Deep Infection Rate Research Articles

A Study on the Outcome of Antibiotic Eluting Intramedullary Interlocking Nails in the Primary Fixation of Gustilo and Anderson Grades II and IIIA Open Fractures of Tibia

Introduction:The incidence and outcome of infection in open tibial fractures is adequately recorded in literature. The aim of this study is to find out the deep infection rate, union rate, and functional outcome of open tibial fractures managed by prophylactic antibiotic eluting interlocking nail.Methodology:A total of 18 patients with 20 open tibial fractures who met the study criteria were included and followed up for a minimum of 1 year after surgical intervention. Reamed intramedullary interlocking nailing with antibiotic eluting nail was done followed by adequate skin cover.Results:The outcomes were assessed using lower extremity functional scale and radiological union scale in tibial fractures both of which showed maximum improvement in initial 3 months followed by a steady improvement till 1 year with a good degree of correlation between the two scales. The total incidence of deep infection in this study was 5% (n = 1). All cases achieved union and independent ambulation by 1 year.Conclusion:Our study shows good radiological and functional outcomes with prophylactic antibiotic-coated nailing of open tibial fractures of Grades II and IIIA. The rate of deep infection is 5% and union rate is 100% in our study. Further comparative studies are required for drawing more conclusions on application of the results in clinical practice.

Efficacy of Povidone Iodine Solution in the Prevention of Surgical Site Infections in Minimally Invasive Instrumented Spinal Fusion Surgery.

Study Design:A retrospective case-controlled study.Objectives:To evaluate overall infection rate and adverse event after harvesting bone graft soaking and surgical wound irrigation by povidone iodine solution (PVI) in the minimally invasive instrumented spinal fusion surgery. In order to reduce the rate of surgical site infection in spinal surgery, surgical wound irrigation by povidone iodine solution has been well-established. However, the efficacy of autologous bone graft soaking by PVI has not been evaluated before.Methods:This is a retrospective cohort study. 120 patients were enrolled in the PVI group and compared with 124 patients in the historical cohort. In the PVI group, the harvesting autologous bone graft was soaking and the surgical wound was also irrigated by diluted PVI solution. The outcome measures were overall infection rate, superficial wound infection and deep infection. In addition, the delayed union of the fusion mass was also evaluated through the radiograph evaluation.Results:Both groups shared similar patient demographics instead of body mass index. The use of PVI solution had decreased the overall infection rate (0% versus 4.03%, p = 0.026) and deep infection rate (0% versus 3.23%, p = 0.047). In addition, there was no delayed bone healing in the PVI group after autologous bone graft soaking.Conclusions:In this study, we conclude that harvested autologous bone graft after PVI soaking in spinal fusion surgery can decrease the incidence of deep infection.

Wound complications, infections and nonunions do not increase with open reduction of tibia shaft fractures treated with intramedullary devices

Introduction: Tibia shaft fractures on common injuries and commonly treated with intramedullary implants. The effect of open reduction on fracture healing and wound healing is not well described. Methods: A retrospective chart review of 32 cases of open or closed tibia shaft fractures treated by a single surgeon at a Level 3 trauma center with open reduction and use of an intramedullary implant. Re-operation rates for any reason, deep and superficial infection rate and fracture healing were recorded. Results: All 32 patients healed their fractures and 4 patients require removal of painful hardware. Two cases superficial infection occurred, and no cases of deep infection occurred. Conclusion: Open reduction of tibia shaft fractures can be done safely and effectively using appropriate technique in a diverse set of patients that present in a community type setting.

Is primary total elbow arthroplasty appropriately compensated compared to other major total joint arthroplasty?

