Aggressive Infections In
Patients Treated With
External Fixators
Scott J. Schoenleber, MD
James J. Hutson, Jr., MD
Disclosures
I have no conflicts.
This study was approved by our institutional review board.
Background
• Infections are extremely common in external fixation
– Range 11-97% 4-8
• Vast majority are managed without difficulty 2,4,7,9-10
• Uncommon reports of atypical and aggressive infection
– TSS 11-12
– Necrotizing fasciitis 4
Study Aim
• To describe unusual, rare, and aggressive infections in patients with external fixators
• To identify potential risk factors
• To identify management protocols and correlate with outcomes
Material and Methods
• Single-surgeon database from 1991 to present
– 1166 patients
• Retrospective chart review
INCLUSION
• Any form of ex fix
• Atypical infection as determined by senior author
EXCLUSION
• Standard superficial or deep pin site infection
• Typical osteomyelitis
Demographics
• 12 patients (11 M, 1 F)
• Median age 43.5y (range 16 to 65y)
• No patient treated for isolated deformity
Risk Factors for Severe
Infection Positive response
(of 12)
Open fracture 8
HIV status 0
Smoking status 4
Adult comorbidities 0
TIME IN DAYS RANGE
Mean time from injury to initial tx 1.4
0 to 12 days
Median time from initial to definitive tx 16.0
0 to 354 days
Less severe Atypical Bone or Joint 1. Late
2. Aggressive
Soft Tissue Infection 1. Pan-pin cellulitis
2. Necrotizing fasciitis
Unusual / Aggressive Infection Types
More severe
INFECTION TYPE
1. Atypical late
2. Atypical aggressive
3. Pan-pin cellulitis
4. Necrotizing fasciitis
PRESENTING FEATURES
1. Vague, nonspecific pain/drainage 1+ years after tx
2. Fluctuance, effusion, drainage (aggressive features)
3. Diffuse swelling, erythema, drainage, smokers
4. Severe swelling, purulent drainage, sepsis
Presenting characteristics
Atypical Late Infections • Mean number of debridements: 3.0 / patient
• Mean time from injury to infection: 1162.3 days – Range 204-2056 days
Patient Injury Risk Factors Infection type Number of
debridements Micro-biology Outcome Function
3 G3B tibia Crush Olive wire
abscess 3 MSSA Salvage
Good; required late ankle fusion
5 Closed plateau Acute
definitive tx Late septic knee with recurrence 5
MRSA, recurrent
MRSA
Salvage; knee
arthrodesis Fair
6 G3B tibia 1 PPD
smoker
Intramedullary abscess in
mature regenerate 1
Group A strep Salvage
Good; full work on
motorcycles
Olive wire abscess 3 years after fixator removal, pt previously asymptomatic
Atypical Aggressive Infections
• Mean number of debridements: 4.7 / patient
• Mean time from injury to infection: 59.6 days – Range 46-77 days
Patient Injury Risk Factors Infection type Number of
debridements Microbiology Outcome Function
2 G3B pilon Sewage
contamination Unusual organism 9
M. fortuitum, E. faecalis, E. cloacae Salvage
Good; working
as plumber
4 G3B pilon Delayed
presentation
Recurrent aggressive septic
arthritis 4 MRSA, then
MSSA Death Death
11 G2 tibia Prolonged ICU
stay Hematoma infection 1 MRSA Salvage Good;
full work
Pan-Pin Cellulitis
Patient Injury Risk
Factors Number of
debridements Microbiology Outcome Function
8 G3A pilon 1 PPD
smoker 4
MRSA, MRSA recurrence,
E. Cloacae + A. baumannii Salvage
Poor; debilitating ankle
arthritis
9 G3A tibia
1 PPD smoker,
degloving injury 1 MSSA
Salvage; nonunion
successfully repaired
Good; full work as welder
10 Closed plateau
Severe fracture blisters 6 P. aeruginosa Lost to follow-up Lost to follow-up
• Mean number of debridements: 3.7 / patient • Mean time from injury to infection: 89.3 days
– Range 48-124 days
Necrotizing Fasciitis
Patient Injury
Days from infection to amputation
Number of debridements Microbiology Outcome Function
1 G3B plateau 0 unknown
Leclercia adecarboxylata,
Enterobacter agglomerans, E.
faecalis
Through knee amputation
Good; functional prosthesis
user
7 Closed pilon 2 4 MRSA BKA Good;
working full time
12 Closed
navicular 2 6 MSSA BKA
Good; walking well with
prosthesis
• Mean number of debridements*: 5.0 / patient • Mean time from injury to infection: 35.0 days
• Range 3-68 days • Mean time from infection to amputation: 1.3 d
Microbiology
MRSA 33%
MSSA 19%
Enterococcus faecalis 9%
Enterobacter cloacae 9%
Group A strep 5%
Pseudomonas aeruginosa
5%
Acinetobacter baumannii
5%
Mycobacterium fortuitum 5%
Leclercia adecarboxylata 5%
Enterobacter agglomerans 5%
MRSA
MSSA
Enterococcus faecalis
Enterobacter cloacae
Group A strep
Pseudomonas aeruginosa
Acinetobacter baumannii
Mycobacterium fortuitum
Leclercia adecarboxylata
Enterobacter agglomerans
Patient Outcomes
Amputation
Death Union
Nonunion
Salvage
Amputation
Death
Union
Nonunion
• Injury and infection difficult to delineate
– Severe post-traumatic arthritis
• 8/12 with good function
Conclusions
1. Severe and unusual infections can rarely develop in high-risk patients with external fixators
2. These can be life- and limb-threatening
3. Early, aggressive surgical debridement (including amputation as necessary) is indicated
Thank You
References
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