Risk Of Deep Wound Infection Research Articles

Shoulder arthroplasty for inflammatory arthritis is associated with higher rates of medical and surgical complications: a nationwide matched cohort analysis from 2016-2020

Inflammatory arthritis (IA) represents a less common indication for anatomic and reverse total shoulder arthroplasty (TSA) than osteoarthritis (OA). The safety and efficacy of anatomic and reverse TSA in this population has not been as well studied compared to OA. We analyzed the differences in outcomes between IA and OA patients undergoing TSA. Patients who underwent primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) from 2016-2020 were identified in the Premier Healthcare Database. Inflammatory arthritis (IA) patients were identified using International Classification of Diseases, Tenth Revision, diagnosis codes and compared to osteoarthritis controls. Patients were matched in a 1:8 fashion by age (±3 years), sex, race, and presence of pertinent comorbidities. Patient demographics, hospital factors, and patient comorbidities were compared. Multivariate regression was performed following matching to account for any residual confounding and 90-day complications were compared between the 2 cohorts. Descriptive statistics and regression analysis were employed with significance set at P<.05. Prior to matching, 5685 IA cases and 93,539 OA controls were identified. Patients with IA were more likely to be female, have prolonged length of stay and increased total costs (P<.0001). After matching and multivariate analysis, 4082 IA cases and 32,656 controls remained. IA patients were at increased risk of deep wound infection (OR 3.14, 95% CI 1.38-7.16, P=.006), implant loosening (OR 4.11, 95% CI 1.17-14.40, P=.027), and mechanical complications (OR 6.34, 95% CI 1.05-38.20, P=.044), as well as a decreased risk of postoperative stiffness (OR 0.36, 95% CI 0.16-0.83, P=.002). Medically, IA patients were at increased risk of PE (OR 2.97, 95% CI 1.52-5.77, P=.001) and acute blood loss anemia (OR 1.27, 95% CI 1.12-1.44, P<.0001). Inflammatory arthritis represents a distinctly morbid risk profile compared to osteoarthritis patients with multiple increased surgical and postoperative medical complications in patients undergoing aTSA and rTSA. Surgeons should consider these potential complications and employ a multidisciplinary approach in preoperative risk stratification of IA undergoing shoulder replacement.

Comparing the 30-Day Complications Between Smokers and Nonsmokers Undergoing Surgical Fixation of Ankle Fractures.

Background:There have been conflicting reports regarding the effect of smoking on complications after surgical treatment of ankle fractures. This study aimed at identifying the complications for which smokers and subgroups of smokers are at a higher risk compared to nonsmokers when undergoing surgery for fixation of rotational ankle fractures.Methods:The American College of Surgeons National Surgical Quality Improvement Program data set from 2008 to 2019 was used to compare the 30-day wound, cardiac, renal, and infectious complications, related readmissions, and return to the operating room between the 2 cohorts.Results:Of 33 741 patients included, 25 642 (76.0%) were nonsmokers and 8099 (24.0%) were smokers. Multivariate analysis showed that smokers were at a higher risk for deep wound infection (OR 2.34, 95% CI 1.48-3.69, P < .001), wound dehiscence (OR 2.43, 95% CI 1.56-3.77, P < .001), related return to the operating room (OR 1.69, 95% CI 1.36-2.11, P < .001), and related readmissions (OR 1.67, 95% CI 1.32-2.09, P < .001). Smokers at an increased risk for deep infection included patients between 50 and 59 years (OR 5.75, 95% CI 1.78-18.5, P = .003), who were Black (OR 4.24, 95% CI 1.04-17.23, P = .044), who had body mass index (BMI) 35 to 39.9 (OR 3.73, 95% CI 1.46-9.50, P = .006), or operative times between 60 and 90 minutes (OR 3.64, 95% CI 1.79-7.39, P < .001). Smoker subgroups at a higher risk for wound dehiscence included patients between 50 and 59 years (OR 9.86, 95% CI 3.29-29.53, P < .001), with operative times between 90 and 120 minutes (OR 4.88, 95% CI 1.89-12.58, P < .001), with BMI 30 to 34.9 (OR 3.06, 95% CI 1.45-6.45, P = .003) and who underwent spinal/epidural anesthesia (OR 9.31, 95% CI 2.31-37.58, P = .002).Conclusion:Smokers were at an increased risk for deep wound infection, wound dehiscence, related reoperations, and related readmissions after ankle fracture surgery. Certain subgroups were at an even higher risk for these complications.Level of Evidence:Level III, retrospective cohort study.

