23

Surgical management of infection

Manuel Llusa, Xavier Mir and Xavier Flores

Introduction

Management of severe traumatic defects of the upper limb presents an important

challenge to orthopaedic and plastic surgeons. Recent advances in reconstructive
microsurgery have made it possible to transfer free cutaneous, muscle, myocutaneous,
fasciocutaneous, bone and osteocutaneous flaps to solve a wide spectrum of post-
traumatic defects. All of these complex techniques, and even the more simple surgeries
require a previously clean wound to obtain a good result.
Ideally, infection should be avoided but the kind of high-energy trauma that results in
fractures and soft tissue injuries with high wound contamination make it difficult to
prevent infection. Management protocols for acute situations begin with irrigation,
debridement and stabilization of the fractures as soon as possible. Infected fractures
require similar radical treatment. In fact, all patients with open fractures should be
considered as being infected.

Irrigation and debridement

Predebridement cultures are taken and gross debris cleaned by irrigating the wound
profusely with sterile saline solution (up to 10 litres of normal saline). The majority of
authors recommend a mechanical irrigating system with pulsating or jet lavage (Gustilo
1989, Johnson 1989).
After the initial cultures, intravenous antibiotic therapy is begun depending on the
prophylactic protocol (see Antibiotic treatment at the end of the chapter). With open
fractures bacterial contamination is present 6575% of the time. It should be emphasized
that emergency cultures have little correlation with organisms isolated from infected
wounds (Gustilo 1990, Seekamp et al 2000). Wound cultures should be taken from the
deeper part of the wound. Cultures taken superficially or from inside the sinus tract, in
chronic cases, can be misleading and bear no relation to the infecting organism inside the
deep part of the wound (Gustilo 1989). The most significant infecting organisms in high-
energy fractures are Gram-negative rods (75%) or the same along with Gram-positive
organisms (24%) (Johnson 1989).
Following initial irrigation the draping of the extremity is changed and debridement is
performed. Generally tourniquet is not applied in order to distinguish between viable and
nonviable tissue.
Debridement must be radical including all devitalized tissues and devascularized bone
fragments with the exception of intraarticular fragments with cartilage, if possible, to
 Severe traumatic defects of the upper limb 378

preserve future joint function. Some authors suggest that debridement must be very
aggressive, such as when ablating tumours (Tomaino 1999). However, we think that the
debridement must be radical but functional, trying to conserve at least the basic elements
for future movement if possible. The real soft tissue injury is usually more extensive than
initially appreciated. Serial debridements repeated every 4872 hours permit the surgeon
to define the real extent of the wound (Weiland and Yaremchuck 1990). On other
occasions, severe and frank infections make it obligatory to perform a one-stage wide and
radical debridement with composite tissue losscombination of soft tissue, tendon, nerve
and bone (Fig. 1).
Extensive bone fragmentation should be carefully evaluated. Devascularized bone
fragments with no soft tissue attachments should be

Figure 1
Severe infection of the dorsum of the hand and wrist
affecting soft tissue, tendons, muscle and bones
composite tissue loss.

removed without hesitation. Currently the availability of cancellous or free bone grafting
(microvascular fibular or iliac crest) or bone transport gives the surgeon confidence that
the bone defects can be reconstructed later (Wood and Gilbert 1977, Gerwin and Weiland
1992).

Fracture stabilization

Once final debridement is completed fracture stabilization is performed. It has been

demonstrated that early fracture stabilization reduces wound infection rates (Anderson
and Meyer 1993). External fixation devices can be used in the majority of cases. They are
easy to apply, allow daily wound care and serial debridements, and permit secondary
procedures such as skin closure and plastic surgery procedures for wound coverage when
infection has been eradicated (Fig. 2) (Wild et al 1982, Soucacos et al 1995).
The techniques used to achieve fracture stability in upper extremity fractures differ
from those for lower extremity fractures. Primary internal fixation, by plating or
intramedullary nailing, can be used in diaphyseal fractures, in cases with low risk of
infection due to the rich blood supply and abundant soft tissue envelope, especially in
 Surgical management of infection 379

humerus and forearm fractures (Tomaino 1999). Plating is a good option in fractures
around epiphyseometaphyseal bone. At the level of the

Figure 2
Fracture stabilization with external fixation facilitates skin
coverage and plastic procedures.

hand Kirschner wires are a fast and safe option (Tomaino 1999).
In the presence of infection, if the internal fixation device is loose and the fracture
becomes unstable, it should be removed and changed to external fixation after wide
debridement. But if the internal fixation provides rigid fracture stability it can be
maintained even if it is exposed (Gustilo 1990). Internal fixation has the advantage of
permitting easy care for soft tissue problems, and avoids the risk of pin track sepsis often
seen with external devices. If there is any doubt we prefer to apply an external fixation
and later change to internal fixation as soon as possible (when signs and symptoms of
infection have subsided) to avoid pin track infection (Figs 35).
 Severe traumatic defects of the upper limb 380

Figure 3
Elbow open fracture grade IIIC with severe bone loss.
Ipsilateral fracture of the radius and ulna.

