Preoperative Antibiotics in Wrist Arthroscopy

      Purpose

      This study seeks to evaluate the need for preoperative antibiotics for wrist arthroscopy.

      Methods

      A retrospective review of 576 consecutive wrist arthroscopies was performed over a 10-year period at a single ambulatory surgery center. The chart of each included patient was reviewed for postoperative infections following the National Nosocomial Infections Surveillance criteria for diagnosis.

      Results

      Of the 576 wrist arthroscopies reviewed, 324 met the inclusion criteria. Preoperative antibiotics were administered in 209 cases (65%) and not administered in 115 cases (35%). There were 116 cases (36%) with concomitant open soft tissue procedures. We identified 2 infections (0.6% overall infection rate), both of which were in patients who had received preoperative antibiotics. Both of these patients underwent concomitant percutaneous pinning of carpal bones with Kirschner wires, which were buried beneath the skin.

      Conclusions

      Administering preoperative antibiotics for routine wrist arthroscopy does not appear to lower the surgical site infection rate. The rate of surgical site infection is so low in both cohorts that a meaningful difference cannot be determined between the 2 groups. This study adds to the current body of literature suggesting that it is acceptable practice to withhold preoperative antibiotics for surgeries that have a very low rate of infection.

      Type of study/level of evidence

      Therapeutic IV.

      Key words

      Wrist arthroscopy is a commonly used technique for the evaluation and treatment of intra-articular pathology, with an estimated 25,000 cases performed in the United States in 2006.
      • Jain N.B.
      • Higgins L.D.
      • Losina E.
      • Collins J.
      • Blazar P.E.
      • Katz J.N.
      Epidemiology of musculoskeletal upper extremity ambulatory surgery in the United States.
      Among surgeons who perform these procedures, there is heterogeneity in the practice of administering preoperative antibiotics. However, there is no clear evidence that preoperative antibiotics lower the incidence of infection for this type of procedure.
      The Journal of Hand Surgery will contain at least 2 clinically relevant articles selected by the editor to be offered for CME in each issue. For CME credit, the participant must read the articles in print or online and correctly answer all related questions through an online examination. The questions on the test are designed to make the reader think and will occasionally require the reader to go back and scrutinize the article for details.
      The JHS CME Activity fee of $15.00 includes the exam questions/answers only and does not include access to the JHS articles referenced.
      Statement of Need: This CME activity was developed by the JHS editors as a convenient education tool to help increase or affirm reader’s knowledge. The overall goal of the activity is for participants to evaluate the appropriateness of clinical data and apply it to their practice and the provision of patient care.
      Accreditation: The ASSH is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
      AMA PRA Credit Designation: The American Society for Surgery of the Hand designates this Journal-Based CME activity for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
      ASSH Disclaimer: The material presented in this CME activity is made available by the ASSH for educational purposes only. This material is not intended to represent the only methods or the best procedures appropriate for the medical situation(s) discussed, but rather it is intended to present an approach, view, statement, or opinion of the authors that may be helpful, or of interest, to other practitioners. Examinees agree to participate in this medical education activity, sponsored by the ASSH, with full knowledge and awareness that they waive any claim they may have against the ASSH for reliance on any information presented. The approval of the US Food and Drug Administration is required for procedures and drugs that are considered experimental. Instrumentation systems discussed or reviewed during this educational activity may not yet have received FDA approval.
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      ASSH Disclosure Policy: As a provider accredited by the ACCME, the ASSH must ensure balance, independence, objectivity, and scientific rigor in all its activities.

      Disclosures for this Article

      Editors

      Jennifer Moriatis Wolf, MD, has no relevant conflicts of interest to disclose.

      Authors

      All authors of this journal-based CME activity have no relevant conflicts of interest to disclose. In the printed or PDF version of this article, author affiliations can be found at the bottom of the first page.

      Planners

      Jennifer Moriatis Wolf, MD, has no relevant conflicts of interest to disclose. The editorial and education staff involved with this journal-based CME activity has no relevant conflicts of interest to disclose.

