Smoking is a risk factor of organ/space surgical site infection in orthopaedic surgery with implant materials

Implanted Pulse Generators in Lower Extremity Neuroprostheses: A 25-Year Review

OBJECTIVES

Neuroprosthetic devices can improve quality of life by providing an alternative option for motor function lost after spinal cord injury, stroke, and other central nervous system disorders. The objective of this study is to analyze the outcomes of implanted pulse generators that our research group installed in volunteers with paralysis to assist with lower extremity function over a 25-year period, specifically, to determine survival rates and common modes of malfunction, reasons for removal or revision, and precipitating factors or external events that may have adversely influenced device performance.

MATERIALS AND METHODS

Our implantable receiver-stimulator (IRS-8) and implantable stimulator-telemeter (IST-12 and IST-16) device histories were retrospectively reviewed through surgical notes, regulatory documentation, and manufacturing records from 1996 to 2021.

RESULTS

Most of the 65 devices (64.6%) implanted in 43 volunteers remain implanted and operational. Seven underwent explantation owing to infection; seven had internal failures, and six were physically broken by external events. Of the 22 devices explanted, 15 were successfully replaced to restore recipients' enhanced functionality. There were no instances of sepsis or major health complications. The five infections that followed all 93 IRS and IST lower extremity research surgeries during this period indicate a pooled infection rate of 5.4%. The Kaplan-Meier analysis of technical malfunctions between the implant date and most recent follow-up shows five-, ten-, and 20-year device survival rates of 92%, 84%, and 71%, respectively.

CONCLUSIONS

Incidence of malfunction is similar to, whereas infection rates are slightly higher than, other commonly implanted medical devices. Future investigations will focus on infection prevention, modifying techniques on the basis of recipient demographics, lifestyle factors, and education, and integrating similar experience of motor neuroprostheses used in other applications.

Microbiological Profile and Outcome of Surgical Site Infections Following Orthopedic Surgeries in a Tertiary Care Hospital

Surgical site infections (SSIs) are one of the most common adverse events that occur in hospitalized patients undergoing surgical procedures or in outpatient surgical measures, regardless of the advances in preventive procedures. SSI may lead to disastrous consequences in orthopedic practice as it may involve the joints and bones and is extremely difficult to get rid of the infection. The present study was designed to evaluate the rates, risk factors, microbiological profiles, and outcomes of SSIs following orthopedic procedures in patients admitted to a tertiary care hospital in Eastern India during the study period of September 2022 to March 2024. A total of 1327 patients who underwent orthopedic surgeries were followed up for the development of SSI, among whom 105 (7.9%) developed SSI, making an incidence rate of 7.9%. The incidence of SSI in different surgeries was 9.5% (34/359) in closed reduction with fixation, 8.5% (65/766) in open reduction with internal fixation, 4.4% (3/69) in hip arthroplasty, and 2.3% (3/133) in knee arthroplasty. Maximum (27.6%) patients having SSI were of the age group of 20-29 years, and 87.62% were males. The habit of smoking was found to be highly statistically significant. The common gram-positive organisms isolated were Staphylococcus aureus and Enterococcus species, which were mostly sensitive to vancomycin, linezolid, teicoplanin, and tigecycline. The common gram-negative organisms isolated were Klebsiella pneumoniae, Pseudomonas species, Escherichia coli, and Acinetobacter species, many of which were multidrug-resistant organisms and were sensitive to amikacin, amoxicillin-clavulanate, and ceftriaxone.

Marginal bone resection and immediate internal fixation in multidrug resistant chronic septic nonunions of lower limb long bones: a case series

PURPOSE

This study aimed to evaluate the efficacy of a combined treatment approach integrating extensive debridement, immediate internal fixation, and the Masquelet technique for the management of infected nonunion of long bones in the lower limbs caused by multidrug-resistant (MDR) and extensively drug-resistant (XDR) bacteria.

METHODS

This retrospective case series was conducted at the Imam Khomeini Hospital Complex, Tehran, Iran, a tertiary-level academic referral centre. The study documented consecutive cases of patients presenting with infected nonunion of the tibia or femur, with a positive culture for MDR or XDR bacteria, treated between January 2019 and December 2022. Inclusion criteria were adults with a confirmed diagnosis of infected nonunion due to MDR or XDR bacteria, with exclusion criteria including patients with unrelated infections or allergies to the components of the treatment regimen. The primary outcomes measured were infection resolution and bone healing.

RESULTS

The study cohort comprised 16 patients, predominantly male (87.5%) with an average age of 38.5 years. Methicillin-resistant Staphylococcus aureus (MRSA) was identified as the causative agent in 31.25% of the infections. Patients were followed for a period ranging from 12 to 26 months. The treatment protocol was uniformly applied across all cases. Successful bone union was observed in the majority of patients within 140 to 240 days following grafting. However, there were two instances where amputation was necessitated due to the failure to eradicate the infection. Complications arose in three cases during the follow-up period: two required re-debridement due to a recurrence of the infection, and one was subjected to bone transport owing to persistent nonunion. Notably, all cases that either failed or encountered complications were smokers.

CONCLUSIONS

In this integrated approach, high rates of infection resolution and bone healing were achieved, suggesting this method as a viable option for these complex cases.

Epidemiology of complications after non-compulsory planned hardware-removal after limbs fracture

INTRODUCTION

Removal of hardware (HR) following a fracture is a frequent question from patients. The incidence of this kind of intervention remains very variable depending on the healthcare systems and its interest is debated in view of the benefits and associated risks that remain poorly defined. Mandatory preoperative information cannot be given optimally in this context.

OBJECTIVE

To determine the rate of complications (major and minor) after non-compulsory planned hardware-removal following a limb fracture.

HYPOTHESIS

The rate of major complications was greater than 1%.

METHODS

A 10-year retrospective single-center study included 1990 patients who had undergone routine HR. Analysis of medical records, with a minimum of one year of follow-up, allowed us to collect: patient data, the type and anatomical location of the osteosynthesis material, as well as the occurrence of a postoperative complication, categorized as a major complication (resulting in either a new surgical procedure, re-hospitalization, or lasting functional impairment) or a minor complication.

RESULTS

Overall, 4.1% (79/1990) of patients experienced postoperative complications, including 1.56% (31/1990) major complications and 21 surgical revisions (1.06%). The time to onset of complications was 9.1 +/- 8.4 days. The most common complications were deep infections and impaired skin healing with superficial infection (55/79, 69.6%). Locations "around the knee" and "around the ankle" were at higher risk of complications (p < 0.01). Smoking was identified as a significant risk factor for complications, particularly deep infection (p = 0.004, OR = 8.7 [1.98; 38.11]).

DISCUSSION

Non-mandatory routine RH has a significant complication rate even in a healthy population. Preoperative information of the patient and the assessment of the benefit/risk balance are essential in this indication. This study also raises the question of mandatory smoking cessation preoperatively.

LEVEL OF EVIDENCE

IV; retrospective study.

Smoking is not closely related to revision for periprosthetic joint infection after primary total knee and hip arthroplasty

BACKGROUND

The influence of smoking on the risk of periprosthetic joint infection (PJI) remains unclear. The objective was to explore the impact of smoking on PJI after primary total knee (TKA) and hip (THA) arthroplasty.

HYPOTHESIS

Current smoking patients should have an increased risk of PIJ compared with nonsmoking patients.

PATIENTS AND METHODS

A prospective registry-based observational cohort study was performed. A total of 4591 patients who underwent primary TKA (3076 patients) or THA (1515) were included. According to the smoking status at the time of arthroplasty, patients were classified as nonsmokers (3031 patients), ex-smokers (688), and smokers (872). Multivariate analysis included smoking status, age, gender, education level, body mass index, American Society of Anesthesiologists class, diagnosis (osteoarthritis, rheumatism), diabetes, chronic obstructive pulmonary disease, perioperative blood transfusion, site of arthroplasty (knee, hip), length of operation, and length of stay.

