The role that fomites have to play in surgical site infection (SSI) and periprostheitic joint infection (PJI) has been observed and researched in the past. However the role that cellphones play in the transfer of microorganisms from hands to surgical sites and the indiscriminate use of cellphones within the Orthopaedics, could increase the risk of infection. This study aimed to measure the contamination of cellphones of health care workers (HCW's) in a South African tertiary hospital. Secondarily was to investigate the cellphone hygiene behaviour of HCW's. A prospective cross-sectional study was conducted in June 2022. Samples were taken from the the participant's cellphones under an aseptic technique and sent for microbiology. The participants also filled out a questionnaire on cellphone behaviour. The inclusion criteria was orthopaedic HCW's working in the institution; This included nurses and doctors in the orthopaedic theatres and main orthopaedic wards. Sixty-two participants were included; 54 from Orthopaedics and 7 from Anaesthesia. From the samples, 71% grew pathogens while 30,64% grew two or more colonies. This is slightly lower than other studies which showed contamination up to 100%. Micro-organisms cultured included Staphylococcus species; S.Epidermidis, Methycillin sensitive S.aureas; and E.Coli. Cellphone hygiene behaviour was also better than most other studies in terms of frequency of cleaning the devices and hand hygiene around cellphone usage. This which may be a contributing factor to the lower micro-organism contamination. This study should be the first of many as we have identified that there are indeed pathogens on cellphones transferable to patients; causing sepsis. Though cellphones have become vital in patients management in the hospital setting, factors such as improvement in cellphone hygiene through education and frequent cleaning of cellphones will aid in disabling the negative impact of cellphones in the orthopaedic environment

The aim of this study was to determine the incidence, annual trend, perioperative outcomes, and identify risk factors of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis. Risk factors for early-onset deep SSI were assessed. We performed a retrospective population-based cohort study using prospectively collected patient-level data from several provincial administrative data repositories between January 2013, and March 2020. The diagnosis of early-onset deep SSI was based on published Centre for Disease Control/National Healthcare Safety Network (CDC/NHSN) definitions. The Mann-Kendall Trend Test was used to detect monotonic trends in early-onset deep SSI rates over time. The effects of various patient and surgical risk factors for early-onset deep SSI were analyzed using multiple logistic regression. Secondary outcomes were 90-day mortality and 90-day readmission. A total of 20,580 patients underwent primary TKA for osteoarthritis. Forty patients had a confirmed deep SSI within 90-days of surgery representing a cumulative incidence of 0.19%. The annual infection rate did not change over the 7-year study period (p = 0.879). Risk factors associated with early-onset deep SSI included blood transfusions (OR, 3.93 [95% CI 1.34-9.20]; p=0.004), drug or alcohol abuse (OR, 4.91 [95% CI 1.85-10.93]; p<0.001), and surgeon volume less than 30 TKA per year (OR, 4.45 [1.07-12.43]; p=0.013). Early-onset deep SSI was not associated with 90-days mortality (OR, 11.68 [0.09-90-58]; p=0.217), but was associated with an increased chance of 90-day readmission (OR, 50.78 [26.47-102.02]; p<0.001). This study establishes a reliable baseline infection rate for early-onset deep SSI after TKA for osteoarthritis through the use of a robust methodological process. Several risk factors for early-onset deep SSI are potentially modifiable or can be optimized prior to surgery and be effective in reducing the incidence of early-onset SSI. This could guide the formulation of provincial screening programs and identify patients at high risk for SSI