BackgroundPrimary total elbow arthroplasty (TEA) is an uncommon operation and performed less frequently than total shoulder (TSA), knee (TKA), and hip (THA) arthroplasty. Despite lower implant survival rates and higher complications rates compared to TSA, TKA, and THA, the Centers for Medicare and Medicaid (CMS) have assigned similar work relative value unit (wRVU) allotments and estimated operative times across all 4 forms of major joint arthroplasty. In this study, we determine temporal trends in CMS wRVU allotments, and operative time estimates for these 4 surgeries and compare actual operative times and postoperative complication rates. MethodsCMS wRVU allotments and estimated operative times were collected from all publicly available CMS publications for primary TEA, TSA, TKA, and TSA. We used the National Quality Improvement Program database from 2010 to 2017 to determine actual operative times for these surgeries. Multiple linear regression analysis was used to compare wRVU/h amongst the 4 surgeries, controlling for patient demographics, comorbidity, and hospital setting. Thirty-day complication rates were also compared. ResultsFrom 2012 to 2017, Medicare observed a 13% decline in total TEA procedures performed in comparison to a 70% increase for TSA and 29% increase in THA. The number of unique providers performing TEA declined (−6%) in comparison to a growth in surgeons performing TSA, TKA, and THA. TEA was associated with the longest operative time (152 ± 57 minutes, P < .0001) and lowest wRVU/h (10.2, P < .0001). TKA and THA had the shortest operative time (90 ± 29 and 90 ± 32, respectively) with the greatest wRVU/h (15.78 and 15.71). TEA remained the lowest wRVU/h procedure even after controlling for patient age, sex, body mass index, hospital setting, and comorbidity (P < .0001). Thirty-day complication rates for all surgeries were low, but TEA had higher rates of wound dehiscence, deep infection, pneumonia, reintubation, pulmonary embolism, and myocardial infarction (all P < .01). ConclusionDespite similar wRVU assignments and operative time estimates for primary TEA, TSA, TKA, and THA; TEA is on average a longer surgery and carries a greater 30-day postoperative risk profile. Although CMS has assessed primary TEA to have similar work and time requirements compared to its counterparts, this procedure may be under-valued in comparison to other forms of major joint arthroplasty. Level of EvidenceLevel III; Economics.

The Orthopaedic Trauma Society classification of open fractures.

To describe a new objective classification for open fractures of the lower limb and to correlate the classification with patient-centred outcomes. The proposed classification was investigated within a cohort of adults with open fractures of the lower limb who were recruited as part of two large clinical trials within the UK Major Trauma Network. The classification was correlated with patient-reported Disability Rating Index (DRI) and EuroQol five-dimension questionnaire (EQ-5D) health-related quality of life in the year after injury, and with deep infection at 30 days, according to the Centers for Disease Control and Prevention definition of a deep surgical site infection. A total of 748 participants were included in the analysis. Of these, 288 (38.5%) had a simple open fracture and 460 (61.5%) had a complex fracture as defined by the new classification system. At 12 months, the mean DRI in the simple fracture group was 32.5 (SD 26.8) versus 43.9 (SD 26.1) in the complex fracture group (odds ratio (OR) 8.19; 95% confidence interval (CI) 3.69 to 12.69). At 12 months the mean health-related quality of life (EQ-5D utility) in the simple fracture group was 0.59 (SD 0.29) versus 0.56 (SD 0.32) in the complex fracture group (OR -0.03; 95% CI -0.09 to 0.02). The differences in the rate of deep infection at 30 days was not statistically significant. The Orthopaedic Trauma Society open fracture classification is based upon objective descriptors of the injury and correlates with patient-centred outcomes in a large cohort of open fractures of the lower limb. Cite this article: Bone Joint J 2020;102-B(11):1469-1474.

Clinical characteristics and molecular analysis of USA300 and ST 764 methicillin-resistant Staphylococcus aureus isolates from outpatients in Japan by PCR-Based open reading frame typing

IntroductionUSA300 is the most common community-acquired methicillin-resistant Staphylococcus aureus (MRSA) strain. Sequence type (ST) 764 MRSA is a new local variant of the ST 5 lineage. The objective of this study was to determine the clinical characteristics of USA300 and ST 764 infections among outpatients in Japan. MethodsWe obtained MRSA isolates from 132 outpatients who visited our hospital from January 2016 to December 2017 and compared USA300 infection group to ST 764 infection group. Molecular analysis, including that of various toxins and other virulence factors, of the MRSA isolates were performed. In particular, we investigated the relationships among PCR-based open reading frame typing (POT) scores, MRSA clones, and virulence factors. ResultsTwenty-seven USA300 isolates (20.5%) and 16 ST 764 isolates (12.1%) were identified. Although USA300 and ST 764 had lower rates of risk factors, their infection rates were higher. USA300-infected patients had higher rates of deep skin and soft tissue infections compared with the non-USA300 CA-MRSA-infected patients. Notably, the USA300 and ST 764 isolates had unique POT scores. ConclusionsOur results indicated that USA300 MRSA was spreading in an area 120 km west of Tokyo, Japan. We observed multiple cases of ST 764 MRSA infection, raising concerns about the antimicrobial resistance of ST 764, as it limits the choices of antibiotics to treat infection. The POT score can predict the presence of toxins and virulence factors, as well as the clone identity of MRSA with high accuracy.