Evaluation of the Functional and Radiological Outcomes of Antibiotic-Coated Intramedullary Interlocking Nailing for Gustilo and Anderson Grades 2 and 3 Open Tibial Shaft Fractures.

Background: Tibial shaft fractures are the most common fractures among long bones. At present, implants coated with broad-spectrum antibiotics have been developed, and antimicrobial eluting implants are widely used in clinical practice.Materials and methods: This prospective study was conducted among 40 patients with tibial shaft fractures who visited the Department of Orthopedics in RL Jalappa Hospital, Tamaka, Kolar, Karnataka, from February 2021 to September 2021. As it is a large trauma center near the national highway, all 40 cases, including the referral cases, were operated within two months of the initiation of the study, with the last case operated in March 2021. The inclusion criteria were: patients aged more than 18 years, diaphyseal tibial fractures definitively treated by antibiotic coated intramedullary nailing, and Gustilo and Anderson grades 2, 3A, and 3B open tibial shaft fractures. All patients with grades 2, 3A, and 3B open fractures of the tibial shaft were treated with antibiotic-coated nails and followed up at one, three, and six months post-surgery.Results: The mean age of patients was 35.6 years, and the mean union time of fractures was 4.2 months. Road traffic accidents (RTA) are the most common etiology for tibial bone fractures. In this study, grade 3A open fractures had the highest number of cases (N = 26). No patients in the present study developed superficial or deep infections post-operatively. All patients were assessed with Johner-Wruhs criteria at each follow-up, and they showed improvement in knee and ankle joint mobility, pain, and deformity. Most patients achieved good functional results after postoperative follow-up, followed by those with excellent results. According to the radiographic union scale in tibial shaft fractures criteria, 23 patients showed good radiological results after postoperative follow-up, followed by 15 patients with excellent and 2 patients with fair results.Conclusion: Most of the patients showed good to excellent functional and radiological results according to Johner-Wruhs and Radiographic Union Scale for Tibial fractures (RUST) criteria. The use of antibiotic-coated nails to treat compound tibial fractures was associated with a decreased risk of deep wound infections and good fracture healing.

Open Abdominal Aortic Aneurysm Repair Is Associated with Higher Mortality Among Nonobese Patients and Higher Risk of Deep Wound Infections Among Obese Patients

Prevalence of obesity in the United States is increasing. The impact of obesity on outcomes after endovascular and open abdominal aortic aneurysm (AAA) repair is largely unknown. The purpose of this analysis was to compare the postoperative outcomes between obese and nonobese patients after these operations. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from years 2013-2015 was analyzed. Preoperative, intraoperative, and postoperative variables were compared between obese and nonobese patient groups. Then obese and nonobese patients were divided into 2 groups each, based on the type of surgery (endovascular repair of abdominal aortic aneurysms (EVAR) versus. open AAA repair), and the outcomes were compared. Then multivariant analysis was used to compare impact of operative modality on outcomes for obese and nonobese patients. A total of 6,859 patients (men 80%, women 20%) underwent surgical procedures for AAA during this time period. Among these patients, 2,218 (32.3%) had body mass index (BMI) ≥30, and 4,641 (67.7%) had BMI <30. Obese patients were less likely to be>80years old, women, nonwhites, and smokers. Obese patients had lower mortality and higher risk of deep wound infections after surgery (P<0.05). Among the obese patients, 83.1% underwent EVAR and 16.9% underwent open AAA repair; patients undergoing EVAR had shorter operative times, shorter length of hospital stays, and mortality (P<0.05). Among nonobese patients, 81% underwent EVAR and 19% underwent open AAA repair. Patients undergoing EVAR had shorter duration of operation, length of hospital stay, and mortality (P<0.05). Overall, mortality was the highest among nonobese patients undergoing open AAA repair (odds ratio (OR) 0.66, confidence interval (CI) 0.44-0.99, P<0.05). Incidence of deep wound infections was the highest among obese patients undergoing open AAA repair (OR 4.3, CI: 1.2-14.6, P<0.05). Nonobese patients have high mortality after open AAA repair, and obese patients have higher incidence of deep wound infections after open AAA repair. For patients deemed appropriate anatomic candidates, EVAR should be preferred for nonobese patients to improve mortality and for obese patients to reduce the incidence of deep wound infections.

