Management of Orthopedic Plate Exposure: A Case Series Evaluating Advanced Wound Care and Delayed Hardware Removal

Management of Orthopedic Plate Exposure: A Case Series Evaluating Advanced Wound Care and Delayed Hardware Removal | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Management of Orthopedic Plate Exposure: A Case Series Evaluating Advanced Wound Care and Delayed Hardware Removal Riccardo Garibaldi, Paolo Ivan Fiore, Seraina Rietschi, Jerome Cottet, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7764817/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Mar, 2026 Read the published version in European Journal of Orthopaedic Surgery & Traumatology → Version 1 posted 9 You are reading this latest preprint version Abstract Background Plate exposure following open reduction and internal fixation (ORIF) poses significant challenges, including infection risk and impaired fracture healing. Traditional management often involves aggressive surgical interventions.​ Methods This retrospective case series examines seven patients treated between 2020 and 2025 who developed plate exposure after ORIF of lower extremity fractures. Management included local wound care with advanced dressings (Apligraf®, NuShield®), negative pressure wound therapy, targeted antibiotic therapy when indicated, and delayed hardware removal post-fracture consolidation.​ Results All patients achieved complete wound healing, with a mean closure time of 143 days. Radiographic union was confirmed in all cases except one asymptomatic nonunion. Antibiotics were administered in four cases, guided by clinical signs and microbiological findings. No infections were detected at the time of hardware removal.​ Conclusions A conservative approach utilizing advanced wound care techniques and delayed hardware removal can effectively manage plate exposure without necessitating early implant removal or flap coverage. This strategy may reduce patient morbidity and preserve fracture stability. Orthopedic implants Plate exposure Wound healing Negative pressure wound therapy Advanced wound dressings Figures Figure 1 Figure 2 Introduction Wound dehiscence with subsequent exposure of orthopedic implants, especially after open reduction and internal fixation of fractures (ORIF), represents a significant challenge in orthopedic trauma surgery. The exposure of metallic implants increases the risk of deep infection and compromised fracture healing. The risk of implant exposure is influenced by several factors, including the anatomical location, the quality of the overlying soft tissue, and the presence of comorbidities that impair wound healing ( 1 ). Sites such as the distal tibia and calcaneus are particularly susceptible due to limited soft tissue coverage and poor vascularity ( 1 ). When wound dehiscence leads to implant exposure the treatment goal is to eradicate the infection while maintaining mechanical stability of the fracture. ( 2 ). Traditional management strategies have often emphasized aggressive surgical debridement with early implant removal and soft tissue reconstruction using local or free flaps. Although the use of coverage flaps and skin grafts remains a valid strategy, they are not without complications, particularly in the foot region, where achieving not only coverage but also mechanical function recovery is crucial. (12, Cho) While these approaches remain valuable, recent advancements suggest alternative strategies that minimize the need for premature implant removal and complex reconstructive procedures (Cho, 6). In cases of acute infection, local debridement combined with antibiotic therapy is a viable option, provided the implant remains stable.( 3 ). This approach allows fracture healing while adequately controlling infection through systemic antibiotics and rigorous debridement protocols. Even plate exposure seems not to be a contraindication for this treatment approach. As recent studies have shown that advanced local wound care, including negative wound pressure therapy and skin substitutes, can effectively manage plate exposure and often avoid the need for surgical flaps ( 2 ). In selected cases as children or due to lack of alternative treatment strategies, conservative treatment with or without antibiotics and delayed implant removal has led to successful outcomes ( 2 ) Therefore, we believe that exploring alternative treatment methods deserves attention. The present study aims to describe our experience in managing seven patients with plate exposure in the foot and ankle region. Employing a conservative approach that combines local wound care with advanced dressings, antibiotic treatment if the wound was previous infected and delayed implant removal in radiographic confirmed union. By sharing these outcomes, we aim to contribute to the growing body of evidence supporting alternative management strategies for plate exposure in orthopedic trauma patients. Materials and Methods This case series reports on seven consecutive patients treated for plate exposure at our institution from 2020 to 2025. The plate exposure was in four out of seven cases due to an acute infection and in the other cases no active infection was noticed before or after plate exposure. The cohort included all fracture of the foot and ankle: Four patients with malleolar fractures Two patients with calcaneal fractures One patient with a Lisfranc injury Patient Characteristics Among the seven patients analyzed, there were four men and three women with a medium age of 54 years (range: 20–77 years). Of these, only two patients were smokers, none reported drug use, and none had diabetes. The mean size of the plate exposure was 2,9 cm2, with a minimum of 0.4 cm2 and a maximum of 7 cm2. Treatment Protocol In our case series, four patients developed an acute infection following open reduction and internal fixation for a fracture around the ankle. Infection was defined by both systemic symptoms and clinical signs of local infection, such as purulent drainage or erysipelas. The wound was surgically debrided and antibiotic therapy was initiated based on microbiological findings. The difficult wound healing after debridement resulted in plate exposure, which was managed with various wound care approaches in the outpatient setting (see table). In cases where plate exposure occurred without any clinical signs of infection, the wounds were treated in an outpatient setting. We recommend hardware removal after fracture consolidation for all patients; however, two patients either refused or delayed this procedure (see table). Of the seven patients, the four patients who had a local infection before plate exposure were treated with antibiotics until fracture consolidation. The antibiotic treatment lasted for a minimum of six weeks or until the plate was removed. Wound Care Management: Standard Dressing Changes: These were performed initially during the inpatient stay and subsequently in the outpatient wound care clinic. The patient was seen in a one to two week interval after discharge. Depending on the wound appearance different dressing were used (s. table) Negative wound pressure therapy (NWPT): For the two patients managed with NWPT, dressing changes were conducted every five days in the outpatient setting. Wound Dressing Materials For bedside dressing changes, two advanced