Risk Factors of Surgical Site Infection after Acetabular Fracture Surgery

Abstract

Background:

Surgical site infections (SSI) after acetabular fracture surgery are uncommon but devastating. It is still unknown which risk factors contribute to SSI. The primary objective of this study is to investigate the risk factors of SSI after acetabular fracture surgery.

Methods:

A total of 338 patients who underwent the acetabular fracture surgical procedure were studied retrospectively. Post-operative SSI developed in 16 patients. From the medical record, age, gender, body mass index (BMI), Injury Severity Score (ISS), active smokers, diabetes mellitus, causes of fracture, associated injuries, classification of the acetabular fracture, time from injury to operation, operative approaches, use of the Intra-Aortic Balloon Occlusion (IABO), operative time, surgical blood loss, and days in the intensive care unit (ICU) were extracted. Univariate and multivariable analysis were performed to determine the association between risk factors and infection.

Results:

There were 10 males and six females in the infected group. According to the univariate analysis, the patients in whom SSI developed were more obese (higher BMI), more severely injured in terms of ISS, and had longer ICU stays. The operative time was longer, and estimated blood loss was larger in the infected group. Associated injuries such as Morel-Lavallée lesion, abdominal trauma, and urinary tract trauma were common in the infected group. Combined approaches and IABO were more commonly applied in the infected group. Multivariate analysis indicated that the operative time, Morel-Lavallée lesion, and abdominal trauma are the independent risk factors for SSI.

Conclusions:

To reduce the incidence of SSI in patients with acetabular fractures, special attention should be paid to the obese patients, Morel-Lavallée lesion, and concomitant abdominal trauma. Keeping the operative time short also reduces the risk of SSI. It is important to perform surgical intervention immediately after the infection occurs.

Surgical site infection (SSI) is defined as an infection at the site of operation that occurs within 30 d after the procedure or within 1 y if a foreign body was implanted during the operation [1]. The SSI is an unfortunate and troublesome complication after surgery, usually leading to increased morbidity, mortality, length of hospital stay, and health-care costs [2,3]. A great variety of risk factors for SSI after orthopedic surgery are reported, including patient-related (e.g., increased age, diabetes mellitus, obesity, previous surgical infection, poor nutrition), injury-related (e.g., open fracture grade, presence of compartment syndrome) and surgery-related (e.g., operation duration, surgical site classification, excessive blood loss, and antibiotic prophylaxis) factors [4 –6].

The treatment of patients with acetabular fractures is challenging. Surgical treatment of acetabular fractures was established by Judet [7] in 1964. In the last 30 years, open anatomical reduction of the articular surface with a rigid internal fixation became the standard management for these fractures [8]. The operative treatment often necessitates extensive surgical exposure, long operative time, and high blood loss. Post-operative SSI after the acetabular fracture surgical procedure is fortunately uncommon. Still, the results from an infection are devastating, limiting the patient's physical performance substantially and dramatically impairing life quality [9,10].

Suzuki et al. [11] reported 326 patients who underwent acetabular fracture surgery in which SSI developed in 17 patients, including 10 deep infections and seven superficial infections. The univariate analysis showed that the Injury Severity Score (ISS), intensive care unit (ICU) stays, amount of packed red blood cells (PRBCs) transfused, operative time, operative blood loss, body mass index (BMI), and frequent performance of combined approach were associated with the development of an infection. The BMI, the ICU stays, and the Morel-Lavallée lesion were independent risk factors in the multivariable analysis. Sagi et al. [12] reported that patients needing preoperative angioembolization and having a BMI >30 have a significant increase in their risk of post-operative infection, particularly if associated with leukocytosis. Besides, few studies focused on the SSI after acetabular fracture surgical treatment. The study was designed to identify the risk factors for and the management of post-operative SSI.

Patients and Methods

This study was performed in the Department of Orthopedic Surgery, Shandong Provincial Hospital, affiliated to Shandong University in Jinan, Shandong Province, PR China. Permission was obtained from the hospital ethics committee.

