Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures

A technique for introducing broad-spectrum topical antibiotics during open reduction and internal fixation of acetabular fractures

Postoperative surgical site infections remain a significant and prevalent complication after open reduction and internal fixation of acetabular fractures. Local antibiotics have been shown to decrease risk of postoperative infection, although recent evidence is conflicting. We provide a consistent and replicable technique for delivering intraoperative broad-spectrum antibiotics in the form of a putty applied directly to surgical implants. With this technique, systemic levels of those antibiotics remain safe and stable.

Antibiotics for preventing infection at the surgical site: Single dose vs. multiple doses

Background

Surgical site infections are common and expensive infections that can cause fatalities or poor patient outcomes. To prevent these infections, antibiotic prophylaxis is used. However, excessive antibiotic use is related to higher costs and the emergence of antimicrobial resistance.

Objectives

The present meta-analysis aimed to compare the effectiveness of a single dosage versus several doses of antibiotics in preventing the development of surgical site infections.

Methods

PubMed was used to find clinical trials evaluating the effectiveness of a single dosage versus several doses of antibiotics in avoiding the development of surgical site infections. The study included trials that were published between 1984 and 2022. Seventy-four clinical trials were included in the analysis. Odds ratios were used to compare groups with 95% confidence intervals. The data were displayed using OR to generate a forest plot. Review Manager (RevMan version 5.4) was used to do the meta-analysis.

Results

Regarding clean operations, there were 389 surgical site infections out of 5,634 patients in a single dose group (6.90%) and 349 surgical site infections out of 5,621 patients in multiple doses group (6.21%) (OR = 1.11, lower CI = 0.95, upper CI = 1.30). Regarding clean-contaminated operations, there were 137 surgical site infections out of 2,715 patients in a single dose group (5.05%) and 137 surgical site infections out of 2,355 patients in multiple doses group (5.82%) (OR = 0.87, lower CI = 0.68, upper CI = 1.11). Regarding contaminated operations, there were 302 surgical site infections out of 3,262 patients in a single dose group (9.26%) and 276 surgical site infections out of 3,212 patients in multiple doses group (8.59%) (OR = 1.11, lower CI = 0.84, upper CI = 1.47). In general, there were 828 surgical site infections out of 11,611 patients in a single dose group (7.13%) and 762 surgical site infections out of 11,188 patients in multiple doses group (6.81%) (OR = 1.05, lower CI = 0.93, upper CI = 1.20). The difference between groups was not significant.

Conclusion

The present study showed that using a single-dose antimicrobial prophylaxis was equally effective as using multiple doses of antibiotics in decreasing surgical site infections.

Timing of antibiotic administration, wound debridement, and the stages of reconstructive surgery for open long bone fractures of the upper and lower limbs

BACKGROUND

Open fractures of the major long bones are complex limb-threatening injuries that are predisposed to deep infection. Treatment includes antibiotics and surgery to debride the wound, stabilise the fracture and reconstruct any soft tissue defect to enable infection-free bone repair. There is a need to assess the effect of timing and duration of antibiotic administration and timing and staging of surgical interventions to optimise outcomes.

OBJECTIVES

To assess the effects (risks and benefits) of the timing of antibiotic administration, wound debridement and the stages of surgical interventions in managing people with open long bone fractures of the upper and lower limbs.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and clinical trial registers in February 2021. We also searched conference proceedings and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs that recruited adults with open fractures of the major long bones, comparing: 1) timings of prophylactic antibiotic treatment, 2) duration of prophylactic antibiotic treatment, 3) timing of wound debridement following injury or 4) timing of the stages of reconstructive surgery.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We aimed to collect data for the following outcomes: limb function, health-related quality of life (HRQoL), deep surgical site infection, delayed or non-union, adverse events (in the short- and long-term course of recovery), and resource-related outcomes.

MAIN RESULTS

We included three RCTs of 613 randomised participants with 617 open fractures. Studies were conducted in medical and trauma centres in the USA and Kenya. Where reported, there was a higher proportion of men and a mean age of participants between 30 and 34 years old. Fractures were in the upper and lower limbs in one study, and were tibia fractures in two studies; where reported, these were the result of high-energy trauma such as road traffic accidents. No studies compared the timing of antibiotic treatment or wound debridement. Duration of prophylactic antibiotic treatment (1 study, 77 participants available for analysis) One study compared antibiotic treatment for 24 hours with antibiotic treatment for five days. We are very uncertain about the effects of different durations of antibiotic treatment on superficial infections (risk ratio (RR) 1.19, 95% CI 0.49 to 2.87, favours 5 day treatment; 1 study, 77 participants); this was very low-certainty evidence derived from one small study with unclear and high risks of bias, and with an imprecise effect estimate. This study reported no other review outcomes. Reconstructive surgery: timing of the stages of surgery (2 studies, 458 participants available for analysis) Two studies compared the timing of wound closure, which was completed immediately or delayed. In one study, the mean time of delay was 5.9 days; in the other study, the time of delay was not reported. We are very uncertain about the effects of different timings of wound closure on deep infections (RR 0.82, 95% CI 0.37 to 1.80, favours immediate closure; 2 studies, 458 participants), delayed union or non-union (RR 1.13, 95% CI 0.83 to 1.55, favours delayed closure; 1 study, 387 participants), or superficial infections (RR 6.45, 95% CI 0.35 to 120.43, favours delayed closure; 1 study, 71 participants); this was very low-certainty evidence. We downgraded the certainty of the evidence for very serious risks of bias because both studies had unclear and high risks of bias. We also downgraded for serious imprecision because effect estimates were imprecise, including the possibility of benefits as well as harms, and very serious imprecision when the data were derived from single small study. These studies reported no other review outcomes.

AUTHORS' CONCLUSIONS

We could not determine the risks and benefits of different treatment protocols for open long bone fractures because the evidence was very uncertain for the two comparisons and we did not find any studies addressing the other possible comparisons. Well-designed randomised trials with adequate power are needed to guide surgical and antibiotic treatment of open fractures, particularly with regard to timing and duration of antibiotic administration and timing and staging of surgery.

Type of antibiotic but not the duration of prophylaxis correlates with rates of fracture-related infection

PURPOSE

The issue of optimal prophylactic antibiotic administration for closed and open fracture surgeries remains controversial. The purpose of this study was to assess the role of type and duration longer than 48 h of antibiotic prophylaxis on the rates of fracture-related infection (FRI).

METHODS

This is a single-center, prospective observational cohort study carried out with patients undergoing surgery for implants insertion to fracture stability. Risk estimates were calculated on the variables associated with factors for FRI and reported as a prevalence ratio (PR) with respect to the 95% confidence interval (CI).

RESULTS

Overall, 132 patients were analyzed. The global rate of FRI was 15.9% (21/132), with open and closed fractures accounting for 30.5% (11/36) and 10.4% (10/96), respectively. The FRI rates in patients undergoing orthopedic surgery for fracture stabilization who received prophylactic antibiotic for up to and longer than 48 h were 8.9% and 26.4%, respectively. This difference did not reach statistical significance (prevalence ratio [PR] = 2.6, 95% confidence interval [95% CI]: 0.9-7.3. p = 0.063).

CONCLUSIONS

Duration of antibiotic prophylaxis for surgical orthopedic fractures was not correlated with rates of FRI.

Antibiotic prophylaxis as a quality of care indicator: does it help in the fight against surgical site infections following fragility hip fractures?

INTRODUCTION

Fragility hip fractures are associated with increased morbidity, mortality, and costs. To improve patient care, quality indicator programs were introduced. Yet, the efficacy of these programs and specific quality indicators are questioned. We aimed to determine whether defining prophylactic pre-surgical antibiotic treatment as a quality indicator affected hip fracture outcomes.

MATERIALS AND METHODS

A retrospective study comparing consecutive patients, 65 years and older, who were operated for fragility hip fractures between 01/01/2011 and 30/06/2016, before and after the prophylactic pre-surgical antibiotic treatment quality indicator, which was introduced in 01/2014. Primary outcomes were 1-year surgical site infections (SSI). Secondary outcomes were meeting the quality index and mortality rates, either within a hospital or during the first post-operative year.

RESULTS

904 patients, ages 82.5 ± 7.2 years were operated for fragility hip fractures. 403 patients presented before the antibiotic prophylaxis quality indicator, and 501 following its administration. Patients demographics were comparable. In the pre-quality indicator period, documentation of prophylactic antibiotic treatment was lacking. Only 19.6% had a record for antibiotic administration in their surgical records and for merely 10.4% the type of antibiotic was stated. However, in the post-quality indicator period, 97.0% of patients had a registered prophylactic antibiotic regimen in the hour preceding the surgical incision (p  < 0.001). Post-operative SSI rates were equivalent, and as were in-hospital infections, mortality and recurrent hospitalizations CONCLUSIONS: The introduction of the pre-operative antibiotic treatment quality indicator increased the documentation of antibiotic administration yet failed to influence the incidence of post-operative orthopaedic and medical infections in fragility hip fracture patients.