Judicious Use of Early Fixation of Closed, Complete Articular Pilon Fractures Is Not Associated With an Increased Risk of Deep Infection or Wound Complications.

To compare the deep infection rates after immediate versus staged open reduction internal fixation (ORIF) for pilon fractures. Retrospective cohort study. Three academic Level I trauma centers. Four hundred one patients with closed OTA/AO type 43C distal tibia fractures treated with ORIF. Sixty-six percent were men, and the mean age was 45.6 years. The median (interquartile range) follow-up was 1.7 (1.0-3.7) years. Acute, primary (<24 hours) versus delayed, staged ORIF (>24 hours). Deep infection or wound complication as defined by return to operating room for surgical irrigation and debridement. Patients were grouped by time from presentation to surgery: acute ORIF (n = 99) and delayed ORIF (n = 302). Acute ORIF was more frequent in patients with OTA/AO type 43C1 fractures, low-energy mechanisms (ie, fall from standing), younger and female patients. Patients who demonstrated severe swelling (242, 80%), swelling and fracture blisters (26, 9%), swelling and ecchymosis precluding planned surgical approach (4, 1%), polytrauma requiring resuscitation (20, 6%), who were transferred from an outside facility with external fixator in place (6, 2%), who had evolving compartment syndrome (2, 1%), and who required medical clearance (2, 1%) underwent staged, delayed fixation. There were significantly more 43C1 fractures in the acute fixation group (31% vs. 7%, P < 0.001) and significantly more 43C3 fractures in the delayed group (63% vs. 37%, P < 0.001). The overall deep infection rate was 17%. Early surgery was not associated with an increased risk of postoperative wound complication (early 12% vs. delayed 18%, P = 0.235). Multivariate analysis adjusted for timing of surgery found high-energy trauma [odds ratio (OR) 4.0, 95% confidence interval (CI) 1.1-13.8], smoking (OR 2.4, CI 1.3-4.6), male sex (OR 2.1, CI 1.0-4.1), and increasing age (OR 1.02, CI 1.00-1.04, P = 0.040) to be independent predictors of deep infection. Diabetes demonstrated a nonstatistically significant increased risk (OR 2.6, 95% CI 0.9-7.3, P = 0.063). This study confirms the high risk of infection after the fixation of tibial plafond fractures. If early definitive fixation is considered, extreme care should be taken to carefully evaluate the soft tissue envelope and assess for other risk factors (such as age, male sex, smokers, diabetics, and those with higher-energy fracture patterns) that may predispose the patient to a postoperative soft tissue infection. Our study has shown that the judicious use of early definitive fixation in closed pilon fractures, in the appropriate patient, and with careful evaluation of the soft tissue envelope, is likely safe and does not seem to increase the risk of wound complications and deep infection in the hands of experienced fracture surgeons. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Local antibiotics in primary hip and knee arthroplasty: a systematic review and meta-analysis.

Infection is a truly devastating complication of total joint arthroplasty, causing most patients to undergo a revision surgery, and to bear significant psychological and financial burden. The purpose of this study is to systematically evaluate the literature to determine the efficacy and complication profile of local antibiotic application in primary total joint arthroplasty. All studies of primary total joint arthroplasty which assessed local antibiotics in any form other than antibiotic-impregnated cement as an intervention were included. Studies that reported at least one outcome related to infection and were available in full text in English were eligible for inclusion. Studies which included both primary and revision cases but did not report the stratified data for each type of surgery and studies on fracture populations were excluded. A total of 9 studies involving 3,714 cases were included. The pooled deep infection rate was 1.6% in the intervention groups and 3.5% in the control groups. Meta-analysis revealed a RR of 0.53 (95%CI: 0.35-0.79, p = 0.002) with no heterogeneity (I2 = 0%) for infection in the intervention groups. Meta-analysis revealed a non-significant reduction in superficial infection rates in the intervention groups; however, there was a significant increase in aseptic wound complications in the intervention groups. Local antibiotic application results in a moderate reduction in deep infection rates in primary total joint arthroplasty, with no significant impact on superficial infection rates. However, local antibiotic application may be associated with a moderate increase in aseptic wound complications.

