Hospital cost of dislocation after primary total hip arthroplasty. Risk factors associated with deep surgical site infections after primary total knee arthroplasty: an analysis of 56,216 knees. Risk factors for deep surgical site infections after spinal fusion An Increase in Compliance With the Surgical Care Improvement Project Measures Does Not Prevent Surgical Site Infection in Colorectal Surgery Wound Infection After Elective Colorectal Resection Accuracy of economic studies on surgical site infection. Antibiotic prophylaxis and the risk of surgical site infections following total hip arthroplasty: timely administration is the most important factor. Prospective Controlled Trial of STAR Total Ankle Replacement versus Ankle Fusion: Initial Results The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Presurgical Skin Preparation With a Novel 2% Chlorhexidine Gluconate Cloth Reduces Rates of Surgical Site Infection in Orthopaedic Surgical Patients A prospective, randomised, controlled trial of the use of drains in total hip arthroplasty. Prevention of surgical site infections by an infusion of topical antibiotics in morbidly obese patients. The Bisurface Total Knee Replacement: A Unique Design for Flexion Four-to-Nine-Year Follow-up Study* Single vs Repeat Surgical Skin Preparations for Reducing Surgical Site Infection After Total Joint Arthroplasty: A Prospective, Randomized, Double-Blinded Study. Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project. Healthcare Savings Associated with Reduced Infection Rates Using Antimicrobial Suture Wound Closure for Cerebrospinal Fluid Shunt Procedures Comparative study of innovative postoperative wound dressings after total knee arthroplasty. Procedure-specific surgical site infection rates and postdischarge surveillance in Scotland. Risk factors for surgical-site infection following primary total knee arthroplasty. Total ankle arthroplasty in inflammatory joint disease with use of two mobile-bearing designs. Midterm Survivorship of the Lefèvre Constrained Liner: A Consecutive Multisurgeon Series of 166 Cases. A randomised controlled trial of the clinical effectiveness and cost-effectiveness of different knee prostheses: the Knee Arthroplasty Trial (KAT). Surveillance and epidemiology of surgical site infections after cardiothoracic surgery in The Netherlands, 2002-2007.
BACKGROUND The treatment of dislocation following primary total hip arthroplasty usually requires the use of expensive hospital re sources and sometimes requires revision surgery . The hospital costs associated with treating this complication have not been previously analyzed , to our knowledge . The purpose of this study was to assess the financial impact of treating dislocations at our institution . METHODS Between 1997 and 2001 , 3671 patients underwent a total of 4054 consecutive primary total hip arthroplasties at our institution . The patients were prospect ively followed at regular intervals , and their follow-up data were recorded in an institutional total joint registry . Ninety-nine hips ( 2.4 % ) in ninety-nine patients dislocated . The costs to our institution to treat these dislocations were evaluated by determining the cost of each treatment episode required to reestablish hip stability and were expressed as the percent increase in cost compared with that of an uncomplicated primary total hip replacement . RESULTS Of the ninety-nine hips that dislocated , sixty-two ( 63 % ) remained stable after one or more closed reductions and thirty-seven ( 37 % ) ultimately required revision surgery . The hospital cost of each closed reduction episode represented 19 % of the hospital cost of an uncomplicated total hip replacement . When revision surgery was eventually needed , the average hospital costs of one or more closed reductions and the subsequent revisions represented 148 % of the hospital cost of an uncomplicated primary total hip replacement . CONCLUSIONS Dislocation after primary hip replacement continues to be a prevalent and costly complication that diminishes the cost-effectiveness of an otherwise very successful surgical procedure BACKGROUND Deep surgical site infection  following total knee arthroplasty is a devastating complication . Patient and surgical risk factors for this complication have not been thoroughly examined . The purpose of this study was to evaluate risk factors associated with deep surgical site infection following total knee arthroplasty in a large U.S. integrated health-care system . METHODS A retrospective review of a prospect ively followed cohort of primary total knee arthroplasties recorded in a total joint replacement registry from 2001 to 2009 was conducted . Records were screened for deep surgical site infection with use of a vali date d algorithm , and the results were adjudicated by chart review . Patient factors , surgical factors , and surgeon and hospital characteristics were identified with use of the total joint replacement registry . Cox regression models were used to assess risk factors associated with deep surgical site infection . RESULTS A total of 56,216 total knee arthroplasties were identified ; 63.0 % were done in women , the average age of the patients was 67.4 years ( st and ard deviation [ SD ] = 9.6 ) , and the average body mass index ( BMI ) was 32 kg/m2 ( SD = 6 ) . The incidence of deep surgical site infection was 0.72 % ( 404/56,216 ) . In a fully adjusted model , patient factors associated with deep surgical site infection included a BMI of ≥35 ( hazard ratio [ HR ] = 1.47 ) , diabetes mellitus ( HR = 1.28 ) , male sex ( HR = 1.89 ) , an American Society of Anesthesiologists ( ASA ) score of ≥3 ( HR = 1.65 ) , a diagnosis of osteonecrosis ( HR = 3.65 ) , and a diagnosis of posttraumatic arthritis ( HR = 3.23 ) . Hispanic race was protective ( HR = 0.69 ) . Protective surgical factors included use of antibiotic irrigation ( HR = 0.67 ) , a bilateral procedure ( HR = 0.51 ) , and a lower annual hospital volume ( HR = 0.33 ) . Surgical risk factors included quadriceps-release exposure ( HR = 4.76 ) and the use of antibiotic-laden cement ( HR = 1.53 ) . In a sub analysis , operative time was a risk factor , with a 9 % increased risk per fifteen-minute increment . CONCLUSIONS Use of a comprehensive infection surveillance system , combined with a total joint replacement registry , identified patient and surgical factors associated with infection following total knee arthroplasty in a large sample . High-risk patients should be counseled , and modifiable clinical conditions should be optimized . Use of antibiotic irrigation should be encouraged , but antibiotic-laden cement may not be useful . LEVEL OF EVIDENCE Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence Surgical site infections ( SSI ) are undesired and troublesome complications after spinal surgery . The reported infection rates range from 0.7 to 11.9 % , depending on the diagnosis and the complexity of the procedure . Besides operative factors , patient characteristics could also account for increased infection rates . Because the medical , economic and social costs of SSI are enormous , any significant reduction in risks will pay dividends . The purpose of this study is to compare patients who developed deep SSI following lumbar or thoracolumbar spinal fusion with a r and omly selected group of patients who did not develop this complication in order to identify changeable risk factors . With a case – control analysis nested in a historical cohort of patients who had had a spinal fusion between January 1999 and December 2008 , we identified 36 cases with deep SSI ( CDC criteria ) . Information regarding patient-level and surgical-level risk factors was derived from st and ardized but routinely recorded data and compared with those acquired in a r and om selection of 135 uninfected patients . Univariate analyses and a multivariate logistic regression were performed . The overall rate of infection in 1,615 procedures ( 1,568 patients ) was 2.2 % . A positive history of spinal surgery was associated with an almost four times higher infection rate ( OR = 3.7 , 95 % BI = 1.6–8.6 ) . The risk of SSI increased with the number of levels fused , patients with diabetes had an almost six times higher risk and smokers had more than a two times higher risk for deep SSI . The most common organism cultured was Staphylococcus aureus . All infected patients underwent at least one reoperation , including an open débridement and received appropriate antibiotics to treat the organism . Patients who had had a previous spinal surgery are a high-risk group for infection compared with those that never had surgery . Total costs associated with preventive measures are substantial and should be compensated by health care insurance companies by means of separate clinical pathways . High-risk patients should be informed about the increased risk of complications PURPOSE : The primary goal of the Surgical Care Improvement Project is to improve quality of care by implementing evidence -based health care practice s that prevent surgical complications . This study was design ed to test the hypothesis that an increase in compliance with quality process measures decreases the rate of surgical site infections in patients undergoing colorectal surgeries . METHODS : A multidisciplinary task force implemented and monitored compliance with individual quality measures in patients undergoing elective colorectal resections at a tertiary institution . Individual compliance rates and infections were collected prospect ively and review ed monthly . For data analysis , patients were assigned to 2 consecutive 14-month periods : period A ( April 1 , 2006 to May 31 , 2007 ) and period B ( June 1 , 2007 to July 31 , 2008 ) . Comparisons between periods were performed to determine the association of compliance with process measures and outcomes in infections . RESULTS : A total of 491 consecutive patients were treated during the study periods ( period A : n = 238 ; period B : n = 253 ) . There were no statistically significant differences in patient characteristics , diagnoses , or surgical procedures between periods . Compliance with all process measures significantly increased within periods except for perioperative glucose control . Global compliance ( compliance with all measures per patient ) significantly improved from period A to B ( 40%–68 % , respectively ; P < .001 ) . In total , 99 patients ( 19 % ) developed surgical site infections ( period A , 18.9 % ; period B , 19.4 % ) . CONCLUSION : An increase in compliance with the Surgical Care Improvement Project aim ed to prevent surgical site infections does not translate into a significant reduction of surgical site infections in patients undergoing colorectal resections Introduction : Surgical site infection ( SSI ) is a potentially morbid and costly complication following major colorectal resection . In recent years , there has been growing attention placed on the accurate identification and monitoring of such surgical complications and their costs , measured in terms of increased morbidity to patients and increased financial costs to society . We hypothesize that incisional SSIs following elective colorectal resection are more frequent than is generally reported in the literature , that they can be predicated by measurable perioperative factors , and that they carry substantial morbidity and cost . Methods : Over a 2-year period at a university hospital , data on all elective colorectal resections performed by a single surgeon were retrospectively collected . The outcome of interest was a diagnosis of incisional SSI as defined by the Center of Disease Control and Prevention . Variables associated with infection , as identified in the literature or by experts , were collected and analyzed for their association with incisional SSI development in this patient cohort . Multivariate analysis by stepwise logistic regression was then performed on those variables associated with incisional SSI by univariate analysis to determine their prognostic significance . The incidence of SSI in this study was compared with the rates of incisional SSI in this patient population reported in the literature , predicted by a nationally based system monitoring nosocomial infection , and described in a prospect ively acquired intradepartmental surgical infection data base at our institution . Results : One hundred seventy-six patients undergoing elective