Prolonged Post-surgical Drain Retention Increases Risk for Deep Wound Infection After Spine Surgery

Surgical site infections (SSIs) complicate 1% to 9% of elective spine surgeries. Previously identified risk factors include diabetes mellitus type 2, obesity, and chronic kidney disease. We sought to determine whether the use of postoperative surgical site drains is associated with deep SSIs. We retrospectively identified patients operated for deep SSIs after surgery for degenerative spine pathologies between July 2016 and December 2018. Patients were excluded if the reason for operation was other than deep SSI or if their primary operation was for infection or tumor. Using their index procedure and the electronic medical record, patients were matched to controls based on age, surgical invasiveness, International Classification of Diseases, Tenth Revision, Clinical Modification code, race, and sex. Our main outcome of interest was whether drain retention time, total output, or daily output differed significantly between cases and controls. We identified 38 patients who met inclusion criteria. Infected patients had a higher body mass index (34.2 vs. 29.9 kg/m2; P= 0.001), higher odds of having diabetes mellitus type 2 (55.3% vs. 18.4%; P= 0.002), longer drain retention time (5.5 vs. 3.5 days; P= 0.02), and longer inpatient stay (9.5 vs. 4.3 days; P= 0.005). Multivariable logistic regression demonstrated that even after controlling for the other risk factors, drain retention time independently predicted postoperative surgical site infection (odds ratio: 1.36; P= 0.02). Prolonged surgical drain retention correlates with risk of deep SSI after surgery for degenerative spine disease independent of surgical invasiveness, diabetes mellitus type 2 status, and total drain output. Our data suggest early postoperative drain removal may potentially decrease the risk of SSI and shorten duration of hospital stay.

Surgical wound infection following open humeral fracture caused by Mycobacterium houstonense: a case report

BackgroundHistorically Mycobacterium houstonense belongs to the unnamed third biovariant complex of the Mycobacterium fortuitum group, which are sorbitol positive. To date, there have been few reports of human infection induced by M. houstonense worldwide.Case presentationWe describe the case of a 68-year-old man with surgical wound infection, following an open humeral fracture, caused by M. houstonense and Escherichia coli. An implant bone plate had been embedded for internal fixation during surgery on the humeral fracture previously. A week later E. coli was isolated from the skin wound secretions. Cefoperazone-sulbactam was used for treatment for two weeks but the infection was not controlled, with a subsequent risk of deep wound infection. External fixation of the fracture was then performed instead of internal fixation. Ten days later, M. houstonense was isolated from new wound secretions. M. houstonense was identified by the molecular sequencing method. The TREK Diagnostic System was used to test the susceptibility to antibiotics by the microbroth dilution method. Levofloxacin and amikacin were used for treatment according to the results of the susceptibility test and the patient’s condition obviously improved.ConclusionTo the best of our knowledge, this is the first case in China of human surgical wound infection caused by M. houstonense following open humeral fracture. The combination of levofloxacin and amikacin was effective in the treatment of M. houstonense infection.

Correction of Adolescent Idiopathic Scoliosis Using a Convex Pedicle Screw Technique: A Novel Technique for Deformity Correction.