Civilian Ballistic Tibia Shaft Fractures Compared With Blunt Tibia Shaft Fractures: Open or Closed?

To identify a group of ballistic tibia fractures, report the outcomes of these fractures, and compare them with both closed and open tibia fractures sustained by blunt mechanisms. We hypothesized that ballistic tibia fractures and blunt open fractures would have similar outcomes. Retrospective cohort study. A single Level-1 trauma center. Adult patients presenting with ballistic (44), blunt closed (179), or blunt open (179) tibia fractures. Intramedullary stabilization of tibia fracture. Unplanned reoperation, soft tissue reconstruction, nonunion, compartment syndrome, and fracture-related infection. Compared with the blunt closed group, the ballistic fracture group required more operations (P < 0.01), had a higher occurrence of soft tissue reconstruction (P < 0.01), and higher incidence of compartment syndrome (P = 0.02). Ballistic and blunt closed groups did not significantly differ in rates of unplanned reoperation (P = 0.67), nonunion (11.4% vs. 4.5%, P = 0.08), or deep infection (9.1% vs. 5.6%, P = 0.49). In comparison to the blunt open group, the ballistic group required a similar number of operations (P = 0.12), had similar rates of unplanned reoperation (P = 0.10), soft tissue reconstruction (P = 0.56), nonunion (11.4% vs. 17.9%, P = 0.49), and fracture-related infection (9.1% vs. 10.1%, P = 1.0) but a higher incidence of compartment syndrome (15.9% vs. 5.0%, P = 0.02). Ballistic tibia fractures require more surgeries and have higher rates of soft tissue reconstruction than blunt closed fractures and seem to have outcomes similar to lower severity open fractures. We found a significantly higher rate of compartment syndrome in ballistic tibia fractures than both open and closed blunt fractures. When treating ballistic tibia fractures, surgeons should maintain a high level of suspicion for the development of compartment syndrome and counsel patients that ballistic tibia fractures seem to behave like an intermediate category between closed and open fractures sustained through blunt mechanisms. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Is it Safe to Offer Total Ankle Replacement (TAR) Surgery in Patients with Type II Diabetes?

Category:Ankle; Ankle Arthritis; Diabetes; Midfoot/ForefootIntroduction/Purpose:The indications for Total Ankle Replacement (TAR) in patients with Type II Diabetes mellitus is poorly defined and there is paucity of literature reporting clinical, radiological and patient reported outcomes for TAR in this patient group. We aimed to explore the ideal pre-operative criteria for TAR in patients with Type II DM based on results from our center.Methods:We studied the x-rays, clinical findings and patient reported outcomes of surgery at pre-op and 5 years for patients who underwent a total ankle replacement at our center between 2006 and 2014 who had Type II DM. This was a retrospective study. The above findings were also compared between patients who had Type II DM vs. who were not diabetic. Pre-operative screening for diabetic patients included Hb1Ac levels, clinical reporting of swelling, warmth, erythema findings, neurovascular status including proprioception, vibration and neuro filament tests. Statistical analysis of WOMAC and SF-36 scores and differences between diabetic and non-diabetic patients were calculated using General Linear Model - repeated measures ANOVA. Patient satisfaction was analyzed using chi-square test. Rates of superficial and deep infection as well as revision were recorded.Results:Of 230 patients, 9 (3.9%) were diabetic. Pre-op radiographic analysis showed features confining to OA; x-ray, CT scan showed no signs of bone debris, fragmentation per articular fractures. Talus was not translated, no evidence of OA in Subtalar or Talonavicular joint. At 5 years, there was no implant subsidence, loosening, migration or peri-prosthetic cysts; hind and midfoot joints had no features of diabetic arthropathy/collapse. Comparing outcomes to Non-diabetic TAR patients, WOMAC & SF-36 scores showed significant (p<0.05) improvement and no significant difference between groups from pre-op to 5 years. In the diabetic group there was 1 superficial infection (11%) 1 deep infection that required revision (11%) compared to 30 superficial infections (13.6%), 1 deep infection (0.5%) and 12 revisions (5.4%) in the non-diabetic group.Conclusion:Painful end stage OA in Type II DM can be treated by TAR, taking into consideration the inclusion and exclusion criteria that we have used in our series.

Treatment options for infected bone defects in the lower extremities: free vascularized fibular graft or Ilizarov bone transport?

