Effect of a standardized treatment regime for infection after osteosynthesis

Abstract

Background: Infection after osteosynthesis is an important complication with significant morbidity and even mortality. These infections are often caused by biofilm-producing bacteria. Treatment algorithms dictate an aggressive approach with surgical debridement and antibiotic treatment. The aim of this study is to analyze the effect of such an aggressive standardized treatment regime with implant retention for acute, existing <3 weeks, infection after osteosynthesis.

Methods: We conducted a retrospective 2-year cohort in a single, level 1 trauma center on infection occurring within 12 months following any osteosynthesis surgery. The standardized treatment regime consisted of implant retention, thorough surgical debridement, and immediate antibiotic combination therapy with rifampicin. The primary outcome was success. Success was defined as consolidation of the fracture and resolved symptoms of infection. Culture and susceptibility testing were performed to identify bacteria and resistance patterns. Univariate analysis was conducted on patient-related factors in association with primary success and antibiotic resistance.

Results: Forty-nine patients were included for analysis. The primary success rate was 63% and overall success rate 88%. Factors negatively associated with primary success were the following: Gustilo classification (P = 0.023), higher number of debridements needed (P = 0.015), inability of primary closure (P = 0.017), and subsequent application of vacuum therapy (P = 0.030). Adherence to the treatment regime was positively related to primary success (P = 0.034).

Conclusions: The described treatment protocol results in high success rates, comparable with success rates achieved in staged exchange in prosthetic joint infection treatment.

Keywords: Fracture; Infection; ORIF; Osteomyelitis; Osteosynthesis; Treatment.

Fig. 1

A flow scheme of the standardized treatment regime as executed in our hospital

Fig. 2

Patient identification and inclusion

Fig. 3

Example of an infection after intramedullary osteosynthesis for a tibial shaft fracture (AO42-C2). 1 At presentation at the emergency department. 2 After nailing, the fracture was accompanied by a compartment syndrome treated with fasciotomy. 3 Patient presented on the emergency department with redness, swelling, and elevated CRP and leukocytes 7 months after initial osteosynthesis. The patient was admitted, and a thorough surgical debridement was performed immediately, the nail was left in situ. Intraoperative tissue cultures were obtained, and empirical antibiotic combination therapy was started. 4 Six months later, the fracture showed bridging of three cortices on X-ray and all signs and symptoms of infection were diminished. The patient visited the outpatient clinic 2 years later for an unrelated issue. The leg was entirely healed without pain with full weight bearing and full range of motion. The nail was never removed