Treatment of post-operative infections following proximal femoral fractures: Our institutional experience

Injury, Int. J. Care Injured 42 (2011) S5, S28–S34

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Treatment of post-operative infections following proximal femoral fractures: Our institutional experience A.A. Theodoridesa , T.C.B. Pollardb , A. Fishlocka , G.I. Mataliotakisa , T. Kelleyb , C. Thakarb , K.M. Willettb , P.V. Giannoudisa a Academic

Department of Trauma and Orthopaedic Surgery, Leeds General Infirmary, University of Leeds, Leeds, b Oxford Trauma Unit, The John Radcliffe Hospital, and Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK

article info

abstract

Keywords: Proximal femoral fracture Neck of femur fracture Infection Treatment Cost

Proximal femoral fractures (PFFs) are a major health concern in the elderly population. Improvements made in implants and surgical techniques resulted in faster rehabilitation and shorter length of hospital stay. Despite this, the reduced physiological reserve, associated comorbidities and polypharmacy intake of the elderly population put them at high risk of postoperative complications particularly of infectious origin. Out of 10 061 patients with proximal femoral fractures 105 (1.05%) developed surgical site infection; 76 (72%) infections occurred in patients who had sustained intracapsular (IC) fractures with the remaining 29 (28%) infections occurring in patients with extracapsular (EC) neck of femur fractures. The median number of additional surgical debridements was 2 (range 1–7). MRSA was isolated in 49 (47%) of the cases; 38 patients (36%) ultimately underwent a Girdlestone’s excisional arthroplasty. Mortality at 30 days and 3 months was 10% and 31%, respectively. It was noted that post-operative hip infection predisposed to a prolonged length of stay in the acute unit and subsequently to a more dependent destination after discharge. © 2011 Elsevier Ltd. All rights reserved.

Introduction Proximal femoral fractures (PFFs) are a major health concern in the elderly population with strong associated morbidity and mortality and result in additional costs to the hospital and society.1,2 The oneyear mortality rate ranges from 14% to 36% despite improvements in surgical technique, anaesthesia and nursing care.3,4 Post-operative complications can have a threefold increase in 1-year mortality rates.5 The reduced physiological reserve, associated co-morbidities and polypharmacy intake of the elderly population put them at high risk of post-operative infections alone and when they do occur they place an even greater cost to the health service in terms of additional operative interventions, revision of metalwork, extra bed stays which are often in higher dependency areas with more intense medical and nursing care. Their mobility often worsens, causing them to lose their independence and become residents in longterm care facilities.1 Whitehouse et al.6 showed that surgical site infections occurred in 1–3% of orthopaedic surgical procedures, and they prolonged hospital stay by a median of 2 weeks, doubled the rate of rehospitalisation, increased health costs fourfold and decreased overall physical and social functioning. With the ever increasing elderly * Corresponding author. Peter V. Giannoudis MD, FRCS, Academic Department of Trauma and Orthopaedic Surgery, School of Medicine, University of Leeds, LIMM Section Musculoskeletal Disease, Leeds, LS1 3EX, UK. Tel.: +44 113 392 2750; fax: +44 113 292 3290. E-mail address: [email protected] (P.V. Giannoudis). 0020-1383/ $ – see front matter © 2011 Elsevier Ltd. All rights reserved.

population surgical site infections will become ever more prevalent. Surgical site infections (SSI) account for 11% of all nosocomial infections in the elderly.7 Documented co-morbidities which are prevalent in the elderly population and are known predictors of surgical site infections8 include: diabetes mellitus, peripheral vascular disease, malnutrition, chronic hypoalbuminaemia and reduced body fat predisposing to hypothermia. However, these have not been substantiated specifically for the elderly population. Compared with the younger population, the elderly (65 years and over) have a fivefold greater mortality and a double hospitalisation stay when they sustain surgical site infections.9 Torgerson et al.10 calculated in 2001 that the overall cost of medical and social care for patients with hip fractures is £1.73 billion per year in the UK, which is similar to the £1.75 billion for coronary heart disease. They also estimated that a single hip fracture has a combined medical and social care cost of £20 000. Lawrence et al.11 estimated the NHS expenditure for each fracture alone to be just over £12 000 which was £7000 more than previous estimates. With the number of hip fractures being 70 000 in 2008 and rising by 2% each year this cost is only going to grow (BOA, 2008).12 Even though surgical site infections (SSIs) in PFF are known to have such an adverse impact on patients and society as a whole, their treatment has not been well documented in the literature. The aims of this study were to ascertain the impact of this by quantifying the length of hospital stay and overall mortality rates and to review the current treatment of deep wound SSIs in our institutions.