RESULTS

There were PJI after 59 (1.9%) TKA and 27 (1.8%) THA (p=0.840). There were PJI in 47 (1.6%) nonsmokers, 12 (1.7%) ex-smokers, and 17 (1.9%) smokers (p=0.413). There were wound complications (delayed wound healing and superficial wound infection) in 34 (0.7%) nonsmokers, 9 (1.3%) in ex-smokers, and 17 (1.9%) in smokers (p=0.045). In multivariate analysis, only the female gender was a significant predictor of PJI (OR 1.3, 95% CI 1.1-2.4 [p=0.039]). Specifically, the categories of ex-smokers (OR 0.8, 95% CI 0.2-1.7 [p=0.241]) and smokers (OR 1.1, 95% CI 0.6-1.5 [p=0.052]) were not significant predictors. The 4-year arthroplasty survival with PJI as the endpoint was 99.1% (95% CI: 99.0-99.7) for nonsmokers, 99.0% (95% CI: 98.8-99.2) for ex-smokers, and 98.7% (95% CI: 98.2-99.0) for smokers was not significantly different between smoking status groups (p=0.318).

DISCUSSION

Smoking was not identified as a significant predictor for PJI following primary TKA or THA.

LEVEL OF EVIDENCE

III, prospective cohort study.

Incidence of Infections, Explantations, and Displacements/Mechanical Complications of Spinal Cord Stimulation During the Past Eight Years

OBJECTIVES

The overall awareness and potential of real-world data have drastically increased in the medical field, with potential implications for postmarket medical device surveillance. The goal of this study was to evaluate real-world data on incidence of infections, explantations, and displacements/mechanical complications of spinal cord stimulation (SCS) during the past eight years and to forecast point estimates for the upcoming three years on the basis of the identified patterns.

MATERIALS AND METHODS

Based on electronic health records from 80 healthcare organizations within the TriNetX data base in the USA, data of 11,934 patients who received SCS as treatment for persistent spinal pain syndrome type 2 (PSPS T2) were extracted. Events of interest were explantations and displacements/mechanical complications of both the lead and implanted pulse generator (IPG), in addition to infection rates from 2015 to 2022. Mann-Kendall tests were performed to detect monotonic trends in the time series. Forecasts were conducted for the upcoming three years for every event of interest.

RESULTS

Statistically significant increasing time trends were revealed for the annual incidence of IPG and lead displacements/mechanical complications in patients with PSPS T2 over the past eight years. These time trends were visible in both male and female patients and in smokers and nonsmokers. For annual incidence of explantations and infections, no significant time effect was observed. In 2025, the incidence of displacements/mechanical complications of the lead (3.07%) is predicted to be the highest, followed by explantations of the IPG (2.67%) and lead (2.02%).

CONCLUSIONS

Based on real world data, device explantation was the most frequent event of interest, with negative peaks in the time series in 2016 and 2020, presumably due to the introduction of rechargeable pulse generators and to the COVID-19 pandemic, respectively.

Body Mass Index Greater Than 46 Associated With Increased Risk of 30 Day Complications Following Adult Tonsillectomy: A Retrospective Cohort Study

Background: The study aimed to identify data-driven body mass index (BMI) thresholds that are associated with varying risk of 30 day complications following adult tonsillectomy. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was utilized to conduct a retrospective cohort analysis of patients undergoing adult tonsillectomy from 2005 to 2019. Stratum-specific likelihood ratio (SSLR) analysis was conducted to determine data-driven BMI strata that maximized the likelihood of 30 day complications following adult tonsillectomy. Patient demographics and clinical comorbidities were compared using chi-squared analysis and student t tests, where appropriate, for each stratum. Multivariable regression analysis was conducted to confirm association between identified data-driven strata with 30 day complication rates. Results: In total, 44,161 patients undergoing adult tonsillectomy were included in this study. SSLR analysis identified 2 BMI categories: 18 to 45 and 46+. Relative to the 18 to 45 BMI cohort, the 46+ BMI cohort was more likely to have 30 day all-cause complications after surgery [odds ratio (OR): 1.62, P = .007]. Specifically, the 46+ BMI cohort had significantly higher odds for 30 day major medical complications (OR: 2.86, P = .001), pulmonary domain complications (OR: 1.86, P = .041), unplanned reintubation (OR: 2.65, P = .033), and deep vein thrombosis (OR: 6.54, P = .026). Conclusions: We identified a BMI threshold of 46+ that was associated with a significantly increased risk of 30 day all-cause complications following adult tonsillectomy. These BMI strata can guide preoperative planning and risk-stratifying models for predicting 30 day complications in tonsillectomy surgery.

Prevalence of surgical site infection and risk factors in patients after knee surgery: A systematic review and meta-analysis

The present systematic review and meta-analysis aimed to determine the prevalence of surgical site infection (SSI) and risk factors in patients after knee surgery. A comprehensive and systematic search was carried out across various international electronic databases, including Scopus, PubMed and Web of Science, as well as Persian electronic databases like Iranmedex and the Scientific Information Database (SID). This search involved the utilization of keywords derived from Medical Subject Headings, such as 'Prevalence', 'Surgical wound infection', 'Surgical site infection' and 'Orthopaedics', spanning from the earliest records up to 1 October 2023. To assess the quality of the included studies, the Appraisal tool for Cross-Sectional Studies (AXIS tool) was utilized. The study encompassed a combined participant pool of 11 028 individuals who underwent knee surgery across seven selected studies. The collective prevalence of SSI in patients who underwent knee surgery, as reported in the seven included studies, was determined to be 3.0% (95% CI: 1.2% to 7.5%; I2  = 96.612%; p < 0.001). The combined prevalence of SSI in patients with DM, as reported in six studies, was 5.1% (95% CI: 1.7% to 14.5%; I2  = 79.054%; p < 0.001). Similarly, the pooled prevalence of SSI in patients with HTN, drawn from four studies, was 1.8% (95% CI: 0.7% to 4.5%; I2  = 63.996%; p = 0.040). Additionally, the collective prevalence of SSI in patients with a history of tobacco use, based on findings from six studies, was 4.8% (95% CI: 1.4% to 15.2%; I2  = 93.358%; p < 0.001). Subgroup analysis was conducted within six studies, categorizing them by two countries, namely China and the USA. These analyses revealed that the prevalence of SSI following knee surgery was 3.0% in China and 2.0% in the USA. It is noteworthy that variations in SSI prevalence across different studies may be attributed to a multitude of factors, particularly varying risk factors among patient populations. To address this issue and mitigate the impact of SSI on knee surgery patients, it is advisable to develop tailored interventions.

Prevalence of surgical site infection and risk factors in patients after foot and ankle surgery: A systematic review and meta-analysis

The present systematic review and meta-analysis aimed to determine the prevalence of surgical site infection (SSI) and related factors in patients after foot and ankle surgery. A comprehensive, systematic search was conducted in different international electronic databases, such as Scopus, PubMed, Web of Science and Persian electronic databases such as Iranmedex and Scientific Information Database (SID) using keywords extracted from Medical Subject Headings such as 'Prevalence', 'Surgical wound infection', 'Surgical site infection' and 'Orthopaedics' from the earliest to 1 June 2023. The appraisal tool for cross-sectional studies (AXIS tool) evaluates the quality of the included studies. A total of 10 447 patients undergoing foot and ankle surgery participated in nine studies. The pooled prevalence of SSI in patients who underwent foot and ankle surgery was reported in nine studies was 4.2% (95% CI: 2.4%-7.2%; I2  = 96.793%; p < 0.001). The odds ratio of SSI prevalence in men was higher than that of women and was significant (OR: 1.335; 95% CI: 1.106-1.612; Z = 3.009; p = 0.003). The pooled prevalence of SSI in patients with hindfoot fracture sites reported in five studies was 4.9% (95% CI: 2.6%-8.9%; I2  = 90.768%; p < 0.001). The pooled prevalence of SSI in patients with diabetes mellitus (DM) reported in six studies was 9.1% (95% CI: 5.6%-14.6%; I2  = 73.957%; p = 0.002). The pooled prevalence of SSI in patients with hypertension (HTN) reported in five studies was 5.5% (95% CI: 2.5%-11.6%; I2  = 91.346%; p < 0.001). The pooled prevalence of SSI in patients with tobacco use reported in eight studies was 6.6% (95% CI: 4.1%-10.4%; I2  = 85.379%; p < 0.001). In general, the existing differences in the prevalence of SSI after foot and ankle surgery in different studies can be based on different risk factors such as comorbidities and gender. Therefore, it is suggested to design appropriate interventions to reduce SSI in these patients.

