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
Every month, JBJS publishes 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, Chad A. Krueger, MD, JBJS Deputy Editor for Social Media, selected the five most clinically compelling findings from among the 25 noteworthy studies summarized in the July 3, 2019 “What’s New in Orthopaedic Trauma” article.
Proximal Humeral Fractures in the Elderly
–A recent meta-analysis1 analyzing data from >1,700 patients older than 65 who experienced a proximal humeral fracture found no difference in Constant-Murley scores at 1 year between those treated operatively (most with ORIF using a locking plate) and those treated nonoperatively. There was also no between-group difference with respect to reoperation rates among a subgroup of patients from the 7 randomized trials examined in the meta-analysis.
–A study using MRI to evaluate soft-tissue injuries in 17 cases of “simple elbow dislocation”2 found that the most common soft-tissue injury was a complete tear of the anterior capsule (71% of cases), followed by complete medial collateral ligament (MCL) tears (59%) and lateral collateral ligament tears (53%). These findings challenge previous theories positing that elbow instability starts laterally, with the MCL being the last structure to be injured.
Pertrochanteric Hip Fractures
–A trial randomized 220 patients with a pertrochanteric fracture to receive either a short or long cephalomedullary nail.3 There were no significant differences between the 2 groups at 3 months postsurgery in terms of Harris hip and SF-36 scores, but patients treated with the short nail had significantly shorter operative times, less blood loss, and shorter hospital stays. The incidence of peri-implant fractures between the 2 devices was similar.
Ankle Syndesmosis Injuries
–A randomized trial involving 97 patients with syndesmosis injuries compared functional and radiographic outcomes between those treated with a single syndesmotic screw and those treated with suture-button fixation. At 6 months, 1 year, and 2 years after surgery, patients in the suture-button group had better AOFAS scores than those in the screw group. CT scans at 2 years revealed a significantly higher tibiofibular distance among the screw group, an increase in malreduction that was noted only after screw removal. That finding could argue against early routine syndesmotic screw removal.
–A randomized trial among 470 patients4 facing elective removal of hardware used to treat a below-the-knee fracture compared the effect of intravenous cefazolin versus saline solution in preventing surgical site infections (SSIs). The SSI rate was surprisingly high in both groups (13.2% in the cefazolin group and 14.9% in the saline-solution group), with no statistically significant between-group differences. The authors recommend caution in interpreting these results, noting that there may have been SSI-diagnosis errors and that local factors not applicable to other settings or regions may have contributed to the high SSI rates.
- Beks RB, Ochen Y, Frima H, Smeeing DPJ, van der Meijden O, Timmers TK, van der Velde D, van Heijl M, Leenen LPH,Groenwold RHH, Houwert RM. Operative versus nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials. J Shoulder Elbow Surg.2018 Aug;27(8):1526-34. Epub 2018 May 4.
- Luokkala T, Temperley D, Basu S, Karjalainen TV, Watts AC. Analysis of magnetic resonance imaging-confirmed soft tissue injury pattern in simple elbow dislocations. J Shoulder Elbow Surg.2019 Feb;28(2):341-8. Epub 2018 Nov 8.
- Shannon S, Yuan B, Cross W, Barlow J, Torchia M, Sems A. Short versus long cephalomedullary nailing of pertrochanteric hip fractures: a randomized prospective study. Read at the Annual Meeting of the Orthopaedic Trauma Association; 2018 Oct 17-20; Orlando, FL. Paper no. 68.
- Backes M, Dingemans SA, Dijkgraaf MGW, van den Berg HR, van Dijkman B, Hoogendoorn JM, Joosse P, Ritchie ED,Roerdink WH, Schots JPM, Sosef NL, Spijkerman IJB, Twigt BA, van der Veen AH, van Veen RN, Vermeulen J, Vos DI,Winkelhagen J, Goslings JC, Schepers T; WIFI Collaboration Group. Effect of antibiotic prophylaxis on surgical site infections following removal of orthopedic implants used for treatment of foot, ankle, and lower leg fractures: a randomized clinical trial. 2017 Dec 26;318(24):2438-45.
Orthopaedic educators have long confronted the subtle implication that resident participation in surgical care can contribute to patient harm or even death. While there have been numerous changes in residency education to improve the supervision and training of residents, the reality is that surgical trainees have to learn how to operate. This fact can leave surgical patients understandably nervous, and many of them heave heard rumors of a “July effect”—a hypothetical increase in surgery-related complications attributed to resident education at the beginning of an academic year. To provide further clarity on this quandary, in the November 21, 2018 issue of The Journal, Casp et al. examine the relationship between complication rates after lower-extremity trauma surgery (for hip fractures, predominantly), the participation and seniority of residents, and when during the academic year the surgery occurred.
The authors used the NSQIP surgical database to examine >1,800 patient outcomes after lower-extremity surgery according to academic-year quarter and the postgraduate year of the most senior resident involved in the case. The analysis revealed two major findings:
- Overall, there was no “July effect” at the beginning of the academic year in terms of composite complication rates.
- Cases involving more senior residents were associated with an increased risk of superficial surgical site infection during the first academic quarter.
While the authors were unable to provide a precise reason for the second finding, they hypothesized that it could have been related to more stringent data collection early in the academic year, senior-resident inexperience with newly increased responsibilities, or the warm-temperature time of year in which the infections occurred. Casp et al. emphasize that the database used in the study was not robust in terms of documenting case details such as complexity and the degree of resident autonomy, which makes cause-and-effect conclusions impossible to pinpoint.
