The Role of Prophylactic Antibiotics for Percutaneous Procedures in Orthopaedic Surgery

doi:10.4236/ss.2011.26075

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Surgical Science, 2011, 2, 348-352

doi:10.4236/ss.2011.26075 Published Online August 2011 (http://www.SciRP.org/journal/ss)

The Role of Prophylactic Antibiotics for Percutaneous

Procedures in Orthopaedic Surgery

A. Gulati1*, A. Dixit2, D. M. Williamson1

1Great Western Hospital, Swindon, UK

2University Hospital of Leicester, Leicester, UK

E-mail: *[email protected]

Received May 5, 2011; revised June 30, 2011; accepted July 8, 2011

Abstract

Introduction: This study investigates the current practice of surgeons in the United Kingdom with regards to

their usage of prophylactic antibiotics for percutaneous orthopaedic procedures. Methods: An electronic sur-

vey of 10 questions was devised and sent to all members of the British Orthopaedic Association. Three hun-

dred and three replies were obtained (172 consultants, 131 trainees). Results: Only half the numbers of or-

thopaedic surgeons would routinely use antibiotics for percutaneous K-wire fixation. Of the other half, 28%

would never prescribe antibiotics and 22% would use them in special circumstances only. These ‘special

circumstances’ were also not standardised. 92% of those who did prescribe antibiotics would administer sin-

gle dose only and the majority (90%) would administer them during induction. There was no significant dif-

ference between trainees and consultants or between different orthopaedic procedures with regards to

whether prophylactic antibiotics were prescribed or not. Discussion: This survey highlights the split of opin-

ion amongst practising orthopaedic surgeons as to the necessity or otherwise of antibiotic prophylaxis in

percutaneous orthopaedic procedures. There are no reliable guidelines and further work should be carried out

to investigate this subject.

Keywords: Prophylactic Antibiotics, Percutaneous Procedures, K-Wires

1. Introduction

Infections in orthopaedics and trauma surgery are par-

ticularly challenging due to changing epidemiology and

bacteriology of microbes, and the propensity for long-

term morbidity. The issue is further complicated by rap-

idly increasing prevalence of antimicrobial resistance.

Surgical site infections are a major source of postop-

erative illness, accounting for nearly 25% of all nosoco-

mial infections in the United States each year. The esti-

mates from the Centre for Disease Control and Preven-

tion (CDC) suggest that approximately 500,000 surgical

site infections occur annually in the United States [1]. In

the United Kingdom, an estimated 320,000 patients ac-

quire one or more hospital acquired infections every year

during their in-patient stay, and these infections cost the

hospital sector an estimated £930 million per year [2].

Numerous exogenous and endogenous factors have

been implicated in contributing to the onset of bone and

joint infection thereby resulting in increased morbidity,

hospital stay, and health care costs. Hence, it is not un-

common in many situations in orthopaedic surgery to

prescribe prophylactic antibiotics, particularly when car-

rying out an invasive procedure. However, inappropriate

use of antibiotics may not actually prevent postoperative

infections but instead it may contribute to the develop-

ment of antibiotic resistance. This may then predispose

patients to further infections, increasing the risk of ad-

verse reactions and healthcare costs [3].

The use of prophylactic antibiotics is considered rou-

tine in some orthopaedic procedures such as joint re-

placement [4], spine surgery and major fracture fixation.

There are, however, no clear guidelines [5,6] about using

prophylactic antibiotics for percutan eous Kirschner wires

(K-wires) in orthopaedic surgery. This aim of this study

was to investigate the current practice of orthopaedic

surgeons in the United Kingdom (UK) with regards to

the use of prophylactic antibiotics when carrying out

procedures which involve the insertion of percutaneous

K-wires.

A. GULATI ET AL.349

2. Methods

An electronic survey was devised and sent to all mem-

bers of the British Orthopaedic Association. A further

reminder, two weeks after the first invitation, was sent so

as to increase the response rate. Three hundred and four

replies were obtained of which 172 were from consult-

ants and 132 were from surgeons of other grades (non-

training career-grade orthopaedic surgeons and trainees).

The statistical analyses of responses was carried out

using Chi squared, Pearson’s correlation co-efficient and

Spearman correlation, where indicated, to test for sig-

nificance. The α-level of significance was defined as 5%.

SPSS® 12.0.1 for Windows (SPSS Inc., Chicago, IL,

USA) software was employed for statistical analysis of

the data.

3. Results

The first part of the analysis was to assess whether the

obtained responses allow a homogenous comparison of

the representative data.

Fifty-seven percent consultants, 39% trainee registrars,

3% non-training career-grade surgeons and 1% Senior

House Officers (SHOs) participated in the survey ( Table

1). In terms of clinical practice, 20% had 0 - 5 years,

31% had 5 - 10 years, 22% had 10 - 15 years, 12% had

15 - 20 years and 15% had >20 years of orthopaedic ex-

perience. The responses were obtained from trauma and

orthopaedics surgeons covering almost all the subspe-

cialties (16% hip, 13% upper limb, 1 1% knee, 8% hands,

8% foot and ankle, 6% trauma, 6% general orthopaedics,

1% spine, 1% orthopaedic oncology and 24% trainees

with no primary subspecialty interest) at the time of par-

ticipation. The responses, therefore, came from a sample

representative of differing grades of orthopaedic sur-

geons, surgical experience and subspecialty interest set-

ting a platform for meaningful statistical analysis.

