Surgical Infection Society–Chest Wall Injury Society Recommendations for Management of Surgical Site or Implant-Related Infections After Surgical Stabilization of Traumatic Rib or Sternal Fractures

Abstract

Background:

Surgical stabilization of rib fractures (SSRF) and surgical stabilization of sternal fractures (SSSF) involves open reduction and internal fixation of fractures with an implantable titanium plate to restore and maintain anatomic alignment. The presence of this foreign, non-absorbable material presents an opportunity for infection. Although surgical site infection (SSI) and implant infection rates after SSRF and SSSF are low, they present a challenging clinical entity.

Methods:

The Surgical Infection Society's Therapeutics and Guidelines Committee and Chest Wall Injury Society's Publication Committee convened to develop recommendations for management of SSIs or implant-related infections after SSRF or SSSF. PubMed, Embase, Web of Science and the Cochrane database were searched for pertinent studies. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation.

Results:

For patients undergoing SSRF or SSSF who develop an SSI or an implant-related infection, there is insufficient evidence to suggest a single optimal management strategy. For patients with an SSI, systemic antibiotic therapy, local wound debridement, and vacuum-assisted closure have been used in isolation or combination. For patients with an implant-related infection, initial implant removal with or without systemic antibiotic therapy, systemic antibiotic therapy with local wound drainage, and systemic antibiotic therapy with local antibiotic therapy have been documented. For patients who do not undergo initial implant removal, 68% ultimately require implant removal to achieve source control.

Conclusions:

Insufficient evidence precludes the ability to recommend guidelines for the treatment of SSI or implant-related infection following SSRF or SSSF. Further studies should be performed to identify the optimal management strategy in this population.

Rib fractures are common injuries and exist along a spectrum from isolated, non-displaced rib fractures to a clinical flail chest with paradoxical chest wall movement.^1–4 Consensus guidelines recommend surgical stabilization of rib fractures in patients with flail chest or multiple displaced rib fractures with physiologic compromise.^5–7 Surgical stabilization of rib fractures (SSRF) and surgical stabilization of sternal fractures (SSSF) entail open reduction and internal fixation of the fractured ribs or sternum with a plate construct, restoring anatomic alignment and thereby enabling normal physiologic function with reduced pain. Most constructs are composed of titanium plates and screws, although some absorbable plate constructs exist. In addition to traditional surgical site infections (SSIs) that can occur any time the natural integumentary protection of the skin is violated, presence of this foreign, non-absorbable material presents opportunity for an implant-related infection.⁸

Although SSI rates and implant-related infection rates after SSRF and SSSF are low these infections present a challenging clinical entity, which can result in considerable patient morbidity.^8,9 Unfortunately, minimal published literature exists providing guidance describing the management of patients who develop surgical site or implant-related infections after SSRF or SSSF. To address this deficit, the Surgical Infection Society's (SIS) Therapeutics and Guidelines Committee convened with the Chest Wall Injury Society's (CWIS) publications committee to develop pragmatic recommendations to assist in management of these infections.

Objectives

Our clinical questions were defined as follows:

Population: adult patients (>18 years of age) with chest wall injury undergoing SSRF or SSSF.

Intervention: surgical site or implant-related infection.

Comparator: infection management strategies.

Outcomes: bony union, implant removal, duration of antibiotic therapy, mortality.

Clinical Question 1: In adult patients who underwent SSRF or SSSF who develop an SSI (non-implant) post-operatively, what is the optimal management strategy to maximize bony union and minimize implant removal, duration of antibiotic therapy, and mortality?

Clinical Question 2: In adult patients who underwent SSRF or SSSF who develop an implant-related infection post-operatively, what is the optimal management strategy to maximize bony union and minimize implant removal, duration of antibiotic therapy, and mortality?

