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A novel technique for the treatment of infected metalwork in orthopaedic patients using skin closure over irrigated negative pressure wound therapy dressings

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There has been recent interest in the use of negative pressure wound therapy (NWPT) as an adjunct to parenteral antibiotics in the treatment of infection in orthopaedic patients with metalwork in situ. To address some of the limitations of standard NPWT in this situation, the senior author has developed a modified method of treatment for infected metalwork (excluding arthroplasty) in orthopaedic patients that includes irrigation and skin closure over the standard NPWT dressing. This retrospective study examined the outcome of a case series of 16 trauma and orthopaedic patients with deep infection involving metalwork in whom this modified form of NPWT was used. In conjunction with standard parenteral antibi- otic therapy and a multidisciplinary approach, this modified technique included serial debridements in theatre, irrigation and negative pressure dressings over a white polyvinyl alcohol foam (KCI, Kidlington, UK) as well as closure of the skin over the foam. Among the 16 patients, there was a variety of upper and lower limb as well as spinal trauma and elective cases. In all 16 patients, there was successful resolution of the infection with no early or unplanned removal of any metalwork required. Patients with infected metalwork are a heterogeneous group, and often suffer high morbidity and mortality. The modified NPWT technique shows potential as an adjunct in the treatment of complex orthopaedic patients with infected metalwork.
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118 Ann R Coll Surg Engl 2013; 95: 118–124
ORTHOPAEDIC
Ann R Coll Surg Engl 2013; 95: 118–124
doi 10.1308/003588413X13511609957254
KEYWORDS
Vacuum-assisted closure – Negative pressure wound therapy – Infected orthopaedic metalwork
Accepted 17 October 2012
CORRESPONDENCE TO
Rory Norris, 22 The Peacocks, Longbridge, Warwick CV34 6BS, UK
E: rory_norris@yahoo.co.uk
A novel technique for the treatment of infected
metalwork in orthopaedic patients using skin
closure over irrigated negative pressure wound
therapy dressings
R Norris, AWP Chapman, S Krikler, M Krkovic
University Hospitals Coventry and Warwickshire NHS Trust, UK
ABSTRACT
INTRODUCTION There has been recent interest in the use of negative pressure wound therapy (NWPT) as an adjunct to
parenteral antibiotics in the treatment of infection in orthopaedic patients with metalwork in situ. To address some of the
limitations of standard NPWT in this situation, the senior author has developed a modified method of treatment for infected
metalwork (excluding arthroplasty) in orthopaedic patients that includes irrigation and skin closure over the standard NPWT
dressing.
METHODS This retrospective study examined the outcome of a case series of 16 trauma and orthopaedic patients with deep
infection involving metalwork in whom this modified form of NPWT was used. In conjunction with standard parenteral antibi-
otic therapy and a multidisciplinary approach, this modified technique included serial debridements in theatre, irrigation and
negative pressure dressings over a white polyvinyl alcohol foam (KCI, Kidlington, UK) as well as closure of the skin over the
foam.
RESULTS Among the 16 patients, there was a variety of upper and lower limb as well as spinal trauma and elective cases. In
all 16 patients, there was successful resolution of the infection with no early or unplanned removal of any metalwork required.
CONCLUSIONS Patients with infected metalwork are a heterogeneous group, and often suffer high morbidity and mortality.
The modified NPWT technique shows potential as an adjunct in the treatment of complex orthopaedic patients with infected
metalwork.
Despite many prophylactic measures, infection of the im-
plant occurs in 1–12% of orthopaedic patients operated on
for arthroplasty or osteosynthesis.1 Patients with infected
metal implants suffer signicant morbidity and mortality,
and treatment of infection in relation to metalwork is usu-
ally a prolonged and expensive process, with signicant im-
pact on a patient’s quality of life and health. There may be
many contributing factors to the development and persist-
ence of infection, eg medical co-morbidity, host immuno-
suppression, poor tissue viability and the type of metalwork
involved. At present, there is no gold standard agreed for
treatment of these patients and, in our unit, these patients
are generally managed by a multidisciplinary team (MDT)
approach including orthopaedic surgeons and microbiol-
ogists.
More recently, negative pressure wound therapy (NPWT)
dressings have been used to allow retention of the metal-
work while still curing the infection. This therapy is not a
substitute for established practice but should be seen as an
adjunct and may provide a valuable alternative when reten-
tion of the metalwork is desired. The standard principles of
an MDT approach, debridement, irrigation and microbiol-
ogy sampling prior to commencing antibiotic treatment are
still essential in the treatment of these cases.
NPWT dressings are a form of NPWT and consist of three
main components. A specialised foam dressing is placed
into the wound and sealed with adhesive dressings. A tube
is attached that connects to a pump, which then provides
continuous or intermittent negative pressure, and allows
monitoring and regulation of the pressure inside the wound.
NPWT dressings are reported to promote wound healing by
reducing oedema and toxins, reducing the bacterial load,
stimulating angiogenesis and bringing the wound edges
closer together.2
VAC Instill® (KCI, Kidlington, UK) refers to conventional
NPWT combined with a continuous perfusion or irriga-
2829 Norris.indd 118 05/02/2013 15:23:50
119Ann R Coll Surg Engl 2013; 95: 118–124
NORRIS CHAPMAN KRIKLER KRKOVIC A NOVEL TECHNIQUE FOR THE TREATMENT OF INFECTED
METALWORK IN ORTHOPAEDIC PATIENTS USING SKIN CLOSURE
OVER IRRIGATED NEGATIVE PRESSURE WOUND THERAPY
DRESSINGS
A NOVEL TECHNIQUE FOR THE TREATMENT OF INFECTED
METALWORK IN ORTHOPAEDIC PATIENTS USING SKIN CLOSURE
OVER IRRIGATED NEGATIVE PRESSURE WOUND THERAPY
DRESSINGS
tion system and has been shown to be effective in treating
wounds with very high bacterial burdens.3 The VAC Instill®
option offers the possibility of regular cleansing of foam
sponges (which prolong their life and therefore reduce the
required frequency of dressing changes) and enables con-
tinuous irrigation of the wound with uid, which may help
to decrease the overall bacterial load. The major disadvan-
tage of VAC Instill® in the context of infected metalwork is
that the exposed metalwork is only covered by the NPWT
sponge and transparent adhesive dressings, and may be
prone to leaking, loss of pressure or secondary infection if
the seal is not maintained.
In an attempt to overcome these difculties, we changed
our working practice with regard to the use of NPWT dress-
ings in patients with infected metalwork. The senior author
(MK) has developed a modied method of NPWT for pa-
tients with infected metalwork using a combination of the
irrigation NPWT and wound closure to allow the metalwork
to remain in situ while the infection is being treated.
