SLR - October 2022 - Matine Mirsaidi, DPM
Reference: Major Extremity Trauma Research Consortium (METRC). Effect of supplemental perioperative oxygen on ssi among adults with lower-extremity fractures at increased risk for infection: a randomized clinical trial. J Bone Joint Surg Am. 2022;104(14):1236-1243.Level of Evidence: Level 1 study
Reviewed By: Matine Mirsaidi, DPM
Residency Program: Carl T Hayden Phoenix VA
Podiatric Relevance: The effect of supplemental perioperative oxygen among patients undergoing surgery for a tibial plateau, tibial pilon, or calcaneal fracture is unknown. This study aimed to determine the effectiveness of a high fraction of inspired oxygen (FiO2, 80%) versus low FiO2 (30%) in reducing surgical site infections in these patients. The primary hypothesis of the article was that a higher level of perioperative oxygen, when compared with a lower level (80% versus 30% FiO2 [fraction of inspired oxygen]), reduces the risk of SSI in patients with a tibial pilon, tibial plateau, or calcaneal fracture deemed to be at high risk for infection when treated with plate and screw fixation.
Methods: A randomized controlled trial was conducted at 29 U.S. trauma centers. The study enrolled 1,231 patients who were 18 to 80 years of age and had a tibial plateau, tibial pilon, or calcaneal fracture and were thought to be at elevated risk for infection based on their injury characteristics. Patients were randomized to receive 80% FiO2 (treatment group) or 30% FiO2 (control group) in the operating room and for up to 2 hours in the recovery room. The primary outcome was a composite of either deep surgical site infection (treated with surgery) or superficial surgical site infection (treated with antibiotics alone) within 182 days following definitive fixation. Secondary outcomes included these surgical site infections at 90 and 365 days after surgery
Results: The modified intention-to-treat analysis included 1,136 patients with 94% of expected follow-up through 182 days. Surgical site infection occurred in 40 (7.0%) of the patients in the treatment group and 60 (10.7%) of the patients in the control group. The treatment intervention demonstrated a similar effect at 90 days and 365 days. Secondary analyses demonstrated that the effect was driven by a reduction in superficial surgical site infections.
Conclusions: Among tibial plateau, pilon, or calcaneal fracture patients at elevated risk for surgical site infection, a high perioperative FiO2 lowered the risk of surgical site infection. The findings support the use of this intervention, although the benefit appears to mostly be in reduction of superficial infections. I believe this intervention appears to provide some clinical benefit of at least reducing superficial infections, is low-cost, and likely has few risks in this patient population.