Thurs., 10/18/07 Reconstruction, Paper #18, 5:10 pm OTA-2007
Managing Acute Infections after ORIF with Hardware in Place
Eric Rightmire, MD (n); David Zurakowski, PhD (n); Mark S. Vrahas, MD (n);
Massachusetts General Hospital Brigham and Women’s Hospital, Boston, Massachusetts, USA
Purpose: Managing infections in acute fractures treated with open reduction and internal fixation (ORIF) is an ongoing dilemma. Little published data exists to support the current practice of suppressing these infections while leaving stable hardware in place until the fracture heals. This study evaluates the effectiveness of this approach.
Methods: Potential subjects were identified from a central trauma database and were selected based on specific inclusion and exclusion criteria. Patients who developed infections after the definitive ORIF of acute fractures were candidates for inclusion. Infections had to have occurred after definitive fixation and before union. 6 months follow-up was required for all cases that went on to union (successes). Fractures that required hardware revision or removal were considered failures and were included regardless of follow-up. Data including age, gender, tobacco use, diabetic status, site of fracture, OTA class, open grade, type of fixation, joint involvement, and organism were gathered and compared between the groups through analysis of variance.
Results: 69 cases were available for analysis. Suppressive treatment with stable hardware left in place was successful in 47 cases (69%) and failed in 22 cases (31%). The only independent predictor of outcome was smoking. A Kaplan-Meier survivorship analysis demonstrated smokers to be at significantly higher risk of failure than nonsmokers (log-rank test = 6.85, P = 0.009) with more failures and earlier failures in the smoking group. In the group of 47 patients who were managed successfully to union by suppressive therapy, 19 went on to have hardware removed for various reasons, and 28 were left with hardware in place. Of the group with retained hardware, 10 (36%) developed recurrent infections requiring hardware removal. In the group of 19 with hardware removed after union, 3(16%) also developed recurrent infections.
Conclusion: Our study suggests that it is possible to achieve union and manage infection with hardware in place. However, the success rate (69%) is not as high as one would like. This is particularly true for smokers, who had a 3.7 times greater likelihood of failure per month than nonsmokers. Given the relatively high failure rate, it may be time to consider different treatment strategies.
If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing.