Outpatient management of infected hardware in the oncology patient.

Reconstruction of surgically created defects in patients with head and neck cancer sometimes requires the use of reconstructive plating devices to stabilize freely mobile bony segments. Early immobilization decreases shear forces on bony segments, which in turn decreases healing time and leads to early reestablishment of normal function.

Despite advances in plating technology and a greater understanding of bone physiology and biomechanics, reconstructive plates are not immune to problems associated with other foreign bodies. For example, they are susceptible to both extrusion and infection. Common causes of secondary hardware infections include placement of an unsterile implant, infection of local overlying soft tissues, and ischemia secondary to adjuvant radiotherapy.

The standard treatment for infected hardware involves removal of the hardware and hospitalization for an extended course of microbe-specific intravenous antibiotics. Removing a piece of hardware that has been placed during complex reconstructive surgery can be technically challenging. It can also expose patients to potential surgical complications and further compromise their rehabilitation. Moreover, many patients who have been discharged from the hospital only recently will be extremely reluctant to be readmitted.

Fortunately, removal of infected hardware is not necessary in all cases. We successfully treated a 52-year-old man with infected hardware by conservative incision and drainage and outpatient parenteral antibiotics.

The patient had a complex medical history of recurrent left parotid adenoid cystic carcinoma. His tumor was initially diagnosed in 1978. At that time, he underwent a parotidectomy with positive margins and postsurgical electron-beam radiotherapy. He remained in clinical remission until 2003, when he began to complain of left facial weakness, numbness, and swelling. Magnetic resonance imaging revealed extensive tumor recurrence in the left parotid bed and carotid canal. The patient underwent salvage surgery and adjuvant neutron-beam radiotherapy; the surgery included a total parotidectomy and lateral skull base resection. The surgical defect was reconstructed with a scapular microvascular free flap secured with titanium reconstruction plates.

Seven months postoperatively, the patient returned with purulent draining wounds overlying the left parietal and occipital areas with associated exposed hardware and a subdermal communication between the two wounds. He said his scalp wounds had been draining for the previous 4 weeks. Otherwise, he was healthy and a very active golfer, and he wished to avoid spending any unnecessary time in the hospital. He was also reluctant to undergo any major surgical procedures to his craniofacial region, and he did not desire to have his reconstruction plates removed if there was an alternative therapy.

We performed a resection of the fistulas and placed a peripherally inserted central catheter (PICC). Thereafter, the patient received home antibiotic therapy based on intraoperative cultures, and he and his wife performed local wound care. Two weeks after the initiation of home treatment, the patient's occipital wound had completely healed and the parietal wound had developed granulation tissue without residual purulent drainage (figure, A). Also, the communication between the two scalp wounds no longer existed. The PICC was removed. At 4 weeks, the parietal wound had healed, and the patient exhibited no signs of infection or hardware extrusion (figure, B).

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This patient did not require hospitalization during his entire management course, and he was able to play golf throughout treatment.

Suggested reading

Board N, Brennan N, Caplan GA. A randomised controlled trial of the costs of hospital as compared with hospital in the home for acute medical patients. Aust N Z J Public Health 2000:24:305-11.

Dubois A, Santos-Eggimann B. Evaluation of patients' satisfaction with hospital-at-home care. Eval Health Prof 2001:24:84-98.

Grayson ML, Silvers J, Turnidge J. Home intravenous antibiotic therapy. A sate and effective alternative to inpatient care. Med J Aust 1995:162:249-53.

Ryan F. Osborne, MD, FACS; Jason S. Hamilton, MD

From the Osborne Head and Neck Institute (Dr. Osborne and Dr. Hamilton) and the Head and Neck Cancer Center. Cedars- Sinai Medical Center (Dr. Osborne), Los Angeles.