Effectiveness of an Online Course on Fracture-Related Infections

This study aims to evaluate the effectiveness of an online course to enable orthopaedic surgeons to acquire the core competencies necessary to prevent and treat fracture-related infections (FRI). This study included orthopaedic surgeons and residents from Latin American countries who attended an online course focused on FRI. The online course included: didactic lectures, small-group clinical case discussions, and panel case discussions. The course was delivered using Zoom® platform and designed to address four core competencies: prevention, definition and diagnosis, antimicrobial therapy, and surgical treatment. An online questionnaire was created distributing 16 questions through six clinical scenarios. Participants were invited to answer the questionnaire before and after the course. Sixty of the 78 course participants answered the pre-course, and 42 the post-course assessment. Relative to before the course, the mean post-course assessment score rose significantly for prevention of FRI (4.1 before and 4.5 after; p = 0.014), definition and diagnosis (2.4 before and 3.4 after; p = 0.001), and surgical treatment (2.2 before and 2.8 after; p = 0.011). The final score encompassing all four core competencies also rose significantly (2.7 before and 3.3 after; p = 0.001). The online course on FRI was feasible and effective, significantly increasing course users’ knowledge of overall competency in managing FRI.

Risk Factors for Deep Surgical Site Infection in Patients With Operatively Treated Tibial Plateau Fractures: A Retrospective Multicenter Study

OBJECTIVES

To identify the potential controllable risk factors for surgical site infection (SSI).

DESIGN

A retrospective cohort study.

SETTING

Seven Level-I trauma centers.

PATIENTS/PARTICIPANTS

Patients with OTA/AO 41 B or C tibial plateau fractures (n = 2106).

INTERVENTION

Various surgical treatments for tibial plateau fractures.

MAIN OUTCOME MEASUREMENTS

The primary outcome was SSI after the index operation. The secondary outcomes were the risk factors for SSI, identified using backward stepwise generalized multiple regression analysis.

RESULTS

Of the 2106 enrolled patients, 94 had deep SSIs. The average SSI rate was 4.5%. Fracture morphology revealed type B injuries in 57.5% and type C in 42.5% of the patients. Univariate regression analysis revealed that several factors, namely, number of comorbidities [>6 vs. none; odds ratio (OR) 8.01, 95% confidence interval (CI) 2.8-22.8, P < 0.001], diabetes mellitus (OR 3.5, 95% CI 2.0-6.3, P < 0.001), high body mass index (OR 1.3, 95% CI 1.1-1.6, P = 0.001), OTA/AO fracture type C (OR 5.6, 95% CI 3.3-9.5, P < 0.001), compartment syndrome (OR 9.1, 95% CI 5.7-14.8, P < 0.001), and open fracture (OR 6.6, 95% CI 3.7-11.7, P < 0.001), were associated with a significantly higher SSI risk. Analysis of microbial sensitivity tests revealed that 55.1% of the pathogens were resistant to perioperative antibiotic prophylaxis.

CONCLUSIONS

Most of the identified risk factors cannot be controlled or are subject to other factors that are difficult to control. However, our data suggest that the choice of perioperative antibiotic prophylaxis may influence the rate of SSI. This possibility should be investigated in a prospective randomized controlled trial.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical and Radiological Outcomes of Trochanteric AO/OTA 31A2 Fractures: Comparison between Helical Blade and Lag Screw - A Retrospective Cohort Study

INTRODUCTION

The purpose of this study was to compare the clinical and radiological outcomes of AO/OTA type 31A2 fractures treated by the use of trochanteric nails either with a blade or a screw.

PATIENTS AND METHODS

This study was designed retrospectively. Between May 2007 and May 2014, a total of 144 patients with trochanteric fractures were admitted to the clinic, and only 65 of them met the inclusion criteria. Thirty-two of them (blade group) were treated with a helical blade and the rest of the 33 patients (screw group) were treated with a screw. The mean ages of the patients were 76.01 and 75.82, respectively (p = 0.905). The mean follow-up time was 27.6 months (blade group: 34.2 ± 19.1 months; screw group: 18.6 ± 7.9 months; p < 0.001). Between these two groups, we evaluated the differences in tip apex distances (TAD), calcar-referenced tip-apex distances (Cal-TAD), implant positions, cut-out rates, and implant failures. Functional outcomes were measured with the help of the Harris Hip Score.

RESULTS

No significant differences were seen between the blade and screw groups by means of cutting out, implant positions, and varus collapse. Cutting out was seen in a total of six patients (blade group n = 2; screw group = 4; p = 0.672) and varus collapse in nine patients (blade group n = 5, screw group n = 4; p = 0.733). Harris Hip Scores were similar between the two groups (blade group: 72.70 ± 18.43; screw group: 80.83 ± 18.75; p = 0.84).

Compliance with national guidelines for antibiotic prophylaxis in hip fracture patients: a quality assessment study of 13 329 patients in the Norwegian Hip Fracture Register

OBJECTIVE

We assessed compliance with new guidelines for prophylactic antibiotics in hip fracture surgery in Norway introduced in 2013.

DESIGN

The data from the Norwegian Hip Fracture Register was used to assess the proportion of antibiotics given according to the national guidelines.

SETTING

All hospitals in Norway performing hip fracture surgery in the period from 2011 to 2016.

PARTICIPANTS

We studied 13 329 hemiarthroplasties (HAs) for acute hip fracture.

MAIN OUTCOME MEASURE

Type and timing between first and last dose of prophylactic antibiotics compared with the national guidelines.

RESULTS

Before the guidelines were introduced, the recommended drugs cephalotin or clindamycin was used in only 86.2% of all HAs. In 2016, one of the two recommended drugs was administered in 99.2% of HAs. However, hospitals' adaption of the recommended administration of the two drugs improved slowly, and by the end of the study period, only three out of five HAs were performed with the correct drug administered in the correct manner. We found major differences in compliance between hospitals.

CONCLUSIONS

The change towards correct administration of antibiotic prophylaxis was varied both when investigating university and non-university hospitals. We suggest that both hospital leaders and the national Directorate of Health need to investigate routines for better dissemination of information and education to involved parties. Strong leadership concerning evidence-based guidelines on antibiotic prophylaxis in surgery may take away some autonomy from executing healthcare professionals, but will result in better patient care and antibiotic stewardship.

Non-inferior comparative study comparing one or two day antimicrobial prophylaxis after clean orthopaedic surgery (NOCOTA study): a study protocol for a cluster pseudo-randomized controlled trial comparing duration of antibiotic prophylaxis

Background

Antimicrobial prophylaxis (AMP) is one of the most important measures for preventing surgical site infections (SSIs); however, controversies remain regarding its adequate duration. Although the World Health Organization and the Center for Disease Control and Prevention do not recommend additional AMP after closure, the American Society of Health-System Pharmacists and the Musculoskeletal Infection Society permit the use of postoperative AMP, but recommend discontinuation within 24 h. Similarly, the Japanese Society of Chemotherapy and the Japan Society for Surgical Infection also permit AMP within 24–48 h after various orthopaedic procedures. In these guidelines, recommendations regarding AMP duration were weak due to a relative lack of evidence, and currently, there is no high-quality evidence comparing AMP use within 24 h versus 24–48 h regarding orthopaedic procedures. Urinary tract infection (UTI) and respiratory tract infection (RTI) are also important health care-associated infections (HAIs) faced after surgery. Although AMP duration may affect these HAIs, its effects have not been well evaluated.

Methods

We have organized a multicenter, prospective, cluster pseudo-randomized controlled trial to examine the non-inferiority of shorter AMP duration (within 24 h) against longer duration (24–48 h) in preventing postoperative HAIs. Participating facilities will be divided into two groups. In Group 24, AMP will be discontinued within 24 h after surgery. In Group 48, AMP will be discontinued within 24–48 h after surgery. The group allocation will be switched every 2 months until the targeted recruitment (500 participants per group) is met.

The primary outcome will be the cumulative incidence of all HAIs (SSI, UTI, RTI, and other infectious diseases), which require antibiotic therapies within 30 days after surgery. In addition to mortality and cardiovascular events, prolonged hospitalization (> 30 days) and the rate of antibiotic resistance rate of SSI pathogens will also be evaluated. Outcomes will be evaluated within 30–180 days after surgery in person by the surgeon, by mail, or by telephone survey. Data will be analyzed by a statistician not engaged in data collection.

