Implant Removal Due to Infection After Open Reduction and Internal Fixation: Trends and Predictors

Document Type : RESEARCH PAPER


1 Cooper Medical School of Rowan University, Camden, New Jersey, USA

2 Department of Orthopaedic Surgery, Cooper University Hospital, Camden, New Jersey, USA

3 Oliashirazi Institute at Marshall University, Huntington, West Virginia, USA


Background: Implant removal due to infection is one of the major causes failure following open reduction and internal 
fixation (ORIF). The aim of this study was to determine trends and predictors of infection-related implant removal 
following ORIF of extremities using a nationally representative database.
Methods: Nationwide Inpatient Sample data from 2006 to 2017 was used to identify cases of ORIF following upper and 
lower extremity fractures, as well as cases that underwent infection-related implant removal following ORIF. Multivariate 
analysis was performed to identify independent predictors of infection-related implant removal, controlling for patient 
demographics and comorbidities, hospital characteristics, site of fracture, and year. 
Results: For all ORIF procedures, the highest rate of implant removal due to infection was the phalanges/hand (5.61%), 
phalanges/foot (5.08%), and the radius/ulna (4.85%). Implant removal rates due to infection decreased in all fractures 
except radial/ulnar fractures. Tarsal/metatarsal fractures (odds ratio (OR)=1.45, 95% confidence interval (CI): 1.02-
2.05), and tibial fractures (OR=1.82, 95% CI: 1.45-2.28) were identified as independent predictors of infection-related 
implant removal. Male gender (OR=1.67, 95% CI: 1.49-1.87), Obesity (OR=1.85, 95% CI: 1.34-2.54), diabetes mellitus 
with chronic complications (OR=1.69, 95% CI: 1.13-2.54, P<0.05), deficiency anemia (OR=1.59, 95% CI: 1.14-2.22) 
were patient factors that were associated with increased infection-related removals. Removal of implant due to infection 
had a higher total charge associated with the episode of care (mean: $166,041) than non-infection related implant 
removal (mean: $133,110).
Conclusion: Implant removal rates due to infection decreased in all fractures except radial/ulnar fractures. Diabetes, 
liver disease, and rheumatoid arthritis were important predictors of infection-related implant removal. The study 
identified some risk factors for implant related infection following ORIF, such as diabetes, obesity, and anemia, that 
should be studied further to implement strategies to reduce rate of infection following ORIF.
Level of evidence: III


1. S, D, I. Complications and hardware removal after open
reduction and internal fixation of humeral fractures. -
PubMed - NCBI. [cited 2020 Feb 16]; Available from:
2. Beharrie AW, Beredjiklian PK, Bozentka DJ. Functional
outcomes after open reduction and internal fixation
for treatment of displaced distal radius fractures in
patients over 60 years of age. J Orthop Trauma. 2004
3. Chirodian N, Arch B, Parker MJ. Sliding hip screw
fixation of trochanteric hip fractures: Outcome of 1024
procedures. Injury [Internet]. 2005 Jun 1 [cited 2020
Apr 7];36(6):793–800. Available from: https://www.
4. Grawe B, Le T, Lee T, Wyrick J. Open Reduction and
Internal Fixation (ORIF) of Complex 3- and 4-Part
Fractures of the Proximal Humerus: Does Age
Really Matter? Geriatr Orthop Surg Rehabil. 2012
5. Südkamp N, Bayer J, Hepp P, Voigt C, Oestern H, Kääb
M, et al. Open reduction and internal fixation of
proximal humeral fractures with use of the locking
proximal humerus plate. Results of a prospective,
multicenter, observational study. J Bone Joint Surg
Am. 2009 Jun;91(6):1320–8.
6. Metsemakers WJ, Kuehl R, Moriarty TF, Richards
RG, Verhofstad MHJ, Borens O, et al. Infection after
fracture fixation: Current surgical and microbiological
concepts. Injury [Internet]. 2018 Mar [cited 2020 Feb
16];49(3):511–22. Available from: https://linkinghub.
7. Rightmire E, Zurakowski D, Vrahas M. Acute Infections
After Fracture Repair. Clin Orthop Relat Res [Internet].
