Hardware Removal in Craniomaxillofacial Trauma: A Systematic Review of the Literature and Management Algorithm.
BACKGROUND
Craniomaxillofacial (CMF) fractures are typically treated with open reduction and internal fixation. Open reduction and internal fixation can be complicated by hardware exposure or infection. The literature often does not differentiate between these 2 entities; so for this study, we have considered all hardware exposures as hardware infections. Approximately 5% of adults with CMF trauma are thought to develop hardware infections. Management consists of either removing the hardware versus leaving it in situ. The optimal approach has not been investigated. Thus, a systematic review of the literature was undertaken and a resultant evidence-based approach to the treatment and management of CMF hardware infections was devised.


METHODS
A comprehensive search of journal articles was performed in parallel using MEDLINE, Web of Science, and ScienceDirect electronic databases. Keywords and phrases used were maxillofacial injuries; facial bones; wounds and injuries; fracture fixation, internal; wound infection; and infection. Our search yielded 529 articles. To focus on CMF fractures with hardware infections, the full text of English-language articles was reviewed to identify articles focusing on the evaluation and management of infected hardware in CMF trauma. Each article's reference list was manually reviewed and citation analysis performed to identify articles missed by the search strategy. There were 259 articles that met the full inclusion criteria and form the basis of this systematic review. The articles were rated based on the level of evidence. There were 81 grade II articles included in the meta-analysis.


RESULTS
Our meta-analysis revealed that 7503 patients were treated with hardware for CMF fractures in the 81 grade II articles. Hardware infection occurred in 510 (6.8%) of these patients. Of those infections, hardware removal occurred in 264 (51.8%) patients; hardware was left in place in 166 (32.6%) patients; and in 80 (15.6%) cases, there was no report as to hardware management. Finally, our review revealed that there were no reported differences in outcomes between groups.


CONCLUSIONS
Management of CMF hardware infections should be performed in a sequential and consistent manner to optimize outcome. An evidence-based algorithm for management of CMF hardware infections based on this critical review of the literature is presented and discussed.
From the *Duke University School of Medicine; †Division of Plastic, Maxillofacial and Oral Surgery, Department of Surgery, and ‡Department of Pathology, Duke University Medical Center, Durham, NC.
Thomas J
TJ
Cahill
Rikesh
R
Gandhi
Alexander C
AC
Allori
Jeffrey R
JR
Marcus
David
D
Powers
Detlev
D
Erdmann
Scott T
ST
Hollenbeck
Howard
H
Levinson
D000465:Algorithms; D003661:Decision Support Techniques; D020878:Device Removal / Q000379:methods*; D005593:Fracture Fixation, Internal / Q000295:instrumentation*; D006801:Humans; D016268:Internal Fixators; D008440:Maxillary Fractures / Q000601:surgery; D008446:Maxillofacial Injuries / Q000601:surgery*; D012887:Skull Fractures / Q000601:surgery*; D016896:Treatment Outcome