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Prognosis of deep infection in spinal surgery using implants, treated by retention, removal of bone graft and lengthy antibiotherapy
Pronóstico de la infección profunda en la cirugía raquídea con implante, tratada mediante retención, retirada del injerto óseo y antibioterapia prolongada
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"apellidos" => "Llusá-Pérez" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1988885618300919?idApp=UINPBA00004N" "url" => "/19888856/0000006300000001/v1_201901100606/S1988885618300919/v1_201901100606/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S1988885618300920" "issn" => "19888856" "doi" => "10.1016/j.recote.2018.12.006" "estado" => "S300" "fechaPublicacion" => "2019-01-01" "aid" => "779" "copyright" => "SECOT" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Esp Cir Ortop Traumatol. 2019;63:1-6" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 8 "HTML" => 8 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Superior capsular reconstruction of irreparable rotator cuff tear using autologous hamstring graft" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "1" "paginaFinal" => "6" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Reconstrucción de la cápsula superior en las roturas irreparables del manguito mediante injerto autógeno de isquiotibiales" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 678 "Ancho" => 900 "Tamanyo" => 74667 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Drawing of the superior capsule reconstruction with hamstring allograft.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A.P. 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"apellidos" => "Gómez Cáceres" "email" => array:1 [ 0 => "gomezcaceresabel@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J.S." "apellidos" => "Lucena Jiménez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Á.L." "apellidos" => "Reyes Martín" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "Moriel Durán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "B." "apellidos" => "Sobrino Diaz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "D." "apellidos" => "García de Quevedo Puerta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Cirugía Ortopédica y Traumatología, Hospital Regional Universitario de Málaga, Málaga, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Enfermedades Infecciosas, Hospital Regional Universitario de Málaga, Málaga, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pronóstico de la infección profunda en la cirugía raquídea con implante, tratada mediante retención, retirada del injerto óseo y antibioterapia prolongada" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The constant increase in spinal surgery with vertebral fixation, as well as the number and complexity of its indications, inevitably leads to a higher rate of complications. Of the complications that occur, infections are one of the most common and important types,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> not only because of their morbidity, but also because of the resulting major consumption in healthcare resources.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The incidence of deep surgical wound infections (DSWI) in spinal surgery with implantation varies from 0.7% to 16%.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">2,3</span></a> This wide-ranging variability is associated with several factors, and these without doubt include the heterogeneous criteria used to define DSWI, factors that depend on patient comorbidities<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">2,4,5</span></a> and others connected with the surgical procedure itself such as the duration of the operation, the amount of intra- and perioperative bleeding, a history of spinal surgery, the number of levels fixed and the type of procedure used.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Although it is generally accepted that antibiotic therapy and wound debridement-washing are the fundamental treatments for DSWI, there is no agreement on the imperative need to remove implants and bone grafts<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> to guarantee cure of the infection and prevent secondary problems with stability.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">6–8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of this study is to describe our experience in the treatment of DSWI in patients treated by spinal instrumentation arthrodesis, using a strategy based on the broad debridement of the surgical wound and prolonged administration of antibiotic treatment, while keeping the instrumentation and replacing bone grafts.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study design, scope and population</span><p id="par0025" class="elsevierStylePara elsevierViewall">This observational retrospective study includes all of the patients who received spinal surgery with vertebral fixation during the period from 1 January 2010 to 31 December 2014, in the Trauma and Orthopaedic Surgery Department of our third level university hospital, which has a catchment area of 1,250,000 inhabitants.