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

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

Aim. The efficacy of various irrigation solutions in removing microbial contamination of a surgical wound and reducing the rate of subsequent surgical site infection (SSI), has been demonstrated extensively. However, it is not known if irrigation solutions have any activity against established biofilm. This issue is pertinent as successful management of patients with periprosthetic joint infection (PJI) includes the ability to remove biofilm established on the surface of implants and necrotic tissues. The purpose of this study was to evaluate the efficacy of various irrigation solutions in eradicating established biofilm, as opposed to planktonic bacteria, in a validated in vitro model. Method. Established biofilms of Staphylococcus aureus and Escherichia coli were exposed to different irrigation solutions that included Polymyxin 500,000U/L plus bacitracin 50,000U/L, Vancomycin 1g/L, Gentamicin 80mg/L, Normal saline 0.9%, off-the-shelf Betadine 0.3%, Chlorhexidine 0.05%, Benzalkonium 1.3g/L, Sodium hypochlorite 0.125%, and Povidone-iodine 0.5%. Each experiment was conducted in a 96-well microtiter plate with a peg lid and standardized per the MBEC assay manufacturer's protocol. Following 2 minutes of solution exposure to the irrigation solution, residual biofilms were recovered by sonication. Outcome measures for antibiofilm efficacy were residual colony forming units (CFU) and optical density (690nm). Experiments were conducted in 24 replicates and the observations recorded by two blinded observers. Statistical analysis involved t-tests with Bonferonni adjustment. Results. Povidone-iodine 0.5%, Betadine 0.3%, Benzalkonium 1.3g/L, and Sodium hypochlorite 0.125% were significantly more efficacious against S.aureus biofilm versus all other solutions (p<0.001). Against E.coli biofilm, Povidone-iodine-0.5%, Benzalkonium-1.3g/L and Sodium hypochlorite-0.125% were also most effective compared to other irrigation solutions (p<0.001). Polymyxin-bacitracin, Gentamicin, Vancomycin, and Saline solutions had minimal activity against both E.coli and S.aureus biofilms (p<0.001). Similar trends were observed using both experimental endpoints (CFU and Turbidity) and both investigators (interrater reliability; r=0.99). Conclusion. This in vitro study observed that topical antibiotic solutions do not have any activity against established biofilms. Irrigations solutions containing adequate amount of povidone-iodine, betadine, sodium hypochlorite, and benzalkonium appear to have activity against established biofilm by gram positive and gram negative organisms. The use of these irrigation solutions may need to be considered in patients with established PJI

Staphylococcus aureus is one of the leading causes of surgical site infection (SSI). Over the past decade there has been an increase in methicillin-resistant S. aureus (MRSA). This is a subpopulation of the bacterium with unique resistance and virulence characteristics. Nasal colonisation with either S. aureus or MRSA has been demonstrated to be an important independent risk factor associated with the increasing incidence and severity of SSI after orthopaedic surgery. Furthermore, there is an economic burden related to SSI following orthopaedic surgery, with MRSA-associated SSI leading to longer hospital stays and increased hospital costs. Although there is some controversy about the effectiveness of screening and eradication programmes, the literature suggests that patients should be screened and MRSA-positive patients treated before surgical admission in order to reduce the risk of SSI. Cite this article: Bone Joint J 2013;95-B:4–9

The objective of this study was to determine the effectiveness of screening and successful treatment of methicillin-resistant Staphylococcus aureus (MRSA) colonisation in elective orthopaedic patients on the subsequent risk of developing a surgical site infection (SSI) with MRSA. We screened 5933 elective orthopaedic in-patients for MRSA at pre-operative assessment. Of these, 108 (1.8%) were colonised with MRSA and 90 subsequently underwent surgery. Despite effective eradication therapy, six of these (6.7%) had an SSI within one year of surgery. Among these infections, deep sepsis occurred in four cases (4.4%) and superficial infection in two (2.2%). The responsible organism in four of the six cases was MRSA. Further analysis showed that patients undergoing surgery for joint replacement of the lower limb were at significantly increased risk of an SSI if previously colonised with MRSA. We conclude that previously MRSA-colonised patients undergoing elective surgery are at an increased risk of an SSI compared with other elective patients, and that this risk is significant for those undergoing joint replacement of the lower limb. Furthermore, when an infection occurs, it is likely to be due to MRSA