Discussion

This study may provide valuable information for developing future recommendations for adequate AMP duration after clean orthopaedic surgery.

Trial registration

UMIN000030929, registered January 22, 2018.

Increased risk of mortality after postoperative infection in hip fracture patients

BACKGROUND

Postoperative infection is a common complication in hip fracture patients and the risk appears to have increased during the last decade. However, the impact of infection on mortality after hip fracture surgery remains unclear.

PURPOSE

We aimed to examine the association between infection (any, as well as specific infections), with all-cause mortality following hip fracture surgery.

METHODS

Using Danish nationwide registries, we conducted a population-based cohort study on 74,771 hip fracture patients ≥65 years old operated from 2005 to 2016. We included hospital-treated infection as a time-varying exposure, and calculated 30-days mortality rate per 1000 person-years (PY). We used time-varying Cox Proportional Hazard Regression to compute 30-days adjusted hazards ratios (aHRs) with 95% confidence interval (CI) comparing the mortality of hip fracture patients with and without infections. We adjusted for sex, age, comorbidities, medication use, and marital status.

RESULTS

Within 30 days of surgery, 9592 (12.8%) patients developed a hospital-treated infection. Among these, 30-days mortality was 8.43 per 1000 PY compared with 3.34 among patients without infection (aHR = 2.72, 95% CI: 2.56-2.88). For patients who developed pneumonia, aHR was 4.18 (95% CI: 3.91-4.48), whereas the aHR was 8.86 (95% CI: 7.88-9.95) for patients who developed systemic sepsis. For patients who sustained reoperation due to infection, aHR was 2.95 (95%CI: 1.88-4.64). The mortality was higher in infected vs. non-infected patients irrespective of patients' age, sex and comorbidity.

CONCLUSION

Infection within 30 days of hip fracture surgery is associated with substantially increased mortality risk. Further research should improve our knowledge about patients at increased risk and prevention measures for specific infections.

Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery

BACKGROUND

Surgery has been used as part of breast cancer treatment for centuries; however any surgical procedure has the potential risk of infection. Infection rates for surgical treatment of breast cancer are documented at between 3% and 15%, higher than average for a clean surgical procedure. Pre- and perioperative antibiotics have been found to be useful in lowering infection rates in other surgical groups, yet there is no consensus on the use of prophylactic antibiotics for breast cancer surgery. This is an update of a Cochrane Review first published in 2005 and last updated in 2014.

OBJECTIVES

To determine the effects of prophylactic (pre- or perioperative) antibiotics on the incidence of surgical site infection (SSI) after breast cancer surgery.

SEARCH METHODS

For this fourth update, in August 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase; and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials of pre- and perioperative antibiotics for patients undergoing surgery for breast cancer. Primary outcomes were rates of surgical site infection (SSI) and adverse reactions.

DATA COLLECTION AND ANALYSIS

Three review authors independently examined the title and abstracts of all studies identified by the search strategy, then assessed study quality and extracted data from those that met the inclusion criteria. We contacted study authors to obtain missing information. We evaluated the certainty of evidence using the GRADE approach. We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

A total of 11 randomised controlled trials (2867 participants) were included in the review. No new studies were identified in this update. All studies included breast cancer patients and were based in the hospital setting. Ten studies evaluated preoperative antibiotic compared with no antibiotic or placebo. One study evaluated perioperative antibiotic compared with placebo or no antibiotic. Pooling of the results demonstrated that prophylactic antibiotics administered preoperatively probably reduce the incidence of SSI for patients undergoing breast cancer surgery without reconstruction (pooled risk ratio (RR) 0.67, 95% confidence interval (CI) 0.53 to 0.85; moderate certainty evidence). Anticipated absolute effects were calculated for the outcome incidence of SSI; 105 per 1000 for the none or placebo group and 71 per 1000 (95% CI 56 to 89) for the preoperative antibiotic prophylaxis group. Analysis of the single study comparing perioperative antibiotic with no antibiotic was inconclusive for incidence of SSI (RR 0.11, 95% CI 0.01 to 1.95; very low certainty evidence). No studies presented separate data for patients who underwent reconstructive surgery at the time of removal of the breast tumour.Secondary outcomes were not consistently included in the studies investigating preoperative antibiotic prophylaxis. It is very uncertain whether there is a difference in incidence of adverse events between the treatment and no treatment or placebo groups (10 studies, 2818 participants); very low certainty evidence downgraded one level for serious risk of bias, one level for serious inconsistency and one level for serious imprecision. It is unclear whether there is a difference in time to onset of infection between the treatment and no treatment or placebo groups (4 studies, 1450 participants); low certainty evidence downgraded one level for serious risk of bias and one level for serious inconsistency. It is unclear whether there is a difference in rates of readmission to hospital between the treatment and placebo groups (3 studies, 784 participants); low certainty evidence downgraded one level for serious inconsistency and one level for serious risk of bias. It is unclear whether there is a difference in cost of care between the treatment and no treatment or placebo groups (2 studies, 510 participants); low certainty evidence downgraded one level for serious risk of bias and one level for serious inconsistency. No analysable secondary outcome data were reported for the single study evaluating perioperative antibiotics.

AUTHORS' CONCLUSIONS

Prophylactic antibiotics administered preoperatively probably reduce the risk of SSI in patients undergoing surgery for breast cancer. However, it is very uncertain whether there is an effect on incidence of adverse events. Furthermore, the effects on time to onset of infection, readmission to hospital and cost of care remain unclear. Further studies are required to establish the best protocols for clinical practice.

Single versus separate implant fixation for concomitant ipsilateral femoral neck and shaft fractures: A systematic review

Concomitant ipsilateral femoral neck and shaft fractures are uncommon, occurring in 1-9% of femoral shaft fractures. While this injury typically occurs in young patients following high-energy trauma, little consensus has been established regarding the optimal fixation approach. A multitude of treatment strategies exist, with limited evidence as to which is more favorable. The aim of this study was to appraise current evidence, comparing management with either one single or separate devices for both fractures. A systematic review was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies published between 1992 and 2018 comparing the rate of postoperative nonunion, malunion, delayed union, avascular necrosis, infection or reoperation between at least one method of single device fixation and one method of separate device fixation were included. Six non-randomized cohort studies assessing 173 patients were suitable for inclusion, each comparing single device cephalomedullary nail fixation of both fractures with a combination of devices. All patients presented following high-energy trauma, at a median age of 32 years. While low complication rate and favorable outcomes were found across both groups, no significant difference could be inferred between either treatment strategy. This injury continues to occur in the traditionally described patient group, and results in acceptable postoperative outcomes. A paucity of randomized studies limits the ability to recommend a single or separate device treatment approach, and as such prospective, randomized trials with adequately powered sample sizes are required to definitively compare surgical management strategies in this rare but complex injury.

Duration of antibiotic treatment and risk of recurrence after surgical management of orthopaedic device infections: a multicenter case-control study

Background

Device-related infections in orthopaedic and trauma surgery are a devastating complication with substantial impact on morbidity and mortality. Systemic suppressive antibiotic treatment is regarded an integral part of any surgical protocol intended to eradicate the infection. The optimal duration of antimicrobial treatment, however, remains unclear. In a multicenter case-control study, we aimed at analyzing the influence of the duration of antibiotic exposure on reinfection rates 1 year after curative surgery.

Methods

This investigation was part of a federally funded multidisciplinary network project aiming at reducing the spread of multi-resistant bacteria in the German Baltic region of Pomerania. We herein used hospital chart data from patients treated for infections of total joint arthroplasties or internal fracture fixation devices at three academic referral institutions. Subjects with recurrence of an implant-related infection within 1 year after the last surgical procedure were defined as case group, and patients without recurrence of an implant-related infection as control group. We placed a distinct focus on infection of open reduction and internal fixation (ORIF) constructs. Uni- and multivariate logistic regression analyses were employed for data modelling.

Results

Of 1279 potentially eligible patients, 269 were included in the overall analysis group, and 84 contributed to an extramedullary fracture-fixation-device sample. By multivariate analysis, male sex (odds ratio [OR] 2.06, 95% confidence interval [CI] 1.08 to 3.94, p = 0.029) and facture fixation device infections (OR 2.05, 95% CI 1.05 to 4.02, p = 0.036) remained independent predictors of reinfection. In the subgroup of infected ORIF constructs, univariate point estimates suggested a nearly 60% reduced odds of reinfection with systemic fluoroquinolones (OR 0.42, 95% CI 0.04 to 2.46) or rifampicin treatment (OR 0.41, 95% CI 0.08 to 2.12) for up to 31 days, although the width of confidence intervals prohibited robust statistical and clinical inferences.

