Are Drains Associated With Infection After Operative Fixation of High-Risk Tibial Plateau and Pilon Fractures?

Saturday, October 21, 2023

11:19 AM – 11:25 AM PST

Location: 4B

Presenting Author / Corresponding Author(s)

AB

Adam Boissonneault, MD

Assistant Professor Orthopaedic Trauma
Emory University at Grady Memorial Hospital
University of Maryland Baltimore, Shock Trauma Cen
Atlanta, Georgia, United States

Disclosure(s): No financial relationships to disclose

Co-Author(s)

RO

Robert V. O'Toole, MD

Professor, Orthopaedic Surgery
University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center
Baltimore, Maryland, United States
RH

Roman Hayda, MD
JR

J. Spence Reid, MD

Professor and Chief - Division of Orthopedic Trauma
Penn State College of Medicine
Hummelstown, Pennsylvania, United States
CC

Cyrus Theodore Caroom, MD

Texas Tech University HSC - Dept of Orthopaedics
AC

Anthony R. Carlini, MS

Senior Research Associate
Johns Hopkins Bloomberg School of Public Health
Johns Hopkins Bloomberg School of Public Health
Baltimore, Maryland, United States
AD

Arman Dagal, MD
RC

Renan C. Castillo, PhD

Professor
Johns Hopkins Bloomberg School of Public Health
Baltimore, Maryland, United States
MK

Madhav A. Karunakar, MD

Atrium Health Carolinas Medical Center
CM

Christopher M. McAndrew, MD
PM

Paul E. Matuszewski, MD

Vice Chair of Research, Associate Professor of Orthopaedic Traumatology
Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky School of Medicine
Lexington, Kentucky, United States
GA

Greg Altman, MD
Robert A. Hymes, MD

Chairman
Department of Orthopaedic Surgery, Inova Fairfax Medical Campus
Inova Fairfax Medical Campus
Falls Church, Virginia, United States
Nathan N. O'Hara, PhD

Assistant Professor
University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center
Baltimore, Maryland, United States

Group Author(s)

GM

Group METRC

Hanover, New Hampshire, United States

Purpose: The primary aim of this study was to determine the association of closed suction drainage on postoperative infection rates for high-risk tibial plateau and pilon fractures. We hypothesized that drains would be associated with fewer infections.

Methods: This is a substudy to the VANCO trial (randomized controlled trial of topical vancomycin powder during operative fixation of high-risk tibial plateau or pilon fractures). The primary outcome was deep surgical site infection within 6 months. The use of a closed suction drain was based on surgeon discretion. The use of 1 g of intrawound vancomycin powder at the time of definitive fixation was randomized. Patients were categorized based on the presence of a drain and use of vancomycin powder. We analyzed the additive interaction between drain usage and intrawound vancomycin powder using a Kaplan-Meier estimator.

Results: Of the 978 study patients, 197 (20%) were treated with drains. When comparing deep infection rates between patients with and without drain use, there was no significant association (8% vs 8%, P = 0.88). However, if vancomycin powder use was considered, strong associations were observed. The highest deep infection rate of 13% (95% confidence interval [CI], 6%-20%) was observed in patients treated with drains but had no vancomycin powder placed in the wound. In contrast, patients treated with drains and vancomycin powder placed had the lowest incidence of infection (3%; 95% CI, 0-7%; P = 0.01, Figure 1). The combination of vancomycin powder and drains was associated with a greater benefit than vancomycin alone (incidence, 6%; 95% CI, 1%-13%).

Conclusion: Closed suction drains after operative fixation of high-risk tibia fractures appear to be associated with a large reduction in infection if topical vancomycin powder is used, but associated with an increase in infection if vancomycin powder is not used. Clinicians should be aware of this surprising association that the effect of drains on infection may be strongly influenced by the use of topical antibiotics.

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