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: Despite the ubiquity of hand trauma, there remains insufficient published data to reliably inform these patients of surgical site infection (SSI) risk. We describe the risk of SSI in a single-centre cohort of hand trauma patients, with an analysis of the impact of the COVID-19 pandemic.
Methods: Retrospective data collection of consecutive patients who underwent surgery for hand and wrist trauma in a single plastic surgery centre over two, three-month periods. Demographic, injury and operative details, alongside prophylactic antibiotic use, were recorded. Burn injuries and wounds infected at presentation were excluded. Presence of SSI at 30 days (90 days if a surgical implant was used) was assessed.
Results: Overall, 556 patients - ‘Pre-COVID-19’ (n=310); ‘During COVID-19’ (n=246) - were included. Risk of SSI was 3.6% in the aggregated cohort. Female patients were more likely to develop an SSI, even when adjusted for their greater prevalence of bite aetiologies (adjOR 2.5; 95% CI, 1.00-6.37; p<0.05). The absolute risk of SSI in the ‘Pre-COVID-19’ group was 2.3% and 5.3% in the ‘During COVID-19’ group. The relative risk of developing an SSI in the ‘During COVID-19’ group, was 2.34 (95% CI, 0.95-5.78; p=0.06). Baseline characteristics were equivalent between the two groups.
Conclusion: The risk of SSI in hand trauma is the same as the nationally estimated risk for all surgery; 3-5%. Changes in presentation and practice associated with the first wave of the COVID-19 pandemic did not appear to alter the risk of SSI in patients undergoing surgery for hand trauma.
KeywordsIntroductionEuropean data suggests that hand trauma accounts for up to one-in-five of all Emergency Department attendances.1Manley OWG Wormald JCR Furniss D. The changing shape of hand trauma: an analysis of Hospital Episode Statistics in England.,2Clark DP Scott RN Anderson IW. Hand problems in an accident and emergency department.,3Larsen CF Mulder S Johansen AM Stam C. The epidemiology of hand injuries in The Netherlands and Denmark. In the United Kingdom (UK) alone, around five million people per year injure their hand or wrist, accounting for over 250,000 operations per year.1Manley OWG Wormald JCR Furniss D. The changing shape of hand trauma: an analysis of Hospital Episode Statistics in England., As with all surgery, these procedures carry a risk of developing a surgical site infection (SSI). SSI is defined by the Centers for Disease Control (CDC) criteria as an infection associated with an operative procedure that occurs at, or near the surgical incision, within the 30 days following the procedure, or within 90 days if a prosthetic implant is used during surgery., SSIs are the most common preventable complication following surgery and the most common nosocomial infection.7Klevens RM Edwards JR Richards Jr, CL et al.Estimating health care-associated infections and deaths in U.S. hospitals, 2002.,8Smyth ET McIlvenny G Enstone JE et al.Four country healthcare associated infection prevalence survey 2006: overview of the results. SSIs complicate approximately 3 to 20 percent of all surgical procedures with a national study from the UK finding an SSIs risk of 5 percent.7Klevens RM Edwards JR Richards Jr, CL et al.Estimating health care-associated infections and deaths in U.S. hospitals, 2002.,8Smyth ET McIlvenny G Enstone JE et al.Four country healthcare associated infection prevalence survey 2006: overview of the results. However, this figure may be an underestimate given that over 60 percent of SSIs become evident after discharge and may be treated in the community.9Woelber E Schrick EJ Gessner BD Evans HL. Proportion of Surgical Site Infections Occurring after Hospital Discharge: A Systematic Review.Many have purported a lower SSI risk in hand and wrist surgery, with the anatomical region's excellent blood supply being the explanation.10Nosocomial infections in hand surgery.,11Swanson TV Szabo RM Anderson DD. Open hand fractures: prognosis and classification.,12Glueck DA Charoglu CP Lawton JN. Factors associated with infection following open distal radius fractures. It has been stated that hand surgeons are ‘privileged to operate in an anatomic region that is less vulnerable to infection than most sites of the body.’10Nosocomial infections in hand surgery. However, this is not substantiated by reliable data. Of the small number of studies that directly assess SSI in hand and wrist trauma, the risk ranges from 3 to 10 percent, reflecting similar risk as for all operative procedures.8Smyth ET McIlvenny G Enstone JE et