- Email: [email protected]
Preoperative Antibiotics in Wrist Arthroscopy
SCIENTIFIC ARTICLE
Preoperative Antibiotics in Wrist Arthroscopy Ryan J. Hoel, MD,* Marcus J. Mittelsteadt, MD,* S. Andrew Samborski, MD,† Deborah C. Bohn, MD‡
Purpose This study seeks to evaluate the need for preoperative antibiotics for wrist arthroscopy. Methods A retrospective review of 576 consecutive wrist arthroscopies was performed over a 10-year period at a single ambulatory surgery center. The chart of each included patient was reviewed for postoperative infections following the National Nosocomial Infections Surveillance criteria for diagnosis. Results Of the 576 wrist arthroscopies reviewed, 324 met the inclusion criteria. Preoperative antibiotics were administered in 209 cases (65%) and not administered in 115 cases (35%). There were 116 cases (36%) with concomitant open soft tissue procedures. We identified 2 infections (0.6% overall infection rate), both of which were in patients who had received preoperative antibiotics. Both of these patients underwent concomitant percutaneous pinning of carpal bones with Kirschner wires, which were buried beneath the skin. Conclusions Administering preoperative antibiotics for routine wrist arthroscopy does not appear to lower the surgical site infection rate. The rate of surgical site infection is so low in both cohorts that a meaningful difference cannot be determined between the 2 groups. This study adds to the current body of literature suggesting that it is acceptable practice to withhold preoperative antibiotics for surgeries that have a very low rate of infection. (J Hand Surg Am. 2018;-(-):1.e1-e6. Copyright Ó 2018 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Clean surgery, preoperative antibiotic, preoperative protocol, surgical site infection, wrist arthroscopy.
W
used technique for the evaluation and treatment of intra-articular pathology, with an estimated 25,000 cases performed in the United RIST ARTHROSCOPY IS A COMMONLY
From the *Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN; †Department of Orthopaedics, University of Rochester, Rochester, NY; and the ‡TRIA Orthopaedic Center, Bloomington, MN. Received for publication June 5, 2017; accepted in revised form March 20, 2018. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Deborah C. Bohn, MD, TRIA Orthopaedic Center, 8100 Northland Drive, Bloomington, MN 55431; e-mail: [email protected]. 0363-5023/18/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2018.03.040
States in 2006.1 Among surgeons who perform these procedures, there is heterogeneity in the practice of administering preoperative antibiotics. However, there is no clear evidence that preoperative antibiotics lower the incidence of infection for this type of procedure. The American Association of Plastic Surgeons has recommended that antibiotics are not necessary for clean surgical cases of the hand, because they do not lower the infection rate.2,3 Although this recommendation has been widely accepted for procedures such as carpal tunnel release, our experience is that most patients undergoing wrist arthroscopy are still routinely given preoperative antibiotics.
Ó 2018 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1.e1
1.e2
PREOPERATIVE ANTIBIOTICS IN WRIST ARTHROSCOPY
Looking to the literature regarding arthroscopic procedures performed on other joints, a 2007 review of knee arthroscopies showed that administration of preoperative antibiotics did not change the incidence of surgical site infections.4 Despite evidence that antibiotics do not change the incidence of surgical site infections in knee arthroscopy, a 2009 survey of orthopedic surgeons showed that 85% still administered preoperative antibiotics for arthroscopic meniscectomies.5 The use of preoperative antibiotics does have associated morbidity and cost. Prior literature has shown that diarrhea occurs in 2% to 5% of patients treated with cephalosporins, and that even a single dose of preoperative cephalosporin can precipitate diarrhea or intestinal Clostridium difficile infection.6,7 In addition, careful antibiotic stewardship is critical in modern medical practice to limit the rise in antibiotic-resistant pathogens seen in recent decades. Given the drawbacks of antibiotic overuse and the evidence from knee arthroscopy literature, we sought to investigate the need for preoperative antibiotics in wrist arthroscopy. Our primary objective was to determine if there is a clinically meaningful difference in postoperative infection rates in patients undergoing wrist arthroscopy with or without administration of preoperative antibiotics. The secondary objective was to determine other factors that may be associated with infection in wrist arthroscopy. Our hypothesis was that there would be no difference in the rate of infection whether or not prophylactic antibiotics were given.