First 30 Days Wound-Related Complications in Young Smokers Following Primary Achilles Repair

The Achilles tendon is frequently injured in the young to middle aged population. Previous studies have shown that there is an increased risk of delay in postsurgical wound healing amongst tobacco smoking patients with Achilles tendon injury. This study utilized the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. We included patients between the ages of 18 and 35 years who underwent primary Achilles tendon repair between years 2011 and 2020. The procedure type (with or without graft, CPT 27650 and 27652), patient demographics, and comorbidities were included. Primary outcomes of interest were 30-day readmission, minor complications, outcomes related to wound healing (wound disruption, superficial surgical site infection, deep incisional surgical site infection, organ-space site infections) and reoperations within 30 days of index surgery. A total of 1944 patients met the inclusion criteria for this study. One thousand six hundred and fifty-nine patients were nonsmokers, while 285 were smokers. Logistic regression showed no differences between smokers and nonsmokers (reference group) for 30-day readmission, reoperation, and minor complications. However, Black non-Hispanic patients were found to be 0.3 times (95% confidence interval: 0.1, 0.98) as likely to develop minor complications as compared to the White non-Hispanic patients. Wound-related complications after Achilles tendon repair remain low in younger (18-35 years) patients. When comparing clinical outcomes between nonsmokers and smokers, we found no statistically significant difference in this retrospective study.

Two novel prehabilitation apps to help patients stop smoking and risky drinking prior to hip and knee arthroplasty

PURPOSE

Daily smoking or risky drinking increases the risk of complications after surgery by ~50%. Intensive prehabilitation aimed at complete cessation reduces the complication rate but is time-consuming. The purpose of this study was to carry out preoperative pilot tests (randomized design) of the feasibility (1A) and validation (1B) of two novel prehabilitation apps, habeat® (Ha-app) or rehaviour® (Re-app).

METHODS

Patients scheduled for hip or knee arthroplasty with daily smoking, risky drinking, or both were randomised to one of the two apps. In part 1A, eight patients and their staff measured feasibility on a visual analog scale (VAS) and were interviewed about what worked well and the challenges requiring improvement. In part 1B, seven patients and their staff tested the improved apps for up to two weeks before validating the understanding, usability, coverage, and empowerment on a VAS and being interviewed.

RESULTS

In 1A, all patients and staff returned scores of ≥5 for understanding the apps and mostly suggested technical improvements. In 1B, the scores varied widely for both apps, with no consensus achieved. Two of four patients (Ha-app) and one-third of the patients (Re-app) found the apps helpful for reducing smoking, but without successful quitting. The staff experienced low app competencies among patients and high time consumption. Specifically, patients most often needed help for the Ha-app, and the staff most often for Re-app; however, the staff reported the Re-app dashboard was more user-friendly. Support and follow-up from an addiction specialist staff member were suggested to complement the apps, thereby increasing the time consumption for staff.

CONCLUSIONS

This pilot study to test prototype apps generated helpful feedback for the app developers. Based on the patient and staff comments, multiple improvements in functionality seem required before scaling up the evaluation for effect on prehabilitation and postoperative complications.

Impact of Comorbidities and Previous Surgery on Mid-Term Results of Revision Total Knee Arthroplasty for Periprosthetic Joint Infection

(1) Background: In the treatment of periprosthetic joint infection (PJI), the individual host status and previous surgical procedures appear to have a relevant influence on success rates and clinical outcome of knee revision surgery. Current data about the predictive value are limited in this subgroup of patients. (2) Methods: Retrospectively, 107 patients (109 knees) undergoing two-stage exchange knee arthroplasty for PJI using a rotating-hinge design with at least two years follow-up. The cumulative incidence (CI) for different endpoints was estimated with death as competing risk. Univariate and multivariate analyses for potential predictive factors were performed. Patient-related outcome measures (PROMs) for clinical outcome were evaluated. (3) Results: At 8 years, the CI of any revision was 29.6%, and of any reoperation was 38.9%. Significant predictors for risk of re-revision were the Charlson Comorbidity Index (CCI) and the number of previous surgical procedures prior to explanation of the infected implant. The functional and clinical outcome demonstrated acceptable results in the present cohort with a high comorbidity level. (4) Conclusions: A compromised host status and multiple previous surgical procedures were identified as negative predictors for re-revision knee surgery in the treatment of PJI. Reinfection remained the major reason for re-revision. Overall mortality was high.

Risk Factors for Surgical Site Infections After Single-Level Anterior Lumbar Interbody Fusion

Abstract Background: Anterior lumbar interbody fusion (ALIF) has become an increasingly popular and effective treatment modality for various conditions of the lumbar spine. However, complications after this procedure can be costly. Surgical site infections (SSIs) are one of these types of complications. The present study identifies independent risk factors for SSI after single-level ALIF to identify high-risk patients better. Patients and Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify single-level ALIF patients from 2005 to 2016. Multilevel fusions and non-anterior approach procedures were excluded. Mann-Pearson χ² tests analyzed categorical variables, whereas one-way analysis of variance (ANOVA) and independent t-tests analyzed differences in mean values of continuous variables. Risk factors for SSI were identified via a multivariable logistic regression model. A receiver operating characteristic (ROC) curve was generated utilizing the predicted probabilities. Results: A total of 10,017 patients met inclusion criteria; 80 (0.80%) had developed SSI and 9,937 (99.20%) had not. On multivariable logistic regression models, class 3 obesity (p = 0.014), dialysis (p = 0.025), long-term steroid use (p = 0.010), and wound classification 4 (dirty/infected) (p = 0.002) all independently increased the risk for SSI in single-level ALIF. The area under the receiver operating characteristic curve (AUROC; C-statistic) was 0.728 (p < 0.001), indicating relatively strong reliability of the final model. Conclusions: Several independent risk factors including obesity, dialysis, long-term steroid use, and dirty wound classification all increased risk for SSI after single-level ALIF. By identifying these high-risk patients, surgeons and patients can have more informed pre-operative discussions. In addition, identifying and optimizing these patients prior to operative intervention may help to minimize infection risk.

Racial Disparities in Tympanoplasty Surgery: A 30-Day Morbidity and Mortality National Cohort Study

OBJECTIVES

To assess the impact of race and ethnicity on 30-day complications after tympanoplasty surgery.

METHODS

The National Surgical Quality Improvement Program database was queried for tympanoplasty procedures from 2005 to 2019. Demographic, comorbidity, and postoperative complication data were compared according to race using univariate and binary logistic regression analyses.

RESULTS

A total of 11,701 patients were included, consisting of 80.3% White, 3.0% Black, 7.7% Asian, 5.7% Hispanic, 2.5% American Indian/Alaska Native, and 0.8% other. Binary logistic regression model indicated that Black patients had increased odds of unplanned readmittance (p = 0.033; odds ratio [OR], 3.110) and deep surgical site infections (p = 0.008; OR, 6.292). American Indian/Alaska Native patients had increased odds of reoperation (p = 0.022; OR, 6.343), superficial surgical site infections (p < 0.001; OR, 5.503), urinary tract infections (p < 0.001; OR, 18.559), surgical complications (p < 0.001; OR, 3.820), medical complications (p = 0.001; OR, 10.126), and overall complications (p < 0.001; OR, 4.545).