Identification of References

PubMed, Embase, Web of Science, and Cochrane databases were searched by professional librarians and study investigators on July 12, 2022. The following medical subject headings (MeSH) terms were included: rib, sternum, fixation, fracture, manubrium, chest wall, flail, operation alone and in various combinations (Supplementary Table S1). Only English-language articles were reviewed. Studies were limited to those published in 2010 or later to maximize capture of studies contextually relevant based on modern SSRF and SSSF surgical technique. Articles describing SSRF or SSSF performed of non-united fractures were also excluded to focus the review on acute SSRF or SSSF. Commentaries, operative technique descriptions, and animal studies were excluded. A pediatric patient was defined as a patient <18 years of age. Studies with a majority (>50%) of pediatric patients in their study population were excluded. An SSI was defined as documentation of an SSI by the study authors, without specification of an implant-related infection. An implant-related infection was defined as documentation of infection of the implant by the study authors, or implant removal at the index re-operation. When differentiation between an SSI and implant-related infection was unclear, preference was given to classifying the infection as implant-related given the potential for increased morbidity associated with these infections.

Local antibiotic administration was defined as application of antimicrobial-impregnated gel, slurry, beads, powder, or cement in the wound. Upon completion of the electronic literature search, titles and abstracts from citation lists were reviewed by two authors (B.F., J.F.) to identify potentially relevant studies. Additional studies were sought by examining the bibliographies of studies identified as being adequate for full-text review. Any disagreement about study inclusion was resolved by consensus. Full-text review was performed by two authors (B.F., J.F.) and data abstraction was performed by nine authors (J.F., C.C., M.C., B.F., S.K., B.P., B.S., M.S., J.H.). In total, 2,824 studies were identified, with 31 studies identified through search being used to inform the PICO (Problem/Population, Intervention, Comparison, Outcome) responses (Fig. 1). For qualitative synthesis, quality and certainty of published evidence was evaluated using GRADE definitions.^10,11 Using a process of iterative consensus, all committee members voted to accept or reject the recommendation. This study was Institutional Review Board (IRB)-exempt because all articles were publicly available.

FIG. 1.

Manuscript selection process.

Results

Table 1.

Articles Identified Through Search Reviewed for Clinical Question 1

Name/year	Study design/setting	# Undergoing SSRF or SSSF	# SSI (%)	Initial management strategy	Bony union achieved	Implant removal	Additional comments
Granhed and Pazooki¹² (2014)	Retrospective cohort/single institution	60 SSRF	1 (2)	Systemic abx only	NR	No	Required reoperation after 7 mo of abx only therapy, with 3 mo of abx after drainage for 10 total mo total of abx
Dackam et al.¹³ (2015)	Case report/single institution	1 SSRF	1 (N/A)	Systemic abx and local wound drainage with VAC therapy	NR	No	Repeated surgical debridement and necrosectomy required.
Zhang et al.¹⁴ (2015)	Retrospective case control/single institution	24 SSRF	6 (25)	Systemic abx only	NR	No	Increased HLOS reported among patients with SSI but duration not specified
Kocher et al.¹⁵ (2017)	Retrospective cohort/single institution	61 SSRF (9 had concomitant SSSF)	1 (2)	10 days of VAC therapy	NR	No	—
Oosthuizen et al.¹⁶ (2017)	Case series/single institution	9 SSRF	1 (11)	VAC therapy	NR	No	—
Schots et al.¹⁷ (2017)	Case series/single institution	15 SSRF	2 (13)	“Conservative therapy”	NR	No	—
Iqbal et al.¹⁸ (2018)	Retrospective cohort/single institution	102 SSRF	1 (1)	Systemic abx only	Yes	No	—
Beks et al.¹⁹ (2018)	Retrospective case control/multi-institution	65 SSRF	1 (2)	Systemic abx only	NR	No	—
El-Akkawi et al.²⁰ (2019)	Case report/ single institution	1 SSRF	1 (N/A)	VAC therapy	NR	No	VAC therapy used for 9 d
Patel et al.²¹ (2019)	Retrospective cohort/single institution	37 SSRF	1 (3)	Systemic abx only	NR	No	—
Kalberer et al.²² (2020)	Retrospective cohort/single institution	15 SSSF	1 (7)	Systemic abx only	Yes	No	—
Wijffels et al.²³ (2020)	Retrospective case control/single institution	23 SSRF	3 (13)	2 pts - systemic abx and local drainage 1 pt - drainage and VAC	NR	No	—
Xiao et al.²⁴ (2020)	Retrospective case control/single institution	563 SSRF	43 (8)	Drainage and debridement	NR	No	—
Sedaghat et al.²⁵ (2021)	Retrospective cohort/single institution	63 SSRF	4 (6)	Systemic abx only	NR	No	Only oral abx used
Fugazzola et al.²⁶ (2022)	Case series/single institution	12 SSRF; 1SSSF	2 (15)	“Local medication”	NR	No	—
Prins et al.²⁷ (2022)	Retrospective case control/multi-institution	111 SSRF	1 (1)	NR	NR	No	—
van Gool et al.²⁸ (2022)	Retrospective cohort/single institution	105 SSRF	6 (6)	1 patient – required surgical treatment	Yes	No	—