Conclusion

The optimal duration of systemic antibiotic treatment with surgical concepts of curing wound and device-related orthopaedic infections is still unclear. The risk of reinfection in case of infected extramedullary fracture-fxation devices may be reduced with up to 31 days of systemic fluoroquinolones and rifampicin, although scientific proof needs a randomized trial with about 1400 subjects per group. Concerted efforts are needed to determine which antibiotics must be applied for how long after radical surgical sanitation to guarantee sustainable treatment success.

Improving surgical antibiotic prophylaxis adherence and reducing hospital readmissions: a bundle of interventions including health information technologies

OBJECTIVES

Infection following orthopaedic surgery is a feared complication and an indicator of the quality of the hospital. Surgical antibiotic prophylaxis (SAP) guidelines are not always properly followed. Our aim was to describe and evaluate the impact of a multidisciplinary intervention on antibiotic prophylaxis adherence to hospital guidelines and 30-day postoperative outcomes.

METHODS

The study was carried out from January to May 2016 and consisted of creating a multidisciplinary team, updating institutional guidelines and embedding the recommendations in the computerised physician order entry system which is linked to dose and renal function alerts, educational activities and pharmaceutical bedside care of patients in the orthopaedic department. A prospective pre-post study was carried out in accordance with the Declaration of Helsinki. The following information was recorded: patient and surgery characteristics, adherence to SAP guidelines, surgical site infections, length of hospital stay and rate of readmission 30 days after discharge. Statistical analyses were performed using SPSS 18.0.

RESULTS

Eighty three orthopaedic patients of mean±SD age 68.2±17.0 years (44.6% male, 40 in the pre-intervention group and 43 in the intervention group) were included. Cefazolin was the recommended and most commonly administered antibiotic agent. In the intervention group, an improvement in global adherence to guidelines was achieved (76.7% vs 89.9%; p=0.039): antibiotic duration (75.0% vs 97.7%), correct dosage post-surgery (55.0% vs 76.7%), timing of administration (57.5% vs 72.1%), antibiotic pre-surgery prescription (92.5% vs 97.7%). Three surgical site infections were detected in the pre-intervention group and none in the intervention group (p>0.05). Length of hospital stay was reduced by 1 day and readmission decreased by 15% (p=0.038).

CONCLUSIONS

SAP is used in daily practice in most orthopaedic patients. The implementation of a multidisciplinary programme based on health technology improved the adherence to guidelines and appeared to reduce the readmission rate.

Antibiotic prophylaxis in foot and ankle surgery: a systematic review of the literature

Background

With the advent of bacterial resistance, it is important now more than ever to evaluate use of antibiotic chemoprophylaxis in foot and ankle surgery. Within this area of the body there may be less dissection, surgery time with smaller incisions and importantly smaller sizes of implanted fixation as compared to other bone and joint procedures. Our objective was to systematically evaluate the quality of evidence behind existing guidelines.

Methodology

A systematic literature search was performed: MEDLINE, CINHAL, EMBASE and the Cochrane library from 1990 up to March 2018. To avoid omitting any studies on the subject, Google Scholar was also used. The inclusion criterion were studies exploring perioperative antibiotic use, postoperative infection rates in elective foot and ankle surgery and studies associated with this subject evaluating antibiotic use in clean elective foot and ankle surgery. The exclusion criterion being studies upon contaminated or dirty surgery or those which were inclusive of procedures proximal to the foot and ankle.

Results

Overall 11 studies met the inclusion criteria. From the grading of evidence, 2 level one and 4 level two studies were recognised. These studies ranked relatively highly in comparison to 5 studies that were graded as level three and level four tiers of evidence. Results of SSI rates found within this systematic review ranged from 0% to 9.4% of overall postoperative infections encountered after foot and ankle surgery in the studies analysed.

Conclusion

Whilst fragmented, aspects of antibiotic chemoprophylaxis are established fields in elective surgery with a growing body of evidence. Evidence for antibiotic use however, specifically within elective foot and ankle surgery, is lacking. This systematic review is a seminal paper which delivers an impression of the most influential literature within the field of foot and ankle surgery, with the aim being to entice conclusions and guide future research.

The development of a staphylococcus aureus four antigen vaccine for use prior to elective orthopedic surgery

Staphylococcus aureus (S. aureus) is a challenging bacterial pathogen which can cause a range of diseases, from mild skin infections, to more serious and invasive disease including deep or organ space surgical site infections, life-threatening bacteremia, and sepsis. S. aureus rapidly develops resistance to antibiotic treatments. Despite current infection control measures, the burden of disease remains high. The most advanced vaccine in clinical development is a 4 antigen S. aureus vaccine (SA4Ag) candidate that is being evaluated in a phase 2b/3 efficacy study in patients undergoing elective spinal fusion surgery (STaphylococcus aureus suRgical Inpatient Vaccine Efficacy [STRIVE]). SA4Ag has been shown in early phase clinical trials to be generally safe and well tolerated, and to induce high levels of bactericidal antibodies in healthy adults. In this review we discuss the design of SA4Ag, as well as the proposed clinical development plan supporting licensure of SA4Ag for the prevention of invasive disease caused by S. aureus in elective orthopedic surgical populations. We also explore the rationale for the generalizability of the results of the STRIVE efficacy study (patients undergoing elective open posterior multilevel instrumented spinal fusion surgery) to a broad elective orthopedic surgery population due to the common pathophysiology of invasive S. aureus disease and commonalties of patient and procedural risk factors for developing postoperative S. aureus surgical site infections.

Antibiotic Prophylaxis and DAIR Treatment in Primary Total Hip and Knee Arthroplasty, A National Survey in The Netherlands

BACKGROUND

To prevent postoperative infection the use of systemic antibiotic prophylaxis is common ground. Type of antibiotic used and duration of prophylaxis are subject to debate. In case of suspected early periprosthetic infection a debridement, antibiotics and implant retention (DAIR) procedure is treatment of first choice. This study evaluated the antibiotic prophylaxis and DAIR treatment protocols nationwide as well as reporting of these DAIR procedures to the national joint registry.

METHODS

All institutions that performed total hip or knee arthroplasty were contacted to complete a 16-question online survey. Questions included availability of a protocol, type and duration of antibiotic prophylaxis used and tendency to register infectious complications in the Dutch Arthroplasty Register.

RESULTS

All ninety-nine consulted institutions responded to this survey. All but one institutions have a standardized hospital based protocol for antibiotic prophylaxis in primary total hip or knee arthroplasty. Cefazolin was antibiotic prophylaxis of choice in ninety-four institutions for both primary hip and knee arthroplasty. In ten institutions one preoperative gift of antibiotic prophylaxis was administered. A protocol describing treatment when suspecting early periprosthetic joint infection was present in seventy-one institutions. When performing a DAIR procedure modular parts were exchanged in seventy institutions in case of a hip prosthesis and in eighty-one institutions in case of a knee prosthesis. Sixty-three institutions register DAIR procedures in the Dutch Arthroplasty Register.

INTERPRETATION

In contradiction to the results of a recent study in Great Britain, we have found only little variety in availability of protocols and in the type of antibiotic used as prophylaxis in primary total hip and knee arthroplasty in The Netherlands. Not every institution has a protocol for treatment in suspicion of early infection. Although mobile parts are exchanged in the majority of cases, there appears to be an underreporting of DAIR procedures in the Dutch Arthroplasty Register.

Peri-operative antibiotic treatment of bacteriuria reduces early deep surgical site infections in geriatric patients with proximal femur fracture

PURPOSE

The aim of this study was to conduct a re-evaluation of current strategies for peri-operative prophylaxis of infections in orthopaedic surgery of geriatric patients (≥65 years) with proximal femoral fractures (PFF).

METHODS

Between 01/2010 and 08/2014 all post-operative infections after stabilization of PFF of 1,089 geriatric patients were recorded retrospectively. All patients pre-operatively received a single dose of 1.5 g cefuroxime (group 1). These were compared to prospectively determined post-operative rates of surgical site infection (SSI) of 441 geriatric patients, which were operated on between 09/2014 and 03/2017 due to PFF. In this second group we investigated the urinary tract on admission. Bacteriuria was treated with the pre-operative single dose of 1.5 g cefuroxime along with ciprofloxacin for five days, beginning on admission. Level of significance was set to p < 0.05.