      Learning Objectives

      Upon completion of this CME activity, the learner should achieve an understanding of:
      • The current recommendations for use of preoperative antibiotics for hand surgical cases
      • The risks and benefits associated with the use of antibiotics around elective surgery
      • Considerations in antibiotic use for wrist arthroscopy
      Deadline: Each examination purchased in 2018 must be completed by January 31, 2019, to be eligible for CME. A certificate will be issued upon completion of the activity. Estimated time to complete each JHS CME activity is up to one hour.
      Copyright © 2018 by the American Society for Surgery of the Hand. All rights reserved.
      The American Association of Plastic Surgeons has recommended that antibiotics are not necessary for clean surgical cases of the hand, because they do not lower the infection rate.
      • Ariyan S.
      • Martin J.
      • Lal A.
      • et al.
      Antibiotic prophylaxis for preventing surgical-site infection in plastic surgery: an evidence-based consensus conference statement from the American Association of Plastic Surgeons.
      • Bykowski M.R.
      • Sivak W.N.
      • Cray J.
      • Buterbaugh G.
      • Imbriglia J.E.
      • Lee W.P.A.
      Assessing the impact of antibiotic prophylaxis in outpatient elective hand surgery: a single-center, retrospective review of 8,850 cases.
      Although this recommendation has been widely accepted for procedures such as carpal tunnel release, our experience is that most patients undergoing wrist arthroscopy are still routinely given preoperative antibiotics.
      Looking to the literature regarding arthroscopic procedures performed on other joints, a 2007 review of knee arthroscopies showed that administration of preoperative antibiotics did not change the incidence of surgical site infections.
      • Bert J.M.
      • Giannini D.
      • Nace L.
      Antibiotic prophylaxis for arthroscopy of the knee: is it necessary?.
      Despite evidence that antibiotics do not change the incidence of surgical site infections in knee arthroscopy, a 2009 survey of orthopedic surgeons showed that 85% still administered preoperative antibiotics for arthroscopic meniscectomies.
      • Redfern J.
      • Burks R.
      2009 survey results: surgeon practice patterns regarding arthroscopic surgery.
      The use of preoperative antibiotics does have associated morbidity and cost. Prior literature has shown that diarrhea occurs in 2% to 5% of patients treated with cephalosporins, and that even a single dose of preoperative cephalosporin can precipitate diarrhea or intestinal Clostridium difficile infection.
      • Privitera G.
      • Scarpellini P.
      • Ortisi G.
      • Nicastro G.
      • Nicolin R.
      • de Lalla F.
      Prospective study of Clostridium difficile intestinal colonization and disease following single-dose antibiotic prophylaxis in surgery.
      • Bartlett J.G.
      Clinical practice. Antibiotic-associated diarrhea.
      In addition, careful antibiotic stewardship is critical in modern medical practice to limit the rise in antibiotic-resistant pathogens seen in recent decades.
      Given the drawbacks of antibiotic overuse and the evidence from knee arthroscopy literature, we sought to investigate the need for preoperative antibiotics in wrist arthroscopy. Our primary objective was to determine if there is a clinically meaningful difference in postoperative infection rates in patients undergoing wrist arthroscopy with or without administration of preoperative antibiotics. The secondary objective was to determine other factors that may be associated with infection in wrist arthroscopy. Our hypothesis was that there would be no difference in the rate of infection whether or not prophylactic antibiotics were given.

