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Postoperative Infections and Hardware Failure: Prevention and Management

Understand the risk factors, prevention strategies, and treatment principles for postoperative infections and hardware failure in orthopedic surgery, emphasizing early diagnosis and aggressive action. Learn about common organisms, diagnostic markers, imaging modalities, and modes of hardware failure. Stay informed to optimize patient outcomes.

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Postoperative Infections and Hardware Failure: Prevention and Management

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  1. Infections and Hardware Failure Colin B. Harris, MDAssistant Professor Department of Orthopaedics Rutgers – New Jersey Medical School Newark, NJ

  2. Disclosures • Globus, Inc. – Consulting, teaching

  3. Postoperative Surgical Site Infection (SSI) • Serious postoperative complication • Incidence • 1% non-instrumented cases • 3-12% instrumented fusions Rechtine G, et al J Orthop Trauma 2001, Glassman S et al, Spine 1996.

  4. Sequelae • Pseudoarthrosis (25-50%) • Chronic wounds • Neurologic compromise / paralysis • Sepsis -> death Cahill P, Warnick D, Lee M, et al. Spine 2010;20(35):1211-17.

  5. Risk Factors

  6. Risk Factors

  7. Risk Factors

  8. Other risk factors • Use of microscope (1.4 vs 0.5%)* • Drain use • Fluoroscopy machine • Prolonged retractor use Stolke D, Sollmann WP, Seifert V. Intra- and postoperative complications in lumbar disc surgery. Spine 1989;14:56–59.

  9. Preop evaluation • DM control!! HgbA1C <7.0 • Nutrition • Albumin <3.5g/dL • Total lymphocyte count <1500/mm3 • Transferrin <150 ug/dL • Weight loss • Smoking cessation Hikata T, et al. J OrthopSci 2014.

  10. The basics • Do it yourself • Prep and drape (don’t delegate!) • Be mindful of OR traffic • Irrigate & reposition retractors frequently

  11. Prevention • IV abx 30min prior and 24 hrs postop • 0.3% betadine irrigation + 1gm Vanco powder • Meticulous hemostasis & layered closure • Incisional wound VAC

  12. Types of postoperative infection • Direct inoculation (<90 days) • Early postoperative contamination (subacute) • Hematogenous seeding (late) Mok J, Spine 2009. Cahill P, Spine 2010.

  13. Organisms • S. aureus 73% (5-18% MRSA)* • S. epidermidis • E. coli, E. faecalis – fecal or genitourinary contamination • P. acnes – Low virulence, late hardware infections Pull terGunne A, Cohen D. Spine 2009;34:1422-8.

  14. Diagnosis Signs/symptoms: • Wound drainage (most common) • Increasing pain • Fever • Erythema • Increased warmth Collins I, Wilson-MacDonald J, Chami G et al. Eur Spine J 2008;17:445-50.

  15. Diagnosis Signs/symptoms: • Wound drainage (most common) • Increasing pain • Fever • Erythema • Increased warmth Dx can be difficult Must follow patients long-term Collins I, Wilson-MacDonald J, Chami G et al. Eur Spine J 2008;17:445-50.

  16. Biological Markers • CRP: Normalize 2-3 weeks, most sensitive Takahashi J, Ebara S, Kamimura M, et al. Early-phase enhanced (18)

  17. Biological Markers • CRP: Normalize 2-3 weeks, most sensitive • ESR: Peaks 2 weeks, normalizes 6 weeks Takahashi J, Ebara S, Kamimura M, et al. Early-phase enhanced (18)

  18. Biological Markers • CRP: Normalize 2-3 weeks, most sensitive • ESR: Peaks 2 weeks, normalizes 6 weeks • Lymphopenia: <10% (1,000/µL) at 4 days postop sensitive for infection* Takahashi J, Ebara S, Kamimura M, et al. Early-phase enhanced (18)

  19. Biological Markers • CRP: Normalize 2-3 weeks, most sensitive • ESR: Peaks 2 weeks, normalizes 6 weeks • Lymphopenia: <10% (1,000/µL) at 4 days postop sensitive for infection* • WBC count less reliable Takahashi J, Ebara S, Kamimura M, et al. Early-phase enhanced (18)

  20. Imaging • Plain radiographs • Initial imaging of choice • Normal first 3-4 weeks • Halo/lysis around screws

  21. Imaging • Plain radiographs • Initial imaging of choice • Normal first 3-4 weeks • Halo/lysis around screws Scrutinize carefully for subtle findings!