al.Four country healthcare associated infection prevalence survey 2006: overview of the results.,13Davies J Roberts T Limb R Mather D Thornton D Wade RG. Time to surgery for open hand injuries and the risk of surgical site infection: a prospective multicentre cohort study.,14Post-operative infection following hand surgery. Guidelines for antibiotic use.,15Wade RG Burr NE McCauley G Bourke G Efthimiou O. The Comparative Efficacy of Chlorhexidine Gluconate and Povidone-iodine Antiseptics for the Prevention of Infection in Clean Surgery: A Systematic Review and Network Meta-analysis. There remains insufficient published data to reliably inform hand trauma patients of SSI risk.The COVID-19 pandemic, caused by the SARS-CoV-2 virus, was officially declared by the World Health Organisation on March 11, 2020.16Patel N Reissis D Mair M et al.Safety of Major Reconstructive Surgery During the Peak of the COVID-19 Pandemic in the United Kingdom and Ireland – Multicentre National Cohort Study. Since then, changes in practice across all specialties, including altered referral pathways and changes to surgical management, have become necessary to mitigate infection whilst managing the continued influx of day-to-day trauma.16Patel N Reissis D Mair M et al.Safety of Major Reconstructive Surgery During the Peak of the COVID-19 Pandemic in the United Kingdom and Ireland – Multicentre National Cohort Study.,17Losurdo P Paiano L Samardzic N et al.Impact of lockdown for SARS-CoV-2 (COVID-19) on surgical site infection rates: a monocentric observational cohort study., It stands to reason that these changes, whilst introduced with the objective to limit transmission of COVID-19, may also reduce the risk of other transmissible infections. Recent evidence has also suggested that the patterns of hand trauma presenting to hospital have changed during the COVID-19 pandemic, with an increase in injuries caused by saws and other household tools.19Garude K Natalwala I Hughes B West C Bhat W. Patterns of Adult and Paediatric Hand Trauma During the COVID-19 Lockdown. We describe the risk of SSI in a single-centre cohort of hand trauma patients, with an analysis of the impact of the COVID-19 pandemic.Materials and MethodsAn interrupted time series service evaluation was designed in accordance with the STROBE statement checklist.20von Elm E Altman DG Egger M Pocock SJ Gøtzsche PC Vandenbroucke JP Initiative STROBE The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)statement: guidelines for reporting observational studies. In keeping with UK National Health Service (NHS) Research Authority guidance, ethical approval is not required for such studies. The project was formally registered prospectively. All patients who underwent surgery for hand and wrist trauma in a single secondary plastic surgery unit between 1st May 2019 and 31st July 2019 (Pre-COVID-19) and 16th March 2020 and 16th June 2020 (During COVID-19) were identified from the hospital's operating theatre records and cross-referenced with the plastic surgery department's daily trauma theatre list records. Our time series comprised two cohorts, one from before the COVID-19 pandemic and one group from during the UK's ‘first-wave’, to evaluate the impact of the pandemic with the resultant changes to practice, patterns of injury and surgical management strategies.We reviewed the medical notes of included patients and extracted pre-specified data. Consecutive patients within the two periods who had sustained traumatic injuries to the hand and wrist, irrespective of age (including paediatric patients), were included. Hand and wrist trauma was defined as any soft tissue or bony injury that is sustained distal to, and not including, the distal radius. This included all open and closed fractures of the hand and wrist that require surgical fixation; open and closed soft tissue injuries to the hand and wrist requiring surgical repair, including skin, muscle, tendon, ligament, nerve and vessel injuries; and all fingertip injuries requiring a surgical procedure. ‘Surgical procedure’ was defined as, ‘a medical intervention performed for an injury in a designated operating room where either a new incision was created, or an open wound was accessed.’ Patients were excluded if their injury was caused by thermal burns, caustic agents or electricity, or if their wound was infected at presentation. Patients who sustained polytrauma were included if at least one of their injuries fulfilled the aforementioned inclusion criteria. In these cases, only a subsequent SSI of the hand or wrist operative site was counted in our outcome.
