Copyright
©The Author(s) 2018.
World J Orthop. Nov 18, 2018; 9(11): 271-284
Published online Nov 18, 2018. doi: 10.5312/wjo.v9.i11.271
Published online Nov 18, 2018. doi: 10.5312/wjo.v9.i11.271
Table 1 Studies from orthopedic literature evaluating preoperative hemoglobin A1c and surgical site infections
| Ref. | Study design(level of evidence) | Surgery performed | Groups | Main outcome | Significance |
| Hikata et al[23] (2013) | Retrospective cohort (IV) | Adult elective posterior instrumented thoracic and lumbar spinal arthrodesis | Non-diabetics (n = 309), Controlled diabetics (HbA1c < 7.0; n = 19), Uncontrolled diabetics (HbA1c ≥ 7.0; n = 17) | 10 (3.2%) SSI in non-diabetic group, No SSI in controlled diabetic group, 6 (35.3%) SSIs in uncontrolled diabetic group | Diabetes was an independent risk factor for SSI (P = 0.0005), Significantly higher rate of infection in diabetics with HbA1c ≥ 7.0 (P = 0.006) |
| Adams et al[21] (2013) | Retrospective cohort (II) | Primary total knee arthroplasty | Non-diabetics (n = 32924), Controlled diabetics (HbA1c < 7.0; n = 5042), Uncontrolled diabetics (HbA1c ≥ 7.0; n = 2525) | 216 (0.7%) deep infections in non-diabetics, 58 (1.2%) in controlled diabetics, and 13 (0.5%) in uncontrolled diabetics | No significant association between HbA1c level and deep infection |
| Harris et al[22] (2013) | Retrospective cohort (IV) | Total joint arthroplasty | Controlled diabetics (HbA1c < 7.0; n = 3961), Uncontrolled diabetics (HbA1c ≥ 7.0; n = 2127) | Identical percentage of patients in both groups developed superficial and deep infections | Significant increase in overall complications (P = 0.028), but not infections, for diabetics with HbA1c ≥ 7.0 |
| Iorio et al[17] (2012) | Retrospective cohort (IV) | Primary or revision total hip or knee arthroplasty | Controlled diabetics (HbA1c < 7.0; n = 191), Uncontrolled diabetics (HbA1c ≥ 7.0; n = 85) | 5 (2.6%) infections in controlled diabetics, 5 (5.9%) infections in uncontrolled diabetics | Increased rate of infections in uncontrolled diabetics without statistical significance (P = 0.293) |
| Myers et al[19] (2012) | Retrospective cohort (III) | Ankle and hindfoot fusions | Non-diabetics (n = 74), Controlled diabetics (HbA1c < 7.0; n = 30), Uncontrolled diabetics (HbA1c ≥ 7.0; n = 44) | 1 (1.4%) SSI in non-diabetics, 2 (6.7%) SSI in controlled diabetics, 12 (27.3%) SSI in uncontrolled diabetics | Significantly higher rate of SSI in uncontrolled vs controlled diabetics (P < 0.05) |
| Jämsen et al[18] (2010) | Retrospective cohort (IV) | Primary total knee arthroplasty | Patients with HbA1c < 6.5 (n = 205), Patients with HbA1c ≥ 6.5 (n = 176) | No infections in patients with HbA1c < 6.5, 5 infections in patients with HbA1c ≥ 6.5 (2.84%) | Significant increase in infection rate in patients with HbA1c ≥ 6.5 (P = 0.015) |
| Lamloum et al[20] (2009) | Retrospective cohort (IV) | Any orthopaedic surgical procedure | Controlled diabetics (HbA1c < 7.0; n = 80), Uncontrolled diabetics (HbA1c ≥ 7.0; n = 238) | 10 SSIs in controlled diabetics (12.5%), 33 SSIs in uncontrolled diabetics (13.9%) | No significant difference in SSI occurrence between the two groups (P > 0.05) |
| Marchant et al[16] (2009) | Retrospective cohort (III) | Total joint arthroplasty | Non-diabetics (n = 920555), Controlled diabetics (HbA1c < 7.0; n = 105485), Uncontrolled diabetics (HbA1c ≥ 7.0; n = 3973) | 3807 (0.41%) non-diabetics with infection, 405 (0.38%) controlled diabetics with infection, 47 (1.18%) uncontrolled diabetics with infection | Uncontrolled diabetics had a statistically significant increased rate of infection compared to patients without or with controlled diabetes (P = 0.002) |
Table 2 Studies evaluating the use of vancomycin powder intraoperatively
| Ref. | Study design (level of evidence) | Surgery performed | Groups | Main outcome | Significance |
