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Management Of Infected Hardware - APMA

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Management ofInfected HardwareKIMBERLY K. HURLEY, DPM FACFASBONE & JOINT INSTITUTECOOPER UNIVERSITY HOSPITAL – DEPARTMENT OF PODIATRY

Overview Wound and Hardware Infection can be a Critical Development in DeterminingPatient Outcome Infection Involving Hardware Can Jeopardize Bone Healing Can be Limb Threatening Early Diagnosis is Paramount

Epidemiology Incidence Up to 16% infection rate following traumatic fracturesRisk Factors Host Immunocompetency Extremes of age Diabetes Obesity Alcohol or Tobacco abuse Steroid use Malnutrition Medications Previous Radiation Vascular Insufficiency

Pathophysiology Mechanisms Seeding Disruptionof soft tissue envelope, blood vessels,and periosteum allow bacteria to avoid hostdefenses Directseeding of implant or anatomical structure Hematogenous BiofilmseedingFormation dependenton exopolysaccharide glycocalyx

Bacterial Colonization of Implants Gristina AG, Naylor PT, Myrvik QN: Mechanisms ofMusculoskeletal Sepsis1991 ;22:363-371. Orthop Clin North Am,Biofilm: due to the adsorption of proteins,sugars, and other macromolecules ontothe implant surface--Possible changes in the material itself are attributableto the host or the bacteria-Effects of the implant on the local environment-Systemic effects of the implant in the host

Bacterial Colonization of Implants Archer NK, Mazaitis MJ, Costerton JW, LeidJG,Staphylococcus aureus biofilms: Properties, regulation,Virulence, 2011and roles in human disease.Sep 1;2(5):445- 59. Epub 2011 Sep 1Once the biofilm is formed, takesroughly 6 weeks in order to eradicatethe infection with antibiotics- Staph Aureus is the most common organism to-form a complex multi layer biofilm

BOARD QUESTIONEtiologies of Periprosthetic InfectionType of InfectionEtiologyEarlyPostoperativeInfectionStaph aureusB-hemolytic StrepGram-negativesSymptoms withindays to weeks ofsurgeryChronic InfectionCoag-negative StaphGram-negativesSymptoms severalmonths to 2 yearsafter prosthesisplacementHematogenousseedingTime of OnsetInciting event from prior Within days of incitinginfection in other area eventof the body

But What Does it All Mean? StabilizeFracture Choose optimal hardware for yourprocedure Optimize your patient quit smoking!!! Sterile Technique Pre-op Antibiotics (Post-op x24hrs ifAppropriate)

Treatment of Infected Hardware Systematic Approach Use All Your Resources Infectious Don‘t Hesitate to get 2nd OpinionGet Appropriate Imaging Serial Disease ConsultX-rays, CT, MRI, Bone ScanBe Clear with Patient about Plan and PossibleOutcomes

Treatment 1. Diagnosis of Wound Infection 2. Treatment – Initial Surgery for Fracture SiteInfection 3. Implant Retention or Removal 4. Management of the Infected Wound 5. Wound Closure and Definitive Stabilization 6. Bone and Soft Tissue Reconstruction

Treatment 1.Diagnosis of Wound Infection 2. Treatment – Initial Surgery for Fracture Site Infection 3. Implant Retention or Removal 4. Management of the Infected Wound 5. Wound Closure and Definitive Stabilization 6. Bone and Soft Tissue Reconstruction

Studies Labs WBC may be normal in chronic or indolent infections Erythrocyte Sedimentation Rate may remain elevated for months following initial injury or surgery in absence ofinfection C-Reactive Protein most predictive for postoperative infection in the first week after fracture fixation should decrease from a plateau after postoperative day 2 (after fixation offractures) will increase further or fail to decrease if a hematoma or infection is present Cultures in-office cultures swabs or aspirations of wounds or sinus tracts are unreliable intraoperative deep cultures are most reliable method of isolated causative organisms multiple specimens from varying locations should be obtained

Imaging X-rays Peri-implant lucency can be seen Involucrom - reactive bone surrounding active infection Sequestrom - retained nidus of infected necrotic boneCT Pre-op Planning Evaluate Fracture HealingMRI Rule Out Soft Tissue AbscessWBC Labeled Scans

Treatment 1. Diagnosis of Wound Infection 2.Treatment – Initial Surgery for FractureSite Infection 3. Implant Retention or Removal 4. Management of the Infected Wound 5. Wound Closure and Definitive Stabilization 6. Bone and Soft Tissue Reconstruction

Initial Surgical Management ofInfected Hardware Debridementof Non-viable Tissue ThoroughIrrigation of Tissue with NSS todecrease bacterial load Removeor Maintain Hardware AQuestion of Timing

Treatment 1. Diagnosis of Wound Infection 2. Treatment – Initial Surgery for Fracture Site Infection 3.Implant Retention or Removal 4. Management of the Infected Wound 5. Wound Closure and Definitive Stabilization 6. Bone and Soft Tissue Reconstruction

