Introduction: The prevalence of obesity continues to increase in the United Kingdom leading to a growing burden on the healthcare system. A significant percentage of patients who undergo total knee arthroplasty are obese. A review of the literature reveals that obese patients are at an increased risk of complications including wound problems. The aim of this study was to evaluate the rate of surgical site infection in all patients undergoing a primary total knee arthroplasty and to audit the outcomes for those who were obese. Methods: We retrospectively reviewed data for 839 primary total knee arthroplasties done at a National Arthroplasty Centre over one year (April 2007 – March 2008). BMI data was available for 824 (98%) of the patients and was obtained from the patients’ clinical records. Surgical site infection data had been collected prospectively by the Infection Control team for inpatient stays and up to 30 days post-operatively. Infection data was available for all patients. Patients were grouped based on their BMI and the WHO classifications (WHO Technical Report Series 894). The infection rates were analysed to establish if there were poorer outcomes for obese patients. Results: Based on the WHO classifications, 31.2% of the patients were obese class I (BMI 30 – 35), 19.0% were obese class II (BMI 35 – 40) and 8.6% were obese class III (BMI > 40). There were 23 patients with infections, 22 having superficial infection and only one patient with a deep infection. The overall superficial surgical site infection rate was 2.7%. The superficial surgical site infection rate for the normal weight group was 1.3%, for the overweight group was 2.3%, obese class I was 1.6%, obese class II was 3.2% but for obese class III was 8.5%. The Fisher’s Exact Test between all obese patients and those with BMI < 30 showed no statistically significant difference in superficial surgical site infection rates (p = 0.39). However, it did show a statistically significant difference between superficial surgical site infection rates in the obese class III patients and the rest of the cohort, p = 0.008. Conclusion: Obese class III (BMI > 40) patients are at an increase risk of superficial surgical site infection as compared to other patients undergoing primary total knee arthroplasty. However, obese class I and II patients do not appear to have an increased likelihood of superficial surgical site infection as compared to patients who have BMI < 30. It is therefore important that surgeons are aware of the higher risk of surgical site infection in obese class III patients and recommended that patients in this category should be informed of this by their surgeon when considering primary total knee arthroplasty

The rate of arterial injury in trauma patients with pelvic ring fractures has been cited as high as 15%. Addressing this source of hemorrhage is essential in the management of these patients as mortality rates are reported as 50%. Percutaneous techniques to control arterial bleeding, such as embolization and REBOA, are being employed with increasing frequency due to their assumed lower morbidity and invasiveness than open exploration or cross clamping of the aorta. There are promising results with regards to the mortality benefits of angioembolization. However, there are concerns with regards to morbidity associated with embolization of the internal iliac vessels and its branches including surgical wound infection, gluteal muscle necrosis, nerve injury, bowel infarction, and thigh / buttock claudication. The primary aim of this study is to determine whether pelvic arterial embolization is associated with surgical site infection (SSI) in trauma patients undergoing pelvic ring fixation. This observational cohort study was conducted using US trauma registry data from the American College of Surgeons (ACS) National Trauma Database for the year of 2018. Patients over the age of 18 who were transported through emergency health services to an ACS Level 1 or 2 trauma hospital and sustained a pelvic ring fracture treated with surgical fixation were included. Patients who were transferred between facilities, presented to the emergency department with no signs of life, presented with isolated penetrating trauma, and pregnant patients were excluded from the study. The primary study outcome was surgical site infection. Multivariable logistic regression was performed to estimate treatment effects of angioembolization of pelvic vessels on surgical site infection, adjusting for known risk factors for infection. Study analysis included 6562 trauma patients, of which 508 (7.7%) of patients underwent pelvic angioembolization. Overall, 148 (2.2%) of patients had a surgical site infection, with a higher risk (7.1%) in patients undergoing angioembolization (unadjusted odds ratio (OR) 4.0; 95% CI 2.7, 6.0; p < 0 .0001). Controlling for potential confounding, including patient demographics, vitals on hospital arrival, open fracture, ISS, and select patient comorbidities, pelvic angioembolization was still significantly associated with increased odds for surgical site infection (adjusted OR 2.0; 95% CI 1.3, 3.2; p=0.003). This study demonstrates that trauma patients who undergo pelvic angioembolization and operative fixation of pelvic ring injuries have a higher surgical site infection risk. As the use of percutaneous hemorrhage control techniques increase, it is important to remain judicious in patient selection