surgical procedure performed, whether there were concomitant open procedures, whether preoperative antibiotics were given, and tourniquet time during the case. Additional demographic data such as patient age, sex, diabetic status, and smoking status at the time of surgery were recorded for each case. Electronic medical records were reviewed for 30 days from the time of surgery to identify postoperative infections. Our criteria for a postoperative infection followed the National Nosocomial Infections Surveillance criteria for defining a surgical site infection (SSI), which include infections occurring within 30 days of the operation if there is no retained implant, and within 1 year if there is a retained implant.8 We did not exclude patients who had minor concomitant open procedures for which preoperative antibiotics would not be otherwise indicated (eg, carpal tunnel release, trigger finger release; full list can be found in Appendix A, available on the Journal’s Web site at www.jhandsurg.org). However, we did exclude patients who had open bony procedures and elaborate open soft tissue procedures (eg, open triangular fibrocartilage complex repair; full list can be found in Appendix A). Additional exclusion criteria were an arthroscopy performed for an existing infection (Current Procedural Terminology 29843) and follow-up less than 30 days. The antibiotic protocol at our institution is to administer 2 g of cefazolin or 900 mg of clindamycin (in the case of a penicillin or cephalosporin allergy) intravenously within 30 minutes before skin incision. In patients over 120 kg, the cefazolin dose is increased to 3 g, but the clindamycin dose remains at 900 mg. These doses are based on the American Society of Health-System Pharmacists report from 2013.9
MATERIALS AND METHODS This study was approved by our institutional review board as category 5 research. Approval was received for access to 719 records for 576 unique patients with a waiver of informed consent as research involved no more than minimal risk to subjects. Within our institution, there are surgeons who routinely give preoperative antibiotics for wrist arthroscopy surgery, and others who do not. This created historical cohorts of patients who did and did not receive routine preoperative antibiotics for wrist arthroscopy. We performed a retrospective chart review of a 10-year period (March 15, 2005, to December 31, 2015) at a single orthopedic ambulatory surgery center, querying by Current Procedural Terminology codes for wrist arthroscopy. The specific codes used were 29840, 29844, 29845, and 29846. The operative reports and anesthesia records of each identified case were reviewed to confirm the J Hand Surg Am.
RESULTS We identified 576 wrist arthroscopies performed by 8 surgeons during the time period queried. Of these, 324 met the inclusion criteria. Reasons for exclusion were concomitant open bony or ligamentous procedures at the wrist (173), inadequate follow-up (70), and incomplete data in the operative and anesthesia records regarding the procedure performed or administration of preoperative antibiotics (9). The median patient age was 38 (range, 11e75) years, and the ratio of males to females was almost equal. With respect to recorded medical comorbidities, 13% of the patients were smokers, and 3% had diabetes. Of the 324 cases that met criteria for analysis, the most common indications for the operation were an r
Vol. -, - 2018
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PREOPERATIVE ANTIBIOTICS IN WRIST ARTHROSCOPY
arthroscopic triangular fibrocartilage complex debridement (187) and an arthroscopic synovial debridement (114). Preoperative antibiotics were administered to 209 patients (65%), and 115 patients (35%) did not receive preoperative antibiotics. There were 116 cases (36%) with concomitant open soft tissue procedures, the most common of which was an isolated posterior interosseous neurectomy (Table 1). We identified 2 infections, both of which were in patients who had received preoperative antibiotics. Neither of these patients were smokers, diabetic, and had had previous operations on the same wrist. These 2 patients had body mass indices of 20 and 31. Both infections occurred in patients who had arthroscopic-assisted percutaneous pinning of intercarpal ligament injuries. In both cases, the Kirschner wires were buried subcutaneously and were removed at the time of irrigation and debridement for infection. A tourniquet was not used during the index procedure in either case. Specific details of these 2 infections are listed in Table 2.
TABLE 1. Concomitant Open Procedures in Included Patients No Antibiotic Group
Isolated posterior interosseous neurectomy
34
36
Posterior interosseous neurectomy plus second procedure
12
2
Ganglion excision
7
1
Carpal tunnel release
5
1
Percutaneous pinning of intercarpal ligament tear or distal radius fracture
6
0
First dorsal compartment release
2
2
Trigger finger release
1
1
Other procedure(s)
5
1
72
44
Total
infections occurred in the group that received antibiotics, withholding antibiotics cannot be claimed to be superior because of the low number of infections and lack of power of this study to demonstrate a difference between these groups. Our study showed an overall SSI rate of 0.6% when the 2 groups were combined. This rate approximates the infection rate of clean hand surgery cases.1 This is notably higher than a recent study by Leclercq et al,1,11 in which only 1 deep infection was reported after isolated wrist arthroscopy from a study population of 10,107, although the authors of that study did not specify how many of the total cases had concomitant open procedures, nor how many patients received preoperative antibiotics. The rate of infection in that study was based on a survey sent to surgeons asking them to review their personal complications data. Our surgical site infection rate of 0.6% is also higher than rates of infection reported in knee and shoulder arthroscopy, both of which have been shown in multiple large studies to have infection rates below 0.5%.4,12e14 This discrepancy may be attributable to a longer length of follow-up in this study than in other reports, which is as short as 2 weeks.4,12e14 This study does have considerable limitations. Because infection events are quite rare, we would need a substantially greater number of cases to show any statistically significant difference in infection rate with the use of antibiotics. Assuming a baseline risk of infection of 0.5% and making a theoretical
DISCUSSION Surgical site infection and its prevention is a primary concern for modern health care systems. Worldwide, protocols have been developed for surgical safety that include verification of the administration of preoperative intravenous antibiotics. The American Medical Association published the Center for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection 2017, wherein a systematic review was performed to determine best available evidence-based practices.10 With regard to the use of preoperative intravenous antibiotics, this guideline states, “Administer preoperative antimicrobial agents only when indicated based on published clinical practice guidelines.” There is clear evidence that preoperative antibiotics reduce the rate of SSI for orthopedic procedures such as joint arthroplasty and spine surgery. There are numerous reports, however, that there is neither a statistically nor clinically significant reduction in SSI for orthopedic surgeries in which SSI is rare.2e4 Presumably, based in part on this literature, the American Society of HealthSystem Pharmacists does not recommend surgical antimicrobial prophylaxis for clean orthopedic surgery that does not involve an implant in the hand, knee, or foot in their Clinical Practice Guidelines.9 Our results show that performing wrist arthroscopy without administering preoperative antibiotics does not increase the SSI rate. Although the 2 observed J Hand Surg Am.
Antibiotic Group
Procedure
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PREOPERATIVE ANTIBIOTICS IN WRIST ARTHROSCOPY
TABLE 2.
Characteristics of Patients Who Developed Infections
Patient
1
Age
2
67
21
Diagnosis
Scapholunate ligament tear
Lunotriquetral ligament tear
Procedure performed
Arthroscopic-assisted reduction and percutaneous pinning
Midcarpal debridement, arthroscopic-assisted reduction, and percutaneous pinning
Received antibiotics?
Yes—cefazolin
Yes—cefazolin
Pins buried?
Yes
Yes
Time to infection
39 d
11 d
Infection site
Wrist joint
Wrist joint
Organism
MSSA
MSSA
Intervention required
Surgical debridement Outpatient management Oral dicloxacillin, duration unknown
Surgical debridement Four-day hospitalization Three-week IV ampicillin-sulbactam
Smoking status
Nonsmoker
Nonsmoker
Comorbidities
None
None
IV, intravenous; MSSA, methicillin-sensitive Staphylococcus aureus.
assumption that antibiotic administration could change the rate of infection by 50%, the number needed to treat to prevent 1 infection would be 400. Based on the findings in this study, it is unlikely that antibiotic administration decreases the risk by 50%, and thus the number needed to treat is likely to be dramatically higher, making the development of an appropriately powered study prohibitively impractical. In addition, this is a retrospective review, introducing the possibility of selection bias as to which patients received antibiotics. Although we did not sort the administration of antibiotics by a surgeon, some surgeons in the practice routinely ordered antibiotics and some routinely did not. Also, because there were 8 surgeons involved, variations in technique and skill level, length of procedures, involvement of trainees in some cases, and patient mix could bias the results. Because we excluded cases with concomitant open bony and ligamentous procedures in the same region, our findings can only be applied to wrist arthroscopy with soft tissue or minor concomitant procedures. Despite the above limitations, our results lead us to conclude that preoperative antibiotics do not clearly reduce the infection rate in wrist arthroscopy. The costs and risks associated with administration of antibiotics for a procedure with such a low infection rate likely outweigh any benefit. This study adds to the current body of literature suggesting that it is J Hand Surg Am.
