management of SSI after spine surgery. Additional high-quality investigations are required to assess the efficacy and safety of NPWT in SSI after spine surgery, especially if combined with contraindications or risk factors, such as the presence of intraoperative CSF leak.

LEVEL OF EVIDENCE

Level IV, Systematic review.

A Case of Suspected Neurosarcoidosis Evading Diagnosis With Cervical Biopsy

Neurosarcoidosis is a rare manifestation of sarcoidosis, posing diagnostic challenges due to its varied clinical presentation and the lack of definitive diagnostic tests. We present a case of a 46-year-old African American female with progressive ascending bilateral sensory loss, weakness, and a bifrontal headache. Despite undergoing extensive diagnostic workup including cerebrospinal fluid analysis, neuroimaging, and bronchoscopic evaluation, a definitive diagnosis remained elusive. The patient underwent an open cervical spinal cord biopsy, which did not yield conclusive evidence of neurosarcoidosis. Subsequent complications included suspicion of an epidural abscess and post-operative cervical kyphosis. This case underscores the diagnostic dilemma and potential complications associated with the evaluation and management of neurosarcoidosis, highlighting the importance of a multidisciplinary approach in such cases.

Nutritional Laboratory Studies Prior to Total Knee Arthroplasty: Practice Versus Publication

BACKGROUND

Recent emphasis has been placed on nutritional status assessment prior to total knee arthroplasty (TKA), including multiple American Academy of Orthopaedic Surgeons publications recommending specific laboratory studies; however, the frequency with which surgeons obtain these laboratory studies remains unclear. We sought to assess the incidence of ordering nutritional laboratory studies in the 90 days prior to TKA, utilizing data from a large administrative claims database.

METHODS

With use of the PearlDiver database, we identified 557,670 patients undergoing primary TKA from 2011 to 2020 with a metabolic panel or blood cell count claim within 90 days prior to TKA. We then determined the incidence of prealbumin, transferrin, vitamin D, and zinc laboratory tests claimed 90 days prior to TKA. Associations between claims and the year of surgery, patient demographics, and clinical characteristics were assessed by comparing proportions and chi-square testing.

RESULTS

Nutritional laboratory studies were infrequently claimed within 90 days prior to TKA, with studies for prealbumin being performed in 2.2% of patients; transferrin, 1.9%; vitamin D, 10.2%; and zinc, 0.2%. From 2011 to 2020, there was a moderate but steady increase in the proportion of patients with claims for prealbumin (change from 0.8% in 2011 to 3.4% in 2020; p < 0.001), transferrin (0.8% to 2.7%; p < 0.001), and vitamin D (7.6% to 9.4%; p < 0.001) laboratory tests but there was less of a change for zinc (0.1% to 0.2%; p < 0.001). There were weak-to-absent associations of age, gender, obesity, diabetes, and anemia with laboratory claims.

CONCLUSIONS

Despite multiple publications and recommendations, nutritional laboratory studies are infrequently ordered prior to TKA. Although there has been a slight increase in the use of nutritional laboratory studies over the past decade, patient factors such as gender and obesity were not associated with this increase. Understanding current practice patterns may help target future areas for improvement.

LEVEL OF EVIDENCE

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

Vacuum assisted closure and local drug delivery systems in spinal infections: A review of current evidence

Background

Spinal infections are still showing increased incidence throughout the years as our surgical capabilities increase, coupled with an overall aging population with greater number of chronic comorbidities. The management of spinal infection is of utmost importance, due to high rates of morbidity and mortality, on top of the general difficulty in eradicating spinal infection due to the ease of hematogenous spread in the spine. We aim to summarize the utility of vacuum-assisted closure (VAC) and local drug delivery systems (LDDS) in the management of spinal infections.

Methods

A narrative review was conducted. All studies that were related to the use of VAC and LDDS in Spinal Infections were included in the study.

Results

A total of 62 studies were included in this review. We discussed the utility of VAC as a tool for the management of wounds requiring secondary closure, as well as how it is increasingly being used after primary closure as prophylaxis for surgical site infections in high-risk wounds of patients undergoing spinal surgery. The role of LDDS in spinal infections was also discussed, with preliminary studies showing good outcomes when patients were treated with various novel LDDS.

Conclusions

We have summarized and given our recommendations for the use of VAC and LDDS for spinal infections. A treatment algorithm has also been established, to act as a guide for spine surgeons to follow when tackling various spinal infections in day-to-day clinical practice.

Intra-operative drug level monitoring of pre-operative antibiotic for surgical prophylaxis in the patients of elective spinal surgery

OBJECTIVES

Single dose prophylaxis is good enough for general surgery with low risk patients. However, the evidence for the effectiveness of single dose anti-microbial prophylaxis (AMP) is not conclusive in high risk patients and spinal surgeries requiring instrumentation or the use of implants in particular. No studies have explored the various concentration of ceftriaxone in plasma and tissue as well during an ongoing spinal surgery. Therefore, the objective of study was to correlate the serum and tissue concentrations of ceftriaxone with the SSI and identify patients with increased risk of SSI.

METHODS

It was an open label prospective study in 50 consecutive patients who underwent elective spine surgery under prophylactic cover of ceftriaxone. Serum and tissue concentration were estimated by high pressure liquid chromatography during the ongoing surgery.

RESULTS

Subjects were observed for any post-operative complications including SSI. Serum (p=0.002) and tissue (p=0.012) concentrations of ceftriaxone at the closure of spinal surgery were associated with SSI. Duration of the surgery (p=0.04) and use of implants (p=0.02) were also important surgery related risk factors.

CONCLUSIONS

Serum and tissue concentrations of ceftriaxone at the closure and duration of surgery and instrumentation or use of implants in the spinal surgery are good predictors of SSI.

Assessment of Nutrition Status and Its Effect on Outcomes in Patients With Limb Injuries Using the Subjective Global Assessment as a Screening Tool

Background Malnutrition in hospitalized patients is a significant problem. This study aimed to assess the utility of the Subjective Global Assessment (SGA) in predicting the association between serum biomarkers and malnutrition in patients with limb injuries as well as the impact of malnutrition on clinical and radiological bone healing. Methodology This prospective study included 93 patients with limb injuries. Basic demographic details, serum biomarker levels, nutritional status assessed using the SGA, and the correlation of the Radiological Union Shaft Tibia (RUST) score with nutrition status were assessed along with the secondary outcomes. Results According to the SGA, patients were classified into Group A (well-nourished), Group B (moderately malnourished), and Group C (severely malnourished). Serum biomarkers (albumin, hemoglobin, platelets, and total leucocyte count) were significantly higher in Group A than in Group B + C (p < 0.0001). The nutritional status of patients from admission up to six months in Group A was significantly higher (p < 0.0001) compared to Group B + C. The radiological healing according to the RUST score had a negative correlation with C-reactive protein and a positive correlation with various parameters at six months. Conclusions The serum biomarker levels and the clinical and radiological bone healing, as measured by the RUST scoring system, showed a positive correlation with the nutritional status of the patients. Malnutrition significantly increases the chance of developing complications such as wound infection, decubitus, and infected implants.

Risk Factors for Surgical Site Complications After Outpatient Lumbar Spine Surgery

Background: With the recent increase of minor lumbar spine surgeries being performed in the outpatient setting, there is a need for information on factors that contribute to post-operative complications for these surgeries. Patients and Methods: This was a prospective observational study examining risk factors for self-reported post-operative drainage in patients who underwent lumbar spine surgery. Patient surveys and the hospital's electronic medical records were used to collect data on patient demographic, patient lifestyle, and surgical variables. Univariable and multivariable analyses in addition to a random forest classifier were performed. Results: A total of 146 patients were enrolled in the study with 111 patients included in the final analysis. The average age and body mass index (BMI) of these patients was 66 and 27.8, respectively. None of the 146 patients in this study developed surgical site infection. Older age, no steroid use, no pet ownership, and spine surgery involving two or more levels were all found to be risk factors for wound drainage. Conclusions: This study evaluated lifestyle, environmental, and traditional risk factors for surgical site drainage that have not been explored cohesively related to outpatient orthopedic surgery. Consistent with the existing literature, outpatient spine surgery involving two or more levels was most strongly associated with surgical site drainage after surgery.

Incidence of surgical site infections after cervical spine surgery: results of a single-center cohort study adhering to multimodal preventive wound control protocol

PURPOSE

The incidence of surgical site infections is considered a relevant indicator of perioperative and postoperative care quality. The aim of this study is to analyze and evaluate SSIs after elective cervical spine surgery under the guidance of our preventive multimodal wound protocol.

METHODS

A monocentric observational cohort study analyzed 797 patients who underwent cervical spine surgery from 2005 to 2010 (mean age 51.58 ± 11.74 year, male 56.09%, mean BMI 26.87 ± 4.41, ASA score 1-2 in 81.68% of patients), fulfilling the entry criteria: (1) cervical spine surgery performed by neurosurgeons (degenerative disease 85.19%, trauma 11.04%, tumor 3.76%), (2) elective surgery, (3) postoperative care in our neurointensive care unit. Our preventive wound control protocol management focused mainly on antibiotic prophylaxis, wound hygiene regime, and drainage equipment. All wound complications and surgical site infections were monitored up for 1 year after surgery.