Objectives. The diagnosis of surgical site infection following endoprosthetic reconstruction for bone tumours is frequently a subjective diagnosis. Large clinical trials use blinded Central Adjudication Committees (CACs) to minimise the variability and bias associated with assessing a clinical outcome. The aim of this study was to determine the level of inter-rater and intra-rater agreement in the diagnosis of surgical site infection in the context of a clinical trial. Materials and Methods. The Prophylactic Antibiotic Regimens in Tumour Surgery (PARITY) trial CAC adjudicated 29 non-PARITY cases of lower extremity endoprosthetic reconstruction. The CAC members classified each case according to the Centers for Disease Control (CDC) criteria for surgical site infection (superficial, deep, or organ space). Combinatorial analysis was used to calculate the smallest CAC panel size required to maximise agreement. A final meeting was held to establish a consensus. Results. Full or near consensus was reached in 20 of the 29 cases. The Fleiss kappa value was calculated as 0.44 (95% confidence interval (CI) 0.35 to 0.53), or moderate agreement. The greatest statistical agreement was observed in the outcome of no infection, 0.61 (95% CI 0.49 to 0.72, substantial agreement). Panelists reached a full consensus in 12 of 29 cases and near consensus in five of 29 cases when CDC criteria were used (superficial, deep or organ space). A stable maximum Fleiss kappa of 0.46 (95% CI 0.50 to 0.35) at CAC sizes greater than three members was obtained. Conclusions. There is substantial agreement among the members of the PARITY CAC regarding the presence or absence of surgical site infection. Agreement on the level of infection, however, is more challenging. Additional clinical information routinely collected by the prospective PARITY trial may improve the discriminatory capacity of the CAC in the parent study for the diagnosis of infection. Cite this article: J. Nuttall, N. Evaniew, P. Thornley, A. Griffin, B. Deheshi, T. O’Shea, J. Wunder, P. Ferguson, R. L. Randall, R. Turcotte, P. Schneider, P. McKay, M. Bhandari, M. Ghert. The inter-rater reliability of the diagnosis of surgical site infection in the context of a clinical trial. Bone Joint Res 2016;5:347–352. DOI: 10.1302/2046-3758.58.BJR-2016-0036.R1

C. Difficile infections in elderly patients with hip fractures is associated with high morbidity and mortality. Antibiotic regimens with penicillin and its derivatives is a leading cause. Antibiotic prophylactic preferences vary across different hospitals within NHS. We compared two antibiotic prophylactic regimens - Cefuroxime only prophylaxis and Teicoplanin with Gentamicin prophylaxis in fracture neck of femur surgery, and evaluated the incidence of C. Difficile diarrhea and Surgical Site Infection (SSI). To assess the Surgical Site Infection and C. Difficile infection rate associated with different regimens of antibiotics prophylaxis in fracture neck of femur surgery. Data was analyzed retrospectively. Neck of femur fracture patients treated surgically from 2009 in our unit were included. Age, gender, co morbidities, type of fracture, operation, ASA grade was collected. 1242 patients received Cefuroxime only prophylaxis between January 2009 and December 2012 (Group 1) and 486 patients received Teicoplanin with Gentamicin between October 2015 and March 2017 (Group 2). There were 353 males and 889 female patients in Group 1 and 138 males and 348 female patients in Group 2. The co morbidities in both groups were comparable. Incidence of C. Difficile diarrhea and Surgical Site Infection (SSI) was noted. Statistical analysis with chi square test was performed to determine the ‘p’ value. C. Diff diarrhea rate in Group 2 was 0.41 % as compared to 1.29 % in Group 1. The Surgical Site Infection (SSI) rate in Group 2 was 0.41 % as compared to 3.06 % in Group 1. The comparative results were statistically significant (p = 0.0009). Prophylactic antibiotic regimen of Teicoplanin with Gentamicin showed significant reduction in C. Difficile diarrhea & Surgical Site Infection in fracture neck of femur patients undergoing surgery

