Abstract
Purpose
Open reduction internal fixation of tibial plateau and pilon fractures may be complicated by deep surgical site infection requiring operative debridement and antibiotic therapy. The management of superficial surgical site infection is controversial. We sought to determine whether superficial infection is associated with an increased risk of deep infection requiring surgical debridement after fixation of tibial plateau and pilon fractures.
Methods
This is a secondary analysis of data from the VANCO trial, which included 980 adult patients with a tibial plateau or pilon fracture at elevated risk of infection who underwent open reduction internal fixation with plates and screws with or without intrawound vancomycin powder. An association of superficial surgical site infection with deep surgical site infection requiring debridement surgery and antibiotics was explored after matching on risk factors for deep surgical site infection.
Results
Of the 980 patients, we observed 30 superficial infections (3.1%) and 76 deep infections (7.8%). Among patients who developed a superficial infection, the unadjusted incidence of developing a deep infection within 90 days was 12.8% (95% confidence interval [CI] 1.3–24.2%). However, after a 3:1 match on infection risk factors, the 90-day marginal probability of a deep surgical site infection after sustaining a superficial infection was 6.0% (95% CI − 6.5–18.5%, p = 0.35).
Conclusion
Deep infection after superficial infection is uncommon following operative fixation of tibial plateau and pilon fractures. Increased risk of subsequent deep infection attributable to superficial infection was inconclusive in these data.
Level of evidence
Prognostic Level II.
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Acknowledgements
The authors would like to express a sincere appreciation and note of gratitude in memory of Dr. William De Long, whose work at St. Luke’s University Health Network was integrally involved in the original VANCO study. The authors would like to thank Jose Zubizarretta, Douglas Schaubel and Kevin He for guidance on the statistical analysis. The authors would also like to thank: Gabriela "Hope" Gonzales, CRC (Baylor Scott & White Medical Center) for enrollment, data collection and patient interaction; Colette Lynn Hilliard, MS (Louisiana State University; now at Care Access Research) for work as a study coordinator, patient interaction and data collection; Christina Riggsbee, BSN, CCRC (Mission Hospital) for patient interaction, data collection and enrollment; Lorie M. Gower, CRC (Naval Medical Center Portsmouth) for data collection, enrollment and patient interaction; Kathleen Ringenbach, BSN, CCRN (Penn State Health Milton S. Hershey Medical Center) for enrollment and patient interaction; Nancy E. Swinford, RTR, CCRC (Texas Tech University Health Sciences) for work as a study coordinator; LaRita C. Jones, PhD (University of Mississippi Medical Center; now at California Department of Public Health) for enrollment and patient interaction.
Funding
Work on the original VANCO study was supported by United States Department of Defense Congressionally Directed Medical Research Program award # W81XWH-10-2-0134. No funds, grants, or other support was received for this secondary analysis. The original sponsor had no role in the design or conduct of the trial; the collection, management, analysis, or interpretation of the data; or the preparation, review, or approval of the manuscript for submission. Dr. Patterson declares a grant or contract with AO North America, payment or honoraria from AO North America, and meeting and/or travel support from AO North America. Dr. O’Hara declares stock or stock options with Arbutus Medical Inc. Dr. Scharfstein has no declarations for the submitted work. Dr. Castillo declares grants or contracts with the Department of Defense, the Patient-Centered Outcomes Research Institute, the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. O’Toole declares grants or contracts with the Department of Defense, the Patient-Centered Outcomes Research Institute, and the AO, royalties or licenses with Lincotek-unrelated to this topic, consulting fees from Stryker-unrelated to this topic, payment or honoraria for educational work from Zimmer-unrelated to this topic, patents planned, issued or pending from Lincotek-unrelated to this topic, and stock or stock options from Imagen-unrelated to this topic. Dr. Firoozabadi declares royalties or licenses from Innomed, consulting fees from Smith & Nephew, payment or honoraria from AO North Ameris, and a leadership or fiduciary role with Orthopaedic Trauma Association Research Committee.
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Patterson, J.T., O’Hara, N.N., Scharfstein, D.O. et al. Do superficial infections increase the risk of deep infections in tibial plateau and plafond fractures?. Eur J Orthop Surg Traumatol 33, 2805–2811 (2023). https://doi.org/10.1007/s00590-022-03438-1
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DOI: https://doi.org/10.1007/s00590-022-03438-1