Site Infections In Orthopedic Surgery Research Articles

Duration of surgical antibiotic prophylaxis and surgical site infection in orthopaedic surgery: A prospective cohort study.

The optimal duration for surgical antibiotic prophylaxis (SAP) for preventing surgical site infection (SSI) in orthopaedic surgeries remains poorly supported by high-level evidence. This study aimed to assess the association between SAP duration and the occurrence of SSI within one year postoperatively. This prospective cohort study was based on the database from Surgical Site Infection Surveillance and Improvement Project (SISIP) of a tertiary orthopaedic university hospital from October 2014 to December 2020. The main outcome was SSI, defined according to the CDC/NHSN criteria, determined by review of index hospitalization medical records, microbiology laboratory reports, and readmission records for SSI treatment within one-year after discharge. Adjusted Generalized additive models (GAMs) were performed to assess the relationships between SAP duration and SSI, determined the cut-off point of SAP duration, and estimate the relative contribution of each included variable, across the overall cohort and the three subgroups (open fracture, closed fracture, and non-traumatic group). Multivariable logistic regression models were used to estimate the association between prolonging SAP duration based on the cut-off point and SSI. There were 37,046 patients (55.1% male) included, with the overall SSI incidence of 2.35% (871/37,046). In adjusted GAMs, no statistically significant relationships were observed in overall cohort and open or closed group (P>0.05), but a nonlinear relationship was exhibited non-traumatic group (P=0.03); the cut-off point were 2.4 days for overall cohort and 3.6 days (open), 2.6 days (closed), 1.1 days (non-trauma) for three subgroups. In adjusted logistic regression, prolonging SAP duration did not demonstrate a statistically significant protective effect in overall cohort (aOR=0.868; 95% CI, 0.746-1.011) and three groups (open: aOR=0.867; 95% CI, 0.668-1.124; closed: aOR=0.925; 95% CI, 0.754-1.135; non-trauma: aOR=1.184; 95% CI, 0.832-1.683). The relative contribution ranks of SAP duration were 21st overall among 34 factors, 14th for open fractures, 28th for closed fractures, and 3rd for non-traumatic group among 33 factors. Prolonged postoperative SAP duration has no protective effect against SSI in orthopaedic surgery. Our findings support current guidelines against the practice of continuing SAP postoperatively.

Staphylococcus aureus screening and preoperative decolonisation with Mupirocin and Chlorhexidine to reduce the risk of surgical site infections in orthopaedic surgery: a pre-post study

BackgroundNasal carriage of Staphylococcus aureus is a risk factor for surgical site infections (SSI) in orthopaedic surgery. The efficacy of decolonisation for S. aureus on reducing the risk of SSI is uncertain in this speciality. The objective was to evaluate the impact of a nasal screening strategy of S. aureus and targeted decolonisation on the risk of S. aureus SSI.MethodsA retrospective pre-post and here-elsewhere study was conducted between January 2014 and June 2020 in 2 adult orthopaedic surgical sites (North and South) of a French university hospital. Decolonisation with Mupirocin and Chlorhexidine was conducted in S. aureus carriers starting February 2017 in the South site (intervention group). Scheduled surgical procedures for hip, knee arthroplasties, and osteosyntheses were included and monitored for one year. The rates of S. aureus SSI in the intervention group were compared to a historical control group (South site) and a North control group. The risk factors for S. aureus SSI were analysed by logistic regression.ResultsA total of 5,348 surgical procedures was included, 100 SSI of which 30 monomicrobial S. aureus SSI were identified. The preoperative screening result was available for 60% (1,382/2,305) of the intervention group patients. Among these screenings, 25.3% (349/1,382) were positive for S. aureus and the efficacy of the decolonisation was 91.6% (98/107). The rate of S. aureus SSI in the intervention group (0.3%, 7/2,305) was not significantly different from the historical control group (0.5%, 9/1926) but differed significantly from the North control group (1.3%, 14/1,117). After adjustment, the risk factors of S. aureus SSI occurrence were the body mass index (ORaper unit, 1.05; 95%CI, 1.0-1.1), the Charlson comorbidity index (ORaper point, 1.34; 95%CI, 1.0–1.8) and operative time (ORaper minute, 1.01; 95%CI, 1.00–1.02). Having benefited from S. aureus screening/decolonisation was a protective factor (ORa, 0.24; 95%CI, 0.08–0.73).ConclusionsDespite the low number of SSI, nasal screening and targeted decolonisation of S. aureus were associated with a reduction in S. aureus SSI.