wound care products were utilized: Apligraf ® (Organogenesis Inc., Canton, MA, USA): A novel bi-layered living skin equivalent. Apligraf is derived from foreskin fibroblasts combined with bovine type I collagen to create a neodermis over which cultured neonatal keratinocytes are placed. These keratinocytes proliferate, differentiate, and contribute to effective wound healing. NuShield ® (Organogenesis Inc., Canton, MA, USA): A dehydrated human placental allograft that retains all native layers of placental tissue, including the amnion, chorion, and spongy layer. This product is designed to enhance the wound healing process by preserving critical biological components. Follow-up Protocol Radiographic follow-up was performed to assess bone healing at the following intervals: 6 weeks 3 months 6 months 1 year Bone consolidation was assessed through standard radiographs. When results were inconclusive, CT scans were conducted at the 3-month follow-up. Results All seven patients achieved satisfactory bone healing without signs of nonunion, except for one patient who developed a nonunion of the medial malleolus at the one-year follow-up. In this case, the lateral malleolus and fibula had completely healed, and the patient was asymptomatic; therefore, no treatment was undertaken. (Fig. 1 –2) The mean time to complete wound closure was 143 days (range: 85–243 days). Wound dressings using skin substitutes (Apligraf/NuShield) were maintained until full wound healing was achieved. Plate removal was performed in five of the seven patients in average 169 days (range: 45–311 days) after the initial surgery. Out of the seven patients, only four received antibiotic therapy, with a mean duration of 83 days. This antibiotic treatment was due to an infection which leads to plate exposure. At the time of hardware removal, bacteriological samples were consistently collected to assess for potential infection, and all results showed no bacterial growth. When histopathological examination or sonication was performed, these were also negative (Table 1). Discussion Orthopedic implant exposure has two challenges which are frequently discussed in the literature, the challenge of wound closure and the risk of infection or contamination of the implant. Our conservative treatment approach for plate exposure demonstrated effectiveness, with all patients achieving good clinical outcomes, wound closure by secondary wound healing and bone healing. The protocol, which included the use of antibiotic therapy where needed combined with advanced dressings, eliminated the need for invasive interventions such as extended flaps coverage. This methods aligns with previous reported case reports.. For instance, Melhem et al. reported successful outcomes in three pediatric patients with extensive plate exposure treated conservatively with wound care, antibiotic therapy, and delayed implant removal after confirmed bone healing ( 2 ). In a case reported by Lee et al., a patient with an exposed titanium cranioplasty plate declined the recommended treatment strategy. Instead, the patient was successfully managed with a local application of platelet-rich plasma and a dermal autograft, which was considered a scaffold to support cellular migration ( 15 ). A similar approach was described by Lee et al. in another report involving 14 patients with exposed orthopedic implants. Initial treatment included the use of MatriDerm—a dermal collagen-elastin matrix—combined with negative pressure wound therapy. Once adequate granulation tissue had formed, a split-thickness skin graft was applied. All patients experienced successful wound healing without reported complications ( 16 ). In contrast to this study, our patients were treated with outpatient open wound treatment and did not require an additional surgery. Similarly, the use of advanced wound management techniques, such as negative pressure wound therapy and skin substitutes, has gained prominence as effective strategies to promote tissue granulation and minimize the need for surgical flap coverage ( 4 ). Kunze et al. mentioned that negative pressure wound therapy (NPWT) can enhance tissue granulation, reduce bacterial burden, and promote closure of wounds ( 5 ). One of the key aspects of our protocol was the use of advanced dressings like Apligraf® and NuShield® to facilitate wound healing. These skin substitutes were successfully utilized, as demonstrated by several studies, including those by Metsemakers et al. and Masters et al., who highlighted the positive role of biological materials in promoting wound healing and reducing postoperative complications​​. (10;11) The issue of implant infection following exposure remains a topic of ongoing discussion. This is particularly noteworthy in our case series, as we achieved successful skin closure over the exposed plates. Moreover, in the instances where the plates were subsequently removed, microbiological analysis revealed no presence of pathogens. In our case series we have several cases with a acute infection which lead to plate exposure and was successfully treated with systemic antibiotics. This approach aligns with findings in literature, where implant retention has been successfully achieved in many cases, even in the presence of infection, due to modern techniques such as local and systemic antibiotic treatment. Numerous studies support the idea that a conservative approach with delayed plate removal can be a valid alternative to traditional methods of early removal of the fixation hardware. The approach of conservative treatment, even with clinical sign of infection, as shown by Tsang et al. and Casiraghi et al., suggests that implant retention is feasible in patients with acute infections when treated promptly with surgical washouts, targeted antibiotic therapy, and debridement​​.(7;8). Our study also confirms the findings by Depypere et al. and Onsea et al., who emphasize that a conservative approach, monitored through regular radiographic follow-ups, allows for bone healing without the necessity of early plate removal​​. (6;9) This conservative approach has led to reduced morbidity compared to traditional approaches, avoiding the complications typically associated with invasive treatments, such as early plate removal or flap coverage. Our findings align with the recommendations from Metsemakers et al., who emphasize the importance of a multidisciplinary treatment approach and the use of antibiotic therapies to prevent complications and improve clinical outcomes​ ( 10 ) Moreover, Depypere et al. emphasized the importance of a multidisciplinary approach to managing fracture-related infections, underlining that antibiotic suppression combined with meticulous wound care and delayed hardware removal may improve outcomes in select patients ( 6 ). This study highlights that plate exposure alone is not an indication for antibiotic therapy or acute surgical treatment. In the absence of infection criteria such as redness, warmth, swelling, or frank pus, or signs of systemic infection in the labatory results a conservative treatment approach with bedside dressing changes followed by outpatient wound management can be successfully adopted. This approach does not compromise fracture healing. Our results suggest that a less aggressive treatment approach can be adopted until bone