Fracture-related infections are not uncommon following trauma surgery, but their relationship with recovery has been understudied, a fact that led orthopaedic surgeon William Obremskey, M.D., M.P.H., to further investigate.
Obremskey, who specializes in traumatic injuries and other types of orthopaedic surgery at Vanderbilt University Medical Center, examined how surgical-site infections (SSIs) correlate to recovery outcomes in a group of trauma patients.
“The real focus of the study was the importance of infection in driving functional and quality-of-life outcomes,” Obremskey said. “We looked at the relationship between recovery with factors such as pain perception, social support and preinjury mental health.”
LEAP Studies Spotlight Risk
About 30 years ago, Vanderbilt joined the NIH Lower Extremity Assessment Project (LEAP) to investigate the long-term effects of severe tibia fractures. The high frequency of infection was one of the major issues the study uncovered.
In contrast with other planned surgeries, such as total joint replacement, where the infection rate is 0.5 percent, LEAP data has shown that these traumatic fractures are associated with infection rates of 20 to 30 percent.
Primary Drivers
The study drew on retrospective data from two prior trials, the VANCO study, titled Local Antibiotic Therapy to Reduce Infection After Operative Treatment of Fractures at High Risk of Infection, and the OXYGEN study, formally known as Supplemental Perioperative Oxygen to Reduce Surgical Site Infection After High Energy Fracture Surgery.
The trial included 2,116 patients with tibial plateau, pilon or calcaneal fractures who were at high risk for infection. They were sorted into cohorts of those who developed an infection (182 patients) and those who did not. Functional outcomes at six months were then assessed using the Veterans RAND 12-item health survey (VR-12).
As expected, severe pain was found to be much more common in patients with an infection. Deep surgical-site infection (SSI) had a negative impact on functional recovery, as demonstrated by a 3.3-point reduction in the VR-12 score.
Among those with lower pain severity, significantly worse outcomes occurred in those with infection.
“Pain has been an incredibly understudied and underrepresented problem in orthopedics and orthopedic trauma.”
However, they also found that those with severe pain had equivalent functional outcomes – whether or not they had an infection. This suggests that pain is associated with poor recovery, likely by limiting movement and physical therapy and degrading psychological health.
“Pain has been an incredibly understudied and underrepresented problem in orthopedics and orthopedic trauma. A chronically hypersensitized area and the inflammation that comes with it can hinder the recovery process,” Obremskey said. “When people hurt, their physical performance will decrease as well as the mental health component of their quality-of-life scores.”
Psychosocial Factors
Expanding on this finding, the study highlights that functional outcome and quality-of-life scores are determined not only by pain perception but by psychological stress, mental health disorders, socioeconomic status and social support systems. This indicates a strong need for integrating mental health and social support into rehabilitation programs.
The cause-and-effect relationship swings in both directions. Not only does pain impact outcomes, but following a fracture, decline in lifestyle quality can increase the patient’s perceived level of pain, Obremskey said.
The researchers did find that long-term outcomes for patients with and without surgical-site infections (SSIs) were similar, with the lack of a complication being the only factor correlating with long-term functional improvements.
No Shortcuts on Prevention
Despite evolving protocol improvements, the genesis of most of these surgical-site infections (SSIs) is contamination by external pathogens that enter the body perioperatively. The likelihood of infection increases with delays in getting to a trauma center and the length of time the patient is in the surgery room, with bacteria in the air and on people nearby.
Taking no shortcuts is of paramount importance, starting with proper handwashing and room cleaning.
“Perioperative glucose control, use of systemic and local antibiotics, proper nutrition and wound care – it all matters,” Obremskey said.
Surgeons now are paying more attention overall to holistic patient preparation by monitoring and modifying pre-existing health factors like physical functionality, nutrition, weight and blood glucose levels to lower the likelihood of infection.
“Optimizing the total health of the patient is something we try to do to decrease risk in a manageable way,” Obremskey said. “But in orthopedic trauma we often don’t have that privilege or opportunity prior to surgery, as they do in total joint replacement, because people never plan to break a femur ahead of time!”
He also points out that use of short-term, high-dose local antibiotics can reduce infection rates by up to 50 percent. Skin around the fracture site is routinely treated with a prophylactic solution (chlorhexidine or betadine (povidone-iodine) during prep. Antibiotic ointment in the nose before surgery is an often-overlooked way to help prevent methicillin-resistant staphylococcus aureus (MRSA) infection.
“I’ve been interested in infection prevention since I was a medical student,” he said. I was always inquiring about the actual evidence-based data behind common beliefs like why surgeons wash their hands for 10 minutes.
“An awful lot about surgery has been based on dogma, without much data to support it. So, I’ve used part of my career trying to understand bacteria and how to improve the data available to try to help in infection prevention.”