Effective screening methods to prevent surgical site infections in orthopedic surgery: an observational study

BackgroundThe bacterial source of surgical-site infections (SSIs) can have either endogenous and/or exogenous origins, and some studies have revealed that endogenous transmission is an important pathway for SSIs in orthopedic surgery. However, since the frequency of SSIs is low (0.5–4.7%), screening all surgery patients is labor-intensive and cost-prohibitive. The goal of this study was to better understand how to improve the efficacy of nasal culture screening in preventing SSIs.MethodsNasal cultures for 1616 operative patients over a 3-year period were evaluated for the presence of nasal bacterial microbiota and the species identity. We also investigated the medical factors that influence colonization and evaluated the ratio of agreement between nasal cultures and SSI-causing bacteria.ResultsIn a survey of 1616 surgical cases, 1395 (86%) were normal microbiota (NM), 190 (12%) were MSSA carriers, and 31 (2%) were MRSA carriers. The risk factors for MRSA carriers were significantly higher than the NM group in patients with a history of hospitalization (13 [41.9%], p = 0.015), patients who had been admitted to a nursing facility (4 [12.9%], p = 0.005), and patients who were > 75 years of age (19 [61.3%], p = 0.021). The incidence of SSIs was significantly higher in the MSSA group (17/190 [8.4%]) than the NM group (10/1395 [0.7%], p = 0.00). The incidence of SSIs in the MRSA group (1/31 [3.2%]) tended to be higher than that in the NM group, but there was no statistically significant difference (p = 0.114). The concordance rate between causative bacteria of SSI and species present in nasal cultures was 53% (13/25 cases).ConclusionsThe results of our study suggest screening patients with a history of past hospitalization, a history of admission in a long-term care facility, and older than 75 to reduce SSIs.Trial registrationThis study was approved by the institutional review board of the authors’ affiliated institutions (the ethics committee of Sanmu Medical Center, 2016-02).

INTRA-WOUND ANTIBIOTIC POWDER TO REDUCE DEEP SURGICAL SITE INFECTIONS IN LOWER LIMB AND PELVIC TRAUMA

Surgical site infections following orthopaedic surgery are a serious complication associated with increased morbidity and mortality. Intra-wound antibiotic powder may be able to provide infection prophylaxis locally with less systemic adverse effects, and promising results have been reported in systematic reviews of its use in spine surgery. This study aims to analyse the efficacy and adverse effect profile of intra-wound antibiotics in reducing surgical site infections in orthopaedic surgery for traumatic pelvic and lower limb fractures.A systematic review was conducted for studies reporting on the incidence of surgical site infections following administration of intra-wound antibiotic powder in pelvic and lower limb trauma surgery. Randomised controlled trials, cohort and case-control studies were included. A meta-analysis was conducted for deep surgical site infections.Seven studies were included in the systematic review including six retrospective case-control studies and one randomised controlled trial. Results of the meta-analysis suggest a potential 23% reduction in the odds of developing a deep surgical site infection in patients treated with intra-operative antibiotic powder compared with those managed with intravenous antibiotics alone (OR 0.77, 95% CI 0.52 – 1.13), although the results did not reach statistical significance.Notable selective bias against intra-wound antibiotics and suboptimal study design were found in the retrospective studies, however the randomised controlled trial reported a significant reduction in deep surgical site infections with intra-wound vancomycin powder. There were no reports of systemic adverse outcomes and minimal risk of wound complications with the use of intra-wound antibiotics.This review suggests the use of intra-wound antibiotic powder in pelvic and lower limb trauma surgery may reduce the incidence of deep surgical site infections. Further powered studies including randomised controlled trials are required to confirm the results highlighted in this study.