RESULTS

We had only 2 (0.25%) patients with SSI after cervical spine surgery-one organ/space infection (osteomyelitis, primary due to liquorrhea) after anterior surgical approach, and one deep surgical site infection (due to dehiscence) after posterior approach. We had 17 (2.13%) patients with some wound complications (secretion 7, dehiscence 4, hematoma 1, edema 3, and liquorrhea 2) that were not classified as SSI according to the CDC guidelines.

CONCLUSION

Concerning our study population of patients undergoing elective cervical surgery, with ASA scores 1-2 in 81.68% of our patients, the incidence of SSI was 0.14% after anterior surgical approach, 1.4% after posterior surgical approach, and 0.25% altogether in the referred cohort.

Epidemiology of postoperative spinal wound infection in the Middle East and North Africa (MENA) region

Background

Despite the extensive literature on postoperative spinal wound infection, yet to our knowledge, there is no previous study containing combined data from several sites in the Middle East and North Africa (MENA) region. This study aimed to estimate the incidence of surgical site infection (SSI) following spine surgeries, its associated factors, and management.

Methods

In a retrospective cohort study, medical records of all patients ≥18 years of age who underwent spine surgery at 6 tertiary referral centers in the MENA region between January 2014 to December 2019 (n=5,872) were examined to collect data on the following: (1) Patient's characteristics, (2) Disease characteristics, (3) Spine surgery approach, and (4) Characteristics of Postoperative SSI. The determinants of postoperative SSI were identified using logistic regression analysis. Receiver operating characteristic (ROC) curve was applied to identify the cut-off of the length of stay in the hospital postoperatively till the infection is likely to occur. Significance was set at p<.05.

Results

The overall incidence of SSI was 4.2% (95% CI: 3.72-4.77), in the form of deep (46.4%), superficial (43.1%), dehiscence (9.3%), and organ space (1.2%) infections. After adjusting for all possible confounders, significant predictors of postoperative SSI were; diabetes (OR=2.12, p<.001), smoking (OR=1.66, p=.002), revision surgery (OR=2.20, p<.001), open surgery (OR=2.73, p<.001), perioperative blood transfusion (OR=1.45, p=.033), ASA class III(OR=2.08, p=.002), and ≥4 days length of stay "LOS" (OR= 1.71, p=.001). A cut-off of 4 days was the optimum LOS above which postoperative SSI is more likely to occur, with 0.70 sensitivity, 0.47 specificity, and 0.61 area under the curve.

Conclusions

This is the first study that highlighted the incidence of postoperative SSI in spine surgery in the MENA region. Incidence figures are comparable to figures in different areas of the world. Identifying predictors of SSI might help high‑risk patients benefit from more intensive wound management.

Intrawound low-dose vancomycin is superior to high-dose in controlling the risk of wound dehiscence in spine surgeries

Wound complications in spine surgeries are common and serious. This study aimed to determine the risk of wound dehiscence with a low-dose of intrawound vancomycin compared to that with a high-dose and no-vancomycin and its effectiveness in the prevention of surgical site infection. Patients were categorized into 3 groups. The first group did not receive any intrawound vancomycin. In the second, patients received a high-dose of vancomycin (1 g). The third group included patients who received a low-dose of intrawound vancomycin (250 mg). Patient demographics, clinical data, and surgical data were also collected. Multivariate linear regression analysis was used to examine factors associated with dehiscence or infection. Of the 391 patients included in our study, 56 (14.3%) received a high-dose of intrawound vancomycin, 126 (32.2%) received a low-dose, and 209 (53.5%) did not receive any treatment. The overall incidence of wound dehiscence was 6.14% (24 out of 391 patients). Wound dehiscence was significantly higher (P = .039) in the high-dose vancomycin group than in the low-dose vancomycin group. The overall incidence of postoperative infection was 2.05% (8 patients) and no statistically significant differences were observed between the low-dose and high-dose vancomycin groups. Patients with higher body mass index were more likely to experience wound dehiscence and postoperative infection, irrespective of the dose of vancomycin used. The use of low-dose intrawound vancomycin (250 mg) resulted in less wound dehiscence compared with high-dose vancomycin. Further trials are required to evaluate the effectiveness of the low-dose in preventing postoperative infections.

Perioperative Nutritional Supplementation Decreases Wound Healing Complications Following Elective Lumbar Spine Surgery: A Randomized Controlled Trial

BACKGROUND

The prevalence of malnutrition in patients undergoing lumbar spine surgery ranges from 5% to 50% and is associated with higher rates of surgical site infections, medical complications, longer lengths of stay, and mortality.

PURPOSE

To determine if perioperative nutritional intervention decreases wound healing complications in patients undergoing lumbar spine surgery.

STUDY DESIGN/SETTING

A prospective randomized controlled trial.

MATERIALS AND METHODS

Patients aged 55+ undergoing elective primary lumbar surgery were included. Patients with a preoperative albumin<3.5 g/dL were defined as malnourished. Intervention group received nutritional supplementation (protein shake) twice daily from postoperative day 0 to two weeks postdischarge. Control group was instructed to continue regular daily diets. Primary outcomes included minor in-hospital complications (wound drainage, electrolyte abnormalities, hypotension, ileus, deep venous thrombus) and wound healing complications within 90 days. Secondary outcomes included 90-day emergency room visits, readmissions, and return to the operating room. Baseline data were compared between groups using means comparison tests. Multivariable analysis evaluated association of outcomes with nutritional supplementation. Subanalysis of malnourished patients assessed effects of nutritional supplementation on outcomes.

RESULTS

One hundred three patients were included. Thirty-seven (35.9%) were considered malnourished preoperatively. Forty-six (44.7%) received nutritional intervention and 57 (55.3%) served as controls. Adjusted analysis found patients receiving supplementation had lower rates of in-hospital minor complications (2.1% vs. 23.2%, P <0.01), and perioperative wound healing complications (3.4% vs. 17.9%, P <0.05). Subgroup analysis of 37 malnourished patients demonstrated that malnourished patients who received perioperative nutritional supplementation had lower rates of minor complications during admission (0.0% vs. 34.4%, P =0.01) and return to the operating room within 90 days (0.0% vs. 12.4%, P =0.04).

CONCLUSIONS

Over one third of patients undergoing lumbar surgery were malnourished. Nutritional supplementation during the two-week perioperative period decreased rates of minor complications during admission and wound complications within 90 days. Malnourished patients receiving supplementation less often returned to the operating room. To our knowledge, this is the first study to investigate the effects of perioperative nutritional intervention on wound healing complications for patients undergoing elective lumbar spine surgery.

LEVEL OF EVIDENCE

I.

Full-endoscopic spine surgery diminishes surgical site infections - a propensity score-matched analysis

BACKGROUND CONTEXT

Surgical site infections (SSI) are one the most frequent and costly complications following spinal surgery. The SSI rates of different surgical approaches need to be analyzed to successfully minimize SSI occurrence.

PURPOSE

The purpose of this study was to define the rate of SSIs in patients undergoing full-endoscopic spine surgery (FESS) and then to compare this rate against a propensity score-matched cohort from the National Surgical Quality Improvement Program (NSQIP) database.

DESIGN

This is a retrospective multicenter cohort study using a propensity score-matched analysis of prospectively maintained databases.

PATIENT SAMPLE

One thousand two hundred seventy-seven non-instrumented FESS cases between 2015 and 2021 were selected for analysis. In the nonendoscopic NSQIP cohort we selected data of 55,882 patients.

OUTCOME MEASURES

The occurrence of any SSI was the primary outcome. We also collected any other perioperative complications, demographic data, comorbidities, operative details, history of smoking, and chronic steroid intake.

METHODS

All FESS cases from a multi-institutional group that underwent surgery from 2015 to 2021 were identified for analysis. A cohort of cases for comparison was identified from the NSQIP database using Current Procedural Terminology of nonendoscopic cervical, thoracic, and lumbar procedures from 2015 to 2019. Trauma cases as well as arthrodesis procedures, surgeries to treat pathologies affecting more than 4 levels or spine tumors that required surgical treatment were excluded. In addition, nonelective cases, and patients with wounds worse than class 1 were also not included. Patient demographics, comorbidities, and operative details were analyzed for propensity matching.

RESULTS

In the non-propensity-matched dataset, the endoscopic cohort had a significantly higher incidence of medical comorbidities. The SSI rates for nonendoscopic and endoscopic patients were 1.2% and 0.001%, respectively, in the nonpropensity match cohort (p-value <.011). Propensity score matching yielded 5936 nonendoscopic patients with excellent matching (standard mean difference of 0.007). The SSI rate in the matched population was 1.1%, compared to 0.001% in endoscopic patients with an odds ratio 0.063 (95% confidence interval (CI) 0.009-0.461, p=.006) favoring FESS.

CONCLUSIONS

FESS compares favorably for risk reduction in SSI following spinal decompression surgeries with similar operative characteristics. As a consequence, FESS may be considered the optimal strategy for minimizing SSI morbidity.

Spinal Tuberculosis within the Vertebral Arch Mimicking a Malignant Tumor: Case Report

BACKGROUND

 Spinal tuberculosis is a manifestation of extrapulmonary tuberculosis. The incidence of tuberculosis is low in high-income countries; however, globally, it still remains one of the most frequent fatal infectious diseases. Because of its rarity in developed countries, spinal tuberculosis can be mistaken for malignant tumors of the spine, especially in case of an atypical radiologic manifestation and without pulmonary affection.