We describe our convex segmental pedicle screw technique for the treatment of adolescent idiopathic scoliosis. We developed this technique to achieve optimum 3-dimensional deformity correction while reducing the surgical risks of an inherently dangerous procedure. The surgery involves a wide posterior subperiosteal exposure across the deformity levels to the tips of the transverse processes. Posterior releases are performed through facetectomies. Pedicle screws are placed using a freehand technique based on anatomical landmarks. Adequate screw positioning is assessed with an image intensifier before rod engagement. Segmental pedicle screws are placed across the convexity of each curve included in the fusion. Proximal and distal fixation of the rods on the contralateral side is performed across 2 pedicle screw anchors. We use titanium rods bilaterally. Curve correction is done using the convex pedicle screws by applying segmental vertebral translation and derotation starting with the main thoracic curve followed by the lumbar curve. Segmental compression or distraction is performed at the proximal and distal ends of the construct to level the end vertebrae included in the fusion. Maximum correction of the main thoracic scoliosis is done, whereas the lumbar scoliosis (which is usually more flexible) is corrected to the point that results in a globally balanced spine in the coronal plane. The rod attached on the convex side of the main thoracic scoliosis is overbent to restore thoracic kyphosis, and the aim is always to achieve regional and global sagittal balance. An interfacetal, intertransverse, and interlaminar fusion is performed with use of locally harvested bone supplemented by allograft bone. With previous techniques, the use of bilateral segmental pedicle screw fixation has been advocated as a requirement to achieve adequate deformity correction in patients with adolescent idiopathic scoliosis. This technique is associated with low risks of neurological and vascular complications because the screws are placed at the convex pedicles, away from the spinal cord/cauda equina and the aorta. The use of far fewer pedicle screws compared with previous techniques reduces surgical time and blood loss, which is related to lower postoperative morbidity. It may also decrease the risk of deep wound infection, which is associated with the number of implants used. Low implant density (1.2, with a density of 2 representing placement of pedicle screws bilaterally at every instrumented segment) with our technique can achieve satisfactory scoliosis correction, improved thoracic kyphosis, and normal global sagittal balance. Our use of this technique has resulted in excellent patient satisfaction and functional outcomes with no neurological complications or intraoperative neuromonitoring events, deep wound infections, detected nonunions, or need for revision surgery.

The Association Between Perioperative Outcomes and BMI Among Patients Who Underwent TLH for Uterine Cancer [8J

INTRODUCTION: Greater degree of obesity can pose surgical challenges in patients who undergo open surgery. As total laparoscopic hysterectomy (TLH) is becoming utilized widely for uterine cancer, our objective is to assess the association between patient body mass index (BMI) and perioperative outcomes. METHODS: A retrospective analysis of the American College of Surgeons-National Surgical Quality Improvement (ACS-NSQIP) database during 2005-2013 was conducted. Women with uterine cancer who underwent TLH, including robotically-assisted and conventional routes, were identified. We used preoperative BMI (kg/m2) to estimate the degree of obesity as follows: normal (&lt; 25), overweight (25-29.9), obese (30-39.9), and morbidly obese (≥40). RESULTS: TLH was performed in 3630 women with uterine cancer during 2005-2013. Of those, 15.9%, 18.9%, 36.9%, and 28.2% had normal, overweight, obese, and morbidly obese BMI. The mean operation time (minutes) was significantly higher in overweight (159), obese (158), and morbidly obese (171) women than women with normal BMI (145, p &lt; 0.05). The wound infection rate in the morbidly obese group (1.3%) was higher than for normal (0.2%), overweight (0.1%), and obese (0.5%) women (p &lt; 0.05). We did not observe an association between patient BMI and length of hospital stay, incidence of blood transfusion, or thromboembolic episodes. CONCLUSION: In women with uterine cancer, morbid obesity was associated with greater risk of deep wound infections and greater operation time following TLH. Hospital stay and readmission within 30 days was not affected by the level of obesity.

Dynamic stabilization: a nidus for infection?

Introduction: Dynamic stabilization offers an adjunct to fusion with motion preservation. In comparison, standard instrumented fusion (if) consists of titanium screws and rods/plates, which do not allow for motion at the level of the fusion. The reported infection rate following a standard if ranges from 0.2% to 7%. Methods: a retrospective chart review of 142 patients who underwent posterior lumbar stabilization procedures was conducted. Ten patients received dynamic stabilization and 132 patients had a standard if. Rates of infection, requiring hardware removal, were compared between the aforementioned groups. Results: Of the 132 patients undergoing posterior if, three developed a deep wound infection requiring removal of hardware (2.3%). Of the 10 patients undergoing dynamic stabilization, three developed a deep wound infection (30%) with 2 requiring removal of hardware (20%), secondary to persistent deep wound infection or osteomyelitis at the pedicle screw sites. There was a significantly increased risk of deep wound infection (p < 0.0001) with the use of dynamic stabilization compared to standard if. Conclusions: Our series demonstrates that the infection rate in patients undergoing dynamic stabilization is higher than the infection rate for instrumented fusion without a significant difference in comorbidity scores. We postulate that the polycarbonate urethane spacer acts as a medium for bacteria, whereas the titanium screws and rods are smooth, solid, and inert, resulting in a lower risk of infection.