SSRF = surgical stabilization of rib fractures; SSSF = surgical stabilization of sternal fractures; N/A = not applicable; NR = not reported; SSI = surgical site infection; abx = antibiotics; HLOS = hospital length of stay; VAC = vacuum-assisted closure; pts = patients.

Qualitative synthesis

Seventeen studies, published between 2014 and 2022, addressing Clinical Question 1 were identified through the search. Seven were retrospective cohort studies, five were retrospective case control studies, three were case series, and two were case reports. Combined, there were 1,268 patients of whom 1,252 underwent SSRF and 25 underwent SSSF; nine patients were reported to have both SSRF and SSSF. In total, 76 (6%) SSIs were identified. Seventy-four of those infections occurred among patients undergoing SSRF and two occurred among patients undergoing SSSF (one patient who had both SSRF and SSSF experienced an infection).

Among the 15 studies describing the initial management of SSI, 53 (73%) patients underwent local wound care alone, 15 (21%) patients treated with systemic antibiotic therapy alone, three (4%) underwent systemic antibiotic therapy and local wound care, and two (3%) used local medication. Of the three studies with information about post-infection bony union, all reported bony union was achieved. There were no fatalities reported in patients with an SSI, and no patients required implant removal. Insufficient data were provided on antibiotic use to enable combinatorial analysis of this outcome. Each study included is described below.

In 2014, Granhed and Pazooki¹² published a single-institution retrospective cohort study evaluating 60 patients with flail chest or multiple rib fractures with an unstable chest wall who underwent surgical stabilization. One patient developed a deep infection initially treated with antibiotic agents alone who required subsequent operation for wound drainage and 10 months of antibiotic agents; three of those months occurred after wound drainage.¹² In 2015, Dackam et al.¹³ published a case report of a patient who developed an SSI 10 days after her index operation. Broad-spectrum antibiotic agents were administered, the wound was debrided, and vacuum-assisted closure (VAC) therapy was applied. At six months the patient was reported as having recovered to an asymptomatic state.¹³ Also in 2015, Zhang et al.¹⁴ reported a case control study comparing patients with flail chest and pulmonary contusion undergoing SSRF with those who received only-non-surgical care. Among the 24 patients in the surgical group, six developed an SSI that required “prolonged hospital length of stay and antibiotic administration” without further clinical details reported.¹⁴

In 2017, Kocher et al.¹⁵ published a retrospective cohort study of 61 patients with mechanically ventilated patients with flail chest undergoing SSRF, nine of whom also underwent SSSF. One patient developed a “subcutaneous SSI which healed after 10 days of VAC treatment.”¹⁵ Similarly in 2017, Oosthuizen et al.¹⁵ published a case series of nine patients undergoing surgical stabilization, of whom one developed a superficial SSI treated with a wound VAC that was reported to resolve fully. Also in 2017, Schots et al.¹⁷ published a case series of 15 patients with flail chest undergoing SSRF with concomitant video-assisted thoracoscopic surgery (VATS). Among this series, two patients developed a superficial wound infection that resolved with “conservative treatment” although no further specifics of therapy were provided.¹⁷ After these reports, in 2018 Iqbal et al.¹⁸ published a single-institution retrospective cohort study evaluating outcomes among 102 patients undergoing SSRF, in which one patient was reported to develop a superficial wound infection treated with antibiotic agents.

In 2018, Beks et al.¹⁹ published a multi-institution case control study comparing 332 patients with more than three rib fractures who underwent SSRF with those who did not undergo surgical management. There were 65 patients in the surgical group, in which one patient developed a deep infection near the osteosynthesis and was successfully treated with antibiotic agents.¹⁹ In 2019, El-Akkawi²⁰ reported a case of a patient with flail chest who underwent SSRF and developed a superficial SSI, which was treated with a VAC device for a nine-day period with resolution. Also in 2019, Patel et al.²¹ published a retrospective cohort of 37 patients undergoing SSRF for displaced rib fractures, of which one developed a superficial SSI treated with IV antibiotics.