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Exclusion criteria and definitions</span><p id="par0030" class="elsevierStylePara elsevierViewall">Patients aged less than 14 years old were excluded from the study. The diagnosis of DSWI was made using the criteria of the Centres for Disease Control and Prevention's National Healthcare Safety Network (CDC/NHSN).<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> A patient was considered to have DSWI when they had the following criteria: clear signs of inflammation in the surgical wound, dehiscence or fistulisation, and signs of infection or suppuration during debridement that go beyond the muscle fascia and are in contact with implant material. DSWI was considered to be early onset when the symptoms or signs leading to diagnosis arose before one month after the operation, and late onset when they occurred after more than one month after the operation.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Procedures and preoperative prophylaxis</span><p id="par0035" class="elsevierStylePara elsevierViewall">All of the initial surgical procedures took place under general anaesthetic with antibiotic prophylaxis administered 30<span class="elsevierStyleHsp" style=""></span>min beforehand, consisting of a 2<span class="elsevierStyleHsp" style=""></span>g perfusion of cefazolin, followed by 1<span class="elsevierStyleHsp" style=""></span>g IV/8<span class="elsevierStyleHsp" style=""></span>h during the following 24<span class="elsevierStyleHsp" style=""></span>h. All of the patients were operated using a posterior approach and conventional surgical technique. An allograft was used for the arthrodesis except for occasional usage of iliac crest autograft. After the diagnosis of DSWI, drainage and broad debridement of all necrotic or devitalised tissue were performed as soon as possible, together with abundant washing and the removal of bone grafts, while always keeping vertebral instrumentation. In all cases, and depending on intraoperative findings, 3–5 deep representative samples were taken for culture. They were processed using normal microbiological techniques for the detection of aerobic or anaerobic flora.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Antimicrobial treatment and monitoring</span><p id="par0040" class="elsevierStylePara elsevierViewall">After drainage and debridement and sample-taking for culture the patients were initially treated empirically, followed by planned treatment until they had completed 8 weeks of treatment. Once treatment was completed the patients were followed-up for a period of 12 months.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Data recording</span><p id="par0045" class="elsevierStylePara elsevierViewall">The following variables were recorded: age, sex, reason for initial surgery, postoperative delay to the onset of symptoms, comorbidities, Charlson index, segment involved, number of vertebra fixed, duration of surgery and the need for transfusion. Records also included a complete haemogram, serum levels of creatinin, albumin and PCR, the results of cultures and prognosis, cure, failure or relapse.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical processing</span><p id="par0050" class="elsevierStylePara elsevierViewall">Data were entered in a suitable database and processed using version 23 of the SPSS software package (SPSS Inc., Chicago, IL, USA). Qualitative variables were expressed in percentages and quantitative variables were expressed as an average together with standard deviation (SD) or the mean and interquartile range (IQR), depending on the case in question. Quantitative variable distribution normalcy was studied using the Shapiro–Wilk test. The tests used to compare variables were the chi-squared test for qualitative variables and the Student <span class="elsevierStyleItalic">t</span>-test and Mann–Whitney <span class="elsevierStyleItalic">U</span> test for quantitative variables. A <span class="elsevierStyleItalic">P</span> value ≤.05 was considered significant.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">Thirty-two of the 799 patients included in the study were diagnosed with DSWI, so that the DSWI infection rate in our study amounted to 4%. 3 of these 32 patients (9.4%) did not complete follow-up and they were therefore excluded from the final analysis. The final sample was therefore composed of 29 patients. There were 15 women (51.7%) and 14 men (48.3%), with a mean age of 54.9 years old (IQR: 45.7–67 years old).</p><p id="par0060" class="elsevierStylePara elsevierViewall">The DSWI was early onset in 26 cases (89.6%) and late onset in the remaining 3 (10.4%). The mean time period from surgery until diagnosis of DSWI was 19 days (IQR: 12–37). <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows he most relevant data respecting the diagnosis due to which arthrodesis was indicated, the spinal segments operated and patient comorbidities. It should be pointed out here that Charlson's comorbidity index mean value was 2 (IQR: 0–3).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">An average number of 4 vertebral bodies were treated by fixation (range 2–14). In 5 cases 2 vertebral bodies were fixed (17.24%), 3 were fixed in 15 cases (51.72%), 4 were fixed in 4 cases (13.79%) and more than 4 vertebrae were fixed in the 5 remaining cases (17.24%). The average duration of surgery was 145.77<span class="elsevierStyleHsp" style=""></span>min (SD 59.64).