Understanding and preventing surgical site infection in hand trauma surgery

Hand and wrist injuries, known as hand trauma, are a common occurrence and account for a significant number of Emergency Department (ED) visits and operations in the UK each year. Surgical site infections (SSIs) in hand trauma surgery can lead to additional morbidity, prolonged hospital stays, and even amputation. Antimicrobial sutures have been found to prevent SSIs in other surgical fields, but their effectiveness in hand trauma surgery is unknown. The aim of this thesis was to estimate the risk of SSI in hand trauma surgery and to establish the feasibility of conducting interventional trials to moderate it. The thesis comprises a systematic review, meta-analysis and meta-regression of data from 315,618 patients, an innovative national cohort analysis of primary and secondary care real world data and a multi-centre, randomised, controlled, feasibility trial of antimicrobial sutures in hand trauma surgery. Through my systematic review and meta-analysis, novel summary statistics for overall SSI in hand trauma have been generated, indicating an overall risk of 5% but in the context of substantial variation in SSI reporting. National cohort analyses have added granularity to this summary statistic, demonstrating a risk of superficial SSI of 6.2% by 30 days and 14.4% at 90 days; the deep/organ space SSI risk is 1.4% by 30 days and 2.0% at 90 days. Following this, a feasibility trial of antimicrobial interventions in hand trauma surgery was designed and executed. In seven months, 116 participants were randomised across three sites, demonstrating solid recruitment, randomisation, and adherence. Difficulty was encountered in retention. Comprehensive retention strategies are necessary for future definitive trials in this population. This thesis supports the need for evidence-based prevention of SSI in hand trauma surgery, informed by clinical trials of antimicrobial interventions.