METHODS

 We present the case of a 39-year-old man from South India with quickly progressing gait disturbance and hypesthesia below the Th10 level. Magnetic resonance imaging revealed an osteolytic lesion of the vertebral arch Th2 with central necrosis and compression of the spinal cord altogether highly suspicious for spinal metastasis.

RESULTS

 After surgical removal of the mass by laminectomy, the patient regained normal neurologic function. Histology revealed a severe granulomatous inflammation and DNAhybridization of polymerase chain reaction (PCR) products detected Mycobacterium tuberculosis-specific DNA in the sample. Biopsy of an enlarged hilar lymphnode allowed us to obtain material to successfully perform a drug resistance test to start specific antimicrobial therapy.

CONCLUSION

 Spinal tuberculosis, even with atypical radiologic appearance, has to be considered a differential diagnosis in patients with provenance from endemic countries. A multidisciplinary diagnostic approach helps perform antimicrobial susceptibility testing to avoid delaying the start of antibiotic therapy.

Development and validation of a point-of-care clinical risk score to predict surgical site infection following open spinal fusion

Background

Surgical site infection (SSI) after open spine surgery increases healthcare costs and patient morbidity. Predictive analytics using large databases can be used to develop prediction tools to aid surgeons in identifying high-risk patients and strategies for optimization. The purpose of this study was to develop and validate an SSI risk-assessment score for patients undergoing open spine surgery.

Methods

The Premier Healthcare Database of adult open spine surgery patients (n = 157,664; 2,650 SSIs) was used to create an SSI risk scoring system using mixed effects logistic regression modeling. Full and reduced multilevel logistic regression models were developed using patient, surgery or facility predictors. The full model used 38 predictors and the reduced used 16 predictors. The resulting risk score was the sum of points assigned to 16 predictors.

Results

The reduced model showed good discriminatory capability (C-statistic = 0.75) and good fit of the model ([Pearson Chi-square/DF] = 0.90, CAIC=25,517) compared to the full model (C-statistic = 0.75, [Pearson Chi-square/DF] =0.90, CAIC=25,578). The risk scoring system, based on the reduced model, included the following: female (5 points), hypertension (4), blood disorder (8), peripheral vascular disease (9), chronic pulmonary disease (6), rheumatic disease (16), obesity (12), nicotine dependence (5), Charlson Comorbidity Index (2 per point), revision surgery (14), number of ICD-10 procedures (1 per procedure), operative time (1 per hour), and emergency/urgent surgery (12). A final risk score as the sum of the points for each surgery was validated using a 1,000-surgery random hold-out (independent from the study cohort) sample (C-statistic = 0.77).

Conclusions

The resulting SSI risk score composed of readily obtainable clinical information could serve as a strong prediction tool for SSI in preoperative settings when open spine surgery is considered.

Best Practice Guidelines for Surgical Site Infection in High-risk Pediatric Spine Surgery: Definition, Prevention, Diagnosis, and Treatment

BACKGROUND

Prior "best practice guidelines" (BPG) have identified strategies to reduce the risk of acute deep surgical site infection (SSI), but there still exists large variability in practice. Further, there is still no consensus on which patients are "high risk" for SSI and how SSI should be diagnosed or treated in pediatric spine surgery. We sought to develop an updated, consensus-based BPG informed by available literature and expert opinion on defining high-SSI risk in pediatric spine surgery and on prevention, diagnosis, and treatment of SSI in this high-risk population.

MATERIALS AND METHODS

After a systematic review of the literature, an expert panel of 21 pediatric spine surgeons was selected from the Harms Study Group based on extensive experience in the field of pediatric spine surgery. Using the Delphi process and iterative survey rounds, the expert panel was surveyed for current practices, presented with the systematic review, given the opportunity to voice opinions through a live discussion session and asked to vote regarding preferences privately. Two survey rounds were conducted electronically, after which a live conference was held to present and discuss results. A final electronic survey was then conducted for final voting. Agreement ≥70% was considered consensus. Items near consensus were revised if feasible to achieve consensus in subsequent surveys.

RESULTS

Consensus was reached for 17 items for defining high-SSI risk, 17 items for preventing, 6 for diagnosing, and 9 for treating SSI in this high-risk population. After final voting, all 21 experts agreed to the publication and implementation of these items in their practice.

CONCLUSIONS

We present a set of updated consensus-based BPGs for defining high-risk and preventing, diagnosing, and treating SSI in high-risk pediatric spine surgery. We believe that this BPG can limit variability in practice and decrease the incidence of SSI in pediatric spine surgery.

LEVEL OF EVIDENCE

Not applicable.

Postoperative Bildgebung der Wirbelsäule

Die Bildgebung der postoperativen Wirbelsäule hat im Wesentlichen zwei Aufgaben: Sie dient der Kontrolle des operativen Erfolgs und der Identifikation von Komplikationen. Dafür stehen die konventionelle Röntgenaufnahme, Computertomographie (CT), Myelographie und Magnetresonanztomographie (MRT) zur Verfügung. Unter Berücksichtigung der präoperativen Situation, der durchgeführten Operation und der postoperativen Beschwerdekonstellation ist es Aufgabe der Radiologinnen und Radiologen, die passende Modalität für eine suffiziente Diagnostik zu wählen. Insbesondere der Zustand nach Implantation von Fremdmaterial bedeutet eine technische Herausforderung im Rahmen der Bildakquisition. In der Befundung sehen sich die Radiologinnen und Radiologen mit der Aufgabe konfrontiert, zwischen natürlichen, zu erwartenden postoperativen Veränderungen und relevanten Komplikationen zu differenzieren. Ein reger Austausch mit Patientinnen und Patienten und zuweisenden Klinikerinnen und Klinikern ist dabei unerlässlich. Insbesondere klinische Hinweise auf einen Infekt, neue oder deutliche progrediente neurologische Ausfallserscheinungen und das Konus-Kauda-Syndrom erfordern eine zeitnahe Diagnosestellung, um eine rasche Therapieeinleitung zu gewährleisten.

Surgical Site Infection in the Intensive Care Setting After Posterior Spinal Fusion: A Case Series Highlighting the Microbial Profile, Risk Factors, and the Importance of Comorbid Disease Burden

BACKGROUND

Most posterior spinal fusion (PSF) patients do not require admission to an intensive care unit (ICU), and those who do may represent an underinvestigated, high-risk subpopulation.

OBJECTIVE

To identify the microbial profile of and risk factors for surgical site infection (SSI) in PSF patients admitted to the ICU postoperatively.

METHODS

We examined 3965 consecutive PSF patients treated at our institution between 2000 and 2015 and collected demographic, clinical, and procedural data. Comorbid disease burden was quantified using the Charlson Comorbidity Index (CCI). We performed multivariable logistic regression to identify risk factors for SSI, readmission, and reoperation.

RESULTS

Anemia, more levels fused, cervical surgery, and cerebrospinal fluid leak were positively associated with ICU admission, and minimally invasive surgery was negatively associated. The median time to infection was equivalent for ICU patients and non-ICU patients, and microbial culture results were similar between groups. Higher CCI and undergoing a staged procedure were associated with readmission, reoperation, and SSI. When stratified by CCI into quintiles, SSI rates show a strong linear correlation with CCI ( P = .0171, R = 0.941), with a 3-fold higher odds of SSI in the highest risk group than the lowest (odds ratio = 3.15 [1.19, 8.07], P = .032).

CONCLUSION

Procedural characteristics drive the decision to admit to the ICU postoperatively. Patients admitted to the ICU have higher rates of SSI but no difference in the timing of or microorganisms that lead to those infections. Comorbid disease burden drives SSI in this population, with a 3-fold greater odds of SSI for high-risk patients than low-risk patients.

Clinical Outcomes at One-year Follow-up for Patients With Surgical Site Infection After Spinal Fusion

STUDY DESIGN

Retrospective case-control study.

OBJECTIVE

To compare health-related quality of life outcomes at one-year follow-up between patients who did and did not develop surgical site infection (SSI) after thoracolumbar spinal fusion.

SUMMARY OF BACKGROUND DATA

SSI is among the most common healthcare-associated complications. As healthcare systems increasingly emphasize the value of delivered care, there is an increased need to understand the clinical impact of SSIs.

MATERIALS AND METHODS

A retrospective 3:1 (control:SSI) propensity-matched case-control study was conducted for adult patients who underwent thoracolumbar fusion from March 2014 to January 2020 at a single academic institution. Exclusion criteria included less than 18 years of age, incomplete preoperative and one-year postoperative patient-reported outcome measures, and revision surgery. Continuous and categorical data were compared via independent t tests and χ 2 tests, respectively. Intragroup analysis was performed using paired t tests. Regression analysis for ∆ patient-reported outcome measures (postoperative minus preoperative scores) controlled for demographics. The α was set at 0.05.

RESULTS

A total of 140 patients (105 control, 35 SSI) were included in final analysis. The infections group had a higher rate of readmission (100% vs. 0.95%, P <0.001) and revision surgery (28.6% vs. 12.4%, P =0.048). Both groups improved significantly in Physical Component Score (control: P =0.013, SSI: P =0.039), Oswestry Disability Index (control: P <0.001, SSI: P =0.001), Visual Analog Scale (VAS) Back (both, P <0.001), and VAS Leg (control: P <0.001, SSI: P =0.030). Only the control group improved in Mental Component Score ( P <0.001 vs. SSI: P =0.228), but history of a SSI did not affect one-year improvement in ∆MCS-12 ( P =0.455) on regression analysis. VAS Leg improved significantly less in the infection group (-1.87 vs. -3.59, P =0.039), which was not significant after regression analysis (β=1.75, P =0.050).