acceptable practice to not administer preoperative antibiotics for surgeries that have a very low rate of infection. REFERENCES 1. Jain NB, Higgins LD, Losina E, Collins J, Blazar PE, Katz JN. Epidemiology of musculoskeletal upper extremity ambulatory surgery in the United States. BMC Musculoskelet Disord. 2014;15:4. https://doi.org/10.1186/1471-2474-15-4. 2. Ariyan S, Martin J, Lal A, et al. Antibiotic prophylaxis for preventing surgical-site infection in plastic surgery: an evidencebased consensus conference statement from the American Association of Plastic Surgeons. Plast Reconstr Surg. 2015;135(6): 1723e1739. 3. Bykowski MR, Sivak WN, Cray J, Buterbaugh G, Imbriglia JE, Lee WPA. Assessing the impact of antibiotic prophylaxis in outpatient elective hand surgery: a single-center, retrospective review of 8, 850 cases. J Hand Surg Am. 2011;36(11):1741e1747. 4. Bert JM, Giannini D, Nace L. Antibiotic prophylaxis for arthroscopy of the knee: is it necessary? Arthroscopy. 2007;23(1):4e6. 5. Redfern J, Burks R. 2009 survey results: surgeon practice patterns regarding arthroscopic surgery. Arthroscopy. 2009;25(12): 1447e1452. 6. Privitera G, Scarpellini P, Ortisi G, Nicastro G, Nicolin R, de Lalla F. Prospective study of Clostridium difficile intestinal colonization and disease following single-dose antibiotic prophylaxis in surgery. Antimicrob Agents Chemother. 1991;35(1):208e210. 7. Bartlett JG. Clinical practice. Antibiotic-associated diarrhea. N Engl J Med. 2002;346(5):334e339. 8. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control. 1999;27(2): 97e132. 9. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195e283.
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13. D’Angelo GL, Ogilvie-Harris DJ. Septic arthritis following arthroscopy, with cost/benefit analysis of antibiotic prophylaxis. Arthroscopy. 1988;4(1):10e14. 14. Müller-Rath R, Becker J, Ingenhoven E. Wie hoch ist das statistische Risiko einer Infektion nach ambulanter Arthroskopie?: Eine Auswertung von über 50.000 Fällen anhand der Statistik des BVASK/[What is the statistical risk of infection after outpatient arthroscopy?]. Arthroskopie. 2008;21(2): 87e91.
10. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for disease control and prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017;152(8):784e791. 11. Leclercq C, Mathoulin C. Members of European Wrist Arthroscopy Society. Complications of wrist arthroscopy: a multicenter study based on 10,107 arthroscopies. J Wrist Surg. 2016;5(4):320e326. 12. Armstrong RW, Bolding F, Joseph R. Septic arthritis following arthroscopy: clinical syndromes and analysis of risk factors. Arthroscopy. 1992;8(2):213e223.
J Hand Surg Am.
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APPENDIX A. All Included and Excluded Concomitant Open Procedures Included Concomitant Open Procedures
Excluded Concomitant Open Procedures
Posterior interosseous nerve neurectomy Dorsal wrist ganglion cyst excision Volar wrist ganglion cyst excision Carpal tunnel release First extensor compartment release Trigger finger release Guyon’s canal release Cubital tunnel decompression Digital arthrodesis Percutaneous fracture pinning Incision extension to achieve hemostasis Lateral elbow contracture release
Ulnar shortening osteotomy Removal of ulnar exostosis Carpometacarpal arthrodesis Open scapholunate ligament repair Open scaphoid screw removal Wafer resection of ulnar head Excision of distal radius bone cyst Open pisiform excision Scapholunate capsulorrhaphy Excision of volar forearm mass Radical flexor synovectomy Open triquetral excision Open reduction internal fixation distal radius Open reduction of lunate dislocation Open triangular fibrocartilage repair Open excision ulnar styloid nonunion Open radiocarpal biopsy Proximal row carpectomy Distal radius osteotomy Open fibrous scar removal Open loose body removal from wrist
J Hand Surg Am.
