Infection prevention
Case 1 Figure 1: A fifty-year-old lady presented with a low energy transfer distal femur fracture. Having only minor co-morbidities and classed as a good ‘host’, she underwent surgery to the femur involving two devices: an intramedullary nail, and a plate down the lateral side of the bone. Hydrogel was not used. While a longer operating time and larger surgical incision was anticipated due to the dual methods of fixation, this alone was not deemed enough to justify the use of adjuncts to prevent infection.
Figure 1. AP and lateral intraoperative fluoroscopy views of the right distal femur showing an intramedullary nail and plate construct for treating a distal femur fracture.
Case 2 Figure 2: Three days previously, we operated on an 82-year-old man with a periprosthetic fracture just distal to a prior fixation for a periprosthetic fracture. The first periprosthetic fracture around the stem of the THR only occurred five months prior to this injury and had not yet healed. This was a frail gentleman with multiple medical comorbidities which predisposed him to infection. A different host entirely from case one, but a similar operation utilising a near identical management philosophy for fixation. He had Hydrogel spread on the nail and the plate. His risk profile, albeit a similar operation on the same bone, is markedly different to the lady in case one. This is the rationale – choosing the use of additional measures to minimise risk in the maximally at-risk patient. It was the surgical opinion that a 4th operation in this patient should be avoided at all costs.
Case 3 Figure 3: Later the same week, we operated on a woman with an open complex tibial fracture involving articular injury to the ankle and the tibial shaft in the same leg. Her skin had been damaged, the bone had come through the skin and her risk of infection therefore was greater. She had no host risk factors for infection. She underwent routine orthoplastic care in terms of fracture cleaning and skin management, with direct primary closure achieved. An external fixation device was used to restore weight-bearing. The ankle articular surface was reconstructed using two percutaneous cannulated screws, through intact skin and soft tissues. Neither of these devices were coated with hydrogel. We wanted to make the tibia stable and took the opportunity, given the large exposure to clean the bones, of implanting a small plate to maximise stability to accelerate healing. This plate, given the open fracture and the overlying damaged tissues was coated in Hydrogel.
knee arthroplasty for osteoarthritis using linked registry and administrative health data. Bone Joint J 104-B, 1060–1066 (2022).
4. Hassan Achakri et al. The National Joint Registry 20th Annual Report 2023. (National Joint Registry, London, 2023).
5. He, S.-Y., Yu, B. & Jiang, N. Current Concepts of Fracture-Related Infection. Int J Clin Pract 2023, 1–8 (2023).
6. Royal College of Physicians. 15 Years of Quality Improvement: The 2023 National Hip Fracture Database Report on 2022. (2023).
7. Duckworth, A. D. et al. Deep infection after hip fracture surgery: predictors of early mortality. Injury 43, 1182–6 (2012).
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10. Gristina, A. G., Naylor, P. & Myrvik, Q. Infections from biomaterials and implants: a race for the surface. Med Prog Technol 14, 205–24 (1988).
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Figure 3. CT scan of fractured tibia and ankle. Intraoperative fluroscopy images of ankle and tibia showing reduced fixed fractures and implants coated with DAC given the high risk of contamination and soft tissue trauma.
Conclusion In conclusion, infection following arthroplasty and fracture operations carries a dual burden; it is a disaster for the patient and it is extremely costly for the health service that is treating them. Adoption of every potential antimicrobial adjunct for every case is an impossibility and it is not required. Where impact can be made is in judicious case selection. Identifying those patients in whom risk is elevated and reward is a reality.
CSJ
References 1. Iliaens, J. et al. Fracture-related infection in long bone fractures: A comprehensive analysis of the economic impact and influence on quality of life. Injury 52, 3344–3349 (2021).
Figure 2. Preoperative image demonstrating periprosthetic femur fracture and intraopera- tive fluoroscopy images of reconstruction with an intramedullary nail and plate, both of which were coated with DAC.
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2. Zardi, E. M. & Franceschi, F. Prosthetic joint infection. A relevant public health issue. J Infect Public Health 13, 1888–1891 (2020).
3. Jin, X. et al. Estimating incidence rates of periprosthetic joint infection after hip and
12. Trentinaglia, M. T. et al. Economic Evaluation of Antibacterial Coatings on Healthcare Costs in First Year Following Total Joint Arthroplasty. Journal of Arthroplasty 33, 1656–1662 (2018).
About the authors
Will Eardley is a consultant in complex trauma and limb reconstruction. He has an academic background in both clinical and pre- clinical aspects of trauma
surgery and has completed a doctorate on extremity trauma. He is the Chair of the scientific committee of the Orthopaedic Trauma Society, Vice Chair of the British Orthopaedic Association trauma committee and sits on the National Major Trauma Registry national committee.
Helen Smith is an orthopaedic registrar in the North East of England. She is currently working in Trauma and Limb Reconstruction.
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