In 2020, Kalberer et al.²² published a single-institution retrospective cohort study of 15 patients undergoing SSSF, in which one patient developed a superficial SSI requiring antibiotic agents. Also in 2020, Wijffels et al.²³ published a single-institution retrospective case control study in 2020 comparing patients with flail chest undergoing operative versus non-operative therapy. Among the 23 patients undergoing SSRF, three patients developed an SSI, two of which were treated with drainage and antibiotic agents and one was treated with drainage and negative pressure therapy.²³ Last, in 2020 Xiao et al.²⁴ published a single-institution case-control study of patients treated operatively versus operatively for displaced rib fractures and flail chest. Of the 563 patients who underwent SSRF, 43 patients developed an SSI that underwent drainage or debridement.²⁴

In 2021, Sedaghat et al.²⁵ performed a single-institution retrospective cohort study of 63 consecutive patients undergoing SSRF at a single institution. Four patients experienced wound infections, all of whom were treated with oral antibiotic agents.²⁵ In 2022, Fugazzola et al.²⁶ published a case series of 12 patients who underwent SSRF and one who underwent SSSF with off-label titanium cranio-maxillo-facial implants, of whom two were treated with “local therapy.” No further information was provided other than no infection of the plates occurred.²⁶ Also in 2022, Prins et al.²⁷ published a multi-institution retrospective case-control study evaluating SSRF versus non-operative management for patients with flail and non-flail rib fracture patterns in patients with traumatic brain injury. Among the 111 patients undergoing surgical stabilization, two developed an infection (one implant-related infection and one SSI).²⁷ The patient with an SSI did not require hardware removal; however, further treatment data was not available.²⁷ Finally, in 2022 van Gool et al.²⁸ published a single-institution retrospective cohort study evaluating 105 patients who underwent VATS-assisted SSRF for flail chest, of whom six developed SSIs, three during their admission and three after discharge one of whom required surgical drainage.²⁸

Recommendation

We considered the available evidence describing management of patients with an SSI that is not implant-related after undergoing SSRF/SSSF. There is insufficient evidence to suggest an optimal management strategy among patients undergoing SSRF or SSSF with an SSI that is not implant-related. Future studies reporting on SSIs after SSRF or SSSF are encouraged to include information on causative organisms, duration, and choice of antibiotic therapy, attainment of bony union, need for subsequent surgery, as well as drainage and wound management strategies used.

Grade 2C

Table 2.