CONCLUSION

Development of SSI after thoracolumbar fusion resulted in increased revision rates but did not influence patient improvement in one-year pain, functional disability, or physical and mental health status.

Effect of serologic malnutrition on postoperative wound infection problems after total joint arthroplasty: A meta-analysis

We performed a meta-analysis to evaluate the effect of serologic malnutrition on postoperative wound infection problems after total joint arthroplasty. A systematic literature search up to April 2022, was performed and 446 501 subjects with total joint arthroplasty at the baseline of the studies; 200 433 of them were confirmed serologic malnutrition, and 246 068 were confirmed normal nutrition. Odds ratio (OR) and 95% confidence intervals (CIs) were calculated to assess the effect of serologic malnutrition on postoperative wound infection problems after total joint arthroplasty using the dichotomous method with a random or fixed-effect model. The serologic malnutrition subjects had a significantly higher wound disruption (OR, 1.97; 95% CI, 1.53-2.53, P < 0.001), higher superficial incisional surgical site infection (OR, 2.89; 95% CI, 1.67-5.01, P < 0.001), higher deep incisional surgical site infection (OR, 3.06; 95% CI, 2.36-3.96, P < 0.001), and higher organ space surgical site infection (OR, 3.15; 95% CI, 2.34-4.24, P < 0.001) in subjects after total joint arthroplasty compared with normal nutrition. The serologic malnutrition subjects had a significantly higher wound disruption, superficial incisional surgical site infection, deep incisional surgical site infection, and organ space surgical site infection in subjects after total joint arthroplasty compared with normal nutrition. The analysis of outcomes should be with caution because of the low number of studies in certain comparisons.

Usage of procalcitonin and sCD14-ST as diagnostic markers for postoperative spinal infection

OBJECTIVE

Identifying biomarkers for early diagnosis of postoperative spinal infection is essential to avoid complications after spine surgery. The presented study evaluated serum levels of procalcitonin (PCT), C-reactive protein (CRP), and soluble CD14 subtype (sCD14-ST) in patients who underwent spinal surgery to assess the diagnosis values of PCT and sCD14-ST.

METHODS

Serum levels of PCT, CRP, and sCD14-ST were measured in 490 (289 male/201 female) patients who underwent spinal surgery (SS) before and 1 day after surgery. PCT and sCD14-ST levels of patients diagnosed with postoperative infection (PI) and patients diagnosed with postoperative non-infection (PN) were compared.

RESULTS

Serum levels of PCT, CRP, and sCD14-ST were significantly increased after surgery (F = 58.393, P = 0.000). In patients diagnosed as having a PI, serum levels of PCT and sCD14-ST were positively correlated with each other (r = 0.90, P < 0.01) and with operation duration (r = 0.92, 0.88, P < 0.01). Receiver operating characteristic (ROC) models showed that both PCT (AUC = 0.817, optimal cutoff: 0.69 ng/ml, P = 0.000) and sCD14-ST (AUC = 0.824, optimal cutoff: 258.27 pg/ml, P = 0.000) can distinguish PI versus PN patients well.

CONCLUSION

Our results demonstrated that serum levels of PCT and sCD14-ST have the potential to be used as a diagnostic markers for postoperative spinal infection.

Comparison of Clinical Data Between Patients With Complications and Without Complications After Spinal Tuberculosis Surgery: A Propensity Score Matching Analysis

Purpose

This study used a propensity score matching (PSM) analysis to explore the risk factors of post-operative complications and compared the differences in clinical data between them following spinal tuberculosis surgery.

Methods

The clinical data of patients with spinal tuberculosis were collected in our hospital from June 2012 to June 2021, including general information, laboratory results, surgical information, and hospitalization costs. The data were divided into two groups: complication and without complication groups. The baseline data of the two groups were obtained using the PSM analysis. Univariate and multivariate logistic analyses were used to analyze the differences between the two groups.

Results

A total of 292 patients were included in the PSM analysis: 146 patients with complications and 146 patients without complications. The operation time, incision length, hospital stay, and albumin quantity in the complications group were 162 ± 74.1, 11.2 ± 4.76, 14.7 ± 9.34, and 1.71 ± 2.82, respectively, and those in the without complication group were 138 ± 60.5, 10.2 ± 3.56, 11.7 ± 7.44, and 0.740 ± 2.44, respectively. The laboratory costs, examination costs, guardianship costs, oxygen costs, and total costs in the complications group were higher than those in the without complication group. A significant difference was observed in the albumin quantity by logistic regression analysis (P < 0.05).

Conclusion

Several costs in the complication group were higher than in the without complication group. The albumin quantity may be an independent factor to predict post-operative complications of spinal tuberculosis by logistic regression analysis.

Outcome after Posterior Vertebral Column Resection in Patients with Severe Osteoporotic Fractures—A Retrospective Analysis from Two Centers

Background and Objectives: In osteoporotic fractures of the spine with resulting kyphosis and threatening compression of neural structures, therapeutic decisions are difficult. The posterior vertebral column resection (pVCR) has been described by different authors as a surgical treatment in a single-stage posterior procedure. The aim of this study is to evaluate midterm outcomes of patients treated by pVCR due to severe osteoporotic fractures. Materials and Methods: Retrospective data analysis of all the patients treated for osteoporotic fractures by pVCR from 2012–2020 at two centers was performed. Demographic data, visual analog scale (VAS), Frankel scale (FS), Karnofsky performance status (KPS), radiological result and spinal fusion rates were evaluated. Results: A total of 17 patients were included. The mean age was 70 ± 10.2 y. The mean VAS decreased significantly from 7.7 ± 2.8 preoperatively to 3.0 ± 1.6 at last follow-up (p < 0.001) and the segmental kyphosis decreased from 29.4 ± 14.1° to 7.9 ± 8.0° (p < 0.001). The neurologic function on the FS did not worsen in any and improved in four of the patients. The median KPS remained stable over the whole observation period (70% vs. 70%). Spinal fusion was observed in nine out of nine patients who received CT follow-up >120 days after index surgery. Conclusions: This study showed that pVCR is a safe surgical technique with few surgical complications and no neurological deterioration considering the cohort. The patients’ segmental kyphosis and VAS improved significantly, while the KPS remained stable.

The risk factors of the postoperative poor wound healing in spinal tuberculosis patients: A single centre retrospective cohort study

The purpose of this study is to find out the risk factors of poor wound healing (PWH) in spinal tuberculosis (STB) patients. A total of 232 STB patients who underwent debridement surgery between January 2012 to June 2020 were included in this retrospective study. The study cohort was divided into two groups according to the presence or absence of PWH. The clinical characteristics of STB patients who developed PWH were evaluated, and risk factors were found using logistic regression analysis. Of the 232 patients, 30 developed PWH. Multivariate binary logistic regression analysis showed that pulmonary tuberculosis, long operation time and low postoperative albumin level were independent risk factors for PWH in STB patients. Receiver operating characteristic curve analysis showed that the optimal cutoff value of PWH in operation time and postoperative albumin are 200 minutes and 30 g/L, respectively. Pulmonary tuberculosis, long operation time and low postoperative albumin level are independent risk factors for PWH following surgery for STB. Curing pulmonary tuberculosis, controlling operation time and supervising postoperative serum albumin may decrease the risk of PWH among STB patients.

[Perforator-based keystone flap in the reconstruction of extensive tissue defects after lumbosacral spondylodesis]

BACKGROUND

Prolonged surgical site infections after spinal fusion surgery may lead to exposure of the implant due to the formation of extensive tissue defects and endanger the clinical outcome.

OBJECTIVE

This study aims to enlighten the role of the keystone perforator flap method in the reconstruction of lumbar soft tissue defects.

MATERIAL AND METHODS

The retrospective study included 11 consecutive patients with a wound dehiscence of over 6 × 6 cm defect area persisting for 2 weeks after spinal fusion. The keystone perforator flap was applied for the reconstruction of tissue defects, whereas the arterial blood supply of the flaps was based on the intramuscular and intermuscular perforating branches of the dorsal branches of the lumbar arteries.

RESULTS

The median age of our cohort was 58 years. The median body mass index (BMI) and Charlson comorbidity index (CCI) were 29.9 and 3.4, respectively. In eight cases a lumbosacral was carried out whereas in the remaining series a lumbar fusion was performed. In the course of the subsequent wound revision, on average 4 applications of negative pressure wound therapy (NPWT) were performed. The average defect size was 7.5 cm in width and 16.5 cm in length. The microbiological analysis of the tissue samples obtained intraoperatively after repeated NPWT revealed positive evidence of pathogenic bacteria in all cases. The average duration of inpatient treatment after flap surgery was 15 days, which was significantly shorter than the NPWT management of the open defect wounds (15.5 ± 2.5 vs. 37 ± 16.5, p < 0.05).

CONCLUSION

The keystone perforator flap offers a stable coverage for soft tissue defects and supports infection control after spinal fusion.