      Materials and Methods

      This study was approved by our institutional review board as category 5 research. Approval was received for access to 719 records for 576 unique patients with a waiver of informed consent as research involved no more than minimal risk to subjects.
      Within our institution, there are surgeons who routinely give preoperative antibiotics for wrist arthroscopy surgery, and others who do not. This created historical cohorts of patients who did and did not receive routine preoperative antibiotics for wrist arthroscopy. We performed a retrospective chart review of a 10-year period (March 15, 2005, to December 31, 2015) at a single orthopedic ambulatory surgery center, querying by Current Procedural Terminology codes for wrist arthroscopy. The specific codes used were 29840, 29844, 29845, and 29846. The operative reports and anesthesia records of each identified case were reviewed to confirm the surgical procedure performed, whether there were concomitant open procedures, whether preoperative antibiotics were given, and tourniquet time during the case. Additional demographic data such as patient age, sex, diabetic status, and smoking status at the time of surgery were recorded for each case. Electronic medical records were reviewed for 30 days from the time of surgery to identify postoperative infections. Our criteria for a postoperative infection followed the National Nosocomial Infections Surveillance criteria for defining a surgical site infection (SSI), which include infections occurring within 30 days of the operation if there is no retained implant, and within 1 year if there is a retained implant.
      • Mangram A.J.
      • Horan T.C.
      • Pearson M.L.
      • Silver L.C.
      • Jarvis W.R.
      Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee.
      We did not exclude patients who had minor concomitant open procedures for which preoperative antibiotics would not be otherwise indicated (eg, carpal tunnel release, trigger finger release; full list can be found in Appendix A, available on the Journal’s Web site at www.jhandsurg.org). However, we did exclude patients who had open bony procedures and elaborate open soft tissue procedures (eg, open triangular fibrocartilage complex repair; full list can be found in Appendix A). Additional exclusion criteria were an arthroscopy performed for an existing infection (Current Procedural Terminology 29843) and follow-up less than 30 days. The antibiotic protocol at our institution is to administer 2 g of cefazolin or 900 mg of clindamycin (in the case of a penicillin or cephalosporin allergy) intravenously within 30 minutes before skin incision. In patients over 120 kg, the cefazolin dose is increased to 3 g, but the clindamycin dose remains at 900 mg. These doses are based on the American Society of Health-System Pharmacists report from 2013.
      • Bratzler D.W.
      • Dellinger E.P.
      • Olsen K.M.
      • et al.
      Clinical practice guidelines for antimicrobial prophylaxis in surgery.

      Results

      We identified 576 wrist arthroscopies performed by 8 surgeons during the time period queried. Of these, 324 met the inclusion criteria. Reasons for exclusion were concomitant open bony or ligamentous procedures at the wrist (173), inadequate follow-up (70), and incomplete data in the operative and anesthesia records regarding the procedure performed or administration of preoperative antibiotics (9). The median patient age was 38 (range, 11–75) years, and the ratio of males to females was almost equal. With respect to recorded medical comorbidities, 13% of the patients were smokers, and 3% had diabetes.
      Of the 324 cases that met criteria for analysis, the most common indications for the operation were an arthroscopic triangular fibrocartilage complex debridement (187) and an arthroscopic synovial debridement (114). Preoperative antibiotics were administered to 209 patients (65%), and 115 patients (35%) did not receive preoperative antibiotics. There were 116 cases (36%) with concomitant open soft tissue procedures, the most common of which was an isolated posterior interosseous neurectomy (Table 1).
      Table 1Concomitant Open Procedures in Included Patients
      ProcedureAntibiotic GroupNo Antibiotic Group
      Isolated posterior interosseous neurectomy3436
      Posterior interosseous neurectomy plus second procedure122
      Ganglion excision71
      Carpal tunnel release51
      Percutaneous pinning of intercarpal ligament tear or distal radius fracture60
      First dorsal compartment release22
      Trigger finger release11
      Other procedure(s)51
      Total7244
      We identified 2 infections, both of which were in patients who had received preoperative antibiotics. Neither of these patients were smokers, diabetic, and had had previous operations on the same wrist. These 2 patients had body mass indices of 20 and 31.
      Both infections occurred in patients who had arthroscopic-assisted percutaneous pinning of intercarpal ligament injuries. In both cases, the Kirschner wires were buried subcutaneously and were removed at the time of irrigation and debridement for infection. A tourniquet was not used during the index procedure in either case. Specific details of these 2 infections are listed in Table 2.
      Table 2Characteristics of Patients Who Developed Infections
      Patient12
      Age6721
      DiagnosisScapholunate ligament tearLunotriquetral ligament tear
      Procedure performedArthroscopic-assisted reduction and percutaneous pinningMidcarpal debridement, arthroscopic-assisted reduction, and percutaneous pinning
      Received antibiotics?Yes—cefazolinYes—cefazolin
      Pins buried?YesYes
      Time to infection39 d11 d
      Infection siteWrist jointWrist joint
      OrganismMSSAMSSA
       Intervention requiredSurgical debridement

      Outpatient management

      Oral dicloxacillin, duration unknown
      Surgical debridement

      Four-day hospitalization

      Three-week IV ampicillin-sulbactam
       Smoking statusNonsmokerNonsmoker
       ComorbiditiesNoneNone
      IV, intravenous; MSSA, methicillin-sensitive Staphylococcus aureus.

