Prevention and Management of Wound Infections in Burn Patients.

The leading cause of morbidity in burn patients is infection with pneumonia, urinary tract infection, cellulitis, and wound infection being the most common cause. High mortality is due to the immunocompromised status of patients and abundance of multidrug-resistant organisms in burn units. Despite the criteria set forth by American Association of Burn, the diagnosis and treatment of burn infections are not always straightforward. Topical antimicrobials, isolation, hygiene, and personal protective equipment are common preventive measures. Additionally medical and nutritional optimization of the patients is crucial to reverse the immunocompromised status triggered by burn injury.

Intramedullary Nailing of Intertrochanteric Femoral Fractures in a Level I Trauma Center in Finland: What Complications Can be Expected?

BACKGROUND: Intertrochanteric hip fractures are one of the most common fractures in older people, and the number is estimated to increase. These fractures are often treated with intramedullary nailing; however, various complications have been reported. It is important to identify the potential complications and investigate whether the choice of implant and patient-related factors are associated with the risk of complications to develop better strategies for preventing them. QUESTIONS/PURPOSES: (1) In the treatment of intertrochanteric fractures with intramedullary nailing, what are the risks of major complications and 30-day mortality? (2) Which implant types are associated with greater odds of major complications? (3) Which patient-related factors are associated with increased odds of major complications? METHODS: In this retrospective, comparative study, we reviewed the health records of 2397 patients with a femoral fracture treated at one Level I trauma center between January 2014 and November 2020. Of those, we considered patients who were treated with intramedullary nailing for an intertrochanteric fracture after sustaining a low-energy injury as potentially eligible. Based on this criterion, 53% (1279) were eligible; a further 47% (1118) were excluded because the fixation method was other than intramedullary nailing, the fracture pattern was other than intertrochanteric fracture, or the fracture was caused by a high-energy injury mechanism. Another 4% (97) were excluded because they had incomplete datasets because of follow-up less than 12 months, leaving 49% (1182) for analysis. During the study period, intramedullary nails were generally used to treat nearly all intertrochanteric fractures at our hospital. The risk of complications was then assessed by chart review. Acute myocardial ischemia, cutout, nail breakage, pulmonary embolism, sepsis, stroke, and wound infection were defined as major complications. Cutout, nail breakage, and wound infection were defined as major complications leading to reoperation. To examine the association of implant type and major complications, a logistic regression analysis was performed. Additionally, the risks of major complications leading to reoperation were compared between implants. Finally, a univariable logistic regression analysis was performed to examine the association between patient-related factors and major complications. RESULTS: The overall proportion of patients experiencing complications was 16% (183 of 1182), and the crude percentage of 30-day mortality was 9% (107 of 1182) based on the hospital`s medical records. After controlling for patient-related factors such as disease, age, and smoking, we found that nail type was not associated with odds of major complications leading to reoperation (Gamma3: OR 0.86 [95% CI 0.44 to 1.67]; p = 0.67; Trochanteric Fixation Nail: OR 0.61 [95% CI 0.2 to 1.53]; p = 0.33; Proximal Femoral Nail Antirotation: OR 0.55 [95% CI 0.16 to 1.49]; p = 0.29) compared with the Trochanteric Fixation Nail Advanced. Anticoagulation (OR 1.70 [95% CI 1.11 to 2.59]; p = 0.01), congestive heart failure (OR 1.91 [95% CI 1.13 to 3.11]; p = 0.01), and hypertension (OR 1.67 [95% CI 1.08 to 2.63]; p = 0.02) were associated with a major complication. Liver disease (OR 5.19 [95% CI 0.78 to 20.8]; p = 0.04) was associated with a major complication leading to reoperation. CONCLUSION: This study provides a better understanding of the occurrence of surgical and medical complications after intramedullary nailing of intertrochanteric fractures. The new-generation nail types are comparable options based on the risk of reoperation. Anticoagulation, congestive heart failure, and hypertension were associated with major complications, highlighting the need for careful management and monitoring of these comorbidities during intramedullary nailing procedures.Level of Evidence Level III, therapeutic study.

The influence of different peritoneal dialysis techniques on wound infection in patients with peritoneal dialysis tube.

More and more research has started to investigate the effect of peritoneal dialysis treatment on the incidence of pericatheter wound complications in chronic kidney disease (CKD). This meta-study evaluated the effect of emergency peritoneal dialysis (EPD) with conventional peritoneal dialysis (CPD) in patients with catheter-related complications. We looked up 4 databases: PubMed, EMBASE, Cochrane, and Web of Science, and analysed the data with RevMan 5. There were a total of 15 studies with 3034 participants. While the quality of the research included was fairly good, the evidence was mediocre. In the meta-analyses, the risk of leak in the conduit with PD was very high (OR, 2.48; 95% CI, 1.72, 3.59, p < 0.00001). However, for those treated with urgent medical method prior to initiation of PD, the risk for peritonitis, catheter dysfunction and bleeding was similar compared with CPD. Based on limited information, immediate initiation of PDs is advised in order to increase the quality of life for people in urgent need, except if there is no consideration for loss of fluid. The low quality of the evidence is holding up the evidence. This research, however, is also informative because of the large number of available data. Consequently, additional high quality, large, randomized controlled studies are required to establish.

[Analysis of the postoperative outcome of 81 cases of nasal reconstruction with direct closure]. / Analyse des postoperativen Verlaufs nach 81 Dehnungsplastiken an der Nase.

BACKGROUND: Direct wound closure (side-to-side closure) for closing nasal defects, is controversially discussed. Yet, data supporting one or the other are lacking. MATERIAL AND METHOD: An explorative, partly retrospective, partly prospective observational study including 81 patients was carried out for assessment of the operative results of after direct wound closure stretching rhinoplasty. The occurrence of complications, the esthetic result and influencing factors were examined. To assess the esthetic result the patient and observer scar assessment scale (POSAS) scores of patients and observers were determined. In both scores seven values were determined (1 point normal skin, 10 points worst imaginable scar). The individual values were added to give a total value (minimum 7-maximum 70). RESULTS: After direct wound closure stretching rhinoplasty, 12 out of 81 patients (15 %) developed complications, in 5 cases suture dehiscence, in 5 cases cyst formation, in 4 cases a wound infection and 2 patients developed cyst formation and a wound infection. All suture dehiscences occurred on the lower third of the nose. Most of the patients were satisfied and assessed the scar with an average total value of 13.4 ± 7.07 (minimum 7, maximum 70, n = 42). In the individual assessments pain (1.14 ± 0.57; minimum 1, maximum 10) was rated best and scar color (2.50 ± 1.76; minimum 1, maximum 10) was rated worst. The total assessment in the observer-POSAS was also good with 12.9 ± 4.8 (minimum 7, maximum 70; n = 32). Elasticity was rated best (1.47 ± 0.88; minimum 1, maximum 7) and scar pigmentation (2.34 ± 1.54; minimum 1, maximum 7) worst. No correlations with a complication were found. CONCLUSION: Direct wound closure stretching rhinoplasty is a safe method, especially for defect coverage in the upper two thirds of the soft tissue covering the nose, which in most cases achieved a good cosmetic result.

Hemithyroidectomy, does the indication influence the outcome?

PURPOSE: Hemithyroidectomies are mainly performed for two indications, either therapeutically to relieve compression symptoms or diagnostically for suspicious nodule(s). In case of the latter, one could consider the approach to be rather extensive since the majority of patients have no symptoms and will have benign disease. The aim of this study is to investigate the complication rates of diagnostic hemithyroidectomy and to compare it with the complication rates of compressive symptoms hemithyroidectomy. METHODS: Data from patients who had undergone hemithyroidectomy either for compression symptoms or for excluding malignancy were extracted from a well-established Scandinavian quality register (SQRTPA). The following complications were analyzed: bleedings, wound infections, and paresis of the recurrent laryngeal nerve (RLN). Risk factors for these complications were examined by univariable and multivariable logistic regression. RESULTS: A total of 9677 patients were included, 3871 (40%) underwent surgery to exclude malignancy and 5806 (60%) due to compression symptoms. In the multivariable analysis, the totally excised thyroid weight was an independent risk factor for bleeding. Permanent (6-12 months after the operation) RLN paresis were less common in the excluding malignancy group (p = 0.03). CONCLUSION: A range of factors interfere and contribute to bleeding, wound infections, and RLN paresis after hemithyroidectomy. In this observational study based on a Scandinavian quality register, the indication "excluding malignancy" for hemithyroidectomy is associated with less permanent RLN paresis than the indication "compression symptoms." Thus, patients undergoing diagnostic hemithyroidectomy can be reassured that this procedure is a safe surgical procedure and does not entail an unjustified risk.

