Surgical strategy and outcomes of fracture reconstruction in polytrauma patients with concomitant infection: an ambispective cohort study

Abstract Background We examined physiologic readiness for systemic complications and infection-to-operative-field proximity for wound or implant outcomes in infected polytrauma. Methods This single-centre ambispective cohort included 456 patients with polytrauma and concomitant infection undergoing definitive fracture reconstruction (346 retrospective, 110 prospective). Five domains—white-cell count/trajectory, neutrophil percentage/trajectory, temperature/trajectory, haemoglobin, and platelet count—defined three groups: all met, one unmet, and ≥ 2 unmet. Proximity was remote, adjacent without overlap, or overlapping/involving the operative field. Outcomes were a composite of pneumonia, respiratory failure/acute respiratory distress syndrome, sepsis, or acute kidney injury and any wound/implant adverse outcome. Robust-variance Poisson regression estimated adjusted risk ratios (aRRs) with prespecified covariates. Results The systemic composite occurred in 24/124 (19.4%), 47/172 (27.3%), and 65/159 (40.9%) across systemic Status Adequacy Score; aRRs versus all five criteria met were 1.31 (95% CI 0.85–2.01) and 1.99 (1.33–2.98).Wound/implant events occurred in 52/359 (14.5%), 48/72 (66.7%), and 18/25 (72.0%) across proximity levels; aRRs versus remote were 6.68 (4.54–9.81) and 7.11 (4.73–10.70). Pulmonary versus intra-abdominal infection was not detectably associated with wound outcome (aRR 0.83, 0.62–1.12); wound/soft-tissue infection was (2.17, 1.39–3.40). Each additional 7 days to surgery was associated with the systemic composite (1.09, 1.03–1.16). At one year, poor union occurred in 63.0% with versus 18.1% without an acute wound/implant event (P < 0.001). Conclusions Reduced systemic physiological reserve was associated with an increased risk of systemic composite outcomes, particularly in patients with multiple unmet physiologic criteria, and resource use increased with unmet-criterion burden.Operative-field proximity, rather than systemic infection type alone, was the clearest correlate of wound and implant outcomes. Controlled high inflammation and remote pulmonary or intra-abdominal infection should not automatically mandate delay; These findings provide a clinical basis for individualized assessment of surgical timing and perioperative management based on systemic physiological reserve, inflammatory control, and the relationship between infection and the operative field.