</p><p id="par0070" class="elsevierStylePara elsevierViewall">At the moment of diagnosis 14 patients (48.2%) had leukocytosis; nevertheless, 27 of the 29 patients (93.1%) had raised levels of PCR, with a mean value of 64.9<span class="elsevierStyleHsp" style=""></span>mg/L (IQR: 16–109<span class="elsevierStyleHsp" style=""></span>mg/L). Only 2 patients had normal serum PCR levels (≤3<span class="elsevierStyleHsp" style=""></span>mg/L). Their cultures were negative in both cases, although they had inflammatory macroscopic data that strongly suggested infection.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The cultures were positive in 22 cases (75.8%). The flora was monomicrobial in 15 of these 22 cases (68.2%) with a positive culture, while in the remaining 7 it was polymicrobial. The most frequent causal agent was <span class="elsevierStyleItalic">Staphylococcus aureus,</span> and this was isolated in 7 of the 29 patients with DSWI (24.1%), always alone. In 6 of the 7 patients with polymicrobial infections (85.7%) the cultures contained anaerobic microorganisms, while in the 3 in which <span class="elsevierStyleItalic">Bacteroides</span> spp. was isolated the lumbosacral segment had been operated. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the most relevant microbiological findings.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Due to the microbiological diagnosis the treatment was specific in 22 patients (75.8%) and completely empirical in the remaining 7 (24.2%). The planned 8-week treatment was completed in 25 patients (86.2%). Treatment was suspended in 2 patients (6.8%) after 4 weeks because of severe side effects, while treatment failed in one case, clinical and biological progress was highly positive in the second. Treatment in the remaining 2 cases had to be prolonged until week 12, as although the response was slow it was eventually positive.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Of the 25 patients treated during the planned 8 weeks, 24 (96%) had a favourable prognosis and one patient with <span class="elsevierStyleItalic">S. aureus</span> infection relapsed 9 months after the end of treatment: it was necessary to remove all of the fixation material and undertake a new cycle of treatment.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">The development of a DSWI in an operated patient with vertebral fixations is a severe complication that seriously compromises the success of the previous surgery due to several reasons. Firstly, the proximity or even contact of the infection with osteosynthesis material not only hinders consolidation but also opens a route through which the infection may enter the bone, which would create the possibility of progression to post-surgical vertebral osteomyelitis. Secondly, infection of the still unabsorbed graft favours the development of a bone sequestrum that hinders treatment of the infection. Thirdly, and as a result of the first 2 possibilities, the main aim, i.e., the stability of the fixed segment of the spine, will be severely compromised.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Due to the above reasons, in our study we describe our experience with a therapeutic strategy that by debridement and the withdrawal of unabsorbed graft prevents the formation of a sequestrum, and which by prolonged antimicrobial treatment protects bone tissue with absorbed graft against the development of vertebral osteomyelitis, all without compromising the stability of the fixed segment.</p><p id="par0100" class="elsevierStylePara elsevierViewall">A 4% rate of DSWI such as that found in our study is in line with the rates reported by other authors,<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">2,3</span></a> and it strongly expresses the importance of energetic treatment in this type of increasingly frequent surgery.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The comorbidities of our DSWI patients and their levels of albumin do not differ substantially from those reported in other large series in the literature.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">2–5,10–12</span></a> Nevertheless, it should be pointed out that, unlike our study, the majority of the others did not measure Charlson comorbidity index, which is a highly reliable and standardised overall parameter for evaluating the frailty and life expectancy of patients.</p><p id="par0110" class="elsevierStylePara elsevierViewall">It is a well-known fact that the serum PCR level is a highly sensitive inflammation marker and an extremely useful parameter for monitoring postoperative evolution. This is because after rising immediately after surgery, it normalises from day 10 to day 15; this either does not occur or the level swiftly rises if there is an active infection.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> In our study the mean level of PCR values was 64.9<span class="elsevierStyleHsp" style=""></span>mg/L, which is a similar figure to those reported in other studies.