Surgical Wound Classification and Surgical Site Infections in the Orthopaedic Patient

Hybrid-3D robotic suite in spine and trauma surgery - experiences in 210 patients

BACKGROUND

In modern Hybrid ORs, the synergies of navigation and robotics are assumed to contribute to the optimisation of the treatment in trauma, orthopaedic and spine surgery. Despite promising evidence in the area of navigation and robotics, previous publications have not definitively proven the potential benefits. Therefore, the aim of this retrospective study was to evaluate the potential benefit and clinical outcome of patients treated in a fully equipped 3D-Navigation Hybrid OR.

METHODS

Prospective data was collected (March 2022- March 2024) after implementation of a fully equipped 3D-Navigation Hybrid OR ("Robotic Suite") in the authors level 1 trauma centre. The OR includes a navigation unit, a cone beam CT (CBCT), a robotic arm and mixed reality glasses. Surgeries with different indications of the spine, the pelvis (pelvic ring and acetabulum) and the extremities were performed. Spinal and non-spinal screws were inserted. The collected data was analysed retrospectively. Pedicle screw accuracy was graded according to the Gertzbein and Robbins (GR) classification.

RESULTS

A total of n = 210 patients (118 m:92f) were treated in our 3D-Navigation Hybrid OR, with 1171 screws inserted. Among these patients, 23 patients (11.0%) arrived at the hospital via the trauma room with an average Injury Severity Score (ISS) of 25.7. There were 1035 (88.4%) spinal screws inserted at an accuracy rate of 98.7% (CI95%: 98.1-99.4%; 911 GR-A & 111 GR-B screws). The number of non-spinal screws were 136 (11.6%) with an accuracy rate of 99.3% (CI95%: 97.8-100.0%; 135 correctly placed screws). This resulted in an overall accuracy rate of 98.8% (CI95%: 98.2-99.4%). The robotic arm was used in 152 cases (72.4%), minimally invasive surgery (MIS) was performed in 139 cases (66.2%) and wound infection occurred in 4 cases (1,9%). Overall, no revisions were needed.

CONCLUSION

By extending the scope of application, this study showed that interventions in a fully equipped 3D-Navigation Hybrid OR can be successfully performed not only on the spine, but also on the pelvis and extremities. In trauma, orthopaedics and spinal surgery, navigation and robotics can be used to perform operations with a high degree of precision, increased safety, reduced radiation exposure for the OR-team and a very low complication rate.

Forequarter Amputation and Resection of Ribs 1-4 for Chronic Osteomyelitis

A 78-year-old woman with a history of breast cancer, melanoma, and radiation therapy presented with worsening chronic osteomyelitis and radiation necrosis of her clavicle, scapula, and upper ribs. Despite treatment with vancomycin, she experienced significant lymphedema and near-total loss of motor function in the left upper extremity. Given the progression of the disease and diminished functionality of the limb, a forequarter amputation was determined to be the only viable option beyond supportive care. The forequarter amputation was successful, and it involved the removal of the left clavicle, scapula, ribs 1-4, and the upper extremity. Within a month, the patient regained independence in all activities of daily living, highlighting the potential for improved quality of life from surgical interventions under certain circumstances. Our case serves as a reminder that the utility of the forequarter amputation extends beyond its most common uses, such as trauma or sarcoma, and in rare cases can be an option for refractory osteomyelitis of the proximal upper extremity and chest wall.

Postoperative Complications and Factors Associated with Surgical Site Infection at Muhimbili National Hospital, Dar es Salaam, Tanzania: A cross-Sectional study

Background

Postoperative complications are a leading cause of morbidity and mortality to surgical patients. Different complications are encountered in clinical practice, however surgical site infection (SSI) appears to be the most common. To date, limited published information is known pertaining to the patterns of postoperative complications and factors associated with SSI among patients operated on in other hospitals in Tanzania and referred to Muhimbili national hospital for further management. Therefore, the purpose of this study was to identify patterns of postoperative complications and factors associated with SSI among the study participants.

Methods

This was a hospital based cross-sectional study conducted at Muhimbili national hospital from August 2022 to January 2023, which included 181 patients. Obtained data was analysed using frequency tables, Pearson Chi-squared test and binary logistic regression model, at a level of significance of <0.05.

Results

One hundred eighty one (181) patients were included in this study, of whom 113(62.4%) were females; median age was 39 years. Cigarette smokers and alcohol consumers were 42(23.2%) and 90(49.7%) respectively. Diabetic patients were 8(4.4%), 35(19.3%) were HIV positive and 52(28.7%) had hypertension. Patients whose diagnosis was related to general surgery accounted for 50.2%, whereas 30.9% were obstetric cases. Patients who had undergone Caesarean section were 45(24.9%), whereas 20(11%) patients had undergone total abdominal hysterectomy. Bowel resection and primary anastomosis included 16(8.8%) patients and perforated peptic ulcer repair 8(4.4%) patients. Patients with infected peritoneal collection were 34(18.8%), postpartum haemorrhage 18(9.9%) and bowel perforation 10(5.5%). Patients who had undergone relaparotomy as part of treatment were 70(38.7%), whereas 30(16.6%) patients with SSIs were treated by serial wound dressing and 26(14.4%) patients were admitted and nursed in intensive care unit. None of the factors was found to have a statistically significant association with SSI.

Conclusions

There is a large proportion of patients suffering from postoperative complications after gastroenterology and obstetric surgeries; and of all complications encountered in this study; SSI was the most common contributing 52%, followed by gastrointestinal complications at 31%. Despite the fact that multiple factors were associated with SSI, none of them was found to be statistically significant.

Surgical Site Infections in Gastrointestinal Surgeries: Estimation of Prevalence, Risk Factors and Bacteriological Profile

INTRODUCTION

Surgical site infections (SSIs) are one of the leading causes of operation-related adverse effects. To create an effective hospital infection program, information about a local pattern is essential. The ever-changing pattern of infections and inappropriate use of antibiotics has predisposed to the development of drug-resistant strains and has made the management of SSIs arduous.

AIMS AND OBJECTIVES

The purpose of this study is to estimate prevalence and identify risk factors and commonest organisms associated with SSIs.

METHODOLOGY

In this analytical cross-sectional study, the relationship between various risk factors and the development of SSIs was evaluated in patients undergoing elective surgery and staying at least seven days postoperatively in the Department of Surgical Gastroenterology and Liver transplant for a study duration of two months. Diagnosis of SSIs was based on modified CDC criteria. Wound pus was followed by blood collection in suspected secondary septicemia. MacConkey and blood agar were used to culture pus; brain heart infusion broth was used for blood samples. Antimicrobial susceptibility testing was carried out using Mueller-Hinton agar by the Kirby-Bauer method.

RESULTS

 Twelve out of 50 had developed postsurgical wound infections where Gram-negative organisms prevailed over Gram-positive ones. The associated risk factors identified in this study are age, BMI, wound class, American Society of Anesthesiologists (ASA) score, preprocedural WBC count >10,000, and the duration of surgery. Escherichia coli is the causative microbe for the majority of infections (35.7%). Gram-negative bacteria isolated in this study were extended-spectrum β-lactamase (ESBL) producers. Multidrug-resistant organisms were predominant.  Conclusion: The present study identified an SSI rate of 24% in gastrointestinal surgeries. The sensitivity and resistance pattern of the organisms isolated will help in measures to be taken to devise a proper and effective current hospital antibiotic prophylaxis policy.

Pre-operative mechanical bowel preparation and prophylactic oral antibiotics for pediatric patients undergoing elective colorectal surgery: a protocol for a randomized controlled feasibility trial

BACKGROUND

Infections after elective colorectal surgery remain a significant burden for patients and the healthcare system. Adult studies suggest that the combination of oral antibiotics and mechanical bowel preparation is effective at reducing infections after colorectal surgery. In children, there is limited evidence for either of these practices and the utility of combining oral antibiotics with mechanical bowel preparation remains uncertain.

METHODS

This study aims to determine the feasibility of conducting a randomized controlled trial assessing the efficacy of oral antibiotics, with or without mechanical bowel preparation, in reducing the rates of post-operative infection in pediatric colorectal surgery. Participants aged 3 months to 18 years undergoing elective colorectal surgery will be randomized pre-operatively to one of three trial arms: (1) oral antibiotics; (2) oral antibiotics and mechanical bowel preparation; or (3) standard care. Twelve patients will be included in each trial arm. Feasibility outcomes of interest include the rate of participant recruitment, post-randomization exclusions, protocol deviations, adverse events, and missed follow-up appointments. Secondary outcomes include the rate of post-operative surgical site infections, length of hospital stay, time to full enteral feeds, reoperation, readmission, and complications.

DISCUSSION

If the results of this trial prove feasible, a multi-center trial will be completed with sufficient power to evaluate the optimal pre-operative bowel preperation for pediatric patients undergoing elective colorectal surgery.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03593252.

Associated factors of mortality and morbidity in emergency and elective abdominal surgery: a two-year prospective cohort study at lacor hospital, Uganda

BACKGROUND

The mortality rate associated with open abdominal surgery is a significant concern for patients and healthcare providers. This is particularly worrisome in Africa due to scarce workforce resources and poor early warning systems for detecting physiological deterioration in patients who develop complications.

METHODS

This prospective cohort study aimed to follow patients who underwent emergency or elective abdominal surgery at Lacor Hospital in Uganda. The participants were patients who underwent abdominal surgery at the hospital between April 27th, 2019 and July 07th, 2021. Trained research staff collected data using standardized forms, which included demographic information (age, gender, telephone contact, and location), surgical indications, surgical procedures, preoperative health status, postoperative morbidity and mortality, and length of hospital stay.

