Treatment of post-operative infections following proximal femoral fractures: our institutional experience

Injury, Int. J. Care Injured 42 (2011) S5, S28–S34 Contents lists available at ScienceDirect 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 Discussion
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 Implications
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 2. Eastwood HD. The social consequences of surgical complications for patients who returned to a residential home was decreased by 31.1% and the with proximal femoral fractures. Age Ageing 1993;22:360–4.
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Competing interests
27. Anastopoulos G, Chissas D, Dourountakis J, Ntagiopoulos PG, Magnisalis E, Asimakopoulos A, et al. Computer-assisted three-dimensional correlation All authors declare no conflict of interest regarding the preparation between the femoral neck-shaft angle and the optimal entry point for antegrade nailing. Injury 2010 Mar;41(3):300–5.
28. Beloosesky Y, Hershkovitz A, Guz A, Golan H, Salai M, Weiss A. Clinical characteristics and long-term mortality of occult hip fracture elderly patients.
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