Asian Journal of
Healthy and Science
p-ISSN:
2980-4302
e-ISSN:
2980-4310
Vol. 3 No. March 3, 2024
Risk Factors Associated with Surgical Wound Healing in Orthopedic Surgery Patients at The Dr.
H. Moch Ansari Saleh Banjarmasin General Hospital
Muhammad Nizar1, M. Wibowo Ariyanto2
1Setara Regional Hospital, Barito Kuala, Indonesia
2Dr. H.Moch Anshari Saleh General Hospital, Banjarmasin, Indonesia
Email: aocfkunlam@gmail.com, ariewmuhammad@gmail.com
Abstract
The
healing of surgical wounds holds paramount importance in healthcare, garnering
global attention across various healthcare settings. This study investigated
the medical records of orthopedic surgery patients at Dr. H. Moch. Ansari Saleh Banjarmasin General Hospital between
August and December 2023. The aim was to identify factors influencing surgical
wound healing, which are crucial for preventing delays in specific patient
cohorts. Employing a descriptive observational approach with a cross-sectional
design, data were retrospectively gathered from medical records via purposive
sampling. Analysis was conducted using Microsoft Excel and chi-square tests,
centered on 133 eligible samples. Results highlighted several significant
factors: antibiotic type (p = 0.013), gender (p = 0.040), comorbidities
(p<0.05), surgery type (p<0.05), and length of hospital stay (p<0.05).
Particularly, cefazolin emerged as the predominant antibiotic during the study
period, demonstrating a significant influence on wound healing. Furthermore,
surgery type, duration of hospitalization, gender, and comorbidities emerged as
pertinent contributing factors. These findings underscore the importance of
tailored interventions and meticulous post-operative care to optimize surgical
wound outcomes.
Keywords: Surgical wound healing; antibiotics;
gender; length of stay; type of operation; comorbidity
INTRODUCTION
Healthcare
services are very worried about surgical wound healing. Injuries represent a
major global health issue. In Denmark and the United Kingdom, for every 1000
people, 3–4 have one or more wounds. Many of these develop into long-term
wounds. Regretfully, 15% of the wounds do not heal a year after they are
displayed. For both patients and caregivers, chronic wound development is a
difficult issue
Following
surgery, wound healing is a complex and strictly controlled process that is
essential to retaining the skin's barrier function and all other skin
functions. Numerous factors, both modifiable and non-modifiable, can impact
this process. Infections at the surgical site and wound and tissue dehiscence
are recognized postoperative consequences in orthopaedic surgery, so management
is crucial
Among developed
as well as developing countries, surgical site infections (SSI) are the most
often reported health-acquired infection and surgical complication
Hemostasis, inflammation, proliferation, and remodeling
are the four synchronized steps that make up the normal biological process of
wound healing in the human body. All four stages need to happen in the right
order and within the right amount of time for a wound to heal properly.
Numerous variables may obstruct one or more stages of this process, leading to
incorrect or compromised wound healing
Acute wounds
include wounds from incisions. If the healing process proceeds according to
plan, but if there are any signs of infection or delayed healing, the wound may
also be considered chronic. Wound healing becomes problematic if the number of
bacterial colonies grows to the point where critical colonization occurs in
infection situations
Variables like
the level of contamination and the type of surgery have historically been
thought to be good indicators of wound healing and surgical site infection. However,
more recent study has minimized the significance of surgical method, with other
researchers finding that systemic factors such as advanced age, gender,
lifestyle, and associated morbidity play a significant role in the
pathophysiology of these problems
Dr. H. Moch. Ansari Saleh
Banjarmasin general hospital is one public hospital that offers a variety of
surgical operations, involving orthopedic surgery. Orthopedic surgery through open reduction is done at this
hospital. Amputation and debridement, arthroscopy, ligament reconstruction,
internal fixation, open reduction external fixation, arthroplasty, and many
more operations are available.
Previous studies at
this institution detailed patient demographics, such as age, type of surgery,
length of stay, comorbidities, and antibiotic types used in orthopedic surgery
patients
The study conducted at Dr. H. Moch. Ansari
Saleh Banjarmasin General Hospital aims to determine the relationship between
patient demographics and surgical wound healing, as well as to identify
predictors associated with delayed wound healing in orthopedic surgery
patients. Through the analysis of factors such as age, gender, comorbidities,
lifestyle, type of surgery, and length of hospital stay, the research seeks to
understand the influence of systemic and surgical factors on surgical wound
healing. The ultimate goal is to enhance patient care
and prevent complications in orthopedic surgery patients by identifying factors
that can predict delayed wound healing.
RESEARCH METHODS
This study applied a retrospective methodology and a
cross-sectional descriptive observational research design. The study
participants utilized the orthopedic surgery
hospitalized patients' medical records status at Dr.
