All right, so the title of this audio paper is Retrospective Analysis of Operating Room Irrigation Using a Low-Concentration Chlorhexidine Gluconate for Infection Prevention after Foot and Ankle Surgery. I'm Dr. Calvin Rushing, a fellowship-trained foot and ankle surgeon, and I'd like to thank the American Orthopedic Foot and Ankle Society for giving me the opportunity to present this research. I have made the appropriate disclosures. So as we all know, foot and ankle surgery has a higher surgical site infection rate compared to other aspects of orthopedic surgery. Obviously we know surgical site infection in general increases our hospital length of stay, the number of reoperations, the readmission rates, which obviously adversely impact both the quality and cost of healthcare delivery. Now we use a number of infection prevention strategies, whether it be skin antisepsis or prophylactic antibiotics. The latter of that has been kind of the efficacy of which has been called into question over the past few years in the literature. Nonetheless, the fact that surgical site infection in general is one of the most common complications after foot and ankle surgery does leave or does suggest possibly other possibilities to mitigate infection risk. One of those options is chlorhexidine, CHG. It's bacteriostatic at low concentrations, becomes bactericidal at higher concentrations. It's effective against a number of gram-positive and gram-negatives, as well as fungi. Here it's contained, kind of a self-contained 450 cc irrigation bottle that allows you to kind of using a very controlled pressure, which you can actually kind of manually control with the little tip that attaches to the bottle that you actually can deliver CHG at 0.05%. And because you can control the delivery pressure, you can use it to help remove particulate debris and disrupt bacterial biofilm, obviously reducing infection post-operatively potentially without kind of, you know, the risk of cytotoxicity, allergic reactions, skin irritation, any issues that we see with iodine intraoperatively. So the purpose of this study was straightforward. Basically, I wanted to just assess the incidence of surgical site infection in patients who underwent foot and ankle surgery using this as an intraoperative lavage, prospectively collected data that was retrospectively reviewed, and all elective and non-elective reconstructive procedures that use this CHG lavage, at least 450 cc, which is one bottle, over the course of approximately one year at Dallas Orthopedic and Orthopedic Children's Institute were included. Cases that I used concurrent use of either 500 milligrams or 1 gram of vancomycin powder intraoperatively or where I prescribed post-operative prophylactic antibiotics were excluded, any minimum of three follow-ups, three months follow-up was required for inclusion. So intraoperatively, I used a combination of saline as well as one to two bottles of Uricept intraoperatively, and typically I'll start off and when I expose some of the structures I'm getting down to, obviously you're doing what you typically do, but then after the implants are actually in, I'll put approximately 250 cc of amoxicillin concatenate inside the joint itself and the space itself and let it sit for 20 to 30 seconds, and then I'll continue to use controlled pressure to help remove any other particular debris intraoperatively prior to closure. So primary outcome for this study was just a surgical site infection, defined as superficial or deep, kind of based on the depth of tissue, which we've seen in the literature before. Secondary outcomes including complications and reoperations were also included. Overall surgical site infection, again I said it was superficial or deep, all the superficial were considered skin or septic tissue layer, no deeper, any deeper than that was considered a deep surgical site infection. Treatment for superficial and deep infections are listed there, and any kind of delayed wound healing or post-operative erythema that resolved without the use of oral antibiotics was actually not considered a superficial surgical site infection. Here's the statistical analysis used for the study, and overall the results, to be brief, there are 12 complications in approximately 73 patients. One patient had post-operative erythema, four had delayed wound healing, one had surgical site dehiscence, and six had infection. This is kind of that same data that I just listed over to you, which also breaks down the fact that as far as surgical site infection, two were superficial, four were deep. Overall six surgical site infections in those 73 patients. For those four patients with deep surgical site infections, six reoperations were performed. Three of those patients had ankle surgery, another had combined ankle and foot surgery. All those infections actually occurred kind of early on during that third and fourth post-operative week, and then sent there some bacteria that was isolated from intraoperative cultures. Overall, what we found, which was interesting and something that I was surprised, but it makes it intuitive, is that three of the four patients that actually had surgical site infection after foot and ankle surgery had a history of previous surgical site infection after orthopedic surgery. One patient had had a post-operative surgical site infection requiring a wash-up after a rotator cuff repair, another was after TKA, and so forth. Overall, when we went back, even though it's a smaller cohort, there was a strong association identified. And again, it's intuitive in hindsight. Obviously the limitations of the study were kind of the retrospective design, the short-term follow-up, and lack of comparative outcome data. Obviously I'm now a board member of the ear max, but at the time I was not. So there's obviously a potential conflict of interest there. Nonetheless, the present study does suggest that low incidence of surgical site infection can be seen without the use of prophylactic antibiotics, using this as a lavage, as long as those patients do not have a documented history of previous surgical site infection after orthopedic surgery. So obviously for us, this is practical because it does lend some evidence to the fact that anyone who's seen a patient in the office and looking for surgery, if they have a documented history of surgical site infection after orthopedic surgery, at least for now, it's potentially a good idea for us to consider additional mitigation measures for surgical site infection as opposed to trying to use just the lavage itself. Obviously additional comparative studies are warranted. Thank you.

retrospective analysis

low-concentration chlorhexidine gluconate

infection prevention

foot and ankle surgery

surgical site infections