Risk factors, bacteriological profile and outcome of surgical site infections following orthopaedic surgery.

BACKGROUND AND OBJECTIVES: Surgical site infection (SSI) is a challenge for the surgeon. Incidence of SSI reported in literature varies from 0.5% to 15%. Severity of SSI ranges from superficial skin infection to life-threatening condition like septicaemia. It is responsible for increased morbidity, mortality, and economic burden to the hospital in general, and the patient in particular. The aim of this study was to assess the risk factors, bacteriological profile, length of hospitalization, and cost due to orthopaedic SSI in patients admitted to a tertiary care hospital. MATERIALS AND METHODS: This was a prospective case control study. Cases were diagnosed based on CDC definition of nosocomial SSI. All cases were assessed preoperatively, intraoperatively and postoperatively, according to type of surgery, wound class, duration of operation, antimicrobial prophylaxis, use of drain, preoperative hospital stay, causative micro organism, total hospital stay, readmission rates and cost incurred. Age, sex and surgical procedure matched controls without SSI, were also assessed. Chi-square test and Fisher's exact test were used for analysis. P= <0.05 was considered significant. RESULTS: Out of 1023 patients, 47 cases had SSI, with a rate of 4.6%. Cigarette smoking was a risk factor for SSI (P = 0.0035). The most common etiologic agents were Acinetobacter baumannii and Staphylococcus aureus. Incidence of readmission among SSI cases was more compared to controls (P= 0.0001). Costs attributable to SSI (Indian Rupees) was Rs 32,542 (17,054 to 87,514) which was significantly more than those without SSI (P= <0.001). CONCLUSION: Despite latest surgical amenities, meticulous sterilization protocols and pre-operative antibiotic prophylaxis, SSI continues to be present in healthcare settings. The increase in duration of hospital stay due to SSI adds to additional burden to an already resource-constrained healthcare system.

Parosteal Lipoma of Proximal Radius: A Case Report of an Unusual Swelling and Review of Literature.

INTRODUCTION: Lipomas are considered to be benign tumors comprising 50% of all soft tissue tumors. They originate from mesodermal germ layer but are classified based on component tissue and location. Parosteal lipomas are frequently located at the extremities, particularly at diaphysis or diametaphysis of long bones. CASE REPORT: Here, we report a case of parosteal lipoma with a delayed presentation involving dominant right forearm without any neurological deficits to create awareness of the rare existence of this benign tumor. CONCLUSION: A prompt diagnosis of such tumors has to be done as early as possible.

Is the Cage an Additional Hardware in Lumbar Interbody Fusion for Low Grade Spondylolisthesis? A Prospective Study.

INTRODUCTION: Lumbar interbody fusion has become the standard of care for the management of lumbar instability, where fusion is achieved using bone grafts, cages, etc. AIM: The aim of the study was to compare the outcomes of the interbody fusion using interbody cage technique and stand alone local bone graft technique. MATERIALS AND METHODS: A total of 30 patients, operated for single level instability with low grade lytic and degenerative spondylolisthesis of L4-5/L5-S1, were selected and grouped into two groups: Group I (stand alone grafts) and Group II (interbody cage and graft) based on computer generated random numbers. All patients who underwent interbody fusion through conventional open posterior approach were included in the study. Data regarding the time taken for interbody fusion, formaninal height maintenance, disc height restoration, translation, functional scores (VAS,ODI) and operative complications were analysed using in both the groups was collected and a student's-t test was performed to evaluate the difference. RESULTS: The mean age of patients in Group I was 46.7 years whereas, the mean age of patients in Group II was 43.5 years with mean age of 46.7 years and 43.5 years respectively. Interbody fusion, was achieved in seven and eight months in Group I and II respectively (p>0.05). The clinical results of both groups were comparable and there was no significant difference between the two groups in VAS score (p-0.147) and ODI score (p-0.983). Radiological parameters were also comparable and there was no significant difference between the postoperative measurements of the two groups (p=0.348 for translation, p=0.310 for intervertebral disc height and p=0.135 for foraminal height). One patient in Group I had transient foot drop which recovered, while one in Group II had infection, wound was managed with wound wash and antibiotics and another patient in Group II had pseudoarthrosis. CONCLUSION: Lumbar interbody fusion with standalone local bone grafts is sufficient in single level low grade spondylolisthesis treated by conventional open surgery.

Unstable Distal Radius Fractures Treated by Volar Locking Anatomical Plates.

INTRODUCTION: Fracture of the distal end of radius represents the most common fracture of the upper extremity accounting for 16-20% of all fractures. Plating is now emerging as the gold standard for management of distal radius fractures due to increased rate of complications such as malunion, subluxation/dislocation of distal radio-ulnar joint or late collapse of fracture. Procedures such as closed reduction and cast immobilization, ligamentotaxis with external fixator and percutaneous pin fixation are no longer acceptable. AIM: The purpose of the study was to evaluate the functional and radiological outcome of unstable distal radius fractures treated with the volar locking plate. MATERIALS AND METHODS: We reviewed 53 patients from January 2011 to December 2015, treated for unstable distal radius fractures using a volar locking compression plate. Standard radiographic and clinical assessment after 12 months (range 12-16 months) were measured and final functional and radiological outcome were assessed using the Modified Mayo wrist scoring system and Sarmiento's modification of Lindstorm criteria respectively. RESULTS: There were 42 males and 11 females with an average age of 39.12±31.78 years (18-71 years). At the end of 12 months, 36 patients had an excellent radiological outcome and 10 patients had good radiological outcome as per Sarmiento's modification of Lindstorm criteria. Eleven patients had an excellent functional outcome and 26 patients had a good functional outcome as per modified Mayo wrist scoring system. There was one case of superficial wound infection which subsided with intravenous antibiotics. CONCLUSION: The volar locking plate fixation helps in early mobilization of the wrist, restores anatomy, allows early return to function, prevents secondary loss of reduction and hence is an effective treatment for unstable fractures of the distal radius.