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Table 1 Social dependency and mobility scores Score

Description

Social Dependency Scale 1

Independent in domestic and social activities.

2

Minimal help with shopping may have meals on wheels.

3

Dependent on social support up to three times a week.

4

Dependent on social support more than three times a week, but less than daily. All domestic activities performed by spouse or carer.

5

Dependent on social support more than once daily, or resident in a residential home. Personal care provided by spouse.

6

Resident in nursing home or long stay hospital.

Mobility Score 0

Bedbound.

1

Bed to chair.

2

Mobilises with a frame and the assistance of 2 people.

3

Mobilises with a frame and the assistance of 1 person.

4

Mobilises with a frame alone, without the need for assistance.

5

Walking stick.

6

No aid.

Patients and methods Leeds A retrospective study was carried out of all patients over the age of 65 years who developed surgical site infections (SSIs) following surgery for traumatic proximal femoral fractures (PFF) between 01/01/2004 and 30/08/2010. All patients were treated in a tertiary trauma centre in Leeds. Cases were identified by searching microbiology, pharmacy and hospital administration databases, theatre records and hip fracture database. Deep wound infections were defined by the need for surgical debridement and washout with positive microbiology from tissue deep to the fascia lata. Key demographics and pre-fracture residence (home, residential home, nursing home) were recorded. The fracture pattern (intra- or extra capsular), use of prophylactic antibiotics and type of fixation (cannulated hip screws, dynamic hip screw, hemiarthroplasty) were also recorded. The dates of subsequent surgery including the need for removal of metalwork, and the organism isolated were documented for each of the infected cases. The subsequent antibiotic regimen was identified from patients’ drug charts and in-patient notes. Outcomes: Each patient was studied from the time of presentation to the acute orthopaedic unit, to the time of discharge to their final residence or death (if occurring during the period of care). The details of any readmissions relating to the original injury or surgery were also recorded and notes reviewed. Outcome measures included the length of hospital stay and mortality. The final discharge destination (home, residential or nursing home) for each patient was recorded, and for those patients discharged the mortality data were collected at 6 months post discharge. Oxford The same data were recorded and the same diagnostic criteria were used for the patients treated at the John Radcliffe Hospital, Oxford. All patients with PFF (subtrochanteric fractures excluded) aged 65 years or above, who presented over an 11-year period (1 January 1998 to 29 February 2008) were included. Similarly, deep surgical site infection was defined as microbiological confirmation of infection from culture specimens of tissue samples taken deep to the fascia lata at reoperation.