CONCLUSION

Although Black and American Indian/Alaskan Native patients were more likely to have complications after tympanoplasty surgery after adjusting for comorbidities, age, and sex, these results are tempered by an overall low rate of complications. Future studies should be devoted to understanding the drivers of these health inequities in access to otologic care and surgical treatment to improve outcomes and achieve equitable care.

The role of preoperative albumin and white blood cell count in surgical site infections following whipple surgery

Whipple surgery is associated with a high risk of surgical sites infections (SSIs). Nutritional deficiency has been associated with an increased risk of wound infections. This study aims at exploring the role of preoperative albumin levels in predicting the risk of SSIs following Whipple surgery. A total of 23,808 individuals were identified from the ACS-NSQIP database from years 2011 to 2017. The primary exposure was pre-operative albumin while the secondary exposure was white blood cell (WBC) count. The primary outcome was divided into superficial and deep surgical site infections (S/D SSI) and organ-space SSI. All statistical analyses were conducted using IBM Statistical Package for Social Sciences version 26. Levels of pre-operative serum albumin less than 3.73 g/L, dirty and contaminated wounds and longer operative time were associated with increased odds for developing S/D SSIs (OR = 1.14, OR = 1.17, OR = 1.06, respectively, p-value < 0.05). Pre-operative WBC level (/L) was associated with a risk of developing an organ-space SSI but not S/D SSI (OR = 1.02, p-value  0.003). This study demonstrates the predictive role of pre-operative albumin in developing S/D SSIs and highlights the need to develop therapeutic strategies to optimize the pre-operative nutritional health status of patients undergoing Whipple surgery.

Prevalence, Risk Factors and Microbiological Profile of Orthopaedic Surgical Site Infection in North-Eastern Peninsular Malaysia

Introduction

The devastating outcome of orthopaedic surgical site infections (SSI) are largely preventable if its risk factors, causative organisms and antimicrobial susceptibility patterns in the regional area are known.

Materials and methods

We conducted a retrospective study to address the lack of epidemiological and microbiological data on orthopaedic SSI in Malaysia. All the 80 patients diagnosed and treated for microbiologically proven orthopaedic SSIs in a tertiary hospital in Malaysia from April 2015 to March 2019 were included in a 1:2 case control study.

Results

The prevalence of SSI in clean and clean-contaminated surgeries was 1.243%, which is consistent with most of the studies worldwide, but is low compared to other studies done in Malaysia. The most common type of orthopaedics SSI were internal fixation infections (46.25%), superficial SSIs (25.2%) and Prosthetic joint infections (18.75%). Obesity and tobacco use were found to be significant risk factors of orthopaedic SSI. The most common perioperative prophylaxis used was IV cefuroxime. Majority of the cases (86.5%) received prolonged prophylactic antibiotics. The most common causative agent was Staphylococcus aureus (31.25%), followed by Pseudomonas aeruginosa (26.25%) and Enterobacter spp (7.5%). Methicillin-resistant Staphylococcus aureus (MRSA) accounted for 20% of the S. aureus infections. Up to 19.4% of the Gram-negative organisms are multidrug resistant. The higher rate of isolation of organisms resistant to the prophylactic antibiotics being used may be related to the prolonged use of prophylactic antibiotics, which exerted selective pressure for the acquisition of resistant organisms.

Conclusion

Despite its relatively low prevalence in our local institution and worldwide, the prevention of SSI in orthopaedic practice is crucial to avoid morbidity, mortality and high healthcare cost. This may be achieved by control of modifiable risk factors such as obesity and tobacco use, appropriate use of prophylactic antibiotics and implementation of good surgical and infection control practices.

Organ-Space Surgical Site Infections: Consequences and Prediction Using ACS-NSQIP

BACKGROUND

The incidence of organ-space surgical site infections (OSIs) across the US has not decreased to the same extent as superficial and deep surgical site infections (SSIs). This study aimed to highlight the consequences and create a predictive model of OSIs using 2019 NSQIP data.

MATERIALS AND METHODS

The primary data source was the ACS NSQIP 2019 Participant Use Targeted File (PUF). Chi-squared and independent t-tests evaluated the association of OSIs and other postoperative complications. Variables of interest for our predictive model included 10 surgery types, 10 relevant preoperative laboratory values, and 26 other variables including demographics and comorbidities. A stepwise logistic regression model fit with OSIs as the outcome was used to calculate the predicted ROC and c-index.

RESULTS

A total of 1,076,441 cases submitted from 719 NSQIP-participating sites were included in our analysis, comprised of 16,751 (1.6%) OSIs with a median of 10 days (IQR: 11 days) between surgery and the development of an OSI. Forty-two variables were included in our final multivariable analysis. Esophageal and pancreatic surgeries yielded an approximate 4- and 6-fold higher increase in the odds of OSI, respectively (P < .001). ROC analysis yielded a c-index statistic of 0.846 (Figure 1). Associated consequences of OSIs included hospital readmission (OR = 20.74, 95% CI: 20.094-21.412, p < .001), sepsis (OR = 35.084; 95%CI: 33.75-36.47, p < .001) and higher probabilities of mortality (34% vs. 0.8%, p < .001) and morbidity (16% vs. 5.8%, p < .001).

DISCUSSION

OSIs have extensive consequences and may be predictable. These types of infections are multifactorial and require quality surveillance distinct from other SSIs.

Systematic review and meta-analysis of risk factors for Mesh infection following Abdominal Wall Hernia Repair Surgery

BACKGROUND

Surgical Mesh Infection (SMI) after Abdominal Wall Hernia Repair (AWHR) represents a catastrophic complication. We performed a systematic review and meta-analysis to analyze the risk factors for SMI in the context of AWHR.

METHODS

PubMed, Embase, Scielo, and LILACS were searched without language or time restrictions from inception until June 2021. Articles evaluating the association between demographic, clinical, laboratory and surgical characteristics with SMI in AWHR were included.

RESULTS

23 studies were evaluated, comprising a total of 118,790 patients (98% males; mean age 56.5 years) with a mesh infection pooled prevalence of 4%. Significant risk factors for SMI were type 2 diabetes mellitus, obesity, smoking history, steroids use, ASA III/IV, laparotomy vs laparoscopy, emergency surgery, duration of surgery and onlay mesh position vs sublay. The quality of evidence was regarded as very low-moderate.

CONCLUSION

Several factors, highlighting sociodemographic characteristics, comorbidities, and the clinical scenario, may increase the risk of developing mesh infections in AWHR. The recognition and mitigation of these may significantly reduce mesh infection rates in this context.

The Effect of Operating Room Size on Orthopaedic Surgical Site Infection Rates

OBJECTIVE

With many preventable causes of surgical site infections (SSIs) identified, the effect of operating room (OR) size on SSI rates has not been assessed. This study investigated the effect of OR size on incidence of SSIs for orthopaedic procedures.

BACKGROUND

SSIs remain a common complication within the perioperative realm. Responsible for increasing length of hospitalization and costs, SSIs result in a decreased quality of life for patients.

METHODS

A retrospective review of 11,163 patients who underwent orthopaedic surgery-including total knee and hip arthroplasties, laminectomies, and spinal fusions-between January 2018 and January 2020 were reviewed. Total net square footage (NSF) of all ORs was recorded, and incidence of SSIs was calculated. Cases were categorized based on the size of the OR (small: 250 to 399 NSF; medium: 400 to 549 NSF; and large: 550 to 699 NSF). Chi-square analysis compared infection rates between the different OR sizes, and a binary logistic regression model identified other predictors of infection.