Infections in Burn Patients.

Infections are the leading cause of mortality in burn patients who survive their initial resuscitation. Burn injury leads to immunosuppression and a dysregulated inflammatory response which can have a prolonged impact. Early surgical excision along with support of the multidisciplinary burn team has improved mortality in burn patients. The authors review diagnostic and therapeutic challenges as well as strategies for management of burn related infections.

Robotic Ventral Hernia Repair and Concomitant Procedures: Mid-term Outcomes and Risk Factors Associated With Postoperative Complications.

BACKGROUND: Ventral hernia remains as one of the most performed procedures worldwide. With the aging of the population and increasing comorbidities, it is common for ventral hernia to coexist with other pathologies that require surgery. Patients may opt for concomitant repairs while undergoing ventral hernia surgery. Therefore, the purpose of this study is to investigate the clinical outcomes of robotic ventral hernia repair (RVHR) in patients undergoing concomitant repairs. MATERIALS AND METHODS: Patients who underwent RVHR with concomitant repairs over a period of 9 years were included in this retrospective study. Pre, intra, and postoperative variables including the patient's demographics, hernia characteristics, complications, and hernia recurrence were reported. Univariate analysis was performed to evaluate potential variables associated with increased risk of postoperative complications. RESULTS: A total of 109 (33% females) patients were included in this study. Mean age and body mass index were 59.9±12.7 years and 30.5±5.7 kg/m 2 , respectively. Concomitant repairs were mostly abdominal wall procedures (inguinal hernia repairs, 88.1%). Other procedures included nonabdominal wall surgeries. Incisional hernia repairs were higher than primary repairs (55% vs 45%, respectively). Median operative time and hospital length of stay were 145 min (102 to 245) and 1 day (0 to 1), respectively. Mean postoperative follow-up was 39.2 (4.1 to 93.6) months. In total, 24 patients had postoperative complications, out of which 16 (14.7%) were Clavien-Dindo grade I and II, and 10 (9.2%) were grade III and IV. Nine patients had surgical site events, and two recurrences were recorded. Postoperative complications were associated with incisional hernias [Odds ratio (OR)=8.4; P =0.003; 95% CI=2.092-33.423], nonabdominal wall concomitant procedures (OR=5.9; P =0.013; 95% CI=1.453-24.451), and history of wound infection (OR=3.473; P =0.047; 95% CI=1.016-11.872). CONCLUSIONS: This is the first study to report outcomes of concomitant repairs with RVHR, with notable Clavien-Dindo grade III and IV complications of 9%. Incisional hernia repairs, nonabdominal wall procedures, and a history of wound infection were risk factors for postoperative complications.

A nutritional screening threshold for optimal outcomes after Hartmann's reversal.