A comparative study of one day versus three days peri-operative use of prophylactic antibiotics in orthopedic surgery

Prophylactic systemic antibiotics is the standard practice to prevent surgical site infections in orthopedic surgery including arthroplasty. There is enough evidence showing its utility in preventing or reducing surgical site infection. Timing of administration, antibiotics to be used and duration of antibiotics are controversial points regarding this practice. The present study using Ceftriaxone 1 gram intravenously 3 doses during 24 hours peri-operative period (group 1 n =58) versus 3 days (group 2 n= 57) has been carried out on planned orthopedic surgeries with specific exclusion and followed up for 1 year. None of the cases of either group developed any infection. The study demonstrates the utility of antibiotics prophylaxis and is a step in deciding guidelines about antibiotics use in our country.

Development and validation of a predictive nomogram for preoperative deep vein thrombosis (DVT) in isolated calcaneal fracture

The fact that most of the patients with preoperative DVTs after calcaneal fractures are asymptomatic brought challenges to the early intervention, and periodic imaging examinations aggravated the financial burden of the patients in preoperative detumescence period. This study aimed to use routine clinical data, obtained from the database of Surgical Site Infection in Orthopaedic Surgery (SSIOS), to construct and validate a nomogram for predicting preoperative DVT risk in patients with isolated calcaneal fracture. The nomogram was established base on 7 predictors independently related to preoperative DVT. The performance of the model was tested by concordance index (C-index), receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA), and the results were furtherly verified internally and externally. 952 patients were enrolled in this study, of which 711 were used as the training set. The AUC of the nomogram was 0.870 in the training set and 0.905 in the validation set. After internal verification, the modified C-index was 0.846. Calibration curve and decision curve analysis both performed well in the training set and validation set. In short, we constructed a nomogram for predicting preoperative DVT risk in patients with isolated calcaneal fracture and verified its accuracy and clinical practicability.

EPOS trial: the effect of air filtration through a plasma chamber on the incidence of surgical site infection in orthopaedic surgery: a study protocol of a randomised, double-blind, placebo-controlled trial

IntroductionThere is controversy regarding the importance of air-transmitted infections for surgical site infections (SSIs) after orthopaedic surgery. Research has been hindered by both the inability in blinding the exposure, and...

Incidence and predictors of surgical site infection after distal femur fractures treated by open reduction and internal fixation: a prospective single\u2010center study

BackgroundThere remain limited data on the epidemiological characteristics and related predictors of surgical site infection (SSI) after open reduction and internal fixation (ORIF) for distal femur fractures (DFFs). We designed this single-centre prospective study to explore and forecast these clinical problems.MethodsFrom October 2014 to December 2018, 364 patients with DFFs were treated with ORIF and followed for complete data within one year. Receiver operating characteristic (ROC) analyses, univariate Chi-square analyses, and multiple logistic regression analyses were used to screen the adjusted predictors of SSI.ResultsThe incidence of SSI was 6.0 % (22/364): 2.4 % (9/364) for superficial SSIs and 3.6 % (13/364) for deep SSIs. Staphylococcus aureus (methicillin-resistant S. aureus in 2 cases) was the most common pathogenic bacteria (36.8 %,7/19). In multivariate analysis, parameters independently associated with SSI were: Open fracture (OR: 7.3, p = 0.003), drain use (OR: 4.1, p = 0.037), and incision cleanliness (OR: 3.5, p = 0.002). An albumin/globulin (A/G) level ≥ 1.35 (OR: 0.2, p = 0.042) was an adjusted protective factor for SSI.ConclusionsThe SSI after ORIF affected approximately one in 15 patients with DFFs. The open fracture, drain use, high grade of intraoperative incision cleanliness, and preoperative A/G levels lower than 1.35 were significantly related to increasing the risk of post-operative SSI after DFFs. We recommended that more attentions should be paid to these risk factors during hospitalization.Trial registrationNO 2014-015-1, October /15/2014, prospectively registered.We registered our trial prospectively in October 15, 2014 before the first participant was enrolled. This study protocol was conducted according to the Declaration of Helsinki and approved by the Institutional Review Board. The ethics committee approved the Surgical Site Infection in Orthopaedic Surgery (NO 2014-015-1). Data used in this study were obtained from the patients who underwent orthopaedic surgeries between October 2014 to December 2018.

Is Preoperative Staphylococcus aureus Screening and Decolonization Effective at Reducing Surgical Site Infection in Patients Undergoing Orthopedic Surgery? A Systematic Review and Meta-Analysis With a Special Focus on Elective Total Joint Arthroplasty

BackgroundStaphylococcus aureus is a major pathogen implicated in orthopedic infections worldwide. Preoperative decolonization has been promoted but different strategies present mixed results. Thus, the goals of this study are to determine (1) whether S aureus screening and/or decolonization is effective at reducing surgical site infection in orthopedic surgery, (2) with a special focus on elective total joint arthroplasty (TJA), and (3) which preoperative S aureus screening/treatment strategy is most cost-effective for TJA. MethodsPubMed, Ovid MEDLINE, and Cochrane databases were searched on January 1, 2020, using a systematic strategy. We included papers with data comparing surgical site infection and periprosthetic joint infection rate in orthopedic surgery and/or elective total hip and knee arthroplasty patients before/after S aureus screening and/or decolonization protocol and papers evaluating the cost-effectiveness of different S aureus screening/treatment strategies. ResultsA total of 1260 papers were screened, and 32 papers were ultimately included. Results showed an increased risk of developing any infection (relative risk [RR] = 1.71 ± 0.16) and S aureus infection (RR = 2.79 ± 0.45) after orthopedic surgery without previous nares and whole-body decolonization. Focusing exclusively on elective TJA, there was an increased risk of developing any infection (RR = 1.70 ± 0.17) and S aureus infection (RR = 2.18 ± 0.41) if no decolonization is performed. All strategies appeared to be cost-effective, although universal decolonization without screening seemed to be the most advantageous. ConclusionPreoperative S aureus screening/decolonization protocol lowered the risk of infection after elective orthopedic and TJA surgeries. However, further studies are needed to determine optimal clinical and cost-effective methodologies.

Preoperative Decolonization and Surgical Site Infections in Orthopaedic Surgery: a Prospective Randomized Controlled Trial - 2 Year Outcome in Prosthetic Surgery

Preoperative Decolonization and Surgical Site Infections in Orthopaedic Surgery: a Prospective Randomized Controlled Trial - 2 Year Outcome in Prosthetic Surgery

Prevention of surgical site infections in orthopaedic surgery: a synthesis of current recommendations.

Despite adopted precautions, surgical site infection (SSI) rate in orthopaedic surgery and its consequences still remain a major problem. Worldwide, infection prevention and control in perioperative settings are considered of primary importance for every healthcare system. The management of perioperative infections carries a heavy psychological and financial burden, since patients who experience SSI have increased hospital length of stay, morbidity and mortality rates, and higher hospital costs. As the treatment of such infections is particularly difficult in the presence of an implanted biomaterial, the prevention of SSI in orthopaedic surgery represents a challenging key issue, requiring the integration of a range of measures before, during and after surgery. In fact, over the years several aspects of SSI prevention have been studied in order to identify the best SSI prevention strategies and set out appropriate clinical practices. This article will review and summarize the recent international guidelines released on this subject together with other published relevant evidence.

Waterless Hand Rub Versus Traditional Hand Scrub Methods for Preventing the Surgical Site Infection in Orthopedic Surgery

A retrospective cohort study with prospectively collected data. The aim of this study was to compare SSI incidences, the cost of hand hygiene agents, and hand hygiene time between the traditional hand scrub and the waterless hand rub protocols before orthopedic surgery. Surgical site infections (SSI) prolong hospitalization and are a leading nosocomial cause of morbidity and a source of excess cost. Recently, a waterless hand rub protocol comprising alcohol based chlorhexidine gluconate for use before surgery was developed, but no studies have yet examined its utility in orthopedic surgery. Fourteen hundred consecutive patients who underwent orthopedic surgery (spine, joint replacement, hand, and trauma surgeries) in our hospital since April 1, 2012 were included. A total of 712 cases underwent following traditional hand scrub between April 1, 2012 and April 30, 2013 and 688 cases underwent following waterless hand rub between June 1, 2013 and April 30, 2014. We compared SSI incidences within all and each subcategory between two hand hygiene protocols. All patients were screened for SSI within 1 year after surgery. We compared the cost of hand hygiene agents and hand hygiene time between two groups. The SSI incidences were 1.3% (9 of 712) following the traditional protocol (2 deep and 7 superficial infections) and 1.1% (8 of 688) following the waterless protocol (all superficial infections). There were no significant differences between the two groups. The costs of liquids used for one hand hygiene were about $2 for traditional hand scrub and less than $1 for waterless hand rub. The mean hand hygiene time was 264 seconds with the traditional protocol and 160 seconds with the waterless protocol. Waterless hand rub with an alcohol based chlorhexidine gluconate solution can be a safe, quick, and cost-effective alternative to traditional hand scrub. 3.

