Analysis of the incidence of surgical site infections after open reposition of long bone fractures and closed fracture settings in a 7-year follow-up in an orthopedic and trauma ward in southern Poland.

INTRODUCTION: Surgical Site Infection (SSI) is the most common clinical form of Healthcare-Associated Infections (HAI) in orthopedic and trauma wards. MATERIAL AND METHOD: A retrospective study was conducted at the Department of Orthopedics and Trauma Surgery in Tarnów in 2012-2018. 3 155 patients treated for bone fractures were analyzed, including 1961 Open Reduction of Fracture (FX) and 1 194 Closed Reduction of Fracture with Internal Fixation (CR) surgeries. The study was conducted in accordance with the methodology recommended by the Surveillance Network (HAI-Net), European Centre for Disease Prevention and Control (ECDC). The aim of the study was to assess the incidence of SSI in patients undergoing the FX and CR procedures. RESULTS: 28 SSIs were identified in the examined ward; 16 SSI cases related to the FX procedure and 12 cases related to CR. The incidence for FX was 0.8% and for CR 1%. In patients with diagnosed SSI, the stay in the ward was longer (p <0.001) than in patients without SSI. In FX operations, the standardized risk index (SIR) did not exceed the value of one. Staphylococcus aureus was the most common organism isolated from materials from patients with SSI. CONCLUSIONS: In the examined period, the median age of women was higher than that of men, which may indicate a higher incidence of fractures in women. Patients with diagnosed SSI had a longer stay in the ward than patients without SSI. The incidence of SSI in FX and CR has been reduced compared to previous studies in the same ward.

Does temporary external fixation and staged protocol for closed fractures lead to bacterial contamination of the surgical site and associated complications? - A prospective trial.

INTRODUCTION: Temporary external fixation is a viable option for numerous conditions and fixations in orthopaedic and trauma surgery. If the external fixator is left in place it is necessary to disinfect it prior to surgery, yet the subsequent risk for bacterial contamination of the surgical site originating from the external fixator remains unknown. MATERIAL AND METHODS: In a prospective study, samples were taken at the time of definitive osteosynthesis to assess bacterial contamination of the surgical site and the external fixator in twenty consecutive patients treated with temporary external fixation for closed fractures from October 2016 until March 2017. RESULTS: Twenty external fixators of twenty patients with complete sampling and a mean follow-up of seven months (range: 3-14) were available for analysis. Ten out of 120 cultures of the surgical site (8.3%) were positive for bacterial growth in a total of seven patients (35%). Pathogen's detected were Propionibacterium acnes (60%) and Staphylococcus epidermidis (30%). No contamination of the external fixator was detected. CONCLUSION: We conclude that the presented perioperative management to decontaminate external fixators allows for a safe definitive osteosynthesis in a staged protocol without increasing bacterial contamination of the surgical site. It is safe to leave the external fixator in place for definitive osteosynthesis.

An unusual complication of the traditional treatment of a closed fracture - generalized tetanus: a case report.

BACKGROUND: Tetanus is a severe infectious disease that can lead to death. The clinical manifestations are due to an exotoxin secreted by Clostridium tetani, a spore-producing Gram-positive bacillus. The penetration of the germ is made through a skin opening, independently of the size of the wound. CASE PRESENTATION: A 13-year-old black African boy of the Bantu ethnic group with unknown tetanus vaccination status presented to our pediatric emergency room for the management of chest and vertebral pains which started a few days after traditional treatment by scarification and herbal and leaf ointment. The treatment was initiated by a traditional healer and indicated for a closed fracture of our patient's left forearm sustained during a fight. The diagnosis of generalized tetanus was made on the basis of generalized contractures with opisthotonus, trismus, and autonomic nervous system dysfunction. Despite prompt intensive care management, he died a few hours after admission. CONCLUSION: This case emphasizes the permanent threat of tetanus in our environment especially after cultural and traditional acts like scarification that in this specific case was for a therapeutic purpose.

[Prevalence and frequency of factors associated with infection in patients older than 18 years with closed fractures]. / Prevalencia y frecuencia de factores asociados a infección en pacientes mayores de 18 años con fracturas cerradas.