Aims. This study explores the reported rate of surgical site infection (SSI) after hip fracture surgery in published studies concerning patients treated in the UK. Methods. Studies were included if they reported on SSI after any type of surgical treatment for hip fracture. Each study required a minimum of 30 days follow-up and 100 patients. Meta-analysis was undertaken using a random effects model. Heterogeneity was expressed using the I. 2. statistic. Risk of bias was assessed using a modified Newcastle-Ottawa Scale (NOS) system. Results. There were 20 studies reporting data from 88,615 patients. Most were retrospective cohort studies from single centres. The pooled incidence was 2.1% (95% confidence interval (CI) 1.54% to 2.62%) across ‘all types’ of hip fracture surgery. When analyzed by operation type, the SSI incidences were: hemiarthroplasty 2.87% (95% CI 1.99% to 3.75%) and sliding hip screw 1.35% (95% CI 0.78% to 1.93%). There was considerable variation in definition of infection used, as well as considerable risk of bias, particularly as few studies actively screened participants for SSI. Conclusion. Synthesis of published estimates of infection yield a rate higher than that seen in national surveillance procedures. Biases noted in all studies would trend towards an underestimate, largely due to inadequate follow-up

Aims. Surgical site infection (SSI) after soft-tissue sarcoma (STS) resection is a serious complication. The purpose of this retrospective study was to investigate the risk factors for SSI after STS resection, and to develop a nomogram that allows patient-specific risk assessment. Methods. A total of 547 patients with STS who underwent tumour resection between 2005 and 2021 were divided into a development cohort and a validation cohort. In the development cohort of 402 patients, the least absolute shrinkage and selection operator (LASSO) regression model was used to screen possible risk factors of SSI. To select risk factors and construct the prediction nomogram, multivariate logistic regression was used. The predictive power of the nomogram was evaluated by receiver operating curve (ROC) analysis in the validation cohort of 145 patients. Results. LASSO regression analysis selected possible risk factors for SSI, including age, diabetes, operating time, skin graft or flap, resected tumour size, smoking, and radiation therapy. Multivariate analysis revealed that age, diabetes, smoking during the previous year, operating time, and radiation therapy were independent risk factors for SSI. A nomogram was developed based on the results of multivariate logistic regression analysis. In the development cohort, the incidence of SSI was 4.5% in the low-risk group (risk score < 6.89) and 26.6% in the high-risk group (risk score ≥ 6.89; p < 0.001). In the validation cohort, the incidence of SSI was 2.0% in the low-risk group and 15.9% in the high-risk group (p = 0.004). Conclusion. Our nomogram will enable surgeons to assess the risk of SSI in patients with STS. In patients with high risk of SSI, frequent monitoring and aggressive interventions should be considered to prevent this. Cite this article: Bone Joint J 2024;106-B(5):492–500