colorectal resection were identified for evaluation . The mean patient age was 62 ± 1.2 years , and 54 % were men . Preoperative diagnoses included colorectal cancer ( 57 % ) , inflammatory bowel disease ( 20 % ) , diverticulitis ( 10 % ) , and benign polyp disease ( 5 % ) . SSIs were identified in 45 patients ( 26 % ) . Twenty-two ( 49 % ) SSIs were detected in the outpatient setting following discharge . Of all preoperative and perioperative variables measured , increasing patient body mass index and intraoperative hypotension independently predicted incisional SSI . Although we could not measure statistically increased length of hospital stay associated with SSI , a representative population of patients with SSI accumulated a mean of $ 6200/patient of home health expenses related to wound care . Our rates of SSI were substantially higher than that reported generally in the literature , predicted by the National Nosocomial Infection System , or described by our own institutional surgical infection data base . Conclusions : The incidence of incisional SSI in patients undergoing elective colorectal resection in our cohort was substantially higher than generally reported in the literature , the NNIS or predicted by an institutional surgical infection complication registry . Although some of these differences may be attributable to patient population differences , we believe these discrepancies highlight the potential limitations of systematic outcomes measurement tools which are independent of the primary clinical care team . Accurate surgical complication documentation by the primary clinical team is critical to identify the true frequency and etiology of surgical complications such as incisional SSI , to rationally approach their reduction and decrease their associated costs to patients and the health care system Estimating the cost of hospital infection  has become a matter of increasing interest in terms of health economics . This study aim ed to assess the accuracy of economic studies on hospital infections , using surgical site infection ( SSI ) as an example . A search was performed for original articles reporting the  cost of SSI , published in the English language between 1996 and 2005 . For the critical review , the period of cost tracking , classification of costs and cost counting methods were noted . Fifteen articles met the inclusion criteria . The costs of SSI vary according to surgical procedures , country , publication year , study design and accounting method . Only two studies estimated the additional cost of SSI after discharge . All 15 studies included healthcare costs and none measured patient/family re sources . In 10 studies , the costs were calculated based on accounting . Three studies used estimated costs from the ratio of costs to charges and two studies used charge data in place of cost data . It will become increasingly important for future studies to perform multi-centre prospect i ve surveys , establish a st and ard method for cost accounting , include the cost of healthcare services following hospitalization and consider the morbidity cost to patients themselves from a societal perspective BACKGROUND Surgical site infections ( SSIs ) following total hip arthroplasty can lead to prolonged hospitalization , increased morbidity and mortality , and high costs . This article analyzes the effect of various parameters of surgical antibiotic prophylaxis on the risk of SSI following total hip arthroplasty . METHODS Data about SSI and potential prophylaxis- , patient- , and procedure-related risk factors were prospect ively collected for 1922 patients who underwent elective total hip arthroplasty in 11 hospitals that participated in the Dutch intervention project , Surgical Prophylaxis and Surveillance .  Multivariate logistic regression analysis was performed to correct for r and om variation among hospitals . RESULTS SSIs ( superficial and deep ) occurred in 50 patients ( 2.6 % ) . The highest odds ratios for SSI were found in patients who received prophylaxis after incision ( 2.8 , 95 % confidence interval [ CI ] , 0.9 - 8.6 ; P=.07 ) , had an American Society of Anesthesiology score that was > 2 ( 2.8 , 95 % CI , 0.8 - 9.2 ; P=.09 ) , and experienced a duration of surgery that was > 75th percentile ( 2.5 ; 95 % CI , 1.1 - 5.8 ; P=.04 ) . Prolonged prophylaxis after the end of surgery and the use of antibiotic-impregnated cement did not contribute to fewer SSIs in this study . CONCLUSIONS This study suggests that intervention programs in search of amendable factors to prevent SSI should focus on timely administration of antibiotic prophylaxis Background : Mobile-bearing ankle replacements have become popular outside of the United States over the past two decades . The goal of the present study was to perform a prospect i ve evaluation of the safety and efficacy of a mobile-bearing prosthesis to treat end stage ankle arthritis . We report the results of three separate cohorts of patients : a group of Sc and anavian Total Ankle Replacement ( STAR ) patients and a control group of ankle fusion patients ( the Pivotal Study Groups ) and another group of STAR total ankle patients ( Continued Access Group ) whose surgery was performed following the completion of enrollment in the Pivotal Study . Material s and Methods : The Pivotal Study design was a non-inferiority study using ankle fusion as the control . A non-r and omized multi-centered design with concurrent fusion controls was used . We report the initial perioperative findings up to 24 months following surgery . For an individual patient to be considered an overall success , all of the following criteria needed to be met : a ) a 40-point improvement in total Buechel-Pappas ankle score , b ) no device failures , revisions , or removals , c ) radiographic success , and d ) no major complications . In the Pivotal Study ( 9/00 to 12/01 ) , 158 ankle replacement and 66 arthrodesis procedures were performed ; in the Continued Access Study ( 4/02 to 10/06 ) , 448 ankle replacements were performed , of which 416 were at minimum 24 months post-surgery at time of the data base closure . Results : Major complications and need for secondary surgical intervention were more