Rate Of Deep Surgical Site Infection Research Articles

Getting the drop on Staphylococcus aureus: Semiquantitative Staphylococcus aureus nasal colony reduction in orthopedic surgery reduces surgical site infection.

Surgical site infection (SSI) is a frequent health care-associated infection. We aimed to reduce SSI risk after joint arthroplasty and spine surgery by reducing Staphylococcus aureus colonization burden with presurgery intranasal povidone-iodine (PVP-I) application in conjunction with skin antisepsis ("the intervention"). Retrospective case-control study; postintervention cohort versus a historical cohort. Adults who underwent joint arthroplasty or spine surgery during February 2018 through October 2021 ("post-intervention cohort") included. In the analysis cases any patient who underwent surgery and developed SSI within 90 days postsurgery, controls had no SSI. Postintervention cohort data were compared with a similar retrospective 2016 to 2017 patient cohort that did not use intranasal PVP-I. The postintervention cohort comprised 688 consecutive patients aged 65y/o, 48.8% male, 28 cases, and 660 controls. Relatively more cases than controls had diabetes mellitus (P=.019). There was a 39.6% eradication rate of S aureus nasal colonization post intranasal PVP-I (P<.0001). SSI rate was higher in patients positive versus those negative for S aureus on a 24-hour postsurgery nasal culture (P<.0001). The deep SSI rate per 100 operations postintervention versus the historical cohort decreased for all surgical procedures. Semiquantitative S aureus nasal colony reduction using intranasal PVP-I is effective for decreasing SSI rate in joint arthroplasty and spine surgery. In patients with presurgery S aureus nasal colonization additional intranasal PVP-I postsurgery application should be considered.

Psoriasis Is a Risk Factor for Surgical Site Infection After Primary TKA.

The relationship between psoriasis and complications after primary TKA is not well defined. Current studies are limited to small, single-center studies evaluating fewer than 150 patients with psoriasis, with some studies reporting an increased risk of surgical site infection (SSI) and another reporting no associated risk. There is a need to reevaluate the risk of psoriasis and postoperative complications, including SSI, to better risk-stratify and guide practice in this patient population. (1) Compared with patients without psoriasis, after accounting for potential confounders such as age, insurance, and comorbidities, do patients with psoriasis have a higher odds of superficial SSI after primary TKA? (2) Do patients with psoriasis have a higher odds of deep SSI after primary TKA? Patients 18 years or older who underwent unilateral, primary TKA between 2015 and 2019 were identified in the PearlDiver database (n = 490,722). Patients with rheumatoid, septic, or posttraumatic arthritis were excluded, as well as patients with bone neoplasias (n = 188,557). Additionally, patients with less than 2 years of follow-up (n = 53,673) were excluded. In all, 248,492 patients were included in this study; 0.4% (1078) were in the psoriasis group and 99% (247,414) were in the control group. Overall 2-year superficial and deep SSI rates were stratified and compared between patients with psoriasis and a control group of patients who did not have psoriasis as the primary outcome. Secondary outcomes included the odds of undergoing an aseptic revision or manipulation under anesthesia. In the multivariable analysis, which controlled for potential confounders such as age, sex, Elixhauser comorbidity index, hypertension, diabetes mellitus, and liver disease, the odds of SSI-either superficial or deep-remained higher for patients with psoriasis (OR 1.74 [95% confidence interval 1.03 to 2.96]; p = 0.04). When focusing on superficial infections in the multivariable analysis, patients with psoriasis had a higher odds of superficial SSI than those in the control group (OR 2.83 [95% CI 1.26 to 6.34]; p = 0.01). The odds of deep SSI were not different between the two cohorts in our multivariable analysis (OR 1.32 [95% CI 0.66 to 2.66]; p = 0.43). Patients with psoriasis did not have an increased odds of undergoing an aseptic revision (OR 0.79 [95% CI 0.48 to 1.32]; p = 0.38) or manipulation under anesthesia (OR 0.74 [95% CI 0.52 to 1.06]; p = 0.10). Patients with psoriasis had higher overall rates of SSI at 2 years of follow-up than patients without psoriasis. Our findings suggest that psoriasis is a risk factor for superficial SSI after primary TKA and is an important comorbidity for surgeons to consider before surgery. Further research is needed to assess the role of adjunctive interventions in patients with psoriasis to mitigate the elevated odds of superficial SSI. Level II, prognostic study.

Unipolar Hip Hemiarthroplasty in Geriatric Patients: A Prospective Study and Analysis of Clinical and Radiological Outcomes.