Corynebacterium Jeikeium is a pathogen rarely involved in orthopaedic infections. Till date only 14 cases of osteomyelitis are described in the literature, envolving the tibia, foot and prosthethic (hip and joint) infection. To our knowledge, Corynebacterium Jeikeium as not been reported as an infectious agent of the spine. Our goal is to describe a case of scoliosis surgical site infection by a Corynebacterium Jeikeium specimen. This is a retrospective and descriptive case report based on data from clinical records, patient observation and analysis of complementary exams. We present a 24 year old female with a history of premature birth, West syndrome, spastic cerebral palsy and spina bifida. She was sent to our consult for evaluation of dorsolombar scoliosis. In October of 2014, she was submitted to surgery – posterior spine arthrodesis and instrumentation (D10 to L5) with bilateral pedicle screws and two chromium-cobalt bars. The early post-operative period was without complications. She was discharge at the seventh day of internment and was seen, fifteen days postoperative, at the consultation office, where the dressings were changed, with no signs of surgical site infection. One month post-operative, she recurs to the office because of an apparent seroma at the surgical site wound. There was no reference to fever or other signs of local/systemic infection. A swabbing of the wound was done and the patient was medicated with Ciprofloxacine, 500mg 12/12 hours – the culture came back negative. Seven days later she was seen again, maintaining the seroma with purge of a serous-aspect fluid. Antibiotic therapy was maintained and another swabbing was collected – culture came back negative. Because of suspected surgical site infection, she was re-operated at December of 2014. Surgical wound debridement was performed; three tissue samples and one exudate were sent to the microbiological department. In all samples but one was identified a Corynebacterium Jeikeium. No sensitivity test was performed. Intravenous Vancomicine, 1 gram 12/12 hours was started and maintained during 8 days. Eleven days post-operative she was discharged with oral Vibramicin, 100 milligrams 12/12 hours for two weeks. She is currently being followed at the doctor's office, with no sign of reinfection of the surgical site. This is the first reported case describing an infection of the spine by a Corynebactereium Jeikeium. Isolation of the causative agent of infection and literature-based directed antibiotherapy are important for a successful outcome

The aim of this study was to assess the impact of Covid-19 measures on the rate of surgical site infections (SSI) and subsequent readmissions in orthopaedic patients. Retrospective, observational study in a level 1 major trauma center comparing rates of SSI in orthopaedic patients who underwent surgery prior to the Covid-19 lockdown versus that of patients who underwent surgery during the lockdown period. A total of 1151 patients were identified using electronic clinical records over two different time periods; 3 months pre Covid-19 lockdown (n=680) and 3 months during the Covid-19 lockdown (n=470). Patients were followed up for 1 year following their initial procedure. Primary outcome was readmission for SSI. Secondary outcomes were treatment received and requirement for further surgeries. The most commonly performed procedures were arthroplasty and manipulation under anaesthesia with 119 in lockdown vs 101 non-lockdown (p=0.001). The readmission rate was higher in the lockdown group with 61 (13%) vs 44 (6.5%) in the non-lockdown group (p <0.001). However, the majority were due to other surgical complications such as dislocations. Interestingly, the SSI rates were very similar with 24 (5%) in lockdown vs 28 (4%) in non-lockdown (p=0.472). Twenty patients (4.2%) required a secondary procedure for their SSI in the lockdown group vs 24 (3.5%) in non-lockdown (p=0.381). Mortality rate was similar at 44 (9.3%) in lockdown vs 61 (9.0%; p=0.836). Whilst Covid-19 precautions were associated with higher readmission rates, there was no significant difference in rate of SSI between the two groups

