Lessons Learned from An Implant-Related Infection with Bacillus spp of the Proximal Femur: A Rare and Insidious Complication After Internal Fixation of Closed Fractures
Journal Title: Biomedical Journal of Scientific & Technical Research (BJSTR) - Year 2019, Vol 19, Issue 2
Abstract
Background: Bacillus are Gram-positive, primarily aerobic, rod-shaped and sporeforming bacteria. Ubiquitary in environment, infections with Bacillus are known to occur after open fractures but are rarely described after internal fixation of closed fractures. Based on a case of implant-related infection of the proximal femur with acillus spp after internal fixation, we report on the associated diagnostic and therapeutic challenges. Methods: Case report with review of the essential features. Results: A 74-year-old male suffered a pertrochanteric fracture of the femur due to a low energy fall. Internal fixation was performed with a cephalomedullary nail. Three debridements were performed for postoperative wound oozing before infection with Bacillus spp was detected. Insufficient sampling with misinterpretation and empiric antibiotic treatment delayed proper diagnosis. One-stage implant exchange, local application of antibiotic-loaded calcium sulphate, combined with systemic antibiotic treatment, healed the infection and the fracture. Due to possible spore formation, the antibiotic treatment was maintained for a total of six months. No recurrence of the infection was observed, now over two years later. Conclusion: Orthopaedic or trauma implant-related infections with Bacillus spp are reported rarely, except after open fractures. It usually presents with large seroma, recurrent hematomas or wound oozing. Whenever revising an implant, proper sampling with four to six biopsies is recommended, to avoid misinterpretation and subsequent wrong management, as low virulence microorganisms may cause local infection with few or subtle clinical signs only. Extended duration of antibiotic treatment should be considered for sporulating bacteria, with the aim of reducing the risk of late recurrence.A 74 years old male, known for chronic alcohol abuse, suffered a trochanteric fracture of his left femur following a low energy fall (Figure 1A). Internal fixation with a long cephalomedullary nail (Proximal Femoral Nail Antirotation, DePuy Synthes, Zuchwil, Switzerland) and subtrochanteric cerclage wires was performed within 24 hours (Figure 1B). The patient was discharged home on the 6th day after surgery, fully weight-bearing with crutches. The further initial postoperative course was uneventful. However, five weeks postoperatively the patient had to be readmitted, due to local swelling and wound oozing, associated with elevated white blood count (WBC, 11.4 G/l) and CRP (68 mg/l). The body core temperature was normal. Due to a tonsillitis, an antibiotic treatment with amoxicillin/clavulanate orally had been started four days before by his general practitioner. A wound revision was performed on the day of admission including debridement, irrigation and primary wound closure. Two deep tissue biopsies were sampled for microbiological workup (aerobic and anaerobic cultures, including enrichment broth, with 14 days incubation). All the hardware was retained. Postoperatively, amoxicillin/clavulanate was administered parenterally. Due to persistent wound secretion and persistent elevation of the inflammatory parameters, wound revision was repeated five and nine days later.
Authors and Affiliations
Sebastian Ebert, Christoph Meier, Severin Meili, Peter Wahl
Keywords
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- EP ID EP620700
- DOI 10.26717/BJSTR.2019.19.003274
- Views 106
- Downloads 0
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