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Preoperative Antibiotics in Wrist Arthroscopy Ryan J. Hoel, MD,* Marcus J. Mittelsteadt, MD,* S. Andrew Samborski, MD,† Deborah C. Bohn, MD‡
Purpose This study seeks to evaluate the need for preoperative antibiotics for wrist arthroscopy. Methods A retrospective review of 576 consecutive wrist arthroscopies was performed over a 10-year period at a single ambulatory surgery center. The chart of each included patient was reviewed for postoperative infections following the National Nosocomial Infections Surveillance criteria for diagnosis. Results Of the 576 wrist arthroscopies reviewed, 324 met the inclusion criteria. Preoperative antibiotics were administered in 209 cases (65%) and not administered in 115 cases (35%). There were 116 cases (36%) with concomitant open soft tissue procedures. We identified 2 infections (0.6% overall infection rate), both of which were in patients who had received preoperative antibiotics. Both of these patients underwent concomitant percutaneous pinning of carpal bones with Kirschner wires, which were buried beneath the skin. Conclusions Administering preoperative antibiotics for routine wrist arthroscopy does not appear to lower the surgical site infection rate. The rate of surgical site infection is so low in both cohorts that a meaningful difference cannot be determined between the 2 groups. This study adds to the current body of literature suggesting that it is acceptable practice to withhold preoperative antibiotics for surgeries that have a very low rate of infection. (J Hand Surg Am. 2018;-(-):1.e1-e6. Copyright Ó 2018 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Clean surgery, preoperative antibiotic, preoperative protocol, surgical site infection, wrist arthroscopy.
W
used technique for the evaluation and treatment of intra-articular pathology, with an estimated 25,000 cases performed in the United RIST ARTHROSCOPY IS A COMMONLY
From the *Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN; †Department of Orthopaedics, University of Rochester, Rochester, NY; and the ‡TRIA Orthopaedic Center, Bloomington, MN. Received for publication June 5, 2017; accepted in revised form March 20, 2018. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Deborah C. Bohn, MD, TRIA Orthopaedic Center, 8100 Northland Drive, Bloomington, MN 55431; e-mail: [email protected]. 0363-5023/18/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2018.03.040
States in 2006.1 Among surgeons who perform these procedures, there is heterogeneity in the practice of administering preoperative antibiotics. However, there is no clear evidence that preoperative antibiotics lower the incidence of infection for this type of procedure. The American Association of Plastic Surgeons has recommended that antibiotics are not necessary for clean surgical cases of the hand, because they do not lower the infection rate.2,3 Although this recommendation has been widely accepted for procedures such as carpal tunnel release, our experience is that most patients undergoing wrist arthroscopy are still routinely given preoperative antibiotics.
Ó 2018 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1.e1
1.e2
PREOPERATIVE ANTIBIOTICS IN WRIST ARTHROSCOPY
Looking to the literature regarding arthroscopic procedures performed on other joints, a 2007 review of knee arthroscopies showed that administration of preoperative antibiotics did not change the incidence of surgical site infections.4 Despite evidence that antibiotics do not change the incidence of surgical site infections in knee arthroscopy, a 2009 survey of orthopedic surgeons showed that 85% still administered preoperative antibiotics for arthroscopic meniscectomies.5 The use of preoperative antibiotics does have associated morbidity and cost. Prior literature has shown that diarrhea occurs in 2% to 5% of patients treated with cephalosporins, and that even a single dose of preoperative cephalosporin can precipitate diarrhea or intestinal Clostridium difficile infection.6,7 In addition, careful antibiotic stewardship is critical in modern medical practice to limit the rise in antibiotic-resistant pathogens seen in recent decades. Given the drawbacks of antibiotic overuse and the evidence from knee arthroscopy literature, we sought to investigate the need for preoperative antibiotics in wrist arthroscopy. Our primary objective was to determine if there is a clinically meaningful difference in postoperative infection rates in patients undergoing wrist arthroscopy with or without administration of preoperative antibiotics. The secondary objective was to determine other factors that may be associated with infection in wrist arthroscopy. Our hypothesis was that there would be no difference in the rate of infection whether or not prophylactic antibiotics were given.
