Deep Site Research Articles

Comparison of baseline characteristics and postoperative complications in neuromuscular, syndromic and congenital scoliosis.

Nonidiopathic scoliosis encompasses a group of diagnoses, including neuromuscular scoliosis, syndromic scoliosis and congenital scoliosis. The objective of this study was to compare the preoperative and postoperative clinical differences in pediatric nonidiopathic scoliosis patients with neuromuscular scoliosis vs. syndromic scoliosis/congenital scoliosis. This is a single-center retrospective review of all pediatric patients undergoing spinal instrumentation for nonidiopathic scoliosis during a 5-year period. Neuromuscular scoliosis patients ( n = 144), syndromic scoliosis patients ( n = 44) and congenital scoliosis patients ( n = 52) were compared. Demographics, patient characteristics and outcomes were compared. Neuromuscular scoliosis patients had lower BMI z-scores and were more likely to have pulmonary disease, technology dependence and seizure disorder. Additionally, neuromuscular scoliosis patients underwent bigger procedures with more levels fused and a higher rate of pelvis fixation. By direct comparison, neuromuscular scoliosis patients tended to have more complications including deep surgical site infections, readmission in 30 days, return to operating room in 90 days and emergency care visits in 90 days. When controlling for the differences in their preexisting conditions and surgical procedure, we found that pelvic fixation was a major confounding factor, whereas the others had no effect. We further subanalyzed cerebral palsy patients and found this group to exhibit no difference in complications compared to other neuromuscular scoliosis subtypes. Neuromuscular scoliosis patients have different characteristics and subsequent postoperative complications than those with syndromic scoliosis and congenital scoliosis. The difference in complication profile is mainly due to differences in surgical procedure and a higher rate of pelvic fixation. This should be considered when planning nonidiopathic scoliosis surgery among multidisciplinary teams.

Engineering the Active Site Pocket to Enhance the Catalytic Efficiency of a Novel Feruloyl Esterase Derived From Human Intestinal Bacteria Dorea formicigenerans

The human gut microbiota play essential roles in metabolism and human health, especially by enzymatically utilizing dietary fiber that the host cannot directly digest and releasing functional components including short-chain fatty acids (SCFAs) and hydroxycinnamic acids (e.g., ferulic acid). In our previous study, seven potential feruloyl esterase (FAE) genes were identified from the gut microbiota. In the current work, one of the genes encoding a novel FAE (DfFAE) from Dorea formicigenerans of Firmicutes was bacterially expressed, purified and characterized. The 30.5 kDa type-A DfFAE has an optimum pH and temperature of 8.4 and 40 °C, respectively, exhibiting a higher substrate specificity toward short-chain acyl-ester substrate (pNPA). The AlphaFold2 based ab initio structural modeling revealed a five α-helices cap domain that shaped an unusually narrow and deep active site pocket containing a specific substrate access tunnel in DfFAE. Furthermore, rational design strategy was subjected to the active site pocket in an aim of improving its enzymatic activities. The mutants V252A, N156A, W255A, P149A, and P186A showed 1.8 to 5.7-fold increase in catalytic efficiency toward pNPA, while W255A also exhibited altered substrate preference toward long-chain substrate pNPO (45.5-fold). This study highlighted an unusual active site architecture in DfFAE that influenced its substrate selectivity and illustrated the applicability of rational design for enhanced enzymatic properties.

Staged radiosurgery of large brain metastasis with mass effect and brain dislocation: case report

Introduction. Currently, one of the effective methods of treatment of intracranial metastases is stereotactic radiosurgery. The main factors limiting its use are the size (volume) of the tumor or the location of the metastasis in critical proximity to radiosensitive brain structures, such as the optic pathways, thalamus, brain stem, due to the high risk of developing local radiation necrosis. To reduce the risk of adverse radiation effects, hypofractionated radiotherapy by linac or staged Gamma Knife radiosurgery is used. However, large brain metastases that cause dislocation of the brain midline structures are traditionally considered an object for surgical excision, the main purpose of which is to eliminate the mass effect caused by the tumor.The objective of the publication: to demonstrate a case of successful application of staged Gamma Knife radiosurgery of large brain metastases accompanied by brain compression and dislocation.Materials and methods. Patient, 38‑year-old, with right-sided hemiplegia (0 score) and large (Ø = 3 cm, V = 12.9 cm3) breast cancer metastasis in the deep site of the left hemisphere, accompanied by severe perifocal edema and braindislocation (midline shift up to 15 mm). The treatment was carried out by Gamma Knife in two stages with an interval of 1.5 months.Results. As a result, not only a complete regression both of the perifocal edema and midline shift were noted, but also a significant decrease of the tumor volume and dramatical improvement in the patient’s neurological status already in the interval between the stages of radiosurgery: restoration of active movements in the right limbs (up to 4 score).Conclusion. This case demonstrates the possibility of effective and safe non-invasive treatment of large brain metastases accompanied by brain compression and dislocation, which makes it possible to achieve regression of the mass effect and improve the neurological quality of life of cancer patients.