RESULTS

The present study involved 124 patients, mostly male, with an average age of 35 years, who presented with abdominal pain and varying underlying comorbidities. Elective cases constituted 60.2% of the total. The common reasons for emergency and elective surgery were gastroduodenal perforation and cholelithiasis respectively. The complication rate was 17.7%, with surgical site infections being the most frequent. The mortality rate was 7.3%, and several factors such as preoperative hypotension, deranged renal function, postoperative use of vasopressors, and postoperative assisted ventilation were associated with it. Elective and emergency-operated patients showed no significant difference in survival (P-value = 0.41) or length of hospital stay (P-value = 0.17). However, there was a significant difference in morbidity (p < 0.001).

CONCLUSION

Cholelithiasis and gastroduodenal perforation were key surgical indications, with factors like postoperative ventilation and adrenaline infusion linked to mortality. Emergency surgeries had higher complication rates, particularly surgical site infections, despite similar hospital stay and mortality rates compared to elective surgeries.

Enhancing Healing Strategies: Negative-Pressure Wound Therapy and Delayed Primary Closure in Abdominal Wounds Post-emergency Laparotomy for Intestinal Perforation

Background Intestinal perforation is a life-threatening condition requiring immediate surgical intervention. Surgical-site infections (SSIs) and wound dehiscence are common complications associated with emergency laparotomy for intestinal perforation. Finding optimal wound management and postoperative strategies can significantly impact patient outcomes and reduce the risk of complications. Negative-pressure wound therapy (NPWT) is a relatively recent tool employed in the care of wounds to control SSIs and foster healing. Methodology A prospective, observational, cohort study was conducted among 150 patients who underwent emergency exploratory laparotomy due to intestinal perforation at the general surgery department of a tertiary care hospital in New Delhi between July 2022 and December 2023. Preoperatively, all patients underwent initial resuscitation. Intraoperatively, the extent of peritonitis was determined and was categorized according to the Centers for Disease Control and Prevention (CDC) classification. Postoperatively, NPWT dressing was applied to the patient's midline laparotomy wound on postoperative day (POD) two. Negative pressure was set at 75-125 mmHg with suction. The number of NPWT dressing changes required was documented. The wound was closed with vertical mattress sutures under local anesthesia, delayed primary closure (DPC). The incidence of SSIs, the duration for DPC, the incidence of fascial dehiscence, the number of NPWT dressing changes, and the length of hospital stay were documented according to CDC groups. Results The mean age in CDC categories 2, 3, and 4 were 31.789, 28.733, and 42.676 years, respectively. The most common cause of perforation was enteric fever (n = 42, 28%), followed by tuberculosis (n = 36, 24%). Most patients had no known comorbidities (n = 80, 53.3%). Overall, 16% of patients (n = 24) were both alcoholics and smokers. The most frequent bacteria in all CDC categories was Escherichia coli. Fourteen patients developed burst abdomen in the postoperative period and were excluded from the study. The mean duration of DPC increased with higher CDC categories, with CDC category 4 displaying the most extended mean duration at 10.70 days. The number of NPWT dressing changes increases with higher CDC categories, with CDC category 4 exhibiting the highest mean at 2.00 changes. The mean hospital stay increased with higher CDC categories, with CDC category 4 showing the most extended mean stay at 17.324 days. Statistical analysis revealed no significant association between SSI occurrence and CDC categories. Conclusions NPWT followed by DPC is a promising approach to managing gastrointestinal perforations, reducing SSIs, and potentially improving patient outcomes. However, further research is needed to explore the specific benefits of NPWT in conjunction with DPC and its efficacy in various clinical scenarios.

Advancements in wound healing: integrating biomolecules, drug delivery carriers, and targeted therapeutics for enhanced tissue repair

Wound healing, a critical biological process vital for tissue restoration, has spurred a global market exceeding $15 billion for wound care products and $12 billion for scar treatment. Chronic wounds lead to delayed or impaired wound healing. Natural bioactive compounds, prized for minimal side effects, stand out as promising candidates for effective wound healing. In response, researchers are turning to nanotechnology, employing the encapsulation of these agents into drug delivery carriers. Drug delivery system will play a crucial role in enabling targeted delivery of therapeutic agents to promote tissue regeneration and address underlying issues such as inflammation, infection, and impaired angiogenesis in chronic wound healing. Drug delivery carriers offer distinct advantages, exhibiting a substantial ratio of surface area to volume and altered physical and chemical properties. These carriers facilitate sustained and controlled release, proving particularly advantageous for the extended process of wound healing, that typically comprise a diverse range of components, integrating both natural and synthetic polymers. Additionally, they often incorporate bioactive molecules. Despite their properties, including poor solubility, rapid degradation, and limited bioavailability, various natural bioactive agents face challenges in clinical applications. With a global research, emphasis on harnessing nanomaterial for wound healing application, this research overview engages advancing drug delivery technologies to augment the effectiveness of tissue regeneration using bioactive molecules. Recent progress in drug delivery has poised to enhance the therapeutic efficacy of natural compounds in wound healing applications.

Abdominal wall mass resections: single-center closure practices and outcomes following oncologic resections of abdominal wall fascia

PURPOSE

Radical resections for abdominal wall tumors are rare, thus yielding limited data on reconstruction of defects. We describe surgical management and long-term outcomes following radical tumor resection.

METHODS

This was a single-center retrospective review of patients between January 2010 and December 2022. Variables included operative characteristics, wound complications, hernia development, tumor recurrence, and reoperation. A multivariable analysis compared wound morbidity for suture and mesh repairs while adjusting for defect width, fascial closure, and CDC wound class.

RESULTS

120 patients were identified. Mean follow-up was 3.9 ± 3.4 years. Seventy-five (62.5%) of the masses were primary; most commonly desmoid (n = 25) and endometrioma (n = 27). Forty-five masses were metastases. Mean tumor width was 6.2 ± 3.4 cm; mean defect width was 8.1 ± 4.1 cm. Sixty-one patients (50.8%) had mesh placed, with variation in technique. Postoperative CT scans were available for 88 (73.3%) patients. Forty SSOs (33.3%), 11 SSIs (9.2%), and 18 (15%) SSOPIs occurred within 30 days. On multivariable analysis, increased defect width was associated with SSOPI (OR 1.17, p = 0.041) and CDC wound class II-III was associated with SSI (OR 8.38 and 49.1, p < 0.05) and SSOPI (OR 5.77 and 17.4, p < 0.05); mesh was not associated with these outcomes. Seven patients (5.8%) underwent 30-day reoperations and 35 (20.8%) required additional operations after 30 days. Thirteen percent developed abdominal wall (n = 8) or intra-abdominal tumor recurrence (n = 8) requiring reoperation. Twenty-seven (22.5%) patients developed hernias with a mean fascial defect width of 9.8 ± 7.2 cm.

CONCLUSION

Abdominal wall mass resections are morbid, often contaminated cases with high postoperative complication rates. Risks and benefits of mesh implantation should be tailored on an individual basis.

Roadmap to safety: a single center study of evidence-informed approach to placenta accreta spectrum

Objective

To assess the impact of an evidence-informed protocol for management of placenta accreta spectrum (PAS).

Methods

This was a retrospective cohort study of patients who underwent cesarean hysterectomy (c-hyst) for suspected PAS from 2012 to 2022 at a single tertiary care center. Perioperative outcomes were compared pre- and post-implementation of a standardized Multidisciplinary Approach to the Placenta Service (MAPS) protocol, which incorporates evidence-informed perioperative interventions including preoperative imaging and group case review. Intraoperatively, the MAPS protocol includes placement of ureteral stents, possible placental mapping with ultrasound, and uterine artery embolization by interventional radiology. Patients suspected to have PAS on prenatal imaging who underwent c-hyst were included in the analysis. Primary outcomes were intraoperative complications and postoperative complications. Secondary outcomes were blood loss, need for ICU, and length of stay. Proportions were compared using Fisher's exact test, and continuous variables were compared used t-tests and Mood's Median test.

Results

There were no differences in baseline demographics between the pre- (n = 38) and post-MAPS (n = 34) groups. The pre-MAPS group had more placenta previa (95% pre- vs. 74% post-MAPS, p = 0.013) and prior cesarean sections (2 prior pre- vs. 1 prior post-MAPS, p = 0.012). The post-MAPS group had more severe pathology (PAS Grade 3 8% pre- vs. 47% post-MAPS, p = 0.001). There were fewer intraoperative complications (39% pre- vs.3% post-MAPS, p < 0.001), postoperative complications (32% pre- vs.12% post-MAPS, p = 0.043), hemorrhages >1l (95% pre- vs.65% post-MAPS, p = 0.001), ICU admissions (59% pre- vs.35% post-MAPS, p = 0.04) and shorter hospital stays (10 days pre- vs.7 days post-MAPS, p = 0.02) in the post-MAPS compared to pre-MAPS patients. Neonatal length of stay was 8 days longer in the post-MAPS group (9 days pre- vs. 17 days post-MAPS, p = 0.03). Subgroup analyses demonstrated that ureteral stent placement and uterine artery embolization (UAE) may be important steps to reduce complications and ICU admissions. When comparing just those who underwent UAE, patients in the post-MAPS group experienced fewer hemorrhages greater five liters (EBL >5l 43% pre- vs.4% post-MAPS, p = 0.007).

Conclusion

An evidence-informed approach to management of PAS was associated with decreased complication rate, EBL >1l, ICU admission and length of hospitalization, particularly for patients with severe pathology.