surgical procedure performed, whether there were concomitant open procedures, whether preoperative antibiotics were given, and tourniquet time during the case. Additional demographic data such as patient age, sex, diabetic status, and smoking status at the time of surgery were recorded for each case. Electronic medical records were reviewed for 30 days from the time of surgery to identify postoperative infections. Our criteria for a postoperative infection followed the National Nosocomial Infections Surveillance criteria for defining a surgical site infection (SSI), which include infections occurring within 30 days of the operation if there is no retained implant, and within 1 year if there is a retained implant.8 We did not exclude patients who had minor concomitant open procedures for which preoperative antibiotics would not be otherwise indicated (eg, carpal tunnel release, trigger finger release; full list can be found in Appendix A, available on the Journal’s Web site at www.jhandsurg.org). However, we did exclude patients who had open bony procedures and elaborate open soft tissue procedures (eg, open triangular fibrocartilage complex repair; full list can be found in Appendix A). Additional exclusion criteria were an arthroscopy performed for an existing infection (Current Procedural Terminology 29843) and follow-up less than 30 days. The antibiotic protocol at our institution is to administer 2 g of cefazolin or 900 mg of clindamycin (in the case of a penicillin or cephalosporin allergy) intravenously within 30 minutes before skin incision. In patients over 120 kg, the cefazolin dose is increased to 3 g, but the clindamycin dose remains at 900 mg. These doses are based on the American Society of Health-System Pharmacists report from 2013.9
MATERIALS AND METHODS This study was approved by our institutional review board as category 5 research. Approval was received for access to 719 records for 576 unique patients with a waiver of informed consent as research involved no more than minimal risk to subjects. Within our institution, there are surgeons who routinely give preoperative antibiotics for wrist arthroscopy surgery, and others who do not. This created historical cohorts of patients who did and did not receive routine preoperative antibiotics for wrist arthroscopy. We performed a retrospective chart review of a 10-year period (March 15, 2005, to December 31, 2015) at a single orthopedic ambulatory surgery center, querying by Current Procedural Terminology codes for wrist arthroscopy. The specific codes used were 29840, 29844, 29845, and 29846. The operative reports and anesthesia records of each identified case were reviewed to confirm the J Hand Surg Am.
RESULTS We identified 576 wrist arthroscopies performed by 8 surgeons during the time period queried. Of these, 324 met the inclusion criteria. Reasons for exclusion were concomitant open bony or ligamentous procedures at the wrist (173), inadequate follow-up (70), and incomplete data in the operative and anesthesia records regarding the procedure performed or administration of preoperative antibiotics (9). The median patient age was 38 (range, 11e75) years, and the ratio of males to females was almost equal. With respect to recorded medical comorbidities, 13% of the patients were smokers, and 3% had diabetes. Of the 324 cases that met criteria for analysis, the most common indications for the operation were an r
Vol. -, - 2018
1.e3
PREOPERATIVE ANTIBIOTICS IN WRIST ARTHROSCOPY
arthroscopic triangular fibrocartilage complex debridement (187) and an arthroscopic synovial debridement (114). Preoperative antibiotics were administered to 209 patients (65%), and 115 patients (35%) did not receive preoperative antibiotics. There were 116 cases (36%) with concomitant open soft tissue procedures, the most common of which was an isolated posterior interosseous neurectomy (Table 1). We identified 2 infections, both of which were in patients who had received preoperative antibiotics. Neither of these patients were smokers, diabetic, and had had previous operations on the same wrist. These 2 patients had body mass indices of 20 and 31. Both infections occurred in patients who had arthroscopic-assisted percutaneous pinning of intercarpal ligament injuries. In both cases, the Kirschner wires were buried subcutaneously and were removed at the time of irrigation and debridement for infection. A tourniquet was not used during the index procedure in either case. Specific details of these 2 infections are listed in Table 2.
