Post-operative infection in internally fixed closed fractures – the risk factors, organisms and their sensitivity

Abstract

Introduction: Incidence of infection after internal fixation of closed fractures is generally lower (1−2%). Aim of this study is to find out risk factors and identify the organism and their sensitivity to commonly used antibiotics in post-operative infected cases following internally fixed closed fractures. Material & Methods: 211 patients of all ages and both sexes underwent elective surgery for internal fixation of closed fractures by a single surgical team at our institute from September 2016 to September 2017. 18 of them developed post-operative infection and were retrospectively analysed. Presence of post-operative infection was diagnosed on basis of history, clinical examination, blood parameters and radiographs. Surgical site infection, superficial or deep, florid or low grade, early or delayed or late onset infection were defined as per existing literature. Microscopy, culture and sensitivity test was done on swabs obtained from discharge through surgical site or sinus tract or from deep tissues during surgical exploration under anaesthesia. Results: The post-operative infection rate in our study was 8.53% (18 cases out of 211). Males (n=14), age > 40 years (n=11), femur (n=9, 50%) especially proximal end (n=7), pre-operative hospital stay for > one week and increased duration of surgery of more than 60 minutes were most commonly affected. 5 out of 40 cases (12.5%) of closed reduction and 13 out of 171 cases (7.6%) of open reduction developed post-operative infection. The percentage of post-operative infection with plate, intramedullary nail, screw and bipolar prosthesis implantation are almost similar. Late onset (50%), superficial (61.11%) and low grade infection (77.78%) were more common than their counterparts. Staphylococcus aureus was the most common organism followed by Klebsiella pneumonae. Imipenem, ciprofloxacin& vancomycin were most common sensitive antibiotics. Imipenem showed sensitivity to gram negative organisms but Vancomycin, Co-trimoxazole, Cefoxitim and Linezolid were sensitive to Staphylococcus species including MRSA (Methicillin resistant Staphylococcus aureus). Ciprofloxacin was sensitive to both Staph species & gram negative organisms. 15 patients had at least one comorbidity and 8 patients had more than 2 comorbidities, anaemia being the most common. Conclusion: Knowledge of patient related clinical factors and commonly isolated organisms and their antimicrobial sensitivity patterns within a given hospital assists in prophylaxis and treatment of postoperative infection.

Subtle hip joint subluxation after femoral neck fracture fixation: an ominous sign in a report of two cases

“…Diagnosis of such cases presents a clinical challenge because the hip is a deep structure, and early signs of infection like swelling and erythema may be obscured. Most of the postoperative hip infections after internal fixation occur without any systemic signs such as fever or malaise 10. The picture may even be more silent if the infective agent is a slow-growing organism like in the first patient in this report.…”

“…Most of the postoperative hip infections after internal fixation occur without any systemic signs such as fever or malaise. 10 The picture may even be more silent if the infective agent is a slow-growing organism like in the first patient in this report. Such a scenario may go undiagnosed and progressively evolve into a subluxation or dislocation.…”

“…In the absence of infection, excessive valgus fixation, neck collapse, and capsular injury are the described mechanisms while septic subluxation or dislocation usually involves tense intraarticular collection or destruction of restraining structures caused by hip joint sepsis 6. The deep sepsis in such cases is usually a low-grade infection caused by Staphylococcus aureus or epidermidis presenting without any systemic signs 1,2,10. The outcome in both septic and aseptic dislocations is mostly poor, and often replacement surgery is needed 6…”

“…6 The deep sepsis in such cases is usually a low-grade infection caused by Staphylococcus aureus or epidermidis presenting without any systemic signs. 1,2,10 The outcome in both septic and aseptic dislocations is mostly poor, and often replacement surgery is needed. 6 This report presents two patients with hip subluxation after minimally invasive fixation of displaced transcervical femoral neck fractures with CCS.…”