The advantages of this are that direct wound closure
over the NPWT dressing creates the most effective barrier
to infection, and prevents skin contracture and heat loss in
large wounds. This method also allows continuous irriga-
tion, which has been found to be advantageous in the VAC
Instill® regime.3 Furthermore, this technique deals with the
signicant problem of leakage with the irrigation treatment
and the loss of vacuum as well as maintaining wound and
metalwork sterility with it only being exposed during wound
debridement in the operating theatre.
Methods
A retrospective review was carried out on all patients treated
by a single orthopaedic consultant with the modied NPWT
as part of their surgical treatment for infection between
2008 and 2010. As the aim of this study was to review the
use of the modied technique in patients with metal work
in situ only, patients were excluded from review if there was
no metalwork in situ, if it was removed prior to the NPWT
commencing or if they had an arthroplasty or hemiarthro-
plasty (as different treatment protocols exist in patients who
have undergone arthroplasty-type procedures). Patients
were also excluded if they did not tolerate the NPWT, if they
were transferred to another hospital during treatment or if
they were not t enough to complete the treatment.
All patients were also treated with antibiotics targeted
to their infective organism, from samples taken during the
rst debridement. There was no standardised antibiotic for-
mulary due to the heterogenic nature of the patients and
each patient’s antibiotic regimen was decided based on
microbiologist advice.
The patients’ electronic and paper medical records
were reviewed. The data collected included information
on the type of metal implant involved, whether the infec-
tion occurred early in the postoperative course (<6 weeks
postoperatively) or late (>6 weeks), the demographics of
the patients, the microbiology involved and whether they
were elective or trauma patients. The primary endpoint was
whether the patient retained his or her metal implant with
resolution of the infection. The infection was considered re-
solved if there were no clinical signs of infection and infec-
tion parameters were normal, including C-reactive protein
(CRP), erythrocyte sedimentation rate (ESR) and white cell
count (WCC). As per standard practice in patients with in-
fected metalwork, the patients in this case series underwent
routine examination and investigations including blood pa-
rameters for infection (CRP, ESR, WCC and blood cultures)
as well as any appropriate imaging.
All patients went to the operating theatre for an initial
thorough and complete debridement of the infected tissue
under general anaesthesia (GA), leaving the metalwork in
situ. Tissue and uid samples are also taken at this time for
microbiological analysis. The VAC® system was used for this
study. The VAC® dressing was then applied to the wound in
the standard fashion directly onto the metalwork and tissue
without any lining but, for this modied technique, a small
pore non-adherent white polyvinyl alcohol foam (KCI, Kid-
lington, UK) was substituted for the wide pore black poly-
urethane foam (GranuFoam™; KCI, Kidlington, UK). The
hydrophilic white polyvinyl alcohol foam is advantageous as
the bacterial load counts are known to be lower than with
the black polyurethane foam and the foam can therefore
be left in for longer periods of time, which decreases the
number of visits to the operating theatre.
In addition to the white foam, two Redivac drains (Bi-
omet, Bridgend, UK) were led out through the skin with the
help of a trocar (Fig 1). A sterile trocar from the Redivac
Figure 1 Negative pressure wound therapy irrigation
arrangement
With/without
antibiotics
Ringer’s solution
NaCl – saline
VAC® system
Wall vacuum
Redivac system
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120 Ann R Coll Surg Engl 2013; 95: 118–124
NORRIS CHAPMAN KRIKLER KRKOVIC A NOVEL TECHNIQUE FOR THE TREATMENT OF INFECTED
METALWORK IN ORTHOPAEDIC PATIENTS USING SKIN CLOSURE
OVER IRRIGATED NEGATIVE PRESSURE WOUND THERAPY
DRESSINGS
drain works well for this purpose, and we prefer this tech-
nique to a skin incision for the insertion of the drain as this
leads to leakage and loss of vacuum. One drain was attached
to the vacuum source (theatre suction system) at 125mmHg
and the other to a bag of normal saline to provide irrigation.
Normal saline is the uid of choice for irrigation. Ringer’s
lactate or glucose solutions should be avoided to prevent
bacterial overgrowth. Irrigation and suction were applied
as soon as possible after the foam was placed in situ into
the wound to prevent formation of blood clots on the foam.
The wound was closed in layers (over the VAC® foam)
with interrupted absorbable synthetic braided sutures to the
deeper fascial layers and subcutaneous tissue, and a contin-
uous synthetic non-absorbable nylon suture for the skin (Fig
2). If the subcutaneous tissue was also infected, a separate
piece of foam was applied to this layer. After wound closure,
the suction drain was attached to a VAC® machine (or wall
suction) on the continuous setting. The uid was set to run
in at a rate of 2l every 24 hours, which provided continual
cleansing to the wound and foam as shown in Figure 1.
The VAC® dressing was left in situ for approximate-
ly 6–8 days. The patient was then taken back to the
operating theatre under GA for a second debridement and
change of the dressing. At this stage, it was possible to
distinguish clearly between vital (covered with granula-
tion tissue) and necrotic tissue (Fig 3). The VAC® dressing
was reapplied as described above but the sponges were
slightly undersized to accommodate for wound shrinkage
as the infection is treated and the tissues heal. This process
was repeated every 6–8 days until the wound looked clean,
with no necrotic tissue, and the infection parameters had
normalised.
Once the resolution of infection was achieved, the VAC®
dressing was removed completely under GA, including all
sponge debris, and the wound was closed in a standard fash-
ion with a Redivac drain left in situ for 72 hours, which was
later removed on the ward. Most patients required three vis-
its to theatre under GA: one for the initial debridement, one
for a second debridement and smaller foam insertion, and
a third for closure.