Patient demographic details, including age, sex, American Society of Anesthesiologists (ASA) grade and smoking status, were extracted, alongside details of relevant co-morbidities, such as diabetes, concurrent medication, including steroid use, and any other causes of immunocompromise. Specifics of the injuries were detailed, including whether the patient suffered an open or closed injury. Open injuries were then stratified to one of three groups: ‘sharp laceration’, ‘blunt laceration’ or, a ‘rip, tear or crush’ injury. The contamination status of the wound was gathered.
Operative details including, type of surgery, whether a prosthesis or implant was used, perioperative prophylactic antibiotic use and procedure setting (main theatres or in a minor-operating theatre) were captured.
Patients’ hospital notes from our centre – including ward notes, follow-up letters, clinic letters, and emergency department attendances - were examined for evidence of the development of an SSI within 30 days (90 days if a surgical implant was used), according to CDC criteria. For these patients, specifics of the treatment for their SSI were extracted, including antibiotic use and re-operation.
Data analysisContinuous variables were assessed for normality using Shapiro-Wilk Test; normality was rejected if pP values were calculated using an unpaired t test for continuous data with Gaussian distribution and using Mann-Whitney U test for non-normal variables. Chi-square test was used to evaluate associations between categorical variables, with Fisher's exact test used when cell values were below five. Statistical significance was defined as a p22Statistics notes. Units of analysis. All analyses were performed in R (v4.0.3).We anticipated that there would be a low event rate of SSI, based on current literature, and therefore did not plan to perform any more complex statistical analyses. During data analysis we encountered an association between sex and SSI risk, which was potentially confounded by bite injury. We therefore proceeded with an a posteriori logistic regression analysis to handle this confounding. Bite pattern was prioritised based on clinical reasons, before any multivariable analysis was undertaken.
ResultsOverall, 556 patients (n = 310 in the ‘Pre-COVID-19’ group, and n = 246 in the ‘During COVID-19’ group) underwent surgery for hand and wrist trauma during this time-period and were included in this study. Twenty patients developed an SSI, giving an overall risk of 3.6 percent in the aggregated cohort. All of these patients received antibiotics for the SSI and 12 returned to theatre for further surgery. The baseline characteristics for all 556 patients are shown in Table 1.Table 1Patient Characteristics
The majority of cases (n = 406; 73 percent) of hand and wrist trauma were sustained by men and the median age was 39. Three-hundred and thirty-seven (61 percent) procedures were carried out in a minor-operating theatre. Most were ‘sharp’ injuries (n = 238, 45 percent), followed by ‘rip, tear or crush’ injuries (n = 219, 39 percent). Animal bites accounted for 69 (12 percent) of the injuries. Another 100 (18 percent) of patients had other causes of wound contamination with substances such as wood, soil, metal and gravel.