consolidation is achieved, thus avoiding additional surgical stress and the risk of complications in an already fragile and compromised area. Based on our observations, we hypothesize that distinguishing between contamination and infection is crucial. An exposed plate might lead to bacterial contamination, which does not necessarily lead to an infection requiring acute surgical debridement and plate removal. (13;14) Limitations: This study has several limitations. First, the retrospective design and the small sample size limit the generalizability of the findings. Additionally, the patient population was heterogeneous in terms of fracture type, anatomical location, and treatment course, which introduces variability in outcomes and makes direct comparisons challenging. Another important limitation is the lack of systematic microbiological or histopathological assessment in all cases. While bacteriological samples were collected at the time of implant removal, no biopsies were performed during the initial management. Therefore, the presence of biopsy-negative infections cannot be entirely excluded. This factor should be considered when interpreting the results, as subclinical or low-grade infections might have gone undetected despite the apparent clinical and radiographic resolution. Conclusions This case series demonstrates that a conservative approach to managing plate exposure, combining antibiotic therapy if needed, advanced wound care with skin substitutes, and delayed plate removal, can be highly effective in achieving bone healing without the need for early implant removal or flap coverage. The results of this study contribute to the growing body of evidence supporting implant retention as a viable option in the management of plate exposure, particularly in patients without signs of active infection or with well-controlled infection. The use of advanced wound care techniques, such as NWPT and biological skin substitutes, plays a key role in promoting wound healing and preventing complications. Declarations Acknowledgments The authors would like to thank the nursing staff of the [anonymised] wound care unit for their valuable support in patient care. Funding This research received no external funding. Conflicts of Interest The authors declare that they have no conflicts of interest. Data Availability Statement The datasets generated and/or analyzed during the current study were collected using REDCap electronic data capture tools hosted at [anonymised]. Data are available from the corresponding author on reasonable request. Author Contributions Author 1: Study conception and design, data collection, manuscript drafting. Author 2: Data collection, patient follow-up, and manuscript editing. Author 3: Data collection and literature review. Author 4: Data collection and literature review. Author 5: Study design, supervision, and critical revision. Author 6: Data analysis and interpretation, critical revision of the manuscript. All authors reviewed and approved the final version of the manuscript. Ethics Approval This study was approved by the [anonymised]. Informed Consent Informed consent was obtained from all individual participants included in the study. References Ieropoli G, Villafañe JH, Zompi SC, Morozzo U, D’Ambrosi R, Usuelli FG, Berjano P (2017) Successful treatment of infected wound dehiscence after minimally invasive locking-plate osteosynthesis of tibial pilon and calcaneal fractures by plate preservation, surgical debridement and antibiotics, Foot (Edinb), 33, 44-47 Melhem E, Bayoud W, Ghanem I (2019) Bone healing is achievable despite extensive wound dehiscence and wide plate and screws exposure in children, Orthop Traumatol Surg Res, 105, 757-760 Baertl S, Rupp M, Alt V (2024) The DAIR-procedure in fracture-related infection: when and how, Injury, 55 Suppl 6, 111977 Cho EH, Garcia R, Pien I, Thomas S, Levin LS, Hollenbeck ST (2014) An algorithmic approach for managing orthopaedic surgical wounds of the foot and ankle, Clin Orthop Relat Res, 472, 1921-1929 Kunze KN, Hamid KS, Lee S, Halvorson JJ, Earhart JS, Bohl DD (2020) Negative-pressure wound therapy in foot and ankle surgery, Foot Ankle Int, 41, 364-372 Depypere M, Morgenstern M, Kuehl R, Senneville E, Moriarty TF, Obremskey WT, et al. (2020) Pathogenesis and management of fracture-related infection, Clin Microbiol Infect, 26, 572-578 Casiraghi A, Galante C, Rohayem M, Vittone G, Domenicucci M, Cattaneo S, et al. (2023) Implant retention with serial debridement and use of antibiotic-loaded calcium sulfate beads in acute fracture-related infection after pelvic ring or acetabular fractures: a retrospective case series of 7 cases, Injury, 54, 1082-1087 Tsang SJ, Ferreira N (2023) The role of implant retention and conservative management in fracture-related infection, J Orthop, 48, 47-51 Onsea J, Van Lieshout EMM, Zalavras C, Sliepen J, Depypere M, Noppe N, et al. (2022) Validation of the diagnostic criteria of the consensus definition of fracture-related infection, Injury, 53, 1867-1879 Metsemakers WJ, Morgenstern M, Senneville E, Borens O, Govaert GAM, Onsea J, et al. (2020) General treatment principles for fracture-related infection: recommendations from an international expert group, Arch Orthop Trauma Surg, 140, 1013-1027 Masters EA, Trombetta RP, de Mesy Bentley KL, Boyce BF, Gill AL, Gill SR, et al. (2019) Evolving concepts in bone infection: redefining "biofilm", "acute vs. chronic osteomyelitis", "the immune proteome" and "local antibiotic therapy", Bone Res, 7, 20 Li RG, Zeng CJ, Yuan S, Hu JJ, Zhang P, Chen YB, et al. (2021) Reconstruction of large area of deep wound in the foot and ankle with chimeric anterolateral thigh perforator flap, Orthop Surg, 13, 1609-1617 Moore K, Gupta N, Gupta TT, Patel K, Brooks JR, Sullivan A, et al. (2022) Mapping bacterial biofilm on features of orthopedic implants in vitro, Microorganisms, 10, 586 Previ L, Iorio R, Solmone M, Mazza D, Marzilli F, Di Niccolo R, et al. (2024) Worrying presence of asymptomatic bacterial colonisation on implanted orthopedic devices, Cureus, 16, e68126 Lee SK, An YS, Choy WS (2023) Management of hardware-exposed soft tissue defects using dermal substitutes and negative pressure wound therapy, Ann Plast Surg, 90, 242-247 Lee IL, Lin YN, Huang SH, Chung CL, Chuang CH, Chen RF, et al. (2020) A simple way to manage a chronic ulcer at the cranioplasty titanium implant exposure site by dermal autograft and platelet-rich plasma: a case report, Med Case Rep Study Protoc, 1, e000 Table 1 Age Fracture Type Surgical Treatment Time of Plate Exposure Wound Treatment During Plate Exposure Antibiotic Therapy Biopsy Plate Exposure Duration 77 Lateral Malleolar ORIF, implant removal at 6 weeks After ORIF VAC Therapy Co-Amoxicillin Until implant removal Hardware removal: negative (on antibiotics) 5 weeks 69 Distal tibia (spiral) + fibula Multiple surgeries, flap failure, delayed implant removal a year after initial trauma After flap failure NuShield None Implant exchange: S. epidermidis (1/4); hardware removal: negative, negative sonication 9 months after flap failure 55 Lisfranc ORIF, implant removal at 3 months After ORIF VAC Therapy Apligraf None Implant removal: negative 3 months 21 Bimalleolar ORIF, Debridement + VAC at 2 weeks, implant removal at 3 month After debridement NuShield 4 weeks Bactrim Debridement: S. epidermidis resistant, Hardware removal: negative, histophathology negativ, 2 months 78 Calcaneus + Talus ORIF, debridement partial implant removal (2 screws) at 2 weeks After debridement Apligraf + VAC Therapy 3 months Clindamycin First debridement S. epidermidis, than negative (on antibiotics) 4 months 64 Trimalleolar ORIF, implant change after 2 weeks, debridement + VAC after 3 weeks After debridement NuShield 3 months Ciprofloxacin Debridement: E. cloacae, E. hormaechei 4 months 60 Calcaneus ORIF, hardware removal at 9 months After ORIF Honey + standard dressing None Hardware removal: Negative, histopathology negative, sonication negative 3 months Table 1. Patient characteristics, type of fracture, treatment strategies, antibiotic therapy, microbiological findings, and duration of plate exposure in the case series. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 03 Mar, 2026 Read the published version in European Journal of Orthopaedic Surgery & Traumatology → Version 1 posted Editorial decision: Revision requested 25 Jan, 2026 Reviews received at journal 19 Jan, 2026 Reviewers agreed at journal 15 Jan, 2026 Reviews received at journal 03 Dec, 2025 Reviewers agreed at journal 22 Nov, 2025 Reviewers invited by journal 05 Nov, 2025 Editor assigned by journal 07 Oct, 2025 Submission checks completed at journal 07 Oct, 2025 First submitted to journal 02 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7764817","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":525922351,"identity":"0ef4d7fa-076c-4198-ab86-bb9cb2d557d8","order_by":0,"name":"Riccardo 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1","display":"","copyAsset":false,"role":"figure","size":219790,"visible":true,"origin":"","legend":"\u003cp\u003eexample of a wound with the osteosythesis plate visibly before (1) and after (2) several months of extensive wound treatment\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7764817/v1/77b8545e76ce74b85aaccc6c.png"},{"id":93342658,"identity":"c5dfaadd-cca2-4302-b8a2-178b5c9a1e01","added_by":"auto","created_at":"2025-10-12 14:43:34","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":192836,"visible":true,"origin":"","legend":"\u003cp\u003eexample of a wound with the osteosythesis plate visibly before (1) and after (2) several months of extensive wound treatment\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7764817/v1/cb6bde885706ca9ad680ef47.png"},{"id":104250618,"identity":"f9149587-028a-49ec-b0de-c3dc483926a5","added_by":"auto","created_at":"2026-03-09 16:02:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":953208,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7764817/v1/3432ffe3-fc76-4a2c-8aa4-3882d1d05dd6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Management of Orthopedic Plate Exposure: A Case Series Evaluating Advanced Wound Care and Delayed Hardware Removal","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWound dehiscence with subsequent exposure of orthopedic implants, especially after open reduction and internal fixation of fractures (ORIF), represents a significant challenge in orthopedic trauma surgery. The exposure of metallic implants increases the risk of deep infection and compromised fracture healing.\u003c/p\u003e\u003cp\u003eThe risk of implant exposure is influenced by several factors, including the anatomical location, the quality of the overlying soft tissue, and the presence of comorbidities that impair wound healing (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Sites such as the distal tibia and calcaneus are particularly susceptible due to limited soft tissue coverage and poor vascularity (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). When wound dehiscence leads to implant exposure the treatment goal is to eradicate the infection while maintaining mechanical stability of the fracture. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTraditional management strategies have often emphasized aggressive surgical debridement with early implant removal and soft tissue reconstruction using local or free flaps. Although the use of coverage flaps and skin grafts remains a valid strategy, they are not without complications, particularly in the foot region, where achieving not only coverage but also mechanical function recovery is crucial. (12, Cho) While these approaches remain valuable, recent advancements suggest alternative strategies that minimize the need for premature implant removal and complex reconstructive procedures (Cho, 6). In cases of acute infection, local debridement combined with antibiotic therapy is a viable option, provided the implant remains stable.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). This approach allows fracture healing while adequately controlling infection through systemic antibiotics and rigorous debridement protocols. Even plate exposure seems not to be a contraindication for this treatment approach. As recent studies have shown that advanced local wound care, including negative wound pressure therapy and skin substitutes, can effectively manage plate exposure and often avoid the need for surgical flaps (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In selected cases as children or due to lack of alternative treatment strategies, conservative treatment with or without antibiotics and delayed implant removal has led to successful outcomes (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eTherefore, we believe that exploring alternative treatment methods deserves attention. The present study aims to describe our experience in managing seven patients with plate exposure in the foot and ankle region. Employing a conservative approach that combines local wound care with advanced dressings, antibiotic treatment if the wound was previous infected and delayed implant removal in radiographic confirmed union. By sharing these outcomes, we aim to contribute to the growing body of evidence supporting alternative management strategies for plate exposure in orthopedic trauma patients.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis case series reports on seven consecutive patients treated for plate exposure at our institution from 2020 to 2025. The plate exposure was in four out of seven cases due to an acute infection and in the other cases no active infection was noticed before or after plate exposure. The cohort included all fracture of the foot and ankle:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eFour patients with malleolar fractures\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTwo patients with calcaneal fractures\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eOne patient with a Lisfranc injury\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003ePatient Characteristics\u003c/p\u003e\u003cp\u003eAmong the seven patients analyzed, there were four men and three women with a medium age of 54 years (range: 20\u0026ndash;77 years). Of these, only two patients were smokers, none reported drug use, and none had diabetes. The mean size of the plate exposure was 2,9 cm2, with a minimum of 0.4 cm2 and a maximum of 7 cm2.