Aims. Deep surgical site infection (SSI) is common after lower limb fracture. We compared the diagnosis of deep SSI using alternative methods of data collection and examined the agreement of clinical photography and in-person clinical assessment by the Centers for Disease Control and Prevention (CDC) criteria after lower limb fracture surgery. Methods. Data from two large, UK-based multicentre randomized controlled major trauma trials investigating SSI and wound healing after surgical repair of open lower limb fractures that could not be primarily closed (UK WOLLF), and surgical incisions for fractures that were primarily closed (UK WHiST), were examined. Trial interventions were standard wound care management and negative pressure wound therapy after initial surgical debridement. Wound outcomes were collected from 30 days to six weeks. We compared the level of agreement between wound photography and clinical assessment of CDC-defined SSI. We are also assessed the level of agreement between blinded independent assessors of the photographs. Results. Rates of CDC-defined deep SSI were 7.6% (35/460) after open fracture and 6.3% (95/1519) after closed incisional repair. Photographs were obtained for 77% and 73% of WOLLF and WHiST cohorts respectively (all participants n = 1,478). Agreement between photographic-SSI and CDC-SSI was fair for open fracture wounds (83%; k = 0.27 (95% confidence interval (CI) 0.14 to 0.42)) and for closed incisional wounds (88%; k = 0.29 (95% CI 0.20 to 0.37)) although the rate of photographically detected deep SSIs was twice as high as CDC-SSI (12% vs 6%). Agreement between different assessors for photographic-SSI (WOLLF 88%, k = 0.63 (95% CI 0.52 to 0.72); WHiST 89%; k = 0.61 (95% CI 0.54 to 0.69)); and wound healing was good (WOLLF 90%; k = 0.80 (95% CI 0.73 to 0.86); WHiST 87%; k = 0.57 (95% CI 0.50 to 0.64)). Conclusion. Although wound photography was feasible within the research context and inter-rater assessor agreement substantial, digital photographs used in isolation overestimated deep SSI rates, when compared to CDC criteria. Wound photography should not replace clinical assessment in pragmatic trials but may be useful for screening purposes where surgical infection outcomes are paramount. Cite this article: Bone Joint J 2021;103-B(12):1802–1808

Aims. This study aims to estimate economic outcomes associated with 30-day deep surgical site infection (SSI) from closed surgical wounds in patients with lower limb fractures following major trauma. Methods. Data from the Wound Healing in Surgery for Trauma (WHiST) trial, which collected outcomes from 1,547 adult participants using self-completed questionnaires over a six-month period following major trauma, was used as the basis of this empirical investigation. Associations between deep SSI and NHS and personal social services (PSS) costs (£, 2017 to 2018 prices), and between deep SSI and quality-adjusted life years (QALYs), were estimated using descriptive and multivariable analyses. Sensitivity analyses assessed the impact of uncertainty surrounding components of the economic analyses. Results. Compared to participants without deep SSI, those with deep SSI had higher mean adjusted total NHS and PSS costs (adjusted mean difference £1,577 (95% confidence interval (CI) -951 to 4,105); p = 0.222), and lower mean adjusted QALYs (adjusted mean difference -0.015 (95% CI -0.032 to 0.002); p = 0.092) over six months post-injury, but this difference was not statistically significant. The results were robust to the sensitivity analyses performed. Conclusion. This study found worse economic outcomes during the first six months post-injury in participants who experience deep SSI following orthopaedic surgery for major trauma to the lower limb. However, the increase in cost associated with deep SSI was less than previously reported in the orthopaedic trauma literature. Cite this article: Bone Jt Open 2022;3(5):398–403

Aims. This study aims to determine difference in annual rate of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis, and to identify risk factors that may be associated with infection. Methods. This is a retrospective population-based cohort study using prospectively collected patient-level data between 1 January 2013 and 1 March 2020. The diagnosis of deep SSI was defined as per the Centers for Disease Control/National Healthcare Safety Network criteria. The Mann-Kendall Trend test was used to detect monotonic trends in annual rates of early-onset deep SSI over time. Multiple logistic regression was used to analyze the effect of different patient, surgical, and healthcare setting factors on the risk of developing a deep SSI within 90 days from surgery for patients with complete data. We also report 90-day mortality. Results. A total of 39,038 patients underwent primary TKA for osteoarthritis during the study period. Of these, 275 patients developed a deep SSI within 90 days of surgery, representing a cumulative incidence of 0.7%. The annual infection rate did not significantly decrease over the seven-year study period (p = 0.162). Overall, 13,885 (35.5%) cases were excluded from the risk analysis due to missing data. Risk factors associated with early-onset deep SSI included male sex, American Society of Anesthesiologists grade ≥ 3, blood transfusion, acute length of stay, and surgeon volume < 30 TKAs/year. Early-onset deep SSI was not associated with increased 90-day mortality. Conclusion. This study establishes a reliable baseline infection rate for early-onset deep SSI after TKA for osteoarthritis using robust Infection Prevention and Control surveillance data, and identifies several potentially modifiable risk factors. Cite this article: Bone Joint J 2023;105-B(9):971–976