RESULTS

A total of 141 patients of group 2 had a bacteriuria. Seventy-seven of these patients revealed biochemical signs of manifest urinary tract infection. Multi-resistant pathogens were found in 15 patients and pathogens were cefuroxime-resistant in 37. The differences of SSI after at least three months were 2.1% in group 1 and 0.45% in group 2 for all patients with surgery of PFF (p < 0.02) and for those with arthroplasty (p < 0.037) significant.

CONCLUSIONS

The immediate antibiotic therapy of a prevalent bacteriuria for five days decreases the risk of SSI after surgery of PFF. Our single-centre study can only point out the problem of prevalent reservoirs of pathogens and the need for treatment. Evidence-based therapy concepts (indications of antibiotics, classes, duration) have to be developed in multi-centric and prospective studies.

Antibacterial Prophylaxis for Surgical Site Infection in the Elderly: Practical Application

Surgical site infections are among the most common healthcare-associated infections and are linked with increased length of hospitalization, re-admission, mortality and significant financial burden. Risk factors for the occurrence of surgical site infections include variables related to the surgical procedure as well as host factors. Increasing age is associated with the occurrence of surgical site infections. The aim of this review is to give an update on the antibiotic prophylaxis for surgical site infection in elderly people. We focused on specific issues and practical applications, such as the importance of targeting the antimicrobial agent to the susceptibility pattern of colonizing flora in selected cases and the need for dosage modifications.

Vaccine development to prevent Staphylococcus aureus surgical-site infections

BACKGROUND

Staphylococcus aureus surgical-site infections (SSIs) are a major cause of poor health outcomes, including mortality, across surgical specialties. Despite current advances as a result of preventive interventions, the disease burden of S. aureus SSI remains high, and increasing antibiotic resistance continues to be a concern. Prophylactic S. aureus vaccines may represent an opportunity to prevent SSI.

METHODS

A review of SSI pathophysiology was undertaken in the context of evaluating new approaches to developing a prophylactic vaccine to prevent S. aureus SSI.

RESULTS

A prophylactic vaccine ideally would provide protective immunity at the time of the surgical incision to prevent initiation and progression of infection. Although the pathogenicity of S. aureus is attributed to many virulence factors, previous attempts to develop S. aureus vaccines targeted only a single virulence mechanism. The field has now moved towards multiple-antigen vaccine strategies, and promising results have been observed in early-phase clinical studies that supported the recent initiation of an efficacy trial to prevent SSI.

CONCLUSION

There is an unmet medical need for novel S. aureus SSI prevention measures. Advances in understanding of S. aureus SSI pathophysiology could lead to the development of effective and safe prophylactic multiple-antigen vaccines to prevent S. aureus SSI.

Current practice of antibiotic prophylaxis for surgical fixation of closed long bone fractures: a survey of 297 members of the Orthopaedic Trauma Association

Background

The risk of postoperative surgical site infection after long bone fracture fixation can be decreased with appropriate antibiotic use. However, there is no agreement on the superiority of a single- or multiple-dose perioperative regimen of antibiotic prophylaxis. The purpose of this study is to determine the following: 1) What are the current practice patterns of orthopaedic trauma surgeons in using perioperative antibiotics for closed long bone fractures? 2) What is the current knowledge of published antibiotic prophylaxis guidelines among orthopaedic trauma surgeons? 3) Are orthopaedic surgeons willing to change their current practices?

Methods

A questionnaire was distributed via email between September and December 2015 to 955 Orthopaedic Trauma Association members, of whom 297 (31%) responded.

Results

Most surgeons (96%) use cefazolin as first-line infection prophylaxis. Fifty-nine percent used a multiple-dose antibiotic regimen, 39% used a single-dose regimen, and 2% varied this decision according to patient factors. Thirty-six percent said they were unfamiliar with Centers for Disease Control and Prevention (CDC) antibiotic prophylaxis guidelines; only 30% were able to select the correct CDC recommendation from a multiple-choice list. However, 44% of surgeons said they followed CDC recommendations. Fifty-six percent answered that a single-dose antibiotic prophylaxis regimen was not inferior to a multiple-dose regimen. If a level-I study comparing a single preoperative dose versus multiple perioperative antibiotic dosing regimen for treatment of closed long bone fractures were published, most respondents (64%) said they would fully follow these guidelines, and 22% said they would partially change their practice to follow these guidelines.

Conclusion

There is heterogeneity in the use of single- versus multiple-dose antibiotic prophylaxis for surgical repair of closed long bone fractures. Many surgeons were unsure of current evidence-based recommendations regarding perioperative antibiotic use. Most respondents indicated they would be receptive to high-level evidence regarding the single- versus multiple-dose perioperative prophylactic antibiotics for the treatment of closed long bone fractures.

Electronic supplementary material

The online version of this article (doi:10.1186/s13037-016-0118-5) contains supplementary material, which is available to authorized users.

Antibiotics and antiseptics for preventing infection in people receiving revision total hip and knee prostheses: a systematic review of randomized controlled trials

BACKGROUND

Infection rates in revision (second and subsequent) major joint arthroplasty continues to be a significant issue with rates 2-3 times those of primary procedures. The effect of antibiotic and antiseptic prophylaxis on outcomes for this type of surgery has not been adequately reviewed.

METHODS

A systematic search of the main databases for randomized controlled trials (RCTs) evaluating antibiotics and antiseptics was conducted to evaluate the predetermined endpoints of infection.

RESULTS

There were five (5) RCTs identified that examined the effects of antibiotic and antiseptic prophylaxis on infections after revision total hip arthroplasty [THA] (total of 304 participants) and total knee arthroplasty [TKA] (total of 206 participants). For TKA, preoperative systemic intravenous (IV) antibiotic prophylaxis plus antibiotic cement may be effective in reducing the incidence of infection in revision TKA at 8+ years. These results however should be interpreted with caution due to the significant biases. For revision THA, there is no RCT evidence that antibiotics/antiseptics have any effect on the infection rate.

CONCLUSIONS

There is a lack of high quality data demonstrating an effect of antibiotics or antiseptics on infection rates in revision THA/TKA. Considering the rate of infections in revisions is 2-3X that of primary procedures and; there is a consensus recommendation to use similar antibiotic and antiseptic regimens in both primary and revision procedures, there is a need for high quality studies in revision THA/TKA.

Cefepime versus Ceftriaxone for perioperative systemic antibiotic prophylaxis in elective orthopedic surgery at Bugando Medical Centre Mwanza, Tanzania: a randomized clinical study

BACKGROUND

Antimicrobial prophylaxis reduces the incidence of postoperative wound infections especially among patients undergoing orthopedics surgery. However, there is dearth of information on the clinical effectiveness, spectrum limitations and practical contextual information on third and fourth generation cephalosporins. The aim of this study was to evaluate the efficacy and safety of cefepime and ceftriaxone as peri-operative systemic antimicrobial prophylaxis in elective orthopedic surgery in our center.

METHODS

This study was a prospective, randomized, open label comparative clinical study of patients undergoing elective orthopedic procedures at the Bugando Medical Centre (BMC) between June 2014 and February 2015. Two hundred thirty participants were enrolled in the study and randomly assigned into Ceftriaxone regimen (group A) or Cefepime regimen (group B). Participants in ceftriaxone or cefepime group received 50 mg/kg up to 2 g single dose perioperative intravenous infusion at least 30 min before incision. Both groups were followed for 30 days using a Center for Disease Control superficial surgical site infection criterion for the outcome. A two-tailed margin of equivalence was set at 5% analyzed on the intent to treat.

RESULTS

All 230 participants were subjected to final analysis with no patient being lost to follow-up. Superficial surgical site infection occurred in 5 out of 117 (4.3%, 0.6 to 7.9 at 95% CI) patients receiving cefepime compared to 3 out of 113 (2.7%, 0.3 to 5.6 at 95% CI) among patients receiving ceftriaxone regimen. The absolute difference of 1.6% (95% Confidence Interval: -6.3 to 3.1), equivocally lies outside the 5% statistically significant margin of presumed clinical equivalence.

CONCLUSION

The difference between cefepime and ceftriaxone in preventing SSIs following elective clean orthopedic surgery was not statistically significant.

TRIAL REGISTRATION

Pan African Clinical Trial Registry: PACTR201406000803420.

Surgical site infection in high-energy peri-articular tibia fractures with intra-wound vancomycin powder: a retrospective pilot study

BACKGROUND

Surgical site infections (SSI) continue to be a significant source of morbidity despite the introduction of perioperative intravenous antibiotics. Our objective was to assess the efficacy of local vancomycin powder on lowering deep SSI rates in high-energy tibial plateau and pilon fractures.

