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Scientific Articles   |    
Maintenance of Hardware After Early Postoperative Infection Following Fracture Internal Fixation
Marschall Berkes, MD1; William T. Obremskey, MD, MPH2; Brian Scannell, MD3; J. Kent Ellington, MD3; Robert A. Hymes, MD4; Michael Bosse, MD3;
1 Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 71st Street, New York, NY 10021
2 Division of Orthopaedic Trauma, Vanderbilt University Medical Center, 1215 21st Avenue South, MCE South Tower, Suite 4200, Nashville, TN 37232
3 Carolinas Medical Center, 1001 Blythe Boulevard, Medical Center Plaza 602, Charlotte, NC 28203
4 Inova Fairfax Hospital, 8503 Arlington Boulevard 200, Fairfax, VA 22031
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

A commentary by Michael J. Patzakis, MD, is available at www.jbjs.org/commentary and as supplemental material to the online version of this article.
Investigation performed at Vanderbilt University Medical Center, Nashville, Tennessee; Carolinas Medical Center, Charlotte, North Carolina; and Inova Fairfax Hospital, Fairfax, Virginia

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Apr 01;92(4):823-828. doi: 10.2106/JBJS.I.00470
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Abstract

Background: 

The development of a deep wound infection in the presence of hardware after open reduction and internal fixation presents a clinical dilemma, and there is scant literature to aid in decision-making. The purpose of the present study was to determine the prevalence of osseous union with maintenance of hardware after the development of postoperative infection within six weeks after internal fixation of a fracture.

Methods: 

The present study included 121 patients from three level-I trauma centers, retrospectively identified from billing and trauma registries, in whom 123 postoperative wound infections with positive intraoperative cultures had developed within six weeks after internal fixation of acute fractures. The incidence of fracture union without hardware removal was calculated, and the parameters that predicted success or failure were evaluated.

Results: 

Eighty-six patients (eighty-seven fractures; 71%) had fracture union with operative débridement, retention of hardware, and culture-specific antibiotic treatment and suppression. Predictors of treatment failure were open fracture (p = 0.03) and the presence of an intramedullary nail (p = 0.01). Several variables were not significant but trended toward an association with failure, including smoking, infection with Pseudomonas species, and involvement of the femur, tibia, ankle, or foot.

Conclusions: 

Deep infection after internal fixation of a fracture can be treated successfully with operative débridement, antibiotic suppression, and retention of hardware until fracture union occurs. These results may be improved by patient selection based on certain risk factors and the specific bacteria and implants involved.

Level of Evidence: 

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    William T. Obremskey, MD, MPH
    Posted on May 11, 2010
    Dr. Obremskey responds to Drs. Gohiya and Poorva
    Chief Division of Orthopaedic Trauma, Vanderbilt Orthopaedic Institute, Nashville, Tennessee

    Thank you for your letter on a recent article, “Maintenance of Hardware After Early Postoperative Infection Following Fracture Internal Fixation” in JBJS (A) Volume 92. Your question asked me to provide more information on the type of open fractures that were included in this retrospective review of fractures that had internal fixation, but developed a postoperative wound infection. This information may have been helpful. We felt that, given only 48 fractures in this series were open, further subdividing these into type I, II, and III fractures would dilute the numbers in each area and prevent meaningful analysis. I want to emphasize that the main purpose of this retrospective series is to be prognostic in helping clinicians educate patients and themselves on the ability to salvage internal fixation until bony union occurs with antibiotic suppression.

    As this is a retrospective study, it gives no information on incidence and risk of infection of open or closed fractures treated with plates or nails. There was not a higher failure rate in the nailing group as you suggested in your letter as there was no indication of the total number of intramedullary nails treated with closed and/or open fractures at these different centers. Again, we simply followed the patients who presented with a postop wound infection that was confirmed with an open irrigation and debridement and positive culture. It may be that knowing the classification of type I, type II, or type III open fracture may improve one’s prognostic capacity on ability to eradicate infection until bony union with maintaining hardware, but we did not have an adequate sample size and distribution of fractures in each group to adequately analyze this.

    I want to emphasize that this article does not provide any recommendation on treatment options of intramedullary nailing or plate fixation of open or closed fractures. I believe that should be determined by other literature, a physician’s expertise and experience, and implants available as well as the fracture type.

    Again, thank you for your question and I hope that these answers clarified these two points that you raised.

    Ashish Gohiya
    Posted on May 03, 2010
    Maintenance of Hardware After Early Postoperative Infection Following Fracture Internal Fixation
    Gandhi Medical College, Bhopal, India

    To the Editor:

    I read the article by Berkes et al. with great interest on a topic on which scanty literature is available (1). In conclusion, the author stated that two variables, stabilization with intramedullary nail and history of open fracture, are associated with lower success rates (1). Out of 48 open fractures in this retrospective series, 20 failures were noted. Specific grading of these open fractures could have been more informative as different grades of open fractures are associated with different risks and severity of infection ranging from 0-2 % in grade I to 10–50 % in grade III B (2). The higher failure rate in the nailing group is surprising as nailing is associated with a lower infection rate than plating (3). As such, in this study of 123 fractures, only 26 fractures are nailed where as 48 fractures are open fractures. This questions the treatment policy as treatment of choice for open fractures is unreamed intramedullary nailing (2,3).

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

    References

    1. Berkes M, Obremskey WT, Scannell B, Ellington K, Hymes RA, Bosse M; Southeast Fracture Consortium. Maintenance of hardware after early postoperative infection following fracture internal fixation. J Bone Joint Surg Am. 2010;92:823-8.

    2. Gustilo RB, Merkow RL, Templeman D. The management of open fractures, J Bone Joint Surg Am. 1990;72:299-304.

    3. Bhandari M, Guyatt GH, Swiontkowski MF, Schemitsch EH. Treatment of open fractures of the shaft of tibia. J Bone Joint Surg Br. 2001;83:62-8.

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