Avoid removal of ankle fracture hardware to manage infection until after bone union

Treatment up to 10 weeks postop should include irrigation, debridement, cultures, and antibiotics.

Issue: October 2008

A retrospective study of infected operatively treated ankle fractures has revealed that stable hardware should not be removed until after 3 months postoperative and after suppression of the infection with irrigation and debridement.

“It would be helpful to have a multidisciplinary approach with an orthopedic surgeon and an infectious disease specialist. This would really help take care of these patients,” lead investigator Charalampos G. Zalavras, MD, said.

The study, conducted at the Los Angeles County and University of Southern California Medical Centers consisted of patients treated for infection following operative management of ankle fractures between 2000 and 2004 and included 20 men and six women at a mean age of 43 years.

Zalavras presented results at the recent Musculoskeletal Infection Society 18th Annual Open Scientific Meeting.

$Figure 1: This patient’s operatively treated ankle fracture became infected.$
This patient’s operatively treated ankle fracture became infected. Surgeons considered it healed at the time.

$Figure 2 : During the debridement, surgeons decided to remove the fracture fixation hardware$
During the debridement, surgeons decided to remove the fracture fixation hardware because they determined the ankle was already stable.

Images: Zalavras CG

Suppressing infection

“If someone presents early after fixation of the fracture and the hardware is not loose, we don’t remove the hardware because if we do that the fracture would fall apart,” he said (Figure 1).

The ideal situation he described involved suppressing infection with the first irrigation and debridement, which in this series was only attempted in patients presenting at up to 10 weeks postop. “Usually at about 3 months we go back with a second surgery and we remove the hardware and we perform a second irrigation and debridement,” Zalavras explained to Orthopedics Today.

28% recurrence rate

Twenty-one patients (81%) were compromised hosts and many presented with more than one risk factor for a poor host.

Investigators identified smoking and low albumin in 14 patients each. Five patients each presented with diabetes mellitus and intravenous drug abuse. At presentation 22 patients or 85% had wound drainage and four patients had soft tissue swelling (Figure 2).

Infection recurred in five patients or 28% of the 18 patients who completed a minimum 6-month follow-up. However, Zalavras said he felt treatment overall was relatively successful in this difficult-to-treat population.

“We had two patients [who] underwent the full treatment with irrigation and debridement and hardware removal and antibiotic therapy and the infection recurred,” which is about an 11% recurrence rate, Zalavras said.

Surgeons performed post-debridement flap coverage in three patients. One diabetic patient with cirrhosis was primarily treated with a below-knee amputation and two additional patients eventually needed an amputation.

Multiple cultures

Staphylococcus aureus and Staphylococcus epidermis, the most common pathogens identified in the study, were found in 17 and six patients, respectively. Zalavras recommended performing multiple cultures when possible and guiding antibiotic therapy based on the findings.

“I think our study is going to add useful information about the management of these infections,” he said.

A note from the editor
Look for the next installment of Infection Watch in the November issue. Craig J. Della Valle, MD, will discuss diagnosing infections.

For more information:

Charalampos G. Zalavras, MD, can be reached at University of Southern California (USC), Los Angeles County and USC Medical Center, Department of Orthopedic Surgery, 1200 N. State St., GNH 3900, Los Angeles, CA 90033; 323-226-7346; e-mail: zalavras@usc.edu. He has no direct financial interest in any products or companies mentioned in this article.

Reference:

Zalavras CG, Christensen T, Rigopoulos N, et al. Infection following operative management of ankle fractures. Presented at the 18th Annual Open Scientific Meeting of the Musculoskeletal Infection Society. Aug. 8-9, 2008. Lake Tahoe, Calif.