Autologous platelet-rich fibrin (PRF) augmentation as an add-on therapy in deep surgical site infections (dSSIs) after instrumented spinal surgery: preliminary results of a single institution case series

BACKGROUND

Deep surgical site infections (dSSIs) after instrumented spinal surgery pose major therapeutic challenges. Standard treatment involves surgical debridement, wound drainage, and long-term antibiotic administration. Autologous platelet-rich fibrin (PRF) constitutes a biomaterial obtained from patients' own blood that contains leukocytes, chemokines and growth factors boosting cicatrization. Due to favorable results reported from other surgical disciplines such as dentistry, orthopedics, maxillofacial and plastic surgery using PRF, the authors hypothesized that PRF augmentation will promote wound healing in dSSIs.

OBJECTIVE

To report our preliminary results on the safety and efficacy of autologous-PRF as an add-on therapy on a pilot case series of persistent dSSI after instrumented spinal surgery.

METHODS

Among the 293 patients who underwent dorsal decompression and stabilization of the cervical, thoracic, and lumbar spine due to degenerative diseases in our department, 12 patients (4%) presented persisting dSSI after standard wound debridement and antibiotic treatment. PRF augmentation was used during a second surgical revision as an add-on therapy to standard debridement. In all cases, the wound was primarily closed without drains.

RESULTS

Wound healing was completed between 14 and 21 days after the second surgical revision in all patients. At a median follow-up of 8 months (range: 6 to 18 months), no recurrence of dSSI nor complications were encountered in any case.

CONCLUSIONS

Our preliminary results suggest that PRF augmentation in persistent dSSI after instrumented spinal surgery appears to be a safe and effective strategy to promote wound healing. Prospective controlled studies are required to define the efficiency of PRF more clearly in both treating and preventing dSSI.

Impaired Oral Health in Older Orthopaedic In-Care Patients: The Influence of Medication and Morbidity

Introduction

Fall-related injuries are prevalent in older patients and often lead to increased morbidity, medication, and impaired functions. We studied older trauma patients with the aim to describe their oral health in comparison to morbidity and medication.

Material and Methods

The study included 198 patients, ≥65 years, admitted with an orthopedic trauma. Oral examinations included number of natural teeth, dental implants, missing, decayed and restored teeth, root remnants, and pocket depth. Data on comorbidities and medication were assembled. Statistical analyses were carried out with logistic regression models, adjusted for age, gender, comorbidity, and polypharmacy.

Results

Overall, 198 patients participated, 71% women, mean age 81 years (±7.9), 85% resided in their own homes, 86% had hip fractures. Chronic diseases and drug use were present in 98.9%, a mean of 6.67 in Charlson comorbidity index (CCI), 40% heart diseases, 17% diabetes, and 14% dementia. Ninety-one percent were dentate (181), mean number of teeth 19.2 (±6.5), 24% had decayed teeth, 97% filled teeth, 44% <20 teeth, and 26% oral dryness. DFT (decayed, filled teeth) over mean were identified in patients with diabetes (p=0.037), COPD (p=0.048), polypharmacy (p=0.011), diuretics (p=0.007), and inhalation drugs (p=0.032). Use of ≥2 strong anticholinergic drugs were observed in patients with <20 teeth and DFT over mean (p=0.004, 0.003). Adjusted for age, gender, CCI, and polypharmacy.

Conclusion

The study showed that impaired oral health was prevalent in older trauma patients and that negative effects on oral health were significantly associated with chronic diseases and drug use. The results emphasize the importance of identifying orthogeriatric patients with oral health problems and to stress the necessity to uphold good oral care during a period when functional decline can be expected.

Postoperative lumbar spine MRI: How well does a radiology report that raises suspicion for infection correlate with true clinical infection?

INTRODUCTION

Interpretation of a lumbar spine MRI in the immediate postoperative period is challenging, as postoperative tissue enhancement and fluid collections may be mistaken for infection. Radiology reports may use ambiguous language, creating a clinical problem for a surgeon in determining whether a patient needs treatment with antibiotics or revision surgery. Moreover, retrospective criticism of management in instances of a true infection may lead to medicolegal ramifications.

METHODS

A retrospective review of patients undergoing posterior-approach lumbar decompressive surgery with or without fusion over a 30-month period identified those undergoing postoperative MRI within 10 weeks of surgery. Patients initially operated upon for infection were excluded. The MRI reports were analyzed for language describing findings suspicious for infection and those of these with true infections were identified.

RESULTS

Of 487 patients undergoing posterior lumbar spine decompression surgery, 68 (14%) had postoperative MRI within 10 weeks. Of these, the radiology reports raised suspicion for infection in 20 (29%), of which 2 (10%) patients had a true infection. Two patients underwent reoperation for new motor deficit from seroma/hematoma. Of 63 patients who had MRI to evaluate complaints of back and/or leg pain without new motor deficits, the MRI significantly altered management in 3 patients (4.8%).

CONCLUSION

Radiology reports of postoperative lumbar spine MRIs frequently use language that raises suspicion for infection; but it is uncommon, however, that these patients harbor true infections. A radiology report describing possible infectious findings may not be considered significant without corroboration with other laboratory and clinical data.

Preoperative prognostic nutritional index is useful factor for predicting postoperative delirium after primary total joint arthroplasty

Background

Postoperative delirium (PD), as an acute brain failure, is widely reported as a very common postoperative complication, and it is closely associated with increased morbidity and mortality. Recently, malnutrition is reported as one of the risk factors for PD. The prognostic nutritional index (PNI) is a simple method for nutritional evaluation. However, few studies have discussed the effectiveness of PNI as a nutritional assessment in predicting PD after primary total joint arthroplasty (TJA). The aim of this study is to investigate potential risk factors including PNI for PD following primary TJA.

Methods

A retrospective analysis of 994 patients was performed to identify risk factors associated with PD after primary TJA by using univariate and multivariate analyses. A receiver operating characteristic curve and the area under the curve were applied to evaluate the significant results of the multivariate analysis and the optimal cutoff value (CV).

Results

Postoperatively, sixty-seven patients (67/994, 6.7 %) experienced PD. Univariate analysis demonstrated that operative time, duration of anesthesia, age, hypertension, serum albumin, and PNI differed between the PD and non-PD groups (P < 0.05). Multivariate logistic regression analysis showed that the preoperative PNI (odds ratio [OR]: 0.908; 95 % confidence interval [CI]: 0.840–0.983; CV: 47.05), age of patients (OR: 1.055; 95 % CI: 1.024–1.087; CV: 73.5 years), and hypertension (OR: 1.798; 95 % CI: 1.047–3.086), were independently associated with PD (P < 0.05).

Conclusions

A low preoperative PNI associated with malnutrition was demonstrated to be an independent risk factor for PD following primary TJA. Patients with preoperative low PNI should be cautioned and provided with adequate nutritional intervention to reduce postoperative PD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04626-6.

Risk of reoperation and infection after percutaneous endoscopic lumbar discectomy and open lumbar discectomy : a nationwide population-based study

AIMS

Open discectomy (OD) is the standard operation for lumbar disc herniation (LDH). Percutaneous endoscopic lumbar discectomy (PELD), however, has shown similar outcomes to OD and there is increasing interest in this procedure. However despite improved surgical techniques and instrumentation, reoperation and infection rates continue and are reported to be between 6% and 24% and 0.7% and 16%, respectively. The objective of this study was to compare the rate of reoperation and infection within six months of patients being treated for LDH either by OD or PELD.

METHODS

In this retrospective, nationwide cohort study, the Korean National Health Insurance database from 1 January 2007 to 31 December 2018 was reviewed. Data were extracted for patients who underwent OD or PELD for LDH without a history of having undergone either procedure during the preceding year. Individual patients were followed for six months through their encrypted unique resident registration number. The primary endpoints were rates of reoperation and infection during the follow-up period. Other risk factors for reoperation and infection were also evalulated.

RESULTS

Out of 549,531 patients, 522,640 had undergone OD (95.11%) and 26,891 patients had undergone PELD (4.89%). Reoperation rates within six months were 2.28% in the OD group, and 5.38% in the PELD group. Infection rates were 1.18% in OD group and 0.83% in PELD group. The risk of reoperation was lower for patients with OD than for patients with PELD (adjusted hazard ratio (HR) 0.38). The risk of infection was higher for patients with OD than for patients undergoing PELD (HR, 1.325).

CONCLUSION

Compared with the OD group, the PELD group showed higher reoperation rates and lower infection rates. Cite this article: Bone Joint J 2021;103-B(8):1392-1399.

Preoperative prognostic nutritional index as a predictive factor for medical complication after cervical posterior decompression surgery: A multicenter study

STUDY DESIGN

Retrospective longitudinal cohort study.

OBJECTIVE

To investigate postoperative medical complications in patients with malnutrition after cervical posterior surgery.

METHODS

A total of 256 patients were participated and divided into PNI < 50 group (group L) or PNI ≥ 50 (group H). Patient data, preoperative laboratory data, surgical data, hospitalization data, JOA score, complication data were measured.