RESULTS

Overall, 137 patients (1.2%) developed an SSI. Of these infections, 16 (11.7%) occurred in small ORs, 83 (60.6%) in medium ORs, and 38 (27.7%) in large ORs. The incidence of SSIs was 0.7% in small ORs, 1.3% in medium ORs, and 1.8% in large ORs. Factors found to significantly impact SSI's included medium-sized ORs, younger patients, procedure type (fusions and emergencies/traumas), longer procedures, and higher American Society of Anesthesiologists scores (>3).

CONCLUSION

Our study shows that OR size in addition to various other perioperative parameters plays a role in the rate of SSIs for orthopaedic procedures.

LEVEL OF EVIDENCE

Retrospective Cohort Study; Level III Evidence.

Incidence and Predictors of Surgical Site Infection Complications in Diabetic Patients Undergoing Lower Limb Amputation

BACKGROUND

Surgical site infections (SSIs) following lower extremity amputations (LEAs) are a major cause of patient morbidity and mortality. The objectives of this study are to investigate the annual incidence of SSI and risk factors associated with SSI after LEA in diabetic patients.

METHODS

LEAs performed on diabetic patients between 2005 and 2017 were retrospectively analyzed from the American College of Surgeons National Surgical Quality Improvement Program database. Incidence rates were calculated and analyzed for temporal change. Multivariable logistic regression was conducted to identify the independent predictors of SSIs in LEA.

RESULTS

In 21,449 diabetic patients, the incidence of SSIs was 6.8% after LEA, with an overall decreasing annual trend (P = 0.013). Amputation location (below-knee in reference to above-knee) [OR (95% CI): 1.35 (1.20 - 1.53), P <0.001], smoking [OR (95% CI): 1.25 (1.11 - 1.41), P <0.001)], female sex [OR (95% CI): 1.16 (1.03 - 1.30)], preoperative sepsis [OR (95% CI): 1.24 (1.10 - 1.40), P <0.001], P = 0.013], emergency status [OR (95% CI): 1.38 (1.17 - 1.63), P <0.001], and obesity [OR (95% CI): 1.59 (1.12 - 2.27), P = 0.009] emerged as independent predictors of SSIs, while moderate/severe anemia emerged as a risk-adjusted protective factor [OR (95% CI): 0.75 (0.62 - 0.91), P = 0.003]. Sensitivity analysis found that moderate/severe anemia, not body mass index (BMI) class, remained a significant risk factor in the development of SSIs in below-the-knee amputations; in contrast, higher BMI, not preoperative hematocrit, was significantly associated with an increased risk for SSI in above-the-knee amputations.

CONCLUSIONS

The incidence of SSIs after LEA in diabetic patients is decreasing. Overall, below-knee amputation, smoking, emergency status, and preoperative sepsis appeared to be associated with SSIs. Obesity increased SSIs in above-the-knee amputations, while moderate/severe preoperative anemia appears to protect against below-the-knee SSIs. Surgeons should take predictors of SSI into consideration while optimizing care for their patients, and future studies should investigate the role of preoperative hematocrit correction and how it may influence outcomes positively or negatively.

Dynamics of skin microbiota in shoulder surgery infections

Post-surgical infections arise due to various contributing factors. Most important is the presence of potential pathogenic microorganisms in the skin complemented by the patient´s health status. Cutibacterium acnes is commonly present in the pilosebaceous glands and hair follicle funnels in human skin. After surgical intervention, these highly prevalent, slow-growing bacteria can be found in the deeper tissues and in proximity of implants. C. acnes is frequently implicated in post-surgical infections, often resulting in the need for revision surgery. This review summarizes the current understanding of microbial dynamics in shoulder surgical infections. In particular, we shed light on the contribution of C. acnes to post-surgical shoulder infections as well as their colonization and immune-modulatory potential. Despite being persistently found in post-surgical tissues, C. acnes is often underestimated as a causative organism due to its slow growth and the inefficient detection methods. We discuss the role of the skin environment constituted by microbial composition and host cellular status in influencing C. acnes recolonization potential. Future mapping of the individual skin microbiome in shoulder surgery patients using advanced molecular methods would be a useful approach for determining the risk of post-operative infections.

Risk factors, bacteriological profile and outcome of surgical site infections following orthopaedic surgery

Background and Objectives:

Surgical site infection (SSI) is a challenge for the surgeon. Incidence of SSI reported in literature varies from 0.5% to 15%. Severity of SSI ranges from superficial skin infection to life-threatening condition like septicaemia. It is responsible for increased morbidity, mortality, and economic burden to the hospital in general, and the patient in particular. The aim of this study was to assess the risk factors, bacteriological profile, length of hospitalization, and cost due to orthopaedic SSI in patients admitted to a tertiary care hospital.

Materials and Methods:

This was a prospective case control study. Cases were diagnosed based on CDC definition of nosocomial SSI. All cases were assessed preoperatively, intraoperatively and postoperatively, according to type of surgery, wound class, duration of operation, antimicrobial prophylaxis, use of drain, preoperative hospital stay, causative micro organism, total hospital stay, readmission rates and cost incurred. Age, sex and surgical procedure matched controls without SSI, were also assessed. Chi-square test and Fisher’s exact test were used for analysis. P= <0.05 was considered significant.

Results:

Out of 1023 patients, 47 cases had SSI, with a rate of 4.6%. Cigarette smoking was a risk factor for SSI (P = 0.0035). The most common etiologic agents were Acinetobacter baumannii and Staphylococcus aureus. Incidence of readmission among SSI cases was more compared to controls (P= 0.0001). Costs attributable to SSI (Indian Rupees) was Rs 32,542 (17,054 to 87,514) which was significantly more than those without SSI (P= <0.001).

Conclusion:

Despite latest surgical amenities, meticulous sterilization protocols and pre-operative antibiotic prophylaxis, SSI continues to be present in healthcare settings. The increase in duration of hospital stay due to SSI adds to additional burden to an already resource-constrained healthcare system.

The Effect of Passive Smoking on Early Clinical Outcomes After Total Knee Arthroplasty Among Female Patients

PURPOSE

The aim of this study was to assess whether passive smoking affects clinical outcomes among female patients with knee osteoarthritis after being treated with total knee arthroplasty (TKA).

METHODS

The study prospectively enrolled 216 female patients who did not smoke and those patients were classified into three groups in terms of the severity of exposure to environmental tobacco smoke. A three-month follow-up was conducted to assess the physical and mental outcomes between the three groups. The physical outcomes were evaluated by the visual analogue score (VAS), range of motion (ROM), hospital for special surgery (HSS) knee score, and postoperative complications. The mental outcomes were assessed by the anxiety and depression scale (HADS) and medical outcome study short form 36 (SF-36). Subgroup analysis of patients with and without surgical site infection (SSI) was also calculated.

RESULTS

Baseline characteristics were similarly distributed between the three groups (P>0.05). Patients in the heavy passive smoking group had a higher VAS and a lower ROM score as compared with patients in the no and mild passive smoking group at discharge (P<0.01), 1 month (P<0.01), and 3 months (P<0.01) after surgery. Patients in the heavy passive smoking group also had a higher rate of HADS more than 8 at postoperative 1 month (P=0.01) and 3 months (P=0.03) and lower SF-36 summary (P<0.01) and HSS score (P<0.01) at postoperative 3 months. Forty-five postoperative complication events were observed during follow-up. Patients in the heavy passive smoking group (8.51%) had the highest SSI rate, followed by patients in the mild (1.82%) and no passive smoking group (0.88%) at discharge (P=0.02) and postoperative 1 month (P=0.03).

CONCLUSION

Passive smoking negatively affects TKA among female patients. It may trigger poor pain and functional outcomes, aggravate depression and anxiety, and deteriorate quality of life after discharge from hospital. Avoiding exposure to smoking environment may be beneficial among TKA female patients before and after surgery.

