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Hardware removal benefits children with infection after posterior spinal fusion

Almost half of the patients who retained their hardware required a second irrigation and debridement.

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CHICAGO � Children who develop infection after posterior spinal fusion with instrumentation are nearly 50% more likely to retain the infection if hardware is not removed during the initial irrigation and debridement, said a surgeon speaking here.

In reaching her conclusions, Christine Ho, MD, of Dallas, and her colleagues evaluated 53 scoliosis patients who required surgical irrigation and debridement for infection after posterior spinal fusion and instrumentation. All were treated at Children�s Hospital of Los Angeles from 1995 to 2002.

�Of 43 patients who had retention of implants at first irrigation and debridement, 47% required a second irrigation and debridement, compared to only 20% of patients who had their implants removed,� Ho said at the American Academy of Orthopaedic Surgeons 73rd Annual Meeting.

While five of the 43 (12%) patients who had implants retained required a third irrigation and debridement, none of the patients who had initial implant removal underwent a third irrigation and debridement. Researchers ruled out pathogen, use of allograft and patient diagnoses as predictors for second irrigation and debridement, Ho said.

Idiopathic scoliosis

Patients underwent posterior spinal fusion for the following diagnoses: 21 patients (40%) with idiopathic scoliosis, 12 patients (23%) with cerebral palsy, three patients (6%) with spina bifida and one patient (2%) with congenital scoliosis. Seventeen patients (32%) were treated for various other diagnoses, including anoxic brain injury, polio, muscular dystrophy and dwarfism.

�We ... found that our idiopathic [scoliosis] patients did not clear infection any better than any of our other patients,� Ho said. In the 21 idiopathic scoliosis patients, eight (38%) required a second irrigation and debridement, while 14 of the 32 (44%) other diagnoses required a second irrigation and debridement � not a significant difference (P>.05).

Researchers separated the patients according to early or late infection. Early infected patients were those who presented with infections before the six-month postop mark, because surgeons generally consider the spine fused by this point, Ho said. They found slightly more patients with early debridement (59%), but all were equally divided among diagnoses.

Coagulase-negative staphylococcus was the most common pathogen for infection, Ho said. Researchers found this pathogen in 25 cultures (47%) � 14 early infections and 11 late.

Use of wound VAC

Surgeons at the Children�s Hospital of Los Angeles typically follow irrigation and debridement with primary closure over the drain. �It is up to the surgeon�s judgment as to whether the fusion is solid and the implants are removed or retained,� Ho said.

In some patients, surgeons successfully used a wound vacuum assisted closure (VAC) device. One of those patients, who also had Meckel-Gruber syndrome, developed an early infection at three weeks postop and essentially required eight irrigation and debridements with plastic surgeon assistance, Ho said.

Although the wound VAC successfully treated the patient�s wound, �her infections did not completely resolve until the implants were removed at 19 months after her initial posterior spinal fusion,� Ho said.

Researchers at Children�s Hospital of Los Angeles performed radiographic follow-up on 10 of the 53 patients to determine if correction is lost after implant removal.

Results showed: an average 9� loss of correction in the thoracic coronal plan; an average 3� loss in the lumbar coronal plane; an average 15� loss in the thoracic sagittal plane; and an average 8� loss in the lumbar sagittal plane, Ho said.

�Sixty percent of our patients had greater than 10� loss of correction in any plane,� Ho said. �We do realize that this is a small number of patients and that longer-term follow-up would be ideal.�

The hospital has developed a new protocol when treating these patients, effectively reducing the average infection rate to 0.7%, Ho said. Based on recommendations from Infectious Disease Service, surgeons now give patients vancomycin and ceftazidine preoperatively and perform jet lavage with detergent after decortication.

For more information:

• Ho C, Skaggs D, Weiss J, et al. Management of spinal wound complications in pediatric scoliosis patients. #412. Presented at the American Academy of Orthopaedic Surgeons 73rd Annual Meeting. March 22-26, 2006. Chicago.