MATERIALS AND METHODS

A retrospective review of all tibial plateau and pilon fractures treated in 2012 at our level I trauma center identified 222 patients. Of these, 107 patients sustained high-energy injuries that required staged fixation, and 93 had minimum 6 month follow-up. Ten patients received 1 gram vancomycin powder directly into the surgical wound at the time of definitive fixation, and the remaining 83 patients served as controls. SSI was defined according to criteria from the Centers for Disease Control. Demographic data, patient comorbidities, injury and treatment details, and infection details were recorded. Descriptive and comparative statistics were performed.

RESULTS

Amongst the vancomycin powder group, 1 patient (10 %) developed a deep SSI; in the control group, 14 (16.7 %) developed deep SSI. The rate of deep SSI between the groups was not statistically significantly different (P = 1.0). The groups were statistically similar with regard to injuries, treatment, comorbidities, and infectious outcomes (P values range = 0.06-1.0).

CONCLUSIONS

The application of local vancomycin powder into surgical wounds of high-energy tibial plateau and pilon fractures did not reduce the rate of deep SSI in this retrospective review. There is a need to find effective, cheap, and widely available methods for prevention of SSI. Basic science and larger prospective clinical studies are needed to further delineate the role of local vancomycin powder as a modality to reduce deep SSI in extremity trauma.

Older Patients Are Immunocompromised by Cytokine Depletion and Loss of Innate Immune Function After HIP Fracture Surgery

PURPOSE/INTRODUCTION

We have examined the immune status of elderly patients who underwent surgery for a hip fracture, an injury associated with poor postoperative outcomes, to identify specific immune defects.

METHODS

In a cohort observational study, 16 patients undergoing surgery for hip fractures had immune function evaluation prior to surgery, and then at 3 and 7 days postoperatively, using flow cytometry for phenotype and for monocyte and granulocyte phagocytic function and respiratory burst. Serum samples were stored and batch analyzed using a human cytokine 25-plex panel.

RESULTS

We report significant loss of innate immune function, related specifically to reduced granulocyte numbers by day 7 (P < .0001, flow cytometry; P < .05 white blood cells), and although granulocyte ability to take up opsonized Escherichia coli was increased (P < .05), the ability of those cells to generate a respiratory burst was reduced at days 3 and 7 (P < .05). Monocyte respiratory burst was also significantly reduced (P < .05). Serum cytokine levels indicated very poor T-cell function.

CONCLUSION

We have demonstrated that the antimicrobial immune response is profoundly reduced after surgery in elderly patients with hip fractures. The effect was sustained up to 7 days postoperatively, identifying these patients as particularly vulnerable to bacterial infections.

Length of preoperative hospital stay: a risk factor for reducing surgical infection in femoral fracture cases

OBJECTIVE

To analyze infections of the surgical site among patients undergoing clean-wound surgery for correction of femoral fractures.

METHODS

This was a historical cohort study developed in a large-sized hospital in Belo Horizonte. Data covering the period from July 2007 to July 2009 were gathered from the records in electronic medical files, relating to the characteristics of the patients, surgical procedures and surgical infections. The risk factors for infection were identified by means of statistical tests on bilateral hypotheses, taking the significance level to be 5%. Continuous variables were evaluated using Student's t test. Categorical variables were evaluated using the chi-square test, or Fisher's exact test, when necessary. For each factor under analysis, a point estimate and the 95% confidence interval for the relative risk were obtained. In the final stage of the study, multivariate logistic regression analysis was performed.

RESULTS

432 patients who underwent clean-wound surgery for correcting femoral fractures were included in this study. The rate of incidence of surgical site infections was 4.9% and the risk factors identified were the presence of stroke (odds ratio, OR = 5.0) and length of preoperative hospital stay greater than four days (OR = 3.3).

CONCLUSION

To prevent surgical site infections in operations for treating femoral fractures, measures involving assessment of patients' clinical conditions by a multiprofessional team, reduction of the length of preoperative hospital stay and prevention of complications resulting from infections will be necessary.

A retrospective study of antibiotic prophylaxis value in surgical treatment of lower limb fracture

BACKGROUND

Surgical site infections (SSI) are nosocomial infections that cause considerable problems in orthopaedic surgery. Antibiotic prophylaxis can be used to reduce the risk for SSI. There is no universal antibiotic that can be recommended for prophylaxis in terms of coverage of all possible pathogens because of antibiotic resistance, and there are no universal recommendations for different types of patients in terms of injury type, selected operation and risk factors for development of SSI. The aim of this study was to analyse the effectiveness of antibiotic prophylaxis in surgical treatment (ORIF) of closed lower limb fractures in young, healthy patients.

PATIENTS AND METHODS

Patient details were collected from the patient histories. Inclusion criteria for participants were age 20-30 years, not suffering from any type of chronic disease or state that may affect postoperative infection and ISS≤9. Antibiotic prophylaxis use and outcome (SSI) were compared between two groups of patients. Data were analysed using descriptive statistics, Fisher's exact test and t-test for proportions.

RESULTS

A total of 347 patients with closed lower limb fractures treated with ORIF met the inclusion criteria. There were 290 male and 57 female patients, with an average age of 24.47 years. Prophylactic antibiotics were given to 242 patients (69.74%); 2g ceftriaxone was administered to 88.02% of the patients who received antibiotic prophylaxis. Ten patients developed postoperative infection (eight out of 242 with antibiotic prophylaxis and two out of 105 without antibiotic prophylaxis). The difference between the two groups was not statistically significant (Fisher's exact test, P=0.749).

CONCLUSION

Antibiotic prophylaxis was ineffective in preventing SSI in patients with no risk factors for SSI who were undergoing ORIF for closed lower limb fractures.

Lower reoperation rate for cemented femoral stem than for uncemented femoral stem in primary total hip arthroplasty following a displaced femoral neck fracture

Introduction: Acute displaced femoral neck fractures are often treated with cemented hemiarthroplasty (HA). There is increasing evidence that total hip arthroplasty (THA) may be a better alternative, but the degree to which the fixation of the femoral stem used affects the outcome is not fully known. The aim of this study is to compare rates of operative complications and implant survival following THA treatment of displaced femoral neck fractures with either a cemented or an uncemented femoral stem.

Methods: The study consists of two groups of patients (N = 334), who were treated for a displaced femoral neck fracture with THA at the Regional Hospital of Viborg during 2007–2012. The first group (50.9%) had uncemented (Corail^®) stem while the second group (49.1%) had cemented (Exeter^®) stem implanted. Nearly all patients had uncemented dual mobility cup (Saturne^®) as acetabular component and were followed up to three months postoperatively. Data regarding rates of implant survival and operative complications were obtained by retrospective review of medical records.

Results: We found a statistically significant difference regarding rates of postoperative reoperation with 1.2% (95% CI 0.005–0.03) for cemented and 5.9% (95% CI 0.02–0.09) for uncemented stem (p = 0.02). The main causes for reoperation were peri-prosthetic fractures and deep infections. There was no difference regarding dislocation or peroperative complications. Rates of dislocation were 4.3% (95% CI 0.012–0.07) for cemented and 3.5% (95% CI 0.008–0.06) for uncemented stem (p = 0.72). Rates of peroperative complications were 6.1% (95% CI 0.024–0.1) for cemented and 8.2% (95% CI 0.04–0.12) for uncemented stem (p = 0.1).

Discussion: Our results indicate that cemented femoral stem is superior to cementless when rates of reoperation are compared.

Management of femoral neck fractures in the young patient: A critical analysis review

Femoral neck fractures account for nearly half of all hip fractures with the vast majority occurring in elderly patients after simple falls. Currently there may be sufficient evidence to support the routine use of hip replacement surgery for low demand elderly patients in all but non-displaced and valgus impacted femoral neck fractures. However, for the physiologically young patients, preservation of the natural hip anatomy and mechanics is a priority in management because of their high functional demands. The biomechanical challenges of femoral neck fixation and the vulnerability of the femoral head blood supply lead to a high incidence of non-union and osteonecrosis of the femoral head after internal fixation of displaced femoral neck fractures. Anatomic reduction and stable internal fixation are essentials in achieving the goals of treatment in this young patient population. Furthermore, other management variables such as surgical timing, the role of capsulotomy and the choice of implant for fixation remain controversial. This review will focus both on the demographics and injury profile of young patients with femoral neck fractures and the current evidence behind the surgical management of these injuries as well as their major secondary complications.

Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery

BACKGROUND

Surgery has been used as part of breast cancer treatment for centuries; however any surgical procedure has the potential risk of infection. Infection rates for surgical treatment of breast cancer are documented at between 3% and 15%, higher than average for a clean surgical procedure. Pre- and perioperative antibiotics have been found to be useful in lowering infection rates in other surgical groups, yet there is no consensus on the use of prophylactic antibiotics for breast cancer surgery.