A greater proportion of female patients developed SSIs than male patients in this cohort (OR, 2.83; 95 percent CI, 1.15 to 6.94; pp = 0.013). Female patients also sustained more animal bites (23 percent vs. 8.4 percent, p2(4) = 6.198, p 0.045. The model explained 42.0% of the variance in SSI, according to Nagelkerke's R2Clark DP Scott RN Anderson IW. Hand problems in an accident and emergency department.. Females remained at higher odds of developing an SSI, adjusted for the greater proportion with a bite injury mechanism (adjusted odds OR, 2.5; 95 percent CI, 1.00 to 6.37, p 0.049, Table 2 [Table, SDC 2]).Table 2Univariable and multivariable logistic regression for gender, bite and risk of SSI
The ‘Pre-COVID-19’ group and the ‘During COVID-19’ group had similar pre-operative baseline characteristics in terms of age, sex and mechanism of injury, as can be seen in Table 3. The minor-operating theatre was used more in the ‘During COVID-19’ group (pp = 0.0012). The absolute risk of SSI in the ‘Pre-COVID-19’ group was 2.3 percent and 5.3 percent in the ‘During COVID-19’ group. The relative risk (RR) of developing an SSI in the ‘During COVID-19 group, was 2.34 (95 percent CI, 0.95 to 5.78, p = 0.06).Table 3Baseline characteristics and operative variables for hand and wrist trauma patients operated on ‘pre-COVID-19 pandemic’ and ‘during COVID-19 pandemic’
DiscussionThe overall risk of SSI in our cohorts was in line with the national UK estimate of 3-5 percent for all surgical procedures.8Smyth ET McIlvenny G Enstone JE et al.Four country healthcare associated infection prevalence survey 2006: overview of the results. The pandemic led to a shift towards minor-operating theatre and local anaesthetic procedures, which did not appear to be associated with an increased risk of SSI.Our results are comparable with the findings of a recent multi-centre cohort study examining upper extremity surgery, for any indication, during the COVID-19 pandemic, which, as a secondary outcome, found the risk of SSI to be 3 percent.23Corona Hands CollaborativeThe effect of the pandemic on the clinical pathway of patients with SSI is unclear. It is possible patients with hand and wrist SSI may have chosen to avoid hospitals due to the risk of contracting COVID-19, preferentially seeking treatment in primary care settings. In contrast, with the concomitant reduction of primary care availability during the pandemic, it is also feasible that more SSI patients will have attended the emergency department for treatment. The latter cohort of patients will have been identified in our cohort, whereas the former will not. This could lead to either apparent underestimation or overestimation of SSI risk that is specific to hand and wrist patients during the pandemic. Further evaluation of national primary care datasets would help to ascertain the number of patients that are treated for hand SSI, giving a more accurate representation of overall risk.
Fewer patients received surgery for hand and wrist trauma in our centre during the first wave of the COVID-19 pandemic. Patient characteristics were comparable to those presenting prior to the pandemic, other than fewer patients smoking, which may be explained by data suggesting that smoking cessation attempts have increased in the UK during the pandemic.24Jackson SE Garnett C Shahab L Oldham M Brown J. Association of the COVID-19 lockdown with smoking, drinking and attempts to quit in England: an analysis of 2019-20 data. This similarity between the two groups indicates that a comparable patient population with equivalent types of injuries are presenting with hand and wrist trauma during the COVID-19 pandemic, despite national lockdown and changes to peoples’ working and social lives. These findings are reflected in other studies examining hand trauma during the COVID-19 pandemic.19Garude K Natalwala I Hughes B West C Bhat W. Patterns of Adult and Paediatric Hand Trauma During the COVID-19 Lockdown.,25Atia F Pocnetz S Selby A Russell P Bainbridge C Johnson N. The effect of the COVID-19 lockdown on hand trauma surgery utilization. Discourse looking at the specific activity implicated have suggested that sports related trauma was reduced whilst domestic ‘do-it-yourself’ (DIY) injuries and injuries related to deliberate self-harm (DSH) were more prevalent.19Garude K Natalwala I Hughes B West C Bhat W. Patterns of Adult and Paediatric Hand Trauma During the COVID-19 Lockdown.,25Atia F Pocnetz S Selby A Russell P Bainbridge C Johnson N. The effect of the COVID-19 lockdown on hand trauma surgery utilization.,26Ho E Riordan E Nicklin S. Hand