|Year : 2019 | Volume
| Issue : 1 | Page : 1-5
Early postoperative wound infections in hemiarthroplasties in South-South, Nigeria: A multicenter-based study
Edwin Omon Edomwonyi1, R E T Enemudo2
1 Department of Orthopaedics and Trauma, Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria
2 Department of Orthopaedics and Trauma, Delta State University, Oghara, Delta State, Nigeria
|Date of Submission||24-Feb-2018|
|Date of Decision||02-Apr-2020|
|Date of Acceptance||22-Jun-2020|
|Date of Web Publication||21-May-2021|
Dr. Edwin Omon Edomwonyi
Department of Orthopaedics and Trauma, Irrua Specialist Teaching Hospital, Irrua, Edo State
Source of Support: None, Conflict of Interest: None
Background: The most common treatment for displaced femoral neck fractures in the elderly patient is hemiarthroplasty. Postoperative wound infection is considered early when it occurs within 30 days of orthopedic operations. Infection rates vary in the literature. Availability of descriptive data is limited. Patients and Methods: Medical records of 40 out of 52 patients who had hemiarthroplasties in Irrua Specialist Teaching Hospital, Irrua, Edo State and Delta State University Teaching Hospital Oghara, 2007–2016 were reviewed retrospectively. All patients had prophylactic as well as presumptive antibiotic treatment. All had ceftriaxone and metronidazole at one point or the other. Results: Of the 40 patients, age range was 17–91 years; median age was 65 years with a slight female to male preponderance. Twenty-two (55%) patients were 60–90 years of age. Trivial/domestic falls accounted for the majority, 26 (65%) patients. Only 3 (7.5%) patients presented within 24 h. Hypertension (HT) was the most common comorbid medical condition, 67.5%. Wound infection was the most common complication noted 7 (17.5%). Polymicrobial (mixed) infection agents ranked the highest among the microbes' cultures. Five out of the seven patients with wound infection had superficial wound infection. Two had deep wound infections. Ceftriaxone and metronidazole were the most commonly used antibiotics and the most effective against infections. Genticin was uncommon. Conclusion: Sixty-seven percent of patients studied had wound infection. Superficial wound infections were the most predominant type of early postoperative wound infection, and polymicrobial mixed infection agents were the most implicated. HT was the most common comorbid medical condition identified.
Keywords: Early postoperative wound infections, elderly patients, hemiarthroplasties, South-South Nigeria
|How to cite this article:|
Edomwonyi EO, Enemudo R E. Early postoperative wound infections in hemiarthroplasties in South-South, Nigeria: A multicenter-based study. Niger J Surg Sci 2019;29:1-5
|How to cite this URL:|
Edomwonyi EO, Enemudo R E. Early postoperative wound infections in hemiarthroplasties in South-South, Nigeria: A multicenter-based study. Niger J Surg Sci [serial online] 2019 [cited 2021 Oct 18];29:1-5. Available from: https://www.njssjournal.org/text.asp?2019/29/1/1/316586
| Introduction|| |
Hemiarthroplasty is currently the treatment of choice and the most common treatment of displaced intracapsular fractures of the femoral neck among elderly patients., It restores mobility while preventing the complications associated with decreased ambulation following such injuries, although it is associated with a 10% risk of reoperations.,
Complications related to the surgical procedure in the intraoperative, early postoperative, and late postoperative periods occur. They may affect nonmusculoskeletal organ systems. Limb length discrepancies, neurovascular injuries, fractures, hematoma formation, heterotopic ossification, thromboembolism, dislocations, and infections among others are known complications.
Postoperative wound infection is considered early when it occurs within 30days of orthopedic operations. Late infection, is noted, as the most frequent local complication associated with hemiarthroplasty.
A late infection is the most frequent local complication associated with hemiarthroplasty.
