SLR - January 2010 - Jamie A. Bakal
Reference:
Viol, A., Pradka, S., Baumeister, S-P., et al. (2009). Soft tissue defects and exposed hardware: A review of indications for soft-tissue reconstruction and hardware preservation. Journal of Plastic and Reconstructive Surgery, 123, 1256-1263.
Scientific Literature Review
Reviewed by: Jamie A. Bakal, DPM
Residency Program: Kaiser North Bay Consortium, Vallejo
Podiatric Relevance:
Exposed and/or infected hardware traditionally has been managed with irrigation and debridement, intravenous antibiotics and usually the removal of the hardware. For the foot and ankle surgeon, this is an unfortunate complication that may occur as a result of trauma, wound dehiscence or underlying infection following surgical osteotomy, arthrodesis or ORIF. This algorithm may aid the surgeon in making decisions about using plastic surgery techniques such as grafts and flaps to perform soft tissue reconstruction and salvage the exposed hardware.
Methods:
A current literature (PubMed) review from 1960 to the present time was performed to identify factors with prognostic application for the management of exposed hardware prior to soft tissue reconstruction. In addition, all references were reviewed to identify additional studies relevant to this topic. All review articles were excluded.
Results:
An extensive review of the literature revealed several parameters significant for the treatment and preservation of exposed hardware with soft tissue reconstruction. An algorithm was created which included location of the hardware, the presence of infection, the duration of hardware exposure, and the presence of hardware loosening. In lower extremity reconstruction, the more proximal the level of the hardware, the higher the possible amputation site. If there is a documented infection either through clinical or positive wound culture diagnosis, the authors suggest that for periods less than 2 weeks hardware may be salvageable. If the hardware has been exposed for a period of more than 2 weeks, removal of hardware is indicated either with or without soft tissue reconstruction. Regardless, it has commonly been agreed that irrigation, debridement, antibiotic therapy and soft tissue coverage of exposed hardware should be performed as early as possible. Identifying infected hardware can be challenging. Usually clinical signs of hardware loosening in the presence of infection are an indication for removal. However, radiographic signs of an infection with hardware loosening (such as periprosthetic osteolysis) are not always reliable when used alone.
Conclusions:
Traditional management of exposed hardware usually includes removal of the hardware. With this algorithm however, if the hardware is stable, has been exposedless than 2 weeks, there is no documented infection and the location of the hardware is in a feasible location, plastic surgical soft tissue coverage may be an option.