Low success rate seen in treating acute post-ORIF infections with retained hardware

However, Investigator notes in some cases leaving plates and screws in may be unavoidable.

BOSTON — Treating infections while attempting to achieve fracture union with open reduction with internal fixation is possible, but the overall success rate may only be 69%, according to recent investigation.

"It is widely accepted that deep infections cannot be cured in the presence of hardware. However, removing the hardware complicates the management of acutely infected fractures," said Mark S. Vrahas, MD, of Massachusetts General Hospital, Brigham and Women's Hospital.

Orthopedic dogma says that fractures will heal in the presence of infections, as long as the hardware remains stable, he said here at the 23rd Annual Meeting of the Orthopaedic Trauma Association.

"Thus the orthopedic approach to manage acute deep infections is to reduce the bacterial load with irrigation and debridement and then to suppress the infection until the fracture heals. Although this view is widely held, there is little published evidence supporting its validity," Vrahas said.

To evaluate this approach, Vrahas and his colleagues identified 69 cases of patients who developed infections between 1 and 16 weeks after open reduction and internal fixation (ORIF) from a central trauma database. Data in the study included, age, gender, tobacco use, diabetes status, site of fracture, OTA classification of fracture, open grade, type of fixation, joint involved and organism.

Of the 69 cases, 47 (69%) had successful suppressive treatment with the hardware in place. "The only independent predictor of outcome was smoking," he said. Fractures that required hardware revision or removal were considered failures.

Of the 47 who were treated successfully, 19 went on to have the hardware removed for various reasons. Of the group who retained their hardware, 10 developed recurrent infections and eventually required hardware removal, bringing the success rate even lower. In the group who had the hardware removed after union, three also developed recurrent infections.

"The success rate of 42% using the orthopedic dogma is not as good as we would like. Maybe it is time to consider alternatives," Vrahas said.

These results are very similar to what is reported for debridement with retention of prosthesis in the total joint literature, where the current standard is a two-stage revision. "However it is a much more difficult situation for us as trauma surgeons," he said. "Removing the hardware would significantly destabilize the fracture."

Based on this work, Vrahas said in his own practice, if the fracture is around the joint and the hardware cannot be removed, he continues with the standard approach. "However if there is an opportunity to remove the hardware and sterilize the wound before continuing fixation, I will do that," he said.

For more information:
Vrahas MS, Rightmire E, Zurakowski D. Managing acute infections after ORIF with hardware in place. Paper #18. Presented at the 23rd Annual Meeting of the Orthopaedic Trauma Association. Oct. 17-20. Boston.