PURPOSE: Determining is nutritionally replete enough for Hartmann's reversal (HR) can be controversial and multifactorial. While there are many preoperative nutritional screening tools, the impact of malnourishment on HR has not been evaluated. The study aims to clarify how often patients undergoing HR are high risk for malnourishment at the time of surgery and how this impacts postoperative outcomes. METHODS: From 2012-2019, all elective HRs were identified in ACS-NSQIP. Patients were categorized in a malnourished group if they met one of the following criteria: (1) BMI < 18.5 kg/m2, (2) albumin < 3.5 g/dL, or (3) > 10% body weight loss in the last 6 months. Bivariate associations of preoperative demographics and postoperative outcomes were analyzed. Multivariable logistic regression was performed to identify independent predictors for 30-day mortality and organ space wound infection. RESULTS: 8878 procedures were evaluated (well-nourished = 7116 and malnourished = 1762). The malnourished group had higher mortality (p < 0.001), shorter operating time (p < .001), longer length of stay (p = 0.016), and higher rates of infection (p = 0.011), reintubation (p = 0.002), bleeding (p < 0.001), sepsis (p = 0.001), and reoperation (p = 0.018). In multivariate regression models, malnourishment was an independent predictor for mortality (OR = 2.72, p < 0.001) and wound infection (OR = 1.19, p = 0.028). CONCLUSION: A large percentage of patients undergoing HR were classified as being high-risk for malnutrition. Malnourishment was associated with some worse postoperative compilations including death and wound infection. Surgeons should routinely use preoperative screening for malnutrition to identify and attempt to optimize nutritional status prior to undergoing Hartmann's Reversal.

Outcomes of perineal reconstruction with inferior gluteal artery myocutaneous flaps and primary closure following abdominoperineal resection.

BACKGROUND: Perineal wound morbidity following abdominoperineal resection (APR) is a significant challenge. Myocutaneous flap-based techniques have been developed to overcome morbidity associated with perineal reconstruction. We reviewed outcomes for patients undergoing APR in a hospital that performs inferior gluteal artery myocutaneous (IGAM) island transposition flaps and primary closure (PC) for perineal reconstruction. METHODS: A retrospective study of patients who underwent APR for malignancy between January 2012 and March 2020 was performed and outcomes between IGAM reconstruction and PC compared. Primary outcomes were wound infection and dehiscence. Secondary outcomes included return to theatre, operative time, length of stay, flap loss and perineal hernia incidence. RESULTS: One-hundred and two patients underwent APR, with 50 (49%) who had PC and 52 (51%) had IGAM flap reconstructions. There were no differences between each group with regards to wound infection (23 vs. 22%, P = 0.55) or wound dehiscence (25 vs. 24%, P = 0.92). Thirteen (25%) IGAM patients required a return to theatre compared to three PC patients (6%) (P = 0.008). IGAM procedures required twice the overall operative time (506 vs. 240 min, P = 0.001) with no differences between groups when comparing the APR component (250 vs. 240 min, P = 0.225). The IGAM group had a longer length of stay (median 13 days vs. 9 days, P = 0.001). Only one IGAM flap was lost and no symptomatic hernias were identified. CONCLUSION: Perineal closure technique did not affect the incidence of wound infection or dehiscence. Closure technique should be tailored to underlying patient characteristics and surgical pathology.

Disease Progression After Unicompartmental Arthroplasty: Add a Compartment or Revise to Total Knee Arthroplasty?

BACKGROUND: Five percent to 7% of unicompartmental knee arthroplasties (UKA) require revision for disease progression in untreated compartment(s), most commonly to total knee arthroplasty (TKA). TKA requires removal of bone and usually the anterior cruciate ligament. Preserving the UKA and converting to a bicompartmental arthroplasty (BCA) by performing a second UKA is an alternative. METHODS: The results of 73 UKA-BCA patients were compared to 75 patients treated by UKA-TKA revision. Knee Society, Knee Osteoarthritis Outcome Score Joint Replacement, and patient satisfaction scores were collected by a blinded therapist. Patients were asked about their implant preference and recovery. Twenty-two UKA-BCA revision patients had a UKA (6) or TKA (16) in the contralateral knee; thus, a direct comparison of UKA-BCA to both UKA and TKA was possible. RESULTS: Of the UKA-BCA patients, 69 (94%) had excellent or good, 2 (3%) fair, and 2 (3%) poor outcomes with 1 patient requiring revision to TKA. Of patients with a TKA in the contralateral knee, 13 (81%) preferred the UKA-BCA replacement and 3 (19%) preferred the TKA. All patients said the UKA-BCA revision recovery was similar or easier than their initial UKA. Of UKA-TKA revisions, 59 (79%) had excellent or good, 9 (12%) fair, and 7 (9%) poor outcomes. There was 1 wound infection and 1 re-revision in the UKA-BCA group and 1 wound infection and 3 re-revisions in the UKA-TKA group. The Knee Osteoarthritis Outcome Score Joint Replacement and Knee Society Scores were better for UKA-BCA compared to UKA-TKA. CONCLUSION: UKA-BCA is a successful treatment for disease progression following UKA.