Femoral neck fractures (FNF) in the geriatric population are commonly treated with hip replacement procedures, such as total hip arthroplasty, unipolar hip hemiarthroplasty (UHA), and bipolar hip hemiarthroplasty (BHA). The optimal treatment remains controversial, considering outcomes and cost-effectiveness, with UHA often being cheaper. This prospective observational study aims to evaluate UHA's clinical and radiological outcomes, safety, and survivorship compared to existing literature. We followed 90 elderly patients who underwent UHA following FNF. We assessed patients using the Parker score before and after surgery, as well as Harris Hip Score (HHS), and Postel-Merle d'Aubigné (PMA) scores postoperatively. All complications, acetabular erosions and heterotopic ossifications (HO), were documented. One year post-surgery, 26.7% of patients had passed away, mostly due to declining general health status. Systemic complications occurred in 14.4% of cases, with a 1.1% rate of deep surgical site infections. A single dislocation resulted from excessive stem anteversion. UHA implant survival rate was 97.8% after 4years. The Parker score remained stable, and HHS at 6 and 12months was 71.5 ± 12.9 and 70.9 ± 11.8, respectively, while PMA score was 14.3 ± 2.4 and 14.5 ± 2.1, respectively. Five hips showed Baker I acetabular wear. HO were noted as Brooker I in 12 patients, II in 4 patients, and IV in 1 patient. UHA exhibited comparable systemic complication rates, implant survivorship, and dislocation rates to those in the literature for both UHA and BHA. The deep surgical site infection rate was lower than reported for BHA. Patients' functional and mental abilities did not decline based on clinical scores. Acetabular wear in UHA was similar to its bipolar counterpart, while HO were only minor findings with no clinical implications. In elderly patients, UHA demonstrated clinical and radiological outcomes similar to BHA in existing literature. UHA may represent a cost-effective alternative for patients with limited life expectancy.

Comparison of Early Complication Rates After High Tibial Osteotomy Versus Unicompartmental Knee Arthroplasty for Knee Osteoarthritis.

Although both high tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) can be utilized to treat unicompartmental osteoarthritis (OA) in select patients, the early complication rates between the 2 procedures are not well understood. Understanding of the complication profiles for both procedures would help clinicians counsel patients with unicompartmental knee OA who may be eligible for either treatment option. To compare the 30-day complication rates after HTO versus UKA for the treatment of knee OA using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Cohort study; Level of evidence, 3. NSQIP registries between 2006 and 2019 were queried using Current Procedural Terminology codes to identify patients undergoing HTO and UKA for knee OA. Patients >60 years of age were excluded. Patient demographics, preoperative comorbidities, and intraoperative data were collected. Postoperative 30-day complications, including venous thromboembolism (VTE), urinary tract infection (UTI), transfusion, surgical-site infection (SSI), and reoperations were recorded. Complication rates between treatment groups were compared using a multivariate logistic regression model adjusted for sex, age, body mass index, steroid use, respiratory status (smoking/dyspnea/chronic obstructive pulmonary disease), diabetes, and hypertension. A total of 156 patients treated with HTO and 4755 patients treated with UKA for knee OA were identified. Mean patient ages were 46 years for the HTO group and 53.4 years for the UKA group. Operative time was significantly longer in the HTO group versus the UKA group (112 minutes vs 90 minutes; P < .001). Multivariate analyses found no significant differences in VTE (1.3% vs 0.6%), UTI (0.6% vs 0.3%), transfusion (0.6% vs 0.2%), deep SSI (0.6% vs 0.1%), and reoperation (1.3% vs 1%) rates between HTO and UKA groups. The HTO group had a higher rate of superficial SSI compared with the UKA group (2.6% vs 0.6%; P = .006) (adjusted odds ratio, 4.2; 95% CI, 1.4-12.5; P = .01). There were no differences in 30-day VTE, UTI, transfusion, deep SSI, and reoperation rates for HTO versus UKA in the treatment of knee OA. HTO was associated with a higher rate of superficial SSI compared with UKA. These findings serve to guide clinicians in counseling patients regarding the early risks after HTO and UKA.

DEEP INFECTION RATE RESULTING IN REOPERATION FOR SEPSIS FOLLOWING MINOR HAND SURGERY WITH WIDE-AWAKE LOCAL ANAESTHESIA, NO TOURNIQUET (WALANT), AND FIELD STERILITY IN AN OUTPATIENT SETTING

This study aims to determine the incidence of surgical site infection leading to reoperation for sepsis following minor hand procedures performed outside the main operating room using field sterility in the South African setting.The investigators retrospectively reviewed the records of 485 patients who had WALANT-assisted minor hand surgery outside a main operating theatre, a field sterility setting between March 2019 and April 2023. The primary outcome was the presence or absence of deep surgical site infection that required reoperation within four weeks. Cases included where elective WALANT minor hand procedures, a minimum age of 18 with complete clinical records.The patients were mostly female (54.8%), with a mean age of 56.35 years. The majority of cases were trigger finger and carpal tunnel release. An overall 485 cases were reviewed, the deep surgical site infection rate resulting in reoperation within 4 weeks post-operatively was 1.24% ((95% Confidence Interval (CI) 0.0034 to 0.0237); p = 0.009).Minor hand procedures performed under field sterility using WALANT have a low surgical site infection rate. The current study's infection rates are comparable to international surgical site infection rates for similar surgeries performed in main operating rooms using standard sterilisation procedures. Field sterility is a safe and acceptable clinical practice that may improve work efficiency in public sector.