Systematic review and meta-analysis of the additional benefit of local prophylactic antibiotic therapy for infection rates in open tibia fractures treated with intramedullary nailing.

PurposeThis analysis compared the rate of deep wound infections in patients with open tibia fractures, treated with intramedullary nails, receiving additional locally-delivered antibiotics to those receiving standard care.MethodsTwo systematic literature searches identified studies reporting infection rates in patients treated with intramedullary nails for tibia fractures receiving systemic antibiotics only (search one) and in patients receiving adjunctive locally-administered antibiotics peri-operatively at the tissue-implant interface (search two). After applying inclusion and exclusion criteria, 14 and seven papers from searches one and two, respectively, were included in meta-analyses.ResultsThe absolute rate of infection was lower for all Gustilo-Anderson grades of tibia fractures when local antibiotics were administered as adjunctive prophylactic therapy. For severe fractures, classified as GAIII fractures, patients receiving systemic antibiotics only had an infection rate of 14.4 % [95 % CI: 10.5 %, 18.5 %]; adding local antibiotics reduced the rate to 2.4 % [0.0 %, 9.4 %], with an odds ratio of 0.17. Risk of deep wound infections increased with severity of fracture, rising to over 31 % in GIIIB&C fractures for patients receiving systematic antibiotics only, but to below 9 % with additional local antibiotics.ConclusionThe findings support consideration of augmenting the antibiotic prophylaxis regimen to include locally-delivered antibiotics. Patients with severe fractures will obtain greatest benefit from infections avoided. No trial directly compared the two treatments for open tibia fractures, limiting the ability to attribute the differences in observed infection rates directly to the treatments themselves. A large comparative study to improve the evidence on relative effect size is merited.Level of evidence: Level III.

Deep Wound Infections After Spinal Fusion in Children With Cerebral Palsy

Prospective cohort. To (1) calculate the rate of deep wound infection in children with cerebral palsy (CP) after spinal fusion surgery; (2) identify factors (patient, laboratory, and surgical) associated with deep wound infection development; and (3) report causative organisms. Wound infection after spine fusion for CP is more common than after spine fusion for most other diagnoses. We prospectively gathered data on 204 consecutive pediatric patients with CP who underwent surgery at 7 institutions. Univariate and multivariate regression analysis was performed to analyze patient, laboratory, and surgical characteristics to identify factors that were significantly associated with infection development. Statistical significance was set at a value of P less than 0.05. Deep wound infection developed in 13 (6.4%) children. The mean time to infection development was 34.2 ± 60.2 days. On univariate analysis, older age, larger curve size, presence of gastrostomy/gastrojejunostomy tube, higher preoperative serum white blood cell count, and longer operative time were significantly associated with deep wound infection. On multivariate analysis, only the presence of a gastrostomy/gastrojejunostomy tube remained significant (1.9-fold risk of deep wound infection compared with patients without tubes). Escherichia coli was the most common organism cultured from the wound sites (5 patients). Other infective agents were: Pseudomonas aeruginosa (2), methicillin-susceptible Staphylococcus aureus (1), Proteus mirabilis (1), and polymicrobial organisms (4). Deep wound infection occurred in 6.4% of children with CP after spinal fusion. The presence of a gastrostomy/gastrojejunostomy tube was a significant predictor of infection. Gram-negative organisms were the most common causative agents. Surgeons should be cognizant of these factors when treating children with CP and may consider Gram-negative antibiotic prophylaxis.

