Treatment of post-operative infections following proximal femoral fractures: our institutional experience
Injury, Int. J. Care Injured 42 (2011) S5, S28–S34
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j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / i n j u r y
Treatment of post-operative infections following proximal femoral fractures: Ourinstitutional experience
A.A. Theodoridesa, T.C.B. Pollardb, A. Fishlocka, G.I. Mataliotakisa, T. Kelleyb, C. Thakarb, K.M. Willettb,P.V. Giannoudisa
aAcademic Department of Trauma and Orthopaedic Surgery, Leeds General Inﬁrmary, University of Leeds, Leeds, bOxford Trauma Unit, The John Radcliffe Hospital, and NufﬁeldDepartment of Orthopaedics, Rheumatology, and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
Proximal femoral fractures (PFFs) are a major health concern in the elderly population.
Improvements made in implants and surgical techniques resulted in faster rehabilitation and
shorter length of hospital stay. Despite this, the reduced physiological reserve, associated co-
morbidities and polypharmacy intake of the elderly population put them at high risk of post-
operative complications particularly of infectious origin.
Out of 10 061 patients with proximal femoral fractures 105 (1.05%) developed surgical site
infection; 76 (72%) infections occurred in patients who had sustained intracapsular (IC) fractureswith the remaining 29 (28%) infections occurring in patients with extracapsular (EC) neck of femurfractures. The median number of additional surgical debridements was 2 (range 1–7). MRSA wasisolated in 49 (47%) of the cases; 38 patients (36%) ultimately underwent a Girdlestone’s excisionalarthroplasty.
Mortality at 30 days and 3 months was 10% and 31%, respectively. It was noted that post-operative
hip infection predisposed to a prolonged length of stay in the acute unit and subsequently to amore dependent destination after discharge.
2011 Elsevier Ltd. All rights reserved. Introduction
population surgical site infections will become ever more prevalent. Surgical site infections (SSI) account for 11% of all nosocomial
Proximal femoral fractures (PFFs) are a major health concern in the
infections in the elderly.7 Documented co-morbidities which are
elderly population with strong associated morbidity and mortality
prevalent in the elderly population and are known predictors
and result in additional costs to the hospital and society.1,2 The one-
of surgical site infections8 include: diabetes mellitus, peripheral
year mortality rate ranges from 14% to 36% despite improvements in
vascular disease, malnutrition, chronic hypoalbuminaemia and
surgical technique, anaesthesia and nursing care.3,4 Post-operative
reduced body fat predisposing to hypothermia. However, these
complications can have a threefold increase in 1-year mortality
have not been substantiated speciﬁcally for the elderly population.
rates.5 The reduced physiological reserve, associated co-morbidities
Compared with the younger population, the elderly (65 years and
and polypharmacy intake of the elderly population put them at high
over) have a ﬁvefold greater mortality and a double hospitalisation
risk of post-operative infections alone and when they do occur
stay when they sustain surgical site infections.9
they place an even greater cost to the health service in terms of
Torgerson et al.10 calculated in 2001 that the overall cost of med-
additional operative interventions, revision of metalwork, extra bed
ical and social care for patients with hip fractures is £1.73 billion
stays which are often in higher dependency areas with more intense
per year in the UK, which is similar to the £1.75 billion for coronary
medical and nursing care. Their mobility often worsens, causing
heart disease. They also estimated that a single hip fracture has a
them to lose their independence and become residents in long-
combined medical and social care cost of £20 000. Lawrence et al.11
estimated the NHS expenditure for each fracture alone to be just
Whitehouse et al.6 showed that surgical site infections occurred
over £12 000 which was £7000 more than previous estimates. With
in 1–3% of orthopaedic surgical procedures, and they prolonged
the number of hip fractures being 70 000 in 2008 and rising by 2%
hospital stay by a median of 2 weeks, doubled the rate of rehos-
each year this cost is only going to grow (BOA, 2008).12
pitalisation, increased health costs fourfold and decreased overall
Even though surgical site infections (SSIs) in PFF are known to
physical and social functioning. With the ever increasing elderly
have such an adverse impact on patients and society as a whole,their treatment has not been well documented in the literature.
