Surgical Wound Classification and Surgical Site Infections in the Orthopaedic Patient

Ikemefuna Onyekwelu, Ramakanth Yakkanti, Lauren Protzer, Christina M Pinkston, Cody Tucker, David Seligson, Ikemefuna Onyekwelu, Ramakanth Yakkanti, Lauren Protzer, Christina M Pinkston, Cody Tucker, David Seligson

Abstract

Introduction: The Centers for Disease Control and Prevention created a surgical wound classification system (SWC: I, clean; II, clean/contaminated; III, contaminated; and IV, dirty) to preemptively identify patients at risk of surgical site infection (SSI). The validity of this system is yet to be demonstrated in orthopaedic surgery. We hypothesize a poor association between the SWC and the rate of subsequent SSI in orthopaedic trauma cases.

Methods: Nine hundred fifty-six orthopaedic cases were reviewed. Wounds were risk stratified intraoperatively using the SWC grades (I-IV). SSI was diagnosed clinically or with objective markers. The SWC was compared with SSI rates using a Fisher exact test. Significance was set at P < 0.05.

Results: Four hundred patients met the selection criteria. The rate of infection was not significantly different across the SWC grades (P = 0.270). There was a significantly higher risk of SSI among patients with diabetes (P = 0.028).

Conclusions: The Centers for Disease Control and Prevention SWC showed poor utility in predicting and risk stratifying postoperative SSIs in orthopaedic surgical cases.

Conflict of interest statement

No commercial funding or grants were used for this study. Dr. Seligson or an immediate family member serves as a board member, owner, officer, or committee member of the Kuntscher Society; has received research or institutional support from Pacira Pharma; and serves as a paid consultant to Stryker. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr. Onyekwelu, Mr. Yakkanti, Ms. Protzer, Ms. Pinkston, and Mr. Tucker.

Figures

Figure 1
Figure 1
Flow diagram of patient selection and review process
Figure 2
Figure 2
CDC class versus SSI rate per class. There was no significant difference in the rate of infection across the CDC wound classes (P = 0.27); this trend remained true when CDC wound classifications III (contaminated) and IV (dirty/infected) were combined (P = 0.15). CDC = Centers for Disease Control and Prevention, SSI = surgical site infection.
Figure 3
Figure 3
CDC classification versus percent cases/SSIs per class. Percentage of cases/SSIs in each class. CDC = Centers for Disease Control and Prevention, SSI = surgical site infection
Figure 4
Figure 4
Extremity versus percent SSI. Patients with lower extremity injuries had a significantly higher incidence of SSI (20 of 197) compared with upper extremity injuries (3 of 155) or pelvic/sacrum injuries (4 of 48) (P = 0.002). CDC = Centers for Disease Control and Prevention, SSI = surgical site infection

References

    1. References printed in bold type are those published within the past 5 years.

    1. Lee J, Singletary R, Schmader K, Anderson DJ, Bolognesi M, Kaye KS: Surgical site infection in the elderly following orthopaedic surgery. Risk factors and outcomes. J Bone Joint Surg Am 2006;88:1705-1712.
    1. Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ: 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. Infect Control Hosp Epidemiol 2002;23:183-189.
    1. Thakore RV, Greenberg SE, Shi H, et al. : Surgical site infection in orthopedic trauma: A case-control study evaluating risk factors and costs. J Clin Orthop Trauma 2015;6:220-226.
    1. Graf K, Ott E, Vonberg RP, et al. : Surgical site infections—economic consequences for the health care system. Langerbecks Arch Surg 2011;396:453-459.
    1. Greene LR: Guide to the elimination of orthopedic surgery surgical site infections: An executive summary of the Association for Professionals in Infection Control and Epidemiology elimination guide. Am J Infect Control 2012;40:384-386.
    1. Surgical Site Infection (SSI) Event: Center for Disease Control. 2010. . Updated January 2015. Accessed March 3, 2015.
    1. Ortega G, Rhee DS, Papandria DJ, et al. : An evaluation of surgical site infections by wound classification system using the ACS-NSQIP. J Surg Res 2012;174:33-38.
    1. Malpiedi PJ, Peterson KD, Soe MM, et al. : 2011 National and State Healthcare-Associated Infections Standardized Infection Ratio Report. 2012. .
    1. Levy SM, Lally KP, Blakely ML, et al. : Surgical wound misclassification: A multicenter evaluation. J Am Coll Surg 2015;220:323-329.
    1. Mu L, Edwards J, Horan T, Berrios-Torres S, Fridkin S: Improving risk- adjusted measures of surgical site infection for the National Healthcare Safety Network. Infect Control Hosp Epidemiol 2011;32:970-986.
    1. Garner JS: CDC guideline for prevention of surgical wound infections, 1985. Supersedes guideline for prevention of surgical wound infections published in 1982. (Originally published in November 1985). Revised. Infect Control 1986;7:193-200.
    1. Simmons BP: Guideline for prevention of surgical wound infections. Infect Control 1982;3:185-196.
    1. Chapman MW: Role of bone stability in open fractures. Instr Course Lect 1982;31:75-87.
    1. Olsen MA, Nepple JJ, Riew D, et al. : Risk factors for surgical site infection following orthopaedic spinal operations. J Bone Joint Surg Am 2008;90:62-69.
    1. Wukich DK, Lowery NJ, McMillen RL, Frykberg RB: Postoperative infection rates in foot and ankle surgery: A comparison of patients with and without diabetes mellitus. J Bone Joint Surg Am 2010;92:287-295.
    1. Harris AM, Althausen PL, Kellam J, Bosse MJ, Castillo R; Lower Extremity Assessment Project (LEAP) Study Group: Complications following limb-threatening lower extremity trauma. J Orthop Trauma 2009;23:1-6.
    1. Browne J, Novicoff W, D'Apuzzo M: Medicaid payer status is associated with in-hospital morbidity and resource utilization following primary total joint arthroplasty. J Bone Joint Surg Am 2014;96:e180.
    1. Bowen TR, Widmaier JC: Host classification predicts infection after open fracture. Clin Orthop Relat Res 2005;433:205-211.
    1. Gustilo RB, Mendoza RM, Williams DN: Problems in the management of type III (severe) open fractures: A new classification of type III open fractures. J Trauma 1984;24:742-746.

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