Operative and Clinical Markers of Deep Wound Infection After Spine Fusion in Children With Cerebral Palsy

Infection after spine fusion for neuromuscular scoliosis has been shown to range from 4.2% to 20.0% prevalence. Although there are studies, which have examined deep wound infection and spine fusion surgery as well as risk factors for deep wound infection, there are limited studies evaluating clinical and radiographic factors associated with this complication. We aimed to determine the clinical and operative factors associated with deep wound infection after spine fusion in pediatric patients with cerebral palsy (CP). Medical records of 236 pediatric patients, aged between 5.6 and 21 years (mean=13.8 ± 3.4), with CP who underwent spine fusion from 1995 to 2006 were reviewed. Of these, 22 patients had deep wound infection. To assess the differences in clinical, radiographic, and other predisposing factors, we used χ statistic and Fisher exact, and to determine the predisposing factors of deep wound infection, we used binomial regression model. The period prevalence of deep wound infection was 9.3%. In the unadjusted model, body weight, residual postoperative Cobb angle, length of hospitalization, packed red blood cells, and skin breakdown were the factors significantly associated with deep wound infection (P<0.05). After controlling for confounding, skin breakdown due to the instrumentation and residual postoperative Cobb angle were the 2 most potent markers of deep wound infection. There was a significant 4% increased risk of deep wound infection for 1-degree increase in the residual Cobb angle from the noncase mean residual Cobb angle of 23.69 degrees (adjusted risk ratio=1.04; 95% confidence interval, 1.01-1.08). Likewise, compared with those without skin breakdown, those with skin breakdown were 12 times as likely to develop deep wound infection (risk ratio=12.92; 95% confidence interval, 1.00-172.00). Residual postoperative Cobb angle and skin breakdown due to unit rod instrumentation were the 2 most significant predisposing factors to deep wound infection. Other factors included body weight, packed red blood cells, and length of hospitalization. As the overall prevalence of deep wound infection is relatively high in CP patients after spine fusion, and considering the cost of hospitalization and other related comorbidities, surgeons should recognize these predisposing parameters to prevent deep wound infection in CP patients while correcting curve deformities. Level III retrospective study.

Limb salvage or amputation? The use of a gentamicin coated nail in a severe, grade IIIc tibia fracture.

Severe grade IIIc tibial fractures have limited treatment options. The decision between limb salvage or amputation depends on many factors, including the age and health status of the patient, as well as the soft tissue status and associated injuries. Until recently, intramedullary nailing was not a favoured treatment option in such tibial fractures, since it is associated with an increased risk of deep wound infections and osteomyelitis. Here we present a case where a novel polylactic acid/gentamicin coated unreamed tibial nail (UTN-PROtect(®)) has been used to successfully salvage the limb of a 17-year-old man, where prolonged external fixation or amputation would have been the standard treatment. This case demonstrates that treating severe grade IIIc tibial fractures with the acid/gentamicin coated unreamed tibial nail (UTN-PROtect(®)) is a viable alternative to prolonged external fixation or amputation. The gentamicin-loaded coating of the UTN-PROtect(®) nail, which releases the antimicrobial agent directly at the bone-implant inter-face, overcomes the limitation of insufficient antibiotic delivery. Awareness of this case and the existing literature supporting the use of an antibiotic coated nail may assist surgeons in their decisions on how to treat severe grade IIIc fractures.

Arthroplasty or internal fixation for displaced femoral neck fractures: which is the optimal alternative for elderly patients? A meta-analysis

We conducted an up-to-date meta-analysis of 20 eligible randomised controlled trials (RCTs) containing 3,109 patients to compare arthroplasty with internal fixation of displaced femoral neck fractures regarding the effect on clinical outcomes. Computerised databases were searched for RCTs published from January 1979 to May 2008. The results showed that compared to internal fixation arthroplasty led to significantly fewer surgical complications at two and five years postoperatively and reduced the incidence of reoperation at one, two and five years postoperatively (P < 0.001). However, arthroplasty was associated with greater risk of deep wound infection, longer operating time and greater operative blood loss. Arthroplasty substantially increased the risk of reoperation following deep wound infection (P < 0.05). For mortality, there was increased postoperative risk for arthroplasty compared with internal fixation, but there was no statistically significant difference between the two groups at the different follow-up times. For pain at one year postoperatively, the result showed no statistically significant difference.

