Fate of Patients With a "Surprise" Positive Culture After Nonunion Surgery.
OBJECTIVE
Review the impact of unexpected positive cultures from definitive surgery for nonunion regarding postoperative treatment and ultimate result.


METHODS
Retrospective multicenter case series.


METHODS
Three level-one trauma centers.


METHODS
Six-hundred sixty-six consecutive nonunions were treated during the study period. Four-hundred fifty-three cases (68%) were considered at risk for indolent infection (prior open fracture, surgery, or infection) and had cultures taken at the time of definitive surgery.


METHODS
Intraoperative cultures during definitive operative treatment of nonunions.


METHODS
The incidence of "surprise" positive cultures was determined, and the course of the patients was documented including the use of antibiotics, surgery performed, and the outcome regarding infection and union.


RESULTS
Ninety-one (20%) cases had a surprise positive culture despite negative inflammatory markers. Most of bacteria isolated from the cultures were Staphylococcus species. Eight (9%) of the ninety-one cultures were considered probable contaminants and no antibiotics were given, 5 of these patients healed. The other 83 patients were treated with antibiotics, initially 66 (80%) healed and 12 (14%) remained infected. Eighty-two percent of patients with augmentation healed as compared with 86% of those not grafted.


CONCLUSIONS
The treatment of nonunions is challenging, and in patients with a history of surgery or open fracture, we found that 20% had positive intraoperative cultures from the definitive surgery. We recommend intraoperative cultures for all patients undergoing revision surgery. The use of culture-specific antibiotics is justified based on the overall low rate of infection in this complex population and the high rate of chronic infection (25%) for those treated as contaminants. Patients may be counseled that a positive culture after nonunion surgery is a treatable problem but does increase the risk of infection and additional surgery as compared with those with a negative intraoperative culture.


METHODS
Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
*Department of Orthopaedic Surgery, Boston University Medical Center, Boston, MA;†Department of Orthopaedic Surgery, University of Nebraska Medical Center, Omaha, NE;‡Department of Orthopaedic Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO;§Orthopaedic Associates of Michigan, Michigan State University, Grand Rapids, MI; and‖Center for Orthopedic Research and Education (CORE), Banner University Medicine, Phoenix, AZ.
Dana
D
Olszewski
Philipp N
PN
Streubel
Charlton
C
Stucken
William M
WM
Ricci
Martin F
MF
Hoffmann
Clifford B
CB
Jones
Debra L
DL
Sietsema
Paul
P
Tornetta
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001424:Bacterial Infections / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology*; D016025:Bone Transplantation / Q000706:statistics & numerical data*; D015984:Causality; D015897:Comorbidity; D005260:Female; D005593:Fracture Fixation, Internal / Q000706:statistics & numerical data*; D017759:Fractures, Malunited / Q000453:epidemiology* / Q000382:microbiology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D016459:Prosthesis-Related Infections / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology*; D012189:Retrospective Studies; D016896:Treatment Outcome; D014481:United States; D055815:Young Adult
D000900:Anti-Bacterial Agents