* Corresponding author. Peter V. Giannoudis MD, FRCS, AcademicDepartment of Trauma and Orthopaedic Surgery, School of Medicine,
The aims of this study were to ascertain the impact of this by
University of Leeds, LIMM Section Musculoskeletal Disease, Leeds,
quantifying the length of hospital stay and overall mortality rates
LS1 3EX, UK. Tel.: +44 113 392 2750; fax: +44 113 292 3290.
and to review the current treatment of deep wound SSIs in our
E-mail address: [email protected] (P.V. Giannoudis).
0020-1383/ $ – see front matter 2011 Elsevier Ltd. All rights reserved. A.A. Theodorides et al. / Injury, Int. J. Care Injured 42 (2011) S5, S28–S34
Table 1Social dependency and mobility scores
Social Dependency Scale
Independent in domestic and social activities.
Minimal help with shopping may have meals on wheels.
Dependent on social support up to three times a week.
Dependent on social support more than three times a week, but less than daily. All domestic activities performed by spouse or carer.
Dependent on social support more than once daily, or resident in a residential home. Personal care provided by spouse.
Resident in nursing home or long stay hospital. Mobility Score
Mobilises with a frame and the assistance of 2 people.
Mobilises with a frame and the assistance of 1 person.
Mobilises with a frame alone, without the need for assistance. Patients and methods
For the period prior to 1 March 2003, cases were identiﬁed
by searching hospital administration and microbiology databases,
operating theatre logs, and line insertion team records. The case
A retrospective study was carried out of all patients over the
notes were reviewed for each patient and the diagnosis of deep
age of 65 years who developed surgical site infections (SSIs)
wound infection conﬁrmed.13 From 1 March 2003, dedicated audit
following surgery for traumatic proximal femoral fractures (PFF)
staff have collected data prospectively for all hip fracture patients.
between 01/01/2004 and 30/08/2010. All patients were treated in a
The data collection is compatible with the National Hip FractureDatabase and managed adhering to the Caldicott principles.14 Cases
tertiary trauma centre in Leeds. Cases were identiﬁed by searching
from 1 March 2003 were identiﬁed by interrogating the unit’s
microbiology, pharmacy and hospital administration databases,
database and then cross-referenced with operation theatre logs,
theatre records and hip fracture database. Deep wound infections
were deﬁned by the need for surgical debridement and washoutwith positive microbiology from tissue deep to the fascia lata.
Key demographics and pre-fracture residence (home, residential
Treatment of infection
home, nursing home) were recorded. The fracture pattern (intra- or
The treatment of deep wound infection consists of a full
extra capsular), use of prophylactic antibiotics and type of ﬁxation
and, if necessary, repeated surgical debridement together with
(cannulated hip screws, dynamic hip screw, hemiarthroplasty)
close liaison with clinical microbiologists. Most patients receive
were also recorded. The dates of subsequent surgery including
intravenous antibiotics for 6 weeks followed by oral suppressive
the need for removal of metalwork, and the organism isolated
therapy as appropriate. Refractory cases may require removal of
were documented for each of the infected cases. The subsequent
antibiotic regimen was identiﬁed from patients’ drug charts and
Routine prophylactic intravenous antibiotics were administered
on induction of anaesthesia prior to their initial fracture surgery.
Outcomes: Each patient was studied from the time of
The choice of antibiotic was according to local microbiological
presentation to the acute orthopaedic unit, to the time of discharge
guidelines. All patients received prophylaxis. All patients undergo-
to their ﬁnal residence or death (if occurring during the period
ing hemiarthroplasty received two further doses of antibiotic post-
of care). The details of any readmissions relating to the original
injury or surgery were also recorded and notes reviewed. Outcomemeasures included the length of hospital stay and mortality. The
Oxford matched cohort study
ﬁnal discharge destination (home, residential or nursing home) for
Using methods described previously by our unit13,15 each infected
each patient was recorded, and for those patients discharged the
case was matched with two control cases taken from the same
mortality data were collected at 6 months post discharge.