Does Nasal Screening for Methicillin-Resistant Staphylococcus aureus (MRSA) Prevent Deep Surgical Site Infections for Elective Cervical Spinal Fusion?

Retrospective cohort study. The objective of this study was to determine the relationship between nasal methicillin-resistant Staphylococcus aureus (MRSA) testing and surgical site infection (SSI) rates in the setting of primary posterior cervical instrumented spine surgery. Preoperative MRSA screening and decolonization has demonstrated success for some orthopedic subspecialties in prevention of SSIs. Spine surgery, however, has seen varied results, potentially secondary to the anatomic and surgical heterogeneity of the patients included in prior studies. Given that prior research has demonstrated greater propensity for gram positive SSIs in the cervical spine, we sought to investigate if MRSA screening would be more impactful in the cervical spine. Adult patients undergoing primary instrumented posterior cervical procedures from January 2015 to December 2019 were reviewed for MRSA testing <90 days before surgery, preoperative mupirocin, perioperative antibiotics, and SSI defined as operative incision and drainage (I&D) <90 days after surgery. Logistic regression modeling used SSI as the primary outcome, MRSA screening as primary predictor, and clinical and demographic factors as covariates. This study included 668 patients, of whom MRSA testing was performed in 212 patients (31.7%) and 6 (2.8%) were colonized with MRSA. Twelve patients (1.8%) underwent an I&D. On adjusted analysis, preoperative MRSA testing was not associated with postoperative I&D risk. Perioperative vancomycin similarly had no association with postoperative I&D risk. Notably, 6 patients (50%) grew methicillin sensitive Staphylococcus aureus from intraoperative cultures, with no cases of MRSA. There was no association between preoperative nasal MRSA screening and SSIs in primary posterior cervical instrumented procedures, nor was there any association between vancomycin or infection rate. Furthermore, there was a preponderance of gram positive infections but none caused by MRSA. Given these findings, the considerable cost and effort associated with MRSA testing in the setting of primary posterior cervical instrumentation may not be justified. Further research should investigate if higher-risk scenarios demonstrate greater utility of preoperative testing.

Benthic and Pelagic Contributions to Primary Production: Experimental Insights From the Gulf of Trieste (Northern Adriatic Sea)

Although the 14C-method remains one of the most sensitive measures of primary production in marine ecosystems, few data from coastal sublittoral areas are available. We applied an integrated approach to quantify the benthic (PPs) and pelagic (PPw) contributions to total primary production (PPt) in a 17-m deep coastal site. From March 2015 to March 2019, we carried out 16 in situ experiments on a seasonal basis, at the LTER site C1, whereas benthic rates were estimated in the laboratory. To relate PP to seawater physical features and to the water column stability, the Brunt-Väisälä frequency was calculated. We further related our PP rates to the abundance, biomass, main taxonomic groups and diversity of eukaryotic phytoplankton and microphytobenthos (MPB). In November 2018, the maximum PPw (6.71 ± 0.82 µgC L-1 h-1) was estimated at the surface layer, in correspondence to the highest value of dinoflagellates biomass (29.35 µgC L-1), on the account of small (&amp;lt;20 µm) naked and thecate forms. PPi, integrated over the water column, displayed the highest values in July 2017 and July 2018. In sediments, negative PPs values were estimated in late autumn/winter, when minima of MPB abundance occurred. The highest rates were displayed in January 2018 and October 2016 (28.50 and 17.55 mgC m-2 h-1), due to the presence of dominant diatoms Paralia sulcata and Nitzschia sigma var. sigmatella, respectively. The PPs contribution to PPt was negligible (&amp;lt;2%) in 6 out of 16 experiments, with a mean value of 11.3% (excluding negative PPs values) over the study period, while it reached up to 43% in January 2018. The principal component analyses revealed that nutrients availability affected the seasonal development of pelagic and benthic phototrophs and primary production more than the physical variables, except for the surface layer of the water column where temperature and salinity were the main drivers. Our results add on the limited database on primary production in sublittoral areas and represent one of the few attempts, on a global scale, of integrating pelagic and benthic primary production using the 14C method to quantify the overall ecosystem productivity.