DoD-VA Trauma Infection Research Collaboration.

BACKGROUND: In the aftermath of wars, there is a surge in the number of wounded service members who leave active duty and become eligible for healthcare through the Department of Veterans Affairs (VA). Collaborations between the Department of Defense (DoD) and VA are crucial to capture comprehensive data and further understand the long-term impact of battlefield trauma. We provide a summary of the development, methodology, and status of an effective collaboration between the Infectious Disease Clinical Research Program and the St. Louis VA Health Care System with the multicenter, observational Trauma Infectious Disease Outcomes Study (TIDOS), which examines the short- and long-term outcomes of deployment-related trauma. METHODS: As part of TIDOS, wounded service members who transitioned to participating military hospitals in the United States (2009-2014) were given the opportunity to enroll in a prospective follow-up cohort study to continue to capture infection-related data after their hospital discharge. Enrollees in the TIDOS cohort who left military service and received health care through the VA also had the option of consenting to have relevant VA medical records abstracted and included with the study data. Infections considered to be complications resulting from the initial trauma were examined. RESULTS: Among 1,336 TIDOS enrollees, 1,221 (91%) registered and received health care through the VA with 633 (47%) consenting to follow-up using VA records and comprising the TIDOS-VA cohort. Of the first 337 TIDOS-VA cohort enrollees, 38% were diagnosed with a new trauma-related infection following hospital discharge (median: 88 days; interquartile range: 18-351 days). Approximately 71% of the infections were identified through DoD sources (medical records and follow-up) and 29% were identified through VA electronic medical records, demonstrating the utility of DoD-VA collaborations. The TIDOS DoD-VA collaboration has also been utilized to assess intermediate and long-term consequences of specific injury patterns. Among 89 TIDOS-VA cohort enrollees with genitourinary trauma, 36% reported sexual dysfunction, 21% developed at least one urinary tract infection, 14% had urinary retention/incontinence, and 8% had urethral stricture. The rate of urinary tract infections was 0.05/patient-year during DoD follow-up time and 0.07/patient-year during VA follow-up time. CONCLUSIONS: Wider capture of infection-related outcome data through the DoD-VA collaboration provided a clearer picture of the long-term infection burden resulting from deployment-related trauma. Planned analyses include assessment of osteomyelitis among combat casualties with amputations and/or open fractures, evaluation of mental health and social factors related to injury patterns, and examination of health care utilization and cost in relation to infectious disease burdens.

Impact of delayed sternal closure on wound infections following neonatal and infant cardiac surgery.

OBJECTIVES: Delayed sternal closure is a routine procedure to reduce hemodynamic and respiratory instability in pediatric patients following cardiac surgery, particularly in neonates and infants. In this setting, the possible links between sternal wound infection and delayed sternal closure are still a matter of debate. As a part of our routine, there was a low threshold for delayed sternal closure, so we reviewed our experience with sternal wound infections with a focus on potentially related perioperative risk factors, particularly delayed sternal closure. METHODS: We retrospectively identified 358 operated neonates (37%) and infants (mean age 3.6 months) in our local congenital heart disease database between January 2013 and June 2017. Potential risk factors for sternal wound infections, such as age, gender, complexity (based on Aristotle- and STS-EACTS mortality category), reoperation, use of cardiopulmonary bypass, extracorporeal membrane oxygenation, mortality and delayed sternal closure (163/358, 46%), were subjected to uni- and multivariate analysis. RESULTS: A total of 26/358 patients (7.3%) developed a superficial sternal wound infection. There were no deep sternal wound infections, no mediastinitis or sepsis. Applying univariate analysis, the prevalence of sternal wound infections was related to younger age, more complex surgery and delayed sternal closure. However, in multivariate analysis, sternal wound infection was only associated with delayed sternal closure (p = 0.013, odds ratio 8.6). Logistic regression revealed the prevalence of delayed sternal closure to be related to younger age, complexity, and the use of extracorporeal membrane oxygenation. CONCLUSION: In patients younger than one year, sternal wound infections are clearly related to delayed sternal closure. However, in our cohort, all sternal wound infections were superficial and acceptable, considering the improved postoperative hemodynamic stability.