prospectively collected dataset. Controls were matched basedon eight factors known to inﬂuence outcome after proximal
femoral fracture.16–18 These were: same sex, age within 4 years,same fracture type (intra- or extracapsular), American Society
The same data were recorded and the same diagnostic criteria
of Anaesthesiologists (ASA) grade within one grade, identical
were used for the patients treated at the John Radcliffe Hospital,
pre-fracture residence, identical operation performed (parallel
Oxford. All patients with PFF (subtrochanteric fractures excluded)
cancellous screw, or hemiarthroplasty for intracapsular fractures,
aged 65 years or above, who presented over an 11-year period
and compression hip screw (CHS) for extracapsular fractures), social
(1 January 1998 to 29 February 2008) were included. Similarly, deep
dependency within one grade and mobility scores within one grade
surgical site infection was deﬁned as microbiological conﬁrmation
of infection from culture specimens of tissue samples taken deep
Patients complicated by deep infection and the non-infected
controls were studied from acute admission through acute hospital,
A.A. Theodorides et al. / Injury, Int. J. Care Injured 42 (2011) S5, S28–S34
Table 2Organisms involved in the infected cases
Methicillin-sensitive Staph. aureus
Table 3Length of in-patient stay (all patients): mean (SD)
intermediate care and/or community rehabilitation hospital until
The median number of additional surgical debridements was 2
discharge. The date of acute admission was recorded, as were
(range 1 to 7). The details of the infecting organisms are shown in
the date of operation and grade of the operating surgeon for
Table 2; 49 (47%) cases involved MRSA. In 26 cases 2 organisms
the primary procedure. Demographic information such as age,
and in 11 cases 3 organisms were cultured. In 3 cases 4 different
sex, ASA score, mobility score, social dependency score and pre-
organisms were grown over the course of the patient’s treatment.
admission residential status were also recorded. Ultimate discharge
Ultimately 38 patients (36%) underwent a Girdlestone’s excisional
destination (own home, residential or nursing care facility) for
those surviving to discharge was recorded. Mortality informationwas obtained from the Ofﬁce of National Statistics in November
2009 over 1 year after the last patient was included in the study. From these data, mortality probability was calculated at various
Of 74 cases that survived to ﬁnal discharge from acute or
time points. The number of surgical debridements and details
rehabilitation beds, 32 (43%) returned home, 20 (27%) were
of organisms cultured from deep samples were recorded for the
discharged to a residential home and 22 (30%) to a nursing home
infected cases. Outcome measures included mortality and length of
facility. Of these 74, 41 (55%) returned to equivalent residential
stay in the acute, community and rehabilitation hospitals, and ﬁnal
status, 22 (30%) dropped a single grade (e.g home to residential
home), and 11 (15%) dropped two grades (e.g home to nursing
The data were analysed using SPSS statistics software, ver-
sion 17.0. Fisher’s exact test was used for 2 × 2 contingency tables
Mortality at 30 days, 3 months and 1 year was 10%, 31%, and 45%,
and Student’s t-test for continuous data. A p-value of less than 0.05
Results: Combined Leeds and Oxford infected cohort
Based on our matching criteria, it was possible to match 162
uninfected controls with the 87 infected Oxford cases. Breakdowns
Of the 4823 Oxford patients with PFF, there were 87 (1.8%) who
for the length of stay (LOS) of the infected and control cases are
were complicated with deep surgical site infection. Of the 5238
shown in Table 3. The major difference was in the LOS in the acute
Leeds patients there were 18 (0.35%) conﬁrmed cases of deep
unit, with the period spent in community rehabilitation similar
Of 105 infected cases, there were 86 (81.9%) females and 19
Although mortality was higher in the infected cases at 3 months
(18.1%) males (mean age 83 years); 76 (72%) sustained intracapsular
and 1 year, this did not reach statistical signiﬁcance (Table 4).
(IC) fractures with the remaining 29 (28%) extracapsular (EC) neck
Because of the longer length of stay of the infected cases, a higher
of femur fractures; 74 (70%) patients were admitted from home,
proportion died during their in-patient stay; 26 of 87 infected cases
14 (13%) from a residential home, 8 (8%) from a nursing home,
died whilst in hospital or community hospital care, versus 25 of 162
and 9 (9%) were already hospital in-patients at the time of fracture.
controls (odds ratio 2.4, p = 0.009).
