n Feature Article

Is Antibiotic Prophylaxis Necessary in

Elective Soft Tissue Hand Surgery?
Rick Tosti, MD; John Fowler, MD; Joe Dwyer, MD; Mitchell Maltenfort, PhD;
Joseph J. Thoder, MD; Asif M. Ilyas, MD

abstract
Full article available online at Healio.com/Orthopedics. Search: 20120525-20

Antibiotic prophylaxis for clean soft tissue hand surgery is not yet defined. Current
literature focuses on overall orthopedic procedures, traumatic hand surgery, and car-
pal tunnel release. However, a paucity of data exists regarding the role of antibiotic
prophylaxis in a broader variety of soft tissue hand procedures. The goal of the current
study was to evaluate the rates of surgical site infection following elective soft tissue
hand surgery with respect to administration of prophylactic antibiotics.

A multicenter, retrospective review was performed on 600 consecutive elective soft

tissue hand procedures. Procedures with concomitant implant or incomplete records
were excluded. Antibiotic delivery was given at the discretion of the attending sur-
geon. Patient comorbidities were recorded. Outcomes were measured by the presence
of deep or superficial infections within 30 days postoperatively. The 4 most common
procedures were carpal tunnel release, trigger finger release, mass excision, and first
dorsal compartment release. The overall infection rate was 0.66%. All infections were
considered superficial, and none required surgical management. In patients who re-
ceived antibiotic prophylaxis (n5212), the infection rate was 0.47%. In those who did
not receive prophylaxis (n5388), the infection rate was 0.77%. These differences were
not statistically significant (P51.00).

Drs Tosti, Fowler, Dwyer, and Thoder are from the Department of Orthopaedic Surgery and Sports
Medicine, Temple University School of Medicine, Dr Maltenfort is from Statistics and Clinical Research,
Rothman Institute, and Dr Ilyas is from Rothman Institute, Thomas Jefferson University, Philadelphia,
Pennsylvania.
Drs Tosti, Fowler, Dwyer, Maltenfort, Thoder, and Ilyas have no relevant financial relationships to
disclose.
This study was conducted at Temple University Hospital and its affiliates.
Correspondence should be addressed to: Rick Tosti, MD, Department of Orthopaedic Surgery and
Sports Medicine, Temple University School of Medicine, 3401 N Broad St, Philadelphia, PA 19140
([email protected]).
doi: 10.3928/01477447-20120525-20

JUNE 2012 | Volume 35 • Number 6 e829

n Feature Article

S
urgical wound infections following
hand surgery can lead to fibrosis, Table 1
stiffness, loss of function, and am- Surgical Care Improvement Project Guidelines Related to Infection
putation.1,2 Conventionally, prophylactic
administration of antibiotics periopera- SCIP INF 1 Prophylactic antibiotic received within 1 h prior to surgical incision
tively is intended to decrease the rate of SCIP INF 2 Prophylactic antibiotic selection for surgical patients
postoperative infections and prevent such
SCIP INF 3 Prophylactic antibiotics discontinued within 24 h after surgery end time
complications.3,4 However, the role of (48 h for cardiac patients)
antibiotics in hand surgery is still con- SCIP INF 4 Cardiac surgery patients with controlled 6 am postoperative serum
troversial because these drugs may cause glucose measurement
complications such as clostridium diffi- SCIP INF 5a Postoperative surgical site infection diagnosed during index hospitalization
cile colitis, allergic reactions, and antibi- SCIP INF 6 Surgery patients with appropriate hair removal
otic resistance; a risk-to-benefit analysis SCIP INF 7 Colorectal surgery patients with immediate postoperative normothermia
regarding their usefulness in clean ortho-
Abbreviations: INF, infection; SCIP, Surgical Care Improvement Project.
pedic procedures remains unproven. Fur-
thermore, antibiotic prophylaxis for sur-
gery has recently emerged at the forefront
of administrative policies because the Sur- the Greater Philadelphia region between All patients were prescrubbed with a 4%
gical Care Improvement Project (SCIP) 2007 and 2010. Full Institutional Review chlorhexadine gluconate sponge diluted
guidelines (Table 1) have influenced the Board approval was obtained before data in 500 mL of sterile water. Surgical sites
practice routines and reimbursement rates collection. Patient records were collected were then dried with sterile towels and
of surgical centers, which are related to according to International Classification draped using a sterile technique. Cefazo-
compliance with antibiotic prophylaxis of Diseases-9 codes for the most com- lin (n5187) was considered the first-line
regimens.5 mon soft tissue elective hand surgeries agent if prophylaxis was chosen; if cepha-
Studies on the administration and ex- during this time, which included carpal losporins were contraindicated, vanco-
clusion of perioperative antibiotics in or- tunnel release, mass excision, trigger fin- mycin (n55) or clindamycin (n520) was
thopedic surgery have reported postopera- ger release, and first dorsal compartment selected. Antibiotics were administered
tive infections rates ranging from ,1% to release. Mass excision included resection within 1 hour of incision; however, they
15%.2,6-15 However, many of these studies of the following lesions: ganglion cyst, were given at the discretion of the attend-
include traumatic, contaminated wounds mucous cyst, epidermal inclusion cyst, li- ing hand surgeon. All surgical wounds
from a variety of orthopedic procedures poma, glomus tumor, giant cell tumor of were irrigated with 0.9% saline prior to
and operative sites. Of reports that focus tendon sheath, neuroma, and granuloma. closure, approximated with nylon sutures,
exclusively elective procedures of the Soft tissue procedures concomitantly per- and covered with nonadherent sterile
hand, only carpal tunnel syndrome has formed with a joint or bone procedure or dressings. Absorbable sutures were not
been investigated in this regard.7,8 Because any procedure involving an implant were used to close wounds.
a paucity of data exists in assessing the excluded; nerve and tendon repairs and re- Patients were followed up at 2- and
usefulness of antibiotic prophylaxis in all constructions were also excluded because 4-week intervals after the index operation.
clean soft tissue hand operations, the goal these operations are routinely adminis- Because surgical wound infection is most
of the current study was to report the rates tered prophylaxis. Any surgery involving likely to present during this time,8,16 the
of postoperative infection for a variety of incision into a prior operative site (reop- search was limited to all records within
elective hand procedures with respect to erations) were excluded to prevent con- the 30-day postoperative period. Office
the administration of perioperative antibi- founding. Charts with incomplete medical visit, inpatient, and emergency room re-
otics. The primary outcome measure was records were excluded in the final statisti- cords were reviewed for the presence of
postoperative infection defined by Centers cal analysis (n545). superficial or deep infection. Superficial
for Disease Control guidelines. Patient demographic data and known and deep infections were defined by Cen-
risk factors for infection were recorded. ters for Disease Control criteria (Table 2).8
Materials and Methods The use or exclusion of an antibiotic Superficial infections were treated with
A retrospective review was performed agent, the type of antibiotic agent, the type intravenous or oral antibiotic therapy, and
of 645 consecutive elective hand sur- of procedure, and the development of sub- deep infections were surgically drained or
gery patients from 3 surgical centers in sequent infection were additionally noted. debrided.