common in the Pivotal Study arthroplasty group than the Pivotal Study ankle fusion group . In the Continued Access Group , secondary procedures performed on these arthroplasty patients decreased by half when compared with the Pivotal Arthroplasty Group . When the Pivotal Groups were compared , treatment efficacy was higher for the ankle replacement group due to improvement in functional scores . Pain relief was equivalent between fusion and replacement patients . The hypothesis of non-inferiority of ankle replacement was met for overall patient success . Conclusion : By 24 months , ankles treated with STAR ankle replacement ( in both the Pivotal and Continued Access Groups ) had better function and equivalent pain relief as ankles treated with fusion . Level of Evidence : II , Prospect i ve Controlled Comparative Surgical OBJECTIVE To measure the impact of orthopedic surgical-site infections ( SSIs ) on quality of life , length of hospitalization , and cost . DESIGN A pairwise-matched ( 1:1 ) case-control study within a cohort . SETTING A tertiary-care university medical center and a community hospital . PATIENTS Cases of orthopedic SSIs were prospect ively identified by infection control professionals . Matched controls were selected from the entire cohort of patients undergoing orthopedic surgery who did not have an SSI . Matching variables included type of surgical procedure , National Nosocomial Infections Surveillance risk index , age , date of surgery , and surgeon . MAIN OUTCOME MEASURES Quality of life , duration of postoperative hospital stay , frequency of hospital readmission , overall direct medical costs , and mortality rate . RESULTS Fifty-nine SSIs were identified . Each orthopedic SSI accounted for a median of 1 extra day of stay during the initial hospitalization ( P = .001 ) and a median of 14 extra days of hospitalization during the follow-up period ( P = .0001 ) . Patients with SSI required more rehospitalizations ( median , 2 vs 1 ; P = .0001 ) and more total surgical procedures ( median , 2 vs 1 ; P = .0001 ) . The median total direct cost of hospitalizations per infected patient was $ 24,344 , compared with $ 6,636 per uninfected patient ( P = .0001 ) . Mortality rates were similar for cases and controls . Quality of life was adversely affected for patients with SSI . The largest decrements in scores on the Medical Outcome Study Short Form 36 question naire were seen in the physical functioning and role-physical domains . CONCLUSIONS Orthopedic SSIs prolong total hospital stays by a median of 2 weeks per patient , approximately double rehospitalization rates , and increase healthcare costs by more than 300 % . Moreover , patients with orthopedic SSIs have substantially greater physical limitations and significant reductions in their health-related quality of life BACKGROUND Postoperative surgical site infections ( SSIs ) are a common complication of joint surgery . Prevention depends on adequate preoperative skin antisepsis . In previous studies , use of a 2 % chlorhexidine gluconate ( CHG ) no-rinse cloth reduced SSI rates in general surgery patients . METHODS Patients admitted for a total joint procedure used a skin antisepsis protocol incorporating 2 % CHG no-rinse cloths to do a site-specific wash on the night before surgery and in the holding area just before surgery . RESULTS In the 3 quarters before implementation of the protocol , the SSI rate was 3.19 % . In the 3 quarters after the 2 % CHG cloth was introduced , the SSI rate decreased to 1.59 % , representing a 50.16 % reduction in SSIs . CONCLUSIONS The rate of SSI was cut in half after the introduction of 2 % CHG no-rinse cloths in the place of a povidone-iodine ( Betadine ) skin antiseptic in orthopaedic patients undergoing total joint procedures . Further testing using r and omization comparative protocol s are required to conclude that the decreased SSI was in fact a direct result of the 2 % CHG protocol The routine use of surgical drains in total hip arthroplasty remains controversial . They have not been shown to decrease the rate of wound infection significantly and can provide a retro grade route for it . Their use does not reduce the size or incidence of post-operative wound haematomas . This prospect i ve , r and omised study was design ed to evaluate the role of drains in routine total hip arthroplasty . We investigated 552 patients ( 577 hips ) undergoing unilateral or bilateral total hip arthroplasty who had been r and omised to either having a drain for 24 hours or  not having a drain . All patients followed st and ardised pre- , intra- , and post-operative regimes and were independently assessed using the Harris hip score before operation and at six , 18 and 36 months follow-up . The rate of superficial and deep infection was 2.9 % and 0.4 % , respectively , in the drained group and 4.8 % and 0.7 % , respectively in the undrained group . One patient in the undrained group had a haematoma which did not require drainage or transfusion . The rate of transfusion after operation in the drained group was significantly higher than for undrained procedures ( p < 0.042 ) . The use of a drain did not influence the post-operative levels of haemoglobin , the revision rates , Harris hip scores , the length of hospital stay or the incidence of thromboembolism . We conclude that drains provide no clear advantage at total hip arthroplasty , represent an additional cost , and expose patients to a higher risk of transfusion BACKGROUND The reported incidence of surgical site infection after abdominal surgery in morbidly obese patients is high ( about 15 % in most studies ) , and this is associated with considerable disability and an increased economic burden . Topical antibiotics may reduce the incidence of serious infections . METHODS St and ard techniques for the prevention of surgical site infections were used along with the introduction of kanamycin into the subcutaneous space of morbidly obese patients at the time of closure and allowing it to dwell for 2 h. Eight hundred thirty-seven evaluable patients were followed for the development of site complications for at least six weeks postoperatively . RESULTS One of the 65 patients with a revisional procedure had a primary deep incisional surgical site infection , as did one of the 772 patients with a primary operation .  