Three (4%) of the IC fractures underwent cannulated screw ﬁxation,
Of the infected cases surviving to discharge to home, residential
and 73 (96%) were treated with cemented hemiarthroplasty. All 29
or nursing care, 26 of 60 (43%) returned to a more dependent
EC fractures were treated with a dynamic hip screw.
destination (i.e. downgrade). In the controls, only 23 of 137 (17%)
A.A. Theodorides et al. / Injury, Int. J. Care Injured 42 (2011) S5, S28–S34
Table 4Mortality at 30 days, 3 months and 1 year, from the Oxford matched cohorts of 87 infected and 162 control cases
Table 5Recently published studies reporting on infection and mortality rates following proximal femoral fractures
a In patients operated within less than 18 h from the fracture.
cases were discharged to a downgrade destination (odds ratio 3.8,
p < 0.001). A summary of the most recent studies reporting on
Pre-operative antibiotic prophylaxis is one of the main factors
infection rates and mortality following PFF is shown in Table 5.19–25
to inﬂuence the incidence of post-operative infections.42–45 Inour institutions prophylaxis has always been advised by our
microbiology department. In general, until 2008 cefradine and
The mainstay of the treatment of proximal femoral fractures, either
gentamicin with 2 post-op doses of cefradine were used. It was
IC or EC, is surgical. Multiple implants, such as cannulated screws,
then changed to a single shot of augmentin and gentamicin, due to
sliding screw devices, intramedullary nails, hemi- and total hip
Clostridium difﬁcile concerns, and teicoplanin instead of augmentin
arthroplasties can be used for this purpose.26–37 The presence in the
was administered in case of allergy to penicillin. Known methicillin
elderly of multiple co-morbidities and a compromised immunity as
resistant Staphylococcus aureus (MRSA) carriers got vancomycin
well as a reduced bone stock, predispose them to post-operative
medical and functional deterioration, periprosthetic fractures,
It is reported that the preferred prophylactic antibiotic came from
delayed healing, implant loosening and increased mortality rates,
the cephalosporin group, whereas ceftriaxone was found to be the
which have been well described in the literature.38–40 A major
most cost-effective.42,45 The effect of a single dose is similar to those
post-operative complication, which may also be an aftermath
from repeat doses, given that this antibiotic is active throughout
of the other complications, is infection. The latter, regardless of
the operation.42,45 In the study by Thyagarajan et al.,43 where the
its causative micro-organism or extent, complicates further the
MRSA infection rate was 14.28% (3 out of 21), it was reported that
rehabilitation and diminishes the overall outcome.
teicoplanin should be used for antibiotic prophylaxis in high-risk
Comparison with the literature: We examined similar studies in
patients such as those being MRSA carriers or conﬁrmed MRSA
the literature using matched control groups for the comparison of
positive. Starks et al.46 showed a single dose of cefuroxime (1.5 g)
the demographic data. In the study by Pollard et al.41 the mean
and gentamicin (240 mg) intravenously at induction of anaesthesia,
age of the patients sustaining PFF and the male to female ratio
improved their overall infection rates from 5.7% to 3.2%, of which
are almost the same. The percentage of female patients was 83.6%
the MRSA infection rate reduced from 63% to 50.0%.
vs. 81.9% in the present study. Also the ratio of the IC to EC
Surgical treatment: The treatment pathway of PFF post-operative
fractures is almost the same; 67.0% vs. 72.0% for IC and 33.0% vs.
infection is dependent upon the severity of the infection in terms of
28.0% for EC, respectively. The percentages of patients treated with
the type and virulence of the micro-organism implicated, the extent
hemiarthroplasty and DHS were similar: 62.3% vs. 69.5% and 33.0%
of the infection at the time of diagnosis and the local destruction
vs. 28.0% respectively. Great similarity is presented in the residential
around the infected area. The latter may be translated into non-
origin of the patients with 69.0% vs. 70.0% in the present study being
union or total ﬁxation failure. Therefore early diagnosis is of utmost
admitted from their home, 16.0% vs. 13.0% from a residential home,
importance. In the study of Pollard et al.,41 the time interval from
7.0% vs. 8.0% from a nursing home and 8.0% vs. 9.0% being already
the initial operation to the decision of debridement was 14 (range
in-patients at the time of fracture.