Operative TreatmentAcute Infection Occurs in first 2 weeks If hardware maintains absolutestability, it may be possible to retainuntil fracture is healed Delayed Infection Occurs greater than 2 weeks afterinitial surgery Usually requires removal ofhardware at initial washout,stabilization of fracture withexternal fixator, antibiotics implant

Clinical Evidence Viol A, Pradka SP, Baumeister SP, Wang, Soft-tissue defects andexposed hardware: a review of indications for soft-tissuereconstruction and hardware preservation. Plast Reconstr Surg.2009Apr;123(4):1256-63.-The following parameters were identified asimportant for the potential salvage of exposedhardware with soft-tissue coverage:- Stable Hardware- Time of Exposure less than 2 weeks- Control of Infection- Location of Hardware

Clinical Evidence Chen CE, Ko JY, Wang JW, Wang CJ. Infection after Intramedullary Nailing of theFemur. J Trauma. 2003 Aug;55(2):338-44.- Retentionof the intramedullary nail is performed if thefixation is stable and the infection is under control Zych GA, Hutson JJ Jr. Diagnosis and Management of Infection after TibialIntramedullary Nailing. Clin Orthop Relat Res. 1995 Jun;(315):153-62.--20 patients with infection after intramedullary nailing ofthe tibiaTreatment protocols were based on the time of onsetof infection (acute, subacute, and chronic) and thestatus of bone healing.Acute infection group managed successfully with nailretention, debridement, soft tissue coverage, and IVantibiotics

Clinical Evidence Berkes M, Obremskey WT, Scannell B, Ellington JK, Maintenance ofHardware After Early Postoperative Infection Following Fracture InternalFixation. J Bone Joint Surg Am. 2010 Apr;92(4):823-8.---Eighty-six patients (eighty-seven fractures; 71%) hadfracture union with operative debridement,retention of hardware, and culture-specificantibiotic treatment and suppression.Predictors of treatment failure were open fracture(p 0.03) and the presence of an intramedullarynail (p 0.01).Failure trended toward an association with smokingand infection with Pseudomonas species

Treatment 1. Diagnosis of Wound Infection 2. Treatment – Initial Surgery for Fracture Site Infection 3. Implant Retention or RemovalManagement of theInfected Wound 4. 5. Wound Closure and Definitive Stabilization 6. Bone and Soft Tissue Reconstruction

4. Management of the InfectedWound1. Deep Cultures should beobtained in the OR2. Antibiotic Therapy should beheld prior to obtaining culturesunless patient septic3. ID Consult4. 6 weeks IV antibiotics

4. Management of the InfectedWound Consider Negative Pressure Therapy Decrease Dead Space Hardware Coverage

Treatment 1. Diagnosis of Wound Infection 2. Treatment – Initial Surgery for Fracture Site Infection 3. Implant Retention or Removal 4. Management of the Infected Wound 5.Wound Closure and DefinitiveStabilization 6. Bone and Soft Tissue Reconstruction

5. Wound Closure and DefinitiveStabilization Delayed Primary Closure Skin Grafting Secondary Intention Bone Healing with prolonged period of immobilization or stagedORIF

Treatment 1. Diagnosis of Wound Infection 2. Treatment – Initial Surgery for Fracture Site Infection 3. Implant Retention or Removal 4. Management of the Infected Wound 5. Wound Closure and Definitive Stabilization 6.Bone and Soft TissueReconstruction

6. Bone and Soft Tissue Reconstruction Stage procedure to remove hardware and obtain deep culturesprior to performing reconstruction Obtain stat gram stain immediately in OR prior to administeringprophylactic antibiotics Plan back up fixation as patient will likely have inadequate bonestock Pre-opPlan Advanced Imaging, BoneGraft, Bone Stim, Multiple Forms of Fixation

Treatment of Infected Hardware Race between fracture/osteotomy healing and infectionsuppression/wound healing1.Suppression of Acute Infectious Process2.Soft Tissue Coverage3.Fracture/Osteotomy Healing1.6 weeks of IV antibiotics followed by oral suppressive therapy2.If removal of hardware is a possibility, oral suppression can bediscontinued3. If secondary/staged procedure, take cultures at time of hardwareremoval

Operative Treatment Pearls Indications ANY active infectionTechnique Maintain Hardware if stability at risk with removal in acute phase ofinfection Low-pressure irrigation with normal saline (I use Cysto tubing) Thorough identification and debridement of infection Deep bone specimens for culture and biopsy

THANK YOU

exposed hardware: a review of indications for soft-tissue reconstruction and hardware preservation. Plast Reconstr Surg. 2009Apr;123(4):1256-63.-The following parameters were identified as important for the potential salvage of exposed hardware with soft-tissue coverage: -Stable Hardware-Time of Exposure less than 2 weeks-Control of Infection