Previous hip surgeries, corticosteroid therapy, immunosuppressive therapy, female gender, age, and diabetes mellitus (DM) are among the notable risk factors for infection following hemiarthroplasty. Others are prolonged operative time, inadequate antibiotic prophylaxis, rheumatoid arthritis, sickle cell disease, postoperative hematoma, body mass index, smoking, urinary tract infection, and delay in the surgery.
Deep infections are costly, disabling, and painful, sometimes requiring removal of the prosthesis in order to achieve control. It is associated with a mortality of 2.5%.
Septic complications have threatened the continuous viability of surgeries involving the use of modern hip prosthetic technology. Charnley et al. reported an infection rate of 6.8% of the first 683 procedures. Wilson et al. in the United States of America reported 11% of 100 arthroplasties.
The incidence of prosthetic joint infection (PJI) in hemiarthroplasties following femoral neck fractures vary 2%–17% generally.
In early PJI, soft-tissue debridement with retention of the prosthesis is an attractive option: success rate has been reported to be 65%–75%., In PJI after hemiarthroplasty, however, a lower success rate has been reported.
Deeper understanding of patient selection, surgical technique, the operating room environment, and use of prophylactic antibiotics has drastically reduced the risk of this serious complication.
However, in our environment, infection has persisted and even aggravated by the fact that the patients are elderly, presenting late after traditional bone setter's (TBS) intervention, have comorbid medical conditions such as DM, hypertension (HT), chronic obstructive airway disease, and anemia. Some of these patients may have fecal incontinence, which may explain why the posterior approach to hemiarthroplasty is often associated with a greater risk of sepsis.
Postoperative wound infections raises the patient's morbidity status, increases medical bills prolong their hospital stay, causes serious deterioration in a patient's daily function and quality of life. From an economic view point, it accounts for 17% of nosocomial infections and cost 1–10 billion USD annually. One year mortality for patients with wound infection was 35.4%–50%, which was significantly higher than those without it, 24.1%–30%;, yet, the literature on this subject is limited, particularly in our environment. Hence, we decided to review the incidence of early wound infection and associated factors among patients and proffer possible solutions.
| Patients and Methods|| |
This is a retrospective study spanning 10 years (2007–2016) 52 patients were admitted and underwent hemiarthroplasty in Irrua Specialist Teaching Hospital Irrua and Delta State university teaching Hospital Oghara Delta State, both in South-South Nigeria. Case notes were retrieved and reviewed. Forty patients were included, and 12 were excluded on the basis of incomplete records.
Ethical clearance was sought and obtained from the relevant authorities.
Sociodemographic data, time between injury and presentation, comorbid medical condition, blood transfusion, prophylactic antibiotics, wound infection, infecting organisms, and mode of treatment of the infection were extracted.
Wound infection was regarded as purulent drainage from the wound or positive microorganism culture of aseptically aspirated fluid or tissue or from a swab and pus are present.
In addition to one or more signs of inflammation, for example, pain or tenderness, localized swelling are present.
Superficial wound infection – Skin and subcutaneous tissue.
Deep wound infection – Deep soft tissue below the deep fascia.
Data were analyzed using the descriptive statistics such as percentages and tables.
| Results|| |
The age range of patients was 17–91 years. Male:female ratio of 1:1.1. Median age was 65 years.
Majority of patients, 22 (55%) patients were 60–90 years of age [Table 1].
Etiology was domestic accident or trivial falls in 26 (65%) patients, as shown in [Table 2].
Only 3 (7.5%) patients presented within 24 h of injury. It was delayed in 16 (40%) patients who presented after 24 h but <1 week. Late presenters constituted 52.5% [Table 3].
Comorbid medical conditions were prevalent among our study population. Nearly 92.5% had one comorbid medical condition or another. HT was the most common, 27 (67.5%) patients followed by DM in 11 (27.5%) patients [Table 4].