All patients who underwent operative acetabular fracture treatment between June 2001 and June 2011 were included in the retrospective study. All surgical procedures were performed strictly observing the general rules of sterility. All surgical incisions were disinfected with povidone-iodine and irrigated with physiologic saline before closure. Routine prophylactic intravenous antibiotics were administered on induction of anesthesia before the initial fracture surgical procedure. The patients received another dose of antibiotics if the operative time exceeded 3 h. The choice of antibiotic treatment was according to local microbiologic guidelines. Of these, SSI developed in 16 patients (10 males), with patient age ranging from 29 to 52 years (average age, 37.2±8.4 years).

Patient-related characteristics, injury-related characteristics, and surgery-related characteristics were compared for patients who did not experience SSI (non-infected group) with those patients who experienced SSI (infected group) after the acetabular fractures surgical procedure. Univariate statistics were calculated for each measurement as well as for the demographic and injury characteristics. Categoric variables were compared using the chi-square and Fisher exact test. Multivariable analysis was performed to identify risk factors independently associated with SSI.

The following variables were considered for inclusion into the logistic regression models: Age, gender, BMI, ISS, active smokers, diabetes mellitus, causes of fracture, associated injuries, classification of acetabular fracture (classified according to the AO classification), time to operation (time from injury to operation), operative approaches, use of the Intra-Aortic Balloon Occlusion (IABO), operative time (from anesthesia to recovery), blood loss during operation, and the days spent in the ICU. Any variable with p<0.05 on univariate analysis was used as the criterion for entry of a predictor variable into a backward logistic regression model.

The causes of the fracture included traffic accident, falling from height, and crushing injury. As associated injuries, concomitant fractures, Morel-Lavallée lesion, abdominal trauma, urinary tract trauma, thoracic trauma, and traumatic brain injury were registered. The operative approaches were the combined anterior-posterior approach, Kocher-Langenbeck (K-L) approach, extended iliofemoral approach, ilioinguinal approach, and modified Stoppa approach. The blood loss (mL) during surgery was measured by adding the suction bottle volume to the increase in weight of the surgical packs and swabs. All the statistical analysis was performed using SPSS version 16.0 (SPSS, Chicago, IL). The level of significance was set at p<0.05.

The treatment of the infection consisted of a full and, if necessary, repeated surgical debridement together with postoperative continuous irrigation and antibiotic therapy. The bacterial culture was performed by clinical microbiologists. Most patients received intravenous antibiotics for 6 wks as appropriate. The choice of antibiotics was according to local microbiologic guidelines first and then according to the results reported by the clinical microbiologists. Infections refractory to treatment measures may necessitate removal of implants. If necessary, total hip arthroplasty (THA) was performed after the infection was controlled.

Results

A total of 338 patients with acetabular fractures (225 males and 113 females) underwent operative reduction and internal fixation (ORIF) in our department from June 2001 to June 2011, and 16 (4.7%) patients had a SSI. Tables 1 and 2 provide a summary of the univariate analysis of patients with and without SSI. There was no significant difference with regard to patient-related factors such as age (p=0.154), gender (p=0.704), and incidence of active smokers (p=0.786). The presence of diabetes mellitus was higher in the group with SSI, although it did not reach statistical significance (p=0.207). The BMI was different between the groups, however, with patients who had SSI having a higher mean BMI (p=0.000).

Table 1.

Univariate Analysis for Numerical Variables

Variable	Patients with infection (16)	Patients without infection (322)	p
Age (y)	37.2±8.4	39.1±7.2	0.154
BMI	27.3±2.3	22.6±3.5	0.000
ISS	30.9±17.4	17.5±14.9	0.001
ICU stay (days)	3.1±1.8	1.5±1.3	<0.05
Time to operation (days)	9.0±3.6	8.0±4.3	0.181
Operative time (hours)	6.1±1.8	3.4±0.9	<0.05
Blood loss (mL)	1993.8±615.6	1420.3±785.3	0.0002

Values are mean±standard deviation. p<0.05 denotes significance.

BMI=body mass index; ISS=injury severity score; ICU=intensive care unit.

Table 2.

