The objective of this study was to compare infection rate, antibiotic administration, preparation-to-incision time and cost of full surgical preparation and draping vs semi-sterile technique in CRPP of supracondylar fractures. There was no difference in infection rate between approaches, with only one patient having a reported infection across both groups, supporting our hypothesis. Cost savings were estimated to be approximately $28 [CDN] per case when using semi-sterile technique over full preparation and draping, and a decreased preparation-to-incision time was also identified, translating to shorter overall surgical time.
The rate of infection found in the current study using the semi-sterile technique were similar to the findings of Iobst et al.4. This study also supported the assertion in the current study that patients likely do not need pre-operative antibiotics administration. In contrast, Turgut et al.2 recently found high pin tract infection rates of 7.3% in a semi-sterile technique. In this large study, 712 patients had CRPP of supracondylar fractures with the semi-sterile technique of which 52 (7%) developed pin tract infections. Infection was not well defined and patients were asked to visit their family doctor for pin site care every 4 days until they were removed. Kao et al.13 reported on a series of 61 patients treated for elbow fractures finding that infection rates were significantly higher in patients who had daily pin-site care then in patients who did not. This could explain the higher infection rates seen in Turgut et al.2 compared with Iobst et al.4 and the current series.
A comparison of infection rates based on placement of pins including crossed or lateral pin fixation in 56 participants was reported by Shamsuddin et al.14 and found the rates were comparable. The current study was based on the use of lateral pins almost exclusively, but the findings of Shamsuddin et al.14 may support that the findings may extend to medial pins. However, this would need to be verified in further study.
Parikh et al.15 found that the risk of intracapsular pin placement using parallel lateral pins was found to be greater than either crossed or divergent lateral configurations. It is of interest that parallel lateral pins were used in the only infection found in our series with an associated septic arthritis of the elbow. This may suggest that the use of crossed or divergent lateral pins may reduce cases of septic arthritis.
The sole infection in the current study series was caused by Enterobacter cloacae which is a clinically significant gram-negative, anaerobic, rod-shaped bacterium. This bacterium is commensal in the enteric flora since they are found in soil and sewage, as well as in the human gastrointestinal tract.16 The authors suggest this infection may have been from hematogenous spread or inadequate hand-hygiene of surgical staff.
Surgical time and cost difference between semi-sterile and full preparation and draping techniques have not been well reported in the literature. This is an important factor in the current state of cost savings and quality issues in surgery. Analysis at our institution found a cost savings when using semi-sterile technique rather than full preparation and draping, in terms of surgical supply costs and decreased preparation-to-incision time. Although this savings initially does not seem substantial, the high volume of supracondylar fractures treated yearly as well as decreased surgical time makes these factors of greater importance to the health care system.
There were some limitations in the current study. The sterility of wires, drapes, scrubbing characteristics of staff assistants, gloving techniques, operation theatre conditions, number of skin piercings by wires and patient's nutrition status were not accounted for; however, the impacts of these should assumedly be comparable regardless of which technique was used. With the low incidence of infection found, these variables did not have a notable impact. Fracture type was not recorded for 60 patients in the semi-sterile group as well as 68 patients in the full preparation and draping group. Number of k-wires and medial pins were also not charted or available on x-ray for a small percentage of patients in each group as demonstrated in Table 1.
As this study pertained to both sexes and all skeletally immature individuals under 16 years of age, it is reasonable to assume that semi-sterile technique can be used safely to treat most supracondylar fractures with CRPP. The study findings cannot be generalized to patients with open fractures, those with additional ipsilateral arm fractures or those that are immunocompromised.