For the period prior to 1 March 2003, cases were identified by searching hospital administration and microbiology databases, operating theatre logs, and line insertion team records. The case notes were reviewed for each patient and the diagnosis of deep wound infection confirmed.13 From 1 March 2003, dedicated audit staff have collected data prospectively for all hip fracture patients. The data collection is compatible with the National Hip Fracture Database and managed adhering to the Caldicott principles.14 Cases from 1 March 2003 were identified by interrogating the unit’s database and then cross-referenced with operation theatre logs, radiology and microbiology databases.15 Treatment of infection The treatment of deep wound infection consists of a full and, if necessary, repeated surgical debridement together with close liaison with clinical microbiologists. Most patients receive intravenous antibiotics for 6 weeks followed by oral suppressive therapy as appropriate. Refractory cases may require removal of implants. Routine prophylactic intravenous antibiotics were administered on induction of anaesthesia prior to their initial fracture surgery. The choice of antibiotic was according to local microbiological guidelines. All patients received prophylaxis. All patients undergoing hemiarthroplasty received two further doses of antibiotic postoperatively. Oxford matched cohort study Using methods described previously by our unit13,15 each infected case was matched with two control cases taken from the same prospectively collected dataset. Controls were matched based on eight factors known to influence outcome after proximal femoral fracture.16–18 These were: same sex, age within 4 years, same fracture type (intra- or extracapsular), American Society of Anaesthesiologists (ASA) grade within one grade, identical pre-fracture residence, identical operation performed (parallel cancellous screw, or hemiarthroplasty for intracapsular fractures, and compression hip screw (CHS) for extracapsular fractures), social dependency within one grade and mobility scores within one grade (See Table 1). Patients complicated by deep infection and the non-infected controls were studied from acute admission through acute hospital,

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Table 2 Organisms involved in the infected cases Group

Organism

Gram-positive cocci

MRSA

49

Methicillin-sensitive Staph. aureus

24

Coagulase-negative Staphylococcus

21

Enterococcus species

12

Gram-positive rods Gram-negatives

Number of cases

Group G Streptococcus

3

Diphtheroids

6

Proteus species

14

Escherichia coli

15

Enterobacter species

8

Pseudomonas species

5

Gram-negative bacilli

2

Unspecified anaerobes

2

Table 3 Length of in-patient stay (all patients): mean (SD) Cohort

Trauma unit (acute bed days)

Infected cases

68 (44)

27 (39)

91 (62)

Controls

20 (25)

24 (36)

40 (42)

p-value

<0.001

0.51

<0.001

intermediate care and/or community rehabilitation hospital until discharge. The date of acute admission was recorded, as were the date of operation and grade of the operating surgeon for the primary procedure. Demographic information such as age, sex, ASA score, mobility score, social dependency score and preadmission residential status were also recorded. Ultimate discharge destination (own home, residential or nursing care facility) for those surviving to discharge was recorded. Mortality information was obtained from the Office of National Statistics in November 2009 over 1 year after the last patient was included in the study. From these data, mortality probability was calculated at various time points. The number of surgical debridements and details of organisms cultured from deep samples were recorded for the infected cases. Outcome measures included mortality and length of stay in the acute, community and rehabilitation hospitals, and final discharge destination. The data were analysed using SPSS statistics software, version 17.0. Fisher’s exact test was used for 2 × 2 contingency tables and Student’s t-test for continuous data. A p-value of less than 0.05 was considered significant. Results: Combined Leeds and Oxford infected cohort Group demographics Of the 4823 Oxford patients with PFF, there were 87 (1.8%) who were complicated with deep surgical site infection. Of the 5238 Leeds patients there were 18 (0.35%) confirmed cases of deep surgical site infection. Of 105 infected cases, there were 86 (81.9%) females and 19 (18.1%) males (mean age 83 years); 76 (72%) sustained intracapsular (IC) fractures with the remaining 29 (28%) extracapsular (EC) neck of femur fractures; 74 (70%) patients were admitted from home, 14 (13%) from a residential home, 8 (8%) from a nursing home, and 9 (9%) were already hospital in-patients at the time of fracture. Three (4%) of the IC fractures underwent cannulated screw fixation, and 73 (96%) were treated with cemented hemiarthroplasty. All 29 EC fractures were treated with a dynamic hip screw.