Univariate Analysis for Categorical Variables

Variable	Patients with infection (16)	Patients without infection (322)	p
Gender			0.704
Male	10	216
Female	6	106
Causes of injury			0.827
Traffic accident	8	162
Falling from height	6	103
Crushing	2	57
Associated injuries
Combined with other fractures	7	108	0.400
Morel-Lavallée lesion	8	10	0.000
Abdominal trauma	10	38	0.000
Urinary tract trauma	6	26	0.002
Thoracic trauma	4	27	0.071
Traumatic brain injury	1	43	0.705
Types of acetabular fracture			0.103
Type A	2	117
Type B	6	109
Type C	8	96
Active smokers	4	96	0.786
Diabetes mellitus	2	16	0.207
Intra-Aortic Balloon Occlusion	6	26	0.025
Operative approaches			0.001
Combined approach	10	93	0.009
(anterior and posterior)
K-L approach	4	72	0.764
Extended iliofemoral approach	2	8	0.076
Ilioinguinal approach	0	99	0.004
Modified Stoppa approach	0	50	0.143

Values are total number; p<0.05 denotes significance.

K-L approach=Kocher-Langenbeck approach.

The injury-related factors were significantly related to the presence of SSI in the univariate analysis, except for the types of the acetabular fracture (p=0.103) and the causes of the injuries (p=0.827). The ISS was higher in the infected group and was associated with SSI (p=0.001). The patients associated with Morel-Lavallée lesion (p=0.000), abdominal trauma (p=0.000), or urinary tract trauma (p=0.002) had a higher rate of SSI. Thoracic trauma (p=0.071), traumatic brain injury (p=0.705), and concomitant other fractures (p=0.400), however, were not significantly related to the rate of SSI.

Surgery-related factors were also analyzed in a univariate analysis to determine their effect on SSI. The operative time was significantly longer in the infected group than in the non-infected group (p<0.05). The mean blood loss was significantly related to the increased rate of SSI (p=0.0002). To reduce the blood loss during the operation, six patients in the infected group and 26 patients in the non-infected group underwent the procedure of IABO (p=0.025). The approach for internal fixation most frequently used was the ilioinguinal approach, and the operative approach was different between the infected and non-infected groups (p=0.001), in which the combined anterior-posterior approach was related to the increased rate of the infection (p=0.009). The time from injury to operation did not appear to be different between infected and non-infected groups (p=0.181). The length of ICU stay can increase the rate of SSI (p<0.05).

Multivariable analysis was performed using those covariates found to be statistically significant in the univariate analysis (Table 3). Multivariable logistic regression analysis showed that BMI (odds ratio [OR] 1.433, p=0.021), operative time (OR 3.504, p=0.000), Morel-Lavallée lesion (OR 89.694, p=0.003) and abdominal trauma (OR 28.867, p=0.001) were the independent risk factors.

Table 3.

Multivariate Analysis for Variable Test

Variable	Coefficient	OR	95% CI	p
BMI	0.360	1.433	1.056–1.944	0.021
Operative time	1.254	3.504	1.822–6.741	0.000
Morel-Lavallée lesion	4.496	89.694	4.496–1789.344	0.003
Abdominal trauma	3.363	28.867	3.893–214.075	0.001

p<0.05 denotes significance.

OR=odds ratio; CI=confidential interval; BMI=body mass index.

All patients with infection underwent early thorough surgical debridement and microbiologic sampling. According to the microbiology results, the most common causative organism was Staphylococcus aureus (n=10, 62.5%), followed by Escherichia coli accounting for 2.5% (n=4) and Klebsiella pneumoniae accounting for 12.5% (n=2). Two patients recovered after 4 wks of treatment without implant removal, and solid bony fusion was radiographically evident after 4 mo. The Harris hip score was 94 points and 92 points. The other 14 patients underwent the removal of the implants after 2.2 mo and then continued to be treated by lavage and antibiotics for an average of 2.7 mo.

The fracture had healed in two patients, and the Harris hip score was 78 points and 82 points. Four of them had non-union of the fracture and underwent internal fixation again with bone grafting 3 mo later after the infection was controlled. The fractures of four patients had healed, and the average Harris score was 71 points in the final follow-up. The last eight patients underwent THA eventually because of hip joint destruction and poor function. In the final follow-up of these eight patients, two had excellent, four good, and two fair results of function of the hip joint.

Discussion

The management of acetabular fractures is challenging, and both conservative and surgical treatment are associated with serious complications, such as sciatic nerve damage, heterotopic ossification, femoral head necrosis, deep vein thrombosis, post-traumatic osteoarthritis, and SSI [13]. The presented review of one of the world's largest acetabular fracture cohorts allows identification of high-risk patients and treatment optimization. Main findings of this study were that operative time, concomitant Morel-Lavallée lesion, abdominal trauma, and BMI are associated with SSI.