RESULTS

Group L and group H were 127 and 129 patients, each PNI was L: 44.8 ± 4.3, H: 54.6 ± 4.0, P < 0.01. There was significant difference in mean age (L: 72.2 years vs H: 64.8 years, P < 0.01), BMI (23.1 vs 24.7, P < 0.01), serum albumin (L: 3.9 ± 0.4 g/dl vs H: 4.4 ± 0.3 g/dl, P < 0.01), total lymphocyte count (L: 1.3 ± 0.5 10³/µL vs H: 2.1 ± 0.7 10³/μL, P < 0.01), hospital stay (L: 25.0 days vs H: 18.8 days, P < 0.05), discharge to home (87.5% vs 57.5%, P < 0.01), delirium (L: 15.9% vs H: 3.9%, P < 0.01), medical complications (L: 25.2% vs H: 7.0%, P < 0.01), pre- and post- operative JOA score (L: 11.3 ± 2.8 vs H: 12.4 ± 2.6, P < 0.01; L: 13.3 ± 3.0 vs H: 14.1 ± 2.4, P = 0.02). Multiple logistic regression analysis showed that significant risk factors for medical complications were PNI<50 (P = 0.024, odds ratio [OR] 2.746, 95% confidence interval [CI] 1.143-6.600) and age (P = 0.005, odds ratio [OR] 1.064, 95% confidence interval [CI] 1.020-1.111).

CONCLUSION

Medical complications are significantly higher in patients with PNI < 50 and higher age. The results showed that PNI is a good indicator for perioperative medical complications in cervical posterior surgery. Improvement of preoperative nutritional status is important to avoid medical complications.

LEVEL OF EVIDENCE

3.

Malnutrition is Associated with Poor Postoperative Outcomes Following Laparoscopic Hysterectomy

Background:

Malnutrition continues to be pervasive among the general population, with rates as high as 50% of patients undergoing surgical procedures. Data is limited about women undergoing surgery for non-malignant gynecologic indications (generally elective laparoscopic hysterectomies, after failed conservative measures). With the significant increase in benign gynecologic surgery, it is of the upmost importance that surgeons optimize modifiable risk factors for patients undergoing laparoscopic hysterectomy. The purpose of this study is to identify the impact of malnutrition on postoperative outcomes in patients undergoing laparoscopic hysterectomy for benign conditions.

Methods:

A retrospective cohort study was conducted utilizing data that was collected through the American College of Surgeon’s National Surgical Quality Improvement Program (NSQIP) Database. All patients that underwent laparoscopic hysterectomy for benign indications were identified. Patients with malnutrition were identified by either low albumin (≤ 3.5 g/dL), low body mass index (≤ 18.5), or 10% weight loss within 6 months. The frequency of postoperative complications was evaluated with univariate and multivariate analyses where appropriate.

Results:

Following adjustment, multivariate analysis illustrated pre-operative malnutrition to be a risk factor for the following complications: any complication, death, bleeding requiring transfusion, wound, cardiac, pulmonary, renal, thromboembolic, sepsis complications, extended length of stay, and reoperation (p ≤ 0.05 for all).

Conclusion:

Malnourished patients were at significantly higher risk of developing postoperative complications during the acute postoperative period. With elective laparoscopic hysterectomies, pre-operative evaluation and intervention for malnutrition should be considered to improve nutritional status.

Imaging Assessment of the Postoperative Spine: An Updated Pictorial Review of Selected Complications

Imaging of the postoperative spine requires the identification of several critical points by the radiologist to be written in the medical report: condition of the underlying cortical and cancellous bone, intervertebral disc, and musculoskeletal tissues; location and integrity of surgical implants; evaluation of the success of decompression procedures; delineation of fusion status; and identification of complications. This article presents a pictorial narrative review of the most common findings observed in noninstrumented and instrumented postoperative spines. Complications in the noninstrumented spine were grouped in early (hematomas, pseudomeningocele, and postoperative spine infection) and late findings (arachnoiditis, radiculitis, recurrent disc herniation, spinal stenosis, and textiloma). Complications in the instrumented spine were also sorted in early (hardware fractures) and late findings (adjacent segment disease, hardware loosening, and implant migration). This review also includes a short description of the most used diagnostic techniques in postoperative spine imaging: plain radiography, ultrasound (US), computed tomography (CT), magnetic resonance (MR), and nuclear medicine. Imaging of the postoperative spine remained a challenging task in the early identification of complications and abnormal healing process. It is crucial to consider the advantages and disadvantages of the imaging modalities to choose those that provide more accurate spinal status information during the follow-up. Our review is directed to all health professionals dealing with the assessment and care of the postoperative spine.

Risk factors for surgical site infection following spinal surgery in Saudi Arabia: A retrospective case-control study

ABSTRACT

Surgical site infections (SSIs) are common complications after spinal surgery that result in increased morbidity, mortality, and healthcare costs. It was estimated that SSIs after spinal surgery resulted in a 4-fold increase in health care costs. The reported SSI rate following spinal surgery remains highly variable between approximately 0.5% and 18%. In this study, we aimed to estimate the SSI rate and identify possible risk factors for SSI after spinal surgery in our Saudi patient population.We conducted a single-center, retrospective case-control study in Saudi Arabia that included patients who developed SSIs, while the controls were all consecutive patients who underwent spinal surgery between January 2014 and December 2016. We extracted data on patient characteristics, anthropometric measurements, preoperative laboratory investigations, preoperative infection prevention measures, intraoperative measures, comorbidities, and postoperative care.We included 201 consecutive patients in our study; their median age was 56.9 years, and 51.2% were men. Only 4% (n = 8) of these patients developed SSIs postoperatively. Postoperative SSIs were significantly associated with longer postoperative hospital stays, hypertension, higher American Society of Anesthesia (ASA) scores, longer procedure durations, and the use of a greater number of blood transfusion units.This study revealed a low SSI rate following spinal surgery. We identified a history of hypertension, prolonged hospitalization, longer operative time, blood transfusion, and higher ASA score as risk factors for SSI in spine surgery in our population. As our findings are from a single institute, we believe that a national research collaboration among multiple disciplines should be performed to provide better estimates of SSI risk factors in our patient population.

Risk factors associated with surgical site infections after thoracic or lumbar surgery: a 6-year single centre prospective cohort study

BACKGROUND

Surgical site infection (SSI) is a risk in every operation. Infections negatively impact patient morbidity and mortality and increase financial demands. The aim of this study was to analyse SSI and its risk factors in patients after thoracic or lumbar spine surgery.

METHODS

A six-year single-centre prospective observational cohort study monitored the incidence of SSI in 274 patients who received planned thoracic or lumbar spinal surgery for degenerative disease, trauma, or tumour. They were monitored for up to 30 days postoperatively and again after 1 year. All patients received short antibiotic prophylaxis and stayed in the eight-bed neurointensive care unit (NICU) during the immediate postoperative period. Risk factors for SSI were sought using multivariate logistic regression analysis.

RESULTS

We recorded 22 incidences of SSI (8.03%; superficial 5.84%, deep 1.82%, and organ 0.36%). Comparing patients with and without SSI, there were no differences in age (p=0.374), gender (p=0.545), body mass index (p=0.878), spine diagnosis (p=0.745), number of vertebrae (p=0.786), spine localization (p=0.808), implant use (p=0.428), American Society of Anesthesiologists (ASA) Score (p=0.752), urine catheterization (p=0.423), drainage (p=0.498), corticosteroid use (p=0.409), transfusion (p=0.262), ulcer prophylaxis (p=0.409) and diabetes mellitus (p=0.811). The SSI group had longer NICU stays (p=0.043) and more non-infectious hospital wound complications (p<0.001). SSI risk factors according to our multivariate logistic regression analysis were hospital wound complications (OR 20.40, 95% CI 7.32-56.85, p<0.001) and warm season (OR 2.92, 95% CI 1.03-8.27, p=0.044).

CONCLUSIONS

Contrary to the prevailing literature, our study did not identify corticosteroids, diabetes mellitus, or transfusions as risk factors for the development of SSI. Only wound complications and warm seasons were significantly associated with SSI development according to our multivariate regression analysis.

Postoperative Prophylactic Antibiotics in Spine Surgery: A Propensity-Matched Analysis

BACKGROUND

Surgical site infections are common and costly complications after spine surgery. Prophylactic antibiotics are the standard of care; however, the appropriate duration of antibiotics has yet to be adequately addressed. We sought to determine whether the duration of antibiotic administration (preoperatively only versus preoperatively and for 24 hours postoperatively) impacts postoperative infection rates.

METHODS

All patients undergoing inpatient spinal procedures at a single institution from 2011 to 2018 were evaluated for inclusion. A minimum of 1 year of follow-up was used to adequately capture postoperative infections. The 1:1 nearest-neighbor propensity score matching technique was used between patients who did and did not receive postoperative antibiotics, and multivariable logistic regression analysis was conducted to control for confounding.

RESULTS

A total of 4,454 patients were evaluated and, of those, 2,672 (60%) received 24 hours of postoperative antibiotics and 1,782 (40%) received no postoperative antibiotics. After propensity-matched analysis, there was no difference between patients who received postoperative antibiotics and those who did not in terms of the infection rate (1.8% compared with 1.5%). No significant decrease in the odds of postoperative infection was noted in association with the use of postoperative antibiotics (odds ratio = 1.17; 95% confidence interval, 0.620 to 2.23; p = 0.628). Additionally, there was no observed increase in the risk of Clostridium difficile infection or in the short-term rate of infection with multidrug-resistant organisms.

CONCLUSIONS

There was no difference in the rate of surgical site infections between patients who received 24 hours of postoperative antibiotics and those who did not. Additionally, we found no observable risks, such as more antibiotic-resistant infections and C. difficile infections, with prolonged antibiotic use.