Polymicrobial infection agents rank the highest among the microbes responsible for wound infection, as shown in [Table 5]. Wound infections generally were the most common complication, 7 (17.5%) patients as shown in [Table 6], whereas pneumonia was the least among patients who had hemiarthroplasty [Table 6].
Five (71%) patients out of a total of seven patients that had early wound infections had superficial wound infections. All seven patients were operated using the posterior hip approach. These were treated with wound dressings and use of sensitive antibiotics and wounds healed. Two (29%) patients had deep infections. They had incision and drainage, debridement and secondary wound closure and their wounds healed. None had implant removed.
Antibiotics were liberally used. All had prophylactic antibiotics. In 92.5% of cases, it was extended up to 2 weeks converting it to presumptive. All patients had ceftriaxone and metronidazole among the various combinations of antibiotics. There was extensive use of blood transfusion, 31 (77.5%) patients had 2 or more units.
No mortality was recorded.
| Discussion|| |
Hemiarthroplasty for femoral neck fractures and femoral head lesions is associated with the modest rate of complications.
An overall prevalence rate of complications was 32.5%. Sadegh et al. and Shah et al., reviewed 173,508 patients and 150 patients, respectively, in two different studies and recorded 20%–23% complications. Our smaller number of patients may explain the apparently higher figures recorded. This is a limitation of our study. The small number limits our statistical strength.
Wound infection ranked the most common complication, 17.5%. Eyichukwu and Iyidobi reported 26.1% in 2008 and Nwankwo et al. 15% in 1990. Both authors did their studies in Enugu, South-East Nigeria. Other authors working in Lagos reported 20%. In the Western literature, wound infection rates are 2%–17%.,, Deterioration in the state of facilities of infrastructures in public hospitals due to neglect, use of posterior approach for hemiarthroplasties in most of our patients in this study whose fecal continence was questionable. Late presentation in the hospital was found in our study, where only 7.5% of patients presented in <24 h. This, among other reasons, may be responsible, for the relatively higher rates of infection recorded. Nonfunctional health insurance system, ignorance, poverty, and patronage of TBS are the established reasons why patients present late to our public hospitals. It is known that scarification marks are often applied to the injured hip to let out “bad blood” and herbs applied in unhygienic environment, thereby introducing germs and microorganisms.
All patients had prophylactic antibiotics and 90% had theirs extended to 2 weeks making it presumptive. Infection rate was still high. Efficacy of the drugs may be doubtful, delay, or inadequate prophylaxis may account for this. In a study from Sweden, knee arthroplasty register, only 57% of the patients had adequate timing of the prophylaxis. A formal verbal checklist “safe surgery” is strongly advised. Ceftraixone and flagyl combination was the most common. All patients had ceftriaxone/metronidazole combination while others had other antibiotics added at different points. This was observed to be the most protective. Genticin was added in only 17.5% of cases apparently because of the risk of ototoxicity or nephrotoxicity. Similar finding was reported by other authors.,
Polymicrobial agents rank the highest, 28.6%, among microorganisms causing wound infection in our study. Similarly high figures, 26.7% and 38% were reported Eyichukwu and Iyidobi and Ellen et al., respectively. Pseudomonas was reported as the most common implicated organism in a study in Enugu, South-East Nigeria in the 90s. Two decades later, another study in the same establishment, revealed coliform organisms This reveals the varied nature of the microorganisms implicated in wound infections following hemiarthroplasties in different places and at different times in the same location.
Staphylococcus aureus accounted for 14.3% among those that had wound infection. Eyichukwu and Iyidobi recorded 20%. Our study further revealed that a significantly high proportion, 28.6% were culture negative, as shown in [Table 5]. These may be unusual strains requiring specialized facilities or very strict conditions to the culture.
There was no mortality, although polymicrobial infections are associated treatment failures and higher mortalities. Again, our small sample size limits our statistical strength. This may explain no mortality recorded.
