Management of Post-Operative Soft Tissue and Bone Infections

Management of Post-Operative Soft Tissue and Bone Infections

Thomas S. Roukis, DPM, PhD, FACFASChi f Li b P i S iChief, Limb Preservation Service

Department of Vascular/Endovascular SurgeryMadigan Army Medical Center, Tacoma, WA

4th Annual International External Fixation SymposiumSan Antonio, TX: 13 December 2008

Where We’re Going…

4th Annual International External Fixation Symposium

December 11-14, 2008

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Where We’re Going…Incidence of Infection

•Elective foot and ankle surgeryOpen fractures•Open fractures

Prevention of Infection•Host factors•Peri-operative factors•Intra-operative factorsp

Diagnosis of InfectionTreatment of Infection

•Basic principlesConclusions

Incidence of Infection: Elective F & A Surgery

Infections After Foot and Ankle Surgery: ELECTIVE• Overall: 1.43 to 5.3%• Hospital Setting: 2 2%• Hospital Setting: 2.2%• Outpatient Surgery Setting: 1.35%• Ankle Fusion: 9.3%• Subtalar Joint Fusion: 5.8%• STAPH. Species: 83%

Infections After Foot and Ankle Surgery: EMERGENTInfections After Foot and Ankle Surgery: EMERGENT• Logarithmic increase in incidence of infection• Poly-microbial organisms• Attention to detail with initial triage of wound, timing to OR,

resuscitation of patient, and “ortho-plastic” approach most important factors determining development of infection



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Prevention of Infection:HOST FACTORS

Prevention of Infection: Host FactorsMajor Medical Morbidities: DIABETES• Diabetic foot and ankle fractures ± dislocation are BAD!

Overall complication rate: 29% ORIF; 83% CastOverall infection rate: 25% ORIF; 40% CastOverall infection rate: 25% ORIF; 40% Cast

• Infections more frequent and more severe in diabetic patients‘Amputation rate: 5% diabetics; 0.4% non-diabetics [12.5x’s ↑]Worse results with: IDDM; >10 yrs. DM; Neuropathy; Nephropathy;

PVD; H/O Charcot event; H/O Amputation



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Prevention of Infection: Host FactorsMajor Medical Morbidities: NEUROPATHY

Prevention of Infection: Host FactorsMajor Medical Morbidities: RENAL FAILURE



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Prevention of Infection: Host FactorsMajor Medical Morbidities: MALNUTRITION

Prevention of Infection: Host FactorsMajor Medical Morbidities: IMMUNOCOMPROMISED



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Prevention of Infection: Host FactorsTobacco ⇒ 10x ↑ Non-union; 40x ↑ wound problems

• Nicotine is major concernAl H d id C b id• Also Hydrogen cyanide, Carbon monoxide

• Cumulative effect

J. Foot Ankle Surg. 37: 69-74, 1998

i f f iPrevention of Infection:PERI-OPERATIVE

FACTORSFACTORS



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Prevention of Infection: Peri-Operative FactorsSurgical Preparation: WHAT WORKS?

• Pre-operative antibacterial shower?Meta-analysis [6 studies]: pre-operative bathing with 4% chlorhexidine gluconate vs. placebo or bar soap ⇒ no reduction in post-op sx. site infectionsg p p p p f

• Hair removal?No benefit; Use clippers rather than razor if necessary

• ETOH soaked scrub brush prior to surgical preparation?No benefit compared to standard surgical preparation alone

• Sterile incise adhesive barrier or glove to cover toes?No benefit compared to standard surgical preparation alone

• “Floss” webspaces?Significantly reduces residual bacteria within interspaces

• Most efficacious surgical preparation for foot and ankle surgery?3-minute Chlorhexidine gluconate 4% scrub with foam brushes followed by painting with ethyl alcohol 99% and iodine 1% [“Tincture of Iodine”]Residual bacteria exclusively aerobic, gram positive organisms ≈ 10% @ toes

• Recommendations? Pre-op shower with antibacterial soap; Don’t shave; Pre-prep with ETOH scrub brush; Floss the webspaces; Use prep above; Cover toes

Prevention of Infection: Peri-Operative FactorsPre-Operative Prophylactic Antibiosis: WHAT’s STANDARD?

• Choices?Cefazolin 1 to 2-g IV or Cefuroxime 1-g IVClindamycin 600 to 900-mg IV Vancomycin 1-g IV 60-minutes [MRSA, Renal Dz.; DM; Recent Hospitalization]

• Complete infusion 30 to 60 minutes prior to inflation of tourniquet and incision

Post-Operative Prophylactic Antibiosis: WHEN TO USE?• Break in sterile technique• Incisions open > 2 to 3 hours• Repeated tourniquet use• Total course of 24 hours [Infection Rate not less than with single dose]

Post-Operative Ongoing Antibiosis: WHEN TO USE?• Reserved for high risk with course of 3 to 14 days common

[Infection Rate not less than with 24 hour dose; extended course increases resistant URTI]



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Prevention of Infection: Peri-Operative Factors

Corticosteroid Use?• Corticosteroid injection in vicinity of surgical site within 6

weeks increases risk of wound dehiscenceweeks increases risk of wound dehiscence • Systemic corticosteroids, including stress doses, increase

incidence of wound dehiscence and surgical site infection

Prevention of Infection:INTRA-OPERATIVE

FACTORSFACTORS



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Prevention of Infection: Intra-Operative FactorsLimit number of personnel in OR and door open-close cyclesCover ears and jaw line to collect bacteria shedBreak in Sterile Technique: Glove Perforationq

