Failure to Remove Infected Hardware Leads to Amputation

Case Summary

This case involves a middle-aged man who suffered a calcaneal heel fracture. He underwent internal fixation with hardware. Within a week from the surgery date, he was showing symptoms of surgical site infection. Within two weeks, the patient underwent debridement and washout procedures. Cultures were positive for MRSA and Pseudomonas infections.

The orthopedist treated the patient with both IV and oral antibiotics. An infectious disease specialist provided a consultation and recommended hardware removal as the best option to clear the infection. The orthopedist wanted to defer the removal to facilitate the healing of the fracture.

Ultimately, it was believed that the infection was cleared. Six months later, the patient sought treatment from a new orthopedist when his open wound began draining fluid. The second orthopedic surgeon ultimately removed hardware due to the infection. However, the second orthopedic surgeon failed to remove the synthetic grafting. Eventually, the patient required an amputation.

Case Theory

Open calcaneal fractures account for about 2% of fractures. These fractures are severe injuries associated with high rates of infection, uncertain patient outcomes, and frequent amputations. Treatment often consists of surgical or conservative management. Patients treated with open reduction and internal fixation (ORIF) are more likely to develop wound infections. However, surgery generally correlates with improved patient outcomes.

Calcaneal fracture surgery is notoriously associated with postoperative infections leading to hospitalizations and secondary surgeries. The incidence of wound infection following operative treatment of calcaneal fractures is between 2% and 25% with surgical complications occurring in approximately 21% of cases.

In this case, the failure to perform a second surgery and remove infected hardware when recommended by an infectious disease expert was below the standard of care. Additionally, the second surgeon was negligent in failing to remove the surgical grafting, allowing for the infection to continue, resulting in amputation.

Expert Witness Q&A

• At what point is hardware removal warranted in similar patients to ensure timely clearance of a surgical site infection?
• What measures are required during hardware removal to ensure a thorough extraction?
• What is the threshold for an orthopedic surgeon to act when a calcaneal fracture patient presents with signs of infection?
• Are nosocomial infections (MRSA) and Pseudomonas common with calcaneal fracture? What measures should surgeons take to avoid hospital-acquired infections?

Expert Witness Involvement

Orthopedic Surgeon

An orthopedic surgeon can speak to the failure and infection rates of calcaneal fracture repair. This expert can discuss the standard of care when caring for a patient similar to this case.

Infectious Disease Expert

An infectious disease expert can speak to the nosocomial (hospital-acquired) infection pathology and prognosis.