H. Moch. Ansari Saleh Banjarmasin adopted purposive
sampling techniques from August to December 2023. Purposive sampling involves
restricting the types of samples to meet specific criteria and obtain the
desired information for the researcher
The 165 patients with orthopedic
surgery cases were receiving surgery and medical care at Dr.
H. Moch. Ansari Saleh General Hospital in Banjarmasin
provided the medical records that contributed to the data for this study. Note
the following information about the patient's medical condition: age,
comorbidities, length of stay, type of operation, type of antibiotic, and
surgical wound follow-up based on the doctor's examination noted in the medical
record. Within two weeks, patients were evaluated.
Patients who had orthopedic
surgery and had full medical records, including a list of surgical reports and
surgical wound follow-up, were included in the sample. As seen in Image 1, the
selection procedure and the gathering of data from medical records are
represented as a flowchart.
According to data gathered using several operational
definitions, prophylactic antibiotics such as cefazolin, ceftriaxone, and
ceftazidime are administered prior to surgery based on antibiotics used
throughout the research period. Running Research has shown that one of those
categories is the amount of time patients need for surgery. Operation duration
is <1 hour or longer. Type operations can be divided into two groups: clean
and contamination. Surgical wounds may become dry or still wet or leaking when
it comes to healing.
Figure 1. Flowchart-Based
Research Data Retrieval
Microsoft Excel software was then utilized to group
the collected data. Relationship between the healing of surgical wounds and some
of the data taken was analyzed using SPSS (Statistical Package for the Social Sciences) software with chi-square tests.
RESULTS AND DISCUSSION
The strength of the skin barrier is compromised,
leading to an injury to the skin. A wound is any area of tissue damage that
results in a loss of function and anatomical structure. Tissue healing is
essentially what wound healing involves. After a superficial trauma, wound
healing starts right away and may take weeks. The highly structured cellular,
humoral, and molecular systems are part of this dynamic process
Sometimes, primary and secondary healing are used to
categorize wound healing. Primary healing is the simple healing of a
well-approximated, non-infected wound. The best illustration of primary healing
is a surgical wound. The secondary healing stage starts if an infection,
disintegration, hypoxia, or immunological disorder interferes with the wound's
ability to heal. Granulation tissue forms and epithelization occurs over this
newly formed tissue during secondary healing. These kinds of wounds are more
prone to infections and inadequate recovery
Wound healing after surgery is a complex and tightly
controlled process that is required to maintain the skin's barrier function as
well as all other skin functions. Many variables, both changeable and not, can affect
this procedure
The incidence of surgical wound healing in this study
demonstrated the effectiveness of prophylactic antibiotics, as a suitable
choice of prophylactic antibiotic decreases the risk of infection
Table 1 Comparison
of types of antibiotics and the incidence
of
surgical wound healing
|
Surgical
wound healing |
Total (n=133) |
p value |
||
|
|
The wound is dry (%) |
The wound is still
leaking (%) |
|
|
|
Cefazolin |
107 (85,6%) |
18 (14,4%) |
125 |
0,013 |
|
Ceftazidime |
2 (100%) |
0 (0,0%) |
2 |
|
|
Ceftriaxone |
2 (33,3%) |
4 (66,7%) |
6 |
|
Wounds that were still leaking or had not healed
during this trial period were observed in 16.5% of all individuals, or 13.5% of
patients given cefazolin, 0% of patients given ceftazidime, and 3% of patients
given ceftriaxone. Bivariate testing using Fisher's exact test were used
to analyze differences in the three groups' chances
of surgical wound healing.
A common first-generational cephalosporin antibiotic
used for following surgery prophylaxis across several surgical specialties is
cefazolin
According to a number of studies, prophylactic use of
third-generation cephalosporin antibiotics such ceftriaxone and ceftazidime is
not advised by any recommendations. This is due to the fact that the majority
of these medications are more expensive than cefazolin, although having less of
an effect on Staphylococcus sp. bacterial reproduction. Staphylococcus aureus,
the most prevalent natural flora in the epidermis, is the bacteria that the
World Health Organization reports is most frequently discovered to cause
infections in wounds. Given their stronger ability to combat gram-negative
microbes, third- and fourth-generation cephalosporins are expected to be
utilized as helpful antibiotics rather than as a preventative measure once an
infection has already occurred
According to meta-analysis research, it was said that cefazolin
is still the drug of choice or surgical prophylaxis in many procedures due to
its excellent safety profile, affordable price, and focused action against
common surgical operation-related microorganisms
The
relationship between the risk factors present in the patient and surgical wound
healing was analyzed using the Chi square test and presented in Table 2.