Increased operative time has been previously identified as a risk factor for complications following total joint arthroplasty. The purpose of this study was to evaluate the influence of surgical time on 30-day complications following Total Knee Arthroplasty (TKA) and to determine if there were specific time intervals associated with worse outcomes. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was utilized to identify patients ≥18 years who underwent TKA between 2005 and 2016 using procedural codes. Patients with surgical durations >240 minutes were excluded. Patient demographics, operation length, and 30-day major and minor complication rates were captured. Multivariable logistic regression was used to determine if the rate of complications differed depending on length of operation, while adjusting for age, sex, American Society of Anaesthesiologists (ASA) class, functional status, smoking status, comorbidities, anesthesia type, and Body Mass Index (BMI). Multivariable linear regression was used to identify independent predictors of duration of surgery. A total of 213,921 TKA patients (average age 67 ± 10 years) were identified from the database. Within 30-days of the index procedure, 3,321 (1.55%) experienced a major complication, and 6,144 (2.86%) experienced a minor complication. Mean surgical duration was 92 minutes (range 20 – 240). Underweight, or overweight/obese BMI, male sex, hypertension, cancer, dependent functional status, epidural anaesthesia, and ASA class III and IV were determined to be independent predictors of prolonged operation length, while COPD, current smoking, spinal anesthesia, and older age predicted lower operation times. Operation lengths ≥ 90 minutes significantly increased the risk of both major and minor complications (P>0.01). Specifically, the rates of deep vein thrombosis (DVT), unplanned reintubation, surgical site infection (SSI), sepsis, and wound disruption were higher for patients whose operations lasted ≥ 90 minutes (p 0.05). With respect to specific complications, following covariate adjustment, operation lengths ≥ 90 minutes increased the risk of DVT, deep and superficial incisional SSI, and wound disruption, while operation lengths ≥ 120 minutes increased the risk of deep, non-incisional SSI, and sepsis (P < 0 .01). Surgical times of ≥90 minutes independently increase the 30-day risk of DVT, infection, and wound disruption following TKA after controlling for other variables that influence operation length. This study confirms the importance of surgical duration on early outcomes following TKA

Summary. A meta-analysis was performed to compare rate of SSI after application of chlorhexidine vs. iodine in total joint arthroplasty. Chlorhexidine had significantly lower odds of SSI. Introduction. Surgical site infections (SSI) are a significant source of morbidity and mortality. The optimal preoperative skin preparation in lower extremity total joint arthroplasty (TJA) remains debatable between chlorhexidine and iodine-containing solutions. This meta-analysis sought compare SSI rates between chlorhexidine cloth application the night before surgery plus povidone-iodine-alcohol (povidone-iodine) solution at surgery or only povidone-iodine at surgery. Methods. A structured literature search was performed using Web of Science, PubMed, and EMBASE databases for randomized clinical trials (RCTs) and comparative studies that evaluated preoperative chlorhexidine-gluconate versus iodine-alcohol exclusively in TJA patients. Databases were searched from database inception to January 2, 2018, and studies were included if they had specific aims and 1) compared preoperative chlorhexidine-gluconate cloths to povidone-iodine at surgery, or 2) if they compared preoperative chlorhexidine-gluconate cloths and povidone-iodine at surgery, to solely povidone-iodine at surgery. The main outcome was deep or superficial SSI at or before 1 year postoperatively. If multiple studies reported the same patient cohort, the more recent study was used. To compare the chlorhexidine versus povidone-iodine groups, pooled odds ratios (OR) and 95% confidence intervals (95% CI) were used to calculate odds of SSI. Results. Four studies involving 2,997 TJA patients were included in this meta-analysis. Three were retrospective cohort studies, and one was a RCT. One retrospective cohort study assessed chlorhexidine to povidone-iodine using a historical control. One RCT compared chlorhexidine to povidone-iodine. The remaining two studies compared chlorhexidine in addition to povidone-iodine, to only povidone-iodine. Bias analysis showed low-to-moderate quality cohort studies and one moderate-quality RCT. Chlorhexidine had significantly lower odds of SSI compared to povidone iodine (OR=0.28; 95%CI: 0.15–0.51; p<0.0001). Conclusion. Preoperative chlorhexidine-gluconate was superior at reducing SSI risk in patients who underwent lower extremity TJA, compared to povidone-iodine. This can potentially lead to decreased morbidity and lower surgical revision rates for infections. For any figures or tables, please contact authors directly

Aim. Reveal the rate of surgical site infection (SSI) after primary hip and knee arthroplasty in patients with inflammatory joint disease and analyse if the infection rate was correlated to the given anti-rheumatic treatment. The background is that since 2006 patients operated at the orthopaedic department at Skåne University hospital, Lund, Sweden, have continued treatment with TNF-alpha inhibitors during the perioperative period. Method. During 2006 to 2015 494 planned primary hip and knee arthroplasties were performed on 395 patients (236 hip arthroplasties and 239 knee arthroplasties). Data on age, sex, diagnosis, BMI, operation time, ASA-classification, treatment with cDMARDs (conventional disease modifying anti-rheumatic drugs) and bDMARDs (biological disease modifying antirheumatic drugs) and use of prednisolone was collected. The primary outcome variable was prosthetic joint infection (PJI) within 1 year from surgery with a secondary outcome variable being superficial SSI. Results. In 32% (n=159) of the cases the patient was treated with a TNF-alpha inhibitor. The rate of PJI was 1.4% (n=7). The overall rate of infection, including superficial infections, was 2.4% (n=12). All the PJIs occurred after a knee arthroplasty and only 1 patient was treated with a TNF-alpha inhibitor (etanercept). Conclusions. We could not find that continuing treatment with TNF-inhibitors perioperatively led to a higher incidence of PJI or SSI than generally would be expected in a group of patients with an inflammatory joint disease. Based on these results there is no need to discontinue treatment with TNF-inhibitors when performing arthroplasty surgery