Oncological Surgical Wound Care: A Comparison of Theruptor NXT Non-adherent Dressing and the Current Standard of Care

Background Oncological surgeries pose an elevated risk of surgical site infections (SSIs) due to their complexity and various associated treatments, impacting patient outcomes and healthcare costs. This has prompted a focus on advanced wound dressings that provide microbial protection, exudate absorption, and improved product performance, enhancing patient satisfaction. Our study aimed to compare the efficacy and safety of Theruptor NXT with the current standard of care (SOC) practice involving cotton/povidone/micropore dressings in the postoperative wound management of oncological surgeries. Methodology A total of 102 patients who underwent oncological surgeries in the Department of Surgical Oncology, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, India between May and September 2023 were randomized to Theruptor NXT and SOC dressing groups (51 patients each). The incidence of SSIs, wound pain score, cosmetic appearance of the wound, and adverse events were assessed in the two groups at various intervals, i.e., post-surgery day 2 ± 1, day of discharge, and post-surgery day 30 ± 7. Further, the subject satisfaction and product usage were evaluated on post-surgery day 2 ± 1. Results The baseline characteristics were found to be comparable in both groups, i.e., Theruptor NXT and SOC groups. Further, the SSI rates, scar outcomes, and physiological parameters were also similar between the Theruptor NXT and SOC groups, indicating a similar safety profile of both dressings (p > 0.05). However, the product usage assessment revealed statistically significant differences, favoring Theruptor NXT in terms of superior ease of application, stretchability, exudate management, breathability, and non-adherence properties (p < 0.05). Conclusions Our findings suggest that Theruptor NXT wound dressing is a promising, effective, and user-friendly alternative to SOC wound dressing in diverse clinical settings.

Machine Learning Approaches for the Image-Based Identification of Surgical Wound Infections: Scoping Review

BACKGROUND

Surgical site infections (SSIs) occur frequently and impact patients and health care systems. Remote surveillance of surgical wounds is currently limited by the need for manual assessment by clinicians. Machine learning (ML)-based methods have recently been used to address various aspects of the postoperative wound healing process and may be used to improve the scalability and cost-effectiveness of remote surgical wound assessment.

OBJECTIVE

The objective of this review was to provide an overview of the ML methods that have been used to identify surgical wound infections from images.

METHODS

We conducted a scoping review of ML approaches for visual detection of SSIs following the JBI (Joanna Briggs Institute) methodology. Reports of participants in any postoperative context focusing on identification of surgical wound infections were included. Studies that did not address SSI identification, surgical wounds, or did not use image or video data were excluded. We searched MEDLINE, Embase, CINAHL, CENTRAL, Web of Science Core Collection, IEEE Xplore, Compendex, and arXiv for relevant studies in November 2022. The records retrieved were double screened for eligibility. A data extraction tool was used to chart the relevant data, which was described narratively and presented using tables. Employment of TRIPOD (Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis) guidelines was evaluated and PROBAST (Prediction Model Risk of Bias Assessment Tool) was used to assess risk of bias (RoB).

RESULTS

In total, 10 of the 715 unique records screened met the eligibility criteria. In these studies, the clinical contexts and surgical procedures were diverse. All papers developed diagnostic models, though none performed external validation. Both traditional ML and deep learning methods were used to identify SSIs from mostly color images, and the volume of images used ranged from under 50 to thousands. Further, 10 TRIPOD items were reported in at least 4 studies, though 15 items were reported in fewer than 4 studies. PROBAST assessment led to 9 studies being identified as having an overall high RoB, with 1 study having overall unclear RoB.

CONCLUSIONS

Research on the image-based identification of surgical wound infections using ML remains novel, and there is a need for standardized reporting. Limitations related to variability in image capture, model building, and data sources should be addressed in the future.

A predictive nomogram for surgical site infection in patients who received clean orthopedic surgery: a retrospective study

BACKGROUND

Surgical site infection (SSI) is a common and serious complication of elective clean orthopedic surgery that can lead to severe adverse outcomes. However, the prognostic efficacy of the current staging systems remains uncertain for patients undergoing elective aseptic orthopedic procedures. This study aimed to identify high-risk factors independently associated with SSI and develop a nomogram prediction model to accurately predict the occurrence of SSI.

METHODS

A total of 20,960 patients underwent elective clean orthopedic surgery in our hospital between January 2020 and December 2021, of whom 39 developed SSI; we selected all 39 patients with a postoperative diagnosis of SSI and 305 patients who did not develop postoperative SSI for the final analysis. The patients were randomly divided into training and validation cohorts in a 7:3 ratio. Univariate and multivariate logistic regression analyses were conducted in the training cohort to screen for independent risk factors of SSI, and a nomogram prediction model was developed. The predictive performance of the nomogram was compared with that of the National Nosocomial Infections Surveillance (NNIS) system. Decision curve analysis (DCA) was used to assess the clinical decision-making value of the nomogram.

RESULTS

The SSI incidence was 0.186%. Univariate and multivariate logistic regression analysis identified the American Society of Anesthesiology (ASA) class (odds ratio [OR] 1.564 [95% confidence interval (CI) 1.029-5.99, P = 0.046]), operative time (OR 1.003 [95% CI 1.006-1.019, P < 0.001]), and D-dimer level (OR 1.055 [95% CI 1.022-1.29, P = 0.046]) as risk factors for postoperative SSI. We constructed a nomogram prediction model based on these independent risk factors. In the training and validation cohorts, our predictive model had concordance indices (C-indices) of 0.777 (95% CI 0.672-0.882) and 0.732 (95% CI 0.603-0.861), respectively, both of which were superior to the C-indices of the NNIS system (0.668 and 0.543, respectively). Calibration curves and DCA confirmed that our nomogram model had good consistency and clinical predictive value, respectively.

CONCLUSIONS

Operative time, ASA class, and D-dimer levels are important clinical predictive indicators of postoperative SSI in patients undergoing elective clean orthopedic surgery. The nomogram predictive model based on the three clinical features demonstrated strong predictive performance, calibration capabilities, and clinical decision-making abilities for SSI.

Current Advances in Wound Healing and Regenerative Medicine

Treating chronic wounds is a common and costly challenge worldwide. More advanced treatments are needed to improve wound healing and prevent severe complications such as infection and amputation. Like other medical fields, there have been advances in new technologies promoting wound healing potential. Regenerative medicine as a new method has aroused hope in treating chronic wounds. The technology improving wound healing includes using customizable matrices based on synthetic and natural polymers, different types of autologous and allogeneic cells at different differentiation phases, small molecules, peptides, and proteins as a growth factor, RNA interference, and gene therapy. In the last decade, various types of wound dressings have been designed. Emerging dressings include a variety of interactive/ bioactive dressings and tissue-engineering skin options. However, there is still no suitable and effective dressing to treat all chronic wounds. This article reviews different wounds and common treatments, advanced technologies and wound dressings, the advanced wound care market, and some interactive/bioactive wound dressings in the market.

Efficacy of topical atorvastatin-loaded emulgel and nano-emulgel 1% on post-laparotomy pain and wound healing: A randomized double-blind placebo-controlled clinical trial

This study aimed to develop atorvastatin-loaded emulgel and nano-emulgel dosage forms and investigate their efficiency on surgical wound healing and reducing post-operative pain. This double-blind randomized clinical trial was conducted in a surgical ward of a tertiary care hospital affiliated with university of medical sciences. The eligible patients were adults aged 18 years or older who were undergoing laparotomy. The participants were randomized in a 1:1:1 ratio to one of three following groups of atorvastatin-loaded emulgel 1% (n = 20), atorvastatin-loaded nano-emulgel 1% (n = 20), and placebo emulgel (n = 20) twice a day for 14 days. The primary outcome was the Redness, Edema, Ecchymosis, Discharge, and Approximation (REEDA) scores to determine the rate of wound healing. The Visual Analogue Scale (VAS) and quality of life were the secondary outcomes of this study. A total of 241 patients assessed for eligibility; of them, 60 patients completed the study and considered for final evaluation. A significant decrease in REEDA score was observed on Days 7 (63%) and 14 (93%) of treatment with atorvastatin nano-emulgel (p-value < 0.001). A significant decrease of 57% and 89% in REEDA score was reported at Days 7 and 14, respectively, in atorvastatin the emulgel group (p-value < 0.001). Reduction in pain VAS in the atorvastatin nano-emulgel was also recorded at Days 7 and 14 of the intervention. The results of the present study suggested that both topical atorvastatin-loaded emulgel and nano-emulgel 1% were effective in acceleration of wound healing and alleviation of pain of laparotomy surgical wounds, without causing intolerable side effects.

Primary Closure Versus Delayed Primary Closure of Class III and IV Surgical Wounds Following Emergency Laparotomy: A Prospective Comparative Study

Introduction Emergency surgery has a high risk of complications due to the detrimental effect of perioperative sepsis and the relative lack of preoperative optimization of patients. Despite advances in critical care for the management of sepsis, its prevention is dependent on various patient and surgeon factors. Surgical site infection continues to be a major determinant of morbidity and mortality following emergency abdominal surgery, especially in contaminated or dirty wounds. This study aims to compare two techniques of abdominal wall closure, primary closure with subcutaneous suction drains and delayed primary closure following negative pressure wound therapy, in terms of incidence of surgical site infection and morbidity. Materials and methods The study was a prospective comparative study including 50 patients with an acute surgical abdomen requiring laparotomy. The patients were randomized into two groups, Group A (n=25) who underwent primary closure, and Group B (n=25) who underwent delayed primary closure. In Group B patients, a vacuum-assisted closure device was applied in the subcutaneous space for five days prior to the closure of the skin. Outcomes were compared in terms of the incidence of superficial and deep surgical site infection, its association with diabetes mellitus, and the total duration of hospital stay. A chi-square test and an unpaired t-test were used for the test of significance. Results A total of 50 patients, comparable in age, were included in the study. The overall incidence of surgical site infection was significantly higher in patients of Group A as compared to Group B (p=0.0046). There was a positive correlation between diabetes mellitus and the occurrence of wound infection in both groups with the odds ratio being 2.67 and 2.38 respectively. The incidence of superficial wound infection was significantly higher in Group A when compared to Group B (52% versus 24%; p=0.04). Deep surgical site infection was higher in patients of Group A (20% versus 8%) but was not statistically significant (p=0.22). The average duration of hospital stay was 41.56 ± 6.96 and 37.86 ± 6.68 days for patients who developed complications from Groups A and B respectively, while it was nearly two and a half times lower in uncomplicated cases of Groups A and B (11.71± 1.70 days and 16.58± 1.06 days respectively). The one-tailed unpaired t-test showed a significant difference in means of hospital stay between patients with and without complications (T: 17.06, critical value: 1.677). Conclusion Delayed primary closure is an effective method of managing contaminated and dirty wounds following emergency laparotomy. Negative pressure wound therapy is one technique for preventing wound bed infection and accelerating wound healing in such cases. By combining the above in emergency surgeries, the incidence of surgical site infection and duration of hospital stay can be significantly reduced.