Table 2 Risk factors
associated with surgical wound healing
|
Risk factors |
Total (n=133) |
Surgical wound
healing |
p value |
|
|
|
|
The wound is still leaking (n=22) |
The wound is dry (n=111) |
|
|
Gender |
|
|
|
0,040 |
|
Man |
83 |
18 |
65 |
|
|
Woman |
50 |
4 |
46 |
|
|
Age |
|
|
|
0,065 |
|
<18 years |
41 |
7 |
34 |
|
|
18-59 years old |
75 |
9 |
66 |
|
|
>60 years |
17 |
6 |
11 |
|
|
Comorbidities |
|
|
|
0,000 |
|
There exists |
23 |
12 |
11 |
|
|
Nothing exists at all |
110 |
10 |
100 |
|
|
type of surgery |
|
|
|
0,000 |
|
Clean |
111 |
9 |
102 |
|
|
Contamination |
22 |
13 |
9 |
|
|
Operation duration |
|
|
|
0,199 |
|
≤1 hour |
71 |
9 |
62 |
|
|
>1 hour |
62 |
13 |
49 |
|
|
Length of stay |
|
|
|
0,000 |
|
<3 days |
61 |
2 |
59 |
|
|
≥3 days |
72 |
20 |
52 |
|
It was reported in this study that the genders
differed significantly from one another (p=0,040). Several studies have
supported the theory that men and surgical wound healing are more significantly
related. Men and women wound healing differently, depending on the type of
tissue. The superficial wounds heal more quickly in women while mucosal wounds
heal more quickly in men. Gender has been identified as a significant
determinant of epidermal wound healing, with females generally showing better
healing rates than males. In comparison, women's healing of soft tissues
following surgery was significantly slower and needed more post-surgical
interventions than men's
There are a number of hypothesized processes
explaining sex-based variations in wound closure. Many researchers believe that
the hormones testosterone and estrogen play an
important role in the healing of surgical wounds. Nonetheless, our findings
show that during the active early phases of wound healing, sex is not a
significant biological determinant
In this study, there was no significant connection
found between the age component (p=0,065). Surgical wounds do not heal
differently in older or younger patients. This is contradictory to other
studies, which show that aging has significant effects on wound healing. The
aging of the skin is also associated with impaired wound healing, which
prolongs and disturbs the healing process. Elderly patients are more likely to
experience delayed wound closure following surgery, which increases the risk of
scarring and infections
Then, this study shows a significant connection
between the patients' comorbidities (p=0,000). Underlying illnesses or medical
problems known as comorbidities may delay the healing of wounds. Several
additional studies have reported that a number of comorbidities, including
diabetes, malnutrition, stress, autoimmune, and decreased immune function,
cause surgical wounds to heal slowly
According to Table 2, the most common orthopedic surgery procedure was clean surgery. There is a
significant relationship between the type of surgery and surgical wound healing
(p=0,000). The clean surgery includes arthroscopy, ligament
repair, complete knee and total hip replacement, arthroplasty, and open
reduction and internal fixation. The technique is usually arranged as an
optional one. The identical process was carried out at Dr.
H.Moch. Ansari Saleh General Hospital concurrently.
The contaminated procedure given is an example of open reduction external
fixation in open wounds, amputations, tendon repair, and debridement. The
process is usually finished fast or without any delays. Patients who require
immediate surgery are more at risk of wound contamination than those with
elective surgery
Predicting the right surgical classifying will support
in estimating the risk of wound healing, postoperative problems, and surgical
site infection. An accurate classification of wounds may be useful in
determining mortality, morbidity, and the quality of life. Patients undergoing
unclean surgical procedures are more likely to become contaminated by bacteria
both during the surgical procedure and after the wound closure phase. However,
a number of variables, including the location, comorbidities of the patient,
and the extent of the damage, can affect the type of surgery that is chosen.
Due to the classification's lack of detail, this specific type of surgery plan
has been shown to be inefficient in a number of subspecialties, including orthopedic trauma surgery
There
was no significant link found between operation time and surgical wound healing
(p=0,199). This contrasts with other research that suggests the length of
operation influences the patient's prognosis. Additional findings from earlier
research indicate a relationship between longer surgery times and both
in-hospital cost and patient outcomes. Longer operations naturally result in
longer exposure times in the operating field, which may exacerbate hemorrhage,
surgical site infections
The length of stay is the last factor that affects
surgical wound healing (p=0,000). The development of infection in the surgical
wound will fluctuate depending on how long the treatment is administered. A
patient's risk of nosocomial infections increases with length of stay in the
hospital. Many earlier research that claimed that prolonged treatment would
raise the risk of infection support these findings. Thus, among surgical
patients, it is the primary cause of morbidity and mortality
CONCLUSION
In this research, there were 22 samples (16.5%) with
surgical wounds that delayed longer than expected to heal. During the research period, cefazolin was the most widely used antibiotic
and was found to have an important effect on the healing of surgical wounds.
The type of surgery, length of stay, gender, and comorbidities are other
factors that are related. This study has a small sample size and restricted
data availability. If you want to use the research findings, additional factors
must take into consideration the situation in each hospital. The researcher
recommends doing more studies with a bigger sample size.
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Copyright holders:
Muhammad Nizar, M. Wibowo Ariyanto (2024)
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