Articles Identified Through Search Reviewed for Clinical Question 2

Name/year	Study design/setting	# Patients undergoing SSRF or SSSF	# Implant-related infections	Initial management strategy	Bony union achieved	Implant removal after index re-operation	Re-operation after index reoperation	Additional comments
Bottlang et al.²⁹ (2013)	Retrospective cohort/multi-institution	20 SSRF	1(5)	Implant removal and wound debridement	Yes	N/A	No	—
Pieracci et al.³⁰ (2015)	Prospective before-after/single institution	35 SSRF	1(3)	Implant removal	NR	N/A	NR	—
Zhang et al.³¹ (2015)	Retrospective case control/single institution	23 SSRF	1(4)	Implant removal	NR	N/A	NR	—
Caragounis et al. ³² (2016)	Retrospective cohort/single institution	54 SSRF	1(2)	Implant removal	NR	N/A	NR	—
DeFreest et al.³³ (2016)	Retrospective case control/single institution	41 SSRF	2(5)	Implant removal	NR	N/A	NR	—
Thiels et al.³⁴ (2016)	Retrospective cohort/single institution	122 SSRF	5(4)	1-operative debridement with partial removal of hardware + VAC 3-operative debridement with antibiotic bead placement+VAC 1-operative debridement with antibiotic bead placement and no VAC	Yes, for all 5 pts	Yes, for 3 pts	Median (IQR) 2 (2-3) additional operations	Cultures grew only gram-positive organisms. No patients required re-intervention after hardware removed
Drahos et al.³⁵ (2018)	Retrospective cohort/single institution	156 SSRF	2(1)	Implant removal	Yes	No	No	—
Junker et al.³⁶ (2019)	Retrospective cohort/single institution	285 SSRF	10(4)	9-debridement, irrigation, antibiotic bead placement, VAC closure 1-further management information unavailable	Yes	Yes, for 7 patients	Median 2 washouts	Organisms identified included: methicillin-sensitive Staphylococcus aureus, methicillin-resistant S. aureus, methicillin-resistant Staphylococcus epidermidis, Finegoldia magna, and Enterococcus faecalis
Sarani et al.⁸ (2019)	Retrospective cohort/multi-institution	1,224 SSRF	2(<1)	Implant removal	NR	N/A	NR	—
Agrafiotis37 (2020)	Retrospective cohort/single institution	87 SSRF	3(3)	1 pt – systemic abx and local drainage with VAC 2-implant removal and systemic abx	NR	No	Yes	Oral abx continued for 6 weeks after implant removal. Organisms identified included: Enterobacter cloacae, Staphylococcus epidermidis, Staphylococcus aureus (resistance not specified)
Gao et al.³⁸ (2020)	Case report/single institution	1	1(N/A)	Systemic abx and local wound therapy	NR	Yes	Yes	—
Uchida et al.³⁹ (2020)	Retrospective cohort/single institution	20	1(5)	Systemic abx and VAC therapy	NR	No	No	—
Schuette et al.⁴⁰ (2021)	Retrospective cohort/single institution	26	1(4)	Implant removal	NR	NR	NR	—
Prins et al.²⁷ (2022)	Retrospective case control/multi-institution	111	1(1)	Implant removal	NR	NR	NR	—
Prins et al.⁹ (2022)	Retrospective cohort/single	228	4(2)	2 pts – implant removal 2 pts – systemic abx and local wound care	Yes	Yes – for 2 patients initially managed without implant removal	Yes, for 1 patient	Causative organism was methicillin-sensitive Staphylococcus aureus (MSSA) bacteria in all patients. After implant removal, three patients received intravenous and oral antibiotic agents, ranging from two to six weeks, without recurrent infection.

SSRF = surgical stabilization of rib fractures; SSSF = surgical stabilization of sternal fractures; N/A = not applicable; NR = not reported; Abx = antibiotic agents; HLOS = hospital length of stay; VAC = vacuum-assisted closure; pts = patients; IQR = interquartile range

Qualitative synthesis

Fifteen studies addressing Clinical Question 2 were identified through the search of studies published between 2013 and 2022. Ten were retrospective cohort studies, two were retrospective case control studies, one was a prospective non-randomized before-and-after study, one was a case series, and one was a case report. Combined, there were 2,433 patients of whom all underwent SSRF, among which 36 (1%) implant-related infections were identified. No SSSF cases or infections were identified. Eight studies comprising 26 patients with infected hardware contained adequate information to characterize the initial management strategy: seven (26%) underwent implant removal initially with or without systemic antibiotic therapy and local wound care, six (23%) received systemic antibiotic therapy and local wound drainage, and 13 (57%) received systemic and local antibiotic therapy and wound drainage. Of those 19 patients who did not receive initial implant removal, 13 (68%) ultimately required implant removal at a subsequent operation. Of the five studies reporting on bony union, all patients in these studies (n = 22) achieved bony union. There was one fatality identified that was noted to be unrelated to the implant-related infection. Insufficient data were provided on antibiotic use to enable combinatorial analysis of this outcome. Each study included is described below.

In 2013, Bottlang et al.²⁹ published a multi-institution retrospective cohort study evaluating outcomes of 20 consecutive patients with flail chest who underwent surgical stabilization. One patient experienced an implant-related infection.²⁹ The implant was removed 30 days after placement with bony union confirmed at the time of implant removal.²⁹ In 2015, Pieracci et al.³⁰ published a non-randomized prospective before-and-after study comparing patients who underwent surgical stabilization to those who did not. Among the 35 patients undergoing SSRF, there was one patient who underwent implant-removal; however there was insufficient clinical data to characterize the management strategy further.³⁰ Also in 2015, Zhang et al.³¹ published a retrospective case-control study comparing patients with flail chest who underwent SSRF with claw-type titanium plates with non-operative management. Among the 23 patients treated operatively, one patient developed an implant-related infection and subsequently underwent implant removal.³¹