• Rate: 4%• Index finger and thumb of non-dominant hand• 33% during IM nail procedures• 20% Internal Fixation Use w/o K-wires• 78% for main surgeon• 60% un-noticed

Recommendations?Recommendations?• Chlorhexidine gluconate 4% surgical scrub superior to povidone-iodine• Always double glove• Change top gloves for each new procedure• Use separate “dirty” and “clean” set-up with contaminated/infected cases• Change gowns between “dirty” and “clean” portions of surgery

Prevention of Infection: Intra-Operative FactorsLimit Soft-Tissue Dissection and Periosteal StrippingMeticulous Hemostasis to Avoid HematomaHandle Tissues GentlyR d i h d i ≤ 1 /h ↑ I f ti t > 24 hRemove drain when drainage ≤ 1-cc/hr: ↑ Infection rate > 24 hrs.Subcuticular Closure with Monofilament Suture Minimizes Tissue Ischemia and is Associated with Decreased Bacterial Contamination: Layered Closure



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Prevention of Infection: Intra-Operative Factors

Implant site are “Permanently Immuno-compromized”Implant Rate of Infection: Staph. aureus challenge with DCP Plate

• Stainless Steel Infection Rate: 75%; Fibrous capsule; Dead space;• Stainless Steel Infection Rate: 75%; Fibrous capsule; Dead space;Bacterial adherence; Limited host defense; Critical colonization; Infection

• Titanium Infection Rate: 35%; Soft-tissues adhere well

• Difference Related to BiocompatabilityRace: Soft-tissue Integration vs. Bacterial Adherence

BACTERIAL ADHERENCE FACTORSBACTERIAL ADHERENCE FACTORSGlycocalix; Slime; Biofilm

Protects bacteria by:

Inhibiting cellular immune response

Inhibits antibacterial penetration

Promotes bacterial growth

Diagnosis of Infection



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Diagnosis of Infection: Clinical Findings

Some are obvious!

Diagnosis of Infection: Clinical FindingsNeed High Index of Suspicion: Best results if start treatment ≤ 72 hours

Signs and Symptoms: Pain, Calor, Dolor, Rubor, Sinus; Tachycardia, Diaphoresis

Laboratory Values• Complete Blood Cell Count with Manual Differential

Increased WBC (Acute +25%) and “left shift” (Acute +65%) [Immature Neutrophils]Unreliable with diabetes, corticosteroid use, immunocompromised

• Erythrocyte Sedimentation Rate (mm/hr)Normal < 25Osteomyelitis > 70Deep Space Abscess > 100Deep Space Abscess > 100

• Blood Culture: Acute + 50%; Chronic usually -

Culture and Sensitivity: • Aspiration: Acute 85-90% Accurate• Deep Tissue Samples• Bone Biopsy• May require “sonication” of tissue/implant



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Diagnosis of Infection: Clinical FindingsRadiographs

• Osteomyelitis: Earliest signs [focal demineralization, periosteal elevation, cortical irregularity] take 7 days; Require 35-50% ↓ in bone mineral density

• Weightbearing “Stress” Images ± Poor construct ? Non-union• Peri-Implant Lucency ± Poor construct ? Non-union• Change in Position ± Poor construct ? Non-union• Fractured hardware ± Poor construct ? Non-union

Diagnosis of Infection: Clinical FindingsAdvanced Imaging Modalities

• Bone ScintigraphyTechnesium-99 MDP 4-Phase Bone Scan: 94% sensitivity, 95% specificityy p f y

• Other Nuclear ImagingGallium-67: 81% sensitivity, 69% specificity; Ga/Tc: 39% accurateIndium-111 leukocyte scan: In/Tc: 88% accurateTechnesium-99 HMPAO leukocyte scanSulfur colloid leukocyte scan Technesium-99 antigranulocyte monoclonal antibody fragment FAB’

CT S• CT Scan• MRI ± Gadolinium: Sensitivity 92-100%; Specificity 89-100%



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Treatment of Infection:BASIC PRINCIPLES

Treatment of Infection: Basic PrinciplesBasic Principles: Gain Control of Infection, then Reconstruct

• Wide Resection of Infected Tissue• Copious Irrigation ± Pulsed Lavage ± Antibiotics/Surfactants• Polymethylmethacrylate Antibiotic Loaded Bone Cement Beads• Negative Pressure Therapy• Plan for Soft-tissue Coverage and Osseous Reconstruction• PICC Line Culture Directed IV Abx. Directed By Infectious Disease

What About the Hardware?• Goal is Union of Fracture/Osteotomy WITH Cure of Infection• Leave Hardware vs Remove Hardware?• Leave Hardware vs. Remove Hardware?

“The movement of the bone fragments damages tissue & causes tissue death providing a situation supportive of bacterial growth”“The stability of the fracture was the most important factor in reducing the infection rate”

• If hardware is stable, leave it in• If hardware is unstable, remove it: Convert to external fixation



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Treatment of Infection: Basic Principles




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CONCLUSIONS…Post-Operative Infection Following Elective Foot and Ankle Surgery is Rare BUT DevastatingPost Operative Infection Following Emergent Foot andPost-Operative Infection Following Emergent Foot and Ankle Surgery is Common: BE FOREWARNED & BEWARE

Proper Attention to Detail: Pre-; Peri-; Intra-OperativeDiagnosis Based on Clinical, Radiographic, and Laboratory Analysis NOT FoolproofC id D C lt d B BiConsider Deep Cultures and Bone BiopsyBOTTOM LINE:• If the Hardware is Stable, Leave It In• If the Hardware is Unstable, Take It Out; Ex Fix



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THANK YOU !

[email protected]. Rainier at Sunrise



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Documents

Management of Post-Operative Soft Tissue and Bone Infections