Key Insights For Addressing Infected Hardware

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The radiographic findings of a septic nonunion versus an aseptic nonunion may be indistinguishable. Here one can see peri-hardware loosening in both septic and aseptic nonunions.
The arrows show a significant periosteal reaction two weeks after partial hardware removal after a Lapidus arthrodesis. The differential diagnosis is osteomyelitis or stress fracture. Based on the clinical scenario, one should rule out infection via bone
This is an avascular necrosis of the first metatarsophalangeal joint and hallux interphalangeal joint after a closing base wedge osteotomy and an Akin procedure. Involvement of both joints is suspicious for a septic process, and should be excluded.
Here one can see a severe limb-threatening infection and septic nonunion of the midfoot. Initial management of the infection takes priority over the nonunion. One should manage this situation via incision and drainage, removal of the hardware, multiple wa
Here one can see the management of an open Pilon fracture treated with external fixation, limited internal fixation and the VAC® System. Photo A shows the pilon fracture temporarily stabilized with an external fixator and placement of the VAC on the expos
Key Insights For Addressing Infected Hardware
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Author(s): 
By Neal M. Blitz, DPM, FACFAS

   Screws, plates, staples, pins and wires are the hardware that the foot and ankle surgeon uses to fixate fractures, fusions and/or osteotomies. An infection involving hardware may jeopardize the bone healing process and is a precarious situation for both the patient and the surgeon. In some situations, the infection may be easily managed yet it can be limb threatening in other situations. Like any infection, early diagnosis is paramount.

   Hardware is necessary to stabilize osseous segments until one achieves complete bone healing, a process that typically takes six to eight weeks. After that, the implants are theoretically unnecessary and one may remove them. Generally, most surgeons will not recommend hardware removal for at least six months after the index operation, mostly for soft tissue and bone remodeling purposes. However, when the hardware becomes infected, most attempts focus on immediate removal but this often depends on whether or not the underlying bone has healed.

   The term “infected hardware” is often loosely used in clinical practice but is probably an inappropriate designation. The hardware, being an inanimate object, cannot become infected. Rather, it becomes coated with bacteria and may secondarily infect its associated bone.

   Staphylococcus aureus and epidermidis are the most frequent infecting bacteria of orthopedic implants and prostheses, accounting for approximately 50 to 70 percent of infections.1 These bacteria adhere to the implant surface and produce an extracellular glycocalix (slime layer or biofilm) that protects the organism from antibiotics as well as the host immune responses.2 As a result, retained hardware that has been exposed to bacteria may become a nidus for persistent infection if it is not treated or removed.

How To Identify Infected Hardware

   Identifying infected hardware may be a challenging task. In some situations, the diagnosis is straightforward. Subtle infections are frequently more difficult to diagnose and require a detailed workup, and the presence of infection may only be presumptive.

   A thorough timeline detailing the clinical circumstances before and after hardware implantation is crucial. Hardware may become hematogenously infected so one should investigate any bacteremic episode, such as recent dental procedures, upper respiratory or urinary tract infections.3 In stable joint prosthesis, a Staphylococcus aureus bactermia has been associated with a 34 percent implant infection rate.4 In particular, intravenous drug users may be at risk for a hematogenous spread of infections. Patients who are biologically or pharmacologically immunocompromised are theoretically susceptible as well. A septic joint adjacent to retained hardware may secondarily seed the hardware.

   Any information from the patient history that may help identify the infecting agent will help tailor the course of action and treatment program. Though Staphylococcus aureus and epidermidis are most commonly identified, other bacteria (gram negatives, streptococci, enterococci and anaerobes) are common enough and one should consider them.5 Exposure of the implant to bacteria during the index operation is thought to be a leading cause for hardware infection.

   Researchers have reported the incidence of infection following clean orthopedic surgery to be as high as 6.5 percent although certain procedures may have a greater risk for postoperative infection.6 Surgeries that involve percutaneous fixation with pins exiting the skin, like one would see with hammertoe surgery, are at risk for pin tract infections. A study involving distal radius fractures treated with percutaneous exposed Kirschner wires versus those buried deep to the skin demonstrated a significantly greater infection rate with percutaneous wires.7

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