Surgical site infections in orthopedic surgery: incidence and risk factors at an Iranian teaching hospital

Background and objectives: Surgical site infection (SSI) is rare complication in orthopedic surgery and have serious consequences for outcomes and costs. Different risk factors may be involved, including age, sex, body mass index (BMI), prophylactic antibiotics, operation technique and duration, type of shaving, and length of hospitalization. This study aimed to determine the risk factors affecting orthopedic surgical site infections and their incidence at Imam Reza and Taleghani , two major referral teaching hospitals in west of Iran. Design: A prospective cohort study. Methods: A 36-month prospective cohort study, with 1 to 12 months of patient follow-up after surgery, was conducted at the teaching hospital in Iran. Patients (n = 1,900) who had undergone orthopedic surgery were studied between January 2012 and January 2015. Each patient was followed by pre- and post-operative examinations and telephone follow-ups. Results: Of the 1,900 patients, 73 suffered from SSI (3.84%). Methicillin Resistant Staphylococcus aureus (MRSA) 53% (n = 25) and Staphylococcus coagulase-negative 32% (n = 15) are the most common isolated germs. The smoking, high BMI, multiple fractures, increased operation time, increased bed stay, electivity of the operation, type of operation, using prosthetic implant and pre-operation of prophylactic antibiotic were all significantly associated with increased evidence of SSI (P Conclusion: Our study presented that stopping smoking, appropriate pre- and post-operational antibiotic prophylaxis regimens specially when using prosthetic implant, shortening duration of surgery and hospitalization and experience of the surgeon should be helpful to reduce rate of SSI.

Evidence of Operative Environment for Prevention of Surgical Site Infection in Orthopaedic Surgery

Evidence of Operative Environment for Prevention of Surgical Site Infection in Orthopaedic Surgery

Surgical Site Infection in Orthopedic Surgery at Dantec University Hospital Center

Surgical Site Infection in Orthopedic Surgery at Dantec University Hospital Center

Route of transmission of Staphylococcus aureus

Route of transmission of Staphylococcus aureus

Surgical site infection in orthopaedic surgery: an audit of peri-operative practice at a tertiary centre

Abstract Introduction Surgical site infection (SSI) is a common but serious complication in orthopaedic surgery. Multiple peri-operative risk factors have been identified in the incidence of SSIs. A ‘bundle of care' approach has been used to identify and treat the most common risk factors. The aim of this study was to audit current peri-operative practice and compare with current hospital protocols. Methods Orthopaedic surgeries were retrospectively audited at a 350-bed tertiary hospital. Data on peri-operative practice, including patient temperature, blood sugar levels (BSLs), oxygenation, antibiotic use and incidence of SSIs, were collected via online surveying software. Descriptive analysis was performed. Results There were a total of 88 patients who had 95 orthopaedic surgeries. Seven patients developed SSIs. Temperature monitoring occurred in 96% of patients. BSL monitoring was less prevalent, occurring in only 16% of patients without diabetes. Post-operative oxygenation was universal. Only three patients did not receive prophylactic antibiotics in the peri-operative stage. Conclusions We found current peri-operative care to be generally excellent, although implementing a formal ‘bundle of care' may achieve higher rates of normoglycaemia and normothermia.

Propionibacterium persists in the skin despite standard surgical preparation.

Propionibacterium acnes, which normally resides in the skin, is known to play a role in surgical site infection in orthopaedic surgery. Studies have suggested a persistence of propionibacteria on the skin surface, with rates of positive cultures ranging from 7% to 29% after surgical preparation. However, as Propionibacterium organisms normally reside in the dermal layer, these studies may underestimate the true prevalence of propionibacteria after surgical skin preparation. We hypothesized that, after surgical skin preparation, viable Propionibacterium remains in the dermis at a much higher rate than previously reported. Ten healthy male volunteers underwent skin preparation of the upper back with ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol). Two 3-mm dermal punch biopsy specimens were obtained through the prepared skin and specifically cultured for P. acnes. Seven volunteers had positive findings for Propionibacterium on dermal cultures after ChloraPrep skin preparation. The average time to positive cultures was 6.78 days. This study found that Propionibacterium persists in the dermal tissue even after surface skin preparation with ChloraPrep. The 70% rate of persistence of propionibacteria after skin preparation is substantially higher than previously reported. Propionibacteria are increasingly discussed as having an association with infection, implant failure, and degenerative disease. This study confirms the possibility that the dermal layer of skin may be the source of the bacteria.