2008 Feb [cited 2020 Apr 7];466(2):466–72. Available
8. Chitnis AS, Vanderkarr M, Sparks C, McGlohorn J, Holy
CE. Complications, Health Care Resource Utilization
and Costs Associated with Type III Open Fractures
of the Tibial Shaft Requiring Open Reduction and
Internal Fixation. Value in Health [Internet]. 2018
May 1 [cited 2020 Apr 7];21:S177. Available from:
9. Uhthoff HK, Poitras P, Backman DS. Internal plate
fixation of fractures: short history and recent
developments. J Orthop Sci [Internet]. 2006 Mar [cited
2020 Apr 7];11(2):118–26. Available from: https://
10.Rasouli MR, Viola J, Maltenfort MG, Shahi A, Parvizi
J, Krieg JC. Hardware Removal Due to Infection after
Open Reduction and Internal Fixation: Trends and
Predictors. Arch Bone Jt Surg [Internet]. 2015 Jul [cited
2020 Apr 7];3(3):184–92. Available from: https://
11.Otchwemah R, Grams V, Tjardes T, Shafizadeh S,
Bäthis H, Maegele M, et al. Bacterial contamination of
open fractures - pathogens, antibiotic resistances and
therapeutic regimes in four hospitals of the trauma
network Cologne, Germany. Injury. 2015 Oct;46 Suppl
12.Calkins TE, Culvern C, Nam D, Gerlinger TL, Levine
BR, Sporer SM, et al. Dilute Betadine Lavage Reduces
the Risk of Acute Postoperative Periprosthetic Joint
Infection in Aseptic Revision Total Knee and Hip
Arthroplasty: A Randomized Controlled Trial. J
Arthroplasty. 2020 Feb;35(2):538-543.e1.
13.Casqueiro J, Casqueiro J, Alves C. Infections in patients
with diabetes mellitus: A review of pathogenesis.
Indian J Endocrinol Metab. 2012 Mar;16 Suppl 1:S27-
14.Meidani M, Naeini AE, Rostami M, Sherkat R, Tayeri
K. Immunocompromised patients: Review of the most
common infections happened in 446 hospitalized
patients. J Res Med Sci. 2014 Mar;19(Suppl 1):S71-73.
15.Healthcare Cost and Utilization Project (HCUP)
[Internet]. [cited 2019 Sep 14]. Available from:
16.Bohl DD, Basques BA, Golinvaux NS, Baumgaertner
MR, Grauer JN. Nationwide Inpatient Sample and
National Surgical Quality Improvement Program give
different results in hip fracture studies. Clin Orthop
Relat Res. 2014 Jun;472(6):1672–80. [Internet]. [cited 2020 Feb 16]. Available
18.Lovald S, Mercer D, Hanson J, Cowgill I, Erdman M,
Robinson P, et al. Hardware removal after fracture
fixation procedures in the femur. J Trauma Acute Care
Surg. 2012 Jan;72(1):282–7.
19.ICD-9-CM Volume 1 Diagnosis Codes [Internet]. [cited
2020 Jan 19]. Available from: http://www.icd9data.
20.Ranson WA, Neifert SN, Cheung ZB, Mikhail CM, Caridi
JM, Cho SK. Predicting In-Hospital Complications
After Anterior Cervical Discectomy and Fusion:
A Comparison of the Elixhauser and Charlson
Comorbidity Indices. World Neurosurg. 2020
21.Elixhauser A, Steiner C, Harris DR, Coffey RM.
Comorbidity measures for use with administrative
data. Med Care. 1998 Jan;36(1):8–27.
22.Charlson ME, Pompei P, Ales KL, MacKenzie CR. A
new method of classifying prognostic comorbidity in
longitudinal studies: development and validation. J
Chronic Dis. 1987;40(5):373–83.
23.CPI Inflation Calculator [Internet]. [cited 2020 Nov
27]. Available from:
24.Helwig P, Morlock J, Oberst M, Hauschild O, Hübner J,
Borde J, et al. Periprosthetic joint infection--effect on
quality of life. Int Orthop. 2014 May;38(5):1077–81.  25.Darouiche RO. Treatment of Infections Associated
with Surgical Implants.