Figure 2 Fascial and skin closure over the negative pressure wound therapy dressing
Figure 3 Difference between the initial debridement (left) and the second look (right)
2829 Norris.indd 120 05/02/2013 15:23:51
121Ann R Coll Surg Engl 2013; 95: 118–124
NORRIS CHAPMAN KRIKLER KRKOVIC A NOVEL TECHNIQUE FOR THE TREATMENT OF INFECTED
METALWORK IN ORTHOPAEDIC PATIENTS USING SKIN CLOSURE
OVER IRRIGATED NEGATIVE PRESSURE WOUND THERAPY
DRESSINGS
Results
The 60 patients who underwent this modied NPWT in our
department during the study period for any reason were
recorded. The reasons for the therapy are shown in Table
1. Of these patients, a subgroup of 16 (9 male, 7 female)
had NPWT in the presence of infected metalwork. Of this
Table 2 Spinal group results
Patient
number
Patient age Early or late
infection
Procedure Time after
first washout
that NPWT
was applied
Duration of
NPWT
Number
of NPWT
changes
Long-term outcome
1 17 years Late Corrective surgery for
severe scoliosis
0 days 21 days 3 Metalwork retained,
no infection
2 46 years Early Instrumented lumbar
spine fusion
0 days 14 days 2 Metalwork retained,
no infection
3 43 years Early Instrumented lumbar
spine fusion
0 days 14 days 2 Metalwork retained,
no infection
4 41 years Early Instrumented anterior
lumbar spine fusion
0 days 15 days 2 Metalwork retained,
no infection
5 72 years Early Instrumented lumbar
spine fusion
0 days 14 days 2 Metalwork retained,
no infection
NPWT = negative pressure wound therapy
Table 3 Upper limb group results
Patient
number
Patient age Early or late
infection
Procedure Time after first
washout that NPWT
was applied
Duration
of NPWT
Number
of NPWT
changes
Long-term outcome
6 28 years Early Open shoulder stabili-
sation (Latarjet)
12 days 15 days 2 Metalwork retained, no
infection
7 64 years Early Proximal humeral nail 0 days 28 days 4 Metalwork retained, no
infection, fracture union
8 65 years Early ORIF proximal hu-
merus (PHILOS plate)
4 days 14 days 2 Metalwork retained, no
infection, fracture union
9 39 years Early ORIF greater tuberosity 0 days 15 days 2 Metalwork retained, no
infection, fracture union
10 24 years Early Hook plate for ACJ
disruption
2 days 12 days 2 Metalwork retained, no
infection (has since had
plate removed; routine
for type of implant)
NPWT = negative pressure wound therapy; ORIF = ORIF = open reduction internal fixation; PHILOS = Proximal Humeral Interlocking
System; ACJ = acromioclavicular joint
Table 1 All patients undergoing negative pressure wound therapy (NPWT)
Reason for therapy Number of patients
Infections with metalwork in situ 16
Open fractures with tissue loss but no infection 11
Soft tissue cases with no metalwork involved, most of which had no infection present (compartment syndrome,
septic arthritis of the shoulder, muscle repair, spinal decompression)
10
Metalwork removed prior to the use of NPWT 10
Infected arthroplasty/hemiarthroplasty 9
Died of an unrelated cause before completion of treatment 2
Transferred to another hospital during treatment 1
Did not tolerate NPWT 1
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122 Ann R Coll Surg Engl 2013; 95: 118–124
NORRIS CHAPMAN KRIKLER KRKOVIC A NOVEL TECHNIQUE FOR THE TREATMENT OF INFECTED
METALWORK IN ORTHOPAEDIC PATIENTS USING SKIN CLOSURE
OVER IRRIGATED NEGATIVE PRESSURE WOUND THERAPY
DRESSINGS
Table 4 Lower limb group results
Patient
number
Patient age Early or late
infection
Procedure Time after first
washout that NPWT
was applied
Duration of
NPWT
Number
of NPWT
changes
Long-term outcome
11 19 years Early Infection after
tibial plateau
fracture fixation
0 days 36 days 5 Metalwork retained, no
infection, fracture union
12 50 years Early Total hip replace-
ment peripros-
thetic fracture
ORIF
3 days 27 days 4 Metalwork retained, no
infection, fracture union
13 45 years Early Abscess after
ankle fusion
0 days 15 days 2 Metalwork retained,
no infection, metalwork
removed electively 3
months after union
14 61 years Late Wound break-
down after ankle
ORIF
2 days 39 days 5 Metalwork retained,
no infection, fracture
union
15 32 years Late Abscess 2
months into
treatment of open
fracture with ex-
ternal fixation as
definitive fixation
0 days 33 days 4 Treated with external
fixation, no infection,
fracture union
16 22 years Early Infection after
tibial ORIF
0 days 14 days 2 Metalwork retained,
no infection, fracture
union, plate removed
electively at a later date
NPWT = negative pressure wound therapy; ORIF = open reduction internal fixation
subgroup, the mean patient age was 42 years (range: 17–72
years). There were ten trauma and six elective patients.
Thirteen of the infections were of early onset and three
were of late onset. There were ve spinal cases, ve up-
per limb cases and six lower limb cases. Patients required a
mean of 2.8 visits (mode: 2) to theatre to have the dressing
changed or removed after the initial debridement. Each of
the 16 patients retained his or her implant with complete
resolution of the infection. The exact details of each group
are shown in Tables 2 to 4.
The most common infective organisms were Staphyloco-
ccus aureus, coliforms and Enterococcus spp. Overall, there
were 9 different infective organisms in the 16 patients. Each
patient’s antibiotic regimen was tailored to his or her spe-
cic requirements based on the microbiologists’ advice. Full
details of the infective organisms and the antibiotics used
are shown in Tables 5 and 6.
Discussion
The management of implant-related infection is a contro-
versial topic. The conventional method of treating these
infections is serial surgical debridements, culture specic
antibiotic treatment and removal of the implants. There is
a distinction made between early (<8 weeks) and late onset
infections (>8 weeks), with many advocating retention of
the implants in early cases but removal in late cases.4 Treat-
ment of infection in implants used for fracture stabilisation
is further complicated by the fact that skeletal stability will
be lost if implants are removed prior to fracture union.5
Berkes et al have shown a 71% fracture union rate follow-
ing early postoperative wound infection using the standard
techniques described above and implant retention.5
The infective organism is important, with different cure
rates expected for different organisms. S aureus is more
virulent than most and will often present acutely whereas
coagulase-negative Staphylococcus often presents later with
a more indolent clinical presentation.6 Similar to the litera-
ture, our series showed nine different infective organisms
with the most common being S aureus.
The antibiotics used in the treatment of implant-related
infection have been studied extensively over many years.
The main target for these studies has been S aureus owing
to it being the most common infective organism although
the most important factor when deciding on the choice of
antibiotics is the microbiological cultures. Rifampicin has
been shown to be one of the most effective antibiotics, espe-
cially when used in combination with daptomycin.7
Biolm formation is an important consideration with
any infected implant. Biolms are characterised by micro-
colonies of bacteria encased in a protective extracellular
polymeric matrix. They can develop on any abiotic device
2829 Norris.indd 122 05/02/2013 15:23:51
123Ann R Coll Surg Engl 2013; 95: 118–124
NORRIS CHAPMAN KRIKLER KRKOVIC A NOVEL TECHNIQUE FOR THE TREATMENT OF INFECTED
METALWORK IN ORTHOPAEDIC PATIENTS USING SKIN CLOSURE
OVER IRRIGATED NEGATIVE PRESSURE WOUND THERAPY
DRESSINGS
implanted into a living organism. Given that one of the most
common types of device implanted is a joint arthroplasty,
most of the research has been carried out in orthopaedics.