Antiseptic Skin Agents to Prevent Surgical Site Infection After Clean Implant Surgery: Subgroup Analysis of the NEWSkin Prep Trial

Background: There remains debate as to the ideal skin preparation agent to prevent surgical site infection (SSI) after clean implant surgery. This study is a subgroup analysis of all patients undergoing implant surgery in the NEWSkin prep trial. Patients and Methods: The NEWSkin prep trial is a randomized clinical trial (RCT; n = 3300) comparing the three antiseptic skin preparation agents commonly used prior to incisional surgery: chlorhexidine with alcohol (C-Alc), povidone iodine with alcohol (PI-Alc), and aqueous povidone iodine (PI-Aq). All participants who underwent clean incisional surgeries with implants from this trial were selected for analysis. The primary outcome was SSI rate; secondary outcomes were complication rates and re-admission rates. Results: A total of 712 patients in the NEWSkinPrep study underwent clean implant surgery between January 2015 and December 2018. Randomization resulted in the following distribution: C-Alc, 238; PI-Alc, 243; and PI-Aq, 231. Median age of participants was 63 years and 41% were female. Surgical site infection rates were: C-Alc, 10.13%; PI-Alc,11.52%; and PI-Aq, 11.26%. Povidone iodine with alcohol did not appear to be non-inferior to C-Alc (mean difference, 1.39%; 95% confidence interval [CI], -4.17 to 6.95) and PI-Alc was not superior to PI-Aq (mean difference, 0.27%; 95% CI, -5.45 to 5.99; p = 0.9271). There were no differences seen in secondary outcomes between groups. Conclusions: These results indicate a similarity between PI-Alc and C-Alc and that PI-Alc was not superior to PI-Aq. Because this study was not powered to assess these differences in clean cases with implants, additional studies are needed to assess these agents.

Antibiotic Prophylaxis in Surgery: Current Insights and Future Directions for Surgical Site Infection Prevention

Surgical site infections (SSIs) remain a significant concern in the field of surgery, contributing to patient morbidity, prolonged hospital stays, and increased healthcare costs. Antibiotic prophylaxis, the administration of antibiotics before surgery, has been a cornerstone in preventing SSIs for decades. This review explores the current state of antibiotic prophylaxis in surgery, offering insights into its effectiveness, challenges, and emerging trends. In this comprehensive analysis, we delve into the historical development of antibiotic prophylaxis, examining its evolution from early practices to modern guidelines. We explore the various classes of antibiotics commonly used, their dosing regimens, and the importance of timing in optimizing prophylactic interventions. Additionally, we investigate the role of patient-specific factors, such as comorbidities and allergies, in tailoring antibiotic prophylaxis to individual needs. While antibiotic prophylaxis has undeniably reduced the incidence of SSIs, concerns about antimicrobial resistance and adverse effects necessitate a reevaluation of current practices. This review presents a critical assessment of the challenges posed by the overuse and misuse of antibiotics in surgery and highlights the urgent need for judicious antibiotic stewardship. Moreover, the future of antibiotic prophylaxis holds promise with the emergence of innovative strategies such as antimicrobial coatings, probiotics, and immunomodulatory agents. We discuss these novel approaches and their potential to enhance SSI prevention while minimizing antibiotic-related risks. In conclusion, antibiotic prophylaxis in surgery has been instrumental in reducing SSIs, but its continued effectiveness requires a multifaceted approach. By addressing current challenges, promoting antibiotic stewardship, and embracing innovative strategies, we can advance the field of SSI prevention and improve patient outcomes in the years to come. This review provides valuable insights and direction for clinicians, researchers, and policymakers as they navigate the evolving landscape of surgical prophylaxis.

Centers for Disease Control (CDC) Wound Classification is Prognostic of 30-Day Readmission Following Surgery

BACKGROUND

The goal of this study was to investigate factors associated with 30-day readmission in a multivariate model, including the CDC wound classes "clean," "clean/contaminated," "contaminated," and "dirty/infected."

METHODS

The 2017-2020 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all patients undergoing total hip replacement, coronary artery bypass grafting, Ivor Lewis esophagectomy, pancreaticoduodenectomy, distal pancreatectomy, pneumonectomy, and colectomies. ACS-defined wound classes were concordant with CDC definitions. Multivariate linear mixed regression was used to determine risk factors for readmission while adjusting for type of surgery as a random intercept.

RESULTS

477,964 cases were identified, with 38,734 (8.1%) patients having experienced readmission within 30 days of surgery. There were 181,243 (37.9%) cases classified as wound class "clean", 215,729 (45.1%) cases classified as "clean/contaminated", 40,684 cases (8.5%) classified as "contaminated", and 40,308 (8.4%) cases classified as "dirty/infected". In the multivariate generalized mixed linear model adjusting for type of surgery, sex, body mass index, race, American Society of Anesthesiologists class, presence of comorbidity, length of stay, urgency of surgery, and discharge destination, "clean/contaminated" (p < .001), "contaminated" (p < .001), and "dirty/infected" (p < .001) wound classes (when compared to "clean") were significantly associated with 30-day readmission. Organ/space surgical site infection and sepsis were among the most common reasons for readmission in all wound classes.

CONCLUSIONS

Wound classification was strongly prognostic for readmission in multivariable models, suggesting that it may serve as a marker of readmissions. Surgical procedures that are "non-clean" are at significantly greater risk for 30-day readmission. Readmissions may be due to infectious complications; optimizing antibiotic use or source control to prevent readmission are areas of future study.

Surgical site infection and antimicrobial prophylaxis prescribing profile, and its determinants among hospitalized patients in Northeast Ethiopia: a hospital based cross-sectional study

The inappropriate use of surgical antimicrobial prophylaxis is a common cause for increased risk of morbidity and mortality from surgical site infection in patients who underwent surgical procedures. The study aimed to evaluate surgical antimicrobial prophylaxis prescribing patterns, Surgical Site Infection (SSI), and its determinants in the surgical ward of Debre Berhan Comprehensive Specialized Hospital, northeast Ethiopia. A prospective cross-sectional study was conducted from October 1st 2022 to January 31st, 2023. Data collected from patient medical record cards and patient interviews were entered and analyzed using SPSS V26.0. The determinants of surgical site infection were determined from the multivariable logistic regression. P-value ≤ 0.05 was considered statistically significant. Ceftriaxone (70.5%) followed by a combination of ceftriaxone with metronidazole (21.90%) was the most frequently used prophylactic antibiotic. One hundred fifty-nine (78%) of patients were exposed to inappropriately used prophylactic antimicrobials and 62.2% of these were exposed to inappropriately selected antibiotics. One hundred twenty-six (61.9%) patients developed Surgical Site Infection (SSI). Duration of procedure longer than an hour and inappropriate use of antimicrobial prophylaxiswere the independent predictors for the occurrence of surgical site infections. Patients whose operation was lasted in longer than an hour were 3.39 times more likely to develop SSI compared to those whose operation was completed in less than an hour, AOR = 3.39 (95% CI: 1.24-9.30). Similarly, controlling the effect of other covariate variables, individuals who were given inappropriate antimicrobial prophylaxis were 6.67 times more likely to develop SSI compared to those given appropriate prophylaxis, AOR = 6.67 (95% CI: 1.05-42.49). The high rate of SSI requires due attention from clinicians as well as health policymakers. Duration of surgical procedure greater than an hour and inappropriate antimicrobial prophylaxis use was the independent predictor of surgical site infections.

Self-Reported Diagnosis and Management of Surgical Site Infection Highlights Lack of Objective Measures and Treatment Guidance

Background: There is little guidance regarding empiric therapy for superficial surgical site infections (SSIs). Management of incisions with signs of SSI lacks consensus and management is variable among individual surgeons. Methods: The Surgical Infection Society was surveyed regarding management of SSIs. Cases were provided with varying wound descriptions, initial wound class (WC), post-operative day, and presence of a prosthesis. Responses were in multiple-choice format; statistics: χ2; α = 0.05. Results: Seventy-eight members responded. For appearance scenarios, respondents believed that both mild erythema (55%) and clear drainage (64%) could be observed, whereas substantial (>3 cm) erythema or purulence should be treated with complete (22% and 50%) or partial (55% and 40%) opening of the incision. Degree of erythema did not influence administration of antibiotic agents, but purulence was more likely than clear drainage to be treated with antibiotics (38% vs. 6%; p < 0.001). There were no differences based on WC, except that clean cases were more likely than higher WC scenarios to be treated with gram-positive coverage alone (WC 1 [26%] vs. 2 [10%] vs. 3 [13%] vs. 4 [4%]; p < 0.001). Post-operative day (POD) three appeared to be an inflection point for more aggressive treatment of suspected incisional SSI, with fewer (POD 0 [86%] vs. POD day 3 [54%]; p < 0.001) reporting observation. Respondents were more likely to obtain imaging, start broad-spectrum antibiotic agents, and return to the operating room for purulence in the presence of a mesh. Conclusions: Presented with escalating possibility of SSI, respondents reported lower rates of observation, increased use of antibiotic agents, and increased surgical drainage. Many scenarios lack consensus regarding appropriate therapy. The complete elimination of SSIs is unlikely to be accomplished soon, and this study provides a framework for understanding how surgeons approach SSIs, and potential areas for further research or pragmatic guidance.

Endoscopic Thyroidectomy: A 6-Year Experience from a Tertiary Care Teaching Hospital in Western India

Background: Minimally invasive and endoscopic surgical techniques have surpassed the conventional open thyroidectomy for the treatment of thyroid nodules. Trans-axillary, Unilateral Axillo-Breast Approach (UABA), Bilateral Axillo-Breast Approach, and Trans-Oral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) are the most common endoscopic procedures performed currently. This article highlights our experiences with UABA and TOETVA over a period of 6 years. Materials and Methods: Between January 2015 and December 2020, we retrospectively analyzed our experience in Endoscopic thyroidectomy with 119 patients using UABA (n = 72) and TOETVA (n = 47) in our tertiary care teaching hospital. Both approaches used the standard three-port technique. Real time angiography was performed intraoperatively using Indocyanine Green dye to delineate the vessels in all patients. Results: The mean operative time for UABA and TOETVA was 90 and 110 minutes, respectively. Estimated blood loss was 18 mL in the former and 20 mL in the latter. Temporary Recurrent Laryngeal Nerve palsy and Hypoparathyroidism were minimal with TOETVA (5 patients versus 4 patients and 7 patients versus 2 patients). Shorter duration of hospital stay was observed with UABA (3 days versus 5 days). Cosmetic satisfaction was better with TOETVA. Conclusion: Based on our 6-year experience, we propose "JJ Hospital Criteria," which we currently follow to decide which surgical approach will yield best results. UABA and TOETVA are safe, feasible, and give exceptional cosmetic satisfaction. Both approaches should be seen as complementary rather than competitive.

Different Surgeon, Different Closure: Lack of Consensus on Appropriate Closure Technique for Various Case Scenarios

Background: Many techniques for closure of surgical incisions are available to the surgeon, but there is minimal guidance regarding which technique(s) should be utilized at the conclusion of surgery and under what circumstances. Hypothesis: Management of incisions at the conclusion of surgery lacks consensus and varies among individual surgeons. Methods: The Surgical Infection Society membership was surveyed on the management of incisions at the conclusion of surgery. Several case scenarios were provided to test the influences of operation type, intra-operative contamination, and hemodynamic stability on incision management (e.g., close fascia or skin, use of incision/wound vacuum-assisted closure [VAC] device). Responses by two-thirds of participants were required to achieve consensus. Data analysis by χ² test and logistic regression, a = 0.05. Response heterogeneity was quantified by the Shannon index (SI). Results: Among 78 respondents, consensus was achieved for elective splenectomy (91% close skin/dry dressing). Open appendectomy and left colectomy/end-colostomy had the greatest heterogeneity (SI, 1.68 and 1.63, respectively). During trauma laparotomy, the majority used damage control for hemodynamic instability (53%-67%) but not for hemodynamically stable patients (0%-1.3%; p < 0.001). Additional consensus was achieved for close skin/dry dressing for hemodynamically stable trauma splenectomy patients (87%) and fascia open/wound VAC for hemodynamically unstable colon resection/anastomosis (67%). Fecal diversion for rectal injury and colon resection/anastomosis (both when hemodynamically stable) had high heterogeneity (SI, 1.56 and 1.48, respectively). In penetrating trauma, sentiment was for more use of wet-to-dry dressings and incision/wound VAC with increased contamination in hemodynamically stable patients. Conclusions: Damage control was favored in hemodynamically unstable trauma patients, with use of wet-to-dry dressings and incision/wound VAC with spillage after penetrating trauma. However, most scenarios did not achieve consensus. High variability of practices regarding incision management at the conclusion of surgery was confirmed. Prospective studies and evidence-based guidance are needed to guide decision making at end-operation.

A Practical Approach to Predicting Surgical Site Infection Risk Among Patients Before Leaving the Operating Room

A surgical site infection (SSI) prediction model that identifies at-risk patients before leaving the operating room can support efforts to improve patient safety. In this study, eight pre-operative and five perioperative patient- and procedure-specific characteristics were tested with two scoring algorithms: 1) count of positive factors (manual), and 2) logistic regression model (automated). Models were developed and validated using data from 3,440 general and oncologic surgical patients. In the automated algorithm, two pre-operative (procedure urgency, odds ratio [OR]: 1.7; and antibiotic administration >2 hours before incision, OR: 1.6) and three intraoperative risk factors (open surgery [OR: 3.7], high-risk procedure [OR: 3.5], and operative time OR: [2.6]) were associated with SSI risk. The manual score achieved an area under the curve (AUC) of 0.831 and the automated algorithm achieved AUC of 0.868. Open surgery had the greatest impact on prediction, followed by procedure risk, operative time, and procedure urgency. At 80% sensitivity, the manual and automated scores achieved a positive predictive value of 16.3% and 22.0%, respectively. Both the manual and automated SSI risk prediction algorithms accurately identified at-risk populations. Use of either model before the patient leaves the operating room can provide the clinical team with evidence-based guidance to consider proactive intervention to prevent SSIs.

Biosynthetic Mesh Reconstruction after Abdominoperineal Resection for Low Rectal Cancer: Cross Relation of Surgical Healing and Oncological Outcomes: A Multicentric Observational Study

BACKGROUND

Local wound complications are among the most relevant sequelae after an abdominoperineal resection (APR) for low rectal cancer. One of the proposed techniques to improve the postoperative recovery and to accelerate the initiation of adjuvant chemotherapy is the mesh reinforcement of the perineal wound. The aim of the current study is to compare the surgical and oncological outcomes after APR performed with a biosynthetic mesh reconstruction versus the conventional procedure.

METHODS

From 2015 to 2020, in two tertiary centres, the surgical outcomes, the wound events (i.e., surgical site infections, wound dehiscence and the complete healing time) and the oncological outcomes (i.e., time length to start adjuvant chemo-radiotherapy, an over 8-week delay in chemotherapy and the recurrence rate) were retrospectively analysed in patients undergoing APR reinforced with biosynthetic mesh (Group A) and conventional APR (Group B). Results Sixty-one patients were treated with APR (25 in Group A and 36 in Group B). Patients in Group A presented lower time for: healing (16 versus 24 days, p = 0.015), inferior perineal wound dehiscence rates (one versus nine cases, p = 0.033), an earlier adjuvant therapy start (26 versus 70 days, p = 0.003) and a lower recurrence rate (16.6% vs. 33.3%, p = 0.152).

CONCLUSIONS

In our series, the use of a biosynthetic mesh for the neo-perineum reconstruction after a Miles' procedure has resulted in safe, reproducible results affected by limited complications, guarantying a rapid start of the adjuvant therapy with clear benefits in oncological outcomes. Further randomized clinical trials with long-term follow-up are needed to validate these results.

Nutritional Optimization for Post-Spinal Surgery Recovery

Adequate nutritional intake is a key component of uncomplicated recovery from spinal surgery. Though much in the literature exists regarding its importance, specific dietary regimens for spinal surgery remain understudied, and little is available in compiling both preoperative and postoperative nutritional recommendations for patients. The complexity that may exist with these recommendations -- especially in the context of patients with diabetes or those who use substances -- has led in recent years to the development of protocols such as Enhanced Recovery After Surgery (ERAS), which gives providers a guideline upon which to base their nutritional counselling. More innovative regimens, such as the use of bioelectrical impedance analyses to assess nutritional status, have also emerged, resulting in a vast array of dietary recommendations and protocols for spinal surgery. In the following paper, we aim to compile a few of these guidelines, comparing various preoperative and postoperative nutritional strategies as well as making note of special considerations, like patients with diabetes or those who use substances. We also work to overview several such dietary "protocols" available in the literature, with a special focus on ERAS and more recent regimens like the Northwestern High-Risk Spine Protocol. We briefly mentioned preclinical work on novel nutritional recommendations as well. Ultimately, we hope to highlight the importance of nutrition in spinal surgery and address the need for greater cohesion of dietary strategies already in existence.

Outcomes of Open Fronto-Facial Resection for Fungal Osteomyelitis of Frontal Bone

INTRODUCTION

The second wave of coronavirus disease 2019 (COVID-19) led to the resurgence of opportunistic infections due to the injudicious use of steroids. Sinonasal mucormycosis was declared an epidemic in India during the pandemic. Mucormycosis was managed effectively by surgical debridement along with systemic amphotericin B. Currently, a resurgence of mucormycosis following initial treatment, in the form of fungal osteomyelitis of the frontal bone, is being seen in India.

METHODS

This prospective study included 10 patients with fungal osteomyelitis of the frontal bone due to mucormycosis. All patients underwent surgical debridement of the sequestrum and involucrum, with systemic antifungal pharmacotherapy.

RESULTS

The average duration of time until mucormycosis recurrence was 22 days following initial treatment (range 10-33 days). Patients presented with extracranial bossing following outer frontal cortex erosion (n=3), bicortical erosion (n=3), bifrontal involvement (n=2), dural involvement (n=3), and involvement of the brain parenchyma and prefrontal cortex (n=2). All cases underwent debridement of the entire sequestrous bone and involucrum until normal bone could be identified. The mean admission duration was 4 weeks (range 3-6 weeks). All treated patients are currently alive and without disease, confirmed by contrast-enhanced computed tomography.

CONCLUSION

Based on our experience, the successful treatment of fungal osteomyelitis due to mucormycosis requires a four-pronged approach: early detection, multidisciplinary management of comorbidities, surgical debridement of necrotic bone, and adequate systemic antifungal therapy.