Seasonal impact on surgical site infections in hip fracture surgery: Analysis of 330,803 cases using a nationwide inpatient database

BACKGROUND

As the aging population progresses, the number of elderly hip fracture patients is increasing. Elderly patients with hip fractures have a high risk of perioperative complications. One of the major complications after surgery is surgical site infection (SSI), which requires additional surgical interventions and is associated with increased mortality. Previous literature has shown that the risk of SSI is higher during the summer season in orthopedic surgery. However, little is known about the seasonal differences in the risk of SSI after hip fracture surgery. In this study, we aimed to identify the association between seasonality and SSI.

METHODS

We enrolled a total of 330,803 patients undergoing hip fracture surgery (65 years or older) using the Japanese Diagnosis Procedure Combination database. The study period was from April 1, 2011, to March 31, 2016. The data were analyzed to determine the association between seasonality and the incidence of SSI, debridement procedure. The primary outcome was the incidence of SSI and debridement. Other risk factors of SSI and debridement were investigated including seasons and confounders such as sex, age, BMI, smoking status, anticoagulant intake, comorbidities, surgical procedure based on medical diagnosis, waiting times for the surgery, and hospital surgical volume based on the previous literature, the risk of SSI and debridement.

RESULTS

Hip fracture surgeries performed in summer showed the highest risk for SSI and debridement. The risk for SSI was significantly associated with spring, and summer compared to winter (odds ratio [OR], 1.18; p, 0.016; OR, 1.19; p, 0.012, respectively). The incidence of debridement procedures after the initial surgery was also associated with spring, summer, and fall: the risk was the highest in summer (OR, 1.34; p, <0.001). Obesity, smoking history, number of comorbidities, anticoagulant intake before surgery, longer waiting time for surgery, and small hospital surgical volume were significantly associated with the risk of SSI.

CONCLUSIONS

We found a significant association between SSI after surgery for hip fractures and seasonality. Surgeries performed in summer had the highest risk for SSI and subsequent debridement procedures.

Clinical Outcomes of Low-Cost, Anchorless Repair of the Triceps Tendon Using a Proximal Knot Technique

Purpose

To use validated outcome measures to evaluate the clinical results of surgical repair of distal triceps tendon ruptures using transosseous tunnels and high-strength sutures with proximally based knots.

Methods

A consecutive series of traumatic distal triceps tendon ruptures at a single institution was studied. All cases were surgically repaired by 1 surgeon using high-strength suture with a bone tunnel-based repair technique. Repair knots were oriented proximally instead of in the traditional distal position. All patients were evaluated at long-term follow-up with a physical examination performed by the orthopaedic surgeon and the following validated outcome measures: Disabilities of the Arm, Shoulder and Hand score; Mayo Elbow Performance Score; and visual analog scale score.

Results

Seven male patients with a mean age of 38 years (range, 19-50 years) and mean follow-up period of 4.1 ± 1.2 years underwent distal triceps tendon repair with bone tunnels and high-strength sutures with proximally positioned knots. Of the repairs, 4 involved the dominant arm. At final follow-up, the mean Disabilities of the Arm, Shoulder and Hand score was 1.3 ± 3.1; the mean Mayo Elbow Performance Score was 99.3 ± 1.9; and the mean visual analog scale score was 0. One additional patient who declined participation in the study had wound dehiscence and infection with an associated partial rerupture.

Conclusions

This case series of triceps tendon repairs using transosseous tunnels and proximally based knots showed favorable postoperative elbow function based on validated outcome measures.

Level of Evidence

Level IV, therapeutic case series.

Deep Surgical-Site Infection Following Thoracolumbar Instrumented Spinal Surgery: The Experience of 25 Years

BACKGROUND

Deep surgical-site infection following thoracolumbar instrumented spinal surgery (DSITIS) is a major complication in spine surgery and its impact on long-term morbidity and mortality is yet to be determined. This article describes the characteristics and evolution of DSITIS in our center over a period of 25 years.

METHODS

This single-center, retrospective cohort study included patients diagnosed with DSITIS between January 1992 and December 2016 and with a minimum follow-up after infection diagnosis of 1 year. The Infectious Diseases Society of America criteria and/or Centers for Disease Control and Prevention criteria were used to define DSITIS. Patient data (epidemiological and health status), surgical data, infection characteristics and presentation, isolated microorganisms, required surgical debridements, implant removal, and major complications linked to infection were evaluated.

RESULTS

A total of 174 patients (106 females) were included in the analysis. Mean follow-up after infection diagnosis was 40 months (56 patients with over 5 years follow-up). Adolescent idiopathic scoliosis, adult deformity, and degenerative lumbar stenosis were the most frequent etiologies for primary surgery. Presentation of infection was considered early (0-3 months since first surgery) in 59.2% of the cases, delayed (3-24 months) in 11.5%, and late (more than 24 months) in 29.3%. All patients were treated by surgical debridement. More than 1 surgical debridement was necessary in 20.7% of cases. Implants were removed in 46.6% of the patients (72.83% in the first surgical debridement). Most frequently isolated microorganisms were Staphylococcus spp, Enterobacteriaceae, and Cutibacterium acnes. Major complications appeared in 14.3% of the patients, and over 80% of them required major surgeries to resolve those complications.

CONCLUSIONS

Late DSITIS is more frequent than previously reported. In DSITIS culprits, Staphylococcus spp, Enterobacteriaceae, and Cutibacterium acnes predominate. DSITIS produce a high rate of major complications that usually require major surgery for treatment.

LEVEL OF EVIDENCE

3.

Risk factors for increased shoulder Cutibacterium acnes burden

Background

Cutibacterium acnes is the primary cause of shoulder surgery infections, but the predisposition to larger skin counts and potentially higher risk for postoperative infection remains unclear. This study aimed to quantify risk factors influencing endogenous C. acnes burden and to compare counts among 4 shoulder sites.

Methods

C. acnes counts were quantified via a detergent scrub technique for 173 participants. Bivariate and multivariable stepwise linear regression statistical analyses were used to investigate the association of sex, age, ethnicity, degree of hirsutism, diabetes, smoking status, body mass index, and location with counts. A separate Wilcoxon rank-sum test was performed analyzing counts of East/Southeast Asians vs. all other ethnicities.

Results

Sex, age, degree of hirsutism, diabetes, smoking status, and body mass index were included in the multivariable stepwise linear regression analysis. The multiple regression analysis isolated individuals <40 years with the highest burden (P = .001). Males had a 191% increase in C. acnes counts compared with females (P = .001). Increased hirsutism was further indicated to be a risk factor for the male sex although not in a dose-dependent manner (P = .027). Wilcoxon rank-sum test results found that East/Southeast Asians had the lowest load (P = .019), although not significant in the multivariate model.

Conclusion

Surgical site C. acnes infections occur more frequently in younger males, and males <40 years with shoulder-specific hirsutism have the highest preoperative burden. East/Southeast Asians have lower raw counts of C. acnes compared with other ethnicities that may be related to less hirsutism.

Severity and long-term complications of surgical site infections after orthognathic surgery: a retrospective study

Surgical site infections (SSI) occur in 1.4% to 33.4% of cases after orthognathic surgery. This type of complication is a major concern to surgical teams, but there is no consensus for the prevention and treatment of SSI in orthognathic surgery. The purpose of this descriptive study was to evaluate the severity and the consequences of postoperative infections. The charts of all the patients operated on by the orthognathic surgery team between January 2015 and July 2017 were collected. All types of orthognathic procedures (Le Fort I maxillary osteotomy, bilateral sagittal split mandibular osteotomy, and genioplasty) were screened, and patients diagnosed with SSI were included. Demographic data, timing and severity of the infection, as well as long-term complications were recorded. Five hundred and twelve patients were screened. Forty-one patients (8%) presenting with SSI were included. There were 18 men and 23 women. The site of the infection was mandibular for 38 patients (92.7%) and maxillary for 3 patients (7.3%). The average time between surgery and infection was 31.5 days. Twenty-four patients received isolated oral antibiotics for inflammatory cellulitic reaction (58.8%), 15 patients had a localized collection treated by incision and drainage under local anesthesia (36.6%), and 2 patients had an extensive collection requiring surgical drainage under general anesthesia (4.9%). Five patients (12.2%) needed hardware removal for plate loosening, and 2 patients (4.9%) developed chronic osteomyelitis. Infection following orthognathic surgery is easily treated most of the time with no long-term complications. In cases of patients with potential risk factors for severe infection, antibiotics may be given with curative intents.