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 Antibiotic Prophylaxis in Soft Tissue Hand Surgery | Tosti et al

Statistical hypothesis testing was per-

formed via Student’s t test for age and Table 2
Fisher’s exact test for all other variables. Centers for Disease Control Criteria for Surgical Site Infection
Statistical significance was defined as
P,.05. Superficial Infection
Infection occurs within 30 d after the operative procedure and involves only skin and
Results subcutaneous tissue of the incision and patient has at least 1 of the following:
Complete operative and follow-up A. Purulent drainage from the superficial incision.
records were available for 600 patients. B. Organisms isolated from an aseptically obtained culture of fluid or tissue from the
Forty-five charts did not have complete superficial incision.
follow-up records and were excluded. The C. At least 1 of the following signs or symptoms of infection (pain or tenderness,
overall infection rate was 0.66%. The pa- localized swelling, redness, or hea) and superficial incision is deliberately opened by
surgeon, and is culture-positive or not cultured. A culture-negative finding does not
tients were separated into groups based on meet this criterion.
the administration of a prophylactic antibi-
D. Diagnosis of superficial incisional SSI by the surgeon or attending physician.
otic agent (Table 3). Antibiotic prophylaxis
Deep Infection
was administered in 212 patients, and 388
Infection occurs within 30 d after the operative procedure if no implant is left in place or
patients did not receive prophylaxis. Mean within 1 y if implant is in place and the infection appears to be related to the operative
patient age was 54 years (range, 16-95 procedure and involves deep soft tissues (eg, fascial and muscle layers) of the incision
years). Sex, diabetes mellitus, and smok- and patient has at least 1 of the following:
ing status were not significantly different A. Purulent drainage from the deep incision but not from the organ/space component
of the surgical site.
between the groups. Superficial infection
was found in 0.77% of patients who did B. A deep incision spontaneously dehisces or is deliberately opened by a surgeon
and is culture positive or not cultured and the patient has at least 1 of the following
not receive prophylaxis and 0.47% in those signs or symptoms: fever (.38°C) or localized pain or tenderness. A culture-negative
who did receive it; this difference was not finding does not meet this criterion.
statistically significant. No deep infections C. An abscess or other evidence of infection involving the deep incision is found on direct
were identified in either group. examination, during reoperation, or by histopathologic or radiologic examination.