Aim. Periprosthetic joint infections (PJI) and surgical site infections (SSI) are one of the most severe complications in joint arthroplasty. Decolonization measures prior to elective orthopedic surgeries have shown to reduce the risk of infection especially in patient identified as carriers of S. aureus. However additional screening measures can be difficult to implement in daily routine. The objective was to study the influence of universal decolonization with polihaxanid on SSI rates. Method. Between January 2017 and December 2018 patients scheduled for hip or knee joint arthroplasty in 5 participating orthopedic centers received polyhexanid containing decolonization set consisting of oral, nasal and wipes. Patients were instructed to perform a 5 day decolonization regimen 4 days prior to surgery. SSIs were recorded according to modified CDC criteria for a surveillance period of 90days after surgery. Results. During the study period, 4437 decolonization sets were distributed to patients. 1869 patients consented to participate in the study and provide detailed feedback on compatibility and compliance. Overall SSI rate was 0.87 per 100 surgeries prior to introduction of the decolonization, while it was 0.97 per 100 surgeries during the period of decolonization and 0.59 per 100 surgeries in those using the decolonization set. SSI rates due to Staphylococcus aureus were 0.32 per 100 surgeries, 0.21 per 100 surgeries and 0.05 per 100 surgeries respectively. In patients receiving an elective hip-joint arthroplasty SSI rate was 0.93 per 100 surgeries prior to introduction, while it was 1.17 per 100 surgeries during the intervention period and 0.96 per 100 surgeries in patients that used the decolonization set. However SSI rates due to Staphylococcus aureus were 0.30 per 100 surgeries, 0.14 per 100 surgeries and 0.10 per 100 surgeries respectively. In patients receiving, an elective knee-joint arthroplasty SSI rate was 0.52 per 100 surgeries prior to introduction, while it was 0.53 per 100 surgeries during the intervention period and 0.12 per 100 surgeries in patients that used the decolonization set. However, SSI rates due to Staphylococcus aureus were 0.20 per 100 surgeries, 0.13 per 100 surgeries and 0.00 per 100 surgeries respectively. In addition to these preliminary results, we will provide and present a further analysis of the study results. Conclusions. Polyhexanid based universal decolonization measures were safely implemented. Universal decolonization with polyhexanid might have a benefit on S. aureus SSI rates in patients with joint arthroplasty, especially in elective knee arthroplasty. Further evaluations are needed

Aim. Following clean (class I, not contaminated) surgical procedures, the rate of surgical site infection (SSI) should be less than approximately 2%. However, an infection rate of 12.2% has been reported following removal of orthopedic implants used for treatment of fractures below the knee. The objective of this trial was to evaluate the effect of a single dose of preoperative antibiotic prophylaxis on the incidence of SSIs following removal of orthopedic implants used for treatment of fractures below the knee. Method. This multicenter, double-blind, randomized clinical trial included 500 patients from 19 hospitals with a follow-up of 6 months. Eligible were patients aged 18 to 75 years with previous surgical treatment for fractures below the knee who were undergoing removal of orthopedic implants. Exclusion criteria were an active infection or fistula, antibiotic treatment, reimplantation of osteosynthesis material in the same session, allergy for cephalosporins, known kidney disease, immunosuppressant use, or pregnancy. The intervention was a single preoperative intravenous dose of 1000 mg of cefazolin (cefazolin group, n = 228) or sodium chloride (0.9%; saline group, n = 242). Primary outcome was SSI within 30 days as measured by the criteria from the US Centers for Disease Control and Prevention. Secondary outcome measures were functional outcome, health-related quality of life, and patient satisfaction. Results. Among 477 randomized patients (mean age, 44 years [SD, 15]; women, 274 [57%]; median time from orthopedic implant placement, 11 months [interquartile range, 7–16]), 470 patients completed the study. Sixty-six patients developed an SSI (14.0%): 30 patients (13.2%) in the cefazolin group vs 36 in the saline group (14.9%) (absolute risk difference, −1.7 [95% CI, −8.0 to 4.6], P = .60). Conclusions. In patients undergoing surgery for removal of orthopedic implants used for treatment of fractures below the knee, a single preoperative dose of intravenous cefazolin compared with placebo did not reduce the risk of surgical site infection within 30 days following implant removal