All patients had superficial wound infections except two that had deep infections. Wound dressings and antibiotics sufficed in all except those with deep infections.
Increasing comorbidity has been reported as a risk factor for the development of infections. Nearly 92.5% of our patients had at least one comorbid medical condition. HT was the most common, closely followed by DM. Other authors, reported similar trend.
Dislocation of hip arthroplasties has been a concern since the advent of the procedure. Rajak et al., Unwin et al., and Sadegh reported 3%, 6.5%, and 6.6%, respectively. We attribute our relatively higher rate of dislocations (7.5%) to the posterior approach adopted by the majority of our surgeons. An increased risk of dislocation has been shown for the posterior approach compared with the lateral approach,, whereas other authors have reported no association between surgical approach and dislocations following arthroplasty.
Male-to-female ratio was 1:1.1. Other authors, have reported similar finding with median ages, 71 and 67 years, respectively. Fifty-five percent of our patients were between 60 and 90 years, known to be most prone to pathological fractures of the neck of the femur secondary to falls which accounted for the highest in etiology, 65%.
| Conclusion|| |
Wound infections, particularly the superficial variety were the most predominant complication among patients that had hemiarthroplasty, with polymicrobial infection agents, the most commonly implicated.
Notable risk factors were comorbid medical conditions, with HT and diabetes topping the list. Enhancement of our health insurance system and public enlightenments will empower and encourage patients, particularly those with comorbid medical conditions.
Emphasis on surgical prophylaxis through training and retraining of all theater staff, upgrading and reequipment of ailing surgical facilities in our public hospitals will significantly reduce the risk of wound infection following hemiarthroplasty.
Liberal antibiotic usage has not proven beyond all doubts to be of definitive benefit. Double blind prospective studies are required to prove this. Efficient ambulance and trauma services to ensure timely delivery of patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Solomon L, Warwick D, Selvadurai N. Apley's system of orthopaedics and fractures, 8th
Edition Arnold, London NW1 3BH 2001. p. 35-6.
Bhandari M, Deveraux PJ, Turnetta P 3rd
, Swiontkowski MF, Berry DJ, Haidukewych G, et al
. Operative Management of a displaced femoral neck fracture in the elderly patients: An International Survey. J Bone Joint Surg Am 2005;87:2122-30.
Gjertsen JE, Vinje T, Engesaeter LB, Lie SA, Havelin LI, Furnes O, et al
. Internal screw fixation compared with bipolar hemiarthroplasty for treatment of displaced femoral neck fractures in elderly patients. J Bone Joint Surg Am 2010;92:619-28.
Parker M, Gurusamy K. Internal fixation vs. arthroplasty for intracapsular proximal femoral fractures in adults. Cochrane Database Syst Rev 2006;4:CD001708.
Frihagen F, Nordsletten L, Madsen J. Hemiarthroplasty or internal fixation for intracapsular displaced femoral neck fracture: Randomised controlled trial. BMJ 2007;335:1251-4.
Ridgeway S, Wilson J, Charlet A, Kafatos G, Pearson A, Coello R. Infection of the surgical site after arthroplasty of the hip. J Bone Joint Surg Br 2005;87:844-50.
Jose CA, Marisol D. What are the risk factors for infection in hemiarthroplasty and Total hip arthroplasty? Clin Orthop Related Res 2010;468:3268-77.
Canale ST, Beaty JH, Daugherty K, Jones L. Campbell's Operative Orthopaedics. 12th
ed.. Philadephia PA: Eisevier Mosby; 2013. p. 250-1.
Buchheit J, Uhring J, Sergent P, Puyraveau M, Leroy J, Garbuio P. Can Pre-operative CRP levels predict infections of bipolar hemiarthroplasty performed for femoral neck fractures? A retrospective multicentre study. Eur J Orthop Surg Traumatol 2015;25:117-21.
