ABSTRACT
Objective:To investigate the efficacy of internal fixation maintenance after fracture-related infection (FRI).Methods:Retrospectively analyzed were the data of 81 patients with deep FRI after 6 weeks of internal fixation who had been treated with hardware maintenance at Department of Orthopedics, The Second Hospital Affiliated to School of Medicine, Zhejiang University between 2013 and 2021. They were 61 males and 20 females, aged from 11 to 73 years (average, 11 years). After admission, the patients received bacterial culture, thorough debridement, negative pressure suction, soft tissue repair, and local and intravenous antibiotics. If a joint was affected by FRI, its cavity was cleaned and drained. Infection control and fracture healing were regularly observed in all patients. A treatment was considered successful when the internal fixation was maintained until fracture union, and considered as unsuccessful when the internal fixation was removed before fracture union. Risk factors associated with treatment failure were identified from gender, age, smoking, diabetes, fracture type, methicillin-resistant Staphylococcus aureus (MRSA) infection, methicillin-susceptible staphylococcus (MSSA) infection, Pseudomonas aeruginosa infection, Escherichia coli infection, infection by two kinds of bacteria, negative bacterial culture, early infection (within 2 weeks) and local use of antibiotics.Results:All patients were followed up for an average of 30 months (from 6 to 84 months). Fracture union was achieved in 62 (76.5%) patients with infection control and internal fixation retained. Masquelet technique was used to treat bone defects in 2 patients; a muscle flap or skin flap was used to reconstruct soft tissue coverage in 11 cases; fracture union was achieved by antibiotics and dressing changes in 2 patients with sinus tract. Amputation was performed in one unsuccessful case due to uncontrollable infection, and internal fixation was changed to external fixation in the other 18 unsuccessful cases, of which 3 achieved final bone union after application of Masquelet technique, 7 achieved final bone union after application of bone transfer technique, and 3 achieved soft tissue coverage after reconstruction with flap technique. Pseudomonas aeruginosa infection, open fractures and FRI for more than 2 weeks were high risk factors for failure in internal fixation maintenance ( P<0.05). Conclusions:If internal fixation is still stable and effective, hardware maintenance should be tried first in the patients with FRI within 6 weeks after fracture internal fixation. Muscle flap or skin flap surgery should be performed as soon as possible to effectively control infection and promote fracture union in the patients with soft tissue defects after thorough and effective debridement. History of open fracture, Pseudomonas aeruginosa infection, and FRI for over 2 weeks may be risk factors for failure in internal fixation maintenance.
ABSTRACT
Objective To investigate the treatment options for early and delayed postoperative infection of tibial plateau fracture.Methods A retrospective case series study was conducted to analyze 21 patients with postoperative infection of tibial plateau fracture admitted to the Second Affiliated Hospital of Medical College of Zhejiang University from February 2013 to February 2017.There were 16 males and five females,aged 28-68 years,with an average age of 51.9 years.Infection control was achieved in all patients through debridement and local application of antibiotic calcium sulfate or bone cement in all patients and gastrocnemius muscle flap transfer was conducted if necessary.The implants were retained in the 12 patients with early infection through thorough debridement and antibiotic therapy.Of all the nine patients with delayed infection,the implant of one patient was removed after local wound dressing until fracture union and the following debridement closure was performed;two patients with severe damage of knee joint had no chance of reconstruction,with one patient treated with lower femoral amputation and another with replacement of plate by external fixator at stage Ⅰ and arthrodesis at stage Ⅱ.The implants were replaced by external fixator followed by debridement and antibiotic therapy in the remaining six patients with delayed infection,among which stage Ⅱ hone grafting was performed in three patients with bone defect.Infection,bone healing and knee function score of Hospital for Special Surgery (HSS) were evaluated in all patients at regular intervals.Results All patients were followed up for 18-60 months,with an average of 37.4 months.All patients were treated with antibiotic calcium sulfate or bone cement to control infection.Ten patients with infection underwent gastrocnemius muscle flap transfer,and the wounds were healed well with no recurrence of fracture and infection.The implants of 12 patients with early infection were successfully retained,and the fractures were healed.According to HSS scoring criteria,the knee joint function results were excellent in seven patients,good in three,and moderate in two,with an overall excellent and good rate of 83％ (10/12).Infection was controlled in nine patients with delayed infection,and fractures or bone defects were healed in seven patients with delayed infection except patients receiving amputation and joint fusion.According to HSS scoring criteria,knee joint function results were excellent in one patient,good in three,moderate in two and poor in one,with an excellent and good rate of 57％ (4/7).Conclusions Patients with early postoperative infection of tibial plateau fracture may attempt to retain the implants through early debridement and antibiotic therapy.For patients with delayed infection,although implants may also be retained in stable cases with ongoing fracture healing,removal of implants instead by external fixator is recommended and infection can mostly be controlled by debridement and antibiotic therapy.Meanwhile,gastrocnemius muscle flap transfer and antibiotic calcium sulfate or bone cement contributing to the control of infection can achieve good clinical results.