Currently, there is no widely accepted treatment for biolms
other than removal of the infected implant.8,9
Much of the known orthopaedic experience of NPWT
dressings has been with their use in children who develop a
deep spinal infection following spinal fusion and instrumen-
tation.10–12 Most of these operations were carried out in chil-
dren who had cerebral palsy, spina bida or neuromuscular
scoliosis. Removal of the metalwork in these children would
be associated with signicant complications, and many nov-
el techniques have therefore been tried in this specialised
subset of patients to try and cure the infection while still
retaining the implants. Using VAC® therapy, Canavese and
Krajbich report that they were able to retain the metalwork
in 32/33 patients, and cure the infection in 30/33 patients12
while van Rhee et al stated there were no signs of chron-
ic infection in 6/6 neuromuscular scoliosis patients using
VAC® therapy and retaining the metalwork.11
A few other studies have looked at NPWT in infection as-
sociated with arthroplasties and a variety of other orthopae-
Table 6 Detailed microbiology of infections
Patient number Causative organism Antibiotics used (length of course)
1 Coagulase-negative Staphylococcus
and Enterococcus spp
Meropenem and vancomycin (4 weeks), then metronidazole (4 weeks)
2Staphylococcus aureus Rifampicin, metronidazole and clindamycin (2 weeks)
3S aureus Rifampicin and flucloxacillin (2 weeks), then doxycycline (6 weeks)
4S aureus Rifampicin and flucloxacillin (7 weeks)
5 Skin flora only Vancomycin and rifampicin (2 weeks), then flucloxacillin and fusidic acid (2
weeks)
6 Coliform Rifampicin and clindamycin (9 weeks)
7Proteus spp Flucloxacillin (3 weeks), then piperacillin/tazobactam (1 week), then vancomycin
and rifampicin (2 weeks)
8 Coagulase-negative Staphylococcus Flucloxacillin (10 weeks)
9S aureus Rifampicin and flucloxacillin (4 weeks)
10 MRSA Vancomycin, rifampicin, gentamicin, mupirocin and chlorhexidine (2 weeks),
then doxycycline and rifampicin (4 weeks)
11 Coliform Meropenem (2 weeks), then ertapenem (5 weeks)
12 Enterococcus spp Flucloxacillin, amoxicillin (10 weeks) and gentamicin (first 2 weeks only)
13 Coliform and Klebsiella pneumoniae Rifampicin and flucloxacillin (6 weeks)
14 S aureus and Group A Streptococcus Co-amoxiclav (2 weeks)
15 MRSA and Enterococcus spp Flucloxacillin and gentamicin (2 weeks), then clindamycin (2 weeks), mupirocin
and chlorhexidine (thoughout)
16 S aureus and Enterococcus spp Rifampicin, metronidazole and clindamycin (2 weeks)
Table 5 Microbiology summary of infections
Causative organism Organism incidence Antibiotics used
Staphylococcus aureus 6 Flucloxacillin, rifampicin, doxycycline, clindamycin and co-amoxiclav
Enterococcus spp 5 Flucloxacillin, gentamicin, clindamycin, metronidazole, vancomycin,
rifampicin and meropenem
Coliform 3 Flucloxacillin, rifampicin, clindamycin, doxycycline and meropenem
MRSA 2 Vancomycin, rifampicin, gentamicin, mupirocin and chlorhexidine
Coagulase-negative Staphylococcus 2 Flucloxacillin, meropenem, vancomycin and metronidazole
Proteus spp 1 Flucloxacillin, piperacillin/tazobactam,
vancomycin and rifampicin
Klebsiella pneumoniae 1 Flucloxacillin and rifampicin
Skin flora only 1 Vancomycin, rifampicin, flucloxacillin and fusidic acid
Group A Streptococcus 1 Co-amoxiclav
2829 Norris.indd 123 05/02/2013 15:23:51
124 Ann R Coll Surg Engl 2013; 95: 118–124
NORRIS CHAPMAN KRIKLER KRKOVIC A NOVEL TECHNIQUE FOR THE TREATMENT OF INFECTED
METALWORK IN ORTHOPAEDIC PATIENTS USING SKIN CLOSURE
OVER IRRIGATED NEGATIVE PRESSURE WOUND THERAPY
DRESSINGS
dic metal implants.12–14 One paper reported the use of VAC®
dressings in spinal cord injury patients who developed deep
wound infections following spinal instrumentation.14 The
authors had a 100% success rate in covering the metalwork
but had only used it on two patients. Another paper looked
more specically at early hip joint infections following ar-
throplasty.13 There was a resolution of the infection in 26/28
patients, with a mean duration of treatment of 9 days (range:
3–16 days) and a mean follow-up of 36 months. Lehner et al
reported on their experience of NPWT with instillation, and
showed a cure rate of >80% with retention of the implants
in both acute and chronic infections.15
Overall, these papers have shown an 80–100% success
rate in curing the infection while retaining the implant. Our
case series showed an overall success rate in curing the
infection and retaining the implant in 16/16 patients, who
survived to one year. This is similar to most of the other
published series on the subject.
The novel aspects of this modied method are the use
of the polyvinyl alcohol foam and irrigation under suction,
which prolongs the life of the foam and facilitates effec-
tive debridement of infected tissue at regular intervals un-
der GA. The method seems to improve blood supply to the
wound and makes it possible to distinguish easily between
vital (granulation) and non-vital tissue during debridement.
The wound size decreases from treatment to treatment and
skin closure helps to provide an effective barrier to further
infection as well as also minimising wound contracture,
which may otherwise necessitate further procedures such
as skin grafts or skin aps.
The main disadvantage of the treatment is the fact that
inpatient treatment may require a lengthy stay with contin-
uous irrigation and suction. The patient will require at least
three visits to theatre under GA, which may not be appro-
priate if the patient has signicant medical co-morbidities.
There is also the added cost of the NPWT equipment and
the nursing staff on the ward may require extra training on
NPWT. However, as described above, the treatment of in-
fected metalwork poses a signicant clinical challenge and
the modied technique provides an alternative adjunct for
successfully retaining metalwork in these complex patients.
There are some limitations with our study, which includ-
ed the small sample size, the short follow-up period of one
year and the heterogeneous range of conditions included in
the study.
Conclusions
Patients with infected metalwork are a heterogene-
ous group, and often suffer high morbidity and mortality.
NPWT has already shown potential in the treatment of
orthopaedic patients with infected metalwork, particular-
ly in extremity cases. This modied method provides an
adjunct to standard NPWT and may provide a valuable
option for the treatment of orthopaedic patients with infect-
ed metalwork.