Aim. Orthopedic implant related surgical site infection (SSI) is a severe complication which represents an important challenge concerning to its treatment. Therefore, gram-negative orthopedic infections have recently become a global concern. Method. Retrospective study through searching of the SCIH (infection control service) database, concerning to the year 2016 and 2017. Cases selected were those of implant placement clean surgeries (osteosynthesis or prosthetic placement) which evolved with SSI and Gram-negative bacterial growth in bone tissue or periprosthetic cultures. Results. During 2016 and 2017, 6150 clean surgeries with orthopedic implant placement were performed; 140 fulfilled SSI criteria (83 cases of open fracture reduction, 44 of hip arthroplasty, 13 of knee arthroplasty). Main agent of infections was Staphylococcus aureus (32,47%) mostly of them methicillin-sensitive (69,20%). However, Gram-negative bacteria were responsible for 64,95% of infections. (Klebsiella pneumoniae 12.8%; Acinetobacter baumannii and Enterobacter ssp 11.96%; Pseudomonas aeruginosa 9.40%) Among them, 100% Enterobacter ssp. were sensitive to carbapenems and 75% to ciprofloxacin. Klebsiella pneumoniae showed sensitivity to carbapenems in 85.7%, Pseudomonas aeruginosa showed sensitivity in 85.7% to carbapenems and 100% to ciprofloxacin. Acinetobacter baumannii showed the least favorable profile amongst Gram-negatives since only 12.5% of strains were sensitive to carbapenems, 28.6% to Ampicilin-sulbactam, 22.2% to ciprofloxacin, while showing 100% sensitivity to polymyxins. 14 patients in whom Acinetobacter baumannii was isolated were predominantly elderly (median 70 years), most of them have underlying/chronic diseases (71.42%) such as diabetes, arterial hypertension, alcoholism, smoking and heart failure. None presented sepsis related to this infection, but four of them died as result of hospitalization related complications (28,60% mortality rate). Among these deaths, 3 were related to total hip arthroplasty, and one to knee arthroplasty. One patient died as result of external causes. Among the survivors, five showed remission/cure. The follow up was lost in 4 patients. Conclusions. SSI caused by carbepenem-resistant Acinetobacter baumannii represents considerable impact on morbi-mortality in patients who undergo surgery with placement of orthopedic implants

Aim. Determine the incidence of surgical site infections (SSI) after intramedullary nailing (IN) of femoral and tibial diaphyseal fractures and evaluate possible risk factors. Method. Prospective observational cohort study. SSI was defined according to CDC-NHSN criteria and surveillance period for the occurrence of infection was 12 months instead of the 90 days currently recommended. Incidence was calculated as the ratio between the number of patients with SSI and total number of patients. Analysis of potential risk factors included patients-related factors (age, gender, body mass index, active foci of infection, immunosuppressive conditions, ASA score, alcohol or illicit drug abuse, smoking, polytrauma, etiology of fracture, type of fracture if closed or open, classification of fracture according to Müller AO, Tcherne classification for closed fractures, Gustilo-Anderson classification and duration of bone exposure for open fractures, previous stay in other healthcare services, use of external fixator, previous surgical manipulation at same topography of fracture, use of blood products); environmental and surgical-related factors (surgical wound classification, duration of surgery, hair removal, intraoperative contamination, antimicrobial use, presence of drains, hypothermia or hypoxia in the perioperative period, type of IN used, reaming, need for muscle or skin flap repair, use of negative pressure therapy) and microbiota-related factors (presence of preoperative colonization by Staphylococcus aureus or Acinetobacter baumannii). Results. 221 patients were included and completed the 12-month follow-up period. Incidence of SSI was 11.8% after 12-month follow-up, but would be 8.59% if used the 90-day vigilance period currently recommended. In the initial analysis by unadjusted logistic regression, following factors were associated SSI: Müller AO classification of the fracture morphology groups 2 or 3, previous use of external fixator, presence of drains, use of negative pressure therapy and need for muscle or skin flap repair. Preoperative colonization by S. aureus or A. baumannii was not associated with occurrence of infection. In the multiple logistic regression-adjusted analysis, only previous use of external fixator and need for muscle or skin flap repair remained associated with SSI. Conclusions. Incidence of SSI associated with IN for femoral and tibial diaphyseal fractures was 11.8%, but currently recommended vigilance period would be less sensitive for SSI detection after fracture fixation. Previous use of external fixators and need for muscle or skin flap repair were factors associated with occurrence of IN related infection