Figure 4
Temporary external fixation application as an emergency
treatment after debridement. Brachial artery reconstruction
was needed.

When pin sepsis occurs changes to secondary plating or intramedullary nailing have a
high risk of infection (Gustilo 1990). Antibiotic therapy and a delay of 4872 hours after
external fixation removal is recommended. Some authors do not recommend
intramedullary reaming because of the risk of pandiaphyseal osteomyelitis, and others use
unreamed intramedullary nails, especially in the humerus (Gustilo 1990).
If any kind of osteosynthesis is in place and functioning properly, without any sign of
loosening, it should be left in place and an aggressive debridement carried out. Radical
excision of necrotic skin, non-viable tissues and debride
 Surgical management of infection 381

Figure 5
Early elbow arthrodesis due to wide soft tissue loss.
Options such as elbow allograft or elbow prosthesis should
be considered. This patient refused these options.

ment of necrotic bone are performed until viable tissue and a clean wound are obtained.
This step should be done without a tourniquet.

Defect coverage

Initially no attempt to close the wound should be made, unless the surgeons experience
recommends the contrary. Generally it is very difficult to assess, during the initial
treatment, the degree of contamination and vascularization of the injured area. We prefer
to perform a second look and several debridements, especially in polytraumatic patients,
because of the high infection rates. Surgically induced wounds may be closed if there is
no tension on the soft tissue. However, the wound in the area of the open fracture should
not be closed (Johnson 1989).
Timing of wound closure depends on several factors but generally it is possible within
the first few days to a fortnight; the management varies from delayed primary or
secondary closure to local flaps or microvascular free flaps (Soucacos et al 1995). In
 Severe traumatic defects of the upper limb 382

cases with unprotected neurovascular structures additional procedures should be done in

order to cover the vital nerves and vessels (Varecka 1989).
Initially the wound is left wide open or packed with polymethylmethacrylate beads
impregnated with gentamicin sulphate to fill dead space. Recently, biodegradable
delivery systems have been used (Klemm 1993).
The technique of open healing by secondary intention results in a densely fibrotic
wound, increasing the susceptibility to ischaemic complications and decreasing the
functionality of the affected extremity. The technique of Papineau is not recommended
except in very special situations (Weiland and Yaremchuk 1990).
There is a consensus that generally it is better to proceed to early or delayed primary
wound closure or coverage with local, or even better, with free muscle transfer within the
first week (Gerwin and Weiland 1992). The dead space is filled with
polymethylmethacrylate beads (Klemm 1987) or, as has been proposed, with an
antibiotic-impregnated cement block (Masquelet et al 2000), not only to deliver
antimicrobial agents but also to provide some restoration of integrity and stability.
Ideally free muscle flap (latissimus dorsi or rectus abdominis) is adapted to cover the
wound and fill the rest of the dead space. The muscle flap is covered with a meshed split
thickness skin graft. Cutaneous or fasciocutaneous flaps are not used because of their
inability to adapt and fill dead space. The muscle provides a rich vascular supply and
creates an induced membrane over the polymethylmethacrylate cement block (Masquelet
et al 2000). After a period of 46 weeks the cement block is removed and, if the wound is
clean without any sign of infection, bone grafting is performed. Stevanovic et al (1999)
recommend autogenous cancellous bone in small or moderate defects and microvascular
bone transfer in cases of segmental defects greater than 6 cm. The recipient site should be
explored prior to obtaining the bone graft to remove any occult infection. The increase in
blood supply brought by the microvascular muscle transfer aids in the control of infection
and in the rapid incorporation of the cancellous bone graft. Chan et al (2000) suggest that
antibiotic-impregnated autogenous bone grafting is an effective and safe method for the
management of small bone defects and it does not have any adverse effects on bone graft
incorporation.
Simultaneous cancellous bone grafting and muscle flap closure should be avoided
because of the risk of bacterial contamination at the time of closure and possible
reinfection. In some situations one-stage soft tissue reconstruction with a free
osteomyocutaneous flap has been suggested by some authors (Godina 1986).
A practical point to remember is to get in touch with the plastic surgeon as soon as
possible when a free soft tissue flap is indicated, so that it can be planned in advance.
This should be within the first 37 days of injury, when the wound is in optimal
condition.
In some special situations creation of a one bone forearm may be indicated. This
technique sacrifices prono-supination. Reported results indicate a less than ideal outcome
but it should be borne in mind when treating a difficult combination of bone and soft
tissue injury with loss of the distal radio-ulnar joint (Stevanovic et al 1999). In Figures 6
10 we summarize some of the
 Surgical management of infection 383

Figure 6
A young male with an open grade IIIC ulna and radius
fracture. Severe infection was present with bone and soft
tissue loss. Serial debridements were performed. Cultures
isolated Clostridium perfringens.