      Discussion

      Surgical site infection and its prevention is a primary concern for modern health care systems. Worldwide, protocols have been developed for surgical safety that include verification of the administration of preoperative intravenous antibiotics. The American Medical Association published the Center for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection 2017, wherein a systematic review was performed to determine best available evidence-based practices.
      • Berríos-Torres S.I.
      • Umscheid C.A.
      • Bratzler D.W.
      • et al.
      Centers for disease control and prevention guideline for the prevention of surgical site infection, 2017.
      With regard to the use of preoperative intravenous antibiotics, this guideline states, “Administer preoperative antimicrobial agents only when indicated based on published clinical practice guidelines.” There is clear evidence that preoperative antibiotics reduce the rate of SSI for orthopedic procedures such as joint arthroplasty and spine surgery. There are numerous reports, however, that there is neither a statistically nor clinically significant reduction in SSI for orthopedic surgeries in which SSI is rare.
      • Ariyan S.
      • Martin J.
      • Lal A.
      • et al.
      Antibiotic prophylaxis for preventing surgical-site infection in plastic surgery: an evidence-based consensus conference statement from the American Association of Plastic Surgeons.
      • Bykowski M.R.
      • Sivak W.N.
      • Cray J.
      • Buterbaugh G.
      • Imbriglia J.E.
      • Lee W.P.A.
      Assessing the impact of antibiotic prophylaxis in outpatient elective hand surgery: a single-center, retrospective review of 8,850 cases.
      • Bert J.M.
      • Giannini D.
      • Nace L.
      Antibiotic prophylaxis for arthroscopy of the knee: is it necessary?.
      Presumably, based in part on this literature, the American Society of Health-System Pharmacists does not recommend surgical antimicrobial prophylaxis for clean orthopedic surgery that does not involve an implant in the hand, knee, or foot in their Clinical Practice Guidelines.
      • Bratzler D.W.
      • Dellinger E.P.
      • Olsen K.M.
      • et al.
      Clinical practice guidelines for antimicrobial prophylaxis in surgery.
      Our results show that performing wrist arthroscopy without administering preoperative antibiotics does not increase the SSI rate. Although the 2 observed infections occurred in the group that received antibiotics, withholding antibiotics cannot be claimed to be superior because of the low number of infections and lack of power of this study to demonstrate a difference between these groups.
      Our study showed an overall SSI rate of 0.6% when the 2 groups were combined. This rate approximates the infection rate of clean hand surgery cases.
      • Jain N.B.
      • Higgins L.D.
      • Losina E.
      • Collins J.
      • Blazar P.E.
      • Katz J.N.
      Epidemiology of musculoskeletal upper extremity ambulatory surgery in the United States.
      This is notably higher than a recent study by Leclercq et al,
      • Jain N.B.
      • Higgins L.D.
      • Losina E.
      • Collins J.
      • Blazar P.E.
      • Katz J.N.
      Epidemiology of musculoskeletal upper extremity ambulatory surgery in the United States.
      • Leclercq C.
      • Mathoulin C.
      Members of European Wrist Arthroscopy Society. Complications of wrist arthroscopy: a multicenter study based on 10,107 arthroscopies.
      in which only 1 deep infection was reported after isolated wrist arthroscopy from a study population of 10,107, although the authors of that study did not specify how many of the total cases had concomitant open procedures, nor how many patients received preoperative antibiotics. The rate of infection in that study was based on a survey sent to surgeons asking them to review their personal complications data. Our surgical site infection rate of 0.6% is also higher than rates of infection reported in knee and shoulder arthroscopy, both of which have been shown in multiple large studies to have infection rates below 0.5%.
