Fri., 10/17/08 Geriatrics/Reconstruction, Paper #43, 5:05 pm OTA-2008
Maintenance of Hardware after Early Postop Infection following Fracture Internal Fixation
The Southeast Fracture Consortium;
William T. Obremskey, MD, MPH (a-Synthes; e-Medtronic, Osteogenix);
Vanderbilt University, Nashville, Tennessee, USA
Purpose: Our objectives were (1) to determine incidence of hardware retention and bony union associated with postoperative infections within 6 weeks of internal fixation of a fracture, and (2) to determine demographic, injury, and infection parameters that predict failure, ability to maintain hardware, and attain bony union.
Methods: There were 104 patients from 2 Level 1 trauma centers retrospectively identified from billing and trauma registries who developed a postoperative wound infection with a positive intraoperative culture within 6 weeks of internal fixation of an acute fracture. Demographic, comorbidity, infection, and treatment data were collected from chart and radiographic review. IRB approval was obtained. The incidence of fracture union without hardware removal was calculated and the parameters that predicted success or failure were evaluated. χ2 statistical analysis or Fisher exact test was performed.
Results: 78% of patients (81 of 104) were able to obtain fracture union with operative débridement, culture-specific antibiotic treatment, and suppression. 27% of these patients (22 of 81) eventually required hardware removal due to infection recurrence and all of these cases had resolution of the infection after removal of hardware and further treatment with culture-specific antibiotic therapy. 17% of patients (18 of 104) required further débridement, hardware removal, staged reconstruction due to failure, of eradication of infection and ability to obtain union. 5% of the patients (5 of 104) underwent amputation to eradicate infection. Patients in the plate group are more likely to fail (15 of 28; P = 0.0094, Fishers exact test). The following comorbidities and pathogens were not statistically significant, but may help guide treatment decisions. Percentages of patients with successful union without hardware removal are as follows: diabetes 11 of 12 (92%), smoking 43 of 64 (67%), methicillin-resistant Staphylococcus aureus 21 of 33 (64%), methicillin-sensitive S aureus 22 of 27 (81%), Pseudomonas 4 of 7 (57%), enterobacter 8 of 12 (67%), >1 pathogen 18 of 26 (69%). Median antibiotic duration was 6 weeks.
Conclusions: A significant percentage of cases where deep infection presents after fracture internal fixation can be salvaged with operative débridement and antibiotic treatment and suppression until fracture union. A plate, smoking, and some pathogens may decrease incidence of infection eradication.
Significance: Surgeons may be able to predict which patients, fractures, or pathogens can reliably be suppressed or eradicated after an early postoperative wound infection.
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. Δ OTA Grant.