Secondary deep incisional surgical site infections occurred in four patients , two after spontaneous evacuation of a seroma , one from excessive superficial contamination , and one following separation of a nonhealing surgical site . Additionally , 21 patients had minor surgical site complications including incisional separation and stitch-related infections , which required no significant expenditure of re sources . CONCLUSIONS Prolonged contact ( 2 h ) of topical kanamycin solution with the surgical site greatly reduces the incidence of primary infections in the deep subcutaneous space of laparotomy sites in morbidly obese patients Background : The Bisurface knee prosthesis was design ed in 1989 to improve knee flexion without affecting the durability of the prosthesis . The prosthesis has a unique ball- and -socket joint in the midposterior portion of the femoral and tibial components , which functions as a posterior stabilizing cam mechanism and causes femoral rollback . The femoral component was made of alumina ceramic . The purpose of this study was to review the clinical results of the first 223 arthroplasties performed with this prosthesis in order to assess whether this new implant had achieved its design objectives . Methods : From December 1989 to May 1994 , all patients who were scheduled for primary total knee arthroplasty were enrolled in a prospect i ve study of the Bisurface knee . The patients were evaluated clinical ly according to The Hospital for Special Surgery knee-rating system and with a self-administered question naire , and they were evaluated radiographically according to the system of the Knee Society . Kaplan-Meier survivorship analysis was performed with revision of the knee or recommendation for revision as the end point . Results : One hundred and sixty-six patients treated with a total of 223 consecutive primary total knee arthroplasties were enrolled in the study , and 182 knees were followed for 3.9 to 9.0 years ( mean , 5.8 years ) . Preoperatively , the mean Hospital for Special Surgery knee score was 44.5 points . At the time of latest follow-up , the mean knee score was 86.3 points . The mean preoperative and postoperative ranges of flexion were 119 and 124 degrees , respectively . The patients , even those with a good preoperative range of motion , rarely lost deep flexion of the knee after the procedure . A revision operation was performed in eight knees ( because of infection in five , instability in two , and breakage of the peg of the patellar component in one ) . Two knees had recurrent medial-lateral subluxations of the femorotibial articulation , which were treated nonoperatively . No prosthesis had loosened aseptically and no alumina ceramic femoral component had broken by the time of latest follow-up . The rate of survival of the implant was 94 percent ( 95 percent confidence interval , 90 to 98 percent ) at six years . According to the patient question naires , 20 percent of the knees sometimes felt loose in daily living activities , which prompted us to improve the intrinsic stability of the prosthesis by improving the congruity of the ball- and -socket joint . Conclusions : Total knee arthroplasty with the Bisurface prosthesis result ed in an excellent range of motion and a high level of satisfaction with the operation ; the durability of the prosthesis is promising BACKGROUND Preventing surgical site infection ( SSI )  after total joint arthroplasty ( TJA ) is a high priority and is partly linked to the efficacy of surgical site preparation solutions ( SPSs ) in reducing the number of pathogens on the skin before incision . The aim of this study is to investigate the effectiveness of SRS reapplication after draping to reduce the incidence of SSI after TJA . METHODS Six hundred patients undergoing primary TJA between 2010 and 2011 at a single institution were recruited and r and omly assigned to one of 2 groups . The patients in the intervention group ( n = 300 ) received SPS that included alcohol and povidone-iodine before draping and an additional SPS by iodine povacrylex and isopropyl alcohol before application of the final adhesive drape , whereas the patients in the control group ( n = 300 ) received a single SPS with alcohol and povidone-iodine before draping . R and omization was performed by an opaque envelope , and the rates of SSI and blistering were compared between groups . RESULTS Five seventy-seven patients completed the study and were included in the final analysis . There was a significant reduction in the incidence of superficial SSI for the intervention group ( 1.8 % , 5 of 283 ) compared to the control group ( 6.5 % , 19 of 294 , P = .02 ) . There were 2 ( 0.7 % , 2 of 294 ) deep incisional SSIs in the control group , and 2 ( 0.7 % , 2 of 283 ) organ-space SSIs in the intervention group ( P = 1.00 ) . In addition , skin blistering was lower in the intervention group ( 3.5 % , 10 of 283 ) vs the control group ( 6.5 % , 19 of 294 ) , but this difference also did not reach statistical significance ( P = .13 ) . CONCLUSION Reapplication of an SPS after draping and before the application of iodophor-impregnated incisive draping result ed in a significant reduction in the rate of SSI in patients undergoing elective TJA HYPOTHESIS  Surgical site infections ( SSIs ) are a major contributor to patient injury , mortality , and health care costs . Despite evidence of effectiveness of antimicrobials to prevent SSIs , previous studies have demonstrated inappropriate timing , selection , and excess duration of administration of antimicrobial prophylaxis . We herein describe the use of antimicrobial prophylaxis for Medicare patients undergoing major surgery . DESIGN National retrospective cohort study with medical record review . SETTING Two thous and nine hundred sixty-five acute-care US hospitals . PATIENTS A systematic r and om sample of 34,133 Medicare in patients undergoing coronary artery bypass grafting ; other open-chest cardiac surgery ( excluding transplantation ) ; vascular surgery , including aneurysm repair , thromboendarterectomy , and vein bypass operations ; general abdominal colorectal surgery ; hip and knee total joint arthroplasty ( excluding revision surgery ) ; and abdominal and vaginal hysterectomy from January 1 through November 30 , 2001 . MAIN OUTCOME MEASURES The proportion of patients who had parenteral antimicrobial prophylaxis  initiated within 1 hour before the surgical incision ; the proportion of patients who were given a prophylactic antimicrobial agent  that was consistent with currently published guidelines ; and the proportion of patients whose antimicrobial prophylaxis was discontinued within 24 hours after surgery . RESULTS An antimicrobial dose was administered to 55.7 % ( 95 % confidence interval [ CI ] , 54.8%-56.6 % ) of patients within 1 hour before incision .  