The aim of this study was to evaluate the rate of surgical site infection (SSI) in all patients undergoing a primary total knee arthroplasty (TKA) and to audit the outcomes for those who were obese. We retrospectively reviewed data for 839 primary TKAs done at a National Arthroplasty Centre over one year (April 2007 – March 2008). Body mass index (BMI) data was available for 824 (98%) of the patients. Surgical site infection (SSI) data had been collected prospectively by the Infection Control team for up to 30 days post-operatively and was available for all patients. There were 23 patients with SSIs, 22 having superficial SSI and only one patient with a deep SSI. The overall superficial SSI rate was 2.7%. For the BMI< 25 group (9.6% of patients) SSI rate was 1.3%. For BMI 25–30 (31.6% of patients) SSI rate was 2.3%. For BMI 30–35 (31.2% of patients) SSI rate was 1.6%. For BMI 35–40 (19.0% of patients) SSI rate was 3.2%. For BMI > (8.6% of patients) SSI rate was 8.5%. Fisher’s Exact Test between all obese patients (BMI< 30) and those with BMI< 30 showed no significant difference in superficial SSI rates (p = 0.39) but did show a significant difference between superficial SSI rates in the obese class III patients (BMI> 40) and the rest of the cohort (p = 0.008). Obese class III (BMI > 40) patients are at an increase risk of superficial SSI as compared to other patients undergoing primary TKA. However, obese class I and II patients (BMI 30–40) do not appear to have an increased likelihood of superficial SSI as compared to patients who have BMI< 30

Aims. In contrast to operations performed for other fractures, there is a high incidence rate of surgical site infection (SSI) post-open reduction and internal fixation (ORIF) done for tibial plateau fractures (TPFs). This study investigates the effect of induced membrane technique combined with internal fixation for managing SSI in TPF patients who underwent ORIF. Methods. From April 2013 to May 2017, 46 consecutive patients with SSI post-ORIF for TPFs were managed in our centre with an induced membrane technique. Of these, 35 patients were included for this study, with data analyzed in a retrospective manner. Results. All participants were monitored for a mean of 36 months (24 to 62). None were subjected to amputations. A total of 21 patients underwent two-stage surgeries (Group A), with 14 patients who did not receive second-stage surgery (Group B). Group A did not experience infection recurrence, and no implant or cement spacer loosening was noted in Group B for at least 24 months of follow-up. No significant difference was noted in the Lower Extremity Functional Scale (LEFS) and the Hospital for Special Surgery Knee Score (HSS) between the two groups. The clinical healing time was significantly shorter in Group B (p＜0.001). Those with longer duration of infection had poorer functional status (p＜0.001). Conclusion. Management of SSI post-ORIF for TPF with induced membrane technique combined with internal fixation represents a feasible mode of treatment with satisfactory outcomes in terms of infection control and functional recovery. Cite this article: Bone Joint Res 2021;10(7):380–387

