What are the alternatives for secondary surgery in cases of infection, hardware failure, or non-union?

Alternatives to Secondary Surgery for Infection, Hardware Failure, or Non-Union

When secondary surgery is not feasible or has failed, long-term antimicrobial suppression therapy is the primary alternative, with arthrodesis or amputation reserved as salvage options for recalcitrant cases. 1

Primary Non-Surgical Alternative: Chronic Antimicrobial Suppression

For patients who refuse or cannot tolerate additional surgery, indefinite oral antimicrobial suppression is the mainstay alternative. 1 This approach is particularly appropriate when:

• Multiple prior surgeries have failed 1
• Patient has significant comorbidities precluding surgery 1
• Patient explicitly refuses further operative intervention 1
• Reasonable joint function is maintained despite infection 1

Antimicrobial Selection and Duration

• Oral antibiotics with high bioavailability should be selected based on culture sensitivities 1
• Early transition from IV to oral therapy (by day 7) is non-inferior to prolonged IV therapy and reduces catheter-related complications 1
• Suppressive therapy may need to continue for 6 months or even lifelong in cases with gross purulence, multidrug-resistant organisms, or MRSA 1
• Success rates with suppressive therapy alone are lower than surgical cure (typically <80% in ideal situations) 1

Key Caveat

Antimicrobial suppression does not eradicate infection—it only controls symptoms. 1 Patients must understand this represents palliation rather than cure, with ongoing risk of treatment failure, antibiotic toxicity (bone marrow suppression, neuropathies with linezolid), and drug interactions. 1

Surgical Salvage Alternatives When Revision Surgery Fails

Arthrodesis (Joint Fusion)

Arthrodesis eliminates the infected prosthesis while maintaining limb length and some weight-bearing capacity. 1 This is indicated for:

• Patients with limited bone stock or poor soft tissue coverage 1
• Infections with highly resistant organisms lacking effective medical therapy 1
• Failed two-stage exchange where risk of recurrent infection is unacceptable 1
• Total knee or elbow arthroplasty specifically 1

Arthrodesis sacrifices joint mobility but provides stability and can resolve infection in patients unsuitable for reimplantation. 1

Permanent Resection Arthroplasty

Resection arthroplasty (removal of prosthesis without reimplantation) may be considered for non-ambulatory patients or those with severe bone/soft tissue defects. 1 Indications include:

• Non-ambulatory status where joint function is less critical 1
• Medical conditions precluding multiple major surgeries 1
• Severe bone stock loss preventing stable reconstruction 1
• Failed previous two-stage exchange 1

This results in significant functional impairment but can control infection when other options are exhausted. 1

Amputation

Amputation should be the absolute last resort, reserved only for life-threatening situations or when all other options have failed. 1 Consider when:

• Necrotizing fasciitis or severe sepsis threatens life 1
• Complete inability to achieve soft tissue coverage 1
• Severe uncontrolled pain with wound breakdown despite all interventions 1
• Functional benefit of amputation exceeds that of resection arthroplasty 1

Before proceeding with amputation (except in emergencies), referral to a specialized center with expertise in managing complex prosthetic joint infections is strongly advised. 1

Special Considerations for Infected Non-Union Without Prosthesis

For infected non-union of long bones (not involving prosthetic joints), alternatives to repeat internal fixation include:

External Fixation Without Bone Grafting

External fixation (such as Orthofix or Ilizarov methods) can achieve union in infected non-unions without requiring bone grafting. 2 This approach:

• Achieved union in 100% of cases in one series with mean time of 4.5 months 2
• Shortened hospitalization duration 2
• Avoided complications of internal fixation in infected fields 3

Local Antibiotic Delivery Systems

Antibiotic-impregnated calcium sulfate pellets combined with external fixation can eradicate infection and achieve union without systemic IV antibiotics. 4 This novel approach:

• Achieved 100% infection eradication and union in 13 patients with infected non-union 4
• Eliminated complications associated with prolonged IV antibiotic therapy 4
• Required extensive debridement and external stabilization 4

Single-Stage Protocol with Internal Fixation

For carefully selected patients, a single-stage protocol may be attempted: 5

• Antibiotic "holiday" period before surgery 5
• Aggressive surgical debridement with hardware removal 5
• Revision internal fixation with local and systemic antibiotics 5
• Supplemental bone grafting 5

This achieved 100% union and infection resolution in one series, though 45% required re-interventions. 5

Critical Decision-Making Algorithm

When secondary surgery fails or is refused:

1. First-line: Chronic oral antimicrobial suppression if patient has reasonable function and controlled symptoms 1
2. Second-line: Arthrodesis if infection cannot be controlled medically but limb salvage is possible 1
3. Third-line: Resection arthroplasty for non-ambulatory patients or those with inadequate bone stock 1
4. Last resort: Amputation only for life-threatening infection or complete treatment failure 1

Shared decision-making with the patient is essential, clearly outlining benefits and risks of each strategy, as the "ideal situation" is rarely achievable in treatment failures. 1