A systematic review and meta-analysis comparing complications following total hip arthroplasty for systemic lupus erythematosus versus for non-systemic lupus erythematosus.

BACKGROUND: Osteonecrosis of the femoral head is one of the most severe complications in systemic lupus erythematosus (SLE) patients. Total hip arthroplasty (THA) is an effective treatment for femoral head necrosis. However, there is no consensus on the specific effect of THA on SLE patients. The objective of the present study was to review the current evidence regarding rates of THA complications and postoperative function in systemic lupus erythematosus. METHODS: Two independent reviewers searched PubMed, Cochrane Library, and EMBASE from January 1, 2000, to December 29, 2021. The primary outcomes were postoperative complications, including deep vein thrombosis (DVT), hematoma, wound infection, dislocation, periprosthetic fracture, revision, mortality. RESULTS: A total of 179 articles yielded 28 studies eligible for inclusion with 10 studies used for meta-analysis. This study found a statistically significant difference in DVT, dislocation, wound infection, periprosthetic fracture, and revision. CONCLUSIONS: This meta-analysis shows that SLE patients with THA are at an increased risk of DVT, wound infection, dislocation, periprosthetic fracture, revision, periprosthetic joint infection, following THA in comparison with non-SLE patients with THA. There was no adequate evidence to support the notion that the risk of seroma or hematoma following THA is increased in SLE. Also, there was no significant difference in HHS scores between SLE patients and non-SLE patients after THA.

[The golden period for suturing of traumatic wounds].

Traumatic lacerations are a common reason for seeking care at the emergency departments. Clinical guidelines for treatment of traumatic lesions are not the same at all hospitals. Traumatic lacerations are often sought to be sutured within six hours which is characterized as the "golden period". However, this rule is based on an animal experiment conducted by Paul Leopold Friedrich in 1898. Several studies have confirmed that delays in wound closure rarely cause infection as summarised in this review. Wound length and depth, contamination of the wound and diabetes are found to be risk factors for wound infection.

Overriding impaired FPR chemotaxis signaling in diabetic neutrophil stimulates infection control in murine diabetic wound.

Infection is a major co-morbidity that contributes to impaired healing in diabetic wounds. Although impairments in diabetic neutrophils have been blamed for this co-morbidity, what causes these impairments and whether they can be overcome, remain largely unclear. Diabetic neutrophils, isolated from diabetic individuals, exhibit chemotaxis impairment but this peculiar functional impairment has been largely ignored because it appears to contradict the clinical findings which blame excessive neutrophil influx as a major impediment to healing in chronic diabetic ulcers. Here, we report that exposure to glucose in diabetic range results in impaired chemotaxis signaling through the formyl peptide receptor (FPR) in neutrophils, culminating in reduced chemotaxis and delayed neutrophil trafficking in the wound of Leprdb (db/db) type two diabetic mice, rendering diabetic wound vulnerable to infection. We further show that at least some auxiliary receptors remain functional under diabetic conditions and their engagement by the pro-inflammatory cytokine CCL3, overrides the requirement for FPR signaling and substantially improves infection control by jumpstarting the neutrophil trafficking toward infection, and stimulates healing in diabetic wound. We posit that CCL3 may have therapeutic potential for the treatment of diabetic foot ulcers if it is applied topically after the surgical debridement process which is intended to reset chronic ulcers into acute fresh wounds.

Characteristics of Snakebite-Related Infection in French Guiana.