ObjectiveThe objective was to explore the relative indications of free vascularized fibular graft (FVFG) and Ilizarov bone transport (IBT) in the treatment of infected bone defects of lower extremities via comparative analysis on the clinical characteristics and efficacies.MethodsThe clinical data of 66 cases with post-traumatic infected bone defects of the lower extremities who underwent FVFG (n = 23) or IBT (n = 43) from July 2014 to June 2018 were retrieved and retrospectively analyzed. Clinical characteristics, operation time, and intraoperative blood loss were statistically compared between two groups. Specifically, the clinical efficacies of two methods were statistically evaluated according to the external fixation time/index, recurrence rate of deep infection, incidence of complications, the times of reoperation, and final functional score of the affected extremities.ResultsGender, age, cause of injury, Gustilo grade of initial injury, proportion of complicated injuries in other parts of the affected extremities, and numbers of femoral/tibial defect cases did not differ significantly between treatment groups, while infection site distribution after debridement (shaft/metaphysis) differed moderately, with metaphysis infection little more frequent in the FVFG group (P = 0.068). Femoral/tibial defect length was longer in the FVFG group (9.96 ± 2.27 vs. 8.74 ± 2.52 cm, P = 0.014). More patients in the FVFG group presented with moderate or complex wounds with soft-tissue defects. FVFG treatment required a longer surgical time (6.60 ± 1.34 vs. 3.12 ± 0.99 h) and resulted in greater intraoperative blood loss (873.91 ± 183.94 vs. 386.08 ± 131.98 ml; both P < 0.05) than the IBT group, while average follow-up time, recurrence rate of postoperative osteomyelitis, degree of bony union, and final functional scores did not differ between treatment groups. However, FVFG required a shorter external fixation time (7.04 ± 1.72 vs. 13.16 ± 2.92 months), yielded a lower external fixation index (0.73 ± 0.28 vs. 1.55 ± 0.28), and resulted in a lower incidence of postoperative complications (0.87 ± 0.76 vs. 2.21±1.78, times/case, P < 0.05). The times of reoperation in the two groups did not differ (0.78 ± 0.60 vs. 0.98 ± 0.99 times/case, P = 0.615).ConclusionBoth FVFG and IBT are effective methods for repairing and reconstructing infected bone defects of the lower extremities, with unique advantages and limitations. Generally, FVFG is recommended for patients with soft tissue defects, bone defects adjacent to joints, large bone defects (particularly monocortical defects), and those who can tolerate microsurgery.

Skin closure with surgical staples in ankle fractures: a safe and reliable method.

The purpose of this study is to examine the rates of surgical site complications of staple closure versus suture closure following open reduction and internal fixation of closed unstable ankle fractures. Between 2014 and 2016, a total of 545 patients with closed ankle fractures were treated at our level-1 trauma centre by means of open reduction and internal fixation. A total of 360 patients matched the inclusion criteria and were included in the final analysis of this study. This included 119 patients undergoing wound closure using sutures and 241 patients using surgical staples. The demographics, clinical data, and injury characteristics were recorded. The primary outcome measure was the adverse event of any type of surgical site complication. The overall rate of patients with a surgical site complication was 15.6%. There was a trend towards a higher risk of surgical site complication in patients undergoing wound closure with sutures as compared with staples (20.2% versus 13.3%); however, this difference was not statistically significant (P = 0.0897). The rate of superficial surgical site infection also trended higher in patients undergoing wound closure with sutures versus staples without demonstrating statistical significance (10.1% versus 5%, P = 0.0678). The rate of deep surgical site infection was similar in both groups. The use of metal staples remains controversial in the setting of orthopedic surgery, particularly involving the foot and ankle. The current study supports that metal staples are a safe and reliable option in the closure of traumatic ankle fractures.

Clinical and radiographical outcome after surgical treatment of periprosthetic type B proximal femur fractures: a retrospective study.