Antimicrobial agents consistent with published guidelines were administered to 92.6 % ( 95 % CI , 92.3%-92.8 % ) of the patients .  Antimicrobial prophylaxis was discontinued within 24 hours of surgery end time for only 40.7 % ( 95 % CI , 40.2%-41.2 % ) of patients . CONCLUSION Substantial opportunities exist to improve the use of prophylactic antimicrobials for patients undergoing major surgery Background / Aims / Methods : This is a follow-up study from a recent r and omized controlled trial conducted at the Women and Children ’s Hospital of Buffalo that investigated the use of antimicrobial sutures ( AMS ) for wound closure during cerebrospinal fluid shunting procedures . Our purpose was to determine the average cost of shunt infections at our institution and estimate the healthcare savings associated with reduced infection rates secondary to AMS use . Result : We found that the treatment and management of a shunt infection result ed in a 5.3-fold increase in hospital charges . Conclusion : The potential healthcare savings associated with reduced infection rates are significant . These calculations demonstrate the profound economic effect a reduction in shunt infection rates may have on a healthcare system PURPOSE Postoperative wound complications , especially surgical site infections , influence the outcome after total knee arthroplasty . The purpose of our study was to compare four different wound dressings . Following research questions were asked : ( 1 ) Which dressing is associated with least wound complications ? ( 2 ) Which dressing application is the cheapest ? ( 3 ) Which dressing is most comfortable for the patient ? METHODS 111 patients undergoing a total knee arthroplasty were r and omized in 4 groups . Each group received a different dressing with its specific wound management protocol : ( 1 ) Zetuvit ® with Cosmopor E ® , ( 2 ) Zetuvit ® with Opsite Post-Op Visible ® , ( 3 ) Aquacel Surgical ® and ( 4 ) Mepilex Border ® . Follow-up evaluations were performed on the fifth postoperative day and included assessment of the wound , status of the wound dressing and the patient 's own judgment . Cumulative costs were calculated . RESULTS Clinical ly Mepilex Border ® , a silicone dressing , scored the best . No wound complications were seen in this group . The mean number of dressing renewals was 1.9 for the st and ard dressing which was significantly higher ( p<.0001 ) compared to the other dressings . Opsite Post-op Visible ® was the cheapest dressing . Mepilex Border ® had the best scores for pain , freedom of movement and general comfort . CONCLUSIONS Mepilex Border ® is the most skin-friendly dressing . The number of dressing renewals is a defining factor to calculate the costs . Mepilex Border ® appeared to be the best dressing to use after a total knee arthroplasty OBJECTIVE To investigate the impact of  postdischarge surveillance ( PDS )  on surgical-site infection ( SSI ) rates for selected surgical procedures in acute care hospitals in Scotl and . DESIGN Prospect i ve surveillance of SSI after selected surgical procedures . SETTING The Scottish Surveillance of Healthcare Associated Infection Programme ( SSHAIP ) , which is based on the methodology of the Centers for Disease Control and Prevention ( CDC ) National Nosocomial Infections Surveillance system ( NNIS ) . Thirty-two of 46 acute care hospitals throughout Scotl and contributed data to SSHAIP for this study . METHODS Data were from 21,710 operations that took place between April 1 , 2002 , and June 30 , 2004 ; nine categories of surgical procedures were analyzed . CDC NNIS system definitions and methods were used for SSI PDS . PDS is a voluntary component of the m and atory SSI surveillance program in Scotl and .  PDS was categorized as none , passive , active without direct observation , and active with direct observation . RESULTS From our study information , PDS data were available for 12,885 operations ( 59 % ) . A total of 2,793 procedures ( 13 % ) were associated with passive PDS and 10,092 ( 46 % ) with active PDS . The SSI rate among the 8,825 operations with no PDS was 2.61 % ( 95 % confidence interval [ CI ] , 2.3%-3.0 % ) , which was significantly lower than the SSI rate found among the 12,885 operations for which PDS was performed ( 6.34 % [ 95 % CI , 5.9%-6.8 % ] ) . For breast surgery , cesarean section , hip replacement , and abdominal hysterectomy , the rate of SSI when PDS was performed was significantly higher than that when PDS was not performed ( P<.01 for each procedure ) . No differences in SSI rates were found for surgery to repair fractured neck of the femur or for knee replacement . SSI rates were examined according to procedure type , performance of PDS , and NNIS risk index ; rates of SSI increased with NNIS risk index within procedure group and PDS group . Logistic regression analyses confirmed that procedure type , performance of PDS , and NNIS risk index were all statistically independent predictors of report of an SSI ( P<.05 ) . CONCLUSIONS This Scottish national data set incorporates a substantial amount of PDS data . We recommend a procedure-specific approach to PDS , with direct observation of patients after breast surgery , cesarean section , and hysterectomy , for which the length of stay is typically short . Readmission surveillance may be adequate to detect most SSIs after orthopedic surgery or vascular surgery , for which the length of stay is typically longer OBJECTIVE To identify risk factors associated with the development of surgical-site infection ( SSI )  following total knee arthroplasty ( TKA ) . DESIGN A case-control study . SETTING A 1,100-bed , university-affiliated , tertiary-care teaching hospital . METHODS Case- patients with SSI occurring up to 1 year following primary TKA performed between January 1999 and December 2001 were identified prospect ively by infection control practitioners using National Nosocomial Infections Surveillance ( NNIS ) System methods . Three control- patients were selected for each case-patient , matched by date of surgery . Stepwise logistic regression analysis was used to determine the relation of potential risk factors to the development of infection . RESULTS Twenty-two patients with infections ( 6 superficial and 16 deep ) were identified .  