A Self-Sustaining Antibiotic Prophylaxis Program to Reduce Surgical Site Infections.

Background: Our multi-institutional healthcare system had a higher-than-expected surgical site infection (SSI) rate. We aimed to improve our peri-operative antibiotic administration process. Gap analysis identified three opportunities for process improvement: standardized antibiotic selection, standardized second-line antibiotic agents for patients with allergies, and feedback regarding antibiotic administration compliance. Hypothesis: Implementation of a multifaceted quality improvement initiative including a near-real-time pre-operative antibiotic compliance feedback tool will improve compliance with antibiotic administration protocols, subsequently lowering SSI rate. Methods: A compliance feedback tool designed to provide monthly reports to all anesthesia and surgical personnel was implemented at two facilities, in September 2017 and December 2018. Internal case data were tracked for antibiotic compliance through June 2021, and these data were merged with American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data at the case level to provide process and outcome measures for SSIs. Implementation success was evaluated by comparing protocol compliance and risk-adjusted rates of superficial and deep SSI before and after the quality improvement implementation. Results: A total of 20,385 patients were included in this study; 11,548 patients in the pre-implementation and 8,837 in the post-implementation groups. Baseline patient and operative characteristics were similar between groups, except the post-implementation group had a higher median expected SSI rate (2.2% vs. 1.6%). Post-implementation, antibiotic protocol compliance increased from 86.3% to 97.6%, and superficial and deep SSIs decreased from 2.8% to 1.9% (p < 0.001). The odds of superficial and deep SSI in patients in the post-implementation group was 0.69 (0.57, 0.83) times the odds of superficial and deep SSI in pre-implementation patients while adjusting for age, gender, diabetes mellitus, American Society of Anesthesiologists Physical Status (ASA) classification, wound class, smoking, and chronic obstructive pulmonary disease (COPD). Observed-to-expected ratios of superficial and deep SSI decreased from 0.82 to 0.48 after the intervention. Conclusions: Surgical antibiotic prophylaxis standardization and providing near-real-time individualized feedback resulted in sustained improvement in peri-operative antibiotic compliance rates and reduced superficial and deep SSIs.

Effectiveness of chlorhexidine versus povidone-iodine for preventing surgical site wound infection: A meta-analysis.

A systematic evaluation was conducted to assess the efficacy of two disinfectants, chlorhexidine and povidone-iodine, as primary components in preventing surgical site infection (SSI). A comprehensive computerised search was performed in the PubMed, EMBASE, Web of Science, Cochrane Library, CNKI and Wanfang databases for randomised controlled trials (RCTs) on chlorhexidine and povidone-iodine disinfection for the prevention of SSI from inception until July 2023. Two independent researchers completed literature screening, data extraction and quality assessment of the included studies. The meta-analysis was conducted using RevMan 5.4 software. Ultimately, 20 RCTs were included, which included 13 133 patients, with 6460 patients in the chlorhexidine group and 6673 patients in the povidone-iodine group. The meta-analysis results revealed that the incidence rate of surgical site wound infections [odds ratio (OR): 0.67, 95% confidence interval (CI): 0.58-0.78, p < 0.001)], superficial SSI rate (OR: 0.59, 95% CI: 0.46-0.75, p < 0.001) and deep SSI rate (OR: 0.49, 95% CI: 0.31-0.79, p = 0.003) were all lower in patients subjected to chlorhexidine disinfection compared to those patients receiving povidone-iodine disinfection. Existing evidence suggests that chlorhexidine is more effective than povidone-iodine at preventing SSI. However, owing to the potential quality limitations of the included studies, further validation through high-quality large-scale RCTs is warranted.

Does pes anserinus tenotomy affect surgical site infection rate in operative tibial plateau fractures?

