Infirmity and injury complexity are risk factors for surgical-site infection after operative fracture care

Abstract

Background: Orthopaedic surgical-site infections prolong hospital stays, double rehospitalization rates, and increase healthcare costs. Additionally, patients with orthopaedic surgical-site infections (SSI) have substantially greater physical limitations and reductions in their health-related quality of life. However, the risk factors for SSI after operative fracture care are unclear.

Questions/purpose: We determined the incidence and quantified modifiable and nonmodifiable risk factors for SSIs in patients with orthopaedic trauma undergoing surgery.

Patients and methods: We retrospectively indentified, from our prospective trauma database and billing records, 1611 patients who underwent 1783 trauma-related procedures between 2006 and 2008. Medical records were reviewed and demographics, surgery-specific data, and whether the patients had an SSI were recorded. We determined which if any variables predicted SSI.

Results: Six factors independently predicted SSI: (1) the use of a drain, OR 2.3, 95% CI (1.3-3.8); (2) number of operations OR 3.4, 95% CI (2.0-6.0); (3) diabetes, OR 2.1, 95% CI (1.2-3.8); (4) congestive heart failure (CHF), OR 2.8, 95% CI (1.3-6.5); (5) site of injury tibial shaft/plateau, OR 2.3, 95% CI (1.3-4.2); and (6) site of injury, elbow, OR 2.2, 95% CI (1.1-4.7).

Conclusion: The risk factors for SSIs after skeletal trauma are most strongly determined by nonmodifiable factors: patient infirmity (diabetes and heart failure) and injury complexity (site of injury, number of operations, use of a drain).

Level of evidence: Level II, prognostic study. See the Guideline for Authors for a complete description of levels of evidence.

Fig. 1

The graph shows the probability of SSI for patients with tibial shaft fractures or tibial plateau injuries stratified by the number of surgeries and based on risk factors including wound drainage versus no drainage, CHF, and diabetes. Risk increases with increasing number of risk factors and is greater with more than one operation. Probabilities were derived from the multivariable logistic regression analysis.

Fig. 2

The graph shows the probability of SSI for patients with elbow injuries stratified by the number of surgeries and based on risk factors including wound drainage versus no drainage, CHF, and diabetes. Risk increases with increasing number of risk factors and is greater with more than one operation. Probabilities were derived from multivariable logistic regression analysis.

Fig. 3

The graph shows the probability of SSI for patients with injuries other than tibial shaft/plateau or elbow stratified by the number of surgeries and based on risk factors including wound drainage versus no drainage, CHF, and diabetes. Risk increases with increasing number of risk factors and is greater with more than one operation. Probabilities were derived from multivariable logistic regression analysis.