The authors conducted a well organized randomized controlled trial of both elective and emergency hand surgery patients randomizing them to receive or not receive prophylactic antibiotics. Patients with any known immunodeficiency, diabetes, valvular heart defects or known reasons to require antibiotic prophylaxis for dental work, or recent antibiotic exposure were excluded. Patients were subdivided into groups based on the depth of surgery (I-skin and subcutis, II-tendons, arteries, or nerves, III-bones and/or joints) and trauma (IV-defects of any soft tissue elements with or without bony defects). Very meticulous debridements were performed and very meticulous skin preparation and post-operative wound care was performed on all patients. 1340 patients successfully completed the study with a total of 44 infections (3.2%). The no-antibiotics group infection rate was 3.4% and the group that received prophylactic antibiotics had an infection rate of 3.1% (p>0.05). Subgroup analysis did not reveal any differences between depth of surgery and infection rate between antibiotic and no antibiotic groups. Group IV (emergency/trauma), likewise, did not reveal statistically significant differences between the antibiotic group (4% infection rate) and the no-antibiotic group (3% infection rate). There were no differences in overall infection rates between electively operated on patients and those operated on emergently. Length of operation, need for implant/hardware, open vs. closed fracture, and crush vs. clean cut injury were also evaluated with no statistical differences between groups.
Many recent articles have demonstrated the lack of efficacy of routine antibiotics in elective hand surgery. However, this randomized controlled trial also enrolled trauma/emergency patients and still demonstrated no benefit from antibiotic use as long as meticulous debridement and post-operative wound care is performed. This paper provides further evidence that antibiotics are not always useful in otherwise healthy hand surgery patients despite depth of surgery or whether or not the case is elective or emergent. While most surgeons will still likely provide antibiotic coverage to trauma/emergency surgery patients despite the results of this study, it does illustrate the need to further evaluate our antibiotic use practices in this and all populations.