Surgical Site Infection Following Intramedullary Nailing of Subtrochanteric Femoral Fractures.

Michalis Panteli,Peter V Giannoudis,Anthony Howard,James S H Vun,Ippokratis Pountos,Robert M West

doi:10.3390/jcm10153331

Abstract

Aim: To investigate the incidence, risk factors and pathogenic micro-organisms causing superficial and deep infection in subtrochanteric femoral fractures managed with an intramedullary nail. Materials and Methods: Following institutional board approval, all consecutive patients presenting with a subtrochanteric fracture were retrospectively identified, over an 8-year period. Basic demographics, fracture characteristics, fracture union, revision operation, mortality and other complications were reported and analysed. Variables deemed statistically significant (p-value < 0.05) were then included into a revised adjusted model of logistic regression analysis, where we reported on the odds ratio (OR). Results: The overall incidence of infection was 6.4% (n = 36/561; superficial: 3.7%; deep: 2.7%). Associations with deep infection included: non-union (OR 9.29 (2.56–3.38)), the presence of an open fracture (OR 4.23 (3.18–5.61)), the need for massive transfusion (OR 1.42 (2.39–8.39)), post-operative transfusion (OR 1.40 (1.10–1.79)) and prolonged length of stay (OR 1.04 (1.02–1.06)). The Commonest causes of superficial infection were Staphylococcus aureus (28.5%), enteric flora (23.8%) and mixed flora (23.8%); whereas coliforms (60%) and Staphylococcus aureus (26.7%) were the commonest micro-organisms isolated in deep infection. Polymicrobial infection was identified in 38.5% and 80% of superficial and deep infections, respectively. Conclusion: Causative micro-organisms identified in both superficial and deep infection were similar to those reported in post-traumatic osteomyelitis. In an attempt to minimise infection, the treating clinician should focus on modifiable risk factors with adequate patient optimisation, prompt surgical treatment, adequate antibiotic coverage and wound care when treating patients with subtrochanteric femur fracture.

Highlights

Subtrochanteric fractures represent a subgroup of proximal femur fractures, located between the lesser trochanter and 5 cm distal from it [1]
A total of 561 patients (217 male; mean age: 73.1 years old, SD: 19.1 years) with subtrochanteric femur fractures treated with an intramedullary nail were included into the study
The overall incidence of Coliform deep infections was similar to that published in the literature (Enterobacter cloacae 11–12%; Klebsiella pneumoniae 4–12%; Citrobacter koseri 2%) [17,18], we found the incidence of Escherichia coli deep infection in our cohort of subtrochanteric fractures to be nearly double that reported in the literature

Summary

Introduction

Subtrochanteric fractures represent a subgroup of proximal femur fractures, located between the lesser trochanter and 5 cm distal from it [1]. Staphylococcus aureus (S. aureus) is the predominant organism isolated from such infections, having an increasing incidence in the last few decades [15,16,17,18]. Polymicrobic infections have been reported in as many as 29% of the cases, posing an additional challenge to their treatment, leading to a synergistic resistance to a wide range of antibiotics [17,19,20]. Culturenegative infections have been reported in up to 32% of patients [18,19], possibly because of the early targeted start of empirical antibiotic therapy, or the presence of biofilms isolating these organisms from the environment [21,22]

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