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Updated: May 16 2022

Wound & Hardware Infection

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  • summary
    • Wound & Hardware Infection is the most common complication following orthopedic trauma surgery and is a significant source of patient morbidity.
    • Diagnosis can be made clinically with the presence of incisional erythema, dehiscence, purulent drainage and/or persistent fracture nonunion or hardware loosening on radiographs  Intraoperative deep cultures are the most reliable method to isolate causative organisms
    • Treatment is usually surgical irrigation and debridement followed by culture-directed antibiotics.  Hardware removal may be performed acutely or in a delayed fashion depending on fracture healing.
  • Epidemiology
    • Incidence
      • up to 16% infection rate following traumatic fracture
    • Risk factors
      • host immunodeficiency
      • extremes of age
      • diabetes
      • obesity
      • alcohol or tobacco abuse
      • steroid use
      • malnutrition
      • medications
      • previous radiation
      • vascular insufficiency
  • Etiology
    • Pathophysiology
      • mechanisms
        • seeding
          • disruption of soft tissue envelope, blood vessels, and periosteum allow bacteria to avoid host defenses
          • direct seeding of implant and/or anatomical structure
          • hematogenous seeding
        • biofilm formation
          • dependent on exopolysaccharide glycocalyx
  • Presentation
    • History
      • history of trauma must be detailed
        • extent of soft tissue injury
        • extent of bony injury
        • previous or current hardware
        • previous or current surgery at the same site
        • history of previous skin or deep infections
    • Symptoms
      • pain at previous fracture site
        • may indicate infected non-union
      • fevers, chills, and night sweats may be present
    • Physical exam
      • inspection
        • erythema, drainage, or purulence
        • tenderness
      • motion
        • gross motion at fracture site is suggestive of non-union
  • Imaging
    • Radiographs
      • recommended views
        • biplanar images of afflicted area
        • 45 degree orthogonal views can also be obtained to evaluate for union
      • findings
        • acute infection
          • radiographs may be normal
        • sub-acute and chronic infections
          • peri-implant lucency can be seen
          • involucrum
            • reactive bone surrounding active infection
          • sequestrum
            • retained nidus of infected necrotic bone
    • CT
      • indications
        • pre-operative planning
    • MRI
      • indications
        • useful adjunct for diagnosis and delineating extent of disease
        • to assess soft-tissue masses and fluid collections
      • sensitivity and specificity
        • 98% sensitive
        • 78% specific
    • WBC-labeled scans
      • can help determine infection from other similar appearing etiologies
      • helpful to detect bony infection in the setting of hardware
        • hardware can cause metal artifact in an MRI making it difficult to assess for infection
  • Studies
    • Labs
      • WBC
        • may be normal in chronic or indolent infections
      • erythrocyte sedimentation rate (ESR)
        • may remain elevated for months following initial injury or surgery in absence of infection
      • C-reactive protein (CRP)
        • most predictive for postoperative infection in the first week after fracture fixation
        • should decrease from a plateau after postoperative day 2 (after fixation of fractures)
          • 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
  • Treatment
    • Nonoperative
      • chronic suppression with antibiotics
        • indications
          • risk of surgical treatment outweighs the benefit to the host
            • immunosuppressed, elderly, etc.
          • presence of an infected but incompletely healed fracture following internal fixation
        • technique
          • ESR and CRP levels used to assess adequacy of treatment
        • outcomes
          • 32% rate of chronic infected nonunion persisting or worsening despite suppression
    • Operative
      • surgical debridement
        • indications
          • any active infection
        • technique
          • hardware should be maintained if stability at risk with removal
          • low-pressure irrigation with normal saline may be superior to other methods of irrigation
          • thorough identification and debridement of infection key to success
          • deep bony specimens should be obtained for culture as well as biopsy
        • outcomes
          • 71% success seen with debridement and antibiotics for early acute postoperative infection
            • Risk factors for failure include intramedullary nail and open fracture
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