INTRODUCTION: Surgical site infection (ISO) is the most common nosocomial infection and is a process associated with multiple factors, which together generate a condition that directly affects the welfare of the patient. MATERIAL AND METHODS: Cross-sectional study, conducted over 1 year period, the sample size was established for all patients who met the inclusion criteria. An instrument takes the variables; double tabulation of patients is performed in Excel 2013 and data are analyzed in Stata version 11. RESULTS: The average age was 44.3 ± 18.8 years and the male: female ratio is 1.7:1. Clinical features, lower limbs are the most affected and 21.9 % of cases affect the femur. A prevalence of 6.6 % was found, being the most common deep infection classification. Staphylococcus aureus was cultured in 38.5% of which 40% were methicillin sensible. CONCLUSION: ISO prevalence in patients with closed fractures in HUS is 6.6% higher compared with literature data. The findings of this study it was established that hemoglobin below 10 g/dl, transfusion, reoperation and surgical risk ASA were associated statistically with ISO.

La infección de sitio operatorio (ISO) es la infección nosocomial más común y es un proceso asociado a múltiples factores, los cuales en conjunto generan una alteración que afecta directamente el bienestar del paciente.

Prevalencia y frecuencia de factores asociados a infección en pacientes mayores de 18 años con fracturas cerradas / Prevalence and frequency of factors associated with infection in patients older than 18 years with closed fractures

Resumen: Introducción: La infección de sitio operatorio (ISO) es la infección nosocomial más común y es un proceso asociado a múltiples factores, los cuales en conjunto generan una alteración que afecta directamente el bienestar del paciente. Material y métodos: Estudio de corte transversal realizado en un período de un año, el tamaño de la muestra se estableció por el total de pacientes que cumplían los criterios de inclusión; se efectuó doble tabulación de los pacientes en el programa de Excel 2013 y se analizaron los datos en Stata versión 11. Resultados: La edad promedio fue de 44.3 ± 18.8 años y la relación hombre:mujer fue 1.7:1. De las características clínicas, los miembros inferiores fueron los más afectados y 21.9% de los casos afectó el fémur. Se halló una prevalencia de 6.6%, siendo la infección profunda la más frecuente; Staphylococcus aureus se cultivó en 38.5%, de los cuales 40% fue meticilino sensible. Conclusión: La prevalencia de ISO en pacientes con fracturas cerradas en el HUS fue de 6.6%, dato elevado comparado con la literatura. Los hallazgos de este estudio permitieron establecer que la hemoglobina por debajo de 10 g/dl, la realización de transfusión, la reintervención y el riesgo quirúrgico ASA se asociaron de manera estadística a la ISO.

Abstract: Introduction: Surgical site infection (ISO) is the most common nosocomial infection and is a process associated with multiple factors, which together generate a condition that directly affects the welfare of the patient. Material and methods: Cross-sectional study, conducted over 1 year period, the sample size was established for all patients who met the inclusion criteria. An instrument takes the variables; double tabulation of patients is performed in Excel 2013 and data are analyzed in Stata version 11. Results: The average age was 44.3 ± 18.8 years and the male: female ratio is 1.7:1. Clinical features, lower limbs are the most affected and 21.9 % of cases affect the femur. A prevalence of 6.6 % was found, being the most common deep infection classification. Staphylococcus aureus was cultured in 38.5% of which 40% were methicillin sensible. Conclusion: ISO prevalence in patients with closed fractures in HUS is 6.6% higher compared with literature data. The findings of this study it was established that hemoglobin below 10 g/dl, transfusion, reoperation and surgical risk ASA were associated statistically with ISO.

Occult Infection in Aseptic Joint Loosening and the Diagnostic Role of Implant Sonication.

Our aim was to determine the incidence of occult infection and to examine the role of ultrasound sonication of the implants in cases of presumed aseptic loosening in a prospective trial. Joint swabs, aspirates, and deep tissue samples were obtained from around the prosthesis for routine microbiology. Each prosthesis was sonicated and the sonicate examined with Gram staining and extended cultures. There were 106 joints in the study of which 54 were revised for aseptic loosening and 52 were assigned to the control revision group. There were 9 positive cultures with 8/54 positive cultures in the aseptic loosening group and 1/52 in the control revision group (p = 0.017, associated OR 47.7). We found concordant results between sonication fluid culture and conventional samples in 5/9 cultures. Preoperative inflammatory markers were not prognostic for infection. Coagulase-negative Staphylococcus was the most commonly cultured organism (7/9). Previously unrecognised infection was present in 15% of patients undergoing revision for aseptic loosening. Ultrasound sonication of the removed prosthesis was less sensitive than conventional sampling techniques. We recommend routine intraoperative sampling for patients having revision for aseptic loosening, but we do not support the routine use of ultrasound sonication for its detection.