Comparison of Relative Value Units and 30-Day Outcomes Between Primary and Revision Pediatric Spinal Deformity Surgery.

Retrospective cohort study. The aim of this study was to compare the relative value units (RVUs) and 30-day outcomes between primary and revision pediatric spinal deformity (PSD) surgery. PSD surgery is frequently complicated by the need for reoperation. However, there is limited literature on physician reimbursement rates and short-term outcomes following primary versus revision spinal deformity surgery in the pediatric population. This study utilizes data obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Pediatric database. Patients between 10 and 18 years of age who underwent posterior spinal deformity surgery between 2012 and 2018 were included. Univariate and multivariate regression were used to assess the independent impact of revision surgery on RVUs and postoperative outcomes, including 30-day readmission, reoperation, morbidity, and complications. The study cohort included a total of 15,055 patients, with 358 patients who underwent revision surgery. Patients in the revision group were more likely to be younger and male sex. Revision surgery more commonly required osteotomy (13.7% vs. 8.3%, P =0.002).Univariate analysis revealed higher total RVUs (71.09 vs. 60.51, P <0.001), RVUs per minute (0.27 vs. 0.23, P <0.001), readmission rate (6.7% vs. 4.0%, P =0.012), and reoperation rate (7.5% vs. 3.3%, P <0.001) for the revision surgery group. Morbidity rates were found to be statistically similar. In addition, deep surgical site infection, pulmonary embolism, and urinary tract infection were more common in the revision group. After controlling for baseline differences in multivariate regression, the differences in total RVUs, RVUs per minute, reoperation rate, and rate of pulmonary embolism between primary and revision surgery remained statistically significant. Revision PSD surgery was found to be assigned appropriately higher mean total RVUs and RVUs per minute corresponding to the higher operative complexity compared with primary surgery. Revision surgery was also associated with poorer 30-day outcomes, including higher frequencies of reoperation and pulmonary embolism. Level III.

Analysis of Thermal Environment and Its Influencing Factors in Deep Stope of Metal Mine

In order to scientifically evaluate the thermal environment of the deep stope and its influencing factors, research was conducted on the thermal environment in Sanshandao Gold Mine, the theoretical calculations and structural analysis of heat release from 8 types of heat sources in the three sub-levels of -930 m, -945 m, and -960 m were carried out, and quantitative characterization was made on the influential degree of comprehensive heat release on the thermal environment, and it was clear that the heat release from the surrounding rock and mechanical and electrical equipment were the main parts at the deep mining site and the proportion of heat release from other heat sources is basically stable. Then, through the analysis of the influence factors of heat sources in the mining site, 17 evaluation indexes of the influence factors of the mining site thermal environment were sorted out, and the indexes’ weight was calculated based on the entropy weighting method, and it was learned that the largest weight of the influence on the thermal environment factors in a single excavation working face was the water gushing in the roadway. The TOPSIS method was used to comprehensively analyze and rank the thermal damage degree in the three middle sections. The results show that the degree of thermal damage in the -960 m is more severe than that in the -930 m and -945 m. This will provide some basic basis for the evaluation and prevention of thermal damage in deep mining projects, and is of great significance for improving mine production efficiency.

30-day postoperative sepsis risk factors following laminectomy for intradural extramedullary tumors.

