Smoking is Associated with a Higher Risk of Surgical Site Infection after Lower Extremity Fasciotomy

Author(s):
Alejandro De Filippis; Leonardo Diaz; Ricardo Fonseca; Melissa Canas; Hussain Afzal; Jennifer Leonard; Mark Hoofnagle; Kelly Bochicchio; Grant Bochicchio

Background:

Acute compartment syndrome (ACS) of the lower extremity is a surgical emergency seen in trauma patients where the elevated intra-compartmental pressure leads to inadequate oxygen perfusion producing necrosis. Fasciotomy is the standard of care treatment for this condition despite the high rate of post-operative infection. Current smoking has been shown to increase the risk of surgical site infection (SSI) in other surgical procedures.

Hypothesis:

We hypothesize that active smokers have a higher incidence of SSI after therapeutic fasciotomy of the lower extremity.

Methods:

Our prospectively maintained Acute and Critical Care Surgery database spanning 2018 to 2022 was queried for patients admitted to our level-1 Trauma Center who required fasciotomy for lower-extremity trauma complicated by ACS. Demographics, mechanism of injury (MOI), operative and clinical management details, culture results, and clinical outcomes were collected. Patients were stratified based on our primary outcome of SSI, which was confirmed by a clinical team diagnosis and a positive wound culture. We excluded patients treated with prophylactic fasciotomy and/or previous infection within this hospitalization.

Results:

We identified 61 patients with ACS requiring fasciotomy. A total of 11 patients (18%) developed a SSI. Of all patients with fasciotomy smokers made up a significantly larger proportion of the infected than non-infected groups (54.5% vs 18%, P= 0.011). SSI patients received negative pressure wound therapy much longer (11.9 ± 9.6 vs 6.1 ± 4.6 days, P= <0.002) and had a longer time from surgery to closure (TSC) [19.8 ± 23 vs 4.5 ± 3 days, P <0.001]. Hospital Length of Stay (LOS) was also higher in this group (22.8 ± 24.9 vs 10.3 ± 8.8 days, P <0.001).There was no significant difference in the bacteriology between smokers and non-smokers. When analyzed by multi-logistic regression controlling for smoking; TSC, age, obesity, and MOI with primary outcome defined as infection, smoking was found to have a 10-fold increase in SSI (OR 10.33; CI 95% 1.09-97.8; P= 0.042).

Conclusions:

Fasciotomy remains a life-saving procedure for ACS associated with a high incidence of post-operative complications. Patients who smoke have a 10-fold increase risk for SSI after having a fasciotomy due to ACS. We suggest a more aggressive approach be considered in patients with a smoking history requiring a fasciotomy for ACS. Future studies need to focus on optimizing patients who are current smokers.