Management of Infected Proximal Femur after Fracture Fixation
Ahmed Sayed Bakhiet Mohammed;
Abstract
Proximal femoral fractures are the second most common fractures in patients older than 65 years and 1.05% 0f proximal femoral fractures developed surgical site infection.
A high index of suspicion is essential, particularly when the patient presents with a persistently pain despite unremarkable radiographs.
A thorough history and physical examination should precede any tests for the diagnosis of infection. The patient should be carefully questioned regarding any wound-healing complications, early local or distant infection, or prolonged administration of antibiotics after surgery. Delays in discharge from the hospital also suggest an early complication. Questions regarding recent infections, such as skin infections or ulceration, dental infection, or dental manipulations, can also be revealing. Good quality radiographs should be obtained and compared with previous ones. In the early postoperative period ectopic ossification can produce persistent pain and should be considered in the differential diagnosis.
The next tests should be (ESR, CRP and IL-6). If tests are normal, no further tests are necessary but patient put under follow up and observation. If any of these tests is elevated, and the suspicion for infection is high, aspiration is the best choice and culture and sensitivity done, with the patient refraining from antibiotics for at least 2 weeks, should then perform. If the aspiration confirms infection, the surgeon may proceed with the most appropriate treatment.
If the aspiration is negative, and the index of suspicion remains high, an ultrasound and/or an arthrogram are done. If it remains negative, ancillary tests such as a sequential technetium (Tc99m) nuclear scan and (Tc-HIG) scans, tissue culture and recently molecular biologic techniques (PCR, Cloning, IFM &FISH) can be performed. If all these tests are still negative, the surgeon may finally have to resort to the intraoperative tests to distinguish between aseptic loosening and infection. If the frozen section is positive, treatment must be started. Several intraoperative tissue cultures are obtained in all patients. The rational use of preoperative investigations in a sequential fashion will allow the correct diagnosis of infection in the majority of cases.
Treatment is considered what the infection is intra-capsular or extra-capsular.
In intra-capsular infection two stage arthropasty with articulating antibiotic cementless spacer is the best choice in sever infection while one stage change arthroplasty could be do in mild infection with close follow- up.
Girdlestone resection arthroplasty has high rate of mortality and used only as a limb salvage if failed all other techniques.
In extra-capsular infection:
In treatment of intramedullary nail depend on two strategies. "union first strategy" or "the infection elimination first strategy". If fracture stability was dependant on the nail, the nail should not be removed prematurely.
Ilizarov technique in infection is the best when radical debridement done, large bone segment was lost that will be use for maintain length and bone reconstruction.
In treatment of dynamic hip screw the best to do debridement with irrigated with massive normal saline solution antibiotics then reinsert of another dynamic hip screw.
A high index of suspicion is essential, particularly when the patient presents with a persistently pain despite unremarkable radiographs.
A thorough history and physical examination should precede any tests for the diagnosis of infection. The patient should be carefully questioned regarding any wound-healing complications, early local or distant infection, or prolonged administration of antibiotics after surgery. Delays in discharge from the hospital also suggest an early complication. Questions regarding recent infections, such as skin infections or ulceration, dental infection, or dental manipulations, can also be revealing. Good quality radiographs should be obtained and compared with previous ones. In the early postoperative period ectopic ossification can produce persistent pain and should be considered in the differential diagnosis.
The next tests should be (ESR, CRP and IL-6). If tests are normal, no further tests are necessary but patient put under follow up and observation. If any of these tests is elevated, and the suspicion for infection is high, aspiration is the best choice and culture and sensitivity done, with the patient refraining from antibiotics for at least 2 weeks, should then perform. If the aspiration confirms infection, the surgeon may proceed with the most appropriate treatment.
If the aspiration is negative, and the index of suspicion remains high, an ultrasound and/or an arthrogram are done. If it remains negative, ancillary tests such as a sequential technetium (Tc99m) nuclear scan and (Tc-HIG) scans, tissue culture and recently molecular biologic techniques (PCR, Cloning, IFM &FISH) can be performed. If all these tests are still negative, the surgeon may finally have to resort to the intraoperative tests to distinguish between aseptic loosening and infection. If the frozen section is positive, treatment must be started. Several intraoperative tissue cultures are obtained in all patients. The rational use of preoperative investigations in a sequential fashion will allow the correct diagnosis of infection in the majority of cases.
Treatment is considered what the infection is intra-capsular or extra-capsular.
In intra-capsular infection two stage arthropasty with articulating antibiotic cementless spacer is the best choice in sever infection while one stage change arthroplasty could be do in mild infection with close follow- up.
Girdlestone resection arthroplasty has high rate of mortality and used only as a limb salvage if failed all other techniques.
In extra-capsular infection:
In treatment of intramedullary nail depend on two strategies. "union first strategy" or "the infection elimination first strategy". If fracture stability was dependant on the nail, the nail should not be removed prematurely.
Ilizarov technique in infection is the best when radical debridement done, large bone segment was lost that will be use for maintain length and bone reconstruction.
In treatment of dynamic hip screw the best to do debridement with irrigated with massive normal saline solution antibiotics then reinsert of another dynamic hip screw.
Other data
| Title | Management of Infected Proximal Femur after Fracture Fixation | Other Titles | علاج العدوي المصاحبة للكسور في أعلي عظمة الفخذ ما بعد الجراحة | Authors | Ahmed Sayed Bakhiet Mohammed | Issue Date | 2014 |
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