The results of the survey demonstrate a mixture of

opinion and non-uniformity of current practice among

the practicing orthopaedic surgeons. Overall 50% would

always use prophylactic antibiotics when carrying out

percutaneous K-wires, 27% would never use them and

23% would use them only in special circumstances only

(Table 2). These “special circumstances” were also not

standar dis ed an d incl uded open fractures, associated con-

taminated wounds, other co-morbidities, diabetes, paedi-

atric growth plate fractures and fixation of foot fractures.

One response read, “when I remember”.

A subset analysis of those who did prescribe prophy-

lactic antibiotics while using percutaneous K-wires de-

monstrated that 92% surgeons would prescribe only one

dose while 2% would prescribe two doses and 6% would

Table 1. The responses from different grades of orthopaedic

surgeon.

Level Frequency Percent

Consultant 172 56.6

Staff Grade/Associate Specialist 9 3.0

Registrar (trainees) 119 39.1

SHO 4 1.3

Total 304 100

Table 2. The number of participants using antibiotics.

Antibiotics prescription Frequency Percent

Never 83 27.3

Sometimes 69 22.7

Always 152 50.0

Total 304 100

prescribe three doses (Table 3). 98% surgeons would

prescribe antibiotics parenterally (IV or IM) at the time

of induction of general anaesthesia (GA). Two percent

surgeons would prescribe oral antibiotics at the time of

discharge in additio n to the ones prescrib ed at the ti me of

induction.

The survey also investigated procedure-specific anti-

biotic prophylactic use. Eighty-five percent surgeons

would prescribe prophylactic antibiotics for finger pha-

lanx/metacarpal fracture stabilisation, 84% for metatarsal

osteotomy and 82% when performing distal radius frac-

ture fixation or toe fusion.

The second part of the analysis was to collate the re-

sults and assess whether the grade of the surgeon, their

experience or their primary sub-specialist interest influ-

enced the decision as to whether to use antibiotics or not

and the manner in which they were prescribed.

No significant difference was demonstrated between

trainees and consultants (p = 0.45) in terms of decision

whether to prescribe antibiotics or not. The experience of

the surgeon and sub specialist interest also did not influ-

ence this choice (p = 0.34 and p = 0.51 respectively).

There was, however, a significant difference (p = 0.04)

in the number of doses prescribed with more consultants

(Table 4) prescribing three doses of prophylactic antibi-

otics compared with trainees (7.9% and 3.4% respec-

tively). The more experienced surgeons (>20 years ex-

perience) were five times more likely (Table 5) to pre-

scribe three prophylactic doses (p = 0.05) when carrying

out percuta neo us K- wi res.

The preferred rou te of administratio n was intra-v enous

(IV) at the time of general anaesthesia (GA) induction

A. GULATI ET AL.

350

Table 3. The number of doses of prophylactic antibiotics

being used.

Number of doses Frequency Percent

1 204 92.2

2 3 1.6

3 14 6.2

Table 4. The number of doses of prophylactic antibiotics

prescribed by different grades of surgeons.

Number of doses

Level 1 2 3

Total

Consultant 113 1 10 126

Staff Grade/Associate

Specialist 6 1 0 6

Registrar 84 1 3 87

SHO 1 0 1 2

Total 204 3 14 221

Table 5. The number of doses of antibiotics prescribed as

per the experience of the surgeon.

Number of doses

Years practicing

Orthopaedics 1 2 3

Total

0 to 5 yr 46 1 2 49

5 to 10 yr 64 1 4 69

10 to 15 yr 47 0 1 48

15 to 20 yr 26 1 1 28

>20 yr 21 0 6 27

Total 204 3 14 221

and was not dependent on the grade of the surgeon (p =

0.16), their experience (p = 0.39) or primary subspecialty

(p = 0.61). In terms of the procedure-specific results,

there was no significant difference between the grade of

the surgeon, their surgical experience or their sub-spe-

cialist interest.

4. Discussion

Percutaneous K-wires are frequently used in a variety of

clinical situations in orthopaedic surgery for temporary

or permanent fixation of fractures and osteotomies [7].

When the wire is intended to stay in-situ for some time,

there is a potential for micro-organism colonisation and

infection. Few studies have recorded the incidence of

infection following such intervention with ranges from

zero to very low [8,9] to rates of 6.6% [10], 6.8% [11]

and 7.9% [12]. In cases where infection did occur, met-

alwork removal tended to lead to resolution [13,14]. It is,

therefore, a common practice in many situations in

medicine to prescribe prophylactic antibiotics whenever

a foreign body is implanted into the body. We could not

find any clear evidence to support this practice for per-

cutaneous pr o cedures in ort ho paedi c su rgery.