Aim. Nasal colonization with S.aureus (SA) is a risk factor for developing nosocomial infections in cardiac surgery. However, the risk in orthopedic surgery remains unclear, especially in adolescent idiopathic scoliosis (AIS) surgery were data are missing. This study aims to evaluate the efficacy of a preoperative nasal decontamination program in SA healthy carriers on early surgical site infections (SSI) after AIS posterior surgery in a pediatric universitary Parisian hospital. Method. Between 01-01-2014 and 03-31-2017, all AIS patients were screened preoperatively with nasal swabs and decontaminated with mupirocine if positive during the 5 days before surgery. Early SSI were prospectively identified and microorganisms' findings were compared to a previous serie published before the beginning of the decontamination program (2007–2011). Results. Among the 316 AIS posterior procedures performed during the study period, nasal swabs were performed at the average of 100 ± 92 days before surgery. Incidence of positive nasal swab was 22 % (n=71) and all were preoperatively decontaminated. Compared to the series (n=496) published before the decontamination program, the early SSI rate remains stable (8.2% versus 8.5%). But incidence of S.aureus early SSI decreased to 1% (n=4), while it represented 5% (n=25) in the previous study. In our study, none of the S. aureus decontaminated patients had an early S.aureus SSI. For the 4 S.aureus early SSI, preoperative nasal swab was negative, but done with a mean delay of 328 days before surgery, suggesting a possible S.aureus intermittent carriage and the need of shorter delays between nasal swab and surgery to improve the screening. Moreover, the stable rate of early SSI between the 2 periods is due to an increase rate of Propionibacterium acnes, which incidence grown from 0.08% to 6% in our actual series. Conclusions. To conclude, in our study, nasal decontamination divided by 5 the incidence of S.aureus SSI. It seems that nasal swabs should be performed as close as possible to the surgery to optimise the S.aureus screening. In addition, the SSI rate remains very high with the emergence of Propionibacterium acnes and is currently addressed by a multifactorial approach

Current perception is that standard Cefuroxime only [C4] based prophylaxis regimen demonstrated higher association with C Difficile (C. Diff) diarrhoea. This has prompted change in antibiotics prophylaxis combination regimens like Flucloxacillin-Gentamycin (F-G], Teicoplanin- Gentamycin [T-G] and single dose Cefuroxime-Gentamycin [C-G]. The current study was done to investigate the association of C. Diff diarrhoea and surgical site infection (SSI) rate with Cefuroxime only regimen prophylaxis in fracture neck of femur surgery. A retrospective analysis for 2009–2012 was performed for 1502 neck of femur fracture patients undergoing surgery. The factors studied were ASA grade, SSI, C. Diff diarrhoea rates in patients with Cefuroxime (induction plus two doses) based prophylactic regimen. The data was obtained from coding department and further streamlined based on microbiology. 1242 patients were included in the study who received Cefuroxime only regimen. The Male : Female distribution was 353 : 889. The average ASA grade was 3. The analysis demonstrated that C. Diff diarrhoea rate in the study population was 1.29%. The SSI rate stood at 3.06% with superficial infection at 2.5 % and deep at 0.56 %. Our single centre based study demonstrated low C. Difficile related diarrhoea rates with Cefuroxime only regimen. The SSI rates were also low as compared to the current literature thus concluding that Cefuroxime only antibiotic regimen can safely be administered in neck of femur surgery