Papineau debridement, Ilizarov bone transport, and negative-pressure wound closure for septic bone defects of the tibia.

PURPOSE: Ilizarov pioneered bone transport using a circular external fixator. Papineau described a staged technique for the treatment for infected pseudarthrosis of the long bones. This article presents a single-stage Papineau technique and Ilizarov bone transport, and postoperative negative-pressure wound dressing changes for septic bone defects of the tibia. MATERIALS AND METHODS: We studied the files of seven patients (mean age, 32 years) with septic bone defects of the tibia treated with a Papineau technique and Ilizarov bone transport in a single stage, followed by postoperative negative-pressure wound dressing changes. All patients had septic pseudarthrosis and skin necrosis of the tibia. The technique included a single-stage extensive surgical debridement of necrotic bone, open bone grafting with cancellous bone autograft and bone transport, and postoperative negative-pressure wound dressing changes for wound closure. The mean time from the initial injury was 6 months (range, 4-8 months). The mean follow-up was 14 months (range, 10-17 months). RESULTS: All patients experienced successful wound healing at a mean of 29 days. Six patients experienced successful bone regeneration and union at the docking side at a mean of 6 months. One patient experienced delayed union at the docking site, which was treated with autologous cancellous bone grafting. Two patients experienced pin track infection, which was successfully treated with antibiotics and pin site dressing changes. All patients were able to return to their work and previous levels of activity, except one patient who had a stiff ankle joint and had to change his job. No patient experienced recurrence of infection, or fracture of the regenerated or transported bone segment until the period of this study. CONCLUSION: The combined Papineau and Ilizarov bone transport technique with negative-pressure wound closure provides for successful eradication of the infection, reconstruction of the bone defect, and soft-tissue closure. A single-stage surgical treatment is feasible, without any complications.

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

BACKGROUND & OBJECTIVES: Perioperative antimicrobial prophylaxis constitutes the bulk of antimicrobial consumption in any hospital. This study was conducted at a level 1 Trauma Centre of a tertiary care hospital of India to assess the efficacy of a short (24 h) course of perioperative antibiotic prophylactic regimen in preventing surgical site infections (SSI) in open reduction and internal fixation (ORIF) of closed fractures of limbs and to assess if the same can be implemented as a general policy. METHODS: Patients of either sex, aged 18 yr or more, who were scheduled for ORIF and were willing and able to give informed consent, were included in the study. Patients were randomly allocated into two groups. Group 1 (n=100) received 3 doses of 1 g i.v. cefuroxime perioperatively spaced 12 h apart and group 2 (n=97) received the conventional existing regimen [5 days of i.v. antibiotics (cefuroxime 1 g twice daily along with amikacin 15 mg/kg in 2 divided doses), followed by oral cefuroxime, 500 mg twice daily till suture removal]. RESULTS: Of the 197 patients, four patients developed a surgical site infection (three with methicillin resistant Staphylococcus aureus and one Acinetobacter baumanii). Of these, two patients were in group 1 and the remaining two in group 2. These patients were treated with i.v. antibiotics based on the culture and antimicrobial sensitivity reports. The cost of the short course treatment was ` 150 per patient as compared to ` 1,900 per patient for conventional regimen. INTERPRETATION & CONCLUSIONS: There was no significant difference in rates of SSI among the two groups in our study. Cost evaluation revealed that shorter course was less expensive than conventional long course regimen. Implementation of a short course perioperative regimen will go a long way in reducing antimicrobial resistance, cost and adverse reactions to antimicrobials.

Pharmacokinetics of cefuroxime in traumatic wound secretion and antibacterial activity under vacuum therapy.