LEVEL OF EVIDENCE

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

Negative pressure wound therapy in spinal fusion patients

Post-operative wound complications are some of the most common acute complications following spine surgery. These surgical site infections (SSI) contribute to increased healthcare related costs. Negative pressure wound therapy (NPWT) has long been used for treatment of soft tissue injury or defects. NPWT may reduce the incident of SSI following spinal fusion procedures; however, its potential applications need further clarification. Thus, we conducted a retrospective analysis of two cohorts to compare NPWT to traditional sterile dressings following spinal fusions in regards to post-operative outcomes. Following institutional review board approval, 42 patients who had a NPWT were matched by type of surgery to 42 patients who had traditional dressings. A retrospective chart-review was completed. Outcome measures, particularly SSI and need for reoperation, were analyzed using one-way ANOVA for both univariate and multivariate analysis. When controlled for sex and body-mass index, the use of a NPWT was independently correlated with decreased SSI (P = .035). Superficial dehiscence, seroma, need for additional outpatient care, and need for operative revision were all found to occur at higher rates in the traditional dressing cohort. Closed incisional negative pressure wound therapy provides a cost-effective method of decreasing surgical site infection for posterior elective spine surgeries.

Evaluating the role of methicillin-resistant Staphylococcus aureus (MRSA)-specific antibiotic prophylaxis for neurosurgical patients

OBJECTIVE

Surgical site infection (SSI) in neurosurgical patients increases morbidity. Despite the rise of methicillin-resistant Staphylococcus aureus (MRSA) colonization, there is little consensus regarding antibiotic prophylaxis for SSI in MRSA-colonized neurosurgical patients. Our objective was to examine the incidence of SSI in MRSA-colonized neurosurgical patients and interrogate whether MRSA-specific antibiotic prophylaxis reduces SSIs.

METHODS

We performed a retrospective analysis of adult patients undergoing neurosurgical procedures between 2013 and 2018. The primary outcome was SSI in patients with MRSA colonization receiving MRSA-specific antibiotics. Secondary outcomes included predictors of SSI, including whether broad use of MRSA-specific antibiotics affects SSI rate.

RESULTS

Of 9739 procedures, 376 had SSI (3.9 %). Seven hundred forty-four procedures (7.6 %) were performed on patients screened preoperatively for MRSA, including 54 procedures on MRSA-colonized patients. MRSA-colonized patients were more likely than MRSA-non-colonized patients to receive MRSA-specific antibiotics (35.2 % vs. 17.8 %, p = 0.002) for prophylaxis. Nevertheless, MRSA-colonized patients had higher SSI rates compared to MRSA-non-colonized patients (22.2 % vs. 6.4 %, p = 0.00002). MRSA-colonization led to 3.49 greater odds (95 % CI 1.52-7.65, p = 0.002) of SSI relative to MRSA-non-colonization. MRSA-colonized patients receiving MRSA-specific antibiotics, compared to those receiving non-MRSA-specific antibiotics, had lower SSI rates, but this difference was not statistically significant (15.8 % vs. 25.7 %, p = 0.40). In the non-screened population, those receiving MRSA-specific antibiotics, compared to those receiving non-MRSA-specific antibiotics, had significantly higher SSI rates (6.9 % vs. 3.0 %, p = 0.00001). The use of MRSA-specific antibiotic prophylaxis in the non-screened population increased the odds of SSI (OR 1.90, 95 % CI 1.45-2.46, p = 0.0001).

CONCLUSION

MRSA-colonized neurosurgical patients had a higher SSI rate compared to MRSA-non-colonized patients. While MRSA-specific antibiotics may benefit those with MRSA colonization, the difference in SSI rate between MRSA-colonized patients receiving MRSA-specific antibiotics vs. non-specific antibiotics requires further investigation. The broader use of MRSA-specific antibiotics may paradoxically confer an increased risk of SSI in a non-screened neurosurgical population.

Role of Biochemical Nutritional Parameters as Predictors of Postoperative Morbidity in Major Spine Surgeries

Study Design

Prospective cohort study.

Purpose

To evaluate the association between nutritional parameters related to postoperative surgical site infections and duration of hospital stay and intensive care unit (ICU) stay in patients undergoing major spine surgery.

Overview of Literature

Malnutrition is highly prevalent in surgical patients. Malnourished patients are considered to be at higher risk for postoperative morbidity and mortality due to impaired wound healing, delayed inflammation, impaired fibroblast proliferation, and collagen synthesis. Decreased lymphocyte count also impairs the ability of the immune system to eradicate or prevent infection, which predisposes these patients to infections. However, this association between malnutrition and postoperative morbidity is not consistent across studies, thus necessitating further investigation.

Methods

The values of serum albumin, prealbumin, total lymphocyte counts, and transferrin were documented preoperatively and postoperatively on day 5 for all patients undergoing major spine surgery (surgery involving instrumentation of at least three motion segments). In addition, patients’ surgical wound healing status, duration of hospital stay, and duration of ICU stay in the postoperative period were documented. Finally, the statistical correlation between the nutritional markers and these complications was determined.

Results

Low postoperative prealbumin levels was significantly associated with increased complication rates. ICU stay demonstrated a statistically significant association with low postoperative albumin, prealbumin, and transferrin levels. Similarly, we observed that low postoperative albumin and prealbumin levels could significantly predict the need for prolonged hospital stay in patients undergoing major spine surgery.

Conclusions

The magnitude of the decrease in nutritional status due to surgery with respect to albumin and prealbumin levels is a significant (p<0.05) predictor of wound-related complications, rather than a single nutritional parameter evaluated at a point of time.

Sustained Postoperative Fever Without Evident Cause After Spine Instrumentation as an Indicator of Surgical Site Infection

BACKGROUND

Surgical site infection after spinal instrumentation increases morbidity and mortality as well as medical costs and is a burden to both patients and surgeons. Late-onset or sustained fever increases the suspicion for comorbid conditions. This retrospective, exploratory cohort study was conducted to identify the rate of and risk factors for sustained or late-onset postoperative fever after spinal instrumentation operations and to determine its relationship with surgical site infection.

METHODS

Five hundred and ninety-eight patients who underwent lumbar or thoracic spinal instrumentation were retrospectively reviewed. The patients were divided according to (1) whether or not they had had a sustained fever (SF[+] or SF[-]) and (2) whether or not they had had a surgical site infection (SSI[+] or SSI[-]). Clinical characteristics, surgical factors, prophylactic antibiotic usage, fever pattern, and laboratory/imaging findings were recorded for all patients by electronic medical chart review.

RESULTS

In total, 68 patients (11.4%) had a sustained fever. The rate of surgical site infection was significantly higher when the patient had sustained fever (13.2% [9 of 68] compared with 0.9% [5 of 530]; p < 0.001). Comparison of the patients who had a sustained fever but no surgical site infection (SF[+], SSI[-]) and those with both a sustained fever and surgical site infection (SF[+], SSI[+]) showed that continuous fever, an increasing or stationary pattern of inflammatory markers, and a C-reactive protein (CRP) level of >4 mg/dL on postoperative days 7 to 10 were diagnostic clues for surgical site infection. The sensitivity and specificity of postoperative magnetic resonance imaging (MRI) for the detection of surgical site infection were 40.0% and 90.9%, respectively, when MRI was performed within 1 month after surgery.

CONCLUSIONS

Although most patients with sustained fever did not have surgical site infection, fever was significantly related to surgical site infection. Continuous fever, increasing patterns of inflammatory markers, and high CRP on postoperative days 7 to 10 were diagnostic clues for surgical site infection. This study demonstrated provisional results for factors that can discriminate febrile patients with surgical site infection from febrile patients without infection. Further investigation with a larger sample size is warranted for clarification.

LEVEL OF EVIDENCE

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

Multidisciplinary approaches to complication reduction in complex spine surgery: a systematic review

BACKGROUND CONTEXT

Complex spine surgery carries a high complication rate that can produce suboptimal outcomes for patients undergoing these extensive operations. However, multidisciplinary pathways introduced at multiple institutions have demonstrated a promising potential toward reducing the burden of complications in patients being treated for spinal deformities. To date, there has been no effort to systematically collate the multidisciplinary approaches in use at various institutions.

PURPOSE

The present study aims to determine effective multidisciplinary strategies for reducing the complication rate in complex spine surgery by analyzing existing institutional multidisciplinary approaches and delineating common themes across multiple practice settings.

STUDY DESIGN

Systematic review.

METHODS

We followed guidelines established under the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The studies reported on data from PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science and Cochrane. We included articles that described either approaches to, or results from, the implementation of multidisciplinary paradigms during the preoperative, perioperative, and postoperative phases of care for patients undergoing complex spine surgery. We excluded studies that only targeted one complication unless such an approach was in coordination with more extensive multidisciplinary planning at the same institution.

RESULTS

A total of 406 unique articles were identified. Following an initial determination based on title and abstract, 22 articles met criteria for full-text review, and 10 met the inclusion criteria to be included in the review. Key aspects of multidisciplinary approaches to complex spine surgery included extensive preoperative workup and interdisciplinary conferencing, intraoperative communication and monitoring, and postoperative floor management and discharge planning. These strategies produced decreases in surgical duration and complication rates.

CONCLUSIONS

This study represents the first to systematically analyze multidisciplinary approaches to reduce complications in complex spine surgery. This review provides a roadmap toward reducing the elevated complication rate for patients undergoing complex spine surgery.