In 2016, Caragounis et al.³² published a single-institution retrospective cohort study evaluating 54 patients with multiple rib fractures or flail chest who underwent SSRF. One patient was reported to develop osteomyelitis and underwent implant removal seven months after implant placement. ³² Also in 2016, DeFreest et al.³³ published a single-institution retrospective case-control study of patients with radiographic flail chest comparing those who underwent SSRF with those who did not. Among the 41 patients undergoing SSRF, two developed implant-related infections necessitating implant-removal.³³ Thiels et al.³⁴ also published a retrospective cohort study in 2016, evaluating all patients who underwent SSRF at a single institution specifically evaluating for development of hardware infection. Five of the 122 patients developed an implant-related infection.³⁴ Implants were removed in three patients. Patients with an infection underwent a median two additional operations including wound debridement (n = 5), wound VAC placement (n = 3) and antibiotic bead placement (n = 4).³⁴ In this cohort, no patients required re-intervention after hardware removal and all achieved bony union.³⁴ Finally, in 2018 Drahos et al.³⁵ published a single-institution retrospective cohort of 156 patients who underwent SSSRF at their single level 1 trauma center. Two patients were reported to have implant removal because of infection: one after identification of a chronic draining sinus originating from the site of the plate and one with a soft tissue infection overlying the plate which resulted in a wound dehiscence and an exposed plate.³⁵ Both were removed without any subsequent complications.³⁵

In 2019, Junker et al.³⁶ published a single-institution retrospective cohort study of patients receiving SSRF with infected or at-risk hardware managed with antibiotic beads. The authors reported 258 patients who underwent SSRF with 10 implant-related infections.³⁶ Nine patients with implant-related infections had antibiotic beads placed.³⁶ The median number of washouts prior to definitive closure was two.³⁶ Among the seven of nine patients who had beads and hardware removed, the final surgery occurred at a median 182 days post-SSRF. ³⁶ Also in 2019, Sarani et al.⁸ published a multicenter retrospective cohort study evaluating cases of implant failure among patients undergoing SSRF. Among 1,224 SSRF cases, there were two cases of implant failure secondary to an implant-related infection necessitating implant removal.⁸ Unfortunately, there was insufficient clinical data to characterize the management strategy further. ⁸

In 2020 Agrafiotis³⁷ published a single-center case series of 87 patients undergoing SSRF of whom three developed an implant-related infection. One patient was treated with systemic antibiotic therapy and local drainage with VAC therapy; this patient subsequently died from an aspiration event unrelated to the implant-related infection.³⁷ The remaining two patients had implant removal and systemic antibiotic therapy, one of whom required a second operation for repeated debridement.³⁷ For both patients undergoing implant removal, oral antibiotic agents were continued for six weeks after removal.³⁷ Also in 2020, Gao et al.³⁸ published a case report of a patient with an implant-related infection after SSRF. The patient was initially treated with systemic antibiotic therapy and local wound drainage.³⁸ However, despite initial resolution of symptoms, the patient re-presented six months after SSRF with persistent implant-related infection.³⁸ Implants were removed but the patient required two additional debridement procedures.³⁸ The patient ultimately was cleared of infection 13 months after initial SSRF operation.³⁸

In 2020, Uchida et al.³⁹ published a single-institution retrospective cohort study of 20 patients undergoing SSRF for flail chest or multiple displaced rib fractures. One patient developed an implant-related infection with associated osteomyelitis that was treated with antibiotic agents (duration unspecified) and VAC therapy.³⁹ In 2021, Schuette et al.⁴⁰ published a single-institution retrospective cohort study of 26 patients undergoing SSRF for far posterior rib fractures. In this group, one patient developed an implant-related infection requiring implant removal, although this was attributed to intravenous drug use and no further clinical data describing the management strategy were available.⁴⁰ Similarly, in the previously described study by Prins et al.²⁷ in 2022, one of 111 patients undergoing SSRF with a traumatic brain injury developed an implant-related infection, although no further clinical information was available to comment upon management strategy. Finally, in 2022 Prins et al.⁹ also published a single-center retrospective cohort study evaluating 228 patients undergoing SSRF of whom four required implant removal for infection. Two patients required implant removal within the first 30 days, while the other two required implant removal at seven and 17 months, respectively.⁹ The causative agent of infection in all cases was methicillin-sensitive Staphylococcus aureus (MSSA).⁹ All patients received systemic antibiotic agents for two to six weeks after implant removal.⁹ Patients requiring implant removal within 30 days underwent implant removal followed by systemic therapy; in this group there were no re-operations.⁹ For the two patients with infections identified more than 30 days after initial SSRF, patients underwent systemic antibiotic therapy and local wound care initially; both patients ultimately required an operation for implant removal to obtain source control.⁹