Wound infection is frequently reported following snakebite (SB). This study is retrospective. It was conducted in the emergency department and the Intensive Care Unit (ICU) of Cayenne General Hospital between 1 January 2016 and 31 July 2021. We included 172 consecutive patients hospitalized for SB envenoming. All patients were monitored for wound infection. Sixty-three patients received antibiotics at admission (36.6%). The main antibiotic used was amoxicillin-clavulanate (92.1%). Wound infection was recorded in 55 cases (32%). It was 19% in grade 1, 35% in grade 2, and 53% in grade 3. It included abscess (69.1%), necrotizing fasciitis (16.4%), and cellulitis (21.8%). The time from SB to wound infection was 6 days (IQR: 3-8). The main isolated microorganisms were A. hydrophila and M. morganii (37.5% and 18.8% of isolated organisms). Surgery was required in 48 patients (28.1%), and a necrosectomy was performed on 16 of them (33.3%). The independent factors associated with snakebite-associated infection were necrosis (p < 0.001, OR 13.15, 95% CI: 4.04-42.84), thrombocytopenia (p = 0.002, OR: 3.37, 95% CI: 1.59-7.16), and rhabdomyolysis (p = 0.046, OR: 2.29, 95% CI: 1.02-5.19). In conclusion, wound infection following SB is frequent, mainly in grade 2 and 3 envenomed patients, especially those with necrosis, thrombocytopenia, and rhabdomyolysis. The main involved bacteria are A. hydrophila and M. morganii.

Minimizing Antibiotic Use in Urethral Reconstruction.

PURPOSE: There are no established guidelines regarding management of antibiotics for patients specifically undergoing urethral reconstruction. Our aim was to minimize antibiotic use by following a standardized protocol in the pre-, peri- and postoperative setting, and adhere to American Urological Association antibiotic guidelines. We hypothesized that prolonged suppressive antibiotics post-urethroplasty does not prevent urinary tract infection and/or wound infection rates. MATERIALS AND METHODS: We prospectively treated 900 patients undergoing urethroplasty or perineal urethrostomy at 11 centers over 2 years. The first-year cohort A received prolonged postoperative antibiotics. Year 2, cohort B, did not receive prolonged antibiotics. A standardized protocol following the American Urological Association guidelines for perioperative antibiotics was used. The 30-day postoperative infectious complications were determined. We used chi-square analysis to compare the cohorts, and multivariate logistic regression to identify risk factors. RESULTS: The mean age of participants in both cohorts was 49.7 years old and the average stricture length was 4.09 cm. Overall, the rate of postoperative urinary tract infection and wound infection within 30 days was 5.1% (6.7% in phase 1 vs 3.9% in phase 2, p=0.064) and 3.9% (4.1% in phase 1 vs 3.7% in phase 2, p=0.772), respectively. Multivariate logistic regression analysis of patient characteristics and operative factors did not reveal any factors predictive of postoperative infections. CONCLUSIONS: The use of a standardized protocol minimized antibiotic use and demonstrated no benefit to prolonged antibiotic use. There were no identifiable risk factors when considering surgical characteristics. Given the concern of antibiotic over-prescription, we do not recommend prolonged antibiotic use after urethral reconstruction.

Risk Factors for Infection of Sutured Maxillofacial Soft Tissue Injuries.