Posterior laminectomy (LA) for resection of intradural extramedullary tumors (IDEMTs) is associated with postoperative complications, including sepsis. Sepsis is an uncommon but serious complication that can lead to increased morbidity and mortality, prolonged hospital stays, and greater costs. Given the susceptibility of a solid tumor patients to sepsis-related complications, it is important to recognize IDEMT patients as a unique population when assessing the risk factors for sepsis after laminectomy. The study design was a retrospective cohort study. Adult patients undergoing LA for IDEMTs from 2012 to 2018 were identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Baseline patient characteristics/comorbidities, operative and hospital variables, and 30-day postoperative complications were collected. Of 2,027 total patients undergoing LA for IDEMTs, 38 (2%) had postoperative sepsis. On bivariate analysis sepsis was associated with superficial surgical site infection [odds ratio (OR) 11.62, P<0.001], deep surgical site infection (OR 10.67, P<0.001), deep vein thrombosis (OR 10.75, P<0.001), pulmonary embolism (OR 15.27, P<0.001), transfusion (OR 6.18, P<0.001), length of stay greater than five days (OR 5.41, P<0.001), and return to the operating room within thirty days (OR 8.72, P<0.001). Subsequent multivariate analysis identified the following independent risk factors for sepsis and septic shock: operative time ≥50th percentile (OR 2.11, P=0.032), higher anesthesia class (OR 1.76, P=0.046), dependent functional status (OR 2.23, P=0.001), diabetes (OR 2.31, P=0.037), and chronic obstructive pulmonary disease (OR 3.56, P=0.037). These findings can help spine surgeons identify high-risk patients and proactively deploy measures to avoid this potentially devastating complication in individuals who may be more vulnerable than the general elective spine population.

Vancomycin Use in Posterior Lumbar Interbody Fusion of Deep Surgical Site Infection

ObjectiveTo retrospectively analyze if the use of topical intraoperative vancomycin powder reduces deep surgical site infection (DSSI) after posterior lumbar interbody fusion.MethodsAll spinal surgeries for lumbar degenerative disease and underwent posterior fixation interbody fusion between January 2013 and December 2018 were reviewed. A total of 891 patients were included, of which 527 patients (treatment group) received intraoperatively topical vancomycin powder; the others were served as control group. The primary outcomes were the overall incidence of DSSI and the effect of vancomycin on its development. The secondary outcome was risk factors for DSSI. Data on the baseline characteristics, postoperative complications, perioperative risk factors, and one-year postoperative prognoses were extracted from the medical records.ResultsA total of 20 patients met the diagnostic criteria for DSSI (2.24%), of which 7 patients (1.33%) in the treatment group and 13 patients (3.57%) in the control group. There was a significant difference in the incidence of DSSI between the groups (P = 0.026). Multivariate logistic regression analysis with stepwise backward elimination showed that the local use of vancomycin powder was an independent protective factor for DSSI (odds ratio (OR): 0.25, P = 0.01), whereas high body mass index (BMI) (OR: 1.21, P = 0.005), drinking (OR: 5.19, P = 0.005), urinary tract infections (OR: 4.49, P = 0.021), diabetes mellitus (OR: 4.32, P = 0.03), and blood transfusions (OR: 3.67, P = 0.03) were independent risk factors for DSSI.ConclusionThe intraoperative usage of vancomycin powder could reduce effectively decreases the incidence of DSSI after posterior lumbar interbody fusion for degenerative lumbar diseases. High BMI, diabetes mellitus, drinking, and urinary tract infections were independent risk factors for DSSI, whereas the local use of vancomycin protected against these factors.

Microbial Interspecies Associations in Fracture-Related Infection.

Describe co-occurrence or clustering of microbial taxa in fracture-related infections to inform further exploration of infection-related interactions among them. Retrospective review. Level 1 trauma center. Four hundred twenty-three patients requiring surgical intervention for deep surgical site infection between January 2006 and December 2015. None. Connection between microbial taxa. Methicillin-resistant Staphylococcus aureus, methicillin-sensitive Staphylococcus aureus, and coagulase-negative Staphylococcus represented the majority of monomicrobial observations (71%). Gram-negative rods, gram-positive rods, and anaerobes presented more frequently in polymicrobial infections. Enterobacter, vancomycin-sensitive Enterococcus, and Pseudomonas are present in polymicrobial infections with the highest frequencies and represent the top 3 most important nodes within the microorganism framework, with the highest network centrality scores. The present study indicates that there are common microbial taxa (Enterobacter, Enterococcus, and Pseudomonas) that tend to co-occur with other microbes greater than 75% of the time. These commonly co-occurring microbes have demonstrated interactive relationships in other disease pathologies, suggesting that there may be similar important interactions in fracture-related infections. It is possible that these microbial communities play a role in the persistently high failure rate associated with management of infection after trauma. Future studies are needed to study the intermicrobial interactions that explain the frequency at which taxa co-occur. Understanding and potentially disrupting these intermicrobial relationships could inform improvements in the treatment of established infections and in the prevention of infection in high-risk patients. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Can immediate reconstruction with submandibular gland transposition broaden indications for transoral surgery for tonsillar cancer?