To identify risk factors of post-operative infection, multiple covariates must be considered. For example, events leading to an SSI might involve factors such as patient characteristics, operating room environment, operative site preparation and draping, antibiotic administration, surgical technique and post-operative care [5]. Because not every variable that might affect the rate of SSI was accessible in this retrospective review, this study focuses on multiple patient-related, injury-related, and surgery-related variables and specifically seeks to examine treatment variables over which the surgeon has reasonable control.

We found that longer operative time is an important risk factor for post-operative SSI in acetabular fractures, which can increase the SSI risk by about 3.5 times. The prolonged operative time means more extensive soft-tissue stripping and extended exposure of the surgical site. The Thanni et al. [14] study indicated that duration of operation longer than 120 min was a strong predictor of infection. In our study, the average time of the surgical procedure in the infected group was as long as 6 h, which means that SSI has a greater opportunity to develop. There are many variables that can affect operative time—for example, type of fractures, pre-operative planning, the experience of the surgeon, and operating room staff experience. Optimization of the surgical setting therefore becomes a major part of SSI prevention.

The Morel-Lavallée lesion was first described in 1848 by Maurice Morel-Lavallée [15]. The Morel-Lavallée lesion is a closed degloving injury that is associated with severe trauma such as pelvic and acetabular fracture. If not treated appropriately, these lesions can become infected, cause tissue necrosis, or form chronic seromas [16]. Suzuki et al. [11] have reported that the Morel-Lavallée lesion is an independent factor causing infection. Hak et al. [17] reported that the Morel-Lavallée lesion around the acetabulum can increase SSI after acetabular fracture operation. In our study, the OR of the Morel-Lavallée lesion was high, and the risk factor was about 89 times more than that with no Morel-Lavallée lesion in the multivariable analysis.

There exist multiple recommendations for the management of the Morel-Lavallée lesion to minimize SSI risk. Tseng and Tornetta [18] suggested that a delayed acetabular surgical procedure should be performed if a Morel-Lavallée lesion is present. At present, the application of vacuum sealing drainage (VSD) allows early management of pelvic and acetabular fractures with Morel-Lavallée lesion. The VSD improves soft tissue injury in patients with the Morel-Lavallée lesion, allowing early surgical management of acetabular fractures with improved hip function outcome [18 –20].

In our study, there were 18 patients with a Morel-Lavallée lesion, of which eight patients were in the infected group. The retrospective analysis of these cases revealed that all the patients with infection caused by Morel-Lavallée lesion were not treated properly with regard to their soft tissue problem because of unawareness. In our study, some of the patients were treated with VSD, and some were treated with open or percutaneous drainage with debridement.

The patients with mild Morel-Lavallée lesion underwent non-operative management including rest, compression, physiotherapy, and local aspiration. For the infected patients, the reason why the Morel-Lavallée lesion correlated may be as follows: First, the Morel-Lavallée lesion was not initially apparent, so that it was ignored and the fixation was performed directly; second, although the VSD was used in some patients, some necrotic tissue was neglected in the process of debridement; third, some of the acetabular operations were performed at an improper time (not until the dead space was handled and closed carefully, and the surgical incision looked healthy) and with n unreasonable approach (such as the approach around the incision for debridement). In addition, including the Morel-Lavallée lesion in our treatment algorithm will possibly reduce the risk of SSI.

In abdominal trauma, bowel injuries may cause abdominal contamination that may directly infect the acetabular fracture. Dong and Zhou [21] reported that rectal lacerations can lead to increased infection in pelvic injury. During laparotomy of a patient with abdominal trauma, a previously contained infection can spread directly into the pelvic region. In our study, about 62.5% of patients in the infected group had abdominal trauma. The risk was 28 times greater, however, than for those without abdominal trauma. Therefore, identification of these at risk patients and a proper pre-operative antibiotic protocol may reduce the SSI rate.

We recommended that for the patients with abdominal trauma, if there were intestinal injury or organ injury, a broader-spectrum prophylactic agent that covered both gram-positive and gram-negative microbial populations was certainly needed. If the types of injuries were suspicious, however, a broader-spectrum prophylactic agent should be used initially, and then a suitable antibiotic should be chosen according to the drug sensitivity assay after the intestinal injury or organ injury was excluded.