TABLE 1. Concomitant Open Procedures in Included Patients No Antibiotic Group
Isolated posterior interosseous neurectomy
34
36
Posterior interosseous neurectomy plus second procedure
12
2
Ganglion excision
7
1
Carpal tunnel release
5
1
Percutaneous pinning of intercarpal ligament tear or distal radius fracture
6
0
First dorsal compartment release
2
2
Trigger finger release
1
1
Other procedure(s)
5
1
72
44
Total
infections occurred in the group that received antibiotics, withholding antibiotics cannot be claimed to be superior because of the low number of infections and lack of power of this study to demonstrate a difference between these groups. Our study showed an overall SSI rate of 0.6% when the 2 groups were combined. This rate approximates the infection rate of clean hand surgery cases.1 This is notably higher than a recent study by Leclercq et al,1,11 in which only 1 deep infection was reported after isolated wrist arthroscopy from a study population of 10,107, although the authors of that study did not specify how many of the total cases had concomitant open procedures, nor how many patients received preoperative antibiotics. The rate of infection in that study was based on a survey sent to surgeons asking them to review their personal complications data. Our surgical site infection rate of 0.6% is also higher than rates of infection reported in knee and shoulder arthroscopy, both of which have been shown in multiple large studies to have infection rates below 0.5%.4,12e14 This discrepancy may be attributable to a longer length of follow-up in this study than in other reports, which is as short as 2 weeks.4,12e14 This study does have considerable limitations. Because infection events are quite rare, we would need a substantially greater number of cases to show any statistically significant difference in infection rate with the use of antibiotics. Assuming a baseline risk of infection of 0.5% and making a theoretical
DISCUSSION Surgical site infection and its prevention is a primary concern for modern health care systems. Worldwide, protocols have been developed for surgical safety that include verification of the administration of preoperative intravenous antibiotics. The American Medical Association published the Center for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection 2017, wherein a systematic review was performed to determine best available evidence-based practices.10 With regard to the use of preoperative intravenous antibiotics, this guideline states, “Administer preoperative antimicrobial agents only when indicated based on published clinical practice guidelines.” There is clear evidence that preoperative antibiotics reduce the rate of SSI for orthopedic procedures such as joint arthroplasty and spine surgery. There are numerous reports, however, that there is neither a statistically nor clinically significant reduction in SSI for orthopedic surgeries in which SSI is rare.2e4 Presumably, based in part on this literature, the American Society of HealthSystem Pharmacists does not recommend surgical antimicrobial prophylaxis for clean orthopedic surgery that does not involve an implant in the hand, knee, or foot in their Clinical Practice Guidelines.9 Our results show that performing wrist arthroscopy without administering preoperative antibiotics does not increase the SSI rate. Although the 2 observed J Hand Surg Am.
Antibiotic Group
Procedure
r
Vol. -, - 2018
1.e4
PREOPERATIVE ANTIBIOTICS IN WRIST ARTHROSCOPY
TABLE 2.
Characteristics of Patients Who Developed Infections
Patient
1
Age
2
67
21
Diagnosis
Scapholunate ligament tear
Lunotriquetral ligament tear
Procedure performed
Arthroscopic-assisted reduction and percutaneous pinning
Midcarpal debridement, arthroscopic-assisted reduction, and percutaneous pinning
Received antibiotics?
Yes—cefazolin
Yes—cefazolin
Pins buried?
Yes
Yes
Time to infection
39 d
11 d
Infection site
Wrist joint
Wrist joint
Organism
MSSA
MSSA
Intervention required
Surgical debridement Outpatient management Oral dicloxacillin, duration unknown
Surgical debridement Four-day hospitalization Three-week IV ampicillin-sulbactam
Smoking status
Nonsmoker
Nonsmoker
Comorbidities
None
None
IV, intravenous; MSSA, methicillin-sensitive Staphylococcus aureus.
assumption that antibiotic administration could change the rate of infection by 50%, the number needed to treat to prevent 1 infection would be 400. Based on the findings in this study, it is unlikely that antibiotic administration decreases the risk by 50%, and thus the number needed to treat is likely to be dramatically higher, making the development of an appropriately powered study prohibitively impractical. In addition, this is a retrospective review, introducing the possibility of selection bias as to which patients received antibiotics. Although we did not sort the administration of antibiotics by a surgeon, some surgeons in the practice routinely ordered antibiotics and some routinely did not. Also, because there were 8 surgeons involved, variations in technique and skill level, length of procedures, involvement of trainees in some cases, and patient mix could bias the results. Because we excluded cases with concomitant open bony and ligamentous procedures in the same region, our findings can only be applied to wrist arthroscopy with soft tissue or minor concomitant procedures. Despite the above limitations, our results lead us to conclude that preoperative antibiotics do not clearly reduce the infection rate in wrist arthroscopy. The costs and risks associated with administration of antibiotics for a procedure with such a low infection rate likely outweigh any benefit. This study adds to the current body of literature suggesting that it is J Hand Surg Am.