Surgical site infection after hip fracture - mortality and risk factors: an observational cohort study of 1,709 patients

Background and purpose - Surgical site infection (SSI) is a devastating complication of hip fracture surgery. We studied the contribution of early deep SSI to mortality after hip fracture surgery and the risk factors for deep SSI with emphasis on the duration of surgery.Patients and methods - 1,709 patients (884 hemi-arthroplasties, 825 sliding hip screws), operated from 2012 to 2015 at a single center were included. Data were obtained from the Norwegian Hip Fracture Register, the electronic hospital records, the Norwegian Surveillance System for Antibiotic Use and Hospital-Acquired Infections, and the Central Population Register.Results - The rate of early (≤ 30 days) deep SSI was 2.2% (38/1,709). Additionally, for hemiarthroplasties 7 delayed (> 30 days, ≤ 1 year) deep SSIs were reported. In patients with early deep SSI 90-day mortality tripled (42% vs. 14%, p < 0.001) and 1-year mortality doubled (55% vs. 24%, p < 0.001). In multivariable analysis, early deep SSI was an independent risk factor for mortality (RR 2.4 for 90-day mortality, 1.8 for 1-year mortality, p < 0.001). In univariable analysis, significant risk factors for early and delayed deep SSI were cognitive impairment, an intraoperative complication, and increasing duration of surgery. However, in the multivariable analysis, duration of surgery was no longer a significant risk factor.Interpretation - Early deep SSI is an independent risk factor for 90-day and 1-year mortality after hip fracture surgery. After controlling for observed confounding, the association between duration of surgery and early and delayed deep SSI was not statistically significant.

Analysis of growth and biofilm formation of bacterial pathogens on frequently used spinal implant materials

STUDY DESIGN

A microscopy-based investigation of the permissive factors leading towards bacterial adherence on commonly utilized spinal implants.

OBJECTIVE

The adherence and subsequent colonization and biofilm formation of bacteria on orthopaedic implants represents one of the most serious problems facing orthopaedic surgeons. Once a biofilm is formed, surgeons may have to resort to implant removal, a strategy that may cause substantial patient morbidity and lead to additional cost to the healthcare system. This problem has been further compounded by the rise of antibiotic-resistant strains of bacterial pathogens. In this study, two commonly encountered bacterial pathogens in surgical site infections (SSI) were characterized for adherence pattern, density, and propagation on five commonly used spinal implant materials via scanning electron microscopy (SEM) and confocal laser scanning microscopy (CLSM). The results show that bacterial adherence is largely dependent on the microtopographical features observed on the surface of the materials tested.

METHODS

Five commonly utilized spinal implant materials were inoculated with two of the most common nosocomial pathogens and visualized via scanning electron microscopy and confocal laser scanning microscopy.

RESULTS

Analysis of 90 spinal implant pieces showed that even though no material showed the ability to prevent adherence of both pathogens tested, the presence of surface imperfections and rougher microtopography was found to harbor the most bacterial presence.

CONCLUSION

Our data suggests that implants materials with uniform surface and minimal imperfections may reduce the ability of bacterial to adhere to implants.

LEVEL OF EVIDENCE

Level I evidence: "Investigation of a diagnostic test".

Steroid Injection and Open Trigger Finger Release Outcomes: A Retrospective Review of 999 Digits

Background: Open surgical release of the A1 pulley is the definitive treatment for the common hand condition of trigger finger, or inflammatory stenosing tenosynovitis. Anecdotal evidence among hand surgeons has questioned whether or not recent steroid injection may be related to complications following open trigger finger release, particularly wound infection, but no studies have primarily studied this connection to date. We aimed to determine whether recent steroid injection was associated with postoperative surgical infections. Methods: We performed a retrospective chart review of 780 adult patients who had undergone open trigger finger release of 999 digits by 6 fellowship-trained hand surgeons at three affiliated hospital settings from January 1, 2014, to January 1, 2016. Data on timing of steroid injections relative to surgery, number of steroid injections, concomitant conditions, use of antibiotics, and postoperative complications including infections were gathered. Results: Steroid injection timing relative to subsequent operative intervention correlated with postoperative surgical site infection in trigger finger release. Older age and decreasing days between steroid injection and surgery correlated with infection rates. Other factors found to be associated with infection rates included smoking, use of preoperative antibiotics, and use of lidocaine with epinephrine. The other factors examined did not correlate with infection rates. Conclusions: Steroid injection, smoking, increasing age, lesser number of days between steroid injection and surgery, and use of lidocaine with epinephrine are risk factors for postoperative trigger surgical infections. We recommend careful preoperative counseling regarding higher wound healing risks for smokers, avoidance of steroid injections immediately prior to an operative date, and scheduling operative dates that tend to be greater than 80 days from the date of last steroid injection. We also recommend avoidance of epinephrine in the local anesthetic solution, as this may minimize surgical site infection risks.

Effects of Operating Room Size on Surgical Site Infection Following Lumbar Fusion Surgery

Background

Surgical site infections (SSIs) represent a devastating complication after spine surgery. Many factors have been identified, but the influence of operating room (OR) size on infection rate has not been assessed.

Methods

Two thousand five hundred and twenty-three patients who underwent open lumbar spine fusion at a single institution between 2010 and 2016 were included. Patients were dichotomized into large versus small groups based on OR volume. Bivariate logistic regression and a final multivariate model following a multicollinearity check were used to calculate odds of infection for all variables.

Results

A total of 63 patients (2.5%) developed SSIs with 46 (73%) in the larger OR group and 17 (27%) in the smaller OR group. The rate of SSIs in larger ORs was 3.02% compared with 1.81% in smaller ORs. Significant parameters impacting SSI in bivariate analysis included an earlier year of surgery, BMI > 30, more comorbidities, more levels decompressed and fused, smoking, and larger OR volumes. Multivariate analysis identified BMI > 30, Elixhauser scores, smoking, and increasing levels decompressed as significant predictors. Topical vancomycin was found to significantly decrease rate of infection in both analyses.

Conclusions

OR size (large versus small) was ultimately not a significant predictor of infection related to rates of SSIs, although it did show a clinical trend toward significance, suggesting association. Future prospective analysis is warranted.

Level of Evidence

3.

Operative risk stratification in the obese female undergoing implant-based breast reconstruction

The prevalence of obesity is growing, and breast reconstruction in the obese patient is becoming the norm rather than the exception. Our aim was to evaluate implant reconstruction outcomes in the obese female in the presence of coincident surgical risk factors and identify potential risk-reducing interventions. A review of consecutive obese women (BMI ≥ 30) who underwent mastectomy and implant breast reconstruction was performed. Patient demographics, comorbidities, oncologic treatments, and reconstructive procedures and their complications were recorded. A total of 151 women (242 breast reconstructions) were included with mean follow-up of 28 months. Average BMI was 36. Eighty percent of cases were immediate and 20% delayed. ADMs were utilized in 58% of cases. About 25% of patients had diabetes with one-third achieving perioperative glycemic control. About 18% of women were active smokers, and 33% had radiotherapy. Major and minor complications occurred in 42% and 11% of patients, respectively. About 24% of reconstructed breasts required implant removal. Obese patients with prior radiation were three times as likely to develop infection (P = 0.008) and 2.5× as likely to undergo explantation (P = 0.002). Skin flap necrosis was three times as likely in obese smokers (P = 0.01). Increased rates of wound breakdown were identified in obese patients with increasing age (P = 0.005), smoking (P = 0.0035), and radiation (P = 0.023). In the obese radiated and smoking patient subgroups, surgical modifications (use of autologous tissue, delayed breast reconstruction timing, and no ADM) were associated with reduction in the relative risk for implant complications. While obesity alone increases implant breast reconstruction complication rates, the presence of additional risk factors compounds these rates. The use of surgical modifications may reduce the occurrence of perioperative complications in the obese female with coincident surgical risk factors undergoing implant breast reconstruction.