Infection rates per year were 0.95 % , 1.07 % , and 1.19 % in 1999 , 2000 , and 2001 , respectively . Logistic regression analysis identified two variables independently associated with the development of infection : the use of closed suction drainage  ( odds ratio [ OR ] , 7.0 ; 95 % confidence interval [ CI95 ] , 2.1 - 25.0 ; P = .0015 ) and increased international normalized ratio ( INR ) ( OR , 2.4 ; CI95 , 1.1 - 5.7 ; P = .035 ) . Factors not statistically associated with the development of infection included age , NNIS System risk index score , presence of various comorbidities , surgeon , duration of procedure or tourniquet time , type of bone cement or prosthesis used , or receipt of blood product transfusions . CONCLUSIONS The use of closed suction drainage and a high postoperative INR were associated with the development of SSI following TKA . Avoiding the use of surgical drains and careful monitoring of anticoagulant prophylaxis in patients undergoing TKA should reduce the risk of infection BACKGROUND Interest in mobile-bearing total ankle arthroplasty  has increased in recent years . However , to our knowledge , no study has focused exclusively on patients with the diagnosis of inflammatory joint disease or has provided a detailed analysis of the risk factors for failure . METHODS A prospect i ve observational study of the results of cementless mobile-bearing total ankle arthroplasty  in patients with inflammatory joint disease ( mainly rheumatoid arthritis ) was conducted at two centers . Ninety-three total ankle arthroplasties were performed . The LCS ( low contact stress ) prosthesis was used initially , in nineteen ankles , between 1988 and 1992 , and a modification of the LCS prosthesis , the Buechel-Pappas design , was used in seventy-four ankles between 1993 and 1999 . Clinical and radiographic follow-up was performed at yearly intervals . Three clinical scoring systems were used , and any complication was recorded throughout follow-up . Actuarial survival ( with revision as the end point ) , multivariate analysis , and a competing risk approach were used to describe the long-term outcome . RESULTS The clinical result at one year after surgery showed a significant improvement in the scores on all three scoring systems ( p < 0.05 ) . Ankle dorsiflexion ( mean , 7 degrees ) also improved significantly ( p < 0.05 ) compared with the preoperative state . The most frequent complication was a malleolar fracture , which occurred in twenty ankles . Only when it occurred in combination with a deformity in the frontal plane did this complication have an adverse effect on the end result . At a mean follow-up of eight years , seventeen patients ( twenty-one ankles ) had died and fifteen ankles had been revised because of aseptic loosening ( six ankles ) , primary or secondary axial deformity with edge-loading ( six ankles ) , deep infection ( two ankles ) , and a severe wound-healing problem ( one ankle ) , leaving fifty-seven ankles ( 61 % ) that were evaluated . The mean overall survival rate at eight years was 84 % . An increased failure rate was encountered in ankles with a preoperative deformity in the frontal plane of > 10 degrees ( p = 0.03 ) and in ankles in which an undersized tibial component had been implanted ( p = 0.02 ) . CONCLUSIONS Mobile-bearing total ankle arthroplasty is a valid treatment option for the rheumatoid ankle if proper indications are used . Aseptic loosening and persistent deformity are the most important modes of failure BACKGROUND Constrained liners are used as part of a salvage procedure to provide stability for patients at high risk for dislocation after a total hip arthroplasty . However , no recent studies exist highlighting their effectiveness and /or limitations . METHOD This prospect i ve review included 166 consecutive hip arthroplasties , either primary ( 27 % ) or revision ( 73 % ) , with a unique design of a constrained liner : Lefèvre retentive cup . There were 113 females ( 69 % ) , and the average age at index surgery was 75.9 years ( range , 35 - 94 ) . The mean follow-up was 6.2 years ( range , 0.3 - 11 ) . RESULTS Twenty patients had a reoperation ; 10 for infection ( 4 acute and 6 chronic joint infection ) and 10 for cup failure ( 5 fixation failure , 3 aseptic loosening , and 2 dislocation ) . Ten-year survivals for cup revision were 89 % ( CI , 83 - 94 ) and 92 % ( CI , 89 - 97 ) for all revision and revision for noninfectious reasons , respectively . When solely evaluating for dislocation , the survival at 10 years was 99 % ( CI , 97 - 100 ) . Considering primary and revision cases , 10-year survivals cup revision for aseptic reasons were 92.4 % ( CI , 84 - 100 ) and 92.5 % ( CI , 87 - 98 ) , respectively . CONCLUSIONS The Lefèvre retentive cup demonstrated excellent 10-year 's survivorship . With the rate of aseptic loosening around 2 % and a dislocation rate around 1 % , the cup is as effective as other available devices and is therefore a cost-effective tool to reduce the risk of dislocation in at-risk patients undergoing hip arthroplasty BACKGROUND In the late 1990s , new developments in knee replacement were identified as a priority for research within the NHS . The newer forms of arthroplasty were more expensive and information was needed on their safety and cost-effectiveness . OBJECTIVES The Knee Arthroplasty Trial examined the clinical effectiveness and cost-effectiveness of four