Figure 7
Radiographs of the same case as in Fig. 6.

Figure 8
Radical debridement, free latissimus dorsi transfer and
reapplication of the external fixation.
 Severe traumatic defects of the upper limb 384

basic concepts of the surgical management of infection in a severe post-traumatic case.

Antibiotic treatment

The most satisfactory prophylactic procedure to prevent infection in open fractures is

prompt, adequate surgical debridement and antibiotics are no substitute for this (Johnson
1989). Theoretically, prophylactic antibiotic therapy should not be initiated until surgical
debridement and samples for cultures have been taken. However, due to the high
frequency of bacterial contamination, the use of antibiotics for a conta

Figure 9
Four weeks later there were no signs of infection and bone
grafting and osteosynthesis were performed with creation
of a one bone forearm.

Figure 10
Final appearance with resolution of the infection, even
though prono-supination was lost.

minated wound is defined as active therapy and not as prophylaxis (Johnson 1999).
Appropriate therapy should be selected according to the organisms cultured in each
specific case.
 Surgical management of infection 385

The following empirical recommendations can be made for antibiotic treatment of

open fractures and soft tissue injuries, depending on the degree and type of
contamination:
Minimally contaminated soft tissue injuries and type I and type II open fractures
should be treated with a first generation cephalosporin (usually cefazolin) or a
combination of amoxicillin and clavulanate.
Severely contaminated soft tissue injuries and contaminated type II fractures and all
type III open fractures should be treated with a combination of a first generation
cephalosporin with an intravenous aminoglycoside (gentamicin or tobramycin). The
use of a third generation cephalosporin, such as cefotaxime, is a good option. This
antibiotic is very effective against Gram-negative organisms and also against Gram-
positive organisms compared with other third generation cephalosporins. Its use
avoids the risks and side effects of aminoglycosides. However, it should be
remembered that most of the third generation cephalosporins do not cover
Pseudomonas spp. as well as the aminoglycosides. Currently, the use of
amoxicillin/clavulanate is also considered a good choice in empirical antibiotic
treatment of type III open fractures, except in cases with risk of Pseudomonas
contamination or infection. In such a situation gentamicin must be part of the
antibiotic therapy.
Generally prophylactic antibiotics are administred for 4872 hours. In severe cases with
generalized sepsis a penicillinase-resistant synthetic penicillin (cloxacillin 2 gm every 4
hours iv) in combination with an antipseudomonal aminoglycosidic antibiotic
(gentamicin or tobramycin, 80 mg every 8 hours iv) plus clindamycin (900 mg every 8
hours iv) should be administered. Generally these complex cases are managed by
intensive care unit specialists.
In postoperative infections, after fracture reduction and internal fixation,
Staphylococcus aureus, Enterobacteriaceae or Pseudomonas spp. are usually isolated. In
these cases a combination of cloxacillin (2 gm every 4 hours iv) with ciprofloxacin (750
mg every 12 hours po) should be considered or a combination of ciprofloxacin (750 mg
every 12 hours po) with rifampicin (300600 mg every 8 hours po).
When Staphylococcus epidermidis is isolated the appropriate antibiotic is vancomycin
(1 gm every 12 hours iv) and all foreign bodies such as sutures, hardware or
osteosynthesis must be removed.
Once the infection has resolved antibiotic therapy should be restarted as a prophylactic
measure for the following circumstances:
During delayed primary or secondary wound closure, including free flap transfers.
When internal fixation or open reduction and osteosynthesis are performed.
When external fixation is changed to internal fixation (plates or intramedullary
nailing).
In most cases, patients are already on broadspectrum antibiotic treatment because of
previous signs and symptoms of infection, prior to microorganism identification and are
then put on specific treatment adapted to their indivdual situation. At this point, we
recommend collaborating with an infectious disease specialist in complex cases with
antibiotic-resistant microorganisms or in cases with severe medical problems. These
situations demand wide experience in systemic antibiotic management.
 Severe traumatic defects of the upper limb 386

Antibiotic therapy is recommended until adequate soft tissue healing has been
achieved; usually this may take from 36 weeks.

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