Recommendation

We considered the available evidence describing management of patients with an implant-related infection after undergoing SSRF/SSSF. There is insufficient evidence to suggest an optimal management strategy among patients undergoing SSRF or SSSF with an implant-related infection. However, among patients with an implant-related infection, removal of the implant is often required to achieve source control. The decision to remove an implant at the index re-operation should be balanced against the presence of bony union, potential need for prolonged antibiotic use, and need for re-operation. Future studies reporting on implant-related infections after SSRF or SSSF are encouraged to include information on causative organisms, duration and choice of antibiotic therapy, attainment of bony union, need for subsequent surgery, and drainage and wound management strategies used.

Discussion

Surgical site infections and implant-related infections after SSRF or SSSF are uncommon but can be morbid. To date, high-quality evidence suggesting an optimal treatment strategy in this patient population is lacking. There are, however, existing guidelines targeting other patient populations peripherally applicable to the clinical questions posed above have been published and can help provide guidance.

In 2005, Stevens et al.⁴¹ published updated practice guidelines for the diagnosis and management of skin and soft tissue infections after surgery on behalf of the Infectious Diseases Society of America (IDSA). Initial incision and drainage of the infection was recommended. Adjunctive systemic antibiotic therapy was recognized as potentially beneficial if the SSI is associated with systemic response such as temperature >38.5°C, heart rate >110 beats/minute, or white blood cell count >12,000 per microliter, erythema or induration extending >5 cm from the wound edge.⁴¹ First-generation cephalosporins or an antistaphylococcal penicillin targeted to MSSA were recommended for antibiotic agents unless a patient has risk factors for methicillin-resistant Staphylococcus aureus (MRSA), in which case vancomycin, linezolid, daptomycin, telavancin, or ceftaroline were recommended for a brief course.⁴¹ No further specification of antibiotic course durations were provided for SSIs. In patients with cellulitis, the recommended duration of antibiotic therapy is five days, with options for extending the duration of treatment if the infection has not improved.⁴¹ Risk factors for MRSA included nasal colonization, prior MRSA infection, recent hospitalization, and recent antibiotic therapy.⁴¹ Addition of agents active against gram-negative bacteria and anaerobes (cephalosporin or fluoroquinolone in combination with metronidazole) are recommended for infections after operations involving the axilla.⁴¹

In 2013, Osmon et al.⁴² published IDSA guidelines on the diagnosis and management of prosthetic joint infection. Although SSRF and SSSF do not typically involve joints, there are similarities with respect to the presence of an implant. The authors recommend that an implant-related infection should be suspected in a patient with any of the following: a sinus tract or persistent wound drainage over the prosthesis, acute onset of a painful implant, any chronic painful implant particularly in absence of a pain-free interval, or if there is a history of prior wound healing problems or superficial or deep infection.⁴² Obtaining a test for sedimentation rate or C-reactive protein (CRP) should be performed in all patients with a suspected implant-related infection as abnormal sedimentation rate and CRP provide a high level of sensitivity and specificity in a patient where the diagnosis of a prosthetic infection is not readily apparent clinically.⁴² Patients with a well-fixed implant without a sinus tract who are within 30 days of implantation or less than three weeks from the onset of infectious symptoms should be considered for a debridement and implant retention strategy.⁴² The authors note that for patients who do not meet these criteria, a two-stage exchange strategy is commonly used in the United States, with direct implant exchange strategies not recommended unless in the setting of total hip arthroplasty. However, the authors acknowledge that for patients who do not meet implant retention criteria but for whom alternative surgical strategies are clinically prohibitive, an implant retention strategy may still be considered.⁴²

