What is the management of a distal femur fracture with plating, specifically wound debridement and implant removal?

From the Guidelines

The management of a distal femur fracture with plating that requires wound debridement and implant removal should prioritize a thorough debridement, implant removal, and antimicrobial therapy, with consideration of local antibiotic delivery and soft tissue management, as supported by the most recent evidence from 2023 1. The procedure begins with administration of appropriate anesthesia, followed by careful reopening of the surgical site. The surgeon thoroughly cleans the wound, removing all infected, necrotic, or non-viable tissue (debridement), which is a critical step in eliminating bacteria and damaged tissue that could impede healing, as emphasized in the 2020 study on the pathogenesis and management of fracture-related infection 1. Next, the surgeon carefully removes all hardware components, including plates, screws, and any broken implant fragments. Cultures are typically taken to identify specific pathogens, and after implant removal, the surgical field is copiously irrigated with antibiotic solution to further reduce bacterial load. The use of local antibiotic strategies as an adjunct to systemic antibiotics is supported by the 2023 guideline summary on the prevention of surgical site infection after major extremity trauma, which recommends the use of vancomycin powder, tobramycin-impregnated beads, or gentamicin-covered nails 1. Depending on the bone condition, the surgeon may place antibiotic-impregnated beads or cement spacers temporarily, and the wound is then closed in layers if tissue quality permits, or left open for delayed closure if infection is severe. Postoperatively, patients require intravenous antibiotics, such as vancomycin 1g every 12 hours or cefazolin 2g every 8 hours, for 2-6 weeks based on culture results, as recommended by the 2020 study on the pathogenesis and management of fracture-related infection 1. Immobilization with a brace or cast is necessary until definitive treatment, which may include revision surgery with new implants once infection resolves. Physical therapy begins with non-weight bearing exercises and gradually progresses as healing occurs, addressing both the infection and mechanical issues while preparing the site for potential future reconstruction. Key considerations in the management of fracture-related infections include the timing of implant removal, the use of local antibiotic delivery, and the importance of soft tissue management, as highlighted in the 2020 study on the pathogenesis and management of fracture-related infection 1. The 2023 guideline summary on the prevention of surgical site infection after major extremity trauma provides strong recommendations for the use of perioperative and postoperative systemic antibiotics, as well as the use of local antibiotic strategies, emphasizing the importance of a multidisciplinary approach to managing these complex infections 1.

From the Research

Fracture Distal Femur With Plating Managed by Wound Debridement and Implant Removal

• Fracture distal femur with plating is a common treatment approach for distal femur fractures, which can be managed by wound debridement and implant removal in cases of infection or implant failure 2, 3, 4, 5, 6.
• The treatment of distal femur fractures with plating involves the use of locking plates, which provide stability and support to the fracture site, allowing for proper healing 2, 3, 4.
• However, in cases where infection or implant failure occurs, wound debridement and implant removal may be necessary to prevent further complications and promote healing 2, 6.

Wound Debridement and Implant Removal

• Wound debridement involves the removal of dead tissue, bacteria, and other foreign materials from the wound site to prevent infection and promote healing 2, 6.
• Implant removal involves the removal of the locking plate and any other hardware used to stabilize the fracture, which can help to prevent further complications and promote healing 2, 6.
• The decision to perform wound debridement and implant removal is typically made on a case-by-case basis, taking into account the individual patient's condition and the severity of the infection or implant failure 2, 6.

Outcomes and Complications

• The outcomes of wound debridement and implant removal in cases of fracture distal femur with plating can vary depending on the individual patient's condition and the severity of the infection or implant failure 2, 3, 4, 5, 6.
• Complications can include infection, implant failure, and delayed healing, which can be managed with appropriate treatment and care 2, 3, 4, 5, 6.
• Studies have shown that double plating can be a suitable option for periprosthetic distal femur fracture compared to single plate fixation and distal femoral arthroplasty, with equivalent survival free from revision or reoperation 6.

Surgical Techniques

• The surgical technique used for wound debridement and implant removal can vary depending on the individual patient's condition and the severity of the infection or implant failure 2, 3, 4, 5, 6.
• A combined nail-plate construct can be a successful treatment alternative for acute management of distal femur fractures, with a 100% union rate in one study 5.
• Dual plating can be a suitable option for patients with distal femur fractures that have risk factors for instability, varus collapse, or nonunion, with promising results in terms of functional outcomes and complications 3, 4.