49 y/o male is 1 month s/p midfoot fusion.  No significant PMH.  Patient presented for follow up after cast removed to reveal dehisced and infected wound with drainage.  Taken to OR for I&D with noted purulence and exposure down to fascia, bone, and hardware.   Upon return to OR 3 days later, the wound base is stable and granular with hardware exposed but stable.  Closure is planned with abductor hallucis muscle rotation and STSG.  Given that this plate  / screws were exposed and involved in the purulent wound base, must they be removed prior to closure?

The traditional mantra considering exposed hardware was that "exposed hardware was considered infected, and should therefore be removed," however more recently, there has been some literature to suggest that "all or nothing" is not the way to go with regard to hardware removal.  In 2006,  Baumeister et al presented a specific treatment  algorithm which sought to provide the clinician with a basis for determining which hardware would need to be removed.  More recently, one  study  in the Journal of Plastic and Reconstructive surgery suggests that exposed hardware need not be removed if the exposure has been less than 2 weeks, the hardware is stable, and there is limited infection.

Advances in wound healing, such as NPWT and bioengineered alternative tissues (BAT) have greatly increased the clinician's ability to provide soft tissue coverage over potentially exposed hardware.

Ultimately, further evidence based research is necessary.  At this point, however, there is available literature which supports maintaining internal fixation, even when exposed in the wound bed, assuming the length of exposure has been less than 2 weeks, the fixation is stable and intact, and there is minimal to no infection.

I agree with Ryan.

The classic knee-jerk reaction is to get out the exposed hardware. However, the clinical photo you present looks free from gross infection. I assume the radiographs demonstrate the same, a stable construct free from signs of osteomyelitis. That doesn't look like a titanium plate, therefore MRI is probably out. A CT scan with a soft-tissue window can be used to rule out  deep abscess.  A strong argument can and should be made for a PICC line and six weeks of IV Abx as you implement NPWT.

Wound dehiscence is a common complication seen with extra-medullary fixation. Intra-medullary fixation is an alternative as described here:

Thomas S. Roukis, Minimally Invasive Soft-Tissue and Osseous Stabilization (MISOS) Technique for Midfoot and Hindfoot Deformities, Clinics in Podiatric Medicine and Surgery, Volume 25, Issue 4, Surgical Reconstruction of the High-Risk Patient, October 2008, Pages 655-680, ISSN 0891-8422, DOI: 10.1016/j.cpm.2008.05.005.
 
 
The question that begs to be asked here is "why did this incision dehisce?". How were the soft tissues handled during the case? Was "no-touch" technique observed in retracting the soft tissue envelope? Were angiosomes taken into account in planning the incision? 

Can you please post radiographs? Thanks.

I wound leave the hardware in, especially after the I & D and the hardware is stable.  There is no clinical evidence to remove hardware, even if it means loss of stability with internal fixation.

Assuming the patient is on parental antibiotics, leave em in!!!!

Dear John,

I think you have to be pragmatic about these things. "Never" or "Always" is a strong word for any surgical decision making.

In my opinion, the fact that there was infection where the screws were in... automatically means to me that it is (clinical diagnosis of) osteomyelitis of the bone in this area, and this patient needs to be treated as such. It means PICC line and 6-8 weeks of IV antibiotics. Perhaps with life-time oral suppressive antibiotics afterwards, if this patient were much older individual in my institution.

As for taking the hardware out or not? I say, if they are loose, take them out, if they are tightly held and stable, leave them in. 

For the wound closure, I think "muscle flap + STSG" as John suggested is reasonable, but I think Wound VAC + skin graft (or skin substitute) is a fairly reasonable initial approach, with the muscle flap as a back-up option.

I also want to comment that, with the diagnosis of osteomyelitis and wound dehiscence ("Compromised skin flap") qualifies for the treatment indications for hyperbaric oxygen treatment for most insurance policies (except for Blue Cross).

Just my 2 cents here...

Kazu Suzuki

Los Angeles CA