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deformities for children with postoperative deep infections. Indian J Orthop
2010; 44: 177–183.
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of early hip joint infections. Int J Med Sci 2009; 6: 241–246.
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... The wound closure over the NPWT dressing has the benefits of preventing skin contracture and contributes to an infection barrier. This is a repeat study of Norris et al. (2013) [6] with the same technique as the original, carried out by the same surgeon. Variations of modified NPWT are common in the literature, but few are carefully repeated to assess the validity of their results. ...
... The wound closure over the NPWT dressing has the benefits of preventing skin contracture and contributes to an infection barrier. This is a repeat study of Norris et al. (2013) [6] with the same technique as the original, carried out by the same surgeon. Variations of modified NPWT are common in the literature, but few are carefully repeated to assess the validity of their results. ...
... We test our modified technique's reproducibility which is crucial for its validation, to ensure that any differences in the rate of metalwork retainment and infection resolution results from changes in pathology and not from the variability of the technique. Aside from differences in time and location, it was impossible to duplicate every condition of the 2013 study [6], such as microbiology advice. Some of the limitations of the 2013 study were also addressed, such as longer follow-up time. ...
Article
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Purpose Infected orthopaedic metalwork is challenging to treat. Negative pressure wound therapy (NPWT) with irrigation is an emerging therapy for infected wounds as an adjunct to antibiotic therapy. The senior author had devised a modified technique to augment its efficacy, utilising high-flow rate irrigation and skin closure over the standard NPWT dressing. This novel technique was originally evaluated in a different centre and produced 100% success in metalwork retention. The present study is a reproducibility test of the same technique. Methods A retrospective review was performed on 24 patients with infected orthopaedic metalwork, including 3 upper limb and 21 lower limb cases, for outcomes relating to implant retention and infection resolution. Patients underwent a modified NPWT technique as an adjunct to antibiotic therapy and surgical debridement. Detailed medical and microbiology information were obtained from the patient records. Results 23 of 24 (96%) patients had successful metalwork retainment with healed wounds and resolution of infection, allowing fracture union. 27 infective organisms were identified in this cohort, and the antibiotic regimens for each patient are provided. The average follow-up was 663 days. No adverse effects were observed. Conclusion This series supports the modified NPWT technique as a safe, reliable and effective adjunct therapy to resolve metalwork infection. The same results have been reproduced as the previous cohort in a different centre.
... 2,5 More commonly the implicated pathogen in an infection after foot and ankle surgery is S aureus. 9 As a result, empiric antibiotics in infectious cases are often tailored to S aureus and other common pathogens, leaving patients uncovered for P. acnes. 9 Diagnostically, P. acnes poses a challenge as well. ...
... 9 As a result, empiric antibiotics in infectious cases are often tailored to S aureus and other common pathogens, leaving patients uncovered for P. acnes. 9 Diagnostically, P. acnes poses a challenge as well. Cultures may take up to 15 days to grow P. acnes, necessitating laboratories to incubate samples for at least 2 weeks. ...
Article
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Propionibacterium acnes (P. acnes) infections of the foot and ankle are very rare and require a unique approach to prevention, diagnosis, and treatment. Clinicians should consider P. acnes as a cause for all late and indolent orthopedic infections, as appropriate surgical and medical management can result in a good outcome. Propionibacterium acnes (P. acnes) infections of the foot and ankle are very rare and require a unique approach to prevention, diagnosis, and treatment. Clinicians should consider P. acnes as a cause for all late and indolent orthopedic infections, as appropriate surgical and medical management can result in a good outcome.
... 23 Besides exudate control, NPWT has been applied to heal wounds, even with wound infection and underlying orthopedic implants present. 24,25 However, NPWT usually should be applied over several weeks or months for wound healing to be achieved, 26,27 but this was not the case here. Short-term wound healing has been achieved by using silver-impregnated dressings, 28 and this could have been helpful in this case. ...
Article
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Introduction: Treatment of an infected osteosynthesis is usually a complicated process, with its complexity increasing when unforeseen situations appear. Typically, the therapeutic management of such situations is challenging because they are not anticipated in the medical literature and physicians have to look for and adapt novel solutions to a specific patient condition. Case report: A 41-year-old, uncooperative, homeless man, presented to the emergency room with a left olecranon fracture. After planned surgery, the surgical wound became infected with a methicillin-sensitive Staphylococcus aureus because the treatment took place in an unhygienic outpatient hospital setting. The patient refused to remain in the hospital and also failed to complete antibiotic courses prescribed (culture-guided rifampicin 600 mg daily plus levofloxacin 500 mg daily). Instead of removing the osteosynthesis material, the infection was successfully treated by repeated applications of 5 mL of sevoflurane into the surgical wound. Subsequently, wound healing was achieved with a combination of a brief course of negative pressure wound therapy (NPWT), use of silver-impregnated dressings, and irrigation of the wound with sevoflurane. Sevoflurane also provided topical analgesic to ameliorate the pain caused by removing the NPWT sponge. Interestingly, despite extremely poor compliance by the patient to all standard treatment regimens, and the clinical decision to retain the implant, the infection was resolved, and the fracture was consolidated. Conclusions: Local application of sevoflurane in the wound bed appears to exhibit analgesic, antimicrobial, and positive healing effects. It could be a promising alternative treatment to be included as a therapeutic option for wound care.
... It is based on the application of controlled subatmospheric pressure, which removes exudates and infectious and necrotic tissues, helping wound healing and closure. The use of VAC has been reported for the treatment of infection and other wound problems in spinal surgery, in both adult and paediatric populations [4][5][6][7]. In particular, it is a useful method for the treatment of deep wound infections after spinal fusion in paediatric scoliosis, especially in patients with neuromuscular scoliosis and myelodysplasia, and avoids hardware removal [3,8]. ...
Article
Full-text available
Background: The aim of the study is to review the outcome of using the VAC system in children and adolescents who have developed postoperative spinal infection after posterior instrumented spinal fusion, and to evaluate whether this technique is also feasible in patients treated with posterior instrumented fusion with polyester sublaminar bands. Methods: A total of 11 out of 118 consecutive children and adolescents (5 males) with deep postoperative spinal infection were identified; infections were categorised as early (acute), delayed (subacute) or late (chronic) according to time of onset. Irrespective of the etiology and the onset, all the deep infections were managed with the reported technique. All the patients had regular clinical and radiological follow-up. Results: Eight out of 11 patients developed an early (72.7%), 2 a delayed (18.2%) and 1 a late deep postoperative infection (9.1%); 7 out of 11 (63.6%) showed severe mental compromise. No statistically significant differences were observed for mean number of VAC dressing changes (p = 0.81) and mean length of hospitalisation comparing patients with early infection versus patients with delayed or late infections (p = 0.32). Mean number of VAC dressing changes (p = 0.02) and mean number of hospitalisation days (p = 0.05) were higher in patients with underlying neurological disorders than in those without, while mean length of hospitalisation was longer in neuromuscular patients. Conclusions: The application of the VAC system, as an adjunct to surgical debridement and adequate antibiotic therapy, is a reliable method for the treatment of postoperative infection in children and adolescents undergoing spinal instrumentation and fusion. It can reduce the need for further complex soft-tissue procedure, removal of hardware with consequent loss of correction, and pseudoarthrosis. Finally, the use of VAC therapy is not contraindicated in patients treated with hybrid constructs with sublaminar bands. Level of evidence: III.
