Orthopedic Infectious Diseases Online Library

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  • OBJECTIVE Currently, no consensus exists as to whether patients who develop infection of the surgical site after undergoing instrumented fusion should have their implants removed at the time of wound debridement. Instrumentation removal may eliminate a potential infection nidus, but removal may also destabilize the patient’s spine. The authors sought to summarize the existing evidence by systematically reviewing published studies that compare outcomes between patients undergoing wound washout and instrumentation removal with outcomes of patients undergoing wound washout alone. The primary objectives were to determine 1) whether instrumentation removal from an infected wound facilitates infection clearance and lowers morbidity, and 2) whether the chronicity of the underlying infection affects the decision to remove instrumentation. METHODS PRISMA guidelines were used to review the PubMed/MEDLINE, Embase, Cochrane Library, Scopus, Web of Science, and ClinicalTrials.gov databases to identify studies that compared patients with implants removed and patients with implants retained. Outcomes of interest included mortality, rate of repeat wound washout, and loss of correction. RESULTS Fifteen articles were included. Of 878 patients examined in these studies, 292 (33%) had instrumentation removed. Patient populations were highly heterogeneous, and outcome data were limited. Available data suggested that rates of reoperation, pseudarthrosis, and death were higher in patients who underwent instrumentation removal at the time of initial washout. Three studies recommended that instrumentation be uniformly removed at the time of wound washout. Five studies favored retaining the original instrumentation. Six studies favored retention in early infections but removal in late infections. CONCLUSIONS The data on this topic remain heterogeneous and low in quality. Retention may be preferred in the setting of early infection, when the risk of underlying spine instability is still high and the risk of mature biofilm formation on the implants is low. However, late infections likely favor instrumentation removal. Higher-quality evidence from large, multicenter, prospective studies is needed to reach generalizable conclusions capable of guiding clinical practice.

  • Study design: Retrospective cohort study. Objective: To compare short- and long-term outcomes in obese versus nonobese patients undergoing instrumented posterolateral fusion of the lumbar spine. Summary of background data: Obesity is an important public health issue due to the negative effects on quality of life. Some studies have shown an association between obesity and higher rates of complications and unfavorable outcomes after spine surgery. Methods: We retrospectively reviewed medical records for all adult patients undergoing 1- to 3-level posterolateral fusion for degenerative spine disease between 1992 and 2012 at a single institution. Patients were divided into obese (body mass index > 30 kg/m) and nonobese cohorts to compare complications, reoperation rates, and symptom resolution at the last follow-up. A regression model was used to estimate relative risk ratios. Results: During the study period, 732 patients underwent lumbar fusion, with 662 (90.44%) nonobese patients and 70 (9.56%) obese patients in the cohort. Obese patients had significantly higher blood loss intraoperatively (P = 0.002) and a longer average length of stay (P = 0.022). Moreover, obesity was independently associated with a significantly increased risk of developing a postoperative complication (risk ratio 2.14; 95% confidence interval, 1.10-4.16) and surgical site infection (risk ratio 3.11; 95% confidence interval, 1.48-6.52). At the last follow-up, a higher proportion of obese patients had radiculopathy (P = 0.018), motor deficits (P = 0.006), sensory deficits (P = 0.008), and bowel or bladder dysfunction (P = 0.006) than nonobese patients. Conclusion: In this study, obese patients undergoing lumbar fusion had higher blood loss, longer lengths of stay, higher complication rates, and worse functional outcomes at the last follow-up than nonobese patients. These findings suggest that both surgeons and patients should acknowledge the significantly increased morbidity profile of obese patients after lumbar fusion.

Last update from database: 11/10/24, 4:26 PM (UTC)