Community hospital (bed days)

Total (days)

The median number of additional surgical debridements was 2 (range 1 to 7). The details of the infecting organisms are shown in Table 2; 49 (47%) cases involved MRSA. In 26 cases 2 organisms and in 11 cases 3 organisms were cultured. In 3 cases 4 different organisms were grown over the course of the patient’s treatment. Ultimately 38 patients (36%) underwent a Girdlestone’s excisional arthroplasty. Discharge and mortality outcomes Of 74 cases that survived to final discharge from acute or rehabilitation beds, 32 (43%) returned home, 20 (27%) were discharged to a residential home and 22 (30%) to a nursing home facility. Of these 74, 41 (55%) returned to equivalent residential status, 22 (30%) dropped a single grade (e.g home to residential home), and 11 (15%) dropped two grades (e.g home to nursing home). Mortality at 30 days, 3 months and 1 year was 10%, 31%, and 45%, respectively. Matched cohort of Oxford cases Based on our matching criteria, it was possible to match 162 uninfected controls with the 87 infected Oxford cases. Breakdowns for the length of stay (LOS) of the infected and control cases are shown in Table 3. The major difference was in the LOS in the acute unit, with the period spent in community rehabilitation similar between the two groups. Although mortality was higher in the infected cases at 3 months and 1 year, this did not reach statistical significance (Table 4). Because of the longer length of stay of the infected cases, a higher proportion died during their in-patient stay; 26 of 87 infected cases died whilst in hospital or community hospital care, versus 25 of 162 controls (odds ratio 2.4, p = 0.009). Of the infected cases surviving to discharge to home, residential or nursing care, 26 of 60 (43%) returned to a more dependent destination (i.e. downgrade). In the controls, only 23 of 137 (17%)

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Table 4 Mortality at 30 days, 3 months and 1 year, from the Oxford matched cohorts of 87 infected and 162 control cases Time post initial fracture surgery

Infected case mortality (%)

Control case mortality (%)

Odds ratio

p-value

30 days

9 (10)

18 (11)

0.92

1.0

3 months

26 (30)

34 (21)

1.61

0.12

1 year

37 (43)

57 (35)

1.36

0.28

Table 5 Recently published studies reporting on infection and mortality rates following proximal femoral fractures Authors

Year

Patients

Deep wound infection rate N

(%)

Mortality rate

Edwards et al.19

2008

3563

41

1.15

Cumming and Parker20

2007

3180

26

0.82

33% (12 mo)

Partanen et al.21

2006

2276

25

1.10

34.5% (12 mo)

Johnston et al.22

2006

3571

25

0.70

28.2% (12 mo)

Roche et al.23

2005

2448

27

1.10

33% (12 mo)

Dorotka et al.24

2003

182

2

1.10

13.7% (6 mo) a

1995

177

6

3.39

n/a

Varley and a

Milner25

30% (12 mo)

In patients operated within less than 18 h from the fracture.

cases were discharged to a downgrade destination (odds ratio 3.8, p < 0.001). A summary of the most recent studies reporting on infection rates and mortality following PFF is shown in Table 5.19–25 Discussion The mainstay of the treatment of proximal femoral fractures, either IC or EC, is surgical. Multiple implants, such as cannulated screws, sliding screw devices, intramedullary nails, hemi- and total hip arthroplasties can be used for this purpose.26–37 The presence in the elderly of multiple co-morbidities and a compromised immunity as well as a reduced bone stock, predispose them to post-operative medical and functional deterioration, periprosthetic fractures, delayed healing, implant loosening and increased mortality rates, which have been well described in the literature.38–40 A major post-operative complication, which may also be an aftermath of the other complications, is infection. The latter, regardless of its causative micro-organism or extent, complicates further the rehabilitation and diminishes the overall outcome. Comparison with the literature: We examined similar studies in the literature using matched control groups for the comparison of the demographic data. In the study by Pollard et al.41 the mean age of the patients sustaining PFF and the male to female ratio are almost the same. The percentage of female patients was 83.6% vs. 81.9% in the present study. Also the ratio of the IC to EC fractures is almost the same; 67.0% vs. 72.0% for IC and 33.0% vs. 28.0% for EC, respectively. The percentages of patients treated with hemiarthroplasty and DHS were similar: 62.3% vs. 69.5% and 33.0% vs. 28.0% respectively. Great similarity is presented in the residential origin of the patients with 69.0% vs. 70.0% in the present study being admitted from their home, 16.0% vs. 13.0% from a residential home, 7.0% vs. 8.0% from a nursing home and 8.0% vs. 9.0% being already in-patients at the time of fracture. In the study of Partanen et al.21 the mean age of the patients sustaining PFF was 79.7 vs. 83.0 years in the present study. The females sustaining PFF were 2.6 times more in number than males in comparison with 4.3 times more noted in our study. Partanen et al. provide no information regarding the type of initial fixation. As far as the residential status is concerned 48.0% were admitted from their home, 48.0% from a convalescent home and 3.4% from a geriatric department vs. 70.0%, 7.0% and 8.0%, respectively, in the present study.