... It has successfully achieved the effective outcomes, especially in the complex field of wound management such as traumatic injury, infected surgical wound, and DCT exposure. [8][9][10] To obtain more satisfactory functional and cosmetic restoration for severely burnt hands or with infection, we herein present our experience on the use of super-thin abdominal wall glove-like flap combined with the VAC dressing therapy for managing complex hand injuries. ...
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Objective: Extensive deep partial-thickness burns still seriously challenge the surgeon's abilities. This study aimed to assess the impact of early dermabrasion combined with porcine acellular dermal matrix (ADM) in extensive deep dermal burns. Methods: From September 2009 to September 2013, a total of 60 adult patients sustained greater than 50% total body surface area (TBSA) burn by hot water or gas explosion were divided into three groups based on dermabrasion: group A (early dermabrasion and porcine ADM), group B (early dermabrasion and nano-silver dressings), and group C (conservative group). The wound healing time and length of hospital stay were analyzed. Scar assessment was performed at 3 and 12 months after the injury with a modified Vancouver Scar Scale linked with TBSA (mVSS-TBSA). Results: No significant difference was found in mean burn size, burn depth, age, male-to-female ratio, or incidence of inhalation injury between the patients in the three groups (p>0.05). Compared with groups B and C, the patients that received early dermabrasion combined with porcine ADM had a shorter wound healing time (p<0.01). The burn patients treated with early dermabrasion and porcine ADM coverage had a mean length of hospital stay of 28.3 days (±7.2), which was significantly shorter than that of groups B and C (p<0.05-0.01). The mVSS-TBSA of patients in group A was significantly improved in comparison with groups B and C at 3 and 12 months after the injury. There was no significant difference in the mortality rate between the three groups (p>0.05). Conclusion: Early dermabrasion combined with porcine ADM coverage facilitates wound healing, reduces the length of hospital stay, and improves esthetic and functional results in extensive deep dermal burns with burn size over 50% TBSA.
Article
Background: Removal of the infected device has been the general treatment for device-associated infection in antibiotic failure. There have been anecdotal attempts to salvage infected medical devices by introducing a continuous closed irrigation system. Objective: This study examines whether continuous closed irrigation of an infected device is a successful alternative to removal in patients with recalcitrant device-associated infection. Methods: Patients who were diagnosed with recalcitrant periexpander infections during the course of expander-implant breast reconstruction from 2010 to 2018 were enrolled in a retrospective case-control study. Patients who failed antibiotics before 2017 underwent expander removal, but patients since 2017 underwent continuous closed irrigation of the infected expanders. Treatment details and clinical outcomes were compared. Rationale for expander irrigation was based on review of the current literature on biofilm research. Results: During the study period, 21 out of the 1176 patients were diagnosed with periexpander infection recalcitrant to antibiotic therapy. Among the 21 patients, 16 underwent expander removal and five underwent expander irrigation. Clinical outcomes were comparable in terms of resolution of infection signs. The irrigation group showed fewer patients who abandoned reconstruction after infection treatment (removal = 11/16, irrigation = 1/5). Literature review revealed that expander irrigation might have induced hydrodynamic disruption of the biofilm structure. Conclusion: Expander irrigation was less invasive than removal and effective in suppressing severe recalcitrant periexpander infection. Continuous closed irrigation of infected expander devices may be a successful antibiofilm strategy in treating device-associated infections in select patients.
Article
Objective: To investigate the feasibility of Drawtex hydroconductive dressing in treatment of early implantation-associated infection and soft tissue defect after internal fixation of tibial fracture. Methods: Thirty-six New Zealand rabbits were used to prepare the model of early implantation-associated infection after internal fixation of tibial fracture, and randomly divided into 3 groups ( n=12) . The infected wounds were covered with Drawtex hydroconductive dressing (group A), chitosan solution gauze (group B), and normal saline gauze (group C), respectively. The dressing was changed every 2 days. X-ray films were performed at 1, 14, and 21 days. The gross observation, microbiological evaluation, and histological observation were done at 21 days. Results: There was no significant difference in the wound grading according to the James' grading criteria between groups at 21 days ( χ2=3.713, P=0.156). X-ray films showed no bone destruction in all groups at 1 day; and there was no significant difference in radiographic scores between groups ( P>0.05). At 14 days, the mild osteolysis was observed in group B; the radiographic score was significantly lower in groups A and C than in group B ( P<0.05), but there was no significant difference between groups A and C ( P>0.05). At 21 days, the osteolysis and osteomyelitis were observed in groups B and C; the radiographic score was significantly lower in group A than in groups B and C ( P<0.05), but there was no significant difference between groups B and C ( P>0.05). Also, the microorganism in bone tissue of group A was less than that of groups B and C ( P<0.05); and the difference between group B and group C was not significant ( P>0.05). Histological observation showed the mild inflammatory cell infiltration in group A and many inflammatory cells in groups B and C. The Smeltzer histological score was significant lower in group A than in groups B and C ( P<0.05); and there was no significant difference between groups B and C ( P>0.05). Conclusion: Drawtex hydroconductive dressing can be used for the implantation-associated infection after tibial fracture internal fixation. And the effectiveness of Drawtex hydroconductive dressing is better than that of chitosan solution gauze and normal saline gauze.