\u003c/p\u003e\u003cp\u003eTreatment Protocol\u003c/p\u003e\u003cp\u003eIn our case series, four patients developed an acute infection following open reduction and internal fixation for a fracture around the ankle. Infection was defined by both systemic symptoms and clinical signs of local infection, such as purulent drainage or erysipelas. The wound was surgically debrided and antibiotic therapy was initiated based on microbiological findings. The difficult wound healing after debridement resulted in plate exposure, which was managed with various wound care approaches in the outpatient setting (see table).\u003c/p\u003e\u003cp\u003eIn cases where plate exposure occurred without any clinical signs of infection, the wounds were treated in an outpatient setting. We recommend hardware removal after fracture consolidation for all patients; however, two patients either refused or delayed this procedure (see table).\u003c/p\u003e\u003cp\u003eOf the seven patients, the four patients who had a local infection before plate exposure were treated with antibiotics until fracture consolidation. The antibiotic treatment lasted for a minimum of six weeks or until the plate was removed.\u003c/p\u003e\u003cp\u003eWound Care Management:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eStandard Dressing Changes: These were performed initially during the inpatient stay and subsequently in the outpatient wound care clinic. The patient was seen in a one to two week interval after discharge. Depending on the wound appearance different dressing were used (s. table)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNegative wound pressure therapy (NWPT): For the two patients managed with NWPT, dressing changes were conducted every five days in the outpatient setting.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eWound Dressing Materials\u003c/p\u003e\u003cp\u003eFor bedside dressing changes, two advanced wound care products were utilized:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eApligraf \u0026reg; (Organogenesis Inc., Canton, MA, USA): A novel bi-layered living skin equivalent. Apligraf is derived from foreskin fibroblasts combined with bovine type I collagen to create a neodermis over which cultured neonatal keratinocytes are placed. These keratinocytes proliferate, differentiate, and contribute to effective wound healing.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNuShield \u0026reg; (Organogenesis Inc., Canton, MA, USA): A dehydrated human placental allograft that retains all native layers of placental tissue, including the amnion, chorion, and spongy layer. This product is designed to enhance the wound healing process by preserving critical biological components.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eFollow-up Protocol\u003c/p\u003e\u003cp\u003eRadiographic follow-up was performed to assess bone healing at the following intervals:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e6 weeks\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e3 months\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e6 months\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e1 year\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eBone consolidation was assessed through standard radiographs. When results were inconclusive, CT scans were conducted at the 3-month follow-up.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAll seven patients achieved satisfactory bone healing without signs of nonunion, except for one patient who developed a nonunion of the medial malleolus at the one-year follow-up. In this case, the lateral malleolus and fibula had completely healed, and the patient was asymptomatic; therefore, no treatment was undertaken. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026ndash;2)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe mean time to complete wound closure was 143 days (range: 85\u0026ndash;243 days). Wound dressings using skin substitutes (Apligraf/NuShield) were maintained until full wound healing was achieved.\u003c/p\u003e\u003cp\u003ePlate removal was performed in five of the seven patients in average 169 days (range: 45\u0026ndash;311 days) after the initial surgery. Out of the seven patients, only four received antibiotic therapy, with a mean duration of 83 days. This antibiotic treatment was due to an infection which leads to plate exposure.\u003c/p\u003e\u003cp\u003eAt the time of hardware removal, bacteriological samples were consistently collected to assess for potential infection, and all results showed no bacterial growth. When histopathological examination or sonication was performed, these were also negative (Table\u0026nbsp;1).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOrthopedic implant exposure has two challenges which are frequently discussed in the literature, the challenge of wound closure and the risk of infection or contamination of the implant. Our conservative treatment approach for plate exposure demonstrated effectiveness, with all patients achieving good clinical outcomes, wound closure by secondary wound healing and bone healing. The protocol, which included the use of antibiotic therapy where needed combined with advanced dressings, eliminated the need for invasive interventions such as extended flaps coverage.\u003c/p\u003e\u003cp\u003eThis methods aligns with previous reported case reports.. For instance, Melhem et al. reported successful outcomes in three pediatric patients with extensive plate exposure treated conservatively with wound care, antibiotic therapy, and delayed implant removal after confirmed bone healing (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In a case reported by Lee et al., a patient with an exposed titanium cranioplasty plate declined the recommended treatment strategy. Instead, the patient was successfully managed with a local application of platelet-rich plasma and a dermal autograft, which was considered a scaffold to support cellular migration (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). A similar approach was described by Lee et al. in another report involving 14 patients with exposed orthopedic implants. Initial treatment included the use of MatriDerm\u0026mdash;a dermal collagen-elastin matrix\u0026mdash;combined with negative pressure wound therapy. Once adequate granulation tissue had formed, a split-thickness skin graft was applied. All patients experienced successful wound healing without reported complications (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In contrast to this study, our patients were treated with outpatient open wound treatment and did not require an additional surgery.\u003c/p\u003e\u003cp\u003eSimilarly, the use of advanced wound management techniques, such as negative pressure wound therapy and skin substitutes, has gained prominence as effective strategies to promote tissue granulation and minimize the need for surgical flap coverage (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Kunze et al. mentioned that negative pressure wound therapy (NPWT) can enhance tissue granulation, reduce bacterial burden, and promote closure of wounds (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). One of the key aspects of our protocol was the use of advanced dressings like Apligraf\u0026reg; and NuShield\u0026reg; to facilitate wound healing. These skin substitutes were successfully utilized, as demonstrated by several studies, including those by Metsemakers et al. and Masters et al., who highlighted the positive role of biological materials in promoting wound healing and reducing postoperative complications​​. (10;11)\u003c/p\u003e\u003cp\u003eThe issue of implant infection following exposure remains a topic of ongoing discussion. This is particularly noteworthy in our case series, as we achieved successful skin closure over the exposed plates. Moreover, in the instances where the plates were subsequently removed, microbiological analysis revealed no presence of pathogens.