To assess if pes anserinus tenotomy (PAT) during definitive open reduction and internal fixation (ORIF) of tibial plateau fractures is associated with a decreased risk of surgical site infection (SSI) and other postoperative complications. A retrospective review of all adults who underwent ORIF for tibial plateau fractures from April 2005 to February 2022 at single level 1 trauma center was performed. Patients who had a medial approach to the plateau with minimum three-month follow-up were required for inclusion. All patients with fasciotomy for compartment syndrome or with traumatically avulsed or damaged pes anserinus prior to ORIF were excluded. Two groups were created: those who received a pes anserinus tenotomy with repair (PAT group) and those whose pes anserinus were spared and left intact (control group). Patient demographics, injury and operative characteristics, and surgical outcomes were compared. The primary outcomes were rates of deep and superficial SSI. The PAT group had significantly lower rates of deep SSI (9.2% vs. 19.7%, P = 0.009), superficial SSI (14.2% vs. 26.5%), P = 0.007), and any SSI (15.8% vs. 28.9%, P = 0.005). Multiple logistic regression showed that heart failure (aOR = 7.215, 95% CI 2.291-22.719, P < 0.001), and presence of open fracture (aOR = 4.046, 95% CI 2.074-7.895, P < 0.001) were independently associated with increased odds of deep SSI, while PAT was associated with a decreased odds of deep SSI (aOR = 0.481, 95% CI 0.231-0.992, P = 0.048). PAT had significantly lower rates of unplanned return to the operating room (20.8% vs. 33.7%, P = 0.010) and implant removal (10.0% vs. 18.0%, P = 0.042). While these data do not allow for discussion of functional recovery or strength, pes anserinus tenotomy was independently associated with significantly lower rates of infection, unplanned operation, and implant removal. Level III.

Annual incidence and assessment of risk factors for early-onset deep surgical site infection following primary total knee arthroplasty in osteoarthritis.

This study aims to determine difference in annual rate of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis, and to identify risk factors that may be associated with infection. This is a retrospective population-based cohort study using prospectively collected patient-level data between 1 January 2013 and 1 March 2020. The diagnosis of deep SSI was defined as per the Centers for Disease Control/National Healthcare Safety Network criteria. The Mann-Kendall Trend test was used to detect monotonic trends in annual rates of early-onset deep SSI over time. Multiple logistic regression was used to analyze the effect of different patient, surgical, and healthcare setting factors on the risk of developing a deep SSI within 90 days from surgery for patients with complete data. We also report 90-day mortality. A total of 39,038 patients underwent primary TKA for osteoarthritis during the study period. Of these, 275 patients developed a deep SSI within 90 days of surgery, representing a cumulative incidence of 0.7%. The annual infection rate did not significantly decrease over the seven-year study period (p = 0.162). Overall, 13,885 (35.5%) cases were excluded from the risk analysis due to missing data. Risk factors associated with early-onset deep SSI included male sex, American Society of Anesthesiologists grade ≥ 3, blood transfusion, acute length of stay, and surgeon volume < 30 TKAs/year. Early-onset deep SSI was not associated with increased 90-day mortality. This study establishes a reliable baseline infection rate for early-onset deep SSI after TKA for osteoarthritis using robust Infection Prevention and Control surveillance data, and identifies several potentially modifiable risk factors.

Type III Gustilo–Anderson open fracture does not justify routine prophylactic Gram-negative antibiotic coverage

Postoperative surgical site infection (SSI) is common in open long bone fractures, so early administration of prophylactic antibiotics is critical to prevent SSI. However, the necessity of initial broad-spectrum coverage for Gram-positive and -negative pathogens remains unclear. The purpose of this study was to clarify the effectiveness of prophylactic broad-spectrum antibiotics in a large, national-wide sample. We reviewed an open fracture database of prospectively collected data from 111 institutions managed by our society. A retrospective cohort study was designed to compare the rates of deep SSI between narrow- and broad-spectrum antibiotics, which were initiated within three hours after injury. A total of 1041 type III fractures were evaluated at three months after injury. Overall deep SSI rates did not differ significantly between the narrow-spectrum group (43/538, 8.0%) and broad-spectrum group (49/503, 9.8%) (p = 0.320). During propensity score-matched analysis, 425 pairs were analyzed. After matching, no significant difference in the SSI rate was seen between the narrow- and broad-spectrum groups, with 42 SSIs (9.9%) and 40 SSIs (9.4%), respectively (p = 0.816). The probability of deep SSI was not reduced by broad-spectrum antibiotics compared with narrow-spectrum antibiotics in type III open long bone fractures.

Incisional Negative Pressure Wound Therapy Does Not Affect Deep Surgical Site Infection Rates in Neuromuscular Scoliosis Surgery.

Surgical site infection (SSI) is a devastating complication in patients with neuromuscular scoliosis (NMS) undergoing posterior spinal instrumented fusion (PSIF) for progressive scoliosis. Incisional negative pressure wound therapy (INPWT) has been used in other surgical fields to reduce SSI. Our purpose was to examine the prophylactic use of INPWT after NMS surgery to decrease SSI. At a single institution, 71 consecutive patients with NMS underwent PSIF from 2015 to 2019. Starting in 2017, all patients with NMS received INPWT postoperatively until discharge. Rates of deep SSI were compared between the two cohorts of patients. Additionally, patient demographic and operative factors such as American Society of Anesthesiologists score, number of levels instrumented, need for an anterior spinal release, need for spinal fusion to pelvis, blood loss, operative time, fluoroscopy time, length of stay, and transfusion requirement were analyzed for potential influence on deep SSI. There was no significant difference in deep SSI rates between patients who received INPWT (2 of 41) and those treated with a standard postoperative dressing (2 of 30; P=1.0). Although INPWT theoretically can stabilize the wound environment and prevent deep SSI, our findings do not support this. More research is needed to evaluate the efficacy of INPWT after PSIF for NMS. [Orthopedics. 2023;46(6):373-378.].

