Original Article

Skin Complications of Orthopedic Procedures and Devices


Background: Knowledge of skin complications and contributing factors in orthopedic patients is important for design and development of preventive approaches. Therefore, this study was designed to assess skin complications in orthopedic patients.

Methods: In this case-series study, 126 orthopedic patients referred to Rasoul-e-Akram and Bahman hospitals from 2012 to 2016 with skin complications were analyzed. The adverse effects were assessed with respect to type and contributing factors. Fisher's exact test, Chi-square, and independent sample t-test were performed to assess the associations between skin complications and other variables.

Results: Skin complications in orthopedic patients included infections in 33 (26.1%) cases and hypersensitivity reactions in 88 (40%) cases. In total, 66 (55%) cases of fracture and 35 (29.2%) cases of cellulitis were detected, while the remaining cases involved complications such as disc herniation, nerve involvement, and osteoarthritis-related arthroplasty. Severe reactions presenting as toxic epidermal necrolysis were observed in 3 patients, 2 of whom died eventually. Age and gender were not related to the type of skin complications (P>0.05).

Conclusion: Complications due to orthopedic treatments were not common. However, since the disease may become fatal on certain occasions, patients should receive more attention from physicians and nurses.


1. http://www.genou.com/anglais/complications.htm
2. Chee YL, Crawford JC, Watson HG, Greaves M (2008). Guideline on the as-sessment of bleeding risk prior to surgery or invasive procedures; British Committee for Standards in Haematology. Br J Haema-tol, 140(5):496-504.
3. Thompson JS, Baxter BT, Allison JG et al (2003). Temporal patterns of postopera-tive complications. Arch Surg, 138(6):596-602.
4. Pile JC (2006). Evaluating postoperative fe-ver: a focused approach. Cleve Clin J Med, 73 Suppl 1:S62-6.
5. Johnson KA (2012). Complications in or-thopedic surgery. Vet Comp Orthop Trau-matol, 25(5):III.
6. Kujath P, Kujath C (2010). Complicated skin, skin structure and soft tissue infec-tions - are we threatened by multi-resistant pathogens? Eur J Med Res, 15(12):544-53.
7. Thomas P, Schuh A, Ring J et al (2008). [Or-thopedic surgical implants and allergies. Joint statement by the Implant Allergy Working Group (AK 20) of the DGOOC (German Association of Or-thopedics and Orthopedic Surgery), DKG (German Contact Dermatitis Re-search Group) and DGAKI (German Society for Allergology and Clinical Im-munology)]. Hautarzt, 59(3):220-9.
8. Campoccia D, Montanaro L, Arciola CR (2006). The significance of infection relat-ed to orthopedic devices and issues of antibiotic resistance. Biomaterials, 27(11):2331-9.
9. Parvizi J, Antoci V Jr, Hickok NJ, Shapiro IM (2007). Selfprotective smart orthope-dic implants. Expert Rev Med Devices, 4(1):55-64.
10. Difazio RL, Harris M, Feldman L, Mahan ST (2017). Reducing the Incidence of Cast-related Skin Complications in Chil-dren Treated with Cast Immobilization. J Pediatr Orthop, 37(8):526-531.
11. Chirca I, Marculescu C (2017). Prevention of Infection in Orthopedic Prosthetic Sur-gery. Infect Dis Clin North Am, 31(2):253-63.
12. Al-Mulhim FA, Baragbah MA, Sadat-Ali M et al (2014). Prevalence of Surgical Site In-fection in Orthopedic Surgery: A 5-year Analysis. Int Surg, 99(3):264-8.
13. Weigelt JA, Lipsky BA, Tabak YP et al (2010). Surgical site infections: causative pathogens and associated outcomes. Am J Infect Control, 38(2):112–120.
14. Moriarty TF, Schlegel U, Perren S, Richards RG (2010). Infection in fracture fixation: can we influence infection rates through implant design? J Mater Sci Mater Med, 21(3):1031-5.
15. Schmidt AH, Swiontkowski MF (2000). Pathophysiology of infections after inter-nal fixation of fractures. J Am Acad Orthop Surg, 8(5):285-91.
16. Wilson SE (2008). Microbial sealing: a new approach to reducing contamination. J Hosp Infect, 70 Suppl 2:11-4.
17. Dohmen PM (2008). Antibiotic resistance in common pathogens reinforces the need to minimise surgical site infections. J Hosp Infect, 70 Suppl 2:15-20.
18. Reichman DE, Greenberg JA (2009). Reduc-ing surgical site infections: a review. Rev Obstet Gynecol, 2(4):212-21.
19. Song Z, Borgwardt L, Høiby N et al (2013). Prosthesis infections after orthopedic joint replacement: the possible role of bacterial biofilms. Orthop Rev (Pavia), 5(2):65-71.
20. Geipel U, Herrmann M (2004). The infected implant. Part 1: bacteriology. Der Ortho-pade, 33(12):1411-26; 1427-8.
21. Zimmerli W (2006). Infection and musculo-skeletal conditions: Prosthetic-joint-associated infections. Best Pract Res Clin Rheumatol, 20(6):1045-63.
22. Anguita-Alonso P, Hanssen AD, Patel R (2005). Prosthetic joint infection. Expert Rev Anti Infect Ther, 3(5):797-804.
23. Boutoille D, Leautez S, Maulaz D et al (2000). [Skin and osteoarticular bacterial infections of the diabetic foot. Treat-ment]. Presse Med, 29(7):396-400.
