Implant Salvage in Patients With Severe Post-Fracture Fixation Surgical Site Infection Using Negative Pressure Wound Therapy With Intramedullary and Subcutaneous Antibiotic Perfusion

Keisuke Shimbo, MD, PhD; Tatsuhiko Saiki, MD; Haruka Kawamoto; Isao Koshima


Wounds. 2022;34(6):e47-e51. 

In This Article

Abstract and Introduction


Introduction: Post-fracture fixation surgical site infection (SSI) is a devastating complication, and the standard-of-care therapeutic regimen is ineffective in managing it. Negative pressure wound therapy with instillation and dwell time (NPWTi-d) can be used to salvage orthopedic fixation hardware in the setting of infection; moreover, NPWTi-d can be used effectively in the management of superficial post-fracture fixation SSI.

Case Report: Two cases were treated with NPWTi-d. Because of difficulties disrupting the deep dead space biofilm in a deep post-fracture fixation SSI (and because of the risk for bone infection), a double-lumen tube was used for subcutaneous antibiotic perfusion and dead space suction drainage, and bone marrow needles were used for intramedullary antibiotic perfusion to manage or prevent early osteomyelitis. The 2 patients with severe SSI after below-knee fracture fixation were treated with continuous intramedullary and subcutaneous antibiotic perfusion with NPWT to salvage the orthopedic implant. The debrided wounds of the lower leg and heel were reconstructed with free flaps and incisional NPWT, followed by administration of continuous intramedullary and subcutaneous antibiotic perfusion to preserve the titanium plates. In both patients, the wounds healed without complications and remained healed after more than 7 months.

Conclusions: Continuous local antibiotic perfusion around infected orthopedic fixation hardware can be an ideal treatment for patients with SSI after fracture fixation. Although this technique can be improved further, it is more effective than conventional therapy in the management of severe post-fracture fixation SSI with a dead space.


Surgical site infection (SSI) after fracture fixation is associated with higher-grade Gustilo-Anderson open fractures (ie, type III).[1,2] Patients with SSI that has progressed to deep infection or osteomyelitis must undergo multiple surgeries and may experience permanent dysfunction at the fracture site. Radical surgical debridement, orthopedic implant removal, and systemic antibiotic administration are generally performed to control SSIs. Orthopedic implant removal is considered to be an efficacious procedure. For example, 28% to 79% of orthopedic implants are removed after foot, ankle, or lower leg fracture surgery.[3,4] After orthopedic implant removal, postoperative SSI rates are reportedly 0% to 20%.[3–5] The standard-of-care therapeutic regimen is insufficient in the management of SSI after fracture fixation. Some studies have reported the use of negative pressure wound therapy with instillation and dwell time (NPWTi-d) to treat patients with infected orthopedic fixation hardware.[6–9] Although NPWTi-d is thought to be effective in managing superficial SSI after fracture fixation, it may not be therapeutically effective for deep SSI, due to the difficulty of disrupting the biofilm in the deep dead space.[7]

Recently, Himeno et al[10] reported a method for managing limb infection that involves continuous local antibiotic perfusion in conjunction with NPWT. In that study, intramedullary and subcutaneous antibiotic perfusion were applied to manage bone and soft tissue infections, respectively. The authors of this report hypothesized that such antibiotic perfusions could be applied to manage post-fracture fixation SSI with a dead space that would predispose a patient to bone infection. The authors of this case report modified and applied this technique to treat patients with severe SSI after below-knee fracture fixation, with the goal of salvaging the orthopedic implant. The modified technique is described herein.