Do surgical drains reduce surgical site occurrence and infection after incisional hernia repair with sublay mesh? A non-randomised pilot study.

Surgical site occurrence (SSO) and surgical site infection (SSI) are common concerns with incisional hernia repair. Intraoperative drain placement is a common practice aiming to reduce SSO and SSI rates. However, literature on the matter is very poor. The aim of this study is to investigate the role of subcutaneous and periprosthetic drain placement on postoperative outcomes and SSO and SSI rates with incisional hernia repair. A non-randomised pilot study was performed between January 2018 and December 2020 and included patients with elective midline or lateral incisional hernia repair with sublay mesh placement. Patients were prospectively included, followed for 1month and divided into three groups: group 1 without drainage, group 2 with subcutaneous drainage, and group 3 with subcutaneous and periprosthetic drains. Drains were placed at surgeon's discretion. All patients were included in the enhanced recovery program. One hundred and four patients were included. Twenty-four patients (23.1%) did not have drains (group 1), 60 patients (57.7%) had a subcutaneous drain (group 2) and 20 patients (19.2%) had both a subcutaneous and a periprosthetic drains (group 3). SSO rates were significantly different between the 3 groups: 20.8% in group 1, 20.7% in group 2 and 50% in group 3 (p = 0.03). There was no significant difference in deep and superficial SSI rates between the 3 groups. Subgroup analysis revealed that adding a drain in direct contact with the mesh significantly increased SSO rate but did not influence SSI rate. Length of stay was also significantly increased by the presence of a drain, 3.1 ± 1.9days for group 1; 5.9 ± 4.8 for group 2 and 5.9 ± 2.5days for group 3 (p < 0.005). Drain placement in direct contact with the mesh might increase SSO rate. More studies are necessary to evaluate the actual benefits of drainage after incisional hernia repair.

Impact of Coronavirus Disease-2019 Protocols on Primary and Revision Total Knee Arthroplasty.

Background: Surgical site infection (SSI) after total knee arthroplasty (TKA) is associated with increased morbidity and healthcare expenditures. During the coronavirus disease-2019 (COVID-19) pandemic, our institution intensified hygiene standards, including greater glove, personal protective equipment (PPE), and mask use. We assessed the effect of these changes on SSI rates in primary total knee arthroplasty (pTKA) and revision total knee arthroplasty (rTKA). Patients and Methods: A retrospective review was performed identifying TKA from January 2019 to June 2021 at a single institution. Baseline characteristics and outcomes were compared before (January 2019 to February 2020) and during (May 2020 to June 2021) the COVID-19 pandemic when no restriction on operative services was in place and were further analyzed during the first (May 2020 to November 2020) and second (December 2020 to June 2021) periods after full operative services were restored. Results: A total of 3,398 pTKA (pre-pandemic: 1,943 [57.2%]; pandemic: 1,455 [42.8%]) and 454 rTKA (pre-pandemic: 229 [50.4%]; pandemic: 225 [49.6%]) were included. For primary cases, superficial and deep SSI rates were similar before and during COVID-19; however, for revision TKA, the incidence of all (-0.32%, p = 0.035) and superficial (-0.32%, p = 0.035) SSIs decreased during COVID-19. Primary TKA had longer operative times (p < 0.001) and shorter length of stay (LOS; p < 0.001) during COVID-19. Both pTKA (p < 0.001) and rTKA (p = 0.003) were discharged to skilled nursing facilities less frequently during COVID-19 as well. Conclusions: After our hospital implemented COVID-19-motivated hygienic protocols, superficial SSI rates decreased in rTKA but not in pTKA. During COVID-19, patients were less likely to be discharged to skilled nursing facilities, and pTKA operative times increased. Although these changes occurred during intensified hygiene protocols, further research is needed to determine how these factors contributed to the observed changes.

Comprehensive meta-analysis of antibiotic-impregnated bone cement versus plain bone cement in primary total knee arthroplasty for preventing periprosthetic joint infection

