What’s New in Musculoskeletal Infection 2018

Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.

This month, Arvind Nana, MD, and his co-authors of the July 18, 2018 Specialty Update on Musculoskeletal Infection, selected the most clinically compelling findings from among the more than 130 studies summarized in the Specialty Update.

CDC Guidelines on Surgical Site Infection (SSI) Prevention

–The most provocative recommendation in the CDC SSI Prevention Guidelines,¹ released in 2017, was to encourage administration of parenteral antimicrobial prophylaxis prior to surgery so that a bactericidal concentration is established in the tissue and serum when the incision is made. Postoperatively, the CDC recommended that antimicrobial prophylaxis not be administered in clean and clean-contaminated procedures after incision closure, even if a drain is present.

Treating Periprosthetic Infection

–When performing debridement to treat a periprosthetic joint infection, dilute methylene blue (0.1%) applied to the tissue prior to debridement (with removal of excess dye) may help surgeons visualize devitalized tissue (biofilm) that should be debrided at the time of infection.^2,3

Wound Closure

–Two Level-I studies showed that specific wound-closure techniques can improve incisional perfusion. This was seen in the setting of ankle fracture with the Allgower-Donati suture technique⁴ and in elective total knee arthroplasty with a running subcuticular closure⁵.

Antimicrobial Prophylaxis

–Two studies reported on the microbiological impact of locally applied vancomycin powder.^6,7  For patients who developed infections after surgery despite the application of vancomycin powder, a greater frequency of gram-negative organisms was identified, highlighting the importance of obtaining specimens for culture.

Hand Infections

–Atypical hand infections caused by Mycobacterium tuberculosis, non-tuberculous mycobacterium, and fungi are uncommon, making high-level clinical trials unrealistic.  But these atypical infections are frequent enough that multiple cases are reported, drawing attention to the need for awareness of their clinical presentation,⁸ even in immunocompetent patients,⁹ and the need for understanding that cultures should be sent when suspicion is high, even if there is purulence consistent with a typical bacterial infection.¹⁰

References

1. Berrios-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, Reinke CE, Morgan S, Solomkin JS, Mazuski JE, Dellinger EP, Itani KMF, Berbari EF, Segreti J, Parvizi J, Blanchard J, Allen G, Kluytmans JAJW, Donlan R, Schecter WP; Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017 Aug 1;152(8):784-91.
2. Shaw JD, Miller S, Plourde A, Shaw DL, Wustrack R, Hansen EN. Methylene blue guided debridement as an intraoperative adjunct for the surgical treatment of periprosthetic joint infection. J Arthroplasty. 2017 Dec;32(12):3718-23.
3. Parry JA, Karau MJ, Kakar S, Hanssen AD, Patel R, Abdel MP. Disclosing agents for the intraoperative identification of biofilms on orthopedic implants. J Arthroplasty. 2017 Aug;32(8):2501-4.
4. Shannon SF, Houdek MT,Wyles CC, Yuan BJ, CrossWW3rd, Cass JR, Sems SA. Allgower-Donati versus vertical mattress suture technique impact on perfusion in ankle fracture surgery: a randomized clinical trial using intraoperative angiography.  J Orthop Trauma. 2017 Feb;31(2):97-102.
5. Wyles CC, Jacobson SR, Houdek MT, Larson DR, Taunton MJ, Sim FH, Sierra RJ, Trousdale RT. The Chitranjan Ranawat Award: running subcuticular closure enables the most robust perfusion after TKA: a randomized clinical trial. Clin Orthop Relat Res. 2016 Jan;474(1):47-56.
6. Adogwa O, Elsamadicy AA, Sergesketter A, Vuong VD, Mehta AI, Vasquez RA, Cheng J, Bagley CA, Karikari IO. Prophylactic use of intraoperative vancomycin powder and postoperative infection: an analysis of microbiological patterns in 1200 consecutive surgical cases. J Neurosurg Spine. 2017 Sep;27(3):328-34. Epub 2017 Jun 30.
7. Chotai S, Wright PW, Hale AT, Jones WA, McGirt MJ, Patt JC, Devin CJ. Does intrawound vancomycin application during spine surgery create vancomycin-resistant organism? Neurosurgery. 2017 May 1;80(5):746-53.
8. Lopez M, Croley J, Murphy KD. Atypical mycobacterial infections of the upper extremity: becoming more atypical? Hand (N Y). 2017 Mar;12(2):188-92. Epub 2016 Jul.
9. Sotello D, Garner HW, Heckman MG, Diehl NN, Murray PM, Alvarez S. Nontuberculous mycobacterial infections of the upper extremity: 15-year experience at a tertiary care medical center. J Hand Surg Am. 2017 Dec 6:S0363-5023(16)30908-X. Epub 2017 Dec 6
10. Kazmers NH, Fryhofer GW, Gittings D, Bozentka DJ, Steinberg DR, Gray BL. Acute deep infections of the upper extremity: the utility of obtaining atypical cultures in the presence of purulence. J Hand Surg Am. 2017 Aug;42(8):663.e1-8. Epub 2017 May 25.