Rabbit model of Staphylococcus aureus implant-associated spinal infection

Post-surgical implant-associated spinal infection is a devastating complication commonly caused by Staphylococcus aureus. Biofilm formation is thought to reduce penetration of antibiotics and immune cells, contributing to chronic and difficult-to-treat infections. A rabbit model of a posterior-approach spinal surgery was created, in which bilateral titanium pedicle screws were interconnected by a plate at the level of lumbar vertebra L6 and inoculated with a methicillin-resistant S.aureus (MRSA) bioluminescent strain. In vivo whole-animal bioluminescence imaging (BLI) and ex vivo bacterial cultures demonstrated a peak in bacterial burden by day 14, when wound dehiscence occurred. Structures suggestive of biofilm, visualized by scanning electron microscopy, were evident up to 56 days following infection. Infection-induced inflammation and bone remodeling were also monitored using ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography (PET) and computed tomography (CT). PET imaging signals were noted in the soft tissue and bone surrounding the implanted materials. CT imaging demonstrated marked bone remodeling and a decrease in dense bone at the infection sites. This rabbit model of implant-associated spinal infection provides a valuable preclinical in vivo approach to investigate the pathogenesis of implant-associated spinal infections and to evaluate novel therapeutics.

Summary: A model of post-surgical methicillin-resistant Staphylococcus aureus implant-associated spinal infection was created in rabbits, recapitulating acute infection as well as chronic low-burden infection, with structures suggestive of biofilm formation and bone remodeling.

A Retrospective Chart Review on the Role of Suppressive Therapy in the Management of Spinal Infections Involving Hardware

Background

One percent to 8% of patients undergoing spinal instrumentation surgeries develop infections. There is no consensus on the medical and surgical management of these infections.

Methods

We conducted a retrospective chart review based on International Classification of Diseases, Ninth Revision, and Common Procedural Terminology codes relevant to spinal infections with hardware within Emory Healthcare over a 10-year period. Extracted data included patient demographics, clinical presentation, laboratory and microbiologic results, and surgical and medical management including choice and duration of suppressive therapy. Multivariable logistic regression was used to assess the association of length of use of suppressive antibiotics with treatment success and to identify predictors of use of suppressive antibiotics.

Results

Of 869 records, 124 met inclusion criteria. Fifty patients (40.3%) had an infection that occurred after hardware placement, mostly within 3 months postsurgery, while the remainder had vertebral osteomyelitis that required hardware placement. After initial intravenous antibiotic treatment for ≥4 weeks, 72 patients (64.5%) were given suppressive antibiotics. The overall treatment success rate was 78.2%. In spinal infections involving hardware with gram-negative rods, patients were less likely to receive suppressive antibiotics, less likely to have hardware removed, and less likely to have treatment success compared with patients with infections with Staphylococcus species.

Conclusions

Management of spinal infections involving hardware should be tailored to the timing of onset of infection and causative organism. Further studies are needed to determine best management practices, particularly for gram-negative rod infections where the role of further suppressive antibiotics and hardware removal may be warranted.

Preoperative Urinary Tract Infection Increases Postoperative Morbidity in Spine Patients

STUDY DESIGN

Retrospective review.

OBJECTIVE

Compare postoperative infection rates and 30-day outcomes in spine surgery patients with and without a preoperative urinary tract infection (UTI).

SUMMARY OF BACKGROUND DATA

There is mixed evidence regarding safety and risks when operating on spine patients with a preoperative UTI.

METHODS

Using data from the American College of Surgeons National Surgical Quality Improvement Program, we identified all adult patients undergoing spine surgery between 2012 and 2017 with a preoperative UTI. Patients with other preoperative infections were excluded. Our primary outcome was any postoperative infection (pneumonia, sepsis, surgical site infection, and organ space infection). Our secondary outcomes included surgical site infections, non-infectious complications, return to operating room, and 30-day readmission and mortality. We used univariate, then multivariate Poisson regression models adjusted for demographics, comorbidities, laboratory values, and case details to investigate the association between preoperative UTI status and postoperative outcomes.

RESULTS

A total of 270,371 patients who underwent spine surgery were analyzed. The most common procedure was laminectomy (41.9%), followed by spinal fusion (31.7%) and laminectomy/fusion (25.6%). Three hundred fourty one patients had a preoperative UTI (0.14%). Patients with a preoperative UTI were more likely to be older, female, inpatients, emergency cases, with a higher American Society of Anesthesiologists score, and a longer operating time (for all, P < 0.001). Patients with a preoperative UTI had higher rates of infectious and non-infectious complications, return to operating room, and unplanned readmissions (for all, P < 0.001). However, there was no significant difference in mortality (0.6% vs. 0.2%, P = 0.108). Even after controlling for demographics, comorbidities, labs, and case details, preoperative UTI status was significantly associated with more postoperative infectious complications (incidence rate ratio [IRR]: 2.88, 95% confidence interval [CI]: 2.25-3.70, P < 0.001).

CONCLUSION

Preoperative UTI status is significantly associated with postoperative infections and worse 30-day outcomes. Spine surgeons should consider delaying or cancelling surgery in patients with a UTI until the infection has cleared to reduce adverse outcomes.

LEVEL OF EVIDENCE

3.

Preoperative Versus Extended Postoperative Antimicrobial Prophylaxis of Surgical Site Infection During Spinal Surgery: A Comprehensive Systematic Review and Meta-Analysis

Introduction

Surgical site infection (SSI) following spinal surgery is a major source of postoperative morbidity. Although studies have demonstrated perioperative antimicrobial prophylaxis (AMP) to be beneficial in the prevention of SSI among spinal surgery patients, consensus is lacking over whether preoperative or extended postoperative AMP is most efficacious. To date, no meta-analysis has investigated the comparative efficacy of these two temporally variable AMP protocols in spinal surgery. We undertook a systemic review and meta-analysis to determine whether extended postoperative AMP is associated with a difference in the rate of SSI occurrence among adult patients undergoing spinal surgery.

Methods

Embase and MEDLINE databases were systematically searched for clinical trials and cohort studies directly comparing SSI rates among adult spinal surgery patients receiving either preoperative or extended postoperative AMP. Quality of evidence of the overall study population was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group approach. Random effects meta-analyses were performed utilizing both pooled and stratified data based on instrumentation use.

Results

Five studies met inclusion criteria. No individual study demonstrated a significant difference in the rate of SSI occurrence between preoperative and extended postoperative AMP protocols. The GRADE quality of evidence was low. Among the overall cohort of 2824 patients, 96% underwent lumbar spinal surgery. Pooled SSI rates were 1.38% (26/1887) for patients receiving extended postoperative AMP and 1.28% (12/937) for patients only receiving preoperative AMP. The risk of SSI development among patients receiving extended postoperative AMP was not significantly different from the risk of SSI development among patients only receiving preoperative AMP [RR (risk ratio), 1.11; 95% CI (confidence interval) 0.53–2.36; p = 0.78]. The difference in risk of SSI development when comparing extended postoperative AMP to preoperative AMP was also not significant for both instrumented (RR, 0.92; 95% CI 0.15–5.75; p = 0.93) and non-instrumented spinal surgery (RR, 1.25; 95% CI 0.49–3.17; p = 0.65). There was no evidence of heterogeneity of treatment effects for all meta-analyses.

Conclusion

Preoperative AMP appears to provide equivalent protection against SSI development when compared to extended postoperative AMP. Prudent antibiotic use is also known to decrease hospital length of stay, healthcare expenditure, and risk of complications. However, until higher-quality evidence becomes available regarding AMP in spinal surgery, surgeons should continue to exercise discretion and clinical judgment when weighing the effects of patient comorbidities and complications before determining the optimal duration of perioperative AMP.

Electronic supplementary material

The online version of this article (10.1007/s12325-020-01371-5) contains supplementary material, which is available to authorized users.

Hypoalbuminemia and obesity class II are reliable predictors of peri-prosthetic joint infection in patient undergoing elective total knee arthroplasty

Background

Malnutrition is a common and modifiable risk factor for postoperative complications and adverse outcomes in orthopedics. The purpose of this study was to identify biomarkers of malnutrition in patients undergoing elective total knee arthroplasty (TKA) that are predictive of adverse in-hospital postoperative complications, to facilitate the identification of at-risk patients for nutritional optimization before surgery.

Methods

A total of 624 patients who underwent elective TKA between 2013 and 2017 were evaluated; potential biomarkers of preoperative malnutrition, including hypoalbuminemia (serum albumin < 3.5 g/dL), total lymphocyte count (TLC < 1500 cells/mm³), and body mass index (BMI), were assessed for any association with in-hospital postoperative complications.

Results

The prevalence of hypoalbuminemia, low TLC, overweight, obesity class I, and obesity class II were, respectively 2.72%, 33.4%, 14.8%, 44.5%, and 26.9%. There was a significant association between hypoalbuminemia and obesity class II (BMI ≥ 30.0 kg/m²) with rates of peri-prosthetic joint infection, and no significant association between such complications and low TLC, overweight, or obesity class I. Logistic regression analysis showed that patients with hypoalbuminemia or being in obesity class II with gouty arthritis were more likely to suffer from peri-prosthetic joint infection.

Conclusions

Hypoalbuminemia and obesity class II together is a reliable biomarker of preoperative malnutrition for predicting peri-prosthetic joint infection after elective TKA, whereas low TLC, overweight, and obesity class I were not significantly associated with an increased risk of such complications.