Surgical Site Infections in Orthopaedic Surgery Demonstrate Clones Similar to Those in Orthopaedic Staphylococcus aureus Nasal Carriers.

Staphylococcus aureus is the main microbial pathogen in orthopaedic infections, and it adds considerable extra costs to the national health-care system each year. Nasal carriers of Staphylococcus aureus have an increased risk of invasive disease, including surgical site infection. The purpose of the present study was to investigate whether the Staphylococcus aureus carrier clones found in patients undergoing elective orthopaedic surgery were the same as the clones found in isolates from orthopaedic patients with Staphylococcus aureus surgical site infections. Patients admitted for elective orthopaedic surgery underwent nasal cultures for Staphylococcus aureus. Further, orthopaedic patients with a deep surgical site infection caused by Staphylococcus aureus were characterized using the same genotyping methods: multilocus sequence typing and staphylococcal protein A typing. Multilocus sequence typing revealed a large number of genotypes in the two populations. However, 85% of nasal carriers and 90% of surgical site infection isolates could be classified into the same four multilocus sequence typing clonal complexes. The risk of Staphylococcus aureus surgical site infection in nasal carriers compared with non-carriers was 5.8 times higher (95% confidence interval, 1.5 to 23.1 times). Of the nasal carriers, 6.3% (95% confidence interval, 1.7% to 10.9% [seven of 111 patients]) developed a deep Staphylococcus aureus surgical site infection, and all but one patient had identical genotypes in the nasal and surgical site infection isolates. Staphylococcus aureus isolates from nasal carriers and patients with surgical site infection clustered into the same few multilocus sequence typing clonal complexes. This finding confirms the existence of some commonly occurring Staphylococcus aureus clones in different population groups within a geographically restricted area. The almost complete individual concordance between Staphylococcus aureus genotypes in carriers who developed a deep surgical site infection strongly supports transmission from the nose, skin surfaces, and other endogenous body regions as a possible route. Surgical site infections might be more frequently caused by endogenous transmission than was previously assumed. Perioperative preventive efforts must focus more on this route to further decrease the risk of postoperative orthopaedic infections.

Prevalence of surgical site infection in orthopedic surgery: a 5-year analysis.

Surgical site infection (SSI) is disastrous in orthopedic practice as it is difficult to rid the bone and joint of the infection. This study was aimed to assess the prevalence of SSI in orthopedic practice and to identify risk factors associated with surgical site infections. All patients admitted to the orthopedic male and female wards between January 2006 and December 2011 were included in the study group. The data, which were collected from the medical charts and from the QuadraMed patient filing system, included age, sex, date of admission, type of admission (elective versus emergency), and classification of fractures. Analyses were made to find out the association between infection and risk factors, the χ (2) test was used. The strength of association of the single event with the variables was estimated using Relative Risk, with a 95% confidence interval and P < 0.05. A total of 79 of 3096 patients (2.55%) were included: 60 males and 19 females with the average age of 38.13 ± 19.1 years. Fifty-three patients were admitted directly to the orthopedic wards, 14 were transferred from the surgical intensive care unit, and 12 from other surgical wards. The most common infective organism was Staphylococcus species including Methicillin Resistant Staphylococcus aureus (MRSA), 23 patients (29.11%); Acinetobacter species, 17 patients (21.5%); Pseudomonas species, 15 patients (18.9%); and Enterococcus species, 14 patients (17.7%). Fifty-two (65.8%) had emergency procedures, and in 57 patients trauma surgery was performed. Three (3.78%) patients died as a result of uncontrolled septicemia. SSI was found to be common in our practice. Emergency surgical procedures carried the greatest risk with Staphylococcus species and Acinetobacter species being the most common infecting organisms. Proper measures need to be undertaken to control infection rates by every available method; antibiotics alone may not be sufficient to win this war.