Protecting the Crossover Right Internal Thoracic Artery Bypass Graft With a Pedicled Thymus Flap

The right internal thoracic artery graft is placed in jeopardy during repeat sternotomy as it crosses the aorta anteriorly to reach its left-sided coronary targets. We have devised a way of protecting it by means of a pedicled flap taken from the thymic remnants. The flap is easily developed without unduly increasing operative time and morbidity, and it is expected to prevent inadvertent injuries to the graft in the case of mediastinal reentry. Starting in 1999, suitable flaps were obtained in 955 of 1,034 patients (92.4%) receiving an anteaortic crossover right internal thoracic artery-to-coronary graft in our division.

Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults

Displaced intracapsular fractures may be treated by either reduction and internal fixation, which preserves the femoral head, or by replacement of the femoral head with an arthroplasty. To review all randomised controlled trials that have compared internal fixation with arthroplasty for intracapsular femoral fractures in adults. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2005, Issue 4), MEDLINE, EMBASE, the UK National Research Register, several orthopaedic journals, conference proceedings and reference lists of articles. We contacted trialists where possible. All randomised and quasi-randomised controlled trials comparing internal fixation with arthroplasty for intracapsular hip fractures in adults. Trial quality was assessed by use of a 10 item scale. At least two review authors independently assessed trial quality and extracted data. Additional information was sought from trialists. After grouping into three broad categories, comparable groups of trials were subgrouped and where appropriate, data were pooled using the fixed-effect model. Seventeen trials involving 2694 participants were included. Length of surgery, operative blood loss, need for blood transfusion and risk of deep wound infection were significantly less for internal fixation compared with arthroplasty. Arthroplasty had a significantly lower re-operation rate in comparison with fixation. No definite differences for hospital stay, mortality, or regain of same residential state were found. Limited information from some studies suggested pain was less and function was better for a cemented arthroplasty in comparison to fixation. Internal fixation is associated with less initial operative trauma but has an increased risk of re-operation on the hip. Definite conclusions cannot be made for differences in pain and residual disability between the two groups. Future studies should concentrate on better reporting of final outcome measures and there is still a need for studies to define which patient groups are better served by the different treatment methods.

Does use of a right internal thoracic artery increase deep wound infection and risk after previous use of a left internal thoracic artery?

To determine whether adding right internal thoracic artery to previous left internal thoracic artery bypass at reoperation increases deep sternal wound infection and hospital mortality, particularly in diabetic patients. Reoperations (n = 2875; 2381 men) in patients with previous left internal thoracic artery bypass were performed between January 1990 and January 2003; 1939 (67%) had no repeat internal thoracic artery grafting, 923 (32%) received an additional right internal thoracic artery graft, and 13 (0.5%) had bilateral internal thoracic artery grafting with reuse of the left internal thoracic artery. Of the patients, 352 (12%) were insulin-treated and 590 (21%) non-insulin-treated diabetics. Multivariable logistic regression analysis was used to identify preoperative variables associated with right versus non-right internal thoracic artery use in diabetics and nondiabetics and to formulate propensity models. Propensity scores were used for matching and adjusted multivariable analyses of deep wound infection and hospital mortality. Deep wound infection occurred in 3.0% (7/230) of diabetics receiving right internal thoracic artery grafts, 2.2% (5/230) of propensity-matched diabetics receiving non-right internal thoracic artery grafts (P = .6), in 1.1% (6/538) of nondiabetics receiving right internal thoracic artery grafts, and in 1.0% (5/538) of matched non-diabetic patients receiving non-right internal thoracic artery grafts (P = .8). Corresponding hospital mortality in these matched groups was 1.7% (4/230) versus 6.1% (14/230) for diabetics (P = .02) and 2.6% (14/538) versus 3.5% (19/538) for nondiabetics (P = .4). Risk factors for deep wound infection included higher weight (P = .0003), higher New York Heart Association functional class (P = .03), and less severe left anterior descending disease (P = .03). Risk factors for death were (P < .02) emergency operation, mitral valve replacement, and greater number of saphenous vein grafts. Use of the right internal thoracic artery for reoperations does not increase the risk of deep wound infections in diabetics or nondiabetics and does not increase mortality.