  22. Imaging • CT • Loss of bone-implant interface • Lysis/loosening

  23. Imaging • MRI • Best modality for soft tissue • Epidural / psoas abscess • Osteomyelitis

  24. Instrumentation: Modes of Failure • Biologic • Infection • Osteoporosis • Other patient-related issues • Biomechanical • Error in thought process • Error in application O’ Leary P, Ghanayem A. Instrumentation Complications. In Rothman and Simeone The Spine, pp. 1777-88, Elsevier 2011.

  25. Instrumentation: Modes of Failure • Biologic • Infection • Osteoporosis • Other patient-related issues • Biomechanical • Error in thought process • Error in application O’ Leary P, Ghanayem A. Instrumentation Complications. In Rothman and Simeone The Spine, pp. 1777-88, Elsevier 2011.

  26. Instrumentation • Relies on interface between implant and host bone • Stability at expense of higher infection risk • Increased operative time • Glycocalyx biofilm • Titanium vs Stainless Steel

  27. Principles of Treatment • Early diagnosis and treatment critical • Think of infections by chronicity and stability of spine • Act aggressively

  28. Principles of Treatment • Early diagnosis and treatment critical • Think of infections by chronicity and stability of spine • Act aggressively Medical Management

  29. Debridement • Systematic: Superficial to deep • Pulse lavage with NS +/- abx • Removal of loose graft material • Consider antibiotic beads

  30. Debridement • Systematic: Superficial to deep • Pulse lavage with NS +/- abx • Removal of loose graft material • Consider antibiotic beads • If any doubt -> return for serial debridements until clean

  31. When to remove hardware • Failed (loose/broken) instrumentation • Refractory infections • Late hematogenous infection AFTER fusion healing

  32. When to remove hardware • Failed (loose/broken) instrumentation • Refractory infections • Late hematogenous infection AFTER fusion healing Implants can be retained in MOST cases of acute / subacute infections Lall R, Wong A, Lall RR, et al. J ClinNeurosci 2015;22:238-42. Khanna K, Janghala A, Sing D, et al. Int j Spine Surg 2018;12(4):490-97.

  33. Re-instrumentation • Deformity progression, instability • Principles: • Be prepared to upsize screws • Go anterior (if infection posterior) • Consent to go additional levels • Iliac screws • Extension to thoracic spine Chronic antibiotic suppression may be necessary

  34. 67 patient with SSI after instrumented fusion • 28% removal, 9% exchanged, 37% retained with abx • No patients with retained implants had infection recurrency at long-term follow-up

  35. Wound Closure for SSI • Layered with non-braided suture • Plastic Surgery Consult-> paraspinal flaps preferred if unable to obtain tension-free closure • Multiple drains (subfascialand superficial) • Incisional wound VAC

  36. Postop care • Culture-specific IV antibiotics are critical • Infectious Disease consultation • PICC line, 6-8 weeks IV abx • Follow ESR, CRP • Serial MRI -> usually not helpful

  37. Case • 15 months postop T1-T6 posterior fusion-> • Treated outside facility 8 weeks IV abx, wound VAC changes • Instrumentation retained • Persistent fevers 102°F Big Problem

  38. Case

  39. Case

  40. Case

  41. SPY

  42. Take-away points • Be meticulous with technique & don’t delegate

  43. Take-away points • Be meticulous with technique & don’t delegate • High index of suspicion and be aggressive

  44. Take-away points • Be meticulous with technique & don’t delegate • High index of suspicion and be aggressive • Safe to retain implants in most cases

  45. Take-away points • Be meticulous with technique & don’t delegate • High index of suspicion and be aggressive • Safe to retain implants in most cases • Consider staged re-instrumentation • Unstable spine • Progressive deformity • Bone bone loss

  46. Thank you!

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