Although this large database study does not answer granular questions regarding the appropriate role of residents in orthopaedic surgery, it should stimulate further research in this area. Gradually increasing responsibility is necessary within residency programs so that residents develop the skills and decision-making prowess necessary for them to succeed as attending surgeons. Studies like this help guide future research into the important topic of graduate medical education, and they provide patients with some reassurance that the surgical care they receive is not affected by the time during the academic-calendar year in which they receive it.
Marc Swiontkowski, MD
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
–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.
–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.
–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
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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
- 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.
When >10% of patients undergoing procedures to correct a spinal deformity develop one or more surgical-site infections, investigations into how to mitigate such infections seem warranted. This is especially true when a single such infection can cost nearly $1 million to treat—not to mention the physical and psychological burdens.
In the March 21, 2018 edition of JBJS, Thompson et al. report important findings from a retrospective study that sought to evaluate the efficacy of adding topical vancomycin powder to the wounds of patients undergoing growing-spine surgeries to address early-onset scoliosis. The mean patient age at the beginning of the study was 7.1 years.
Cases in which topical vancomycin powder was placed into the wounds at the time of fascial closure (n = 104 cases) had a significantly lower surgical-site infection rate (4.8%), compared with the rate in the 87 cases in which no vancomycin was used (13.8%). Furthermore, the “number needed to treat” found in this study was 11, meaning that for every 11 cases in which vancomycin powder was used, a surgical-site infection was prevented. The authors found no complications related to the use of topical vancomycin and note that their study provides the first evidence supporting the efficacy of vancomycin powder in pediatric spine patients.
Because this study was retrospective and based out of one center, further multicenter, prospective studies are needed to verify these results and to address open questions such as appropriate vancomycin dosages. Still, considering the extremely high costs (economic, physical, social, and psychological) associated with surgical-site infections in these complex patients, it appears that a vial of vancomycin powder costing between $10 and $40 may deliver outstanding value in these scenarios.
Chad A. Krueger, MD
JBJS Deputy editor for Social Media
In the November 18, 2015 edition of JBJS, Lawing et al. present a well-documented cohort study comparing the outcomes of open-fracture management with local administration of aminoglycoside antibiotics plus systemic antibiotics, versus systemic antibiotics alone. The impact of this intervention on the ultimate rate of deep infection is eye-catching. The deep-infection rate in the local-antibiotic group was 6%, compared to 14.2% in the control group (p = 0.011). Moreover, locally administered aminoglycosides did not have a negative impact on nonunion rates, as one might expect due to the osteocyte toxicity reportedly associated with some aminoglycosides.
There are, however, issues of administrator bias with this study, because the use of local antibiotics was based on attending-surgeon preference. In addition, surgeons make other individual judgments about open-fracture management, such as debridement technique, that were not controlled for in this study. We also went through a period of using local antibiotic drips and catheter pumps in the 1990s that did not seem to yield reproducible results.
Lawing et al. conclude with the hope that their study “will provide support for future prospective, blinded, and randomized trials” focused on this intervention. I believe the data here are compelling enough for one of our trauma clinical-trials networks to plan and conduct an adequately powered trial complete with prospective criteria and blinded outcome adjudication. One reason we publish cohort studies in The Journal is to stimulate just that sort of response in the orthopaedic-research community. It is my hope that within a few years, JBJS editors will be reviewing an RCT manuscript that completes the investigative cycle on this important clinical question.
Marc Swiontkowski, MD
A recent case-control study in Foot & Ankle International found that high-risk diabetic patients (mean age of 60) undergoing reconstructive foot and/or ankle surgery were 80% less likely to develop a deep surgical-site infection when surgeons applied vancomycin powder to the surgical wound than when they didn’t. The overall likelihood of any surgical-site infection (deep or superficial) was decreased by 73% in patients who received powdered vancomycin. The cost of vancomycin and the risk of complications associated with it are both low, the study noted.
The authors concluded that “based on this study, orthopaedic foot and ankle surgeons may consider applying 500 mg to 1,000 mg of vancomycin powder prior to skin closure in diabetic patients who are not allergic to vancomycin.”
Surgical site infections (SSIs) can cancel out the benefits of surgery, and they’re the number-one cause of hospital readmissions following surgery. The most prevalent pathogenic culprit is Staphylococcus aureus.
A study of patients undergoing cardiac or hip or knee arthroplasty surgery at 20 hospitals in nine states found that the following protocol reduced the rate of complex (deep incisional or organ-space) S. aureus SSIs by about 40% overall—and by about 50% among patients undergoing hip or knee arthroplasty (an absolute difference of 17 infections per 10,000 joint replacements):
- Preoperative screening of nasal samples
- Intranasal mupirocin and chlorhexidine baths for up to five days prior to surgery for patients testing positive for methicillin-resistant S. aureus (MRSA) or methicillin-susceptible S. aureus (MSSA)
- Perioperative prophylaxis with vancomycin plus cefazolin or cefuroxime for MRSA carriers and perioperative cefazolin or cefuroxime for all others
Rates of complex SSIs decreased most substantially among patients who were fully adherent to the protocol, although only 39% of the subjects experienced implementation of all the steps. Adherence rates were especially low among those who presented in urgent and emergency settings.
In an editorial accompanying the study, Preeti Malani, MD wrote that “although the absolute difference [in infections] seems modest, each complex SSI prevented is clinically meaningful.”