Establishing the need for clinical follow-up after emergency appendicectomy in the modern era: Retrospective case series of 145 patients

Introduction

Emergency appendicectomy (EA) is a commonly performed operation, with an increasing number of EAs being performed as day-case. The aim of this study is to establish if there is a need for post-operative follow-up and if this could prevent adverse outcomes.

Methods

A retrospective analysis of patients who underwent EA at multiple centres over a six-month period was undertaken. They were contacted by telephone and a standardised questionnaire was used to ascertain post-operative outcomes, including duration of analgesia use, duration before return to normal daily activity (ADLs), surgical site infection rates (SSI) and rates of re-presentation to medical services. Patients were stratified into those who underwent laparoscopic versus open appendicectomy, smokers versus non-smokers, and body mass index (BMI).

Results

A total of 145 patients were included in the study. Patients undergoing open surgery (vs. laparoscopic surgery) required analgesia for significantly longer periods, with a significantly longer return to ADLs. Smokers, when compared to non-smokers experienced a significantly longer return to work/school; and significantly higher risk of SSI and re-presenting to accident & emergency; as did patients with a BMI >30 when compared to those with a BMI <30.

Conclusion

Most patients do not need formal outpatient assessment after EA. However, there is clearly a subset of higher risk patients who may benefit from this - patients who are smokers or obese. They have prolonged recovery times, and are at greater risk of SSI. Earlier surgical outpatient follow-up of these patients could prevent adverse outcomes.

Is There an Association Between Smoking Status and Prosthetic Joint Infection After Primary Total Joint Arthroplasty?

BACKGROUND

Recent reports highlighted the association between smoking and higher risk of postsurgical infections. The aim was to compare the incidence of prosthetic joint infection after primary total joint arthroplasty (TJA) according to smoking status.

METHODS

A prospective hospital registry-based cohort study was performed including all primary knee and hip TJAs performed between March 1996 and December 2013. Smoking status preoperatively was classified into never, former, and current smoker. Incidence rates and hazard ratios (HRs) for prosthetic joint infection according to smoking status were assessed within the first year and beyond.

RESULTS

We included 8559 primary TJAs (mean age 69.5 years), and median follow-up was 67 months. There were 5722 never, 1315 former, and 1522 current smokers. Incidence rates of infection within the first year for never, former, and current smokers were, respectively, 4.7, 10.1, and 10.9 cases/1000 person-years, comparing ever vs never smokers, crude and adjusted HRs were 2.35 (95% confidence interval [CI] 1.39-3.98) and 1.8 (95% CI 1.04-3.2). Beyond the first year, crude and adjusted HRs were 1.37 (95% CI 0.78-2.39) and 1.12 (95% CI 0.61-2.04).

CONCLUSION

Smoking increased the infection risk about 1.8 times after primary hip or knee TJA in both current and former smokers. Beyond the first year, the infection risk was similar to never smokers.

Patient engagement with surgical site infection prevention: an expert panel perspective

Despite remarkable developments in the use of surgical techniques, ergonomic advancements in the operating room, and implementation of bundles, surgical site infections (SSIs) remain a substantial burden, associated with increased morbidity, mortality and healthcare costs. National and international recommendations to prevent SSIs have been published, including recent guidelines by the World Health Organization, but implementation into clinical practice remains an unresolved issue. SSI improvement programs require an integrative approach with measures taken during the pre-, intra- and postoperative care from the numerous stakeholders involved. The current SSI prevention strategies have focused mainly on the role of healthcare workers (HCWs) and procedure related risk factors. The importance and influence of patient participation is becoming an increasingly important concept and advocated as a means to improve patient safety. Novel interventions supporting an active participative role within SSI prevention programs have not been assessed. Empowering patients with information they require to engage in the process of SSI prevention could play a major role for the implementation of recommendations. Based on available scientific evidence, a panel of experts evaluated options for patient involvement in order to provide pragmatic recommendations for pre-, intra- and postoperative activities for the prevention of SSIs. Recommendations were based on existing guidelines and expert opinion. As a result, 9 recommendations for the surgical patient are presented here, including a practice brief in the form of a patient information leaflet. HCWs can use this information to educate patients and allow patient engagement.

The Use of a Closed-Suction Drain in Revision Knee Arthroplasty May Not Be Necessary: A Prospective Randomized Study

BACKGROUND

The benefit of suction drains (SD) for the first 24-48 hours following joint replacement surgery is controversial. We aimed to determine if there is any difference in the early outcome of revision TKA when performed with, or without SD.

METHODS

83 cases indicated for revision knee arthroplasty were randomized to receive (42) or not receive (41) a deep intra-articlular drain. First-stage revisions for treating periprosthetic infection were excluded. Patients were statistically compared for demographic parameters, early complications and early knee functional outcome. The assessed outcomes included total blood loss, number of transfusions, fever and wound complication rate at 24 months follow-up. In addition, the change in knee society score at 12 weeks postoperatively was compared between the groups.

RESULTS

There were no significant difference in demographic factors, wound complications, knee scores at 12 weeks and infection rate 24 months after surgery in either group. Average blood loss was 1856ml and 1533ml for the drain and no drain groups, respectively (P value=0.0470). The need for transfusion was significantly less in the no-drain group with an average of 0.15 unit/patient as compared to an average 0.37 unit/patient for the drain group (P value=0.0432).

CONCLUSION

We were unable to find a point of superiority for using a drain for revision knee arthroplasty. Future studies with longer follow-up and larger population of patients are needed to make a valid conclusion.

Current tobacco use is associated with higher rates of implant revision and deep infection after total hip or knee arthroplasty: a prospective cohort study

BACKGROUND

Tobacco smoking is a risk factor for several adverse post-operative outcomes. We aimed to compare the rates of complications in current tobacco users and non-users who underwent primary total hip arthroplasty (THA) or total knee arthroplasty (TKA).

METHODS

All patients who underwent primary THA or TKA at the Mayo Clinic from 2010-2013 were included in the study. Current tobacco use was defined as the use of cigarettes, cigars, pipes, or smokeless tobacco reported at the time of index THA or TKA; current non-users were former users or never users. We used Cox proportional hazards regression to assess the association of current tobacco use status with each post-THA/TKA complication, using hazard ratios and 95% confidence intervals (CI).

RESULTS

Tobacco use status was available for 7926 patients (95%) and not available for 446 patients (5%); 565 (7%) were current tobacco users. Compared to non-users, current tobacco users were more likely to be male (p < 0.001), and less likely to be obese (p ≤ 0.008), be older than 60 years, have Charlson score >0 or have undergone TKA rather than THA (p < 0.001 each). The hazard ratios for deep infection (2.37; 95% CI 1.19, 4.72; p = 0.01) and implant revision (1.78; 95% CI 1.01, 3.13; p = 0.04) were higher in current tobacco users than in non-users. No significant differences were noted for periprosthetic fractures or superficial infections.

CONCLUSIONS

We noted that current tobacco use was associated with high risk of deep infection and implant revision after primary THA or TKA. Future studies should determine the optimal time for tobacco use cessation before elective surgeries such as THA and TKA to improve short-term and long-term arthroplasty outcomes.