PurposeAntibiotic-loaded bone cement (ALBC) was usually used to prevent periprosthetic joint infection (PJI) in primary total knee arthroplasty (PTKA), but whether to use ALBC or plain bone cement in PTKA remains unclear. We aimed to compare the occurrence rate of PJI using two different cements, and to investigate the efficacy of different antibiotic types and doses administered in preventing surgical site infection (SSI) with ALBC. MethodsThe availability of ALBC for preventing PJI was evaluated by using a systematic review and meta-analysis referring to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Existing articles until December 2021 involving PTKA patients with both ALBC and plain bone cement cohorts were scanned by searching “total knee arthroplasty”, “antibiotic-loaded cement”, “antibiotic prophylaxis”, “antibiotic-impregnated cement” and “antibiotic-laden cement” in the database of PubMed/MEDLINE, Embase, Web of Science and the Cochrane Library. Subgroup analysis included the effectiveness of different antibiotic types and doses in preventing SSI with ALBC. The modified Jadad scale was employed to score the qualities of included articles. ResultsEleven quantitative studies were enrolled, including 34,159 knees undergoing PTKA. The meta-analysis results demonstrated that the use of prophylactic ALBC could significantly reduce the prevalence of deep incisional SSI after PTKA, whereas there was no significant reduction in the rate of superficial incisional SSI. Moreover, gentamicin-loaded cement was effective in preventing deep incisional SSI, and the use of high-dose ALBC significantly reduced the rate of deep incisional SSI after PTKA. Besides, no significant adverse reactions and complications were stated during the use of ALBC in PTKA. ConclusionThe preventive application of ALBC during PTKA could reduce the rates of deep PJI. Furthermore, bone cement containing gentamicin and high-dose ALBC could even better prevent deep infection after PTKA. However, the existing related articles are mostly single-center and retrospective studies, and further high-quality ones are needed for confirmation.

Wound photography for evaluation of surgical site infection and wound healing after lower limb trauma.

Deep surgical site infection (SSI) is common after lower limb fracture. We compared the diagnosis of deep SSI using alternative methods of data collection and examined the agreement of clinical photography and in-person clinical assessment by the Centers for Disease Control and Prevention (CDC) criteria after lower limb fracture surgery. Data from two large, UK-based multicentre randomized controlled major trauma trials investigating SSI and wound healing after surgical repair of open lower limb fractures that could not be primarily closed (UK WOLLF), and surgical incisions for fractures that were primarily closed (UK WHiST), were examined. Trial interventions were standard wound care management and negative pressure wound therapy after initial surgical debridement. Wound outcomes were collected from 30 days to six weeks. We compared the level of agreement between wound photography and clinical assessment of CDC-defined SSI. We are also assessed the level of agreement between blinded independent assessors of the photographs. Rates of CDC-defined deep SSI were 7.6% (35/460) after open fracture and 6.3% (95/1519) after closed incisional repair. Photographs were obtained for 77% and 73% of WOLLF and WHiST cohorts respectively (all participants n = 1,478). Agreement between photographic-SSI and CDC-SSI was fair for open fracture wounds (83%; k = 0.27 (95% confidence interval (CI) 0.14 to 0.42)) and for closed incisional wounds (88%; k = 0.29 (95% CI 0.20 to 0.37)) although the rate of photographically detected deep SSIs was twice as high as CDC-SSI (12% vs 6%). Agreement between different assessors for photographic-SSI (WOLLF 88%, k = 0.63 (95% CI 0.52 to 0.72); WHiST 89%; k = 0.61 (95% CI 0.54 to 0.69)); and wound healing was good (WOLLF 90%; k = 0.80 (95% CI 0.73 to 0.86); WHiST 87%; k = 0.57 (95% CI 0.50 to 0.64)). Although wound photography was feasible within the research context and inter-rater assessor agreement substantial, digital photographs used in isolation overestimated deep SSI rates, when compared to CDC criteria. Wound photography should not replace clinical assessment in pragmatic trials but may be useful for screening purposes where surgical infection outcomes are paramount. Cite this article: Bone Joint J2021;103-B(12):1802-1808.

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

Emerging evidences supported that the surgeon case volume significantly affected post-operative complications or outcomes following a range of elective or non-elective orthopaedic surgery; no data has been available for surgically treated tibial plateau fractures. We aimed to investigate the relationship between surgeon volume and the risk of deep surgical site infection (DSSI) following open reduction and internal fixation (ORIF) of closed tibial plateau fracture. This was a further analysis of the prospectively collected data. Adult patients undergoing ORIF procedure for closed tibial plateau fracture between January 2016 and December 2019 were included. Surgeon volume was defined as the number of surgically treated tibial fractures in the preceding 12months and dichotomized on the basis of the optimal cut-off value determined by the receiver operating characteristic (ROC) curve. The outcome was DSSI within oneyear post-operatively. Multiple multivariate logistic models were constructed for "drilling down" adjustment of confounders. Sensitivity and subgroup analyses were performed to assess the robustness of outcome and identify the "optimal" subgroups. Among 742 patients, 20 (2.7%) had a DSSI and 17 experienced re-operations. The optimal cut-off value for case volume was nine, and the low-volume surgeon was independently associated with 2.9-fold (OR, 2.9; 95%CI, 1.1 to 7.5) increased risk of DSSI in the totally adjusted multivariate model. The sensitivity analyses restricted to patients with original BMI data or those operated within 14days after injury did not alter the outcomes (OR, 2.937, and 95%CI, 1.133 to 7.615; OR, 2.658, and 95%CI, 1.018 to 7.959, respectively). The subgroup analyses showed a trend to higher risk of DSSI for type I-IV fractures (OR, 4.6; 95%CI, 0.9 to 27.8) classified as Schatzker classification and substantially higher risk in patients with concurrent fractures (OR, 6.1; 95%CI, 1.0 to 36.5). The surgeon volume is independently associated with the rate of DSSI, and a number of ≥ nine cases/year are necessarily kept for reducing DSSIs; patients with concurrent fractures should be preferentially operated on by high-volume surgeons.