Article
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Since its introduction in clinical practice in the early 1990's negative pressure wounds therapy (NPWT) has become widely used in the management of complex wounds in both inpatient and outpatient care.¹ NPWT has been described as a effective treatment for wounds of many different aetiologies2,3 and suggested as a gold standard for treatment of wounds such as open abdominal wounds,4–6 dehisced sternal wounds following cardiac surgery7,8 and as a valuable agent in complex non-healing wounds.9,10 Increasingly, NPWT is being applied in the primary and home-care setting, where it is described as having the potential to improve the efficacy of wound management and help reduce the reliance on hospital-based care.¹¹ While the potential of NPWT is promising and the clinical use of the treatment is widespread, highlevel evidence of its effectiveness and economic benefits remain sparse.12–14 The ongoing controversy regarding high-level evidence in wound care in general is well known. There is a consensus that clinical practice should be evidence-based, which can be difficult to achieve due to confusion about the value of the various approaches to wound management; however, we have to rely on the best available evidence. The need to review wound strategies and treatments in order to reduce the burden of care in an efficient way is urgent. If patients at risk of delayed wound healing are identified earlier and aggressive interventions are taken before the wound deteriorates and complications occur, both patient morbidity and health-care costs can be significantly reduced. There is further a fundamental confusion over the best way to evaluate the effectiveness of interventions in this complex patient population. This is illustrated by reviews of the value of various treatment strategies for non-healing wounds, which have highlighted methodological inconsistencies in primary research. This situation is confounded by differences in the advice given by regulatory and reimbursement bodies in various countries regarding both study design and the ways in which results are interpreted. In response to this confusion, the European Wound Management Association (EWMA) has been publishing a number of interdisciplinary documents15–19 with the intention of highlighting: • The nature and extent of the problem for wound management: from the clinical perspective as well as that of care givers and the patients • Evidence-based practice as an integration of clinical expertise with the best available clinical evidence from systematic research • The nature and extent of the problem for wound management: from the policy maker and healthcare system perspectives The controversy regarding the value of various approaches to wound management and care is illustrated by the case of NPWT, synonymous with topical negative pressure or vacuum therapy and cited as branded VAC (vacuum-assisted closure) therapy. This is a mode of therapy used to encourage wound healing. It is used as a primary treatment of chronic wounds, in complex acute wounds and as an adjunct for temporary closure and wound bed preparation preceding surgical procedures such as skin grafts and flap surgery. Aim An increasing number of papers on the effect of NPWT are being published. However, due to the low evidence level the treatment remains controversial from the policy maker and health-care system's points of view—particularly with regard to evidence-based medicine. In response EWMA has established an interdisciplinary working group to describe the present knowledge with regard to NPWT and provide overview of its implications for organisation of care, documentation, communication, patient safety, and health economic aspects. These goals will be achieved by the following: • Present the rational and scientific support for each delivered statement • Uncover controversies and issues related to the use of NPWT in wound management • Implications of implementing NPWT as a treatment strategy in the health-care system • Provide information and offer perspectives of NPWT from the viewpoints of health-care staff, policy makers, politicians, industry, patients and hospital administrators who are indirectly or directly involved in wound management.
Article
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Negative pressure wound therapy (NPWT) has shown great advantages in the management of a wide range of clinical problems such as wound or chronic wound healing; open wounds with exposed bone, nerve, or tendon; and orthopaedic implants and related infection in the orthopaedics field. Even though it has shown positive efficacy in treating infection (wound infection or orthopaedic implant infection), its molecular mechanisms of action remain unclear and require further exploration. Since NPWT is widely used in the clinical setting, a comprehensive understanding of its biological effect will assist in appropriate clinical application. This review summarises the biological effect of NPWT on bacteria and cell growth as well as the possible mechanisms associated with NPWT applied in wound healing. We also highlight novel antibacterial dressings for NPWT. PubMed, and Web of Science database searches were conducted. Several search terms were used including negative pressure wound therapy, bacterial growth, growth factor, wound healing, dressing. All databases were searched from inception to 2015, references that lacked original resarch were eliminated.
Article
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Propionibacterium acnes is an important cause of orthopedic-implant-associated infections, for which the optimal treatment has not yet been determined. We investigated the activity of rifampin, alone and in combination, against planktonic and biofilm P. acnes in vitro and in a foreign-body infection model. The MIC and the minimal bactericidal concentration (MBC) were 0.007 and 4 μg/ml for rifampin, 1 and 4 μg/ml for daptomycin, 1 and 8 μg/ml for vancomycin, 1 and 2 μg/ml for levofloxacin, 0.03 and 16 μg/ml for penicillin G, 0.125 and 512 μg/ml for clindamycin, and 0.25 and 32 μg/ml for ceftriaxone. The P. acnes minimal biofilm eradication concentration (MBEC) was 16 μg/ml for rifampin; 32 μg/ml for penicillin G; 64 μg/ml for daptomycin and ceftriaxone; and ≥128 μg/ml for levofloxacin, vancomycin, and clindamycin. In the animal model, implants were infected by injection of 109 CFU P. acnes in cages. Antimicrobial activity on P. acnes was investigated in the cage fluid (planktonic form) and on explanted cages (biofilm form). The cure rates were 4% for daptomycin, 17% for vancomycin, 0% for levofloxacin, and 36% for rifampin. Rifampin cured 63% of the infected cages in combination with daptomycin, 46% with vancomycin, and 25% with levofloxacin. While all tested antimicrobials showed good activity against planktonic P. acnes, for eradication of biofilms, rifampin was needed. In combination with rifampin, daptomycin showed higher cure rates than with vancomycin in this foreign-body infection model.
Article
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Infection is still the major complication of orthopedic implants and projections based on the actual trend indicate that total hip and knee arthroplasties and their consequent infection burden are destined to greatly increase. Staphylococcus aureus and Staphylococcus epidermidis are the leading etiologic agents of orthopedic implant infection. Here we report on epidemiology of implant-related Staphylococcus infections in orthopedics, also referring to our experience, and focus on the crucial role of bacterial adhesins and on their ability to direct the pathogenesis process. Bacteria initiate implant infection by adhering to biomaterials. In the early steps of infection, adhesins mediate the specific interaction between microbial cells and the extracellular matrix proteins filming biomaterial surface. Then adhesin-mediated anchorage allows bacteria to cling to the biomaterial surface and to produce a biofilm that favors their ability to resist antibiotics. With the aim to prevent implant-related infections, anti-infective and infection-resistant biomaterials are being developed. The research for novel therapeutic strategies is incited by the emergence of antibiotic-resistant bacteria. Vaccines against the adhesins or antisense molecules against virulence genes can open a future in combating implant infections.