Appropriateness of surgical antimicrobial prophylaxis in a teaching hospital in Ghana: findings and implications

Background

Surgical site infections (SSIs) are among the most common infections seen in hospitalized patients in low- and middle-income countries (LMICs), accounting for up to 60% of hospital-acquired infections. Surgical antimicrobial prophylaxis (SAP) has shown to be an effective intervention for reducing SSIs and their impact. There are concerns of inappropriate use of SAP in Ghana and therefore our audit in this teaching hospital.

Methods

A retrospective cross sectional clinical audit of medical records of patients undergoing surgery over a 5 month duration from January to May 2021 in Ho Teaching Hospital. A data collection form was designed to collect key information including the age and gender of patients, type and duration of surgery, choice and duration of SAP. The collected data was assessed for the proportion of SAP compliance with Ghana Standard Treatment Guidelines (STGs) and any association with various patient, surgical wound and drug characteristics.

Results

Of the 597 medical records assessed, the mean age of patients was 35.6 ± 12.2 years with 86.8% (n = 518) female. Overall SAP compliance with the STG was 2.5% (n = 15). SAP compliance due to appropriate choice of antimicrobials was 67.0% (n = 400) and duration at 8.7% (n = 52). SAP compliance was predicted by duration of SAP (P < 0.000) and postoperative hospitalization duration (P = 0.005).

Conclusions

SAP compliance rate was suboptimal, principally due to a longer duration of prescription. Quality improvement measures such as education of front-line staff on guideline compliance, coupled with clinical audit and regular updates, are urgently needed to combat inappropriate prescribing and rising resistance rates.

Applications of Electrospun Drug-Eluting Nanofibers in Wound Healing: Current and Future Perspectives

Wounds are a consequence of disruption in the structure, integrity, or function of the skin or tissue. Once a wound is formed following mechanical or chemical damage, the process of wound healing is initiated, which involves a series of chemical signaling and cellular mechanisms that lead to regeneration and/or repair. Disruption in the healing process may result in complications; therefore, interventions to accelerate wound healing are essential. In addition to mechanical support provided by sutures and traditional wound dressings, therapeutic agents play a major role in accelerating wound healing. The medicines known to improve the rate and extent of wound healing include antibacterial, anti-inflammatory, and proliferation enhancing agents. Nonetheless, the development of these agents into eluting nanofibers presents the possibility of fabricating wound dressings and sutures that provide mechanical support with the added advantage of local delivery of therapeutic agents to the site of injury. Herein, the process of wound healing, complications of wound healing, and current practices in wound healing acceleration are highlighted. Furthermore, the potential role of drug-eluting nanofibers in wound management is discussed, and lastly, the economic implications of wounds as well as future perspectives in applying fiber electrospinning in the design of wound dressings and sutures are considered and reported.

Effects on Tissue Integration of Collagen Scaffolds Used for Local Delivery of Gentamicin in a Rat Mandible Defect Model

Surgical site infections (SSIs) are a common complication following orthopedic surgery. SSIs may occur secondary to traumatic or contaminated wounds or may result from invasive procedures. The development of biofilms is often associated with implanted materials used to stabilize injuries and to facilitate healing. Regardless of the source, SSIs can be challenging to treat. This has led to the development of devices that act simultaneously as local antibiotic delivery vehicles and as scaffolds for tissue regeneration. The goal for the aforementioned devices is to increase local drug concentration in order to enhance bactericidal activity while reducing the risk of systemic side effects and toxicity from the administered drug. The aims of this study were to assess the effect of antibiotic loading of a collagen matrix on the tissue integration of the matrix using a rat mandibular defect model. We hypothesized that the collagen matrix could load and elute gentamicin, that the collagen matrix would be cytocompatible in vitro, and that the local delivery of a high dose of gentamicin via loaded collagen matrix would negatively impact the tissue–scaffold interface. The results indicate that the collagen matrix could load and elute the antimicrobial gentamicin and that it was cytocompatible in vitro with or without the presence of gentamicin and found no significant impact on the tissue–scaffold interface when the device was loaded with a high dose of gentamicin.

Surgical Site Infection Following Single-Port Appendectomy: A Systematic Review of the Literature and Meta-Analysis

Introduction

Surgical site infections (SSIs) are one of the most common postoperative complications after appendectomy leading to recurrent surgery, prolonged hospital stay, and the use of antibiotics. Numerous studies and meta-analyses have been published on the effect of open versus conventional laparoscopic appendectomy (CLA) reporting faster postoperative recovery and less postoperative pain for CLA. A development from CLA has been the single-port appendectomy (SPA), associated with a better cosmesis but seemingly having a higher risk of wound infections. The aim of this systematic literature review and meta-analysis is to investigate whether reduced port or SPA alters the ratio of SSIs.

Methods

Pubmed, Embase, and Cochrane databases were screened for suitable articles. All articles published between January 1, 2002, and March 23, 2022, were included. Articles regarding children below the age of 18 were excluded as well as manuscripts that investigated solemnly open appendectomies. Articles were screened for inclusion criteria by two independent authors. Incidence of SSI was the primary outcome. Duration of operation and length of hospital stay were defined as secondary outcomes.

Results

A total of 25 studies were found through a database search describing 5484 patients. A total of 2749 patients received SPA and 2735 received CLA. There was no statistical difference in the rate of SSI (P = 0.98). A total of 22 studies including 4699 patients reported the duration of operation (2223 SPA and 2476 CLA). There was a significantly shorter operation time seen in CLA. The length of hospital stay was reported in 23 studies (4735 patients: 2235 SPA and 2500 CLA). A shorter hospital stay was seen in the SPA group (P &lt; 0.00001). Separately performed analysis of randomized controlled trials could not confirm this effect (P = 0.29).

Discussion

SPA is an equally safe procedure considering SSI compared to CLA and does not lead to an increased risk of SSI. A longer operation time for SPA and a minor difference in the length of stay does lead to the use of SPA in selected patients only.

Diabetes management in spinal surgery

Diabetes mellitus can lead to long-standing complications in multiple arenas. An area that is often overlooked is implications for major surgery. Spinal decompression and fusions have unique challenges in the diabetic patient. In this review, we briefly highlight the pathophysiology of diabetes mellitus prior to examining implications for spinal surgery. We focus on the wound healing process, surgical infection risk, and delayed fusion. The paper then transitions to a focus on early diagnostics as well as pre-operative glucose control. Finally, we highlight important management strategies post operatively, continued necessity of monitoring, and emerging treatment and diagnostic approaches. This paper will serve as a key clinical guide that clinicians can utilize for diagnostic, management, and follow-up planning.

Adaptation of the Centers for Disease Control Surgical Wound Classification System for Orthopaedic Trauma Surgery

OBJECTIVES

To evaluate a proposed orthopaedic-specific surgical wound classification system (SWCS) and the current Centers for Disease Control (CDC) system in a series of detailed clinical vignettes and to identify the degree of satisfaction with CDC SWCS and desire for institution of an orthopaedic-specific SWCS.

METHODS

Forty-five clinical vignettes and a 5-question survey were distributed to current and past members of the Orthopaedic Trauma Association's Classification Committee. Respondents were asked to provide wound class for each vignette using the CDC system and orthopaedic-specific SWCS.

RESULTS

The orthopaedic-specific and CDC SWCS had interclass correlations of 0.95 and 0.91, respectively. When the systems were compared, in 34% of cases, there was no grade change; in 63% of cases, the wound was graded higher using the orthopaedic-specific SWCS. When only the procedure was changed between vignettes, wound classification was infrequently affected. There was near universal dissatisfaction with the CDC SWCS and desire for an orthopaedic-specific system.

CONCLUSIONS

Both the CDC SWCS and orthopaedic-specific SWCS have excellent interobserver reliability. Incorporation of orthopaedic-specific language affects wound classification. There is low satisfaction with the current CDC SWCS and a desire exists for further development and validation of an orthopaedic-specific SWCS.

An Advanced Surgical Dressing for High-risk Patients Undergoing Breast Cancer Surgery: a Case-control Study

Oncological breast surgeries, classified as breast conserving surgery, oncoplastic surgery, and mastectomies (standard or with tissue sparing and reconstruction), are burdened with an overall complication rate up to 33%. Aquacel Ag Surgical is a combined hydrofiber-hydrocolloids dressing. The aim of this study is to evaluate the incidence of surgical site complications in patients presenting with three or more risk factors (or two, of which at least one classified as "high risk"), undergoing breast cancer surgery with/without reconstruction, comparing advanced (Aquacel Ag Surgical) with traditional dressing.

METHODS

This is a retrospective, monocentric, case-control study based at the breast unit of the Città della Salute e della Scienza Hospital of Turin, Italy. Forty-two patients who underwent breast surgeries and met the inclusion criteria were enrolled, from February 1 to July 31, 2018. The primary endpoint was comparing the incidence of surgical site complications (skin alterations, infection, and wound dehiscence) in the two groups. The secondary endpoints were evaluating patient's quality of life, aesthetic outcomes, and compliance to the dressings.

RESULTS

The distribution of risk factors at the baseline between the two groups was balanced, without statistically significant differences. Wound complications' incidence at 1 week was lower in the advanced dressing group (P = 0.015). On the bivariate descriptive analysis, advanced dressing proved to be easier to remove for the operator (P = 0.026). The aesthetic outcomes vouched for better scores in the advanced dressing group.

CONCLUSION

In the presented study Aquacel Ag Surgical dressing reduces surgical site complications in the first week after surgery in patients affected by three or more risk factors (or two with at least one classified as "high risk").

Can BMI be a predictor of perioperative complications in Head and Neck cancer surgery?