Background: Maxillofacial soft tissue injuries (STIs) are common and frequent in emergency departments. The aim of this study was to analyze factors causing infection of maxillofacial STIs. Patients and Methods: Patients with maxillofacial STIs who received sutures and had complete medical records were evaluated. Gender, age, American Society of Anesthesiologists (ASA) grade, diabetes mellitus, wound age, wound length, wound contamination, wound type, and sites were analyzed using univariable analysis and binary logistic regression. Results: There were 3,276 cases included. In the univariable analysis, there was no significant difference in the infection rate between genders or between the wound age groups. In binary logistic regression, age, wound length, wound type, and physician level were risk factors for infection: age of 18-44 years (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.7-2.9), 44-64 years (OR, 3.1; 95% CI, 2.3-4.3), and ≥65 years (OR, 2.6; 95% CI, 1.7-4.1); wound length of 4-8 cm (OR, 1.7; 95% CI, 1.3-2.2) and >8 cm (OR, 2.4; 95% CI, 1.1-5.1); intra-oral wounds (OR, 1.6; 95% CI, 1.1-2.4) and communicating wounds (OR, 3.2; 95% CI, 2.3-4.4); junior specialists (OR, 1.6; 95% CI, 1.2-2.2); and lip (OR, 3.7; 95% CI, 1.1-12.0) and cheek (OR, 4.7; 95% CI, 2.3-17.1) sites. Wound contamination, ASA grade, and diabetes mellitus were not significantly different from wound infection in binary regression analysis. Conclusions: Age (>18 years old), wound length (>4 cm), intra-oral wounds, communicating wounds, suturing by junior surgeons, and lip or cheek injuries may be risk factors for maxillofacial STI infection. Even if the penetrating wound age exceeds 24 hours, it is meaningful to suture if there is no serious infection. For wounds at high risk of infection, further measures should be considered to reduce the possibility of infection, such as improving the surgical training of junior surgeons and improving the patient's wound care.

Operative Ankle Fractures in Complicated Diabetes: Outcomes of Prolonged Non-Weightbearing.

Diabetes increases the risk of developing postoperative complications such as superficial and deep infection, wound dehiscence, and revisional surgery. Prolonged non-weightbearing and/or augmented fixation may reduce postoperative complications in complicated diabetic ankle fractures. This study's purpose was to compare the development of postoperative infection, wound dehiscence, and revisional surgery in complicated diabetic ankle fractures with respect to weightbearing status. We hypothesized that fewer complications would occur in patients with prolonged non-weightbearing. Medical records of 90 surgically treated complicated diabetic ankle fractures were retrospectively reviewed for postoperative radiographs, weightbearing status, and complications. Complicated diabetes was defined as HbA1c ≥ 8% within 1 year of surgery. Twenty-four out of 90 patients had prolonged non-weightbearing status, which was defined as ≥ 8 weeks of non-weightbearing postoperatively. Twelve out of 90 patients had augmented fixation, which was defined as standard open reduction and internal fixation plus ≥ 2 tetra-cortical or > 2 tri-cortical syndesmotic screws with medial plate, external fixation, or other combination. Thirty-three out of 90 patients (36.7%) patients developed complications postoperatively. Patients with prolonged non-weightbearing had less complications (29.2% vs 39.4%, p = .37) and larger HbA1c values compared with early weightbearing patients (10.0 vs 9.3, p = .04). A one-unit increase in creatinine value (mg/dL) revealed a 3.15-fold increase in development of complications (95% confidence interval 1.29-7.65, p = .01). Although not statistically significant, complicated diabetic ankle fractures treated with prolonged non-weightbearing had less complications postoperatively except for ankle Charcot. Creatinine can be utilized as an independent risk factor for postoperative complications in this population.

Bikini anterior hip replacements in obese patients are not associated with an increased risk of complication.

PURPOSE: Direct anterior approach (DAA) arthroplasty has generated great interest because of its minimally invasive and muscle sparing nature. Obese patients are reported to be associated with greater incidence of complications in primary joint replacement. The purpose of this study was to compare patient outcomes and complication rates between obese and non-obese patients undergoing primary total hip arthroplasty (THA) through a Bikini direct anterior incision. METHODS: This retrospective, single surgeon study compared the outcome of 258 obese patients and 200 non-obese patients undergoing DAA THA using a Bikini incision, over a 5-year period. The average follow-up was 3.2 years (range 1.1-5.6 years). RESULTS: There was no statistically significant differences in the complication rate between the two groups. The obese group recorded 2 major (venous thromboembolism and peri-prosthetic fracture) and 2 minor complications (superficial wound infection), compared with the non-obese group, which recorded 2 major (deep-wound infection and peri-prosthetic fracture) and 1 minor complication (superficial wound infection). Patient-reported outcomes (WOMAC and Harris Hip Scores) showed significant post-operative improvements (p < 0.001) and did not differ between the two groups. CONCLUSIONS: Bikini DDA THA does not increase the complication rate in obese patients and offers similar clinical improvements compared to non-obese patients.