Periprosthetic fractures after hip prosthesis represent a constantly increasing clinical problem and a challenging complication to treat surgically. Among these, type B proximal femur fractures should be diagnosed correctly to be treated surgically. The aim of this study was to re-evaluate the type of surgical treatment of periprosthetic fractures. We examined the cases treated between January 2012 and February 2018, classifying them according to the U.C.S. AO/OTA. We evaluated the radiographic outcome according to the Beals and Tower criteria. Patients still alive were also re-evaluated according to the H.H.S. and the WOMAC score. We treated 48 patients (12 men, 35 women, average age 81years), divided into 24 type B1, 14 type B2 and 10 type B3 fractures. The overall consolidation rate was 95.4%, while the major complication (implant dislocation, pseudoarthrosis and deep infection) rate was 12.5%. Clinically, it was possible to reassess 34 patients with a mean follow-up of 38.4months, an average HHS of 75.89 and a mean WOMAC score of 79.93. Periprosthetic type B fractures are difficult to manage and require careful preoperative planning and appropriate intraoperative management. However, the overall clinical and radiographic result was satisfactory, although patients should still be aware of the risk of complications associated with this type of fracture.

Comparison Between Nailing and Plating in the Treatment of Distal Tibial Fractures: A Meta-Analysis.

Background and Aims:To evaluate evidence on the superiority of plate fixation over intramedullary nail fixation in the treatment of distal tibial fractures regarding functional outcomes and complication rates.Material and Methods:Cochrane Controlled Trials Register, Medline, Embase, CINAHL, Scopus, and Web of Science databases were searched in December 2019. The risk of systematic bias was assessed according to the Cochrane Collaboration’s domain-based evaluation framework.Results:The search resulted in 514 records, the final sample included 10 randomized controlled trials (782 patients). There were statistically significant differences in operating time (−11.2, 95% confidence interval: −16.3 to −6.1 min), time to partial weight bearing (−0.96, 95% confidence interval: −1.8 to −0.1 weeks), time to full weight bearing (−2.2, 95% confidence interval: −4.32 to −0.01 weeks), the rates of deep infections (risk ratio = 0.37, 95% confidence interval: 0.19 to 0.69), and the rates of soft-tissue complications (risk ratio = 0.52, 95% confidence interval: 0.33 to 0.82) favoring intramedullary nail. Intraoperative blood loss (127.2, 95% confidence interval: 34.7 to 219.7 mL) and postoperative knee pain and stiffness (relative risk = 5.6, 95% confidence interval: 1.4–22.6) showed significant differences favoring plate fixation. When combining all complication rates, the difference was risk ratio = 0.77 (95% confidence interval: 0.63 to 0.95) favoring intramedullary nail. No significant differences in radiation time, length of incision, length of hospital stay, time to return to work, time to union, the rates of healing complications or secondary procedures, ankle pain or stiffness, or functional scores were found.Conclusion:This meta-analysis suggests that intramedullary nail might be slightly superior in reducing postoperative complications and result in slightly faster healing when compared to plate fixation.

An Updated Evidence About the Role of Timing to Debridement on Infection Rate of Open Tibial Fractures: A Meta-Analysis.

Background and objectivesRecent experimental and clinical evidence supporting early debridement for open fractures has been questioned. Therefore, this systematic review and meta-analysis aimed to summarize and evaluate the current evidence regarding the timing of surgical debridement of open tibial fractures.MethodsA systematic review and meta-analysis were conducted on studies compared the infection rate following early versus late debridement of open tibial fractures. We performed an online, bibliographic, search through the period from January 2000 to June 2020 in five bibliographic databases: Cochrane Central Register of Controlled Trials (CENTRAL), Medline via PubMed, Web of Science, Scopus, and EBSCO host.ResultsNine retrospective studies and six prospective studies were included in the present meta-analysis study. The pooled effect estimate showed no statistically significant difference between early and late debridement regarding the overall infection rate (RD 0.02, 95% CI [0 - 0.04], p = 0.94); there was no significant heterogeneity in the pooled estimate (I2 = 5%). The subgroup analysis showed that the non-significant difference was consistent regardless of the definition of early and late timing to debridement. Likewise, the pooled effect estimate showed no statistically significant difference between early and late debridement regarding the deep infection rate (RD 0.01, 95% CI [-0.01 - 0.03], p = 0.92); there was no significant heterogeneity in the pooled estimate (I2 = 0%). The pooled effect estimate showed no statistically significant difference between early and late debridement regarding the nonunion rate as well. The funnel lots showed little evidence of asymmetry by visual inspection.ConclusionIn conclusion, the current evidence demonstrates no impact of timing to surgical debridement on the infection rate following open tibial fractures in the adult population. Our results demonstrated that the risks of infection, deep infection, and nonunion were similar between patients who underwent delayed versus early debridement.