Aim. To investigate the incidence and time-trend in reoperation due to deep Surgical Site Infection (SSI) following hip fracture surgery. Method. This was a population-based, nationwide, cohort study. We included 74,771 from the Danish Multidisciplinary Hip Fractures Register (1) consisting of patients 65 years of age or older, who underwent surgery between January 1. st. 2005 and December 31. st. 2016 for all types of hip fracture. Cross-linkage with the Danish National Patient Register and The Danish Civil Registration system was made. Demographic data extracted included vital status, civil status, gender, age, Body Mass Index (BMI), fracture classification (AO/OTA 31A-C) and surgical procedures binary registered as joint replacement or internal fixation, Charlson comorbidity index (CCI) and secondary diseases not included in CCI. Outcome was reoperations due to deep SSI in accordance with the definition from Centre for Disease Control (2). We computed cumulative incidence rates and risk ratios (RR) by calendar year periods and by different risk factors, considering death as competing risk and adjusting for age, gender, CCI, fracture type and surgery type. Results. Within 365 days of primary surgery 2.1% of all hip fractures had undergone reoperation due to deep SSI. During the period 2005–2016, the incidence of reoperation due to SSI decreased from 2.7% to 1.7%, We could not identify differences in reoperation due to SSI within one year regarding gender, BMI or CCI. Patients aged above 85 had about 50% lower risk of being reoperated compared with the youngest age group; 65–74 years (RR: 0.5; 95% CI: 0.4:0.6). The RR for reoperation due to deep SSI was lower for patients with pertrochanteric or subtrochanteric fractures (AO/OTA: 31A1-3) versus femoral neck fractures (AO/OTA: 31B1-3), RR was 0.7 (95%CI: 0.7:0.8). However, RR for surgery type (joint replacement vs internal fixation) at 365 days was significantly lower for joint replacement, RR: 0.6 (95% CI: 0.6:0.7). Conclusions. This study shows reoperation risk due to SSI for all types of hip fractures of 2.1%. There was a 45% decrease in reoperation over time from 2005 to 2016. However, the risk of revision is still high, and further action in avoidance of SSI should be taken

As of April 2010 all NHS institutions in the United Kingdom are required to publish data on surgical site infection, but the method for collecting this has not been decided. We examined 7448 trauma and orthopaedic surgical wounds made in patients staying for at least two nights between 2000 and 2008 at our institution and calculated the rate of surgical site infection using three definitions: the US Centers for Disease Control, the United Kingdom Nosocomial Infection National Surveillance Scheme and the ASEPSIS system. On the same series of wounds, the infection rate with outpatient follow-up according to Centre for Disease Control was 15.45%, according to the UK Nosocomial infection surveillance was 11.32%, and according to ASEPSIS was 8.79%. These figures highlight the necessity for all institutions to use the same method for diagnosing surgical site infection. If different methods are used, direct comparisons will be invalid and published rates of infection will be misleading

Objectives. To review the current best surgical practice and detail a multi-disciplinary approach that could further reduce joint replacement infection. Methods. Review of relevant literature indexed in PubMed. Results. Surgical site infection is a major complication following arthroplasty. Despite its rarity in contemporary orthopaedic practice, it remains difficult to treat and is costly in terms of both patient morbidity and long-term health care resources. Conclusions. Emphasis on education of patients and all members of the health-care team and raising awareness in how to participate in preventative efforts is imperative

Objective. To identify risk factors for surgical site infections and to quantify the contribution of independent risk factors to the probability of developing infection after definitive fixation of tibial plateau fractures. Methods. A retrospective analysis was performed at a Level I trauma center between 2004 and 2010. A total of 251 consecutive patients (256 cases) were divided into two groups, those with and those without a surgical site infection. Preoperative and perioperative variables were compared between these groups and risk factors were determined by univariate analyses and multivariate logistic regression. Results. The overall rate of surgical site infection after tibial plateau ORIF was 7.8% (20 of 256). The most common causative pathogens was Staphylococcus aureus (n=15, 75%). Independent predictors of surgical site infection identified by multivariate analyses were open tibial plateau fracture (odds ratio =3.9; 95% confidence interval=1.3–11.6, p =0.015) and operative time (odds ratio=2.7; 95% confidence interval=1.6 − 4.4; p < 0.001). Conclusions. Both open fracture and operative time are independent risks factors for post operative infection

