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| CASE REPORT |
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| Year : 2021 | Volume
: 18
| Issue : 2 | Page : 79-81 |
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Septicemia secondary to late-onset infection after fracture fixation: A rare case report
KR Renjith1, PP Sunil1, Baiju Sam Jacob2, Arvind P Vijayan1
1 Department of Orthopedics, Near Adlux Convention Center, Apollo-Adlux Hospital, Ernakulam, Kerala, India
2 Department of General Medicine, Near Adlux Convention Center, Apollo-Adlux Hospital, Ernakulam, Kerala, India
| Date of Submission | 06-Sep-2021 |
| Date of Acceptance | 19-Sep-2021 |
| Date of Web Publication | 27-Jan-2022 |
Correspondence Address:
K R Renjith
Department of Orthopedics, Near Adlux Convention Center, Apollo-Adlux Hospital, Cable Junction, National Highway 47, Karukutty, Angamaly, Ernakulam - 683 576, Kerala
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/joasis.joasis_20_21
Infection after fracture fixation (IAFF) is one of the most dreadful complications in the treatment of musculoskeletal trauma. Early detection is paramount, and the presentation can be heterogeneous with local as well as systemic features depending on the postoperative duration and microbiological virulence. We describe an unusual presentation of a young adult immunocompetent male with septicemia following late-onset IAFF, where a multidisciplinary approach helped in the early diagnosis and successful treatment.
Keywords: Infection after fracture fixation, orthopedic infection, septicemia
How to cite this article:
Renjith K R, Sunil P P, Jacob BS, Vijayan AP. Septicemia secondary to late-onset infection after fracture fixation: A rare case report. J Orthop Assoc South Indian States 2021;18:79-81 |
How to cite this URL:
Renjith K R, Sunil P P, Jacob BS, Vijayan AP. Septicemia secondary to late-onset infection after fracture fixation: A rare case report. J Orthop Assoc South Indian States [serial online] 2021 [cited 2022 May 27];18:79-81. Available from: https://www.joasis.org/text.asp?2021/18/2/79/336652 |
| Introduction | |  |
Infection after fracture fixation (IAFF) remains a challenging complication in the treatment of musculoskeletal trauma despite numerous advances in the field, and specific criteria for IAFF are not well defined. This contrasts, with prosthetic joint infection (PJI) which is better understood and has effective treatment protocols. Early detection being crucial and the diagnosis mostly being clinical, IAFF can be heterogeneous depending on the timing of presentation and virulence of the organism. Early infections present with systemic manifestations and have localized erythema, pain, and swelling, whereas delayed cases can have less severe features. We present the case of a 22-year-old male patient, who was operated for his left forearm fracture 6 months ago, presented with fever and breathlessness and eventually diagnosed to have septicemia secondary to late onset IAFF.
| Case Report | | |
A 22-year-old healthy male presented to our outpatient department with a history of fever, breathlessness, and jaundice for 1 week duration. Past history was unremarkable except for open reduction and internal fixation of the left radius fracture done 6 months back from a nearby hospital. Local examination of the left forearm revealed well-healed longitudinal scar over the volar surface of the left forearm without any tenderness or restricted mobility. Initial laboratory data were notable for leukocytosis (TC-25000) and elevated liver enzymes (SGOT– 120u/l and SGPT– 110u/l) and computerized tomography (CT) of the chest demonstrated multiple wedge-shaped consolidatory patches with diffuse ground-glass opacity of the bilateral lung parenchyma suggestive of septic pulmonary emboli. In search for a primary infective focus, plain radiographs of the forearm were done which showed good fracture healing with no signs of implant loosening. However, there was periosteal reaction noted at the medial aspect which raised the suspicion for an underlying infection [Figure 1]. | Figure 1: Plain radiograph of right forearm showing periosteal reaction medial to the fracture site with well-fixed implant at 6 months follow-up
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Ultrasonography of the surgical site was performed, and there was a 5 mm × 9 mm collection in the intermuscular plane at the dorsoradial aspect. Wound exploration was planned after counseling the patient, and intraoperatively, there was the presence of frank pus at the surgical site dorsoradially in the intermuscular plane [Figure 2]. | Figure 2: Intraoperative image showing pus in the intermuscular plane following implant removal