Treatment Pre-operative antibiotic prophylaxis is one of the main factors to influence the incidence of post-operative infections.42–45 In our institutions prophylaxis has always been advised by our microbiology department. In general, until 2008 cefradine and gentamicin with 2 post-op doses of cefradine were used. It was then changed to a single shot of augmentin and gentamicin, due to Clostridium difficile concerns, and teicoplanin instead of augmentin was administered in case of allergy to penicillin. Known methicillin resistant Staphylococcus aureus (MRSA) carriers got vancomycin instead of augmentin. It is reported that the preferred prophylactic antibiotic came from the cephalosporin group, whereas ceftriaxone was found to be the most cost-effective.42,45 The effect of a single dose is similar to those from repeat doses, given that this antibiotic is active throughout the operation.42,45 In the study by Thyagarajan et al.,43 where the MRSA infection rate was 14.28% (3 out of 21), it was reported that teicoplanin should be used for antibiotic prophylaxis in high-risk patients such as those being MRSA carriers or confirmed MRSA positive. Starks et al.46 showed a single dose of cefuroxime (1.5 g) and gentamicin (240 mg) intravenously at induction of anaesthesia, improved their overall infection rates from 5.7% to 3.2%, of which the MRSA infection rate reduced from 63% to 50.0%. Surgical treatment: The treatment pathway of PFF post-operative infection is dependent upon the severity of the infection in terms of the type and virulence of the micro-organism implicated, the extent of the infection at the time of diagnosis and the local destruction around the infected area. The latter may be translated into nonunion or total fixation failure. Therefore early diagnosis is of utmost importance. In the study of Pollard et al.,41 the time interval from the initial operation to the decision of debridement was 14 (range 11–22) days. The mainstay of treatment of deep wound infection consists of full and repeated surgical debridement together with intravenous antibiotics. In our study 2 (1–7) debridements were needed on average for the eradication of the infection and ultimately 36.0% Girdlestone procedures were performed for refractory cases. According to our experience there are no specific time frames or rules on the number of surgical debridements. Apart from factors concerning the infection as mentioned above, the decision is based on patient factors and the response at the additional antibiotic