It has been our experience that it depended largely on

the surgeon’s individual training/experience and prefer-

ence as to whether or not to provide antibiotic prophy-

laxis for procedures requiring percutaneous K-wires to

be left in-situ for an extended period. We were surprised

to find that no clear guidelines exist regarding this prac-

tice and were further surprised to find that literature per-

taining to this issue is scant. The Scottish Intercollegiate

Guidelines Network (SIGN) recommend [6] antibiotic

prophylaxis should be administered in orthopaedic sur-

gery if the procedur e involves an insertion of a prosth etic

device or any procedure where there is no direct evi-

dence. The guidelines also recommend prophylactic an-

tibiotics while carrying out an op en reduction of a closed

fracture. However, these guidelines do not specify whe-

ther this recommendation is applicable for percutane-

ously inserted K-wires for closed fractures. The National

Institute for Health and Clinical Excellence (NICE)

guidelines [5] suggest that antibiotic prophylaxis should

be prescribed to patients before clean orthopaedic sur-

gery if it involves a placement of a prosthesis or an im-

plant. Again, these guidelines do not clearly provide ad-

vice about their usage for percutaneously inserted K-

wires which are kept in-situ for few weeks only.

Our survey of practicing British orthopaedic surgeons

reveals that 50% percent surgeons would always use

prophylactic antibiotics while carrying out procedures

involving percutaneous K-wires. In contrast, 27% would

never use them and 23% would use them only in special

circumstances. These circumstances varied widely from

surgeon to surgeon. This non-uniformity of practice is a

clear reflection of lack of reliable and robust evidence-

based guidelines on this topic. The number of doses of

prophylactic antib iotics prescribed was further subject to

inconsistency with the more experienced surgeons five

times more likely to prescribe three prophylactic doses.

In terms of the grade of the surgeon, 8.8% consultants

prescribed three doses compared to 4.8% trainees (p =

0.04). Although this was statistically significant, the

number of surgeons prescribing three doses is probably

too small to emphasise on this and most surgeons would

use a single dose only.

The justification to use antibiotics prophylactically is

perhaps based on the understanding that in surgical pro-

cedures that involve incorporation of an implant, the tis-

sue-implant interface is especially prone to c ontamination.

A. GULATI ET AL.351

This combined with the disturbed bony structure and

reduced local vascularity in trauma patients may impair

the ability to obtain the appropriate antibiotic concentra-

tion locally [15]. Some in-vitro and in-vivo studies have

shown that the local application of gentamicin, deliv ered

from coating on titanium K-wires, can be effective in

providing adequate prophylaxis [15]. Hargreaves et al.

[16] and Rafique et al. [14] described a technique of

burying the wires beneath the skin. This reduced the in-

fective complication rate in these studies of isolated dis-

tal radius and hand fractures respectively. Lethaby et al.

[17] performed a database review to investigate methods

of pin-site care that might reduce infection rates but

failed to find evidence of any particular strategy that

might be superior to others with regard to infection rates.

One of these trials [18] reported that infection rates were

lower (9%) with a regimen that included cleansing with

half strength hydrogen peroxide and application of

Xeroform dressing when compared with other regimens

with different cleansing and dressing regimens (rates >

26%). There was no evidence of a difference between

groups in any of the other trials.

We are aware that this study has some limitations. The

results represent the practice of just over 300 orthopaedic

surgeons in the UK which is a relatively small percent-

age of the total. Furthermore, this survey only reflects the

opinion of the members of the British Orthopaed ic Asso-

ciation. Never the less, we believe that the participants in

the survey provided a representative cohort for mean-

ingful statistical analyses. There was a good mix of re-

sponses from all grades of orthopaedic surgeons encom-

passing all primary orthopaedic sub specialties. The main

aim of this study was to highlight the fact that there are

no evidence-b ased guidelines on this topic and that there

is a split of opinion amongst the practicing orthopaedic

community. Another weakness of the study is that the

final analysis is based on the assumption that th e trainees

participating in the survey reflected their own practice

and not of their hospitals or their orthopaedic teams.

5. Conclusions

This survey serves to highlight the split of opinion

amongst practising orthopaedic surgeons as to the neces-

sity or otherwise of antibiotic prophylaxis but we have

also identified the lack of information available for clini-

cians on which to base this decision. We recommend that

further work should be carried out to investigate this

subject.

6. Competing Interests

The authors declare that they have no competing interests.

7. Authors’ Contributions

AG and DMW helped in conducting the survey. AG and

AD helped in writing up the paper, review of literature

and statistical analysis. DMW supervised the whole pro-

ject and the survey. DMW also edited and modified the

final manuscript. All authors have read and approved the

final manuscript.

8. Acknowledgements

The authors wish to acknowledge all the BOA members

who participated in the survey . A special thanks to Mr J.

Arbuthnot who helped in collecting the data and writing

up the paper. No funding or grant has been received for

the subject or content of the study.

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