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The fracture site showed good healing without any evidence of implant loosening. Thorough debridement and wash were performed along with implant removal, and the pus culture grew methicillin-sensitive Staphylococcus aureus. Subsequent blood cultures also showed similar organism, and the patient was given parenteral culture-sensitive antibiotics for 6 weeks till his blood culture became negative. His general condition dramatically improved immediately after the implant removal surgery along with the initiation of culture-sensitive antibiotics. The follow-up visits at 3 months and 6 months were unremarkable, and his latest radiographs showed complete consolidation of the fracture site without any evidence of osteomyelitis, and there was the resolution of lung findings [Figure 3]. | Figure 3: Plain radiograph of right forearm following implant removal showing healed fracture at 6 months follow-up
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| Discussion | | |
IAFF is one of the most dreadful complications which can result in delayed healing, permanent functional disability, or even amputation of the affected extremity. Reported rates of IAFF range from 1% in closed low-energy fractures to 30% for open tibial fractures.[1] Although patient care has been inspired from PJI guidelines for a long time, Metsemaker's et al. in collaboration with Arbeitsgemeinschaft für Osteosynthesefragen Foundation proposed a definition for IAFF which finally became an international consensus in 2018.[2] Pathogenesis has been largely attributed to the formation of protective biofilms on implant surface by the microorganisms; S. aureus being the most common.[1],[3],[4]
Rapid detection is of paramount importance, and this becomes much easier with the above-mentioned consensus which includes confirmatory as well as suggestive criteria incorporating clinicoradiological and laboratory parameters. However, clinical presentation may vary depending on the timing of presentation after surgery which can be early (<2 weeks), delayed (2–10 weeks), and late (more than 10 weeks).[5] Early infections tend to have wound healing disturbances with persistent pain at the surgical site and associated fever, most often caused by virulent organisms. Delayed and late-onset presentations are usually associated with low virulent organisms which rarely cause systemic manifestations.
Unlike PJI, bone healing is the primary objective of treatment in IAFF, and therefore, suppressive treatment has a major role in unhealed fractures. If the fracture is consolidated, eradication can be the treatment goal where a thorough debridement and complete retrieval of the internal fixation device are performed. Prolonged antimicrobial therapy is considered mandatory with a minimum duration of 6 weeks after complete implant retrieval and 6 weeks to 3 months for retained implants depending on the clinical and biochemical markers for treatment response.[6]
Our patient had septicemia associated with late-onset IAFF which is a very rare phenomenon as per the existing literature. Since his preoperative imaging and intraoperative findings were consistent with fracture union, he had undergone successful eradication of infection by implant removal with thorough debridement of all the infected tissue followed by systemic antibiotic therapy for 6 weeks.
| Conclusion | | |
We emphasize the importance of keeping a high index of suspicion for IAFF as a potential complication following any orthopedic trauma surgery, where a prompt recognition and multidisciplinary approach can result in successful eradication of infection and good clinical outcomes.
Consent
The patients and/or their families were informed that the data from the case would be submitted for the publication and gave their consent.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Trampuz A, Zimmerli W. Diagnosis and treatment of infections associated with fracture-fixation devices. Injury 2006;37 Suppl 2:S59-66.  |
| 2. | Metsemakers WJ, Morgenstern M, McNally MA, Moriarty TF, McFadyen I, Scarborough M, et al. Fracture-related infection: A consensus on definition from an international expert group. Injury 2018;49:505-10. |
| 3. | Trampuz A, Osmon DR, Hanssen AD, Steckelberg JM, Patel R. Molecular and antibiofilm approaches to prosthetic joint infection. Clinical Orthopaedics and Related Research ®. 2003;414:69-88. |
| 4. | Corvec S, Portillo ME, Pasticci BM, Borens O, Trampuz A. Epidemiology and new developments in the diagnosis of prosthetic joint infection. Int J Artif Organs 2012;35:923-34. |
| 5. | Willenegger H, Roth B. Treatment tactics and late results in early infection following osteosynthesis. Unfallchirurgie 1986;12:241-6. |
| 6. | Steinmetz S, Wernly D, Moerenhout K, Trampuz A, Borens O. Infection after fracture fixation. EFORT Open Rev 2019;4:468-75. |
[Figure 1], [Figure 2], [Figure 3]
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