\u003c/p\u003e\u003cp\u003eIn our case series we have several cases with a acute infection which lead to plate exposure and was successfully treated with systemic antibiotics. This approach aligns with findings in literature, where implant retention has been successfully achieved in many cases, even in the presence of infection, due to modern techniques such as local and systemic antibiotic treatment. Numerous studies support the idea that a conservative approach with delayed plate removal can be a valid alternative to traditional methods of early removal of the fixation hardware. The approach of conservative treatment, even with clinical sign of infection, as shown by Tsang et al. and Casiraghi et al., suggests that implant retention is feasible in patients with acute infections when treated promptly with surgical washouts, targeted antibiotic therapy, and debridement​​.(7;8). Our study also confirms the findings by Depypere et al. and Onsea et al., who emphasize that a conservative approach, monitored through regular radiographic follow-ups, allows for bone healing without the necessity of early plate removal​​. (6;9)\u003c/p\u003e\u003cp\u003eThis conservative approach has led to reduced morbidity compared to traditional approaches, avoiding the complications typically associated with invasive treatments, such as early plate removal or flap coverage. Our findings align with the recommendations from Metsemakers et al., who emphasize the importance of a multidisciplinary treatment approach and the use of antibiotic therapies to prevent complications and improve clinical outcomes​ (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eMoreover, Depypere et al. emphasized the importance of a multidisciplinary approach to managing fracture-related infections, underlining that antibiotic suppression combined with meticulous wound care and delayed hardware removal may improve outcomes in select patients (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis study highlights that plate exposure alone is not an indication for antibiotic therapy or acute surgical treatment. In the absence of infection criteria such as redness, warmth, swelling, or frank pus, or signs of systemic infection in the labatory results a conservative treatment approach with bedside dressing changes followed by outpatient wound management can be successfully adopted. This approach does not compromise fracture healing.\u003c/p\u003e\u003cp\u003eOur results suggest that a less aggressive treatment approach can be adopted until bone consolidation is achieved, thus avoiding additional surgical stress and the risk of complications in an already fragile and compromised area. Based on our observations, we hypothesize that distinguishing between contamination and infection is crucial. An exposed plate might lead to bacterial contamination, which does not necessarily lead to an infection requiring acute surgical debridement and plate removal. (13;14)\u003c/p\u003e\u003cp\u003eLimitations:\u003c/p\u003e\u003cp\u003eThis study has several limitations. First, the retrospective design and the small sample size limit the generalizability of the findings. Additionally, the patient population was heterogeneous in terms of fracture type, anatomical location, and treatment course, which introduces variability in outcomes and makes direct comparisons challenging. Another important limitation is the lack of systematic microbiological or histopathological assessment in all cases. While bacteriological samples were collected at the time of implant removal, no biopsies were performed during the initial management. Therefore, the presence of biopsy-negative infections cannot be entirely excluded. This factor should be considered when interpreting the results, as subclinical or low-grade infections might have gone undetected despite the apparent clinical and radiographic resolution.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis case series demonstrates that a conservative approach to managing plate exposure, combining antibiotic therapy if needed, advanced wound care with skin substitutes, and delayed plate removal, can be highly effective in achieving bone healing without the need for early implant removal or flap coverage.\u003c/p\u003e\u003cp\u003eThe results of this study contribute to the growing body of evidence supporting implant retention as a viable option in the management of plate exposure, particularly in patients without signs of active infection or with well-controlled infection. The use of advanced wound care techniques, such as NWPT and biological skin substitutes, plays a key role in promoting wound healing and preventing complications.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgments\u003cbr\u003e The authors would like to thank the nursing staff of the [anonymised] wound care unit for their valuable support in patient care.\u003c/p\u003e\n\u003cp\u003eFunding\u003cbr\u003e This research received no external funding.\u003c/p\u003e\n\u003cp\u003eConflicts of Interest\u003cbr\u003e The authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003eData Availability Statement\u003cbr\u003e The datasets generated and/or analyzed during the current study were collected using REDCap electronic data capture tools hosted at [anonymised]. Data are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eAuthor Contributions\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eAuthor 1: Study conception and design, data collection, manuscript drafting.\u003c/li\u003e\n \u003cli\u003eAuthor 2: Data collection, patient follow-up, and manuscript editing.\u003c/li\u003e\n \u003cli\u003eAuthor 3: Data collection and literature review.\u003c/li\u003e\n \u003cli\u003eAuthor 4: Data collection and literature review.\u003c/li\u003e\n \u003cli\u003eAuthor 5: Study design, supervision, and critical revision.\u003c/li\u003e\n \u003cli\u003eAuthor 6: Data analysis and interpretation, critical revision of the manuscript.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAll authors reviewed and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003eEthics Approval\u003cbr\u003e This study was approved by the [anonymised].