127. Preoperative optimization of modifiable frailty factors reduces risk of hospital acquired conditions in elective surgical spine patients

BACKGROUND CONTEXT Hospital acquired conditions (HACs) were established in the Affordable Care Act, and are defined as reasonably preventable complications that are nonreimbursable. In high risk patient populations for HACs, such as frail surgical spine patients, preoperative evaluation should consider modifiable factors. PURPOSE To identify if optimizing the modifiable factors in the frailty index reduce the risk of developing HACs in population of surgical spine patients. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE This study included 196,523 elective spine surgery patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). OUTCOME MEASURES Modifiable patient frailty factors: hypertension and diabetes mellitus; rates of HACs, superficial or deep surgical site infection (SSI), deep venous thromboembolism (VTE) and urinary tract infection (UTI), across frailty scores. METHODS Patients >18 years who underwent elective spine surgery were identified in ACS-NSQIP database from 2005-2016. HACs identified: SSI, VTE, and UTI. Patient frailty was assessed utilizing the modified NSQIP 5-factor frailty index. The modified frailty score (mFI-5) is assessed on a scale between 0 and 1 (no frailty [NF] 0.5). Descriptive analysis quantified rates of patient characteristics, operative details, and HAC prevalence. Stepwise linear regression models determined significant predictors of baseline frailty using controllable patient factors. HACs were compared between ‘optimized’ and ‘non-optimized’ frailty status in the cohort. Level of significance was set to P RESULTS A total of 196,523 patients (57±14.2 years, 30.4 kg/m2, 48%F) met inclusion criteria. Overall, 5,720 (2.9%) of patients developed an HAC, the most common was an SSI (1.3%), followed by UTI (1.1%). When stratified by the mFI-5 frailty severity groups at baseline, 83.6% of patients were categorized NF, 15.1% MF and 1.3% SF. Within the frailty severity groups, prevalence of overall HACs increased significantly (NF: 2.64%, MF: 4.17%, 5.93%, p CONCLUSIONS Stepwise linear regression models determined that hypertension and diabetes account for 89.7% of variance in baseline mFI-5 score. Patients with these optimal controllable factors had reduced incidence of all hospital acquired conditions. In order to optimize hospital resources and treatment outcomes, physicians and patients should be aware of the modifiable factors that contribute to a patient's frailty that can ultimately impact acquiring HACs. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Trapeziometacarpal prosthesis: an updated systematic review

The trapeziometacarpal prosthesis is mostly used in Europe to treat osteoarthritis of the basal joint of the thumb. Its supposed benefits are that it restores the length of the thumb, improves strength, function and mobility while reducing recovery time compared to other surgical treatments. However, previous reviews of the literature could not confirm these assumptions. This article provides an updated systematic review to help answer to these questions through a methodical statistical analysis and to quantify the two main complications, namely failure and deep infection. To achieve these aims, a selection of articles including implant case series was done in the Medline database based on specific criteria. Data about pain, function, strength, infection, and failure were compiled and a statistical analysis was performed. Results show a fast recovery in terms of pain and function but the positive effect on strength seems limited. The failure rate represented by the revision rate is high and the deep infection rate is fairly low. Randomized controlled studies are needed to obtain reliable data to compare the prosthesis to other surgical treatments.

Negative-pressure wound therapy compared with standard dressings following surgical treatment of major trauma to the lower limb: the WHiST RCT.