Article
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Many natural broad-spectrum cationic antimicrobial peptides (AMPs) possess a general mode of action that is dependent on lipophilicity and charge. Modulating the lipophilicity of AMPs by the addition of a fatty acid has been an effective strategy to increase the lytic activity and can further broaden the spectrum of AMPs. However, lipophilic modifications that narrow the spectrum of activity and exclusively direct peptides to fungi are less common. Here, we show that short peptide sequences can be targeted to fungi with structured lipophilic biomolecules, such as vitamin E and cholesterol. The conjugates were active against Aspergillus fumigatus, Cryptococcus neoformans, and Candida albicans but not against bacteria and were observed to cause membrane perturbation by transmission electron microscopy and in membrane permeability studies. However, for C. albicans, selected compounds were effective without the perturbation of the cell membrane, and synergism was seen with a vitamin E conjugate and amphotericin B. Moreover, in combination with β-cyclodextrin, antibacterial activity emerged in selected compounds. Biocompatibility for selected active compounds was tested in vitro and in vivo using toxicity assays on erythrocytes, macrophages, and mice. In vitro cytotoxicity experiments led to selective toxicity ratios (50% lethal concentration/MIC) of up to 64 for highly active antifungal compounds, and no in vivo murine toxicity was seen. Taken together, these results highlight the importance of the conjugated lipophilic structure and suggest that the modulation of other biologically relevant peptides with hydrophobic moieties, such as cholesterol and vitamin E, generate compounds with unique bioactivity.
Article
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Infections associated with orthopaedic implants remain a serious complication. The main objective in acute infection control is component retention, whereas this option is usually not considered for chronic infections. This multi-centre prospective, non-randomised observational study investigated one possible treatment option for implant retention in combination with negative pressure wound therapy with instillation (NPWTi). Thirty-two patients with an infected orthopaedic implant were analysed. Twenty-two patients had an acute infection (< 8 weeks after implantation) and ten patients had a chronic infection (> 8 weeks and < 36 weeks after implant placement). Polyhexanide was used as the instillation solution in 31 of the 32 cases. Nineteen patients (86.4%) with an acute infection and eight patients (80%) with a chronic infection retained their implant at 4-6 months follow-up after treatment. Our study showed that NPWTi can be used as adjunctive therapy for salvage of acutely infected orthopaedic implants and may even be considered for early chronically infected implants.
Article
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Comparisons of different staphylococci in orthopedic implant infections have rarely been reported. In this study we assessed total joint arthroplasty infections and other orthopedic implant infections due to methicillin-sensitive Staphylococcus aureus (MSSA), methicillin-resistant Staphylococcus aureus (MRSA), and coagulase-negative staphylococci (CoNS). This was a retrospective study performed at the Geneva University Hospitals for the period January 1996 to June 2008. There were 44 infections due to MRSA, 58 due to MSSA, and 61 due to CoNS. Overall cure was achieved in 57% (25/44) of MRSA infections, 72% (42/58) of MSSA infections, and 82% (50/61) of CoNS infections, after a minimum follow-up of 1 year. In the subgroup of arthroplasty infections only, cure was achieved in 39% (7/18) of MRSA, 60% (15/25) of MSSA, and 77% (30/39) of CoNS episodes. In multivariate analysis, arthroplasty (odds ratio (OR) 0.2, 95% confidence interval (95% CI) 0.1-0.6) and MRSA infections (OR 0.3, 95% CI 0.1-0.9) were inversely associated with overall cure for all implants. CoNS infection (OR 3.0, 95% CI 1.2-8.0) and the insertion of a new implant (OR 4.5, 95% CI 1.6-13.1) were associated with higher cure results. Methicillin resistance, immunosuppression, sex, age, duration of antibiotic therapy, one-stage revision, rifampin use, and total number of surgical interventions did not influence cure. MRSA-infected patients had more post-infection sequelae than patients with MSSA or CoNS (Chi-square test 13/44 vs. 93/119, OR 3.4, 95% CI 1.3-8.9, p=0.004). In orthopedic implant infections, S. aureus is more virulent than CoNS. MRSA has the worst outcome and CoNS the best.
Article
Patients with massive venous stasis ulcers that have very high bacterial burdens represent some of the most difficult wounds to manage. The vacuum-assisted closure (VAC) device is known to optimise wound bed preparation; however, these patients have too high a bacterial burden for simple VAC application to facilitate this function. We present the application of the VAC with instillation of dilute Dakins solution as a way of bacterial eradication in these patients. Five patients with venous stasis ulcers greater than 200 cm(2) that were colonised with greater than 10(5) bacteria were treated with the VAC instill for 10 days with 12.5% Dakins solution, instilled for 10 minutes every hour. Two patients had multi-drug-resistant pseudomonas, three with MRSA. All the five had negative quantitative cultures, prior to split thickness skin graft with 100% take and complete healing at 1 year. Adequate delivery of bactericidal agents to the infected tissue can be very difficult, especially while promoting tissue growth. By providing a single delivery system for a bactericidal agent for a short period of time followed by a growth stimulating therapy, the VAC instill provides a unique combination that appears to maximise wound bed preparation.
Article
Postoperative deep infections are relatively common in children with instrumented spinal deformities, whose healing potential is somewhat compromised. Children with underlying diagnosis of cerebral palsy, spina bifida and other chronic debilitating conditions are particularly susceptible. Vacuum-assisted closure (VAC) is a newer technique to promote healing of wounds resistant to treatment by established methods. This article aims to review the efficacy of the VAC system in the treatment of deep spinal infections following spinal instrumentation and fusion in children and adolescents. We reviewed 33 patients with deep postoperative surgical site infection treated with wound VAC technique. We reviewed clinical and laboratory data, including the ability to retain the spinal hardware, loss of correction and recurrent infections. All patients successfully completed their wound VAC treatment regime. None had significant loss of correction and one had persistent infection requiring partial hardware removal. The laboratory indices normalized in all but three patients. Wound VAC technique is a useful tool in the armamentarium of the spinal surgeon dealing with patients susceptible to wound infections, especially those with neuromuscular diseases. It allows for retention of the instrumentation and maintenance of the spinal correction. It is reliable and easy to use.
Article
The development of a deep wound infection in the presence of hardware after open reduction and internal fixation presents a clinical dilemma, and there is scant literature to aid in decision-making. The purpose of the present study was to determine the prevalence of osseous union with maintenance of hardware after the development of postoperative infection within six weeks after internal fixation of a fracture. The present study included 121 patients from three level-I trauma centers, retrospectively identified from billing and trauma registries, in whom 123 postoperative wound infections with positive intraoperative cultures had developed within six weeks after internal fixation of acute fractures. The incidence of fracture union without hardware removal was calculated, and the parameters that predicted success or failure were evaluated. Eighty-six patients (eighty-seven fractures; 71%) had fracture union with operative débridement, retention of hardware, and culture-specific antibiotic treatment and suppression. Predictors of treatment failure were open fracture (p = 0.03) and the presence of an intramedullary nail (p = 0.01). Several variables were not significant but trended toward an association with failure, including smoking, infection with Pseudomonas species, and involvement of the femur, tibia, ankle, or foot. Deep infection after internal fixation of a fracture can be treated successfully with operative débridement, antibiotic suppression, and retention of hardware until fracture union occurs. These results may be improved by patient selection based on certain risk factors and the specific bacteria and implants involved.