e18054 Background: Stratification based on pathologic parameters allows for reduced adjuvant radiotherapy in intermediate risk and observation alone for low risk oropharyngeal p16+ cancer (E3311 ECOG-ACRIN trial). Selection for transoral surgery (TOS), usually robotically assisted, for tonsillar cancers depends on the size and invasiveness of the primary tumor, involvement of adjacent parts such as the soft palate, proximity to external carotid artery branches, medial ipsilateral carotid artery that might be exposed with radical resection, and the likelihood of substantial communication between the oropharynx and internal neck structures. Postoperative recovery can be associated with substantial pain and dysphagia and a length of stay of &gt; 5 days. There is a paucity of simple options for sealing the neck from the pharynx to prevent neck infection, exposure of larger vessels and salivary fistula, so large and deep tonsillar cancers are usually given chemoradiation. Larger surgical defects healing secondarily tend to require longer recoveries due to dysphagia and odynophagia. Methods: A prospective study of vascularized ipsilateral submandibular gland transposition flaps to primarily repair the surgical defect after TOS to resect previously untreated tonsillar cancers was performed from 2019 to 2022. A total of 19 patients underwent resection and repair. These included those with cancers extending to the soft palate (4) and medial position of internal carotid artery adjacent to the tumor (1). All had obvious communication between the neck and the pharynx after TOS, and had branches of the facial and external carotid arteries to the deep resection site ligated with neck dissection, prior to TOS. The submandibular gland flaps were sewn in place using robot assistance and hand. One patient had an extended flap with accompanying submental skin to repair the soft palate. Results: Partial dehiscence superiorly at the palate was the most common complication at 11%. None developed salivary fistulas or deep neck infections. Iatrogenic facial artery pedicle injury that was repaired occurred in one case. Oral intake was started at 1-3 days and length of stay averaged 5 days. There were no bleeding episodes at the TOS sites of cancer resection. All resections had clear margins. All submandibular gland flaps survived, with one patient having attached adipose tissue debrided in the office, healing uneventfully thereafter. Conclusions: The ability to primarily repair after resection of more extensive tonsillar cancers, that leave large communications between the pharynx and the neck, with a readily accessible and easy to harvest submandibular gland flap may change those previously selected for chemoradiation to be able to have TOS instead as initial treatment. This would allow for more pathological risk assessment of tonsil cancers and decreased adjuvant treatment when appropriate.

Surgeon volume and risk of deep surgical site infection following open reduction and internal fixation of closed ankle fracture.

Increasing evidences have shown that surgeon volume was associated with postoperative complications or outcomes in a variety of orthopaedics surgeries, but few were focused on ankle fractures. This study aimed to investigate the deep surgical site infection (DSSI) in association with the surgeon volume following open reduction and internal fixation (ORIF) of ankle fractures. This was a retrospective analysis of the prospectively collected data on patients who underwent ORIF for acute closed ankle fractures between October 2014 and June 2020. Surgeon volume was defined as the number of ORIF procedures performed within 12 months preceding the index operation. The receiver operating characteristic (ROC) curve was constructed to determine the optimal cut-off value, whereby surgeon volume was dichotomized as high or low. The outcome was DSSI within 1year postoperatively. Multivariate logistics analysis was performed to examine the DSSI in association with surgeon volume and multiple sensitivity/subgroup analyses were performed to refine the findings. Among 1562 patients, 33 (2.1%) developed a DSSI. The optimal cut-off value was 7/year. Low-volume (<7/year) was significantly associated with a 5.0-fold increased risk of DSSI (95%CI, 2.2-11.3; P < .001). Sensitivity/subgroup analyses restricted to patients aged <65 years, with or without concurrent fractures, with unimalleolar fractures, bi- or trimalleolar fractures, receiving ORIF within 14 days and those operated by ≥10-year experience surgeons showed the consistently significant results (ORs, 2.7-6.8, all P < .05). The surgeon volume of <7 cases/year is associated with an increased risk of DSSI. It is more feasible that patients with complex fractures or conditions (eg, bi- and trimalleolar or presence of concurrent fractures) are preferentially directed to high-volume and experienced surgeons.

