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A patient with a tibial nonunion has developed a surgical site infection after revision surgery.
Courtesy of Douglas W. Lundy, MD, MBA, FAAOS


Published 3/23/2022
Barbara Krause

AAOS Board of Directors Approves CPG/AUC on Prevention of Surgical Site Infections after Major Extremity Trauma

Board also approves update to the CPG on the Detection and Nonoperative Management of Pediatric Developmental Dysplasia of the Hip in Infants up to Six Months of Age

Board also approves update to the CPG on the Detection and Nonoperative Management of Pediatric Developmental Dysplasia of the Hip in Infants up to Six Months of Age

During their March meeting, the AAOS Board of Directors approved the Clinical Practice Guideline (CPG) and correlating Appropriate Use Criteria (AUC) on the Prevention of Surgical Site Infections after Major Extremity Trauma.

The CPG and AUC were developed in collaboration with the Major Extremity Trauma Research Consortium (METRC) and funded by a Department of Defense grant. The CPG is intended to help prevent surgical site infections (SSIs) in adults who have experienced major extremity trauma, which is defined as any of the following: an open fracture, a major/high-energy closed fracture, a degloving injury, Morel lesions, low- and high-velocity gunshot injuries, a crush injury, a blast injury, and moderate- to high-energy force injuries.

The scope of this CPG covers 14 “strong” and “moderate”-strength recommendations for preoperative, perioperative, and postoperative interventions to decrease SSIs following major extremity trauma. The guideline also includes modifiable factors that are associated with increased risk for SSI following major extremity trauma surgery. Additionally, the CPG offers options, which were formulated with either low-quality evidence, no evidence, or conflicting evidence, for the use of incisional negative-pressure wound therapy for high-risk surgical incisions, the implementation of an orthoplastic team, patient outcomes related to the use of hyperbaric oxygen, preoperative skin preparation, and select modifiable and administrative risk factors.

The new AUC on this topic is based on the evidence provided by the CPG and offers clinicians algorithm-style guidance for appropriate, patient-specific interventions for patients presenting with high-energy extremity trauma who are being considered for surgical intervention. The AUC applies only to patients without the presence of SSI at the extremity trauma site.

When using this AUC, a clinician selects from the following patient indication: Injury Classification, Soft Tissue Characteristic(s), Host Factors/Medical Status, and Surgical Treatment Administered. Once the indication is selected, the online tool responds with “Appropriate” interventions marked with green checkmarks, “May Be Appropriate” interventions with yellow triangles, and “Rarely Appropriate” interventions marked with a red circle with an X.

If, for example, a clinician is evaluating a patient with a closed injury with significant soft-tissue compromise; no or limited comorbidities (healthy, American Society of Anesthesiologists classification 1-2, Charlson Comorbidity Index <3); and acute definitive internal fixation (open reduction–internal fixation/ intramedullary nailing), “Appropriate” treatments are:

  • prophylactic antibiotics at the time of fixation surgery
  • standard surgical skin preparation with povidone iodine
  • standard surgical skin preparation with chlorhexidine
  • perioperative normothermia
  • perioperative glucose control
  • supplemental perioperative oxygenation
  • change of gloves at regular intervals

Treatments that “May Be Appropriate” are:

  • debridement and primary closure or soft-tissue coverage
  • local antimicrobial therapy
  • negative-pressure wound therapy inclusive of incisional negative pressure

“Rarely Appropriate” treatment options are prophylactic antibiotics with and without anaerobic coverage upon initial presentation to the medical center; early debridement and irrigation without additives (e.g., Castile soap); and multiple debridements and secondary closure or soft-tissue coverage.

Additionally, the Board of Directors approved the update to the 2014 CPG on the Detection and Nonoperative Management of Pediatric Developmental Dysplasia of the Hip in Infants up to Six Months of Age.

This CPG was updated via the AAOS CPG Rapid Update Methodology. Rapid updates are considered when both the scope of the CPG (i.e., PICO [population, intervention, comparison, outcome] questions and included treatments) have continued relevance and substantial new evidence has not been published since the date of the last literature search. This methodology resulted in three recommendations being upgraded based on new evidence: the evaluation of infants with risk factors for developmental dysplasia of the hip, surveillance after normal infant hip exam, and type of brace for the unstable hip.

The CPGs, AUC, and accompanying documentation are available at www.orthoguidelines.org.

Barbara Krause is the quality-improvement specialist for clinical quality and value at AAOS. She can be reached at krause@aaos.org.