injuries during COVID-19: Lessons from lockdown.In our cohort, a greater proportion of females developed SSIs than males, even when adjusted for their greater prevalence of bite aetiologies. Previous literature has demonstrated that SSIs generally occur more frequently in male patients than in female patients. Females have been found to be less likely than males to develop SSIs when undergoing hip, knee and intra-abdominal procedures, but more likely to develop SSIs when undergoing coronary artery bypass grafting and hernia repairs.27Aghdassi SJS Schröder C Gastmeier P. Gender-related risk factors for surgical site infections. Results from 10 years of surveillance in Germany. Some investigators have argued that these findings may be explained by differences in fat distribution between male and female patients or even due to differences in bacterial skin colonisation between sexes.27Aghdassi SJS Schröder C Gastmeier P. Gender-related risk factors for surgical site infections. Results from 10 years of surveillance in Germany. Differences in attitude toward seeking medical attention may present another confounding factor contributing to this finding. Men are purportedly less likely to consult their doctor, which could lead to reduced rates of detection of SSI in male patients.28Wang Y Hunt K Nazareth I Freemantle N Petersen I. Do men consult less than women? An analysis of routinely collected UK general practice data.Previous discourse examining SSI risk has reported varying degrees of importance of pre- and perioperative factors, such as wound contamination, grade of vascular disruption, smoking status, presence of systemic illness, use of prophylactic antibiotics and location of procedure, but their findings are often contradictory.11Swanson TV Szabo RM Anderson DD. Open hand fractures: prognosis and classification.,12Glueck DA Charoglu CP Lawton JN. Factors associated with infection following open distal radius fractures.,14Post-operative infection following hand surgery. Guidelines for antibiotic use.,29Jagodzinski NA Ibish S Furniss D. Surgical site infection after hand surgery outside the operating theatre: a systematic review. Our study did not reveal any variation in risk of SSI with different mechanisms of injury, level of contamination, ASA grade or smoking status.The majority of our patients received perioperative prophylactic antibiotics, including those who later developed an SSI. Prophylactic antibiotics in hand surgery is a contentious issue.30Murphy GR Gardiner MD Glass GE Kreis IA Jain A Hettiaratchy S. Meta-analysis of antibiotics for simple hand injuries requiring surgery.,31The role of antibiotics in the management of elective and post-traumatic hand surgery.,32Antibiotics to prevent infection in patients with dog bite wounds: a meta-analysis of randomized trials.,33Antibiotic prophylaxis for mammalian bites. Antibiotic stewardship requires evidence-based rationale for the safe and effective use of antimicrobials. For simple hand injuries that require surgery, the findings of a recent meta-analysis of 2,578 patients suggested that prophylactic antibiotics did not significantly reduce subsequent infection.30Murphy GR Gardiner MD Glass GE Kreis IA Jain A Hettiaratchy S. Meta-analysis of antibiotics for simple hand injuries requiring surgery.The indications for hand and wrist procedures that can be performed as day case procedures under local or regional anaesthetic outside of the main operating room is continually growing.29Jagodzinski NA Ibish S Furniss D. Surgical site infection after hand surgery outside the operating theatre: a systematic review.,34Dillon CK Chester DL Nightingale P Titley OG. The evolution of a hand day-surgery unit.,35Cost minimisation using clinic-based treatment for common hand conditions–a prospective economic analysis. There have been reported worries that these areas may not function with the same stringent level of infection control as the main operating theatre, however the results of our study, alongside those previously published, have not confirmed this belief.29Jagodzinski NA Ibish S Furniss D. Surgical site infection after hand surgery outside the operating theatre: a systematic review.,36Kirschner wire placement in the emergency room. Is there a risk?. We found that there was increased use of the department's minor-operating theatre during the first wave of the pandemic. This is in keeping with guidance published by the British Society for Surgery of the Hand (BSSH) and comparable to other centres in the UK.,23Corona Hands Collaborative
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