      • Bert J.M.
      • Giannini D.
      • Nace L.
      Antibiotic prophylaxis for arthroscopy of the knee: is it necessary?.
      • Armstrong R.W.
      • Bolding F.
      • Joseph R.
      Septic arthritis following arthroscopy: clinical syndromes and analysis of risk factors.
      • D’Angelo G.L.
      • Ogilvie-Harris D.J.
      Septic arthritis following arthroscopy, with cost/benefit analysis of antibiotic prophylaxis.
      • Müller-Rath R.
      • Becker J.
      • Ingenhoven E.
      Wie hoch ist das statistische Risiko einer Infektion nach ambulanter Arthroskopie?: Eine Auswertung von über 50.000 Fällen anhand der Statistik des BVASK/[What is the statistical risk of infection after outpatient arthroscopy?].
      This discrepancy may be attributable to a longer length of follow-up in this study than in other reports, which is as short as 2 weeks.
      • Bert J.M.
      • Giannini D.
      • Nace L.
      Antibiotic prophylaxis for arthroscopy of the knee: is it necessary?.
      • Armstrong R.W.
      • Bolding F.
      • Joseph R.
      Septic arthritis following arthroscopy: clinical syndromes and analysis of risk factors.
      • D’Angelo G.L.
      • Ogilvie-Harris D.J.
      Septic arthritis following arthroscopy, with cost/benefit analysis of antibiotic prophylaxis.
      • Müller-Rath R.
      • Becker J.
      • Ingenhoven E.
      Wie hoch ist das statistische Risiko einer Infektion nach ambulanter Arthroskopie?: Eine Auswertung von über 50.000 Fällen anhand der Statistik des BVASK/[What is the statistical risk of infection after outpatient arthroscopy?].
      This study does have considerable limitations. Because infection events are quite rare, we would need a substantially greater number of cases to show any statistically significant difference in infection rate with the use of antibiotics. Assuming a baseline risk of infection of 0.5% and making a theoretical assumption that antibiotic administration could change the rate of infection by 50%, the number needed to treat to prevent 1 infection would be 400. Based on the findings in this study, it is unlikely that antibiotic administration decreases the risk by 50%, and thus the number needed to treat is likely to be dramatically higher, making the development of an appropriately powered study prohibitively impractical.
      In addition, this is a retrospective review, introducing the possibility of selection bias as to which patients received antibiotics. Although we did not sort the administration of antibiotics by a surgeon, some surgeons in the practice routinely ordered antibiotics and some routinely did not. Also, because there were 8 surgeons involved, variations in technique and skill level, length of procedures, involvement of trainees in some cases, and patient mix could bias the results. Because we excluded cases with concomitant open bony and ligamentous procedures in the same region, our findings can only be applied to wrist arthroscopy with soft tissue or minor concomitant procedures.
      Despite the above limitations, our results lead us to conclude that preoperative antibiotics do not clearly reduce the infection rate in wrist arthroscopy. The costs and risks associated with administration of antibiotics for a procedure with such a low infection rate likely outweigh any benefit. This study adds to the current body of literature suggesting that it is acceptable practice to not administer preoperative antibiotics for surgeries that have a very low rate of infection.