What's New in Orthopaedic Trauma.

What's New in Orthopaedic Trauma.

Sacral-Alar-Iliac (SAI) Fixation in Children With Spine Deformity: Minimum 10-Year Follow-Up.

Sacral-alar-iliac (SAI) screws are utilized to achieve pelvic fixation in spine deformity patients. The primary purpose of this study is to investigate the long-term outcomes of pediatric patients with scoliosis treated with posterior spinal fusion and SAI fixation at 10-year clinical and radiographic follow-up. We reviewed the clinical and radiographic records of patients aged 18 years or below treated for scoliosis with posterior spinal fusion using SAI fixation. Pelvic obliquity and the major coronal curve were determined at the preoperative visit and 6-week, 1-year, 5-year, and 10-year postoperative visits. SAI screw-specific data collected included screw dimensions, rate of screw revision, pain at the SAI screw sites, presence of lucency >2 mm around the screw, screw loosening or breaking, and deep surgical site infections. Ninety-seven of 151 patients (75%) were included. The average age at index surgery was 13.5±3.1 years, and the most common diagnosis was cerebral palsy (67%). The mean duration of follow-up was 11±3 years. The mean pelvic obliquity measured 20±8.0 degrees preoperatively, and 8.7±4.0 degrees at the 10-year follow-up. There were no significant difference in pelvic obliquity when comparing the 10-year follow-up visit with the 6-week postoperative follow-up. Average screw dimensions were 8.4×68.8 mm. By the 10-year follow-up, 4 patients (4%) had at least 1 SAI screw-related complication. Of these patients, 2 (2%) had pain at 1 SAI screw, 4 (4%) had lucency around the screw, and 3 (3%) had broken or loose screws. Two (2%) required SAI screw revision because of late deep wound infection, and underwent exchange with a longer screw. There were no intrapelvic protrusions, vascular, or neurological complications. SAI screws are a safe and effective method for pelvic fixation in children with spinal deformity. The outcomes at ≥10 years are satisfactory, with low rates of long-term complications and excellent postoperative correction and subsequent maintenance of coronal curvature and pelvic obliquity over time. Level IV.

Routine Postoperative Antibiotic Prophylaxis Offers No Benefit after Hepatectomy-A Systematic Review and Meta-Analysis.

Background: Prophylactic antibiotics are frequently administered after major abdominal surgery including hepatectomies aiming to prevent infective complications. Yet, excessive use of antibiotics increases resistance in bacteria. The aim of this systematic review and meta-analysis is to assess the efficacy of prophylactic antibiotics after hepatectomy (postoperative antibiotic prophylaxis, POA). Method: This systematic review and meta-analysis were completed according to the current PRISMA guidelines. The protocol has been registered prior to data extraction (PROSPERO registration Nr: CRD42021288510). MEDLINE, Web of Science and CENTRAL were searched for clinical reports on POA in hepatectomy restrictions. A random-effects model was used for synthesis. Methodological quality was assessed with RoB2 and ROBINS-I. GRADE was used for the quality of evidence assessment. Results: Nine comparative studies comprising 2987 patients were identified: six randomized controlled trials (RCTs) and three retrospectives. POA did not lead to a reduction in postoperative infective complications or have an effect on liver-specific complications—post-hepatectomy liver failure and biliary leaks. POA over four or more days was associated with increased rates of deep surgical site infections compared to short-term administration for up to two days (OR 1.54; 95% CI [1.17;2.03]; p = 0.03). Routine POA led to significantly higher MRSA incidence as a pathogen (p = 0.0073). Overall, the risk of bias in the studies was low and the quality of evidence moderate. Conclusion: Routine POA cannot be recommended after hepatectomy since it does not reduce postoperative infection or liver-specific complications but contributes to resistance in bacteria. Studies into individualized risk-adapted antibiotic prophylaxis strategies are needed to further optimize perioperative treatment in liver surgery.

