What is the treatment for exposed orthopedic hardware (prosthetic devices)?

From the Guidelines

For exposed orthopedic hardware, immediate surgical intervention is necessary, with a focus on debridement, antimicrobial therapy, and possible implant exchange or removal, as the exposure creates a direct pathway for bacteria to enter deeper tissues, potentially causing serious infections like osteomyelitis. The treatment approach should be individualized based on factors such as the stability of the osteosynthetic construct, the presence of a vital soft tissue envelope, and the ability to perform proper debridement 1.

Key Considerations

• The decision to retain or remove the implant should be based on the presence of a stable osteosynthetic construct, a vital soft tissue envelope, and the ability to perform proper debridement 1.
• Antimicrobial therapy should be tailored to the specific pathogen and the patient's host physiology, with a duration of treatment that may range from 6 weeks for osteomyelitis to 12 weeks for eradication therapy 1.
• Local application of antimicrobials, such as gentamicin, tobramycin, vancomycin, and clindamycin, may be used to achieve high local concentrations with low systemic exposure 1.
• Soft tissue management, including reconstruction and revascularization, is crucial for preventing further contamination and promoting fracture healing 1.

Treatment Approach

• Debridement and antimicrobial therapy should be initiated promptly, with the goal of eradicating the infection and promoting fracture healing 1.
• Implant exchange or removal may be necessary in cases where the infection is difficult to treat or the implant is unstable 1.
• Pain management and wound care should be prioritized to prevent further complications and promote healing.

Antibiotic Therapy

• Oral antibiotics, such as cefazolin or clindamycin, may be prescribed to prevent infection, with a duration of treatment that may range from 7-10 days 1.
• The choice of antibiotic should be based on the specific pathogen and the patient's host physiology, with consideration of factors such as antibiotic resistance and drug interactions 1.

From the Research

Treatment Options for Exposed Orthopedic Hardware

• Negative pressure wound therapy (NPWT) is a common treatment for infected wounds, including those with exposed orthopedic hardware 2.
• NPWT has been shown to increase wound healing rates, reduce hospital stay, and decrease adverse events in patients with surgical site infections 2.
• Flap coverage is another treatment option for exposed hardware, particularly in cases of device infection or exposure 3.
• Early debridement and coverage of exposed hardware are crucial for successful treatment of device-related infections 3.

Parameters for Hardware Salvage

• The decision to salvage exposed hardware depends on several parameters, including hardware location, infection, duration of exposure, and presence of hardware loosening 4.
• If certain criteria are met, such as stable hardware, short duration of exposure, and lack of infection, salvage of the hardware with soft-tissue coverage may be a therapeutic option 4.

Efficacy of Negative Pressure Wound Therapy and Antibiotic Beads

• The use of antibiotic beads has been associated with a decreased risk of infection in lower extremity salvage cases 5.
• NPWT, on the other hand, has been linked to an increased risk of complications, although it may still contribute to successful limb salvage 5.
• A treatment regimen combining repetitive debridement, irrigation, and NPWT with antibiotics can significantly reduce bacterial load and lead to successful wound closure 6.