Most long-term follow-up studies report retrospective data, the quality of which remains limited due to their inherent biases. Prospective databases may overcome these limitations, however, feasibility and costs limit their application. To date there exists a paucity of evidence-based literature on which recommendations can be made for the ideal length of follow-up for spinal deformity research. Therefore, our aim was to evaluate the added value of follow-up of patients beyond 2 years following surgery for AIS. A database registry evaluating surgical outcomes for all consecutive AIS patients with post-op data-points of 6 months, 1 year, 2 year, and 5 year was analysed. Surgeon-reported complications, SRS-22 scores, and radiographic data were evaluated. Complications requiring surgical or medical intervention were compared between patients in whom complications developed within 2 years to those in which newly developed complications occurred between >2–5 years. 536 patients were analysed. SRS-22 scores significantly improved at 2 years post-op with no change at 5-year follow-up. Overall complication rate was 33.2% with majority occurring within 2 years (24.8%). The rate of complications occurring >2–5 years requiring intervention was significantly lower than those requiring intervention within 2 years of surgery (4.7% vs 9.7%, p=0.000), however was not negligible. The most common newly observed complication beyond 2 years was pain (1.9%), followed by surgical site infection (SSI) (1.3%) and implant issues (0.56%). There were no significant differences in the rates of crankshaft (p=0.48), implant issues (p=0.56), pseudarthrosis (p=0.19), and SSI (p=0.13) between the 2 time points. Although majority of complications following AIS surgery occurs within 2 years, a non-negligible rate of newly observed complications occur at >2–5 years post-op. Specifically crankshaft, pseudarthrosis, implant issues, and SSI have similar rates of occurrence at these 2 time points

Aim. The incidence of fractured neck of femur (FNOF) is increasing yearly. Many of these patients undergo hip hemiarthroplasty. High dose dual-antibiotic cement (HDDAC) has been shown to reduce rates of deep surgical site infection (SSI) when compared to the current standard low dose single-antibiotic cement (LDSAC) in a quasi-randomised controlled trial. Some concerns exist regarding the use of HDDAC and the development of resistance. We reviewed cases of infection in LDSAC and HDDAC bone cement with regard to causative organism and resistance profile. Method. A retrospective analysis was undertaken of all hemiarthroplasties within our trust from April 2008 to December 2014. We identified all patients in this time period who acquired a deep SSI from the trust SSI surveillance database. The infecting organisms and susceptibility patterns were collated for each cement. Results. We identified 1941 hemiarthroplasties. There were 36 deep surgical site infections representing an infection rate of 3.1% in LDSAC patients and 1.2% in HDDAC patients. A wider variety of organisms were seen in the LDSAC compared to HDDAC. Staphylococcus epidermidis accounted for the majority of infections in both LDSAC and HDDAC patients. Infection with Corynebacterium species and Staphylococcus aureus was eliminated completely in HDDAC. There was minimal change in the proportion of Gram-negative and Gram-positive bacteria. A change in resistance was not demonstrated amongst infections caused by Gram-negative bacteria. In Gram-positive bacteria, resistance to a number of antibiotics increased using HDDAC compared to LDSAC, most notably to clindamycin and gentamicin within the coagulase negative staphylococci. However, levels of resistance remained low to teicoplanin, vancomycin, daptomycin, linezolid and rifampicin. Conclusions. A lower infection rate was seen in HDDAC. Direct comparison demonstrated changes in resistance profiles caused by Gram-positive organisms. 24,000 patients undergo hip hemiarthroplasty annually. Extrapolating our results to this cohort would demonstrate 744 infections in LDSAC and 288 infections in HDDAC. Of these, resistance to both clindamycin and gentamicin would be seen in 180 patients with LDSAC and 177 patients with HDDAC. Overall, this review supports the continued use of HDDAC in FNOF patients. High dose dual antibiotic cement = Copal G+C, Heraeus Medical, UK. Low dose single antibiotic cement = Palacos R+G, Heraeus Medical, UK

