Is Surgical Removal Necessary for Chronic Infection After Fracture?

Is it necessary to extract it?

In May, my husband suffered a work-related injury resulting in an open fracture of his right calf.
Following the doctor's advice, he opted for a titanium alloy material that does not require removal.
However, he has since been in and out of the hospital due to high pain levels and has been treated with antibiotics.
Later, a red, protruding wound appeared at the surgical site.
The doctor indicated that it was infected and required surgery.
Shortly after returning home, the same wound developed pus again.
Upon returning for a follow-up, it was diagnosed as a chronic infection, and the doctor recommended removing the internal fixation (the bone in the infected area has not healed).
I would like to know if removal is absolutely necessary.
Are there no other options for improvement? Initially, we spent over 70,000 on the material based on the doctor's recommendation, and now it seems it needs to be removed.
Will the removal affect his ability to walk? Will he need to rest for a while afterward?

Cai Xiaojie, 30~39 year old female. Ask Date: 2018/03/29

Dr. Shi Guozheng reply Orthopedics

After a fracture, if there is a fixation with a plate and an infection occurs, it is necessary to remove the screws and plate to treat the infection; otherwise, it is difficult to resolve the infection.
Reoperation may be required to improve the condition.

Reply Date: 2018/03/29

More Info

Chronic infections following a fracture, especially after surgical intervention, can be a significant concern. In your case, it appears that your husband has developed a persistent infection at the surgical site after an open fracture of the right leg, which has led to repeated hospital visits and antibiotic treatments. The situation you describe raises several important considerations regarding the necessity of surgical removal of the internal fixation device, in this case, a titanium alloy plate.

Is Surgical Removal Necessary?
In many cases, if a chronic infection is present, the surgical removal of the internal fixation device may be necessary. This is particularly true if the infection is localized around the hardware and is not responding to antibiotic therapy. The presence of the hardware can create a biofilm, a protective layer that bacteria can form, making it difficult for antibiotics to penetrate and effectively treat the infection. By removing the hardware, the source of the infection is eliminated, which often leads to improved healing and resolution of the infection.

However, the decision to remove the hardware is not always straightforward. Factors such as the extent of the infection, the condition of the surrounding bone, and whether the fracture has healed sufficiently must be considered. If the bone has not healed and the hardware is removed, there may be a risk of instability, which could complicate recovery. In some cases, surgeons may opt to leave the hardware in place and manage the infection with aggressive antibiotic therapy and wound care, especially if the bone shows signs of healing.

Alternatives to Removal
If removal of the hardware is not immediately necessary, there are alternative strategies that can be employed to manage chronic infections. These may include:
1. Antibiotic Therapy: Long-term antibiotic treatment, possibly guided by culture and sensitivity testing, can help control the infection. In some cases, intravenous antibiotics may be required.

2. Wound Care: Proper wound care, including cleaning and dressing changes, can help manage the infection. In some cases, negative pressure wound therapy (NPWT) may be utilized to promote healing.

3. Debridement: Surgical debridement may be performed to remove necrotic tissue and any infected material without removing the hardware. This can help reduce the bacterial load and promote healing.

4. Bone Grafting: If there is significant bone loss or non-union, bone grafting may be considered to promote healing.

Impact of Removal on Mobility
Regarding your concerns about the impact of hardware removal on mobility, it is important to understand that while removal may temporarily affect stability, it is often a necessary step towards long-term recovery. After removal, rehabilitation will be essential to regain strength and function in the affected leg. The duration of recovery can vary based on individual circumstances, including the extent of the infection and the overall health of the bone.

Conclusion
In summary, while surgical removal of the internal fixation device may be necessary in cases of chronic infection, it is essential to have a thorough discussion with the orthopedic surgeon regarding the best course of action. Each case is unique, and the decision should be based on a comprehensive assessment of the infection, the state of the bone, and the overall treatment goals. If you have concerns about the treatment plan or wish to explore other options, seeking a second opinion from another orthopedic specialist may provide additional insights and reassurance.

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