<b>Introduction:</b> The effect of BMI on development of perioperative complications in head and neck cancer surgeries is not welldefined. </br></br> <b> Aim:</b> This study aims to evaluate the effect of body mass index (BMI) on the development of surgical complications during the perioperative period in head and neck carcinoma (HNC) patients. </br></br> <b>Materials and methods:</b> This study was conducted from 2019 to 2020. Electronic medical records of 210 patients undergoing major (clean-contaminated) surgeries were analysed. Chi-square test or Fisher exact test for determining association in categorical data and independent T-test or Mann-Whitney U test for comparison between the presence of complications and relation with continuous clinical parameters were used. </br></br> <b>Results:</b> The majority of patients were within normal-weight range (68.57%). Only 12.85% of patients had BMI under 18.5 kg/m2 and 18.57% of patients had BMI equal to or more than 25 kg/m2. Coexisting comorbidities were present in 48.7% of patients with BMI of more than 25 kg/m2. Major and minor complications were present in 10.5% and 16.7% of all patients, respectively. Surgical site infections were present in 18.1% of patients. There was no statistical difference in the rate of complications (major, minor and SSI) in underweight, normal weight and overweight categories. The complications were significantly associated with the extent of surgery (P = 0.00413) and blood loss of more than 775 mL (P-value 0.005). </br></br> <b> Conclusions:</b> In conclusion, the rate of surgical complications in head and neck onco-surgeries is not related to BMI of the patients. The perioperative management of these patients might require some modification due to co-existing comorbidities, but the overall impact on the development of complications could not be proven in this study.

Composite Polyurethane-Polylactide (PUR/PLA) Flexible Filaments for 3D Fused Filament Fabrication (FFF) of Antibacterial Wound Dressings for Skin Regeneration

This paper addresses the potential application of flexible thermoplastic polyurethane (TPU) and poly(lactic acid) (PLA) compositions as a material for the production of antibacterial wound dressings using the Fused Filament Fabrication (FFF) 3D printing method. On the market, there are medical-grade polyurethane filaments available, but few of them have properties required for the fabrication of wound dressings, such as flexibility and antibacterial effects. Thus, research aimed at the production, characterization and modification of filaments based on different TPU/PLA compositions was conducted. The combination of mechanical (tensile, hardness), structural (FTIR), microscopic (optical and SEM), degradation (2 M HCl, 5 M NaOH, and 0.1 M CoCl₂ in 20% H₂O₂) and printability analysis allowed us to select the most promising composition for further antibacterial modification (COMP-7,5PLA). The thermal stability of the chosen antibiotic—amikacin—was tested using processing temperature and HPLC. Two routes were used for the antibacterial modification of the selected filament—post-processing modification (AMI-1) and modification during processing (AMI-2). The antibacterial activity and amikacin release profiles were studied. The postprocessing modification method turned out to be superior and suitable for wound dressing fabrication due to its proven antimicrobial activity against E. coli, P. fluorescens, S. aureus and S. epidermidis bacteria.

Posttraumatic natural killer cell decrease is associated with septic complications

BACKGROUND

There has been paucity in prospective studies investigating trauma-induced changes in the cellular immunity of HIV-seropositive patients and their impact on the clinical outcome after trauma surgery. The role of natural killer (NK) cells especially has not yet been fully elucidated, and the function of this lymphocyte subtype in the immune defense after trauma is still under debate.

METHODS

This prospective study included patients requiring surgery for abdominal gunshot wounds. A blood specimen was obtained on admission, 48 hours after the index operation and, in case of damage control surgery, 48 hours after the first planned second look operation. The quantity and changes of T-, B- and NK cells were analyzed via flow cytometry to investigate whether these numbers had an impact on the postoperative outcome.

RESULTS

A total of 62 patients were recruited in the analysis of which 38 were HIV-negative and 24 HIV-seropositive. After surgery, HIV-negative patients had a more severe decrease of their CD4+ T cells compared to the HIV-seropositive patients. Trauma resulted in a severe decrease of NK cells irrespective of the HIV-serostatus. Patients with more extensive NK cell drop had a significantly higher postoperative complication rate.

CONCLUSIONS

Our data support the association of trauma-induced NK cell decrease with a subsequent significantly higher rate of septic and surgical complications and suggest that these immune cells might play an important role in antibacterial immunity. Strengthening the NK cell function or limiting their decrease in the postoperative course might be of therapeutic value in severely injured trauma patients.

Risk factors, bacteriological profile and outcome of surgical site infections following orthopaedic surgery

Background and Objectives:

Surgical site infection (SSI) is a challenge for the surgeon. Incidence of SSI reported in literature varies from 0.5% to 15%. Severity of SSI ranges from superficial skin infection to life-threatening condition like septicaemia. It is responsible for increased morbidity, mortality, and economic burden to the hospital in general, and the patient in particular. The aim of this study was to assess the risk factors, bacteriological profile, length of hospitalization, and cost due to orthopaedic SSI in patients admitted to a tertiary care hospital.

Materials and Methods:

This was a prospective case control study. Cases were diagnosed based on CDC definition of nosocomial SSI. All cases were assessed preoperatively, intraoperatively and postoperatively, according to type of surgery, wound class, duration of operation, antimicrobial prophylaxis, use of drain, preoperative hospital stay, causative micro organism, total hospital stay, readmission rates and cost incurred. Age, sex and surgical procedure matched controls without SSI, were also assessed. Chi-square test and Fisher’s exact test were used for analysis. P= <0.05 was considered significant.

Results:

Out of 1023 patients, 47 cases had SSI, with a rate of 4.6%. Cigarette smoking was a risk factor for SSI (P = 0.0035). The most common etiologic agents were Acinetobacter baumannii and Staphylococcus aureus. Incidence of readmission among SSI cases was more compared to controls (P= 0.0001). Costs attributable to SSI (Indian Rupees) was Rs 32,542 (17,054 to 87,514) which was significantly more than those without SSI (P= <0.001).

Conclusion:

Despite latest surgical amenities, meticulous sterilization protocols and pre-operative antibiotic prophylaxis, SSI continues to be present in healthcare settings. The increase in duration of hospital stay due to SSI adds to additional burden to an already resource-constrained healthcare system.

Role of Apoptosis in Wound Healing and Apoptosis Alterations in Microgravity

Functioning as the outermost self-renewing protective layer of the human organism, skin protects against a multitude of harmful biological and physical stimuli. Consisting of ectodermal, mesenchymal, and neural crest-derived cell lineages, tissue homeostasis, and signal transduction are finely tuned through the interplay of various pathways. A health problem of astronauts in space is skin deterioration. Until today, wound healing has not been considered as a severe health concern for crew members. This can change with deep space exploration missions and commercial spaceflights together with space tourism. Albeit the molecular process of wound healing is not fully elucidated yet, there have been established significant conceptual gains and new scientific methods. Apoptosis, e.g., programmed cell death, enables orchestrated development and cell removal in wounded or infected tissue. Experimental designs utilizing microgravity allow new insights into the role of apoptosis in wound healing. Furthermore, impaired wound healing in unloading conditions would depict a significant challenge in human-crewed exploration space missions. In this review, we provide an overview of alterations in the behavior of cutaneous cell lineages under microgravity in regard to the impact of apoptosis in wound healing. We discuss the current knowledge about wound healing in space and simulated microgravity with respect to apoptosis and available therapeutic strategies.

Prevalence of Bacterial surgical site infection in traumatic patients undergoing orthopedic surgeries: a cross-sectional study

BACKGROUND AND OBJECTIVE

Infection at the surgical site is one of the most common postoperative complications. Due to the high prevalence of orthopedic surgery site infection, epidemiologic studies that evaluate the frequency distribution of bacterial infection and related risk factors seem crucial. In the present study, we aimed to investigate and evaluate the prevalence of bacterial infections in traumatic operated patients.

METHODS

This is a cross-sectional study that was performed in 2011-2020 on all trauma cases with closed fractures re-admitted to the traumatic referral hospital due to surgical site infection after orthopedic surgeries. Data regarding surgical site culture and antibiogram and the most effective antibiotics were also collected from medical documents of patients.

RESULTS

During this study, 5950 people underwent traumatic closed fracture surgeries, of which 238 (4%) were readmitted due to infection. Data of 157 patients were analyzed and showed that the most common site of infection was knee in 46 patients (29.3%). Data also showed that gram-positive bacteria were detected in 55 patients (56.7%) while gram-negative micro-organisms were found in 42 patients (43.3%). Based on the statistical analysis, vancomycin was the most effective antibiotic in staphylococcus infections. There was also a significantly higher risks of bacterial surgical site infection for tibial injury (OR = 1.18, P < 0.001), knee injury (OR = 1.50, P < 0.001), presence of Staphylococcus (OR = 1.50, P < 0.001) and also Enterobacter (OR = 1.50, P < 0.001) both in the crude and adjusted models.

CONCLUSION

The prevalence rate of infection was 4% and the most common bacteria was Staphylococcus aureus. Vancomycin was also the most effective antibiotic in patients. We suggest that more studies should be conducted on the use of prophylactic antibiotics.

A Polymer-Biologic Hybrid Hernia Construct: Review of Data and Early Experiences

Surgical mesh reinforcement of the human abdominal wall has been found to reduce the chance of recurrence in hernia repairs. While traditionally polymer meshes have been used in hernia repair, alternative mesh options have been engineered to prevent the inflammatory foreign body response invoked by polymers. A reinforced tissue matrix (RTM) mesh has been developed by embedding a polymer within a decellularized extracellular matrix. This combination has been attributed to the recruitment of host cells, a pro-healing response, and attenuation of the foreign body response. This has been observed to lead to the regeneration of functional tissue within the repair site that is reinforced by the polymer to offload abdominal pressures over time. This manuscript presents the review of OviTex, an RTM, in several types of hernia repair. The authors have found that the use of RTM in hernia repair is effective in preventing foreign body response, promoting wound healing, and providing reinforcement to lower the risk of hernia recurrence.

