POST-OSTEOSYNTHESIS INFECTION: EVALUATION OF A HISTORICAL COHORT AND DEVELOPMENT OF A CARE PROTOCOL

Dias Junior, Jair Moreira; Cunha, Pedro Henrique Ananias da; Paro, Marcos Paulo; Pinheiro, Mariana Machado; Passos, Ibsen Barguine Junqueira; Mendes Junior, Adriano Fernando

doi:10.1590/1413-785220253304e277810

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Original Article/Trauma • Acta Ortop Bras 33 (4) • 2025 • https://doi.org/10.1590/1413-785220253304e277810 linkcopy

POST-OSTEOSYNTHESIS INFECTION: EVALUATION OF A HISTORICAL COHORT AND DEVELOPMENT OF A CARE PROTOCOL

INFECÇÃO PÓS-OSTEOSSÍNTESE: AVALIAÇÃO DE COORTE HISTÓRICA E DESENVOLVIMENTO DE PROTOCOLO ASSISTENCIAL

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective: To evaluate patients with post-osteosynthesis infection (POI) in the appendicular skeleton, in a tertiary hospital, and to develop a care protocol for case management, based on cohort data and agreement between attending physicians.

Method: primary, observational, retrospective and comparative study, evaluating cases of POI, from 2014 to 2019, assisted by the service. The outcomes analyzed were length of stay, readmission, fracture site, etiological agent, antibiotic therapy, number of surgeries and clinical outcome after one year (cure or failure, these considered recurrence, amputation or death). Based on this data, a protocol for diagnosing and treating POI was proposed to the institution's orthopedists, with responses assessed in terms of the content validity coefficient, in order to grade compliance with the protocol.

Results: sample of 27 participants, mostly male, with infection in the lower limbs (77.8%), who underwent an average of two surgeries. The average length of stay was 48 days. The median duration of antibiotic therapy was 34 days. Patients with cure criteria used a greater amount of antibiotics compared to other cases (p<0.05). The responses of orthopedists to the management protocol for these cases reached a concordance of 0.91.

Conclusion: The profile of patients and therapy to POI was similar to the literature and supported the development of the care protocol, with high agreement among developers. Level of Evidence III; Observational, Retrospective and Comparative Study.

Keywords:
Trauma; Fracture Fixation; Osteosynthesis; Fracture; Infections; Surgical Wound Infection

Variables	Average ± SD n	Minimum – Maximum %
Age (years)	49.7 ± 18.7	22.0 – 88.0
Sex
Female	8	29.6%
Male	19	70.4%
Internship (days)	48.2 ± 27.6	17.0 – 123.0
Readmission (yes)	20	70.4%
fractured bone
Arm/hand	3	11.1%
Humerus	2	7.4%
Femur	8	29.6%
Leg	2	7.4%
Foot/ankle	5	18.5%
Polytraumatized	7	25.9%
Membrane infection (yes)	10	37.0%
Location of infection
Senior Members	6	22.2%
Lower members	21	77.8%
Germs in culture (yes)	25	92.6%
Surgery (no)	2.2 ± 2.8	0.0 – 15.0
Use of Antibiotics (days)	35.0 ± 15.1	15.0 – 74.0
Classes of antibiotics
Cephalosporins (yes)	15	55.6%
Glycopeptides (yes)	10	37.0%
Aminoglycosides (yes)	6	22.2%
Penicillins (yes)	12	44.4%
Quinolones (yes)	10	37.0%
Other (yes)	21	77.8%
Outcome
Cure	20	74.1%
Recurrence	4	14.8%
Amputation	2	7.4%
Death	1	3.7%

Explanatory variables	Time of internation		p-value	SE
Explanatory variables	<= 39 days	>39 days	p-value	SE
Sex
Female (n=8)	50.0%	50.0%	0.71	0.07
Male (n=19)	57.9%	42.1%
Age	46.8 ± 20.2	53.2 ± 16.8	0.38	0.34
Fracture region
Senior Members (n=5)	100.0%	0.0%	0.08	0.43
Lower Members (n=15)	46.7%	53.3%
Polytraumatized (n=7)	42.9%	57.1%
Diaphyseal Infection
No (n=17)	52.9%	47.1%	0.72	0.07
Yes (n=10)	60.0%	40.0%
Infection site
Lower Members (n=21)	42.9%	57.1%	0.01*	0.48
Senior Members (n=6)	100.0%	0.0%
Germs in culture
Yes (n=25)	56.0%	44.0%	0.87	0.03
No (n=2)	50.0%	50.0%
Use of Classes of Antibiotics
<=2 (n=10)	70.0%	30.0%	0.25	0.22
3 or + (n=17)	47.1%	52.9%

Explanatory variables	Outcome		p-value	SE
Explanatory variables	Healed (n = 20)	Recurrence, amputation or death (n=7)	p-value	SE
Sex
Female (n=8)	62.5%	37.5%	0.63	0.17
Male (n=19)	78.9%	28.1%
Age	46.7 ± 15.8	58.1 ± 24.7	0.17	0.
Internship (days)	43.7 ± 22.9	61.0 ± 37.2	0.16
Surgery
<=1 (n=15)	80.0%	20.0%	0.66	0.15
2 or + (n=12)	66.7%	33.3%
Fracture Region
Upper members (n=5)	60.0%	40.0%	0.60	0.19
Lower members (n=15)	73.3%	26.7%
Polytraumatized (n=7)	85.7%	14.3%
Diaphyseal Infection
No (n=17)	70.6%	29.4%	0.68	0.10
Yes (n=10)	80.0%	20.0%
Infection site
Lower Members (n=21)	76.2%	23.8%	0.63	0.09
Senior Members (n=6)	66.7%	33.3%
Germs in culture
Yes (n=25)	72.0%	28.0%	0.97	0.17
No (n=2)	100.0%	0.0%
Use of Antibiotics (days)	43.7 ± 22.9	61.0 ± 37.2	0.16
Antibiotics class(yes)
Cephalosporins (n=15)	93.3%	6.7%	0.01*	0.49
Glycopeptides (n=10)	70.0%	30.0%	0.71	0.07
Aminoglycosides (n=6)	83.3%	16.7%	0.56	0.11
Penicillins (n=12)	100.0%	0.0%	0.008*	0.53
Quinolones (n=10)	60.0%	40.0%	0.36	0.25
Other (n=21)	66.7%	33.3%	0.15	0.32

No	Items	Relevance
1	Protocol diagnostic criteria	89%
2	Classification of infections with less than 4 weeks as acute and more than 4 weeks as chronic	89%
3	Imaging evaluation with radiography for all patients	89%
4	Surgical treatment	100%
5	Empirical intravenous antibiotic therapy with vancomycin and cefepime	94%
6	Follow-up time of 1 year	83%
	CVC total scale	91%

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[TFN1] SE: size of the effect;

[TFN2] ^*
represents values of p<0.05, by independent Student t test (quantitative variables) and by Qui-Quarter test (qualitative variables).