Del Toro MD, Nieto I, Guerrero F, Corzo J, del Arco A, Palomino J, et al
. Are hip arthroplasty and total hip arthroplasty infections different entities? The importance of hip fractures. Eur J Clin MCB Infect Dis 2014;33:1439-48.
Westberg M, Grogaad B, Snorrason F. Early prosthetic joint infections treated with debridement and implant retention: 38 primary hip arthroplasties prospectively recorded and followed for median 4 years. Acta Orth 2012;8:227-32.
Nwadinigwe CU, Ihezie CO, Iyidobi EC. Fractures in children. Niger J Med 2006;15:81-4.
Chan RN, Hoskinson J, Thompson prosthesis for fracture neck of femur, A comparison of surgical approach. J Bone Joint Surg 1975;57:437-43.
Perencevich EN, Sands KE, Cosgrove SE, Guadagnoli E, Meara E, Platt R. Health and economic impact of surgical site infections diagnosed after hospital discharge. Emerg Infect Dis 2003;9:196-203.
Partanen J, Syrjälä H, Vähänikkilä H, Jalovaara P. Impact of deep infection after hip fracture surgery on function and mortality. J Hosp Infect 2006;62:44-9.
Edwards C, Counsell A, Boulton C, Moran CG. Early infection after hip fracture surgery: Risk factors, costs and outcome. J Bone Joint Surg Br 2008;90:770-7.
Sadegh S, Aiden E, Bijan K, Edris B, Javad M. Early complications of bipolar hemiarthroplasty for femoral neck fractures in the elderly patient. Acad J Surg 2014;1:3-4.
Shah SN, Wainess RM, Karunakar MA. Hemiarthroplasty for femoral neck fracture in the elderly surgeon and hospital volume-related outcomes. J Arthroplasty 2005;20:503-8.
Eyichukwu GO, Iyidobi EC. Early postoperative wound infection in Austin moore hemiarthroplasty in Enugu, Nigeria. NJOT 2008;7:1-2.
Nwankwo OE, Eze CB, Onabowale BO, Osisioma EC. Infection rate using Austin Moore prosthesis for partial hip replacement in an ordinary operating theatre. 11 years experience @ NOH, Enugu. Orient J Med 1990;2:67.
Onche II, Yinusa W. Femoral neck fractures, a prospective assessment of the pattern, care and outcome in an orthopaedic centre. NJOT 2004;3:46-9.
Stefansdottir A, Robertson O, W-Dahl A, Kiernan S, Gustafson P, Lidgren L. Inadequate timing of prophylactic antibiotics in orthopaedic surgery. We can do better. Acta Orthop 2009a: 80:633-8.
Ellen G, Wenger F, Frede F, Leiv OW, Marianne.W. Prosthetic Joint infection- a devastating complication of hemiarthroplasty for hip fracture. Acta Orthop 2017;88:383-9.
Rajak MK, Jha R, Kumar P, Thakur R. Bipolar hemiarthroplasty in intracapsular femoral neck fractures in elderly patients. J Orth Surg (Hong Kong) 2013;21:313-6.
Unwin AJ, Thomas M. Dislocation after hemiarthroplasty of the hip: A comparison of the dislocation rates after posterior and lateral approaches to the hip. Ann R Coll Surg Eng 1994:76:327-9.
Bush JB, Wilson MR. Dislocation after hip hemiarthroplasty: Anterior vs. posterior capsular approach. Int Orthop 2007;30:138-44.
Enocson A, Hedbeck CJ, Tornkvist H, Tidermark J, Lapidus LJ. Unipolar vs. bipolar exeter hip hemiarthroplasty: A prospective cohort study on 830 consecutive hip hemiarthroplasty in patients with femoral neck fractures. Int Orthop 2012;36:711-7.
Sierra RJ, Schleck CD, Cabanela ME. Dislocation of bipolar hemiarthroplasty rate, contributory factors and outcome. Clin Orthop Related Res 2006;442:230-8.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]