Aim. Surgical site infection (SSI) is associated with substantial morbidity, mortality and economic burden. Management of spinal SSI is becoming more challenging especially in instrumented cases, but is not well recognized as high risk procedure. The objective of this study was to determine the impact of procedure type comparing SSI risk with arthroplasties among all orthopaedic procedures. Method. Using prospectively collected data of consecutive samples in multi-center orthopedic SSI surveillance, we explored the differences in SSI rates within 30 days after surgery by procedure types. Patients who underwent surgery of single site between November 2013 and May 2016 were enrolled. SSI was our primary outcome. Urinary tract infection (UTI), and respiratory tract infection (RTI) were also evaluated. The definition of SSI was based on the CDC definition with slight modifications. All patients were followed for 30 days postoperatively. Multivariate logistic regression analyses were done, and variables were carefully selected for adjustments. Results. In total 8,907 single site surgeries were analyzed. There were four major procedure types, fracture repair 31%, arthroplasty 30%, spinal surgery without instrumentation 14.7% and spinal instrumentation surgery 13%. Patient backgrounds were male 41.4%, diabetes 13.5%, rheumatoid arthritis 3.8 %, present smoker 13.4%, mean BMI 23+4, and operative time 144+92 minutes. Cefazolin was administered in more than 98% of all cases, and were administered appropriately before surgery. SSI occurred in 102 cases (1.2%), and the SSI rates were 2.5% in spinal instrumentation surgery and 0.6% in arthroplasty. After adjustment with several clinically relevant variables such as age, sex, diabetes and ASA, spinal instrumentation surgery was the only procedure which remained significant with adjusted odds ratio (aOR) of 3.3 (1.8–6.2, P<0.01) compared with arthroplasties. The risk remained stable after adding further clinically relevant variables (aOR of 2.2 to 3.3). The risk was not significant for spinal surgery without instrumentation (aOR, 1.8; 0.9–3.5, P=0.10). Moreover, the risk of spinal instrumentation surgery was highest for UTI (aOR, 4.7; 2.9–7.6), P<0.01) and RTI (aOR, 3.7; 1.6–8.9), P<0.01) among all procedures. Conclusions. From our study, spinal instrumentation surgery was the only procedure to be significant after multivariate analysis, and the risk for SSI remained 2.2 to 3.3 fold higher compared with arthroplasties. The risk was also highest for several other major healthcare-associated infections. Considering the disastrous consequences, more interests and improvements in total perioperative care are needed for this procedure

Aim. This study aimed to identify risk factors for development of deep periprosthetic joint infection (PJI) in patients following surgical treatment of neck of femur fracture. Method. This study identified a consecutive series of 2,822 (2,052 female, 73%) patients who underwent either hemiarthroplasty (n=1,825, 65%) or fixation (DHS) (n=997, 35%) for fractured neck of femur performed between January 2009 and June 2015 at our institution. Full patient demographics, co-morbidity and peri-operative complication data were determined. The majority of patients were either ASA 2 (n=663, 23%) or ASA 3 (n=1,521, 54%), mean age = 81.3 years (SD 10.3). All patients were followed up post-operatively by a dedicated surgical site infection (SSI) monitoring team in order to identify patients who developed a PJI within 1 year. A stepwise multivariable logistic regression model was used to identify patient and surgical factors associated with increased risk of infection. Predictors with a p-value of <0.20 in the univariate analysis were included in the multivariate analysis. Results. Thirty-nine (39) cases of deep periprosthetic infection were identified (hemiarthroplasty n=35, DHS n=4) representing an overall deep infection rate of 1.4% (hemiarthroplasty 1.9%, DHS 0.4%). The most common infecting pathogen was a pure growth of coagulase negative Staphylococcus (n=9, 23%) followed by a pure growth of Staphylococcus aureus (n=7, 18%). An increased risk of PJI was observed in patients who underwent hemiarthroplasty compared to those treated by fixation (odds ratio (OR) 6.50, 95%CI 2.26 – 18.7, p=0.001). Of patient factors, only blood transfusion within 30 days (OR 3.51, 95%CI 1.72 – 7.13, p=0.001) and the presence or development of pressure sores on or during admission (OR 2.99, 95%CI 1.24 – 7.19, p=0.015) were significantly associated with an increased risk of development of PJI. Use of high-dose dual antibiotic cement (gentamicin and clindamycin) was associated with a two-fold reduction in the risk of PJI (OR 0.39, 95%CI 0.20 – 0.76, p=0.005) vs standard dose gentamicin antibiotic cement. Conclusions. This study found: 1) a deep infection rate similar to that reported earlier from large number studies from the UK, 2) a six-fold higher deep infection rate in hemiarthroplasties, compared to internal fixations, and 3) a three-fold higher infection rate in patients who suffer concomitant pressure sores or receive a blood transfusion up to 30 days post-operatively