When sorting the frequency of super- D. Diagnosis of a deep incisional SSI by a surgeon or attending physician.
ficial infection as a function of procedure, Abbreviation: SSI, surgical site infection.
infections were found in 1% of carpal tun-
nel releases and 0.58% of trigger finger
releases. No infections occurred among
the first dorsal compartment releases or
mass excisions (Table 4). Demographics Table 3
of patients who became infected are list- Overall Comparisons of Antibiotic Prophylaxis
ed in Table 5; 3 of the 4 patients did not
receive antibiotics, 1 was a diabetic, and Antibiotic
none were smokers. Variable No Antibiotics Prophylaxis P
No. of patients 388 212
Discussion Mean age, y 55.9614.7 52.0614.9 ,.01
Numerous reports have evaluated the No. of men (%) 125 (32.2) 67 (31.6) 1
value of antibiotic prophylaxis in ortho-
No. of diabetes mellitus cases (%) 85 (21.9) 58 (27.3) .16
pedic surgery, but most of these studies
No. of smokers (%) 66 (17.0) 49 (23.1) .08
have only included elective hand cases as
No. of carpal tunnel releases (%) 198 (51.0) 102 (48.1) .55
a subset in the study design.2,6,10-15 Thus,
because a paucity of data exists, the au- No. of trigger finger releases (%) 125 (32.2) 50 (23.5) .03
thors of the current study aimed to expand No. of mass excisions (%) 43 (11.1) 38 (17.9) .02
the evidence on this topic with a specific No. of DeQuervain releases (%) 22 (5.7) 22 (10.3) .05
focus on elective soft tissue hand surgery No. of superficial infections (%) 3 (0.77) 1 (0.47) 1
using postoperative infection as a primary No. of deep infections (%) 0 0
outcome measure.

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n Feature Article

difference was not statistically significant.

Table 4 However, shortcomings of the study were
Infection Rates by Procedure low sample size, an unexplained high
infection rate, and a nonrandomized de-
No. (%) sign.13
Procedure Superficial Infection Deep Infection Despite the shortcomings in the lit-
Carpal tunnel release (n5300) 3 (1.00) 0 erature, most reports have demonstrated
Trigger finger release (n5173) 1 (0.58) 0 a low rate of infection following elective
DeQuervain release (n544 0 0 hand surgery, and the clinical significance
0 0
of these rates becomes more relevant
Mass excision (n581)
when juxtaposed against rates of compli-
Total (N5600) 4 (0.66) 0
cations of antibiotics. The prevalence of
drug-resistant hand infections is increas-
ing in communities nationwide, and bac-
Table 5 Whether ideal terial resistance to antibiotics has been
Cases of Surgical Site Infection statistical testing in reported after short prophylactic dos-
this setting can be ing.14,17,18 Furthermore, the incidence of
Patient No./ Antibiotic achieved, the current postoperative pseudomembranous colitis
Sex/Age, y Diabetic Smoker Procedure Agent study demonstrates has been reported to be as high as 6%.18
1/F/40 No No CTR Cefazolin a tangible clinical A risk-to-benefit analysis in this regard
2/M/45 No No CTR None significance: The fre- would provide an interesting implication
3/M/48 Yes No CTR None quency of infection for future trials because rates of postop-
4/M/49 No No TFR None following soft tissue erative infection and antibiotic complica-
Abbreviations: CTR, carpal tunnel release; TFR, trigger finger hand surgery is low. tions in a hand surgery population have
release. The overall rate was yet to be examined concurrently.
0.6%; all of these Notwithstanding that the literature has
were considered su- yet to define specific indications for pro-
This study was limited by the ret- perficial, and none required surgical in- phylaxis in the hand population, surgical
rospective design, which reduced the tervention. No statistically significant dif- centers must have increasing awareness
numbers of available complete records; ferences were detected in infection rates of this issue because physician reim-
as a result, many patients were excluded between patients who received antibiotic bursements are now potentially affected
and some infection cases may have been prophylaxis and those who did not. These by compliance with the SCIP measures.5
treated at alternative centers. Second, the findings are consistent with previously Furthermore, as insurance companies
antibiotics were prescribed nonrandomly published reports. Harness et al8 reported increasingly threaten to withhold reim-
at the discretion of the attending hand sur- a double-blinded, randomized, controlled bursements for complications such as sur-
geon. Third, the rates of infection were so trial of 2336 carpal tunnel releases with an gical site infections, additional data will
low that individual risk factors could not overall infection rate of 0.36%; they did be required to guide these policies.
be assessed; a multivariate analysis was not find that infection rates were signifi-
attempted but could not be constructed cantly higher when bypassing antibiotics. Conclusion
with only 4 infections. Last, the potential Similarly, Hanssen et al7 retrospectively The role of antibiotic prophylaxis in
for type II errors existed because the low reviewed 3620 carpal tunnel releases and hand surgery remains controversial. Some
rates of infection would require thousands found an infection rate of 0.47%; 15 of authors have suggested that this controver-
of patients to achieve the standard 80% the 3620 patients were administered an- sy exists because of convention, varying
power. Defining significance in hypothe- tibiotics preoperatively. Platt and Page13 definitions of superficial and deep infec-
sis testing for studies with close, low per- prospectively evaluated 249 elective and tions, lack of randomized, controlled trials,
centages is difficult; several authors have emergency hand surgery cases for risk and difficulty in statistical testing. The cur-
commented on this quandary by saying, factors associated with postoperative in- rent study suggests that antibiotics added
“the efficacy of such prophylaxis in surgi- fection. In 112 elective cases, infection neither clinical nor statistical protection
cal procedures that have a low infection rates were 8% and 12% for those with and from surgical site infection for elective soft
rate is nearly impossible to prove.”7 without prophylaxis, respectively; this tissue hand surgery. However, a large ran-

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 Antibiotic Prophylaxis in Soft Tissue Hand Surgery | Tosti et al

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