      Appendix A.

      Appendix AAll Included and Excluded Concomitant Open Procedures
      Included Concomitant Open ProceduresExcluded Concomitant Open Procedures
      Posterior interosseous nerve neurectomy

      Dorsal wrist ganglion cyst excision

      Volar wrist ganglion cyst excision

      Carpal tunnel release

      First extensor compartment release

      Trigger finger release

      Guyon’s canal release

      Cubital tunnel decompression

      Digital arthrodesis

      Percutaneous fracture pinning

      Incision extension to achieve hemostasis

      Lateral elbow contracture release
      Ulnar shortening osteotomy

      Removal of ulnar exostosis

      Carpometacarpal arthrodesis

      Open scapholunate ligament repair

      Open scaphoid screw removal

      Wafer resection of ulnar head

      Excision of distal radius bone cyst

      Open pisiform excision

      Scapholunate capsulorrhaphy

      Excision of volar forearm mass

      Radical flexor synovectomy

      Open triquetral excision

      Open reduction internal fixation distal radius

      Open reduction of lunate dislocation

      Open triangular fibrocartilage repair

      Open excision ulnar styloid nonunion

      Open radiocarpal biopsy

      Proximal row carpectomy

      Distal radius osteotomy

      Open fibrous scar removal

      Open loose body removal from wrist

      References

        • Jain N.B.
        • Higgins L.D.
        • Losina E.
        • Collins J.
        • Blazar P.E.
        • Katz J.N.
        Epidemiology of musculoskeletal upper extremity ambulatory surgery in the United States.
        BMC Musculoskelet Disord. 2014; 15: 4
        • Ariyan S.
        • Martin J.
        • Lal A.
        • et al.
        Antibiotic prophylaxis for preventing surgical-site infection in plastic surgery: an evidence-based consensus conference statement from the American Association of Plastic Surgeons.
        Plast Reconstr Surg. 2015; 135: 1723-1739
        • Bykowski M.R.
        • Sivak W.N.
        • Cray J.
        • Buterbaugh G.
        • Imbriglia J.E.
        • Lee W.P.A.
        Assessing the impact of antibiotic prophylaxis in outpatient elective hand surgery: a single-center, retrospective review of 8,850 cases.
        J Hand Surg Am. 2011; 36: 1741-1747
        • Bert J.M.
        • Giannini D.
        • Nace L.
        Antibiotic prophylaxis for arthroscopy of the knee: is it necessary?.
        Arthroscopy. 2007; 23: 4-6
        • Redfern J.
        • Burks R.
        2009 survey results: surgeon practice patterns regarding arthroscopic surgery.
        Arthroscopy. 2009; 25: 1447-1452
        • Privitera G.
        • Scarpellini P.
        • Ortisi G.
        • Nicastro G.
        • Nicolin R.
        • de Lalla F.
        Prospective study of Clostridium difficile intestinal colonization and disease following single-dose antibiotic prophylaxis in surgery.
        Antimicrob Agents Chemother. 1991; 35: 208-210
        • Bartlett J.G.
        Clinical practice. Antibiotic-associated diarrhea.
        N Engl J Med. 2002; 346: 334-339
        • Mangram A.J.
        • Horan T.C.
        • Pearson M.L.
        • Silver L.C.
        • Jarvis W.R.
        Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee.
        Am J Infect Control. 1999; 27: 97-132
        • Bratzler D.W.
        • Dellinger E.P.
        • Olsen K.M.
        • et al.
        Clinical practice guidelines for antimicrobial prophylaxis in surgery.
        Am J Health Syst Pharm. 2013; 70: 195-283
        • Berríos-Torres S.I.
        • Umscheid C.A.
        • Bratzler D.W.
        • et al.
        Centers for disease control and prevention guideline for the prevention of surgical site infection, 2017.
        JAMA Surg. 2017; 152: 784-791
        • Leclercq C.
        • Mathoulin C.
        Members of European Wrist Arthroscopy Society. Complications of wrist arthroscopy: a multicenter study based on 10,107 arthroscopies.
        J Wrist Surg. 2016; 5: 320-326
        • Armstrong R.W.
        • Bolding F.
        • Joseph R.
        Septic arthritis following arthroscopy: clinical syndromes and analysis of risk factors.
        Arthroscopy. 1992; 8: 213-223
        • D’Angelo G.L.
        • Ogilvie-Harris D.J.
        Septic arthritis following arthroscopy, with cost/benefit analysis of antibiotic prophylaxis.
        Arthroscopy. 1988; 4: 10-14
        • Müller-Rath R.
        • Becker J.
        • Ingenhoven E.
        Wie hoch ist das statistische Risiko einer Infektion nach ambulanter Arthroskopie?: Eine Auswertung von über 50.000 Fällen anhand der Statistik des BVASK/[What is the statistical risk of infection after outpatient arthroscopy?].
        Arthroskopie. 2008; 21: 87-91

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