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suppressive therapy. Furthermore the initial surgical treatment may be augmented by additional factors in view of the secondary reconstruction phase. Deep infection may directly affect the hip joint either by the fracture type (comminuted fracture with intra-articular component) or by the fixation failure (e.g. DHS cut out).47 Haidukewych GJ et al.47 stated that under these circumstances, a resection arthroplasty, hardware removal, thorough debridement and the indicated antibiotic treatment, followed by staged replacement arthroplasty, should be performed. In the same study a 100% survival of the THA at 7 years and 87.5% at 10 years was presented noting that no revisions were performed due to any infection or acetabular cartilage wear. Hsieh et al.48 reported the outcome of two-stage arthroplasty performed as a salvage procedure for deep hip infection following intertrochanteric fractures. The use of a cement spacer with antibiotics (vancomycin either alone or in combination with piperacillin or aztreonam), compared with gentamycin impregnated cement beads, seems to give similar results (p = 0.29) concerning the eradication of the initial infection and better results in terms of hip range of motion and patient mobility. The mean interim period was 13.3 (9–22) and 15.1 (7–23) weeks for the beads and for the cement spacer, respectively. There was only one recurrence of infection at an average follow-up of 4.8 years. An antibiotic cement screw is also described for the use after gamma nail removal due to infection. It is inserted in the lag screw hole after the removal of the infected metalwork.49 The advantages of this device are that the screw provides stability in order to support the weakened bone due to the metalwork removal and that the cement delivers antibiotic in high concentration directly in the area of infection.49 Identification of the causative micro-organism: After intraoperative samples are taken, clinical microbiologists are involved in the decision making regarding the identification of the micro-organism and the appropriate antibiotic treatment. There is a high similarity between the causative micro-organisms found in the present study and those isolated by Pollard et al.41 The involved micro-organism in 47% of the cases was MRSA, which is the commonest cause in most studies.19,21,40 In the study by Partanen et al.,21 Staphylococcus aureus was the most common causative micro-organism, either alone or as a mixed infection. In the same study other common bacteria which were isolated were Enterococcus spp. and Staph. epidermidis. Varley et al.25 reported that the infective organism was mostly Staph. aureus being found in 12 cases, with Escherichia coli found in 3, Staph. epidermidis in 2 and 1 case of enterococci. In the study of Sanchez et al.50 the most common infecting organism, being found in 40% of cases, was MRSA. The recurrent post-operative infection following any debridement and hardware exchange seems to be attributed to coagulasenegative Staphylococcus (CNS).40 The antibiotics scheme: In our institutions the treatment of the infected cases consists of 6 weeks of culture-specific intravenous antibiotic and then oral for as long as it is felt to be clinically appropriate. For MRSA infections, intravenous vancomycin was administered initially for a period of 4–6 weeks, which is then switched to either oral lenizolid (for 4 weeks) or teicoplanin treatment for another 6 weeks. Oral rifampicin and doxycycline are prescribed for longer periods of time as clinically indicated. This antibiotic scheme is in line with the literature42,45,48 and the infection is thereafter closely monitored both clinically and through the CRP serum level once or twice a week.48 Nevertheless, Jacqueline et al.51 demonstrated that vancomycin can fail in the treatment of osteoarticular MRSA infections. They went on to show that a new cephalosporin, ceftaroline, was the most effective agent in osteoarticular MRSA infection compared with vancomycin and

linezolid. Ceftaroline has broad coverage and so is effective against most pathogens found in orthopaedic infections. The treatment may stop when the infection has been eradicated and is no longer a threat to the patient’s life. However, the remaining function of the limb may be diminished, due to the extensive debridement operations, possible bone loss or other complications, such as intraoperative femoral fracture, cement spacer fracture or nerve damage.48 Continued surgical treatment: As in the literature, the further hip reconstruction depends on the functional needs and the health status of the patient, and on the feasibility of bony and softtissue restoration.52,53 In our institutions, if suppression is working, and there is no evidence of loosening, then the prosthesis may be retained. In case of failure to control the infection with serial debridements in hemiarthroplasty cases, a Girdlestone would be performed including cement removal. Provided that there are no laboratory or clinical signs of active infection and if the patient is considered reasonably fit then a two-staged revision may be considered. Similarly, it is reported in the literature that the second-stage procedure (salvage procedure, second stage total hip arthroplasty [THA]) is carried out when all cultures are negative, the wound has healed, the CRP level has returned to normal, and the surgery is medically feasible; this is usually 6–12 weeks after the first stage.48,52,53 For fractures treated with a DHS, we use imaging to monitor union, with suppression ongoing, and then we remove the metal once the fracture has united. If the fracture is not healing and the infection is florid then the involvement of the hip joint in the infection and the necessity of preserving the patient’s femoral head must be considered. This rationale is in line with the literature.54 The options at that phase are either hardware removal, further debridement to vascular tissue and fixation with another device in order to proceed for bone gap bridging procedure, or a Girdlestone procedure, which may be permanent41 or may be the transitional stage for a second-stage THA. Implications Hospitalisation: In the studies that used a cohort of patients without comparison with a control group3,19,21,23,24,55 the mean duration of stay after a post-operative hip infection is reported to range from 7.1 days21 to 82.4 days.19 In studies comparing the findings with a control group the mean acute hospitalisation for post-operative PFF infections is reported to be even higher. In the study by Pollard et al.41 the median length of stay was found to be 132.5 (range: 64– 155) days compared with 30.0 (range: 13–53) days in the controls, who did not develop post-operative infection after PFF (p < 0.001). In our study the mean acute bed hospital stay for the patients with post-operative PFF infections was 68 days and there was a significant difference with the hospital stay of the control group. This result is in accordance with the literature. In the patient assessment at 4 months in the study of Partanen et al.21 the mean duration of hospitalisation at the primary hospital was significantly longer for the study than for the control group (p < 0.001). In the study by Siegmeth et al.,56 a significant increase in length of stay was found in patients operated on after 48 hours when compared with those in the earlier group (21.6 vs. 32.5 days). Residence status: In our study, 43% of the patients who had a post-operative hip infection were downgraded after discharge and a significant difference was found in comparison with the control group. These results are in line with the literature. In the study of Palmer et al.57 13% of the patients who had a post-operative hip infection secondary to DHS, 9% of those who had hemiarthroplasty and 33% of those who had cannulated hip screws, were downgraded after discharge. In the study of Partanen et al.21 the percentage of patients after post-operative PFF infection who returned home after

