Implant Salvage in Patients With Severe Post-Fracture Fixation Surgical Site Infection Using Negative Pressure Wound Therapy With Intramedullary and Subcutaneous Antibiotic Perfusion

Post-fracture fixation surgical site infection (SSI) is a devastating complication, and the standard-of-care therapeutic regimen is ineffective in managing it. Negative pressure wound therapy with instillation and dwell time (NPWTi-d) can be used to salvage orthopedic fixation hardware in the setting of infection; moreover, NPWTi-d can be used effectively in the management of superficial post-fracture fixation SSI.Two cases were treated with NPWTi-d. Because of difficulties disrupting the deep dead space biofilm in a deep post-fracture fixation SSI (and because of the risk for bone infection), a double-lumen tube was used for subcutaneous antibiotic perfusion and dead space suction drainage, and bone marrow needles were used for intramedullary antibiotic perfusion to manage or prevent early osteomyelitis. The 2 patients with severe SSI after below-knee fracture fixation were treated with continuous intramedullary and subcutaneous antibiotic perfusion with NPWT to salvage the orthopedic implant. The debrided wounds of the lower leg and heel were reconstructed with free flaps and incisional NPWT, followed by administration of continuous intramedullary and subcutaneous antibiotic perfusion to preserve the titanium plates. In both patients, the wounds healed without complications and remained healed after more than 7 months.Continuous local antibiotic perfusion around infected orthopedic fixation hardware can be an ideal treatment for patients with SSI after fracture fixation. Although this technique can be improved further, it is more effective than conventional therapy in the management of severe post-fracture fixation SSI with a dead space.