Effect of Supplemental Perioperative Oxygen on SSI Among Adults with Lower-Extremity Fractures at Increased Risk for Infection: A Randomized Clinical Trial.

Supplemental perioperative oxygen is a low-cost intervention theorized to reduce the risk of surgical site infections, but its effect among patients undergoing surgery for a tibial plateau, tibial pilon, or calcaneal fracture is unknown. We aimed to determine the effectiveness of a high fraction of inspired oxygen (FiO 2 , 80%) versus low FiO 2 (30%) in reducing surgical site infections in these patients. A randomized controlled trial was conducted at 29 U.S. trauma centers. We enrolled 1,231 patients who were 18 to 80 years of age and had a tibial plateau, tibial pilon, or calcaneal fracture and were thought to be at elevated risk for infection based on their injury characteristics. Patients were randomized to receive 80% FiO 2 (treatment group) or 30% FiO 2 (control group) in the operating room and for up to 2 hours in the recovery room. The primary outcome was a composite of either deep surgical site infection (treated with surgery) or superficial surgical site infection (treated with antibiotics alone) within 182 days following definitive fixation. Secondary outcomes included these surgical site infections at 90 and 365 days after surgery. The modified intention-to-treat analysis included 1,136 patients with 94% of expected follow-up through 182 days. Surgical site infection occurred in 40 (7.0%) of the patients in the treatment group and 60 (10.7%) of the patients in the control group (relative risk [RR], 0.65; 95% confidence interval [CI], 0.45 to 0.96; risk difference [RD], -3.8%; 95% CI, -7.2% to -0.4%; p = 0.03). The treatment intervention demonstrated a similar effect at 90 days (RR, 0.59; 95% CI, 0.37 to 0.93) and 365 days (RR, 0.62; 95% CI, 0.44 to 0.87). Secondary analyses demonstrated that the effect was driven by a reduction in superficial surgical site infections. Among tibial plateau, pilon, or calcaneal fracture patients at elevated risk for surgical site infection, a high perioperative FiO 2 lowered the risk of surgical site infection. The findings support the use of this intervention, although the benefit appears to mostly be in reduction of superficial infections. Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

A systemic review and a meta-analysis on the influences of closed incisions in orthopaedic trauma surgery by negative pressure wound treatment compared with conventional dressings.

We performed a meta-analysis to evaluate the influences of closed incisions in orthopaedic trauma surgery (OTS) by negative pressure wound treatment (NPWT) compared with conventional dressings. A systematic literature search up to March 2022 was done and 14 studies included 3935 subjects with OTS at the start of the study; 2023 of them used NPWT and 1912 were conventional dressings. They were reporting relationships between the influences of closed incisions in OTS by NPWT compared with conventional dressings. We calculated the odds ratio (OR) with 95% confidence intervals (CIs) to assess the influences of closed incisions in OTS by NPWT compared with conventional dressings using the dichotomous methods with a random or fixed-effect model. NPWT had significantly lower deep surgical site infections (SSIs) (OR, 0.65; 95% CI, 0.48-0.87, P= .004), superficial SSIs (OR, 0.34; 95% CI, 0.19-0.61, P< .001), and wound dehiscence (OR, 0.41; 95% CI, 0.21-0.80, P= .009) compared with conventional dressings in subjects with closed incisions in OTS. NPWT showed a beneficial effect on deep SSIs, superficial SSIs, and wound dehiscence compared with conventional dressings in subjects with closed incisions in OTS. Further studies are required to validate these findings.

Is it necessary to apply chemical weed control in short-rotation poplar plantations on deep soil sites?