aspects of knee replacement surgery : patellar resurfacing , mobile bearings , all-polyethylene tibial components and unicompartmental replacement . DESIGN This study comprised a partial factorial , pragmatic , multicentre r and omised controlled trial with a trial-based cost-utility analysis which was conducted from the perspective of the NHS and the patients treated . Allocation was computer generated in a 1 : 1 ratio using a central system , stratified by eligible comparisons and surgeon , minimised by participant age , gender and site of disease . Surgeons were not blinded to allocated procedures . Participants were unblinded if they requested to know the prosthesis they received . SETTING The setting for the trial was UK secondary care . PARTICIPANTS Patients were eligible for inclusion if a decision had been made for them to have primary knee replacement surgery . Patients were recruited to comparisons for which the surgeon was in equipoise about which type of operation was most suitable . INTERVENTIONS Patients were r and omised to receive a knee replacement  with the following : patellar resurfacing or no patellar resurfacing irrespective of the design of the prosthesis used ; a mobile bearing between the tibial and femoral components or a bearing fixed to the tibial component ; a tibial component made of either only high-density polyethylene ( ' all polyethylene ' ) or a polyethylene bearing fixed to a metal backing plate with attached stem ; or unicompartmental or total knee replacement . MAIN OUTCOME MEASURES The primary outcome was the Oxford Knee Score ( OKS ) . Other outcomes were Short Form 12 ; EuroQol 5D ; intraoperative and postoperative complications ; additional surgery ; cost ; and cost-effectiveness . Patients were followed up for a median of 10 years ; the economic evaluation took a 10-year time horizon , discounting costs and quality -adjusted life-years ( QALYs ) at 3.5 % per annum . RESULTS A total of 116 surgeons in 34 centres participated and 2352 participants were r and omised : 1715 in patellar resurfacing ; 539 in mobile bearing ; 409 in all-polyethylene tibial component ; and 34 in the unicompartmental comparisons . Of those r and omised , 345 were r and omised to two comparisons . We can be more than 95 % confident that patellar resurfacing is cost-effective , despite there being no significant difference in clinical outcomes , because of increased QALYs [ 0.187 ; 95 % confidence interval ( CI ) -0.025 to 0.399 ] and reduced costs ( -£104 ; 95 % CI -£630 to £ 423 ) . We found no definite advantage or disadvantage of mobile bearings in OKS , quality of life , reoperation and revision rates or cost-effectiveness . We found improved functional results for metal-backed tibias : complication , reoperation and revision rates were similar . The metal-backed tibia was cost-effective ( particularly in the elderly ) , costing £ 35 per QALY gained . CONCLUSIONS The results provide evidence to support the routine resurfacing of the patella and the use of metal-backed tibial components even in the elderly . Further follow-up is required to assess the stability of these findings over time and to inform the decision between mobile and fixed bearings . TRIAL REGISTRATION Current Controlled Trials IS RCT N45837371 . FUNDING This project was funded by the NIHR Health Technology Assessment programme and the orthopaedic industry . It will be published in full in Health Technology Assessment ; Vol . 18 , No. 19 . See the NIHR Journals Library website for further project information OBJECTIVE Surgical site infections  after cardiothoracic surgery substantially increase the risk for illness , mortality , and costs . Surveillance of surgical site infections might assist in the prevention of these infections . This study describes the Dutch surveillance methods and results of data collected between 2002 and 2007 . METHODS Three cardiothoracic procedures were included : coronary artery bypass graft procedures , valve surgery , and a combination of coronary artery bypass graft procedures with concomitant valve surgery .  The surgical site infections were divided into sternal and harvest-site infections . Postdischarge surveillance of surgical site infections was m and atory for sternal wounds and elective for harvest-site wounds , with a follow-up period of 42 postoperative days . Multivariate logistic regression was used for risk factor analysis of coronary artery bypass grafts , with adjustment for r and om variation among hospitals . RESULTS Eight of the 16 Dutch cardiothoracic centers participated and collected data on 4066 procedures and 183 surgical site infections , revealing a surgical site infection rate of 2.4 % for sternal wounds and 3.2 % for harvest sites . Sixty-one percent of all surgical site infections were recorded after discharge . For sternal surgical site infections after coronary artery bypass graft procedures , the significant risk factors were rethoracotomy , diabetes , preoperative length of stay , and obesity ; for harvest-site infections , the most relevant risk factor was a long time on extracorporeal circulation . Adjusted surgical site infection rates regarding coronary artery bypass graft procedures varied between hospitals from 0.0 % to 9.7 % . CONCLUSIONS Large differences were found in surgical site infection rates between Dutch hospitals , which indicate room for improvement . The follow-up of patients after hospital discharge reduces underestimation of surgical site infection rates
Newer infection prevention techniques , such as preoperative antiseptic scrubbing , are affected and may help reduce the infection rate , while traditionally accepted methods of prophylaxis such as laminar-flow operating rooms and body exhaust suits may raise the infection rate
Despite advances in our underst and ing of surgical site infections following total joint arthroplasty , this serious surgical complication continues to represent a substantial economic burden for the patient , the treating institution and the healthcare system .
After increasing for the past decade , infection rates have stabilized at 1.6 % ; however , the total cost is projected to increase with the total number of revision procedures performed .