OBJECTIVES

To determine the effects of prophylactic (pre- or perioperative) antibiotics on the incidence of surgical site infection (SSI) after breast cancer surgery.

SEARCH METHODS

For this third update we searched the Cochrane Wounds Group Specialised Register (5 December 2013); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); the Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. We applied no language or date restrictions.

SELECTION CRITERIA

Randomised controlled trials of pre- and perioperative antibiotics for patients undergoing surgery for breast cancer were included. Primary outcomes were rates of surgical site infection (SSI) and adverse reactions.

DATA COLLECTION AND ANALYSIS

Two review authors independently examined the title and abstracts of all studies identified by the search strategy, then assessed study quality and extracted data from those that met the inclusion criteria.

MAIN RESULTS

A total of eleven studies (2867 participants) were included in the review. Ten studies evaluated preoperative antibiotic compared with no antibiotic or placebo. One study evaluated perioperative antibiotic compared with no antibiotic. Pooling of the results demonstrated that prophylactic antibiotics administered preoperatively significantly reduce the incidence of SSI for patients undergoing breast cancer surgery without reconstruction (pooled risk ratio (RR) 0.67, 95% confidence interval (CI) 0.53 to 0.85). Analysis of the single study comparing perioperative antibiotic with no antibiotic found no statistically significant effect of antibiotics on the incidence of SSI (RR 0.11, 95% CI 0.01 to 1.95). No studies presented separate data for patients who underwent reconstructive surgery at the time of removal of the breast tumour.

AUTHORS' CONCLUSIONS

Prophylactic antibiotics administered preoperatively reduce the risk of SSI in patients undergoing surgery for breast cancer. Further studies involving patients undergoing immediate breast reconstruction are needed as studies have identified this group as being at higher risk of infection than those who do not undergo immediate breast reconstruction.

Posttraumatic and postoperative osteomyelitis: surgical revision strategy with persisting fistula

INTRODUCTION

Posttraumatic and postoperative osteomyelitis (PPO) with bacteria colonisation during trauma and associated surgery is an increasing clinical problem. This study investigated the treatment of PPO by surgical revision including irrigation, debridement, and temporary hardware maintenance. In addition, a drainage was inserted as persisting fistula to control osteomyelitis until fracture healing was achieved. Trauma- and osteomyelitis-related factors that influenced the study outcome were determined.

PATIENTS AND METHODS

67 consecutive patients with PPO were included. At onset of PPO, patients had incomplete fracture healing. Patients were subdivided by time of PPO occurrence (acute, subacute or chronic), initial soft tissue trauma, anatomical location, and initial fracture type (AO classification). The study outcome measures included radiographic and clinical follow-up.

RESULTS

59 patients could be followed for an average of 23 months after revision surgery. A bone healing was achieved by 89% of patients after 14.7 ± 13.4 weeks. Fractures of the lower extremity, open fractures and comminuted C-type fractures took significantly longer to achieve bone healing (p < 0.05 each). Time of PPO occurrence did not influence bone healing. After fracture consolidation, no re-infection was found.

CONCLUSIONS

This study showed high rates of bone healing, indicating that this strategy with persisting fistula should be considered as alternative treatment option in patients with PPO.

[Procedural organisation: surgical and anaesthesiological management in hip fractures]

In patients with hip fractures, in order to reduce the high number of general complications and those associated with the specific treatment, the functional loss and cognitive impairment, implementation of co-ordinated, multidisciplinary treatment pathways, and rehabilitation, is mandatory. The imminent treatment of proximal femoral fracture consists of major orthopaedic surgery in most cases (total or partial hip arthroplasty, osteosynthesis). After the diagnosis of a hip fracture, an adequate pain medication should be initiated. The decision making for the fracture treatment includes fracture type, patient's age, cognitive function, mobility before the fall and functional demands of the patient in the context of patients life expectancy and goals of care. The anaesthesiological evaluation focuses on risk assessment. Medical abnormalities should be optimized within 24 to 48 h, or an increased perioperative risk due to comorbidities has to be accepted. The timing and the course of further preoperative diagnostic examinations and therapeutic interventions should be co-ordinated between the involved medical disciplines. After the operation a structured screening for delirium should be initiated and further evaluation of patient's nutrition, fall-associated medication, living conditions and osteoporosis treatment has to be performed.

In vitro evaluation of TiO2 nanotubes as cefuroxime carriers on orthopaedic implants for the prevention of periprosthetic joint infections

CONTEXT

The prevention of periprosthetic joint infections requires an antibiotic prophylactic therapy, which could be delivered locally using titanium dioxide nanotubes as novel reservoirs created directly on the orthopaedic implant titanium surface.

OBJECTIVE

In this study, the influence of several parameters that could impact the use of titanium dioxide nanotubes as cefuroxime carriers was investigated.

METHOD

Cefuroxime loading and release was studied for 90 min with three nano-topography conditions (nano-smooth, nano-rugged and nano-tubular), two cefuroxime loading solution concentrations (150 mg/mL and 25mg/mL) and two nano-tubular crystalline structures.

RESULTS

In all tested conditions, maximum amount of cefuroxime was obtained within 2 min. For both cefuroxime loading solution concentrations, nano-smooth samples released the least cefuroxime, and the nano-tubular samples released the most, and a six-fold increase in the concentration of the cefuroxime loading increased the amount of cefuroxime quantified by more than seven times, for all tested nano-topographies. However, the nano-tubes' crystalline structure did not have any influence on the amount of cefuroxime quantified.

CONCLUSION

The results demonstrated that the surface nano-topography and loading solution concentration influence the efficiency of titanium dioxide nanotubes as cefuroxime carriers and need to be optimized for use as novel reservoirs for local delivery of cefuroxime to prevent periprosthetic infections.

Implementation of a short course of prophylactic antibiotic treatment for prevention of postoperative infections in clean orthopaedic surgeries

BACKGROUND & OBJECTIVES

Perioperative antimicrobial prophylaxis constitutes the bulk of antimicrobial consumption in any hospital. This study was conducted at a level 1 Trauma Centre of a tertiary care hospital of India to assess the efficacy of a short (24 h) course of perioperative antibiotic prophylactic regimen in preventing surgical site infections (SSI) in open reduction and internal fixation (ORIF) of closed fractures of limbs and to assess if the same can be implemented as a general policy.

METHODS

Patients of either sex, aged 18 yr or more, who were scheduled for ORIF and were willing and able to give informed consent, were included in the study. Patients were randomly allocated into two groups. Group 1 (n=100) received 3 doses of 1 g i.v. cefuroxime perioperatively spaced 12 h apart and group 2 (n=97) received the conventional existing regimen [5 days of i.v. antibiotics (cefuroxime 1 g twice daily along with amikacin 15 mg/kg in 2 divided doses), followed by oral cefuroxime, 500 mg twice daily till suture removal].

RESULTS

Of the 197 patients, four patients developed a surgical site infection (three with methicillin resistant Staphylococcus aureus and one Acinetobacter baumanii). Of these, two patients were in group 1 and the remaining two in group 2. These patients were treated with i.v. antibiotics based on the culture and antimicrobial sensitivity reports. The cost of the short course treatment was ` 150 per patient as compared to ` 1,900 per patient for conventional regimen.

INTERPRETATION & CONCLUSIONS

There was no significant difference in rates of SSI among the two groups in our study. Cost evaluation revealed that shorter course was less expensive than conventional long course regimen. Implementation of a short course perioperative regimen will go a long way in reducing antimicrobial resistance, cost and adverse reactions to antimicrobials.

Is prophylactic Gentamicin associated with acute kidney injury in patients undergoing surgery for fractured neck of femur?

BACKGROUND

Single dose Gentamicin (240 mg) has been shown to reduce postoperative wound infection in patients with fractured neck of femur when used in a combined antibiotic regimen. However, concerns have arisen about the risk of acute kidney injury (AKI) in these patients.

OBJECTIVE

To determine if the use of prophylactic Gentamicin is associated with AKI in fractured neck of femur patients.

METHODS

A historical cohort study. Pre- and post-operative creatinine mmol/l of 100 successive fractured neck of femur patients admitted from September 2010 were compared to a control of 100 age, sex and procedure matched individuals operated upon before the introduction of prophylactic Gentamicin (2005). AKI was defined as an increase in serum creatinine by over 50% of base line. Statistical significance was regarded as p<0.05.

RESULTS

A significant rise in creatinine levels was observed in both control (p=0.005) and study groups (p=0.001). There was neither a significant difference in peak creatinine between groups (p=0.87) nor in rates of AKI (p=0.568) between the 2 groups.

