Zhenbang Yang

Background: The use of cephalosporins for surgical site infection (SSI) prevention has become a clinical routine, however, high-level evidence regarding the optimal generation for open fractures is currently limited. This study aims to investigate the association between the generation of cephalosporins and SSI risk in open fractures. Methods: This prospective cohort study used data from the Surgical Site Infection in Orthopedic Surgery (SSIOS), a prospectively maintained database, conducted at a tertiary orthopedic university hospital from October 2014 to December 2020. The primary outcome was occurrence of SSI within 1 year after operation, and its association with the generation of cephalosporins was examined using multivariable logistic regressions and generalized estimating equations. Generalized additive models were used to calculate the relative contribution of potential factors likely influencing SSI. Results: A total of 3582 eligible patients, 74.6% males, with a mean age of 43.7 ± 14.1 years, were included. First-, second-, and third-generation cephalosporins were used in 1957 (54.6%), 1219 (34.0%), and 406 (11.3%) patients. Compared to first-generation cephalosporins, the use of second-generation cephalosporins was significantly associated with a higher risk of SSI (absolute risk difference [ARD] = 3.70%; 95% CI, 1.90%–5.51%; adjusted OR [aOR] = 1.604; 95% CI, 1.212–2.124), whereas third-generation cephalosporins were not (ARD = 1.02%; 95% CI, −1.78% to 3.82%; aOR = 1.234; 95% CI, 0.790–1.880). Among the 28 potential factors considered, the generation of cephalosporins was ranked 9th in terms of its impact on the risk of SSI. Conclusion: Perioperative use of higher-generation cephalosporins was not associated with a reduction in postoperative surgical site infections in open fractures. Our study supports existing guidelines that recommend the use of first-generation cephalosporins as the preferred agents for preventing SSIs in open fractures.

Background: The optimal duration for surgical antibiotic prophylaxis (SAP) for preventing surgical site infection (SSI) in orthopaedic surgeries remains poorly supported by high-level evidence. This study aimed to assess the association between SAP duration and the occurrence of SSI within one year postoperatively. Methods: This prospective cohort study was based on the database from Surgical Site Infection Surveillance and Improvement Project (SISIP) of a tertiary orthopaedic university hospital from October 2014 to December 2020. The main outcome was SSI, defined according to the CDC/NHSN criteria, determined by a review of index hospitalization medical records, microbiology laboratory reports, and readmission records for SSI treatment within one year after discharge. Adjusted generalized additive models (GAMs) were performed to assess the relationships between SAP duration and SSI, determine the cut-off point of SAP duration, and estimate the relative contribution of each included variable across the overall cohort and the three subgroups (open fracture, closed fracture, and non-traumatic group). Multivariable logistic regression models were used to estimate the association between prolonging SAP duration based on the cut-off point and SSI. Results: There were 37 046 patients (55.1% male) included, with an overall SSI incidence of 2.35% (871/37 046). In adjusted GAMs, no statistically significant relationships were observed in the overall cohort and open or closed group ( P >0.05), but a non-linear relationship was exhibited in the non-traumatic group ( P =0.03); the cut-off point was 2.4 days for the overall cohort and 3.6 days (open), 2.6 days (closed), 1.1 days (non-trauma) for three subgroups. In adjusted logistic regression, prolonging SAP duration did not demonstrate a statistically significant protective effect in overall cohort (aOR=0.868; 95% CI, 0.746–1.011) and three groups (open: aOR=0.867; 95% CI, 0.668–1.124; closed: aOR=0.925; 95% CI, 0.754–1.135; non-trauma: aOR=1.184; 95% CI, 0.832–1.683). The relative contribution ranks of SAP duration were 21st overall among 34 factors, 14th for open fractures, 28th for closed fractures, and 3rd for the non-traumatic group among 33 factors. Conclusion: Prolonged postoperative SAP duration has no protective effect against SSI in orthopaedic surgery. Our findings support current guidelines against the practice of continuing SAP postoperatively.

Purpose The optimal choice of distal locking modes remains a subject due to limited available data, and therefore, this study aims to investigate the relationship between distal locking mode and postoperative mechanical complications in an intertrochanteric fracture (ITF) population who underwent closed reduction and intramedullary fixation with a PFNA-II. Methods Patients aged 65 years or older who underwent surgery with PFNA-II fixation in a university teaching hospital between January 2020 and December 2021 were potentially eligible. Based on the distal locking mode, patients were classified into static, dynamic, and limited dynamic groups, among which the differences were tested using univariate analysis. Multivariate logistic regression was used to examine whether the distal locking mode was independently associated with the risk of postoperative one year mechanical complications, adjusting for covariates and potential confounders. Subgroup analyses were performed to evaluate the robustness of the findings. Result Among 507 eligible patients, 33 (6.5%) developed postoperative mechanical complications. In the univariate analysis, sex (P = 0.007), fracture type (P = 0.020), LAT Parker ratio (P = 0.023), and lateral femoral (P = 0.003) wall showed that the differences were significant. Compared to the static group, the limited dynamic group and the dynamic group showed higher odds of postoperative mechanical complications (OR = 3.314, 95% CI: 1.215–9.041; and OR = 3.652, 95% CI: 1.451–9.191, respectively). These associations were robust across a series of analyses, including adjusting for confounders and subgroup analyses. Conclusion Using a distal non-static locking mode significantly increases the risk of postoperative mechanical complications, and static locking could be a preferable option when treating an intertrochanteric fracture.

Background: Malnutrition is significantly associated with unfavorable outcomes, but there is little high-level evidence to elucidate the association of malnutrition with losing walking independence (LWI) after hip fracture surgery. This study aimed to assess the association between preoperative nutritional status evaluated by the Controlling Nutritional Status (CONUT) score and walking independence at 180 days postoperatively in Chinese older hip fracture patients. Methods: This prospective cohort study included 1958 eligible cases from the SSIOS database. The restricted cubic spline was used to assess the dose-effect relationship between the CONUT score and the recovery of walking independence. Propensity score matching was performed to balance potential preoperative confounders, and multivariate logistic regression analysis was applied to assess the association between malnutrition and LWI with perioperative factors for further adjustment. Furthermore, inverse probability treatment weighting and sensitivity analyses were performed to test the robustness of the results and the Fine and Gray hazard model was applied to adjust the competing risk of death. Subgroup analyses were used to determine potential population heterogeneity. Results: The authors found a negative relationship between the preoperative CONUT score and recovery of walking independence at 180 days postoperatively, and that moderate-to-severe malnutrition evaluated by the CONUT score was independently associated with a 1.42-fold (95% CI, 1.12–1.80; P=0.004) increased risk of LWI. The results were overall robust. And in the Fine and Gray hazard model, the result was still statistically significant despite the apparent decrease in the risk estimate from 1.42 to 1.21. Furthermore, significant heterogeneities were observed in the subgroups of age, BMI, American Society of Anesthesiologists score, Charlson’s comorbidity index, and surgical delay (P for interaction < 0.05). Conclusion: Preoperative malnutrition is a significant risk factor for LWI after hip fracture surgery, and nutrition screening on admission would generate potential health benefits.