In the study of Partanen et al.21 the mean age of the patients
The mainstay of treatment of deep wound infection consists of
sustaining PFF was 79.7 vs. 83.0 years in the present study. The
full and repeated surgical debridement together with intravenous
females sustaining PFF were 2.6 times more in number than males
antibiotics. In our study 2 (1–7) debridements were needed on
in comparison with 4.3 times more noted in our study. Partanen
average for the eradication of the infection and ultimately 36.0%
et al. provide no information regarding the type of initial ﬁxation.
Girdlestone procedures were performed for refractory cases.
As far as the residential status is concerned 48.0% were admitted
According to our experience there are no speciﬁc time frames or
from their home, 48.0% from a convalescent home and 3.4% from
rules on the number of surgical debridements. Apart from factors
a geriatric department vs. 70.0%, 7.0% and 8.0%, respectively, in the
concerning the infection as mentioned above, the decision is based
on patient factors and the response at the additional antibiotic
A.A. Theodorides et al. / Injury, Int. J. Care Injured 42 (2011) S5, S28–S34
suppressive therapy. Furthermore the initial surgical treatment
linezolid. Ceftaroline has broad coverage and so is effective against
may be augmented by additional factors in view of the secondary
most pathogens found in orthopaedic infections.
The treatment may stop when the infection has been eradicated
Deep infection may directly affect the hip joint either by
and is no longer a threat to the patient’s life. However, the
the fracture type (comminuted fracture with intra-articular
remaining function of the limb may be diminished, due to the
component) or by the ﬁxation failure (e.g. DHS cut out).47
extensive debridement operations, possible bone loss or other
Haidukewych GJ et al.47 stated that under these circumstances, a
complications, such as intraoperative femoral fracture, cement
resection arthroplasty, hardware removal, thorough debridement
and the indicated antibiotic treatment, followed by staged
Continued surgical treatment: As in the literature, the further hip
replacement arthroplasty, should be performed. In the same study
reconstruction depends on the functional needs and the health
a 100% survival of the THA at 7 years and 87.5% at 10 years was
status of the patient, and on the feasibility of bony and soft-
presented noting that no revisions were performed due to any
tissue restoration.52,53 In our institutions, if suppression is working,
infection or acetabular cartilage wear.
and there is no evidence of loosening, then the prosthesis may
Hsieh et al.48 reported the outcome of two-stage arthroplasty
be retained. In case of failure to control the infection with serial
performed as a salvage procedure for deep hip infection following
debridements in hemiarthroplasty cases, a Girdlestone would be
intertrochanteric fractures. The use of a cement spacer with
antibiotics (vancomycin either alone or in combination with
Provided that there are no laboratory or clinical signs of active
piperacillin or aztreonam), compared with gentamycin impregnated
infection and if the patient is considered reasonably ﬁt then a
cement beads, seems to give similar results (p = 0.29) concerning the
two-staged revision may be considered. Similarly, it is reported in
eradication of the initial infection and better results in terms of hip
the literature that the second-stage procedure (salvage procedure,
range of motion and patient mobility. The mean interim period was
second stage total hip arthroplasty [THA]) is carried out when all
13.3 (9–22) and 15.1 (7–23) weeks for the beads and for the cement
cultures are negative, the wound has healed, the CRP level has
spacer, respectively. There was only one recurrence of infection at
returned to normal, and the surgery is medically feasible; this is
usually 6–12 weeks after the ﬁrst stage.48,52,53
An antibiotic cement screw is also described for the use after
For fractures treated with a DHS, we use imaging to monitor
gamma nail removal due to infection. It is inserted in the lag screw
union, with suppression ongoing, and then we remove the metal
hole after the removal of the infected metalwork.49 The advantages
once the fracture has united. If the fracture is not healing and
of this device are that the screw provides stability in order to
the infection is ﬂorid then the involvement of the hip joint in the
support the weakened bone due to the metalwork removal and
infection and the necessity of preserving the patient’s femoral head
that the cement delivers antibiotic in high concentration directly in
must be considered. This rationale is in line with the literature.54
The options at that phase are either hardware removal, further
