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


Surgical site infection after fracture fixation is a devastating complication, and infection control may require orthopedic implant removal or replacement. However, for patients with deep SSI, whose orthopedic implants are difficult to remove, preservation of the orthopedic implant is warranted. Negative pressure wound therapy with instillation and dwell time is recommended as an adjunct therapy in patients with infected or contaminated wounds involving orthopedic fixation hardware.[11] Some studies have reported that NPWTi-d with various types of instillation fluids can be used to salvage infected orthopedic fixation hardware.[6–9] However, Hehr et al[6] reported that original lower extremity hardware was salvaged in only 33% of patients after fracture fixation, which shows the difficulty of using NPWTi-d. Several methods reportedly involve local delivery of antibiotics to control orthopedic infections. The use of antibiotic-impregnated cement and beads,[12] antibacterial powder sprays,[13] and local antibiotic injections[14] in the management of orthopedic infections is long established. These methods are disadvantageous because antibiotic concentrations decrease with time;[15] thus, it is better to use a method that maintains a constant antibiotic concentration.

Based on this finding, the 2 patients in this case report were treated using continuous intramedullary and subcutaneous antibiotic perfusion. That is, 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.

Although the use of topical antiseptic or antibiotic perfusion is considered effective in the management of SSI, Kurlander et al[16] reported the efficacy of a combination of sub-flap irrigation using normal saline and NPWT in the management of infected extremity wounds after flap reconstruction. After debridement, the use of intramedullary and subcutaneous antibiotic perfusion in the patients in the current report may have had a more notable therapeutic effect on the infected wounds in the presence of orthopedic fixation hardware. It is unknown, however, whether the antibiotic perfusion was necessary at all, let alone necessary for 5 days. Subcutaneous flap irrigation using normal saline may have been sufficient. Himeno et al[10] used intramedullary antibiotic perfusion to manage osteomyelitis, but the efficacy of intramedullary antibiotic perfusion for post-fracture fixation SSI was not clarified in their study.

Although intramedullary antibiotic perfusion is effective in managing or preventing early osteomyelitis with seemingly few side effects, more work is required to clarify the procedure and its efficacy. In the 2 patients in this case report, intramedullary antibiotic perfusion apparently affected the bone and orthopedic implant (intramedullary nail and screw) infections. In both patients, the infections were successfully managed without the need for titanium plate removal.