Postoperative fevers occur frequently. During the first 2 to 3 days after surgery, these fevers are often due to atelectasis or the increased inflammatory response that arises from tissue injury during surgery. However, persistent postoperative fevers should be cause for concern. In the August 19, 2020 issue of The Journal, Hwang et al. examine the relationship between sustained fevers after spine instrumentation and postoperative surgical site infection.
The authors retrospectively reviewed 598 consecutive patients who underwent lumbar or thoracic spinal instrumentation. They excluded patients who underwent surgery to treat tumors or infections and those with other identified causes of fever, such as a urinary tract infection or pneumonia. Sustained fevers were defined as those that began on or after postoperative day (POD) 4 and those that started on POD 1 to 3 if they persisted until or beyond POD 5.
Sixty-eight patients (11.4%) met the criteria for a sustained fever after spinal instrumentation. Nine of those 68 (13.2%) were diagnosed with a surgical site infection. Of the 530 patients who did not have a sustained fever, only 5 (0.9%) developed a surgical site infection (p<0.001 for the between-group difference).
Further analysis revealed 3 diagnostic clues for surgical site infections among the patients with sustained fevers:
- Continuous fever (rather than cyclic or intermittent)
- Levels of C-reactive protein (CRP) >4 mg/dL after POD 7
- Increasing or stationary patterns of CRP level and neutrophil differential
In addition, the authors found that CRP levels >4 mg/dL between PODs 7 and 10 had much greater sensitivity for discriminating surgical site infection than gadolinium-enhanced magnetic resonance imaging data obtained within 1 month of the surgical procedure.
Although a vast majority (87%) of patients with sustained postoperative fevers in this study did not develop an infection, persistent fever after spine instrumentation surgery is something to be mindful of. The authors describe their findings as “tentative” and advise readers to interpret them with caution. Those caveats notwithstanding, I consider this information to be valuable because it might help prevent delays in the diagnosis of a potentially serious perioperative complication.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
As JBJS Editor-in-Chief Marc Swiontkowski, MD observed in a recent editorial, some musculoskeletal health professionals “have been set aside to some degree” during the COVID-19 pandemic. However, Dr. Swiontkowski also emphasized that “emergency/urgent procedures [still] need to be carried out.” Which leads to the question: What are the best medical practices for patients who have both fracture and COVID-19 infection.
To help answer that question, JBJS fast-tracked the publication of an article by Mi et al., which retrospectively reviewed the medical records of 10 patients from 8 hospitals in China who had both a bone fracture and COVID-19 infection.
All of the fractures were caused by accidents, most of them low-velocity. Flu-like symptoms of patients with a fracture and COVID-19 disease were diverse, as follows:
- 7 patients (70%) reported fever, cough, and fatigue.
- 4 (40%) had a sore throat.
- 5 (50%) presented with dyspnea.
- 3 (30%) reported dizziness.
- 1 patient (10%) reported chest pain, nasal congestion, and headache.
- 1 patient (10%) reported abdominal pain and vomiting.
Imaging and Lab Results
Six of the 10 patients were positive for SARSCoV-2 based on quantitative reverse transcription polymerase chain reaction (qRT-PCR) of throat-swab samples. All patients ultimately showed evidence of viral pneumonia on computed tomography (CT) scans, but on admission 3 patients did not exhibit severe symptoms or have obvious evidence of COVID-19 on CT scans, and they therefore underwent a surgical procedure. Fever and fatigue signs were observed in these 3 patients after the operation.
The overall results of laboratory tests were as follows:
- 6 patients had lymphopenia (<1.0 x 109 cells/L)
- 9 patients had a high level of C-reactive protein.
- 9 patients had D-dimer levels that exceeded upper normal limits. The authors suggest that this finding “could represent the special laboratory characteristics of fractures in patients with COVID-19.”
Three of the 10 patients underwent surgery; the others were managed nonoperatively due to their compromised status.
All patients received antiviral therapy and antibacterial therapy, and 9 patients were managed with supplemental oxygen. None of the patients received invasive mechanical ventilation or extracorporeal membrane oxygenation because of local limitations in medical technology.
Four patients died in the hospital. Among those who died, surgery had been performed on 1. The clinical outcomes for the 6 surviving patients have not yet been determined.
Because 7 of the 10 patients were determined to have developed a nosocomial infection, the authors emphasize the need “to adopt strict infection-control measures…Doctors, nurses, patients, and families should be wearing protective devices such as an N95 respirator and goggles.”
Mi et al. propose the following 3 additional strategies for patients with a fracture and COVID-19 pneumonia:
- Consider nonoperative treatment for older patients with fractures, such as distal radial fractures, in endemic areas.
- Give patients with a fracture and COVID-19 pneumonia more intensive surveillance and treatment.
- Perform surgery on patients with a fracture and COVID-19 pneumonia in a negative-pressure operating room.