Session V - Knee / Tibia

Fri., 10/11/13 Knee/Tibia, PAPER #67, 3:39 pm OTA 2013

Outcomes of the Patients With Cultured Pathogens at the Time of Nonunion Surgery

David P. Taormina, MS; James H. Lee, BE; Alejandro I. Marcano, MD; Raj Karia, MPH;
Kenneth A. Egol, MD;
Hospital for Joint Diseases, NYU Langone Medical Center, New York, New York, USA

Purpose: This study was conducted to evaluate the incidence and outcomes of patients who cultured positive (PCP) during the surgical treatment of long bone nonunion.

Methods: 288 consecutive patients referred to a tertiary care medical center with a long bone nonunion were consented and enrolled in a prospective database. 216 (75%) who had undergone previous surgery were cultured intraoperatively for aerobic, anaerobic, and fungal pathogens. Standard preoperative lab data were collected on all patients and infectious laboratory markers were ordered on patients suspected for infection. When applicable, patients were recultured at follow-up débridement or revision surgery. All patients with positive operating room cultures were treated in consultation with an infectious disease specialist who prescribed culture sensitivity directed intravenous antibiotics. Patients were followed for at least 1 year after our institution’s first intervention. The primary outcomes assessed are wound complications, antibiotic use, healing, function, and readmission for further surgery.

Results: Initial operative cultures returned positive on 23.6% of patients with an additional 3.1% culturing positive during the course of secondary treatments. All long bones were represented in the sample, but the majority of positive cultures were from tibial nonunions (41.5%). Preoperative white blood cell counts, erythrocyte sedimentation rate, and C-reactive protein were significantly elevated among PCPs (P <0.02). A significantly greater percentage of PCPs (46.7%) developed wound complications during follow-up visits (P <0.01). Antibiotic use averaged 3.2 months, versus 3 days in all other patients (P <0.01). Significantly more PCPs returned to the operating room for irrigation and débridement, averaging 1.3 visits per patient (P <0.01). At 9.8 months, PCPs required an additional 3.5 months more than others to progress to union (P <0.02). Poor outcomes appeared in the 3.1% of patients who initially cultured negative, but converted to positive during the course of treatment. Their mean healing time was 14.3 months. Overall, the PCP group was significantly more likely to undergo removal of hardware (P <0.01) and revision surgery (P <0.05). The poorest outcomes were seen in two of the PCPs (3.3%) who failed several revision surgeries and opted for amputation over further reconstruction attempts. At 1-year follow-up, PCPs reported significantly worse function on 5 of 6 Short Musculoskeletal Function Assessment indices (P <0.01).

Conclusions: In a large sample of nonunion patients, the infected nonunion stood apart on essentially all measures of outcome. Positive operating room culture at any point during the management of long bone nonunion was a prognostic indicator of impaired healing and poorer long-term functional outcomes in this study.

Alphabetical Disclosure Listing

• 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.