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">6,12</span></a> This is a far more sensitive parameter than the total number of leukocytes, which was not raised in half of our patients with DSWI. It should be underlined that, in 2 cases of DSWI PCR levels were normal. This fact, which may be surprising, has already been reported by other authors. Thus Collins et al.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> advise that when diagnosing DSWI, PCR levels should be interpreted in a clinical sense, as they may often be normal in the presence of an active infection caused by pathogens with a low level of virulence. Both patients in our study with normal PCR levels had negative cultures together with the presence of unmistakeable signs of infection in debridement. It is possible that these cases were caused by pathogens which are hardly aggressive, such as <span class="elsevierStyleItalic">Propionibacterium acnes</span>, which live on the skin and habitually cause infection in patients with osteosynthesis material. It is sometimes difficult to isolate these pathogens as they require a prolonged incubation.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Respecting the microbiological findings of our study, 75.8% of the patients had positive cultures, 2/3 of them with monomicrobial infections and one third with polymicrobial infections. These rates are similar to others reported in the literature,<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">6,14</span></a> as is the fact that the microorganism isolated the most often was <span class="elsevierStyleItalic">S. aureus</span><a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> followed by the GNB, and that the polymicrobial infections by enteric flora were most frequent in the patients operated in the lumbosacral segment. Nor should it be forgotten that some flora required special sample processing to be isolated, and the main cause of negative cultures is still the widespread practice of administering antimicrobial treatment to patients before debridement and sample taking for culture.</p><p id="par0120" class="elsevierStylePara elsevierViewall">If we assume that, as occurred in our study, more than 90% of the patients who had a DSWI after vertebral fixation surgery will be diagnosed in the first month after the operation, during which implant removal is not indicated,<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">7,15</span></a> the strategy used in our study is shown to be especially positive, as it achieves a cure in 96% of the patients treated with surgical debridement of the wound and replacement of the bone graft while keeping the instrumentation, with 8 weeks of antibiotic therapy. These results are similar to those achieve with withdrawal of the fixation, and with the additional advantage that spinal stability is maintained.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">13–16</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">This study has a series of limitations that should be taken into account when evaluating its results. Firstly, the fact that it is retrospective prevents rigorous analysis of the risk factors associated with suffering a DSWI. On the other hand, the limited size of its sample makes it impossible to relate the results of the suggested strategy with the different epidemiological variables, the segment involved or the causal microorganism. Thirdly, the follow-up period of one year may not be sufficient to rule out late relapses. Lastly, it may be impossible to extrapolate the external validity of our results to patient cohorts with a higher rate of comorbidities, or to hospitals with less experience in spinal surgery with vertebral fixation or those which do not have a permanent expert consultant in infectious diseases. To conclude, in spite of these limitations the robustness of our results could justify trialling this therapeutic strategy in broader multicentre studies.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Level of evidence</span><p id="par0130" class="elsevierStylePara elsevierViewall">Level of evidence III<span class="elsevierStyleSmallCaps">.</span></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflict of interests</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1135260" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1067359" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1135261" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1067358" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study design, scope and population" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Exclusion criteria and definitions" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Procedures and preoperative prophylaxis" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Antimicrobial treatment and monitoring" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Data recording" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Statistical processing" ] ] ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Level of evidence" ] 9 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-12-30" "fechaAceptado" => "2018-10-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1067359" "palabras" => array:4 [ 0 => "Deep surgical site infection" 1 => "Spinal fusion" 2 => "Antibiotic treatment" 3 => "Retaining instrumentation" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1067358" "palabras" => array:4 [ 0 => "Infección profunda de la herida quirúrgica" 1 => "Artrodesis espinal" 2 => "Tratamiento antibiótico" 3 => "Retención de la instrumentación" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Surgical site infections (SSIs) are complications that predispose to a high risk of unfavourable surgical outcomes. The aim of this study was to assess the SSI rate in this type of patients and their prognosis with similar treatment.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective case series of 799 patients above 18 years old with spinal instrumentation surgery, between January 2010 and December 2014 in the traumatology and orthopaedic surgery department of our institution. All patients with SSIs were treated by debridement, graft replacement, retention of the instrumentation and lengthy courses of antimicrobial therapy. The patients were followed up for a period of 12 months.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Of all the patients with arthrodesis, 32 (4%) had spinal SSIs. Three patients were lost to follow-up. The final sample analyzed comprised 29 cases, with a median age of 54.9 years (IQR, 45.7–67 years) and a Charlson comorbidity index of 2.0 (IQR; 0–3). A microbiological diagnosis was obtained in 75.8% of the cases. Of these, the ISSs were monomicrobial in 68.2% and polymicrobial in 31.8%. Once treatment had been completed, 96% were cured without sequelae, and the rate of recurrence and reoperation was 4%.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Treatment based on debridement, retention of the instrumentation, graft replacement and lengthy courses of antimicrobial therapy seems a very effective strategy in the treatment of patients with deep surgical site infection in spine surgery.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La infección profunda de la herida quirúrgica (IPHQ) es una complicación que predispone a un alto riesgo de fracaso en cirugía raquídea con fijación vertebral. El objetivo del presente estudio ha sido valorar la tasa de IPHQ en este tipo de pacientes y su pronóstico siguiendo un abordaje terapéutico homogéneo.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y método</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional retrospectivo en el que se incluyó a 799 pacientes mayores de 14 años, intervenidos de cirugía raquídea con fijación vertebral entre enero de 2010 y diciembre de 2014, en el Servicio de Traumatología y Cirugía Ortopédica de nuestro centro. Todos los pacientes diagnosticados de IPHQ fueron tratados de forma homogénea mediante desbridamiento, sustitución del injerto óseo, retención del implante y tratamiento antimicrobiano de 8 semanas. Tras finalizar el tratamiento, los pacientes fueron seguidos durante un periodo de 12 meses.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">De total de los pacientes tratados mediante artrodesis, 32 (4%) tuvieron una IPHQ. Tres pacientes fueron perdidos en el seguimiento. La muestra final analizable fue de 29 casos, los cuales tenían una mediana de edad de 54,9 años (IQR: 45,7-67 años) y un índice de comorbilidad de Charlson de 2,0 (IQR: 0-3). El diagnóstico microbiológico fue establecido en el 75,8% de los casos. De ellos, la IPHQ fue monomicrobiana en el 68,2% y polimicrobiana en el 31,8%. Con el abordaje terapéutico aplicado curaron sin secuelas el 96% y la tasa de recidivas y reintervención fue del 4%.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El tratamiento mediante desbridamiento, retención, sustitución del injerto y tratamiento antimicrobiano de 8 semanas parece una estrategia muy eficaz para los pacientes con fijación vertebral que desarrollan IPHQ.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: Gómez Cáceres A, Lucena Jiménez JS, Reyes Martín ÁL, Moriel Durán J, Sobrino Diaz B, García de Quevedo Puerta D. Pronóstico de la infección profunda en la cirugía raquídea con implante, tratada mediante retención, retirada del injerto óseo y antibioterapia prolongada. Rev Esp Cir Ortop Traumatol. 2019;63:7–11.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Total number of patients analysed \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>29 \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Risk factors</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Those with a risk factor</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (58.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Diabetes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (31.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Obesity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (24.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>HIV infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (3.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Without risk factors</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (41.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Reason for surgery</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Disc pathology</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (44.