Chemical weed control has been widely applied in plantation forests around the world. However, understanding the long-term influence of weed control on stand growth and its underlying mechanisms is still limited. We conducted a six-year (2016–2021; an entire rotation) weed control study in Chinese white poplar (Populus tomentosa Carr.) plantations established using tall planting stock on a deep soil site, which is a typical afforestation mode for poplars in north China. Three treatments of chemical weed control degree were implemented: no weeding (W0), removing weeds within 50 cm distance from the tree row (W50) and removing all weeds on the ground (W150). Different tree growth indicators, soil water content (θ), tree root distribution, and soil physical properties were measured. There was no weed control degree effect on θ in 2017 (P = 0.4408) but significant θ difference (P = 0.0140) among treatments existed in 0–30 cm soil in 2021. Different degrees of weed control did not change soil physical properties (P > 0.05) after the long-term application of chemical weeding. There were no differences (P > 0.05) in all growth indicators. But the cumulative increments of tree diameter, height, stand volume index, and biomass at the end of the rotation in W150 were numerically 2–27% lower than W0 and 11–26% lower than W50. The total fine roots biomass increased with decreasing weed control degree, although the difference was non-significant (P > 0.05). The fine root distribution pattern indicated that there might be many fine roots below 200 cm depth. The tree growth response to weed control may be attributed to tall planting stock that avoids light competition from weeds and deep soil resource exploration by tree roots that alleviate competition by shallow weed roots. Consequently, it may be unnecessary to apply chemical weed control in poplar plantations established using tall planting stock on deep soil sites. Our findings provide guidance for the sustainable management of industrial plantation forests.

Fourteen years of pancreatic surgery for malignancy among ACS-NSQIP centers: Trends in major morbidity and mortality

BackgroundThe American College of Surgeons National Surgical Quality Improvement Program was established to help participating hospitals track and report surgical complications with the goal of improving surgical care. We sought to determine whether this has led to improvements in surgical outcomes for pancreatic malignancies. MethodsPatients with pancreatic malignancies who underwent surgical resection were identified from the American College of Surgeons National Surgical Quality Improvement Program database (2006–2019). Thirty-day postoperative major morbidity and mortality were analyzed by year. Major morbidity included organ and deep surgical site infection, venous thromboembolism, cardiac event, pneumonia, acute renal failure, sepsis, and respiratory failure. ResultsOf the 28,888 patients identified, 51% were male, the median age was 68, 74.3% underwent a pancreaticoduodenectomy, and 25.7% underwent a distal pancreatectomy. Among patients who underwent a pancreaticoduodenectomy, there was a significant increase in major morbidity (annual percent change 0.77, P = .012) driven by increases in organ space surgical site infection (annual percent change 3.52, P < .001) and venous thromboembolism (annual percent change 4.72, P = .005). However, there was a decrease in postoperative mortality (annual percent change -4.58, P = .001). For distal pancreatectomy patients, there was no change in rates of overall major morbidity (annual percent change -1.35, P = .08) or mortality (annual percent change -3.21, P = .25). ConclusionAlthough major morbidity and mortality have not significantly changed for distal pancreatectomy patients, mortality has steadily decreased for patients undergoing pancreaticoduodenectomy, despite an increase in major morbidity. Whether this trend reflects a change in patient selection, an increase in detection of postoperative morbidities and/or an improvement in mitigation of these morbidities warrants further study.

Economic outcomes associated with deep surgical site infection from lower limb fractures following major trauma.

AimsThis study aims to estimate economic outcomes associated with 30-day deep surgical site infection (SSI) from closed surgical wounds in patients with lower limb fractures following major trauma.MethodsData from the Wound Healing in Surgery for Trauma (WHiST) trial, which collected outcomes from 1,547 adult participants using self-completed questionnaires over a six-month period following major trauma, was used as the basis of this empirical investigation. Associations between deep SSI and NHS and personal social services (PSS) costs (£, 2017 to 2018 prices), and between deep SSI and quality-adjusted life years (QALYs), were estimated using descriptive and multivariable analyses. Sensitivity analyses assessed the impact of uncertainty surrounding components of the economic analyses.ResultsCompared to participants without deep SSI, those with deep SSI had higher mean adjusted total NHS and PSS costs (adjusted mean difference £1,577 (95% confidence interval (CI) -951 to 4,105); p = 0.222), and lower mean adjusted QALYs (adjusted mean difference -0.015 (95% CI -0.032 to 0.002); p = 0.092) over six months post-injury, but this difference was not statistically significant. The results were robust to the sensitivity analyses performed.ConclusionThis study found worse economic outcomes during the first six months post-injury in participants who experience deep SSI following orthopaedic surgery for major trauma to the lower limb. However, the increase in cost associated with deep SSI was less than previously reported in the orthopaedic trauma literature.Cite this article: Bone Jt Open 2022;3(5):398–403.