Identiﬁcation of the causative micro-organism: After intraoperative
debridement to vascular tissue and ﬁxation with another device in
samples are taken, clinical microbiologists are involved in the
order to proceed for bone gap bridging procedure, or a Girdlestone
decision making regarding the identiﬁcation of the micro-organism
procedure, which may be permanent41 or may be the transitional
and the appropriate antibiotic treatment. There is a high similarity
between the causative micro-organisms found in the present studyand those isolated by Pollard et al.41 The involved micro-organism
in 47% of the cases was MRSA, which is the commonest cause inmost studies.19,21,40
Hospitalisation: In the studies that used a cohort of patients without
In the study by Partanen et al.,21 Staphylococcus aureus was the
comparison with a control group3,19,21,23,24,55 the mean duration of
most common causative micro-organism, either alone or as a mixed
stay after a post-operative hip infection is reported to range from
infection. In the same study other common bacteria which were
7.1 days21 to 82.4 days.19 In studies comparing the ﬁndings with
isolated were Enterococcus spp. and Staph. epidermidis. Varley et al.25
a control group the mean acute hospitalisation for post-operative
reported that the infective organism was mostly Staph. aureus being
PFF infections is reported to be even higher. In the study by Pollard
found in 12 cases, with Escherichia coli found in 3, Staph. epidermidis
et al.41 the median length of stay was found to be 132.5 (range: 64–
in 2 and 1 case of enterococci. In the study of Sanchez et al.50 the
155) days compared with 30.0 (range: 13–53) days in the controls,
most common infecting organism, being found in 40% of cases, was
who did not develop post-operative infection after PFF (p < 0.001).
In our study the mean acute bed hospital stay for the patients
The recurrent post-operative infection following any debridement
with post-operative PFF infections was 68 days and there was a
and hardware exchange seems to be attributed to coagulase-
signiﬁcant difference with the hospital stay of the control group.
This result is in accordance with the literature. In the patient
The antibiotics scheme: In our institutions the treatment of the
assessment at 4 months in the study of Partanen et al.21 the mean
infected cases consists of 6 weeks of culture-speciﬁc intravenous
duration of hospitalisation at the primary hospital was signiﬁcantly
antibiotic and then oral for as long as it is felt to be clinically
longer for the study than for the control group (p < 0.001). In the
appropriate. For MRSA infections, intravenous vancomycin was
study by Siegmeth et al.,56 a signiﬁcant increase in length of stay
administered initially for a period of 4–6 weeks, which is then
was found in patients operated on after 48 hours when compared
switched to either oral lenizolid (for 4 weeks) or teicoplanin
with those in the earlier group (21.6 vs. 32.5 days).
treatment for another 6 weeks. Oral rifampicin and doxycycline are
Residence status: In our study, 43% of the patients who had a
prescribed for longer periods of time as clinically indicated.
post-operative hip infection were downgraded after discharge and
This antibiotic scheme is in line with the literature42,45,48 and
a signiﬁcant difference was found in comparison with the control
the infection is thereafter closely monitored both clinically and
group. These results are in line with the literature. In the study of
through the CRP serum level once or twice a week.48 Nevertheless,
Palmer et al.57 13% of the patients who had a post-operative hip
Jacqueline et al.51 demonstrated that vancomycin can fail in the
infection secondary to DHS, 9% of those who had hemiarthroplasty
treatment of osteoarticular MRSA infections. They went on to show
and 33% of those who had cannulated hip screws, were downgraded
that a new cephalosporin, ceftaroline, was the most effective agent
after discharge. In the study of Partanen et al.21 the percentage of
in osteoarticular MRSA infection compared with vancomycin and
patients after post-operative PFF infection who returned home after
A.A. Theodorides et al. / Injury, Int. J. Care Injured 42 (2011) S5, S28–S34
discharge was decreased by 27.6%. The percentage of the patients
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who returned to a residential home was decreased by 31.1% and the
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Publication summary Efficacy of modified-release versus standard prednisone to reduce duration of morning stiffness of the joints in rheumatoid arthritis (CAPRA-1): a double-blind, randomised controlled trial. Buttgereit F, Doering G, Schaeffler A, et al. Lancet 2008; 371(9608):205-14. Background and key findings It was proposed that by administering glucocorticoids of RA compared w