What is the step-by-step procedure for implant removal and wound debridement in a patient with previous proximal tibia plating?

Step-by-Step Procedure for Implant Removal and Wound Debridement in Proximal Tibia Plating

The optimal procedure for implant removal and wound debridement in a patient with previous proximal tibia plating involves thorough preoperative planning, meticulous surgical technique, and comprehensive postoperative care to minimize complications and ensure successful outcomes.

Preoperative Preparation

1. Imaging Assessment

   • Obtain current radiographs to assess implant position, bone healing status, and any signs of loosening
   • Consider CT scan if there are concerns about component positioning or bone quality

2. Laboratory Evaluation

   • Complete blood count (CBC)
   • C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) to assess for infection
   • Renal function tests to guide medication dosing

3. Antibiotic Prophylaxis

   • Administer appropriate antibiotics within one hour of skin incision 1
   • Follow hospital antibiotic protocols for orthopedic hardware removal

Surgical Procedure

Step 1: Patient Positioning and Preparation

• Position patient supine on operating table with a bump under the ipsilateral hip
• Prep and drape the affected limb using sterile technique
• Apply tourniquet if needed for better visualization

Step 2: Incision and Exposure

• Make incision along the previous surgical scar
• Carefully dissect through subcutaneous tissue to expose the plate
• Identify and protect neurovascular structures

Step 3: Hardware Removal

• Identify all screws and hardware components
• Remove screws systematically, typically starting from one end of the plate
• If screws are stuck, use appropriate extraction tools
• Remove the plate carefully to avoid damage to surrounding tissues
• Collect all hardware components and confirm complete removal

Step 4: Wound Debridement

• Perform thorough debridement of all non-viable tissue 1
• Remove all granulation tissue, necrotic bone, and devitalized soft tissue
• Collect multiple tissue samples (minimum of 3-5) for microbiological culture 1
• Avoid taking superficial swabs as they are often misleading 1
• Create perforations in the bony defect if blood supply is insufficient 1

Step 5: Wound Irrigation

• Perform copious irrigation with sterile saline
• Consider using antibiotic-containing solution based on suspected pathogens
• Rinse the wound thoroughly to remove all debris

Step 6: Wound Assessment

• Evaluate bone quality and stability
• Assess soft tissue coverage and viability
• Determine if additional fixation is needed

Step 7: Closure

• Achieve tension-free closure of the wound 1
• Use monofilament non-absorbable sutures
• Consider layered closure for better wound healing
• If complete closure is not possible, consider negative pressure wound therapy

Postoperative Management

1. Pain Management

   • Implement multimodal analgesia approach
   • Avoid NSAIDs in elderly patients or those with renal dysfunction 2
   • Use opioids cautiously after reviewing renal function 2

2. Wound Care

   • Regular wound assessment for signs of infection or dehiscence
   • Keep surgical site clean and dry
   • Change dressings as needed based on drainage

3. Mobilization and Rehabilitation

   • Begin appropriate range of motion exercises early 2
   • Implement structured rehabilitation program with gradually progressing mobility 2
   • Physical therapy 2-3 times weekly initially, decreasing as patient progresses 2

4. Thromboprophylaxis

   • Use thromboembolism stockings or intermittent compression devices 1, 2
   • Consider pharmacological prophylaxis with low molecular weight heparin if not contraindicated 1, 2
   • Continue prophylaxis for 4 weeks post-operatively 2

5. Antibiotic Management

   • Continue antibiotics based on intraoperative culture results
   • For confirmed infection, provide targeted antimicrobial therapy 1
   • Consider multidisciplinary approach with infectious disease specialists for complex cases 1

6. Follow-up

   • Schedule regular follow-up visits to monitor wound healing
   • Obtain radiographs to assess bone healing
   • Monitor for signs of recurrent infection

Special Considerations

• For Infected Cases:

  • More aggressive debridement may be required
  • Consider two-stage procedures for severe infections 1
  • Prolonged targeted antimicrobial therapy may be necessary 1

• For Elderly Patients:

  • Implement active warming strategies to prevent hypothermia 2
  • Ensure adequate hydration and nutrition 2
  • Remove urinary catheters as soon as possible to reduce infection risk 2

Potential Complications and Management

1. Infection

   • Perform repeat debridement if necessary
   • Consider antibiotic beads for local antibiotic delivery 3
   • Adjust antibiotics based on culture and sensitivity results

2. Poor Wound Healing

   • Consider negative pressure wound therapy
   • Evaluate nutritional status and optimize if deficient
   • Consider plastic surgery consultation for complex soft tissue coverage

3. Recurrent Nonunion

   • Evaluate for underlying infection
   • Consider bone grafting for osseous defects 4
   • Assess need for additional fixation

By following this systematic approach to implant removal and wound debridement, complications can be minimized and optimal outcomes achieved for patients with previous proximal tibia plating.