CONCLUSION

Single preoperative doses of Gentamicin (240 mg) have no detrimental impact on renal function in this group. There is, however, a significant rise in creatinine following fractured neck of femur surgery, independent of Gentamicin.

The application of evidence-based measures to reduce surgical site infections during orthopedic surgery - report of a single-center experience in Sweden

Background

Current knowledge suggests that, by applying evidence-based measures relating to the correct use of prophylactic antibiotics, perioperative normothermia, urinary tract catheterization and hand hygiene, important contributions can be made to reducing the risk of postoperative infections and device-related infections. The aim of this study was to explore and describe the application of intraoperative evidence-based measures, designed to reduce the risk of infection. In addition, we aimed to investigate whether the type of surgery, i.e. total joint arthroplasty compared with tibia and femur/hip fracture surgery, affected the use of protective measures.

Method

Data on the clinical application of evidence-based measures were collected structurally on site during 69 consecutively included operations involving fracture surgery (n = 35) and total joint arthroplasties (n = 34) using a pre-tested observation form. For observations in relation to hand disinfection, a modified version of the World Health Organization hand hygiene observation method was used.

Results

In all, only 29 patients (49%) of 59 received prophylaxis within the recommended time span. The differences in the timing of prophylactic antibiotics between total joint arthroplasty and fracture surgery were significant, i.e. a more accurate timing was implemented in patients undergoing total joint arthroplasty (p = 0.02). Eighteen (53%) of the patients undergoing total joint arthroplasty were actively treated with a forced-air warming system. The corresponding number for fracture surgery was 12 (34%) (p = 0.04).

Observations of 254 opportunities for hand hygiene revealed an overall adherence rate of 10.3% to hand disinfection guidelines.

Conclusions

The results showed that the utilization of evidence-based measures to reduce infections in clinical practice is not sufficient and there are unjustifiable differences in care depending on the type of surgery. The poor adherence to hand hygiene precautions in the operating room is a serious problem for patient safety and further studies should focus on resolving this problem. The WHO Safe Surgery checklist “time out” worked as an important reminder, but is not per se a guarantee of safety; it is the way we act in response to mistakes or lapses that finally matters.

Antimicrobial effects of nanofiber poly(caprolactone) tissue scaffolds releasing rifampicin

This study quantified the antibiotic release kinetics and subsequent bactericidal efficacy of rifampicin (RIF) against Gram-positive and Gram-negative bacteria under in vitro static conditions. Antibiotic-loaded scaffolds were fabricated by electrospinning poly(caprolactone) (PCL) with 10% or 20% (w/w) RIF. Scaffold fiber diameter and RIF loading were characterized, and RIF release kinetics were measured. RIF-releasing and RIF-free scaffolds were inoculated with Pseudomonas aeruginosa and Staphylococcus epidermidis, and the suspended concentration live and dead bacteria were determined by fluorescent microscopy. Adherent bacteria and biofilm formation were examined using scanning electron microscopy. Mean fiber diameters were 557 ± 399 nm for RIF-free, 402 ± 225 nm for 10% RIF, and 665 ± 402 nm for 20% RIF scaffolds. RIF release kinetics exhibited a short-burst release during the first hour, followed by a 7 h, zero-order release during which both RIF scaffolds released ~50% of their initial RIF mass loading. P. aeruginosa and S. epidermidis suspended cell populations proliferated in accordance with logarithmic growth models when exposed to control scaffolds; however both RIF-containing scaffolds completely inhibited bacterial growth in suspension and, subsequently, prevented biofilm formation within the scaffolds through the first 6 h.

Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery

BACKGROUND

Surgery has been used as part of breast cancer treatment for centuries; however any surgical procedure has the potential risk of infection. Infection rates for surgical treatment of breast cancer are documented at between 3% and 15%, higher than average for a clean surgical procedure. Pre- and perioperative antibiotics have been found to be useful in lowering infection rates in other surgical groups, yet there is no consensus on the use of prophylactic antibiotics for breast cancer surgery.

OBJECTIVES

To determine the effects of prophylactic (pre- or perioperative) antibiotics on the incidence of surgical site infection (SSI) after breast cancer surgery.

SEARCH METHODS

For this second update we searched the Cochrane Wounds Group Specialised Register (searched 31 August 2011); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3); Ovid MEDLINE (2008 to August Week 3 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations 30 August 2011); Ovid EMBASE (1980 to 2011 Week 34); and EBSCO CINAHL (2008 to 25 August 2011). We applied no language or date restrictions.

SELECTION CRITERIA

Randomised controlled trials of pre- and perioperative antibiotics for patients undergoing surgery for breast cancer were included. Primary outcomes were rates of surgical site infection (SSI) and adverse reactions.

DATA COLLECTION AND ANALYSIS

Two review authors independently examined the title and abstracts of all studies identified by the search strategy, then assessed study quality and extracted data from those that met the inclusion criteria.

MAIN RESULTS

A total of nine studies (2260 participants) is included in the review. Eight studies evaluated preoperative antibiotic compared with no antibiotic or placebo. One study evaluated perioperative antibiotic compared with no antibiotic. Pooling of the results demonstrated that prophylactic antibiotics administered preoperatively significantly reduce the incidence of SSI for patients undergoing breast cancer surgery without reconstruction (pooled risk ratio (RR) 0.71, 95% confidence interval (CI) 0.53 to 0.94). Analysis of the single study comparing perioperative antibiotic with no antibiotic found no statistically significant effect of antibiotics on the incidence of SSI (RR 0.11, 95% CI 0.01 to 1.95). No studies presented separate data for patients who underwent reconstructive surgery at the time of removal of the breast tumour.

AUTHORS' CONCLUSIONS

Prophylactic antibiotics administered preoperatively reduce the risk of SSI in patients undergoing surgery for breast cancer. Further studies involving patients undergoing immediate breast reconstruction are needed as studies have identified this group as being at higher risk of infection than those who do not undergo immediate breast reconstruction.

Treatment of post-operative infections following proximal femoral fractures: our institutional experience

Proximal femoral fractures (PFFs) are a major health concern in the elderly population. Improvements made in implants and surgical techniques resulted in faster rehabilitation and shorter length of hospital stay. Despite this, the reduced physiological reserve, associated co-morbidities and polypharmacy intake of the elderly population put them at high risk of postoperative complications particularly of infectious origin. Out of 10061 patients with proximal femoral fractures 105 (1.05%) developed surgical site infection; 76 (72%) infections occurred in patients who had sustained intracapsular (IC) fractures with the remaining 29 (28%) infections occurring in patients with extracapsular (EC) neck of femur fractures. The median number of additional surgical debridements was 2 (range 1-7). MRSA was isolated in 49 (47%) of the cases; 38 patients (36%) ultimately underwent a Girdlestone's excisional arthroplasty. Mortality at 30 days and 3 months was 10% and 31%, respectively. It was noted that post-operative hip infection predisposed to a prolonged length of stay in the acute unit and subsequently to a more dependent destination after discharge.

Antimicrobial activity of gentamicin palmitate against high concentrations of Staphylococcus aureus

The reduction of implant related infections plays a pivotal role in orthopaedic surgery as an increasing number of people require implants (up to 200,000 per year in the United States (source: Joint Implant Surgery & Research Foundation 2010)). The aim of the current study is to prevent and thus decrease the number of bacterial infections. Both pre and post operative systemic antibiotic treatment and gentamicin containing bone cements (polymethylmethacrylate, PMMA) are commonly used strategies to overcome infections. In this study, the antimicrobial efficacy of gentamicin sulfate loaded bone cement was compared with titan discs coated with a new form of gentamicin, gentamicin palmitate. Adherence prevention, killing rates and killing kinetics were compared in an in vitro model, using Staphylococcus aureus (S. aureus), which together with Staphylococcus epidermidis (S. epidermidis) represents 60% of bacteria found responsible for hip implant infections (An and Friedman, 1996, J Hosp Infect 33(2):93-108). In our experiments gentamicin, which was applied as gentamicin palmitate on the surface of the implants, showed a high efficacy in eliminating bacteria. In contrast to gentamicin sulfate containing bone cements, gentamicin palmitate is released over a shorter period of time thus not inducing antibiotic resistance. Another benefit for clinical application is that it achieves high local levels of active ingredient which fight early infections and minimize toxic side effects. Furthermore, the short term hydrophobic effect of gentamicin palmitate can successfully impede biofilm formation. Thus, the use of self-adhesive antibiotic fatty acid complexes like gentamicin palmitate represents a new option for the anti-infective coating of cementless titan implants.