Complications

1
Complications

• Infections - Acute

2
Acute Infection

• 2-4 closed fxs (normal host)
• 9-25 open fractures
• Timing generally delayed 2 to 6 weeks
• Usually a localized wound infection not
  osteomyelitis

All need a reasonable game plan
3
Diagnosis

• History drainage, swelling, night pain
• Appearance of wound
• Draining pus active
• Dry redness, swelling
• Low grade temperature
• Generalized malaise

4
Diagnostic Tests

• ESR/CRP
• Scans are a waste of time and money
• Culture of external drainage - WORTHLESS
• Culture of sinus tract maybe helpful
• Done sterilely and from depths of tract
• THE BEST IS Direct evidence
• Aspirate
• Open biopsy

5
Most Important

• Do not procrastinate
• If you think it is infected, you must rule it out

6
Timing of Care

• If not in the joint
• If not sick / septic
• Then NOT EMERGENT
• Schedule ASAP
• Withhold antibiotics

7
At Surgery

• Withhold pre-op antibiotics
• Open wound down to hardware
• Drain or debride and culture abscess / area
• Remove all dead cortical bone, soft tissue
• Check stability of implant
• If stable retain
• If unstable remove (possible external fixation)
• IF IM nail and pus in canal nail out, ream
• Close over drain, if possible, or VAC
• Start antibiotics - vancomycin IV
• Consult ID

8
Local Antibiotic Delivery

• PMMA Beads
• PMMA Rods
• Osteoset Beads dissolve or incorporate
• Mix with Vancomycin or tobramycin

PMMA obligates an additional surgery
9
Antibiotic therapy

• Typically, 6 weeks of IV antibiotics
• Often follow with PO suppression until fracture
  union
• Follow ESR and CRP

10
Hardware Removal

• After Fracture healed
• Expect bone to be able to handle physiologic
  loading without hardware
• Give the patient a choice
• Stop abx and follow ESR / CRP
• Stop abx and remove plate (and re-culture)
• Stop abx and observe, if flares remove implant

11
Cant remove hardware

• Two options
• Continue on long term suppression abx, if
  possible
• Stop abx and observe, treat if infection flares

12
Removal of Hardware

• Vanderbilt and Carolinas Medical Center
• Post ORIF patients with deep infections
• Debridement
• Pathogen specific abx (PICC) for 6 weeks
• Attempt to retain hardware, if stable

Obremsky, Scannell, SEFC OTA 2008
13
Infected Hardware - Acute

• 104 fractures
• 81 treated successfully w/o ROH
• 22/81 late ROH
• 18 required ROH and a staged reconstruction of
  the fracture
• 5 patients amputated for severe infection
• Mean Abx 6 weeks
• Plate smoking more likely to fail no ROH

14
Summary

• Usually localized wound abscess
• Needs aggressive local care
• Fixation retained as long as it is functional and
  intact
• Long term no need for suppressive antibiotics
• DO NOT PROCRASTINATE