| Ghobrial et al[56] (2014) | Retrospective case series (IV) | Spinal procedures for degenerative disease, trauma, pain and scoliosis | Vancomycin powder(range from 1-6 g) applied to subfascial and epifascial layers but not to bone graft (n = 981) | 66 infections identified (6.7%) A number of gram-negative infections were encountered | Vancomycin may increase the incidence of gram-negative or polymicrobial spinal infections |
| Hill et al[55] (2014) | Retrospective cohort (III) | Instrumented or non-instrumented posterior spine surgery in adults | Patients receiving 1-2 g vancomycin powder in surgical bed (n = 150), No vancomycin powder (n = 150) | 5 superficial infections in vancomycin powder group (3.3%), 5 superficial and 6 deep infections in control group (7.3%) | Significantly fewer deep infections in patients treated with vancomycin powder (P = 0.0297) |
| Theologis et al[59] (2014) | Retrospective cohort (III) | Complex adult spinal deformity reconstruction | Patients receiving 1-2 g vancomycin powder in subfascial space (n = 151), No vancomycin powder (n = 64) | 4 infections in first 90 d in treatment group (2.6%), 7 infections in first 90 d in control (10.9%) | Significantly fewer hospital readmissions within 90 d of surgery when using vancomycin powder (P = 0.01) |
| Caroom et al[49] (2013) | Retrospective comparative study of prospectively collected data (II) | Multilevel posterior decompression and instrumentation for cervical spondylitic myelopathy | 1 g vancomycin powder applied subfascially along bone graft and instrumentation (n = 40), No vancomycin powder (n = 72) | Zero infections in vancomycin powder group (0%), 11 infections in control (15%) | Significant decrease in infection rate with use of vancomycin powder (P = 0.007) |
| Gans et al[58] (2013) | Therapeutic retrospective cohort (II) | Pediatric spinal deformity surgery (fusion, growing rods, vertical expandable prosthetic titanium rib) | Patients received 1g vancomycin powder in surgical wound (n = 87) | 3 surgical site infections identified (3.4%) The postoperative systemic vancomycin levels remained undetectable. None of the patients experienced nephrotoxicity or red man syndrome | Local application of vancomycin powder is safe without significant changes in creatinine level or systemic vancomycin level |
| Kim et al[57] (2013) | Retrospective cohort (IV) | Instrumented spinal fusion | Patients receiving 1 g vancomycin powder in surgical wound (n = 34), No vancomycin powder (n = 40) | Zero infections in vancomycin powder group (0%) 5 infections in control (12.5%) | Significant decrease in infection rate with use of vancomycin powder (P < 0.033) |
| Martin et al[53] (2013) | Retrospective cohort (II) | Adult posterior thoracolumbar or lumbar instrumented fusion for spinal deformity | Patients receiving 2 g vancomycin powder in surgical wound (n = 156), No vancomycin powder (n = 150) | 8 infections in vancomycin powder group (5.1%), 8 infections in control (5.3%) | No significant difference in infection rate with use of vancomycin powder (P = 0.944) |
| Pahys et al[50] (2013) | Therapeutic retrospective cohort (II) | Posterior cervical spine surgery | Group 1: Perioperative antibiotics alone (n = 483), Group 2: addition of alcohol foam prep and drain (n = 323), Group 3: group 2 plus vancomycin powder in wound (n = 195) | 9 infections in group 1 (1.86%), 1 infection in group 2 (0.3%), No infections in group 3 (0%) | Significant decrease in infections in both group 2 (P = 0.047) and group 3 (P = 0.048) compared to group 1 |
| Strom et al[48] (2013) | Retrospective cohort (IV) | Instrumented and non-instrumented posterior lumbar laminectomy and fusion | Patients receiving 1 g vancomycin powder in surgical wound (n = 156), No vancomycin powder (n = 97) | Zero infections in vancomycin powder group (0%), 11 infections in control (11%) | Significant decrease in infection rate with use of vancomycin powder (P = 0.000018) |