The BMI was found to be another covariate influencing SSI in patients with acetabular fracture, increasing the SSI by about 1.4 times. Vilar-Compte et al. [22] reported that in obese patients, SSI after surgical procedures was more common than in non-obese patients. The meta-analysis of Yuan and Chen [23] indicates that obese patients had about a two-fold increased risk of SSI in orthopedic surgery. The increased risk of infection in obese patients is most likely caused by the increase in soft tissue trauma, longer operative time, more blood loss, and disturbance of body homeostatic balance [24].

These high-risk patients need special attention if treated surgically. For patients having a BMI of >30, adjustments in dosage of antibiotics according to patient weight are necessary. For these patients, a dose of three grams is more appropriate. More research is needed, however, to better elucidate optimal dosing of weight-based antimicrobials in obesity, with particular focus on efficacy and toxicity [25,26].

Previously reported results [27 –31] indicate that closure with suture and 2-octyl cyanoacrylate (OCA) may confer a clinical advantage. Therefore, the application of topical OCA to the surgical incision may prevent colonization of the surgical site that occurs post-operatively and with routine dressing changes. In addition, metallic skin staples may serve as a cutaneous foreign body that can become colonized by nosocomial bacteria in an immobilized patient. A recent study [32] reported, however, that no statistically significant difference was detected in the primary end point of wound infection when comparing superficial wound closure with metallic staples versus running subcuticular poliglecaprone suture and sealed with OCA in acetabular fracture surgical procedures. In our study, the closures of the incision after acetabular fracture operations were all with a running subcuticular poliglecaprone suture, then sealing the surgical site with 2-octyl cyanoacrylate (OCA); there was no skin closure with metallic staples.

The management of post-operative SSI included thorough surgical debridement, lavage and drainage, and the use of antibiotics as early as possible after microbiologic sampling. If needed, the surgical debridement was performed repeatedly. The choice of antibiotic treatment was adjusted according to the microbiology culture and the results of deep tissue sampling at the time of the operation.

The goals of managing infection associated with internal fixation devices are consolidation of the fracture and prevention of chronic osteomyelitis [33]. Thus, the type of surgical intervention in patients with infected fracture-fixation devices depends on the type of device, the presence or absence of bony union, and the patient's underlying condition [34]. If the implant is stable and no infectious biofilm is found on the hardware, implants should not be removed and should stay in place until bony union is confirmed radiologically. If the infection has spread deep around the implant and loosening occurs, however, antibiotic treatment alone is not appropriate. The implant with dead bone sequesters should be removed to avoid chronic osteomyelitis. A THA can be performed as the definitive method to improve the function of the hip joint after the area has been proven free of infection in deep soft tissue samples.

There are several limitations to our study. First, even though this is one of the world's largest data sets of acetabular fractures, the sample size is small. There are only 16 infected patients admitted in the study. Therefore, the effect of plausible covariates as the ISS or the type of the acetabular fracture on SSI was not statistically significant because of a type II error. Moreover, the experience of the surgeons and the compliance with the aseptic concept may be the risk factors of the infection, but they were not included in the quantitative analysis. These topics could be included in future studies.

The presented study investigates one of the largest published cohorts of surgically treated acetabular fractures. Multiple risk factors associated with SSI after acetabular fracture treatment were identified. In our study BMI, operative time, Morel-Lavallée lesion, and abdominal trauma were found to be independent risk factors. To reduce the incidence of SSI, one should therefore reduce the operative time and identify obese patients or those with Morel-Lavallée lesion and abdominal trauma as high-risk patients. Furthermore, surgical debridement should be performed without delay in cases of acetabular SSI.

Footnotes

Acknowledgment

The authors acknowledge Professor Wun-jer Shen, Dr. Shuai Gao, and Tai hong Gao for their invaluable assistance with the writing of this article.

Author Disclosure Statement

All the authors declare that no competing financial interests exist.

This research was supported by grants from the National Natural Science Foundation of China (No.81300964), the China Postdoctoral Science Foundation (No.2013M531611), and the Natural Science Foundation of Shandong Province (No. ZR2011HM054).

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