Aim. To investigate the effect of intraoperative wound irrigation with povidone-iodine on surgical site infection. Methods. Data were collected prospectively for all cases of instrumented thoracic and lumbar spine surgery undertaken by the senior author (DB) from 01/10/2008 to 1/10/2010. Variables recorded included patient factors (age, co-morbidities, drug history) and operative factors (type of operation, duration of operation, elective/emergency, in hours/out of hours, consultant/junior, perioperative antibiotic administration). Routine povidone-iodine application commenced on 1/06/2009. Surgical site infection was defined as wound infection confirmed on wound swab or blood cultures. Comparison was made between patients receiving povidone-iodine intraoperative wound irrigation and those who did not using Fisher's exact test. Results. Data from 91 consecutive patients who had undergone instrumented thoracic or lumbar fusions under the care of the senior author were analysed. Mean age was 58.0±16.9 years. There was no difference in age (Mean±SD) between those receiving povidone-iodine (59.1 ±16.9y) and those without povidone-iodine administration (55.3 ±16.9) (p=0.33). The number of wound infections was significantly reduced from 19% (5/26) in those without povidone-iodine to 0% (0/65) in those with application of povidone-iodine (p=0.001, Fisher's exact). Conclusion. Intraoperative povidone-iodine irrigation appears to be an effective method of reducing SSIs in instrumented spinal fixation surgery

Aims. The aim of this study was to estimate economic outcomes associated with deep surgical site infection (SSI) in patients with an open fracture of the lower limb. Patients and Methods. A total of 460 patients were recruited from 24 specialist trauma hospitals in the United Kingdom Major Trauma Network. Preference-based health-related quality-of-life outcomes, assessed using the EuroQol EQ-5D-3L and the 6-Item Short-Form Health Survey questionnaire (SF-6D), and economic costs (£, 2014/2015 prices) were measured using participant-completed questionnaires over the 12 months following injury. Descriptive statistics and multivariate regression analysis were used to explore the relationship between deep SSI and health utility scores, quality-adjusted life-years (QALYs), and health and personal social service (PSS) costs. Results. Deep SSI was associated with lower EQ-5D-3L derived QALYs (adjusted mean difference -0.102, 95% confidence interval (CI) -0.202 to 0.001, p = 0.047) and increased health and social care costs (adjusted mean difference £1950; 95% CI £1383 to £5285, p = 0.250) versus patients without deep SSI over the 12 months following injury. Conclusion. Deep SSI may lead to significantly impaired health-related quality of life and increased economic costs. Our economic estimates can be used to inform clinical and budgetary service planning and can act as reference data for future economic evaluations of preventive or treatment interventions. Cite this article: Bone Joint J 2018;100-B:1506–10

Purpose: The aim of this study was to evaluate the rate of surgical site infection (SSI) in all patients undergoing a primary total knee arthroplasty (TKA) and to audit the outcomes for those who were obese. Methods/Results: We retrospectively reviewed data for 839 primary TKAs done at a National Arthroplasty Centre over one year (April 2007 – March 2008). BMI data was available for 824 (98%) of the patients. SSI data had been collected prospectively by the Infection Control team for up to 30 days post-operatively and was available for all patients. Patients were grouped based on their BMI and the WHO classifications (WHO Technical Report Series 894). 31.2% of the patients were obese class I (BMI 30 – 35), 19.0% were obese class II (BMI 35 – 40) and 8.6% were obese class III (BMI > 40). There were 23 patients with SSIs, 22 having superficial SSI and only one patient with a deep SSI. The overall superficial SSI rate was 2.7%. The superficial SSI rates for each group were as follows: normal (BMI < 25) = 1.3%; overweight (BMI 25 –30) = 2.3%; obese class I = 1.6%; obese class II = 3.2%; obese class III = 8.5%. The Fisher’s Exact Test between all obese patients and those with BMI < 30 showed no significant difference in superficial SSI rates (p = 0.39) but did show a significant difference between superficial SSI rates in the obese class III patients and the rest of the cohort (p = 0.008). Conclusions: Obese class III (BMI > 40) patients are at an increase risk of superficial SSI as compared to other patients undergoing primary TKA. However, obese class I and II patients do not appear to have an increased likelihood of superficial SSI as compared to patients who have BMI < 30