Antibiotic-Resistant Profiles of Bacteria Isolated from Cesarean and Surgical Patients from Kasese District Hospitals Western Uganda

Surgical site infections (SSIs) are challenging to treat and often associated with much higher extended stays, morbidity, and mortality, higher treatment costs, especially when the causative agent is multidrug resistance (MDR). This study was designed to determine the prevalence of nosocomial infections and susceptibility profiles of bacteria isolated from Cesarean section (C-section) and surgical patients from Kasese District Hospitals in Western Uganda. A descriptive cross-sectional study was conducted from January to September 2016 involving 303 patients with SSIs in obstetrics & gynecology; and general surgery wards in three health facilities. Clinical-demographic characteristics of patients were obtained using structured questionnaires before surgery. Bacterial analysis of the air and floor of the theatre room was done using the standard culture method. Of the 303 patients enrolled with SSIs (median age 34 years), 71.6% were female, and 28.4% were males. Only 14.5% developed SSIs, with predominant isolates being Staphylococcus aureus 33.33% and Escherichia coli 24%. The majority of recruited participants underwent a C-section of 58% and the least amputations of 0.3%. Duration of operation or surgery, p-value 0.002 (95% CI 1.599-7.667) was significantly associated with SSIs. Gram-negative bacteria were found resistant (50-100%) to ampicillin, gentamycin, and ciprofloxacin, the commonly used post-operative drugs of choice. Hospital-acquired infections were common with emerging antibiotic-resistant strains isolated in most SSIs at Kasese hospitals. The development of resistance to commonly used antibiotics such as ampicillin, gentamycin, and ciprofloxacin than previously reported calls for laboratory-guided SSIs therapy and strengthening infection control policies.

WALANT Hand and Upper Extremity Procedures Performed With Minor Field Sterility Are Associated With Low Infection Rates

Background:

The use of minor field sterility in hand/upper extremity cases has been shown to improve workflow efficiency while maintaining patient safety. As this finding has been limited to specific procedures, we investigated the safety of performing a wide array of hand/upper extremity procedures outside the main operating room using minimal field sterility with Wide-Awake Local Anaesthesia No Tourniquet (WALANT) anaesthesia by evaluating superficial and deep infection rates across a diverse series of cases.

Methods:

This study was a case series conducted between October 2017 and June 2020. Of all, 217 patients underwent hand/upper extremity procedures performed in a minor procedure room via WALANT technique with field sterility. Primary outcome measures include superficial and deep surgical site infections within 14 days post-surgery.

Results:

Of all, 217 patients were included in this study; 265 consecutive hand/upper extremity operations were performed by a single surgeon, with notable case diversity. The majority of patients (n = 215, 99.1%) did not report or present with signs of infection before or after their operation. We report 0% 14-day and 0.37% 30-day surgical site infection rates for such hand/upper extremity procedures performed in a minor procedure room with field sterility.

Conclusion:

Hand/upper extremity procedures performed via WALANT technique with field sterility in a minor procedure room are associated with low surgical site infection rates. These rates are comparable to surgical site infection rates for similar surgeries performed in main operating rooms with standard sterilization procedures. Thus, the implementation of this technique may allow for improved workflow efficiency and reduced waste, all while maintaining patient safety.

Prophylactic sublay non-absorbable mesh positioning following midline laparotomy in a clean-contaminated field: randomized clinical trial (PROMETHEUS)

BACKGROUND

Incisional hernia is a frequent postoperative complication after midline laparotomy. Prophylactic mesh augmentation in abdominal wall closure after elective surgery is recommended, but its role in emergency surgery is less well defined.

METHODS

This prospective randomized trial evaluated the incidence of incisional hernia in patients undergoing urgent midline laparotomy for clean-contaminated surgery. Closure using a slowly absorbable running suture was compared with closure using an additional sublay mesh (Parietex ProGrip™). Patients were randomized just before abdominal wall closure using computer-generated permuted blocks. Patients, care providers, staff collecting data, and those assessing the endpoints were all blinded to the group allocation. Patients were followed up for 24 months by means of clinical and ultrasonographic evaluations.

RESULTS

From January 2015 to June 2018, 200 patients were randomized: 100 to primary closure (control group) and 100 to Parietex ProGrip™ mesh-supported closure (mesh group). Eight patients in the control group and six in the mesh group were lost to follow-up. By 24 months after surgery, 21 patients in the control group and six in the mesh group had developed incisional hernia (P = 0.002). There was no difference between groups in the incidence of haematoma (2 versus 5; P = 0.248) and superficial wound infection (4 versus 5; P = 0.733). Multivariable analysis confirmed the role of mesh in preventing incisional hernia (odds ratio 0.11, 95 per cent c.i. 0.03 to 0.37; P  < 0.001). One patient in the mesh group required mesh removal because of deep infection.

CONCLUSION

Prophylactic mesh-augmented abdominal wall closure after urgent laparotomy in clean-contaminated wounds is safe and effective in reducing the incidence of incisional hernia. Registration number: NCT04436887 (http://www.clinicaltrials.gov).

GRAPHICAL ABSTRACT

An RCT was conducted to compare the widely recommended midline laparotomy closure using a slowly absorbable running suture with closure using a sublay mesh (Parietex ProGrip™), in patients undergoing urgent midline laparotomy for clean-contaminated surgery. Patients were followed up for 24 months with clinical and ultrasonographic evaluation during outpatient visits. Prophylactic reinforcement of the midline abdominal wall, using a ProGrip™ Parietex mesh in the retromuscular position, at the time of urgent laparotomy in clean-contaminated wounds was safe and effective in reducing the incidence of incisional hernia, although larger studies with longer follow-up are required.

Nanomaterials in Wound Healing and Infection Control

Wounds continue to be a serious medical concern due to their increasing incidence from injuries, surgery, burns and chronic diseases such as diabetes. Delays in the healing process are influenced by infectious microbes, especially when they are in the biofilm form, which leads to a persistent infection. Biofilms are well known for their increased antibiotic resistance. Therefore, the development of novel wound dressing drug formulations and materials with combined antibacterial, antibiofilm and wound healing properties are required. Nanomaterials (NM) have unique properties due to their size and very large surface area that leads to a wide range of applications. Several NMs have antimicrobial activity combined with wound regeneration features thus give them promising applicability to a variety of wound types. The idea of NM-based antibiotics has been around for a decade at least and there are many recent reviews of the use of nanomaterials as antimicrobials. However, far less attention has been given to exploring if these NMs actually improve wound healing outcomes. In this review, we present an overview of different types of nanomaterials explored specifically for wound healing properties combined with infection control.

Outcomes of an aseptic technique for Kirschner wire percutaneous pinning in the hand and wrist

INTRODUCTION

Kirschner wires (K-wires) have been shown to effectively stabilize fractures of the hand and wrist, but are associated with high infection rates, which may limit its use. Previous literature has attributed the risk of infection to many different aspects of a fixation technique. However, we introduce an approach to percutaneous K-wire pinning to mitigate the risk of infection.

METHODS

Patients undergoing K-wire fixation procedures of the hand and wrist were retrospectively queried. All cases were performed under the same principles of our technique. None of the K-wires were buried, nor bent and were covered with betadine-soaked alcohol pads as pin site dressings. Pins were removed in an outpatient procedure room up to 12 weeks postoperatively and were then assessed for signs of superficial or deep infection.

RESULTS

90 patients were included in this study across a variety of K-wire fixation operations in the hand and wrist. No patients presented with any signs of infection or other complications necessitating postoperative antibiotics, early pin removal, or reoperation.

DISCUSSION/CONCLUSION

The specific guidelines of our technique resulted in no cases of pin site infection, despite a largely underserved patient population. Our low incidence of infection was maintained without the use of prophylactic antibiotics and in patients with long periods of fixation. While the high infection rates in previous literature have often been associated with wires left exposed, the principles of our technique allow for K-wire fixations to be performed percutaneously without burying the wires. This may allow for improved cost and time efficiency, without compromising patient safety.

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

OBJECTIVES

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Incidence and root causes of surgical site infections after gastrointestinal surgery at a public teaching hospital in Sudan

Background

Surgical site infections (SSIs) are common healthcare-associated infections and associated with prolonged hospital stays, additional financial burden, and significantly hamper the potential benefits of surgical interventions. Causes of SSIs are multi-factorials and patients undergoing gastrointestinal tract procedures carry a high risk of bacterial contamination. This study aimed to determine the prevalence, associated factors, and causing microorganisms of SSIs among patients undergoing gastrointestinal tract surgeries.

Methods

A hospital based, cross-sectional study conducted at Soba University Hospital in Khartoum, Sudan. We included all patients from all age groups attending the gastrointestinal tract surgical unit between 1st September and 31st December 2017. We collected data about the socio-demographic characteristics, risk factors of SSI, and isolated microorganisms from patients with SSIs. A Chi-square test was conducted to determine the relationship between the independent categorical variables and the occurrence of SSI. The significance level for all analyses was set at p < .05.

Results

A total of 80 participants were included in the study. The mean age was 51 +/- 16 years and most of the patients (67.5%) did not have any chronic illness prior to the surgical operation. Most of them (46.3%) of them underwent large bowel surgery. Twenty-two patients (27.5%) developed SSI post operatively and superficial SSI was the most common type of SSIs (81.8%). Occurrence of SSI was found to be associated with long operation time (p > .001), malignant nature of the disease (p > .001), intra-operative blood loss (p > .001), and intra-operative hypotension (p = .013). The most prevalent microorganism isolated from SSI patients was E coli (47.8%), followed by Enterococcus fecalis (13.0%) and combined Pseudomonas aeruginosa + E coli infection (13.0%).

Conclusions

The results showed a high prevalence of SSIs among patients attending the gastrointestinal tract surgical unit and the most prevalent microorganism isolated from them was E coli. Measures should be taken to reduce the magnitude of SSI by mitigating the identified associated factors.