NEJMra035415 [Internet]. 2009 Oct 8 [cited 2020
Apr 7]; Available from:
26.Zalavras CG, Christensen T, Rigopoulos N, Holtom P,
Patzakis MJ. Infection following operative treatment
of ankle fractures. Clin Orthop Relat Res. 2009
27.Younger AS, Duncan CP, Masri BA. Treatment of
infection associated with segmental bone loss in the
proximal part of the femur in two stages with use of
an antibiotic-loaded interval prosthesis. J Bone Joint
Surg Am. 1998 Jan;80(1):60–9.
28.Momaya AM, Hlavacek J, Etier B, Johannesmeyer D,
Oladeji LO, Niemeier TE, et al. Risk factors for infection
after operative fixation of Tibial plateau fractures.
Injury. 2016 Jul;47(7):1501–5.
29.Morris BJ, Unger RZ, Archer KR, Mathis SL, Perdue AM,
Obremskey WT. Risk factors of infection after ORIF of
bicondylar tibial plateau fractures. J Orthop Trauma.
2013 Sep;27(9):e196-200.
30.Henkelmann R, Frosch K-H, Glaab R, Lill H, Schoepp
C, Seybold D, et al. Infection following fractures of
the proximal tibia - a systematic review of incidence
and outcome. BMC Musculoskelet Disord. 2017 Nov
31.Shahi A, Kheir MM, Tarabichi M, Hosseinzadeh HRS,
Tan TL, Parvizi J. Serum D-Dimer Test Is Promising
for the Diagnosis of Periprosthetic Joint Infection and
Timing of Reimplantation. J Bone Joint Surg Am. 2017
Sep 6;99(17):1419–27.
32.Lovald S, Mercer D, Hanson J, Cowgill I, Erdman
M, Robinson P, et al. Complications and hardware
removal after open reduction and internal fixation of
humeral fractures. J Trauma. 2011 May;70(5):1273–
7; discussion 1277-1278.
33.Chung KC, Mathews AL. Management of Complications
of Distal Radius Fractures. Hand Clin [Internet]. 2015
May [cited 2020 Mar 7];31(2):205–15. Available
34.Macera A, Carulli C, Sirleo L, Innocenti M. Postoperative
Complications and Reoperation Rates Following Open
Reduction and Internal Fixation of Ankle Fracture.
Joints [Internet]. 2018 May 21 [cited 2020 Apr
7];6(2):110–5. Available from: https://www.ncbi.
35.Leroux T, Wasserstein D, Henry P, Khoshbin A, Dwyer
T, Ogilvie-Harris D, et al. Rate of and Risk Factors
for Reoperations After Open Reduction and Internal
Fixation of Midshaft Clavicle Fractures: A PopulationBased Study in Ontario, Canada. J Bone Joint Surg Am.
2014 Jul 2;96(13):1119–25.
36.Yasui Y, Shimozono Y, Hung CW, Marangon A, Wollstein
A, Gianakos AL, et al. Postoperative Reoperations and
Complications in 32,307 Ankle Fractures With and
Without Concurrent Ankle Arthroscopic Procedures
in a 5-Year Period Based on a Large U.S. Healthcare
Database. J Foot Ankle Surg. 2019 Jan;58(1):6–9.
37.Böstman O, Pihlajamäki H. Routine implant removal
after fracture surgery: a potentially reducible
consumer of hospital resources in trauma units. J
Trauma. 1996 Nov;41(5):846–9.
38.Naumann MG, Sigurdsen U, Utvåg SE, Stavem K.
Incidence and risk factors for removal of an internal
fixation following surgery for ankle fracture: A
retrospective cohort study of 997 patients. Injury.
2016 Aug;47(8):1783–8.
39.Fenelon C, Murphy EP, Galbraith JG, Kearns SR. The
burden of hardware removal in ankle fractures:
How common is it, why do we do it and what is
the cost? A ten-year review. Foot Ankle Surg. 2019
40.Partio N, Huttunen TT, Mäenpää HM, Mattila VM.
Reduced incidence and economic cost of hardware
removal after ankle fracture surgery: a 20-year
nationwide registry study. Acta Orthopaedica
[Internet]. 2020 Feb 28 [cited 2020 Apr 7];0(0):1–5.
Available from:
41.Kollitz KM, Hammert WC, Vedder NB, Huang JI.
Metacarpal fractures: treatment and complications.
Hand (N Y) [Internet]. 2014 Mar [cited 2020 Mar
7];9(1):16–23. Available from: https://www.ncbi.