The objective of this study was to investigate the pharmacokinetics of cefuroxime in wound secretion and the antibacterial activity of the traumatic wound secretion in patients receiving cefuroxime and in those not receiving antibiotics. Included in the present controlled, prospective, non-randomized study were 12 patients with an open fracture who needed vacuum therapy (group A) and 12 patients with a closed fracture, who, due to soft tissue damage, also underwent treatment with vacuum therapy (group B). Wound secretion was obtained on the first, third and fifth postoperative days and exposed to the test bacteria, Staphylococcus aureus and Staphylococcus epidermidis. Patients in group A underwent systemic antibiotic treatment with cefuroxime administered intravenously at a dose of 1.5 g every 8 hours. Patients in group B did not receive antibiotics. Cefuroxime concentrations were determined using high-performance liquid chromatography (HPLC). Antibacterial activity was determined using the inhibition test. Maximum cefuroxime concentrations in wound secretion were measured at 4-5 hours following intravenous administration and, with a mean concentration of 10 mg/l, remained consistently above the minimum inhibitory concentration (MIC) for the test bacteria at all points during the measurement period. As expected, the antibacterial activity of the wound secretion in patients in group A (cefuroxime) was higher than that in group B (no antibiotics). In group A, antibacterial activity against S. aureus was 94.6% and 100% against S. epidermidis. In group B, antibacterial activity against S. aureus was 61% and 81% against S. epidermidis. Cefuroxime reaches the highest level in wound secretion after 4 hours. The high antibacterial activity of the wound secretion in traumatic closed fractures is elevated by cefuroxime. in addition, our findings show that vacuum therapy of wounds is suitable as a non-invasive method for studying the pharmacokinetics of antibiotics.

[Genetic factors predisposing to bone fracture non-union. A role of single point mutation Asp299Gly TLR4 on pathogen-evoked healing]. / Genetyczna predyspozycja do zaburzen zrostu kostnego--wplyw punktowej mutacji Asp299Gly TLR4 na bakteriozalezne zaburzenia gojenia.

UNLABELLED: We previously reported the presence of the bacterial genetic material (16S rRNA) and viable pathogens in fracture gaps specimens, which suggests an impaired pathogen recognition and/or elimination. The aim of study was to validate the hypothesis that patients with delayed bone fracture healing express the higher frequency of TLR4 mutations. Observations were performed in 295 patients treated due to closed fractures of the long bones of the lower extremity; in 151 with delayed bone union (group A), and in 144 with uneventful healing (group B). Control group consisted of 125 healthy blood donors from ethnically the same as investigations groups polish population. Fracture gaps and deep tissue biopsies served for microbiological studies, and DNA isolated from venous blood leukocyteswas used for analysis of mutations of TLR4 gene at Asp299Gly (1/W) and Thr399Ile (2/W). RESULTS: Microbiological studies revealed positive isolates in 31.5% fracture gaps in group A and 16.4% in group B (p < 0.05). The most frequent isolates were S. epidermidis, S. aureus and S. warneri, capitis, sciuri and lentus, in lower percentage micrococci and enterococci. Amplification of 16S rRNA was positive in 56.8 and 65.2% of fracture gaps in both groups respectively. The frequency of occurrence of 1/W was significantly higher (p <0.05) in subgroups of patients with non-healing infected vs. sterile fractures. In all subgroups with viable pathogens isolated from fracture gaps the frequency of 1/W allele was higher when compared with subgroups, where fracture gaps occurred sterile. DISCUSSION: Performed investigations supported our previously reported observations that gaps of closed bone fractures are not sterile and are positive for 16S rRNA. Genetic predisposal to infection and inflammatory response evoked by a single TLR4 mutation may be one of the factors affecting bone union. Observed coexistence of bacterial colonization with decreased inflammatory reaction observed in individuals bearing TLR4 mutations have to be mentioned as a possible, etiologic factor responsible for delayed healing

Antimicrobial prophylaxis for orthopaedic surgery.

The number and range of orthopaedic procedures performed in the UK has increased over recent decades, with many more devices now being implanted to replace diseased joints, stabilise bone or correct skeletal deformities. With these advances, the number, type and complexity of potential surgical site infections have increased. Postoperative orthopaedic infections can impair the functional result of surgery, prolong hospital admission, harm patients and sometimes prove fatal. They require vigorous treatment with antibiotics and often necessitate further surgery. Here, we discuss measures for preventing surgical site infection after orthopaedic surgery, concentrating on major joint replacement and surgery for long bone fractures.

[Limb preservation after clostridial myonecrosis following internal fixation of a closed femoral fracture]. / Extremitätenerhalt bei Clostridienmyonekrose nach geschlossener Femurfraktur.