211. Patient, surgery, and hospital-related risk factors for hospital acquired conditions following common spinal procedures during inpatient stays

<h3>BACKGROUND CONTEXT</h3> A total of 48,771 hospital-acquired conditions (HACs) have been reported in United States hospitals. These incidents resulted in excess costs of more than $2 billion, which translated to roughly $40,000 per patient per HAC. Along with this direct fiscal burden, enduring an HAC added on average 8.17 days to each patient's hospital stay, which can lead to indirect hidden costs. <h3>PURPOSE</h3> To critically analyze the classical and novel risk factors of HACs following the most prevalent inpatient spine procedures; spinal fusion (463,200 cases/year) and laminectomy (438,200 cases/year). <h3>STUDY DESIGN/SETTING</h3> Systematic review of observational cohort studies. <h3>PATIENT SAMPLE</h3> This study included 6,382 patients who underwent spine fusion or laminectomy. <h3>OUTCOME MEASURES</h3> Patient-, surgical-, hospital-, related risk factors and genetic associations. <h3>METHODS</h3> Several online databases were searched. Using illustrated figures and diagrams, we aim to provide spine surgeons with the knowledge and evidence about the economic impact, patient-, surgery-, and hospital-related risk factors of HACs. Additionally, we present the novel risk factors such as genetic biomarkers. <h3>RESULTS</h3> Patients undergoing fusion and laminectomy experience HACs at rates of 1.4% and 6.5%, respectively. The incidence of HACs most commonly comprises falls and trauma (87%) and SSIs (11%) for thoracolumbar fusion patients, while laminectomy patients experience venous thromboembolism (VTE) (1.4%) and surgical site infection (SSI) (0.2%) most frequently. Increased age is correlated with higher incidence of HACs. Complication rates in those over 65 are as high as 13.46% with wound complications (1.2%-1.69% of cases) and deep vein thrombosis (DVT) (2.1-2.2%) occurring at rates greater than that of those under 65. BMI less than 40 is associated with increased risk of VTE events and SSI, whereas those over 40 have higher risk of urinary tract infection (UTI). Patients who have had previous spinal surgery have a strong risk of developing wound complications (4.6% vs 1.0% among those without prior surgery). Insulin-dependent diabetes (OR=1.72) may increase the rate of complications and deep SSI following thoracolumbar spinal surgery (p=0.050). Steroid use (OR=1.55) may increase a patient's likelihood of complication. Patients with a preoperative psychiatric disorder are at greater risk of a surgical complication. Regarding hospital-related factors, increased operative time is associated with greater risk of HACs. In patients over the age of 75, the length of operation time (p=0.003) is a contributing factor to wound complications. Moreover, teaching hospitals and those with larger bed sizes may be associated with increased risk for HACs. Lastly, weekend admissions are associated with a 45.3% HAC incidence rate compared to a 4.59% rate in weekday admissions. However, higher surgeon volume is associated with lower complications. The pre-admission testing for novel genetic biomarkers of HACs could stratify the risk of HACs for patients. Patients with higher concentrations of miR-582, miR-195, miR- 532, nitric oxide synthase 3 polymorphism are at higher risk to develop VTE. <h3>CONCLUSIONS</h3> Identifying patient-, surgery-, and hospital- related risk factors in the setting of fusion and laminectomy is crucial to providing patients with optimal care and avoiding the penalties of HACs. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Platelet-Rich Plasma: Optimal Use in Surgical Wounds