Major trauma is the leading cause of death in people aged < 45 years. Patients with major trauma usually have lower-limb fractures. Surgery to fix the fractures is complicated and the risk of infection may be as high as 27%. The type of dressing applied after surgery could potentially reduce the risk of infection. To assess the deep surgical site infection rate, disability, quality of life, patient assessment of the surgical scar and resource use in patients with surgical incisions associated with fractures following major trauma to the lower limbs treated with incisional negative-pressure wound therapy versus standard dressings. A pragmatic, multicentre, randomised controlled trial. Twenty-four specialist trauma hospitals representing the UK Major Trauma Network. A total of 1548 adult patients were randomised from September 2016 to April 2018. Exclusion criteria included presentation > 72 hours after injury and inability to complete questionnaires. Incisional negative-pressure wound therapy (n = 785), in which a non-adherent absorbent dressing covered with a semipermeable membrane is connected to a pump to create a partial vacuum over the wound, versus standard dressings not involving negative pressure (n = 763). Trial participants and the treating surgeon could not be blinded to treatment allocation. Deep surgical site infection at 30 days was the primary outcome measure. Secondary outcomes were deep infection at 90 days, the results of the Disability Rating Index, health-related quality of life, the results of the Patient and Observer Scar Assessment Scale and resource use collected at 3 and 6 months post surgery. A total of 98% of participants provided primary outcome data. There was no evidence of a difference in the rate of deep surgical site infection at 30 days. The infection rate was 6.7% (50/749) in the standard dressing group and 5.8% (45/770) in the incisional negative-pressure wound therapy group (intention-to-treat odds ratio 0.87; 95% confidence interval 0.57 to 1.33; p = 0.52). There was no difference in the deep surgical site infection rate at 90 days: 13.2% in the standard dressing group and 11.4% in the incisional negative-pressure wound therapy group (odds ratio 0.84, 95% confidence interval 0.59 to 1.19; p = 0.32). There was no difference between the two groups in disability, quality of life or scar appearance at 3 or 6 months. Incisional negative-pressure wound therapy did not reduce the cost of treatment and was associated with a low probability of cost-effectiveness. Owing to the emergency nature of the surgery, we anticipated that some patients who were randomised would subsequently be unable or unwilling to participate. However, the majority of the patients (85%) agreed to participate. Therefore, participants were representative of the population with lower-limb fractures associated with major trauma. The findings of this study do not support the use of negative-pressure wound therapy in patients having surgery for major trauma to the lower limbs. Our work suggests that the use of incisional negative-pressure wound therapy dressings in other at-risk surgical wounds requires further investigation. Future research may also investigate different approaches to reduce postoperative infections, for example the use of topical antibiotic preparations in surgical wounds and the role of orthopaedic implants with antimicrobial coatings when fixing the associated fracture. Current Controlled Trials ISRCTN12702354 and UK Clinical Research Network Portfolio ID20416. This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 38. See the NIHR Journals Library for further project information.

Implementation of vaginal preparation prior to caesarean section

IntroductionSurgical site infections following caesarean section are associated with significant morbidity. Vaginal preparation is the cleansing of the vaginal epithelium with an antibacterial solution to reduce the bacterial load and...

Retrospective analysis of risk factors for deep infection in lower limb Gustilo\u2013Anderson type III fractures

BackgroundOpen fractures are among the most severe injuries observed in orthopedic patients. Treating open fractures is difficult because such patients with infections may require multiple operations and amputations. Furthermore, only a few studies have focused on antibiotic prophylaxis in open fractures and evaluated how to cover lost soft tissue to increase the success rate of reconstruction. We evaluated the risk factors for deep infection in lower limb Gustilo–Anderson (G–A) type III fractures.Materials and methodsThis retrospective study investigated patients who underwent surgical procedures for lower limb G–A type III fractures between January 2007 and January 2017 at our institution. We enrolled 110 patients with 114 lower limb G–A type III fractures (77 G–A type IIIA fractures and 37 G–A type IIIB fractures) who were followed up for at least 2 years. We compared patients presenting infections with those without infections by assessing the following factors: severe contamination, diabetes, smoking, Injury Severity Scale, segmental fracture, location of fracture, G–A classification, damage control surgery, methods of surgery, timing of fixation, combination of antibiotics used, duration of antibiotic prophylaxis, timing of wound closure, and soft-tissue reconstruction failure.ResultsEighteen fractures presented deep infections. Compared with patients without infections, patients developing infections differed significantly in terms of severe contamination (P < 0.01), G–A classification (P < 0.01), duration of antibiotic prophylaxis (P < 0.01), timing of wound closure (P < 0.01), and incidence of soft-tissue reconstruction failure (P < 0.01). Skin grafting was associated with significantly higher failure rates than muscle and free flap reconstructions (P = 0.04). Treatment with antibiotics was significantly longer in patients with drug-resistant bacterial infections than in those without infections (P < 0.01).ConclusionEarly flaps rather than skin grafting should be used to cover G–A type IIIB fractures, because skin grafting resulted in the highest failure rate among soft-tissue reconstructions in open fractures. Longer duration of antibiotic use had a significant impact not only on deep infection rates but also on the presence of drug-resistant bacteria. These findings suggest that prolonged use of antibiotics should be avoided in cases of open fractures.Level of evidenceLevel IV retrospective observational study.