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discharge was decreased by 27.6%. The percentage of the patients who returned to a residential home was decreased by 31.1% and the percentage of patients who returned to a geriatric department was increased by 44.9%. In the study by Pollard et al.41 it is stated that the likelihood of a patient surviving to final discharge to home or residential or nursing care was significantly lower in the infected group than the control group. Patients in the infected group who survived to discharge were also less likely to return to their prefracture residence compared with the control survivors. Mortality: The resulting mortality following post-operative infections after PFF fixation is reported by many authors.15,21,23,24,40,41,58–63 In our study the mortality rate was found to be 10%, 31%, and 45% for 30 days, 3 months and 1 year, respectively, and interestingly there was no statistically significant difference between the study and the control groups. The latter is in comparison with some reports in the literature, such as the one by Edwards et al.,19 where it is mentioned that pre-discharge mortality was significantly increased with deep wound infection and further increased if an MRSA infection was present. In the same study the one-year mortality was 30%, and this increased to 50% in those who developed an infection (p < 0.001).19 In another study by Cameron et al.,58 which examines the causes of mortality after PFF it was found that the main causes of the excess mortality in the first 9 months were infections for females and cardiac disease for both males and females, whereas bisphosphonate use was associated with a reduction in mortality after hip fracture. It is reported by Lee et al.,40 that the overall mortality rate after a post-operative wound infection following a PFF was 17%. In the study of Partanen et al.21 the overall mortality of the infected patients and controls was 34.5% and 24.1% at 1 year, respectively. Conclusions The demographics and the endpoints of the present study are in accordance with those presented in the literature. The effective antibiotic prophylaxis of the initial operation consists of single dose of antibiotic as long as it is active throughout the operation, and the type of each antibiotic is advised by the microbiology department. The treatment of a post-operative proximal femoral fracture infection consists of all the necessary surgical debridements until the site is considered aseptic and of simultaneous intravenous administration of antibiotics – appropriate for the micro-organism identified from the infected area. Additional aids to surgical debridements, such as antibiotic-impregnated cement spacers or cement beads, may be used at the surgeon’s discretion. The endpoint of the treatment may be either a Girdlestone procedure or a second-stage arthroplasty. The decision between the two is based on the response to the treatment scheme, the health status and the functional needs of each individual. Patients with post-operative hip infection have a significantly longer hospitalisation period, prolonged length of stay in an acute unit and a more dependent residential destination on discharge compared with patients with no post-operative hip infection. The mortality rates at the time intervals studied show no statistical significance between the infected and non-infected patients. Competing interests All authors declare no conflict of interest regarding the preparation and content of this manuscript. References 1. Aagaard H, Noer HH, Scavenius M, Jørgensen PS, Tørholm C. Computer registration of infections used to measure the effect of prophylactic antibiotics on postoperative infections following osteosynthesis in hip fractures. J Hosp Infect 1994;27:257–62.

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