After debridement of an implant-related joint infection with retention of the prosthesis, the authors recommended pathogen-specific intravenous antimicrobial therapy in combination with rifampin for two to six weeks followed by a comparison oral drug and rifampin treatment for a total of three months.⁴² If rifampin cannot be used, four to six weeks of pathogen-specific intravenous therapy is recommended. For patients undergoing resection arthroplasty with or without planned staged re-implantation, four to six weeks of pathogen-specific intravenous or highly bioavailable antimicrobial therapy is recommended.⁴²

In 2019, the American Academy of Orthopaedic Surgeons released a guideline document describing appropriate use criteria for the management of surgical site infections.⁴³ In this guideline document, the authors differentiated between location of infection (superficial, deep, bone, joint), hardware presence (none, internal fixation, arthroplasty, biologic implant), ability for the implant to be removed (no implant, removal associated with high morbidity, removal associated with low morbidity), chronicity of infection (acute, chronic), organism susceptibility (susceptible to routine oral or intravenous antibiotic agents, difficult to treat micro-organism, no organism identified), and medical status (no or limited co-morbidities [healthy, American Society of Anesthesiologies {ASA}, 1–2] or multiple co-morbidities [frail, ASA, 3–4]). This document did not comment on selection of antimicrobials nor was a specific definition of an implant-related infection established.⁴³ However, several scenarios in this document are applicable to patients undergoing SSRF or SSSF with titanium-based implants. For patients with acute or chronic superficial or deep SSI, antimicrobial systemic treatment only, local superficial non-surgical wound care with or without antimicrobial therapy, and surgical debridement with implant retention and suppressive antimicrobials until implant removal were all identified as potentially appropriate treatment strategies depending on the organism identified and medical status of the patient.⁴³ For patient with infections of the bone, antibiotic therapy alone, with or without local superficial wound care was identified as rarely appropriate irrespective of the chronicity of infection.⁴³ In patients with acute and chronic infections of the bone, surgical debridement and suppressive antimicrobials until implant removal, surgical debridement and implant retention/partial exchange/partial removal and appropriate antimicrobial therapy, surgical debridement and implant removal without re-implantation and appropriate antimicrobial therapy, surgical debridement and implant removal with single-staged re-implantation and appropriate antimicrobial therapy, or surgical debridement and implant removal with multistaged re-implantation and appropriate antimicrobial therapy were all recognized as potentially appropriate management therapies. Recommendation grading as appropriate or potentially appropriate varied based on the chronicity of the infection and presence of difficult to treat organisms.⁴³

Conclusions

This guideline document summarizes the current SIS and CWIS recommendations regarding management of SSIs and implant-related infections among patients undergoing SSRF or SSSF. For patients with an SSI, systemic antibiotic therapy, local wound debridement, and VAC have been used in isolation or combination. For patients with an implant-related infection, initial implant removal with or without systemic antibiotic therapy, systemic antibiotic therapy with local wound drainage, and systemic antibiotic therapy with local antibiotic therapy have been used. For patients who do not undergo initial implant removal, 68% ultimately require implant removal to achieve source control. However, limited evidence precludes our ability to make robust recommendations and further studies should be performed to identify the optimal management strategy for patients who undergo SSRF or SSSF and develop an SSI or implant-related infection.

Footnotes

Acknowledgments

The authors would like to thank Chris Stave for his assistance in developing search terms and use of Covidence.

Disclaimer

Volunteer physicians from multiple medical specialties created and categorized these management recommendations. These management recommendations are not intended to be comprehensive or a fixed protocol. Some patients may require more or less treatment or different means of diagnosis. These management recommendations represent patients and situations that clinicians treating or diagnosing traumatic rib or sternal fractures may encounter. The clinician's independent medical judgment, in accordance with the individual patient's clinical circumstances, should always determine patient care and treatment.

Funding Information

No funding was received for this work.

Author Disclosure Statement

No conflicts of interest are reported for any author. Dr. Forrester received unrestricted research funding from Varian and Pacira for an investigator-initiated trial and funding from Eclipse Regenysis for industry-sponsored trial.

Supplementary Material

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