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Vertebral fracture</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (27.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Spondylolysthesis</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (10.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Other diagnoses</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (17.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Segment fixed</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Thoracic</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (44.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Thoracolumbar</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (27.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Lumbar</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (10.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Lumbosacral</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (17.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1936738.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Basal data of patients with DSWI.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Patients with a microbiological diagnosis<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>22<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Monomicrobial infections</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (68.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Gram+</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleBold">9 (40.9)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Staphylococcus aureus</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (31.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Enterococcus faecalis</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (4.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Propionebacterium acnes</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (4.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Gram−</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleBold">6 (27.3)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Proteus mirabilis</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (9.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (4.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Escherichia coli</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (4.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Enterobacter aerogenes</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (4.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Serratia marcescens</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (4.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Polymicrobial infections</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (31.8)<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1936739.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Total number of microorganisms isolated: 35.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">In total, 8 isolations of GNB and 2 isolations of each one of the following: <span class="elsevierStyleItalic">Enterococcus faecalis</span>, <span class="elsevierStyleItalic">S. epidermidis</span>, <span class="elsevierStyleItalic">Peptostreptococcus</span> spp., <span class="elsevierStyleItalic">Propionebacterium acnes</span>, <span class="elsevierStyleItalic">B. fragilis</span> and <span class="elsevierStyleItalic">Prevotella</span> spp.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Microbiological findings.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "[article in German]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "[Management of postoperative wound infections following spine surgery: first results of a multicenter study]" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 1 | 0 | 1 |
| 2024 October | 13 | 1 | 14 |
| 2024 September | 24 | 3 | 27 |
| 2024 August | 24 | 3 | 27 |
| 2024 July | 15 | 5 | 20 |
| 2024 June | 22 | 1 | 23 |
| 2024 May | 17 | 4 | 21 |
| 2024 April | 20 | 7 | 27 |
| 2024 March | 28 | 4 | 32 |
| 2024 February | 30 | 4 | 34 |
| 2024 January | 18 | 5 | 23 |
| 2023 December | 27 | 8 | 35 |
| 2023 November | 27 | 7 | 34 |
| 2023 October | 14 | 6 | 20 |
| 2023 September | 7 | 3 | 10 |
| 2023 August | 9 | 7 | 16 |
| 2023 July | 11 | 7 | 18 |
| 2023 June | 18 | 4 | 22 |
| 2023 May | 50 | 5 | 55 |
| 2023 April | 27 | 3 | 30 |
| 2023 March | 14 | 2 | 16 |
| 2023 February | 7 | 2 | 9 |
| 2023 January | 16 | 6 | 22 |
| 2022 December | 12 | 3 | 15 |
| 2022 November | 15 | 11 | 26 |
| 2022 October | 15 | 4 | 19 |
| 2022 September | 14 | 7 | 21 |
| 2022 August | 15 | 9 | 24 |
| 2022 July | 11 | 20 | 31 |
| 2022 June | 34 | 6 | 40 |
| 2022 May | 22 | 8 | 30 |
| 2022 April | 28 | 12 | 40 |
| 2022 March | 14 | 8 | 22 |
| 2022 February | 18 | 3 | 21 |
| 2022 January | 24 | 5 | 29 |
| 2021 December | 31 | 6 | 37 |
| 2021 November | 22 | 5 | 27 |
| 2021 October | 56 | 10 | 66 |
| 2021 September | 37 | 4 | 41 |
| 2021 August | 27 | 4 | 31 |
| 2021 July | 10 | 4 | 14 |
| 2021 June | 9 | 1 | 10 |
| 2021 May | 8 | 2 | 10 |
| 2021 April | 27 | 2 | 29 |
| 2021 March | 11 | 3 | 14 |
| 2021 February | 13 | 4 | 17 |
| 2021 January | 11 | 3 | 14 |
| 2020 December | 1 | 0 | 1 |
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