A 24-year-old healthy man developed Clostridium perfringens myonecrosis with severe sepsis after plating of a closed femoral fracture. The leg could be preserved by complete resection of the fascia from all muscle compartments of the leg, including the pelvitrochanteric and the iliopsoas muscles, radical removal of necrotic muscle tissue, dissection of the para-aortal infrarenal lymphatics, daily débridements over 2 weeks, and systemic antibiotic therapy. The plate was removed because of a second septic episode followed by temporary stabilization with external fixation. After soft-tissue healing, plate fixation was carried out. The patient developed significant deficit of knee flexion (0 degree/0/20 degrees) due to heterotopic ossification of the quadriceps femoris muscle that could be improved by partial resection of heterotopic bone formation. In the same operation the bony defect of the femur was filled with autologous bone graft. The fracture healed 10 months after the accident. The patient can work full time in his previous profession as a mechanic, but again needs operative mobilization of the knee joint, including open arthrolysis and quadriceps plasty.

Randomised controlled trial of single-dose antibiotic prophylaxis in surgical treatment of closed fractures: the Dutch Trauma Trial.

BACKGROUND: The efficacy of prophylactic antibiotics in fracture surgery remains controversial for lack of well-documented prospective studies. We report here the findings of the Dutch Trauma Trial, a prospective, randomised, double-blind, placebo-controlled study of antibiotic prophylaxis in the primary operative treatment of limb fractures. Ceftriaxone was chosen because of its pharmacokinetic profile, including high serum levels, high tissue penetration, and long elimination half-life, makes it suitable for single-dose prophylaxis. METHODS: Patients aged 18 years or more, attending one of fourteen Dutch centres for acute treatment of closed fractures, were randomly allocated to a single preoperative dose of ceftriaxone 2 g or placebo, and evaluated for development of wound infection and nosocomial infection at 10 days, 30 days, and 120 days. To assess the effects of drop-outs and withdrawals, best-case and worst-case analyses were performed. FINDINGS: A total of 2195 patients were included. The incidence of superficial and deep wound infections after placebo was 8.3%, compared with 3.6% in the ceftriaxone group (p < 0.001, Pearson chi 2-test). The rate of nosocomial infection in the first month was 10.2% with placebo and 2.3% with ceftriaxone (p < 0.001, Pearson chi 2-test). Gram-positive bacteria were found in 74.5% of wound infections and 13.4% of nosocomial infections. INTERPRETATION: Adequate single-dose prophylaxis with a long-acting broad-spectrum antibiotic substantially reduces the incidence of wound infection and early nosocomial infection after surgery for closed fractures.

Antimicrobial susceptibility of microorganisms isolated from equine orthopedic patients.

Positive cultures were obtained from 60 equine orthopedic cases during a 12 year period (1974-1985). These cases consisted of 34 long or cuboidal bone fractures, 13 arthrotomy/arthroscopy procedures for removal or internal fixation of a fracture, 7 proximal splint bone fractures, and 6 facial or mandibular fractures. Excluding the 13 arthrotomies, only 10 (21%) of the 47 were open fractures. Multiple organisms were isolated from 36 cases (20 long or cuboidal bone fractures, 7 splint bone fractures, 5 mandibular fractures, and 4 intra-articular fractures). Of the 142 isolates, 35 (24%) were members of the family Enterobacteriaceae, 33 (23%) Streptococcus spp., and 25 (18%) Staphylococcus spp. with the majority being coagulase positive (65%). Other organisms isolated were Pseudomonas spp. (16, 11%), obligate anaerobes (11, 7%), and Actinobacillus spp. (7, 5%). the remaining 10% consisted of Pasteurella spp., Bacillus spp., Corynebacterium spp., Micrococcus spp., and Actinomyces spp. When comparing results between two time periods (1974-1979 and 1980-1985) there was an increase in the percentage of coagulase positive staphylococci isolates resistant to all antimicrobics tested except oxacillin and amikacin, and Escherichia coli isolates were resistant to all but amikacin. For Pseudomonas spp., resistance to gentamicin increased in the second time period (1980-1986). During the initial time period (1974-1979) culture tests for obligate anerobes were not conducted until 1975. No anerobes were cultured during those initial 5 years; however, one third of those isolated after 1980 were resistant to penicillin and ampicillin.(ABSTRACT TRUNCATED AT 250 WORDS)