42.Bonnevialle P. Operative treatment of early infection
after internal fixation of limb fractures (exclusive of
severe open fractures). Orthopaedics & Traumatology:
Surgery & Research [Internet]. 2017 Feb 1 [cited 2020
Apr 7];103(1, Supplement):S67–73. Available from:
43.Botha-Scheepers SA, Sarembock B. Infections in the
management of rheumatic diseases: An update. S Afr
Med J. 2015 Dec;105(12):1076.
44.Xu Y-Q, Zhu Y-L, Fan X-Y, Jin T, Li Y, He X-Q. ImplantRelated Infection in the Tibia: Surgical Revision
Strategy with Vancomycin Cement [Internet]. Vol.
2014, The Scientific World Journal. Hindawi; 2014
[cited 2020 Apr 7]. p. e124864. Available from: https://
45.Lee D, Lee R, Gowda NB, Probasco WV, Stake S, Ibrahim
G, et al. Impact of diabetes mellitus on surgical
complications in patients undergoing revision total
knee arthroplasty: Insulin dependence makes a
difference. Journal of Clinical Orthopaedics and Trauma
[Internet]. 2020 Jan 1 [cited 2020 Apr 7];11(1):140–
6. Available from:
46.Cheruvattath R, Balan V. Infections in Patients With
End-stage Liver Disease. J Clin Gastroenterol. 2007
47.Caporali R, Caprioli M, Bobbio-Pallavicini F,
Montecucco C. DMARDS and infections in rheumatoid
arthritis. Autoimmun Rev. 2008 Dec;8(2):139–43.
48.Lacaille D, Guh DP, Abrahamowicz M, Anis AH,
Esdaile JM. Use of nonbiologic disease-modifying
antirheumatic drugs and risk of infection in patients
with rheumatoid arthritis. Arthritis Rheum. 2008 Aug
49.MedicalAdvisoryBoard [Internet]. [cited 2020 Feb 16]. Available from:
50.Manidakis N, Dosani A, Dimitriou R, Stengel D,
Matthews S, Giannoudis P. Tibial plateau fractures:
functional outcome and incidence of osteoarthritis
in 125 cases. Int Orthop [Internet]. 2010 Apr [cited
2020 Apr 7];34(4):565–70. Available from: https://
51.Cohen B, Choi YJ, Hyman S, Furuya EY, Neidell M,
Larson E. Gender Differences in Risk of Bloodstream
and Surgical Site Infections. J Gen Intern Med
[Internet]. 2013 Oct [cited 2020 Apr 7];28(10):1318–
25. Available from:
52.Namba RS, Inacio MCS, Paxton EW. Risk factors
associated with surgical site infection in 30,491
primary total hip replacements. J Bone Joint Surg Br.
2012 Oct;94(10):1330–8.
53.Li C, Renz N, Trampuz A. Management of Periprosthetic
Joint Infection. Hip Pelvis [Internet]. 2018 Sep [cited
2019 Sep 18];30(3):138–46. Available from: https://
54.Thangarajah T, Prasad PSV, Narayan B. Surgical Site
Infections Following Open Reduction and Internal
Fixation of Ankle Fractures. Open Orthop J [Internet].
2009 Jul 22 [cited 2020 Apr 7];3:56–60. Available
55.Taneja V. Sex Hormones Determine Immune Response.
Front Immunol [Internet]. 2018 Aug 27 [cited 2020
Apr 7];9. Available from: https://www.ncbi.nlm.nih.
56.Jørgensen TN. Sex disparities in the immune response.
Cell Immunol. 2015 Apr;294(2):61–2.
57. Memtsoudis SG. Limitations Associated with the Analysis
of Data from Administrative Databases. Anesthes
[Internet]. 2009 Aug 1 [cited 2019 Dec 10];111(2):449–
449. Available from: https://anesthesiology.pubs.
58.Weis A, Anderson J, Chang D. Comparing the National
Surgical Quality Improvement Program With the
Nationwide Inpatient Sample Database | Research,
Methods, Statistics | JAMA Surgery | JAMA Network
[Internet]. [cited 2020 Jan 19]. Available from:
Volume 10, Issue 6
June 2022
Pages 514-524
  • Receive Date: 27 November 2020
  • Revise Date: 23 October 2021
  • Accept Date: 25 October 2021
  • First Publish Date: 25 October 2021