Review Question - QID 3809

The patient is presenting with an acute deep infection following open reduction and internal fixation of an unstable ankle fracture. Recent studies have shown that a protocol of early aggressive surgical debridement, maintenance of internal fixation and culture specific antibiotics can be effective at achieving fracture healing.

Management of early postoperative infection following open reduction and internal fixation can be challenging. Effective treatment typically involves a combination of surgical debridement and culture specific antibiotics. Removing internal fixation prior to fracture healing can lead to additional insult to the soft tissue and ongoing inflammation secondary to fracture instability. Recently published protocols have shown effective treatment with maintenance of implants and culture specific antibiotics following early, aggressive surgical debridement.

Berkes et al. performed a multi-center retrospective study of 121 patients with acute postoperative infection (defined as less than 6 weeks from surgery) following internal fracture fixation. The authors demonstrated a 71% rate of success (defined by maintenance of implants until fracture healing) with a protocol of debridement and suppression with culture specific antibiotics. Risk factors for failure of this technique include open fractures and the use of an intramedullary nail for fracture fixation.

Figures A and B show an ankle status post open reduction and internal fixation of a lateral malleolus fracture. There are no signs of loosening of fixation or cortical erosions concerning for osteomyelitis.

Illustrations A and B are weight bearing X-rays that demonstrate the same fracture, now healed, after debridement and culture specific antibiotics. Illustrations C and D demonstrate the same fracture after elective removal of implants at 10 months following the index procedure. Intraoperative cultures at the time of hardware removal were negative for recurrent infection.

Incorrect answers:
Answers 1 and 2: Broad spectrum antibiotics without surgical debridement would not be effective in dealing with the infection in this clinical scenario with purulence tracking to the level of the plate
Answer 3: Surgical debridement and antibiotics would control the infection adequately, however removal of fracture fixation in an unstable fracture would lead to instability, soft tissue inflammation and likely malunion or nonunion that would require complex revision
Answer 5: Although culture specific antibiotics are an improvement over broad spectrum, again surgical debridement in conjunction with antibiotics is the most appropriate choice in this scenario. Intraoperative deep cultures in a sterile environment are preferred over cultures obtained in the office.