Activated platelets release a rich broth of growth factors involved in wound healing. One way to deliver activated platelets to wounds is in the form of platelet-rich plasma (PRP) harvested by centrifuging the patient's venous blood after activating the platelets with collagen or calcium chloride and/or autologous thrombin, then delicately removing the supernatant, called platelet-poor plasma (PPP). Platelet-rich plasma is usually injected into the lesion and/or applied topically, then sealed in or over the wound using a moisture-retentive dressing. Platelet-rich plasma (often with PPP) has been applied at different times, depths, and frequencies to chronic and acute wounds using various PRP doses and vehicles to achieve widely differing results. Meta-analyses have reported that PRP improved healing rates of open diabetic foot ulcers and venous ulcers and may reduce pain and surgical site infection (SSI) incidence in open and closed acute surgical wounds. However, inconsistency in study methods and outcome measures limited consistency of pain and SSI results. No consistent effect on healing or deep SSI rates was reported as a result of adding 1 intraoperative dose of PRP in the surgical site before closing elective foot and ankle surgery incisions of 250 patients as compared with 250 similar patients receiving the same procedure without PRP. After decades of research, ideal parameters of PRP delivery and use on each type of wound remain unclear for improving SSI, acute wound pain, and healing outcomes. This installment of the Evidence Corner reviews 2 surgical studies that may provide clues about optimal PRP use. One triple-blind randomized clinical trial (RCT) focused on irrigation of freshly closed carpal ligament surgical incisions with PRP as compared with PPP. Another non-blind RCT explored the effect of injecting PRP into open pilonidal sinus excisions 4 days and 12 days after surgery.

Intrawound vancomycin application after spinal surgery: a propensity score-matched cohort analysis.

Surgical site infection (SSI) following spine surgery is associated with increased morbidity and healthcare costs. In an effort to reduce SSI rates, the application of intrawound vancomycin powder has gained popularity. However, there is limited high-quality evidence to support the safety and efficacy of this practice. The authors sought to determine if intrawound application of vancomycin powder improves 90-day overall SSI rates. The authors performed a retrospective, vancomycin exposure-matched cohort study at a single tertiary care hospital over 21 months. They included all patients undergoing elective spinal surgery and stratified the patients into two groups: those who received intrawound vancomycin powder application and those who received no application of vancomycin powder. The primary outcome of interest was the 90-day overall SSI rate. Secondary outcomes included rates of superficial SSI, deep SSI, wound disruption, and a post hoc analysis of the microbiology and minimum inhibitory concentrations. Baseline patient demographics, clinical presentation, comorbidities, perioperative factors, and 90-day postoperative outcomes were manually abstracted from patient charts. To mitigate bias, we performed 1:1 matching after calculating propensity scores and identified 1 patient from the no-vancomycin cohort for each patient in the vancomycin cohort. A total of 997 patients met our inclusion criteria (473 patients receiving vancomycin and 524 patients not receiving vancomycin). Propensity score matching produced 221 matched pairs. Risk-adjusted analysis demonstrated similar overall SSI rates between the groups (OR 1.9, p = 0.329). On unadjusted analysis, the overall 90-day SSI rate was greater in the vancomycin group (n = 10 [4.5%]) than in the no-vancomycin group (n = 5 [2.3%]) (p < 0.001), as were the superficial SSI rate (7 [3.2%] vs 4 [1.8%], p < 0.001), deep SSI rate (3 [1.4%] vs 1 [0.5%], p < 0.001), and wound disruption rate (5 [2.3%] vs 1 [0.5%], p < 0.001). No cultured isolate demonstrated vancomycin resistance. The authors observed no difference in SSI rates after the intrawound application of vancomycin powder during spine surgery. Vancomycin use did not contribute to antimicrobial resistance; however, it may select out gram-negative bacteria and increase rates of wound disruption.

A feasibility study of standard dressings versus negative-pressure wound therapy in the treatment of adult patients having surgical incisions for hip fractures: the WHISH randomized controlled trial.

This study sought to compare the rate of deep surgical site infection (SSI), as measured by the Centers for Disease Control and Prevention (CDC) definition, after surgery for a fracture of the hip between patients treated with standard dressings and those treated with incisional negative pressure wound therapy (iNPWT). Secondary objectives included determining the rate of recruitment and willingness to participate in the trial. The study was a two-arm multicentre randomized controlled feasibility trial that was embedded in the World Hip Trauma Evaluation cohort study. Any patient aged > 65 years having surgery for hip fracture at five recruitment centres in the UK was considered to be eligible. They were randomly allocated to have either a standard dressing or iNPWT after closure of the wound. The primary outcome measure was deep SSI at 30 and 90 days, diagnosed according to the CDC criteria. Secondary outcomes were: rate of recruitment; further surgery within 120 days; health-related quality of life (HRQoL) using the EuroQol five-level five-dimension questionnaire (EQ-5D-5L); and related complications within 120 days as well as mobility and residential status at this time. A total of 462 valid randomizations were carried out (232 and 230 in the standard dressing and iNPWT groups, respectively). In the standard dressing group, 14 of 218 patients (6.4%) developed deep SSI. In the iNPWT group, four of 214 patients (1.9%) developed deep SSI. This gives a total rate of SSI of 4.2% (95% confidence interval (CI) 2.7% to 6.5%). Patients and surgeons were willing to participate in the study with 462 patients being recruited from a possible 749 (62.3%). The rate of deep SSI 30 days after surgery for a fracture of the hip was 4%, which makes a study comparing the clinical effectiveness of standard dressings and iNPWT feasible. Cite this article: Bone Joint J2021;103-B(4):755-761.