Is the golden age of surgery over?

An image showing bacteria surviving extreme environments. The image is CC by Dan Graham.

Any orthopaedic surgeon’s (and patient’s) nightmare is postoperative infections. Luckily these have been rare 0,5-1 %, much thanks to sterile technique and antibiotics. Dale et al’s article is therefore of considerable concern: There seems to be a significant increase the number of infections. If this is true, we may see an end to the expansion of orthopaedic surgery…

Study design

The NARA database is a combined effort from the Danish, Finnish, Norwegian, and Swedish arthroplasty registers. By combining the different countries, harmonizing definitions we are able to study rare events such as infections.

Exposure in this study was arthroplasty, and the outcome was revision due to infection. Confounders controlled for:

  • Age
  • Sex
  • Diagnosis (osteoarthrosis (OA), inflammatory hip disease, hip fracture, childhood hip disease, femoral head necrosis, or other diagnoses), prosthesis (monoblock or modular)
  • Type of fixation (uncemented, cemented, hybrid, or inverse hybrid, with plain or antibiotic-loaded cement).

Results

They had almost 3000 patients revised due to infection (0.6 %) in the years 1995-2009. The increase in the later period (2005-2009) was 5 times higher the first 3 months  compared to 1995-1999! The increase was minor in 3-12 months (1.2) while it in the later period was basically unchanged.

A very illustrative version of the increase in relative risk for the different type of implants
There is a rapid increase in recent years, it is hard to explain this by the controlled variables

Discussion

This is a registry study and does not allow for a full, in-depth study but it’s nationwide, cross-nation quality is cause for concern. My main concerns are:

  • Are the bacteria more aggressive?
  • Have we “optimized” surgery too far? Are surgeons sloppy?
  • Are we better at detecting infections? Perhaps we’re better at early identification? But by that logic we should have fewer infections later…

The authors discuss comorbidities but as a “comorbidity researcher” in this field I doubt that explains but a fraction of the infections…

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