| Strom et al[51] (2013) | Retrospective cohort (IV) | Posterior cervical fusion | Patients receiving 1 g vancomycin powder in surgical wound (n = 79), No vancomycin powder (n = 92) | 2 infections in vancomycin powder group (2.5%), 10 infections in control (10.9%) | Significant decrease in infection rate with use of vancomycin powder (P = 0.0384) |
| Tubaki et al[52] (2013) | Prospective randomized controlled trial (II) | Any primary spine surgery excluding biopsy or minimally invasive procedure | Patients receiving 1 g vancomycin powder in surgical wound (n = 433), No vancomycin powder (n = 474) | 7 infections in vancomycin powder group (1.61%), 8 infections in control (1.68%) | No significant difference in infection rate with use of vancomycin powder |
| Molinari et al[54] (2012) | Retrospective case series (IV) | Any spine surgery | Patients receiving 1 g vancomycin powder in surgical wound (n = 1512) | Fifteen infections identified (0.99%) | Low rate of deep spinal wound infection for both instrumented and uninstrumented cases |
| Sweet et al[46] (2011) | Retrospective cohort (IV) | Thoracic or lumbar posterior instrumented fusion | Patients receiving 1 g vancomycin powder in bone graft and 1 g applied directly to deep and superficial wound (n = 911), No vancomycin powder (n = 821) | Two infections in vancomycin powder group (0.2%), Twenty-one infection in control (2.6%) | Significant decrease in infection rate with use of vancomycin powder (P < 0.0001) |
| O’Neill et al[47] (2011) | Retrospective cohort (IV) | Instrumented posterior spine fusion for traumatic injury | Patients receiving 1 g vancomycin powder in surgical wound (n = 54), No vancomycin powder (n = 56) | Zero infections in vancomycin powder group (0%), Seven infections in control (13%) | Significant decrease in infection rate with use of vancomycin powder (P = 0.02) |
Table 3 Clinical orthopedic studies evaluating surgical wound irrigation before closure
| Ref. | Study design (level of evidence) | Surgery performed | Groups | Main outcome | Significance |
| Yazdi et al[64] (2014) | Prospective randomized controlled trial (I) | Arthroscopic ACL reconstruction | Irrigation with 0.9% normal saline and 80 mg/L gentamicin (n = 180), Irrigation with 0.9% normal saline (n = 180) | One infection in gentamicin group (0.57%), Four infections in normal saline alone group (2.2%) | Decreased rate of infection when using gentamicin in irrigating solution (P = 0.4) |
| Brown et al[65] (2012) | Retrospective cohort (IV) | Primary total hip or total knee arthroplasty | Soak wound with 500 mL 0.35% povidone-iodine followed by 1 L NS pulse lavage prior to closure (n = 688), Pulse lavage with 1 L NS only prior to closure (n = 1862) | One infection in betadine group (0.15%), Eighteen infections in saline alone group (0.97%) | Significant decrease in 90-d infection rate when soaking surgical wound with betadine solution prior to closure (P = 0.04) |
| Chang et al[66] (2006) | Prospective randomized controlled trial (I) | Instrumented lumbosacral posterolateral fusion for degenerative spinal disorder with segmental instability | Wounds irrigated with 0.35% povidone-iodine (n = 120), Wounds irrigated with normal saline (n = 124) | No infections in povidone-iodine group, 4.8% infection rate in saline group | Overall infection rate was statistically significant when comparing betadine solution group with no betadine group (P = 0.029) |
| Cheng et al[67] (2005) | Prospective randomized controlled trial (I) | Spinal decompression with or without fusion | Wounds irrigated with 0.35% povidone-iodine (n = 208), Wounds irrigated with normal saline (n = 206) | No infections in povidone-iodine group, 3.5% infection rate in saline group | Overall infection rate was statistically significant when comparing betadine solution group with no betadine group (P = 0.007) |
- Citation: Elgafy H, Raberding CJ, Mooney ML, Andrews KA, Duggan JM. Analysis of a ten step protocol to decrease postoperative spinal wound infections. World J Orthop 2018; 9(11): 271-284
- URL: https://www.wjgnet.com/2218-5836/full/v9/i11/271.htm
- DOI: https://dx.doi.org/10.5312/wjo.v9.i11.271