Hardware-preserving management of early soft-tissue breakdown over stable osteosynthesis: a retrospective single-centre experience

This study evaluates whether a hardware-preservation strategy—restoration of soft tissue coverage over exposed but mechanically stable osteosynthesis combined with systemic antibiotic therapy aimed at limiting progression from contamination to established infection—can represent a viable alternative to hardware removal in selected patients with orthopaedic hardware exposure without overt clinical signs of infection and with negative superficial wound swabs. A retrospective analysis at Circolo and Macchi Foundation Hospital (January 2018–January 2023) examined all cases of soft tissue breakdown over orthopaedic hardware in limb fractures treated with plates. Inclusion criteria required absence of overt clinical signs of infection, negative superficial wound swabs, stable fixation, and no prior plastic surgery at the same site. Treatment was classified as outpatient management (OM: dressings or negative pressure wound therapy) or surgical management (SM: soft tissue reconstruction without hardware revision). Associations with failure were explored using Fisher’s exact test and the Mann–Whitney U test. Twenty-seven patients (median age: 74 years) were included, with 93% of exposures involving the lower limb. Hardware-preservation success was achieved in 24 patients (89%); final functional recovery, including cases requiring subsequent revision, was observed in 26 (97%). All three failures occurred at the malleolar site, involved exposures exceeding 1 cm, and two of three presented after one week. Time to treatment beyond one week showed the most pronounced trend (25.0% vs 5.3%; p = 0.201; OR 6.0), followed by malleolar location (18.8% vs 0%; p = 0.248); neither reached statistical significance. These preliminary findings suggest that hardware preservation may be feasible in selected patients with stable fixation and no overt infection. Failures clustered in malleolar exposures larger than 1 cm, particularly when referral occurred after one week; however, these observations remain hypothesis-generating and require validation in larger, anatomically focused studies.