acceptable practice to not administer preoperative antibiotics for surgeries that have a very low rate of infection. REFERENCES 1. Jain NB, Higgins LD, Losina E, Collins J, Blazar PE, Katz JN. Epidemiology of musculoskeletal upper extremity ambulatory surgery in the United States. BMC Musculoskelet Disord. 2014;15:4. https://doi.org/10.1186/1471-2474-15-4. 2. Ariyan S, Martin J, Lal A, et al. Antibiotic prophylaxis for preventing surgical-site infection in plastic surgery: an evidencebased consensus conference statement from the American Association of Plastic Surgeons. Plast Reconstr Surg. 2015;135(6): 1723e1739. 3. Bykowski MR, Sivak WN, Cray J, Buterbaugh G, Imbriglia JE, Lee WPA. Assessing the impact of antibiotic prophylaxis in outpatient elective hand surgery: a single-center, retrospective review of 8, 850 cases. J Hand Surg Am. 2011;36(11):1741e1747. 4. Bert JM, Giannini D, Nace L. Antibiotic prophylaxis for arthroscopy of the knee: is it necessary? Arthroscopy. 2007;23(1):4e6. 5. Redfern J, Burks R. 2009 survey results: surgeon practice patterns regarding arthroscopic surgery. Arthroscopy. 2009;25(12): 1447e1452. 6. Privitera G, Scarpellini P, Ortisi G, Nicastro G, Nicolin R, de Lalla F. Prospective study of Clostridium difficile intestinal colonization and disease following single-dose antibiotic prophylaxis in surgery. Antimicrob Agents Chemother. 1991;35(1):208e210. 7. Bartlett JG. Clinical practice. Antibiotic-associated diarrhea. N Engl J Med. 2002;346(5):334e339. 8. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control. 1999;27(2): 97e132. 9. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195e283.
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13. D’Angelo GL, Ogilvie-Harris DJ. Septic arthritis following arthroscopy, with cost/benefit analysis of antibiotic prophylaxis. Arthroscopy. 1988;4(1):10e14. 14. Müller-Rath R, Becker J, Ingenhoven E. Wie hoch ist das statistische Risiko einer Infektion nach ambulanter Arthroskopie?: Eine Auswertung von über 50.000 Fällen anhand der Statistik des BVASK/[What is the statistical risk of infection after outpatient arthroscopy?]. Arthroskopie. 2008;21(2): 87e91.
10. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for disease control and prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017;152(8):784e791. 11. Leclercq C, Mathoulin C. Members of European Wrist Arthroscopy Society. Complications of wrist arthroscopy: a multicenter study based on 10,107 arthroscopies. J Wrist Surg. 2016;5(4):320e326. 12. Armstrong RW, Bolding F, Joseph R. Septic arthritis following arthroscopy: clinical syndromes and analysis of risk factors. Arthroscopy. 1992;8(2):213e223.
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APPENDIX A. All Included and Excluded Concomitant Open Procedures Included Concomitant Open Procedures
Excluded Concomitant Open Procedures
Posterior interosseous nerve neurectomy Dorsal wrist ganglion cyst excision Volar wrist ganglion cyst excision Carpal tunnel release First extensor compartment release Trigger finger release Guyon’s canal release Cubital tunnel decompression Digital arthrodesis Percutaneous fracture pinning Incision extension to achieve hemostasis Lateral elbow contracture release
Ulnar shortening osteotomy Removal of ulnar exostosis Carpometacarpal arthrodesis Open scapholunate ligament repair Open scaphoid screw removal Wafer resection of ulnar head Excision of distal radius bone cyst Open pisiform excision Scapholunate capsulorrhaphy Excision of volar forearm mass Radical flexor synovectomy Open triquetral excision Open reduction internal fixation distal radius Open reduction of lunate dislocation Open triangular fibrocartilage repair Open excision ulnar styloid nonunion Open radiocarpal biopsy Proximal row carpectomy Distal radius osteotomy Open fibrous scar removal Open loose body removal from wrist
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