\u003c/p\u003e\n\u003cp\u003eInformed Consent\u003cbr\u003e Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eIeropoli G, Villafa\u0026ntilde;e JH, Zompi SC, Morozzo U, D\u0026rsquo;Ambrosi R, Usuelli FG, Berjano P (2017) Successful treatment of infected wound dehiscence after minimally invasive locking-plate osteosynthesis of tibial pilon and calcaneal fractures by plate preservation, surgical debridement and antibiotics, Foot (Edinb), 33, 44-47\u003c/li\u003e\n\u003cli\u003eMelhem E, Bayoud W, Ghanem I (2019) Bone healing is achievable despite extensive wound dehiscence and wide plate and screws exposure in children, Orthop Traumatol Surg Res, 105, 757-760\u003c/li\u003e\n\u003cli\u003eBaertl S, Rupp M, Alt V (2024) The DAIR-procedure in fracture-related infection: when and how, Injury, 55 Suppl 6, 111977\u003c/li\u003e\n\u003cli\u003eCho EH, Garcia R, Pien I, Thomas S, Levin LS, Hollenbeck ST (2014) An algorithmic approach for managing orthopaedic surgical wounds of the foot and ankle, Clin Orthop Relat Res, 472, 1921-1929\u003c/li\u003e\n\u003cli\u003eKunze KN, Hamid KS, Lee S, Halvorson JJ, Earhart JS, Bohl DD (2020) Negative-pressure wound therapy in foot and ankle surgery, Foot Ankle Int, 41, 364-372\u003c/li\u003e\n\u003cli\u003eDepypere M, Morgenstern M, Kuehl R, Senneville E, Moriarty TF, Obremskey WT, et al. (2020) Pathogenesis and management of fracture-related infection, Clin Microbiol Infect, 26, 572-578\u003c/li\u003e\n\u003cli\u003eCasiraghi A, Galante C, Rohayem M, Vittone G, Domenicucci M, Cattaneo S, et al. (2023) Implant retention with serial debridement and use of antibiotic-loaded calcium sulfate beads in acute fracture-related infection after pelvic ring or acetabular fractures: a retrospective case series of 7 cases, Injury, 54, 1082-1087\u003c/li\u003e\n\u003cli\u003eTsang SJ, Ferreira N (2023) The role of implant retention and conservative management in fracture-related infection, J Orthop, 48, 47-51\u003c/li\u003e\n\u003cli\u003eOnsea J, Van Lieshout EMM, Zalavras C, Sliepen J, Depypere M, Noppe N, et al. (2022) Validation of the diagnostic criteria of the consensus definition of fracture-related infection, Injury, 53, 1867-1879\u003c/li\u003e\n\u003cli\u003eMetsemakers WJ, Morgenstern M, Senneville E, Borens O, Govaert GAM, Onsea J, et al. (2020) General treatment principles for fracture-related infection: recommendations from an international expert group, Arch Orthop Trauma Surg, 140, 1013-1027\u003c/li\u003e\n\u003cli\u003eMasters EA, Trombetta RP, de Mesy Bentley KL, Boyce BF, Gill AL, Gill SR, et al. (2019) Evolving concepts in bone infection: redefining \u0026quot;biofilm\u0026quot;, \u0026quot;acute vs. chronic osteomyelitis\u0026quot;, \u0026quot;the immune proteome\u0026quot; and \u0026quot;local antibiotic therapy\u0026quot;, Bone Res, 7, 20\u003c/li\u003e\n\u003cli\u003eLi RG, Zeng CJ, Yuan S, Hu JJ, Zhang P, Chen YB, et al. (2021) Reconstruction of large area of deep wound in the foot and ankle with chimeric anterolateral thigh perforator flap, Orthop Surg, 13, 1609-1617\u003c/li\u003e\n\u003cli\u003eMoore K, Gupta N, Gupta TT, Patel K, Brooks JR, Sullivan A, et al. (2022) Mapping bacterial biofilm on features of orthopedic implants in vitro, Microorganisms, 10, 586\u003c/li\u003e\n\u003cli\u003ePrevi L, Iorio R, Solmone M, Mazza D, Marzilli F, Di Niccolo R, et al. (2024) Worrying presence of asymptomatic bacterial colonisation on implanted orthopedic devices, Cureus, 16, e68126\u003c/li\u003e\n\u003cli\u003eLee SK, An YS, Choy WS (2023) Management of hardware-exposed soft tissue defects using dermal substitutes and negative pressure wound therapy, Ann Plast Surg, 90, 242-247\u003c/li\u003e\n\u003cli\u003eLee IL, Lin YN, Huang SH, Chung CL, Chuang CH, Chen RF, et al. (2020) A simple way to manage a chronic ulcer at the cranioplasty titanium implant exposure site by dermal autograft and platelet-rich plasma: a case report, Med Case Rep Study Protoc, 1, e000\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table 1","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 3.98482%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.8008%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFracture Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4213%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical Treatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4725%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime of Plate Exposure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3852%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWound Treatment During Plate Exposure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6622%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAntibiotic Therapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6983%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBiopsy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.575%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlate Exposure Duration\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 3.98482%;\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.8008%;\"\u003e\n \u003cp\u003eLateral Malleolar\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4213%;\"\u003e\n \u003cp\u003eORIF, implant removal at 6 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4725%;\"\u003e\n \u003cp\u003eAfter ORIF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3852%;\"\u003e\n \u003cp\u003eVAC Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6622%;\"\u003e\n \u003cp\u003eCo-Amoxicillin\u003c/p\u003e\n \u003cp\u003eUntil implant removal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6983%;\"\u003e\n \u003cp\u003eHardware removal: negative (on antibiotics)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.575%;\"\u003e\n \u003cp\u003e5 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 3.98482%;\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.8008%;\"\u003e\n \u003cp\u003eDistal tibia (spiral) + fibula\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4213%;\"\u003e\n \u003cp\u003eMultiple surgeries, flap failure, delayed implant removal a year after initial trauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4725%;\"\u003e\n \u003cp\u003eAfter flap failure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3852%;\"\u003e\n \u003cp\u003eNuShield\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6622%;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6983%;\"\u003e\n \u003cp\u003eImplant exchange: S. epidermidis (1/4); hardware removal: negative, negative sonication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.575%;\"\u003e\n \u003cp\u003e9 months after flap failure\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 3.98482%;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.8008%;\"\u003e\n \u003cp\u003eLisfranc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4213%;\"\u003e\n \u003cp\u003eORIF, implant removal at 3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4725%;\"\u003e\n \u003cp\u003eAfter ORIF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3852%;\"\u003e\n \u003cp\u003eVAC Therapy\u003c/p\u003e\n \u003cp\u003eApligraf\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6622%;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6983%;\"\u003e\n \u003cp\u003eImplant removal: negative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.575%;\"\u003e\n \u003cp\u003e3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 3.98482%;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.8008%;\"\u003e\n \u003cp\u003eBimalleolar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4213%;\"\u003e\n \u003cp\u003eORIF, Debridement + VAC at 2 weeks, implant removal at 3 month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4725%;\"\u003e\n \u003cp\u003eAfter debridement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3852%;\"\u003e\n \u003cp\u003eNuShield\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6622%;\"\u003e\n \u003cp\u003e4 weeks Bactrim\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6983%;\"\u003e\n \u003cp\u003eDebridement: S. epidermidis resistant, Hardware removal: negative, histophathology negativ,\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.575%;\"\u003e\n \u003cp\u003e2 months\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 3.98482%;\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.8008%;\"\u003e\n \u003cp\u003eCalcaneus + Talus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4213%;\"\u003e\n \u003cp\u003eORIF, \u0026nbsp;debridement partial implant removal (2 screws) at 2 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4725%;\"\u003e\n \u003cp\u003eAfter debridement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3852%;\"\u003e\n \u003cp\u003eApligraf + VAC Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6622%;\"\u003e\n \u003cp\u003e3 months Clindamycin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6983%;\"\u003e\n \u003cp\u003eFirst debridement S. epidermidis,\u003c/p\u003e\n \u003cp\u003ethan negative (on antibiotics)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.575%;\"\u003e\n \u003cp\u003e4 months\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 3.98482%;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.8008%;\"\u003e\n \u003cp\u003eTrimalleolar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4213%;\"\u003e\n \u003cp\u003eORIF, implant change after 2 weeks, debridement + VAC after 3 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4725%;\"\u003e\n \u003cp\u003eAfter debridement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3852%;\"\u003e\n \u003cp\u003eNuShield\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6622%;\"\u003e\n \u003cp\u003e3 months Ciprofloxacin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6983%;\"\u003e\n \u003cp\u003eDebridement: E. cloacae, E. hormaechei\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.575%;\"\u003e\n \u003cp\u003e4 months\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 3.98482%;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.8008%;\"\u003e\n \u003cp\u003eCalcaneus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4213%;\"\u003e\n \u003cp\u003eORIF, hardware removal at 9 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4725%;\"\u003e\n \u003cp\u003eAfter ORIF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3852%;\"\u003e\n \u003cp\u003eHoney + standard dressing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6622%;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6983%;\"\u003e\n \u003cp\u003eHardware removal: Negative, histopathology negative, sonication negative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.575%;\"\u003e\n \u003cp\u003e3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Patient characteristics, type of fracture, treatment strategies, antibiotic therapy, microbiological findings, and duration of plate exposure in the case series.\u003c/p\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-orthopaedic-surgery-and-traumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejos","sideBox":"Learn more about [European Journal of Orthopaedic Surgery \u0026 Traumatology](http://link.springer.com/journal/590)","snPcode":"590","submissionUrl":"https://submission.springernature.com/new-submission/590/3","title":"European Journal of Orthopaedic Surgery \u0026 Traumatology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Orthopedic implants, Plate exposure, Wound healing, Negative pressure wound therapy, Advanced wound dressings","lastPublishedDoi":"10.21203/rs.3.rs-7764817/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7764817/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePlate exposure following open reduction and internal fixation (ORIF) poses significant challenges, including infection risk and impaired fracture healing. Traditional management often involves aggressive surgical interventions.​\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis retrospective case series examines seven patients treated between 2020 and 2025 who developed plate exposure after ORIF of lower extremity fractures. Management included local wound care with advanced dressings (Apligraf\u0026reg;, NuShield\u0026reg;), negative pressure wound therapy, targeted antibiotic therapy when indicated, and delayed hardware removal post-fracture consolidation.​\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAll patients achieved complete wound healing, with a mean closure time of 143 days. Radiographic union was confirmed in all cases except one asymptomatic nonunion. Antibiotics were administered in four cases, guided by clinical signs and microbiological findings. No infections were detected at the time of hardware removal.​\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eA conservative approach utilizing advanced wound care techniques and delayed hardware removal can effectively manage plate exposure without necessitating early implant removal or flap coverage. This strategy may reduce patient morbidity and preserve fracture stability.\u003c/p\u003e","manuscriptTitle":"Management of Orthopedic Plate Exposure: A Case Series Evaluating Advanced Wound Care and Delayed Hardware Removal","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-12 14:43:29","doi":"10.21203/rs.3.rs-7764817/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-26T00:16:53+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-19T20:52:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"213323635995707889902601023239042506365","date":"2026-01-15T16:11:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-03T07:55:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"173970542819942757570646227685483888147","date":"2025-11-22T14:15:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-05T10:17:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-07T11:21:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-07T11:20:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Orthopaedic Surgery \u0026 Traumatology","date":"2025-10-02T08:18:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-orthopaedic-surgery-and-traumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejos","sideBox":"Learn more about [European Journal of Orthopaedic Surgery \u0026 Traumatology](http://link.springer.com/journal/590)","snPcode":"590","submissionUrl":"https://submission.springernature.com/new-submission/590/3","title":"European Journal of Orthopaedic Surgery \u0026 Traumatology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"a18ddaea-5e52-4408-95c3-9269d9b9f1aa","owner":[],"postedDate":"October 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T16:00:54+00:00","versionOfRecord":{"articleIdentity":"rs-7764817","link":"https://doi.org/10.1007/s00590-026-04700-6","journal":{"identity":"european-journal-of-orthopaedic-surgery-and-traumatology","isVorOnly":false,"title":"European Journal of Orthopaedic Surgery \u0026 Traumatology"},"publishedOn":"2026-03-03 15:57:00","publishedOnDateReadable":"March 3rd, 2026"},"versionCreatedAt":"2025-10-12 14:43:29","video":"","vorDoi":"10.1007/s00590-026-04700-6","vorDoiUrl":"https://doi.org/10.1007/s00590-026-04700-6","workflowStages":[]},"version":"v1","identity":"rs-7764817","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7764817","identity":"rs-7764817","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}