Reducing the Risk of Deep Wound Infection in Primary Joint Arthroplasty With Antibiotic Bone Cement

Despite significant advances in intraoperative antimicrobial procedures, deep wound infection remains the most serious complication associated with primary, cemented total joint arthroplasty. A systematic review was conducted to evaluate studies of antibiotic bone cement prophylaxis for reducing the risk of deep wound infection. The literature included 22 articles providing estimates of the prophylactic effectiveness of antibiotic cement. In reducing deep wound infection, antibiotic cement was consistently superior to plain cement, similar to systematic antiobiotics, and independent and additive in effect when combined with other prophylactic measures. Randomized controlled trials in particular had important methodological limitations. However, the collective results nearly unanimously favored prophylactic use of antibiotic cement in primary arthoplasty procedures.

Risk Factors for Pediatric Mediastinitis after Cardiac Surgery: Investigation of a Case Cluster

BACKGROUND: Mediastinitis is a rare but serious complication of cardiothoracic surgery. Active surveillance of children undergoing cardiac surgery with median sternotomy revealed a cluster of five cases of deep sternal wound infection or mediastinitis (DSW-M) within a 2-month period. OBJECTIVES: To identify risk factors for DSW-M in children undergoing median sternotomy. METHODS: Cases of DSW-M were identified by active surveillance of all cardiac surgical patients at the Children's Hospital of Philadelphia. Four control patients were randomly selected from all patients undergoing median sternotomy who survived for >30 days after surgery. Controls for each case were matched by month of surgery and age group. Data was collected from review of microbiology laboratory reports and medical records. RESULTS: Bacterial cultures revealed three infections due to Staphylococcus aureus, and one due to vancomycin-resistant Enterococcus. The fifth patient's infection was polymicrobial; cultures from this patient grew Serratia marcescens and Pseudomonas aeruginosa. DSW-M was more common in children with complex cardiac physiology. Children with two ventricles with a normal aortic arch at the time of surgical procedure had a lower risk of developing DSW-M (p=0.02). Factors associated with an increased risk of deep wound infection included prolonged bypass time (p=0.004), need for re-operation within 48 hours (p=0.04), and inappropriate timing of peri-operative antibiotic prophylaxis (p=0.05). Factors not associated with DSW-M included presence of intracardiac pacemaker wires, right atrial catheters, or the use of prosthetic material. In addition, DSW-M was not associated with a specific surgeon, anesthetist, perfusionist, or nurse. CONCLUSION: DSW-M occurs more commonly following surgical intervention for severe congenital heart anomalies. Most identified risk factors for DSW-M were not modifiable. However, improved timing of peri-operative antibiotic prophylaxis might reduce the incidence of DSW-M in these susceptible patients.

Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults.

Displaced intracapsular fractures may be treated by either reduction and internal fixation which preserves the femoral head, or by replacement of the femoral head with an arthroplasty. To review all randomised trials that have compared internal fixation and arthroplasty. We searched the Cochrane Musculoskeletal Injuries Group specialised register (January 2002), MEDLINE (1966 to January 2002), EMBASE (1988 to 2002, Week 2), Current Contents (1993 to 2002, Week 4), PREMEDLINE (January 2002) and selected orthopaedic journals and conference proceedings, and reference lists of relevant articles. We contacted trialists where possible. All randomised and quasi-randomised trials comparing internal fixation with arthroplasty for intracapsular hip fractures in adults. Trial quality was assessed by use of a 10 item scale. Data from the majority of trials were independently extracted by three reviewers with the remaining extracted by two. Additional information was sought from trialists. After grouping into three broad categories, comparable groups of trials were subgrouped and where appropriate, data were pooled using the fixed effects model. Thirteen trials involving 2091 patients were included. Internal fixation had a reduced length of surgery, operative blood loss, need for blood transfusion and risk of deep wound infection. Arthroplasty had a lower re-operation rate in comparison with fixation. No definite differences for hospital stay, mortality, degree of residual pain, regain of mobility or regain of same residential state were found. Internal fixation is associated with less initial operative trauma but has an increased risk of re-operation on the hip. Definite conclusions cannot be made for differences in pain and residual disability between the two groups. Future studies should concentrate on better reporting of final outcome measures and there is still a need for studies to define which patient groups are better served by the different treatment methods.