Extensive Osteochondroma of Talus Presenting as Tarsal Tunnel Syndrome: Report of a case and Literature Review.

Osteochondroma or exostosis is the most common benign bone tumor, and occurring frequently in the proximal humerus, tibia, and distal femur. It rarely affects talus. Osteochondroma of talus is a very rare etiology of tarsal tunnel syndrome (TTS). We report a rare case of extensive osteochondroma of the talus in a 60 year old female presenting with multiple swellings around the ankle and symptoms suggestive of tarsal tunnel syndrome. En-block excision of the multiple masses was done. Histopathological examination confirmed the diagnosis of osteochondroma. Although most of the osteochondromas are being treated conservatively, those presenting with multiple swellings, restriction of movements and compressive neuropathies should be treated with surgical excision. Excision is a successful method of treatment for symptomatic osteochondromas with low recurrence.

Chronic Osteomyelitis of Clavicle in a Neonate: Report of Morbid Complication of Adjoining MRSA Abscess.

Osteomyelitis of clavicle is rare in neonates. Acute osteomyelitis of clavicle accounts for less than 3% of all osteomyelitis cases. It may occur due to contiguous spread, due to hematogenous spread, or secondary to subclavian catheterization. Chronic osteomyelitis may occur as a complication of residual adjoining abscess due to methicillin resistant staphylococcus aureus (MRSA) sepsis. We report a newborn female with right shoulder abscess that developed chronic clavicular osteomyelitis in follow-up period after drainage. She required multiple drainage procedures and was later successfully managed with bone curettage and debridement. We report this case to highlight that a MRSA abscess may recur due to residual infection from a chronic osteomyelitis sinus. It may be misdiagnosed as hypergranulation tissue of nonhealing wound leading to inappropriate delay in treatment. High index of suspicion, aggressive initial management, and regular follow-up are imperative to prevent this morbid complication.

Type II Intertrochanteric Fractures: Proximal Femoral Nailing (PFN) Versus Dynamic Hip Screw (DHS).

BACKGROUND: Intertrochanteric fracture is one of the most common fractures of the hip especially in the elderly with osteoporotic bones, usually due to low-energy trauma like simple falls. Dynamic Hip Screw (DHS) is still considered the gold standard for treating intertrochanteric fractures by many. Not many studies compare the DHS with Proximal femoral nail (PFN), in Type II intertrochanteric fractures (Boyd and Griffin classification). This study was done to compare the functional and radiological outcome of PFN with DHS in treatment of Type II intertrochanteric fractures. METHODS: From October 2012 to March 2015, a prospective comparative study was done where 30 alternative cases of type II intertrochanteric fractures of hip were operated using PFN or DHS. Intraoperative complications were noted. Functional outcome was assessed using Harris Hip Score and radiological findings were compared at 3, 6, and 12 months postoperatively. RESULTS: The average age of the patients was 60 years. In our series we found that patients with DHS had increased intraoperative blood loss (159ml), longer duration of surgery (105min), and required longer time for mobilization while patients who underwent PFN had lower intraoperative blood loss (73ml), shorter duration of surgery (91min), and allowed early mobilization. The average limb shortening in DHS group was 9.33 mm as compared with PFN group which was only 4.72 mm. The patients treated with PFN started early ambulation as they had better Harris Hip Score in the early post-op period. At the end of 12th month, there was not much difference in the functional outcome between the two groups. CONCLUSION: PFN is better than DHS in type II intertrochanteric fractures in terms of decreased blood loss, reduced duration of surgery, early weight bearing and mobilization, reduced hospital stay, decreased risk of infection and decreased complications.

Predebridement wound culture in open fractures does not predict postoperative wound infection: A pilot study.

BACKGROUND: There is confusion in the current literature regarding the value of obtaining predebridement wound cultures in the management of open fractures with several studies reporting contrasting results. We undertook a pilot study to determine the initial bacterial flora of open fractures in our environment and determine the correlation between subsequent wound infection if any, and the initial bacterial flora. MATERIALS AND METHODS: Initial/predebridement wound swabs were obtained for 32 patients with open fractures. Patients underwent a debridement of the open wound and preliminary stabilization of fracture in the operating room within 24 h. Postdebridement wound cultures were obtained at 48 h and repeated subsequently, if indicated, during the follow-up period. The antibiotic therapy was modified based on the culture reports. RESULTS: Initial wound swab culture showed bacterial contamination in 18 patients (56%); 14 patients (44%) developed an infection in the immediate postoperative period or during follow-up. Age, gender, co-morbid medical condition, delay in presentation, and grade of open fracture were not found to be predictors of postoperative infection. No patient had an infection with the same organism, which was present in the initial culture. CONCLUSION: The findings of this study suggest that the initial flora are not the infecting organisms in the open fracture wounds, and predebridement wound cultures have no value in predicting postdebridement wound infection.