24. Esposito S, Leone S (2008). Prosthetic joint infections: microbiology, diagnosis, management and prevention. Int J Antimi-crob Agents, 32(4):287-93.
25. Legout L, Senneville E (2013). Periprosthetic joint infections: clinical and bench re-search. Scientific World Journal, 2013:549091.
26. Barnes M, Liew S (2012). The incidence of infection after posterior cervical spine surgery: a 10 year review. Global Spine J, 2(1):3-6.
27. Giordano P, Weber K, Gesin G, Kubert J (2007). Skin and skin structure infections: treatment with newer generation fluoro-quinolones. Ther Clin Risk Manag, 3(2):309-17.
28. Misiakos EP, Bagias G, Patapis P et al (2014). Current concepts in the manage-ment of necrotizing fasciitis. Front Surg, 1:36.
29. Madu KA, Enweani UN, Katchy AU et al (2011). Implant associated surgical site in-fection in orthopaedics: a regional hospi-tal experience. Niger J Med, 20(4):435-40.
30. Sansone V, Pagani D, Melato M (2013). The effects on bone cells of metal ions re-leased from orthopaedic implants. A re-view. Clin Cases Miner Bone Metab, 10(1):34-40.
31. Shang X, Wang L, Kou D, et al (2014). Met-al hypersensitivity in patient with posteri-or lumbar spine fusion: a case report and its literature review. BMC Musculoskelet Dis-ord, 15:314.
32. Krecisz B, Kieć-Swierczyńska M, Bakowicz-Mitura K (2006). Allergy to metals as a cause of orthopedic implant failure. Int J Occup Med Environ Health, 19(3):178-80.
33. Dudda M, Godau P, Al-Benna S et al (2013). Vitiligo and allergic complications from orthopaedic joint implants: the role of benzoyl peroxide. Recent Pat Inflamm Aller-gy Drug Discov, 7(2):176-82.
34. Thomas P (2014). Clinical and diagnostic challenges of metal implant allergy using the example of orthopaedic surgical im-plants: Part 15 of the Series Molecular Al-lergology. Allergo J Int, 23(6):179-185.
35. Bircher A, Friederich NF, Seelig W, Scherer K (2012). Allergic complications from or-thopaedic joint implants: the role of de-layed hypersensitivity to benzoyl peroxide in bone cement. Contact Dermatitis, 66(1):20-6.
36. Thomas P, Schuh A, Eben R, Thomsen M (2008). Allergy to bone cement compo-nents. Orthopade, 37(2):117-20.
37. Eben R, Dietrich KA, Nerz C, et al (2010). Contact allergy to metals and bone ce-ment components in patients with intol-erance of arthroplasty. Dtsch Med Woch-enschr, 135(28-29):1418-22.
38. Schuh A, Lill C, Hönle W, Effenberger H (2008). Prevalence of allergic reactions to implant materials in total hip and knee ar-throplasty. Zentralbl Chir, 133(3):292-6.
39. Thomas P, Schuh A, Ring J, Thomsen M (2008). [Orthopedic surgical implants and allergies: joint statement by the implant al-lergy working group (AK 20) of the DGOOC (German association of or-thopedics and orthopedic surgery), DKG (German contact dermatitis research group) and dgaki (German society for al-lergology and clinical immunology)]. Or-thopade, 37(1):75-88.
40. DiFazio R, Vessey J, Zurakowski D et al (2011). Incidence of skin complications and associated charges in children treated with hip spica casts for femur fractures. J Pediatr Orthop, 31(1):17-22.
41. Guo S (2011). Is Velband still a safe and cost effective skin protection beneath the tourniquet in hand surgery? Hand Surg, 16(1):5-8.
42. Ingoe H, Eastwood S, Elson DW, Young CF (2011). Removal of a below knee plaster cast worn for 28 months: a case report. J Med Case Rep, 5:74.
43. Vigier S, Casillas JM, Dulieu V et al (1999). Healing of open stump wounds after vascular below-knee amputation: plaster cast socket with silicone sleeve versus elastic compression. Arch Phys Med Rehabil, 80(10):1327-30.
44. Khan MS, ur Rehman S, Ali MA et al (2008). Infection in orthopedic implant surgery, its risk factors and outcome. J Ayub Med Coll Abbottabad, 20(1):23-5.
45. Swanson TV, Szabo RM, Anderson DD (1991). Open hand fractures: prognosis and classification. J Hand Surg Am, 16(1): 101-7.
46. Ruedi TP (2000). AO principles of fracture man-agement. First edition, Thieme: 729-49
47. Sohrabi M. FakhrtabatabaieSA (1998). Effec-tive time of antibiotic therapy on surgical wound infectin of back bone. Pejohande Quarterly, 3(12): 57-63 (In Persian).
48. Murray CK. Hau JR, Solomkin YS, et al (2008). Prevention and management of infection associated with combat - related extremity injuries. J Trauma, 64(3 Suppl):S239-51.
49. Mokurec m, Fristakova M (2008). Efficacy of antiseptic in the prevention of Post-operative infections of the proximal fe-mur, hip and pelvis regions in orthopedic pediatric patients, Analysis of the first re-sult. Acta Chir Orthop Traumatol Cech, 75(2):106-9.
50. Eyichukwu GO (2010). Non-Steroidal anti inflammatory drugs usage in orthopae-dics and trauma practice. A guide and re-view. Niger J Med, 19(4):374-81.
51. Roujeau JC (1987). Clinical aspects of skin reactions to NSAIDs. Scand J Rheumatol Suppl, 65:131-4.
52. Sirirat Tribuddharat, Thepakorn Sa-thitkarnmanee, Amnat Kitkhuandee et al (2016). A fatal adverse effect of cefazolin administration. Drug Healthc Patient Saf, 8: 9-12.
53. Sun-Kyung Park, Yun Suk Choi (2013). Hy-popigmentation and subcutaneous fat, muscle atrophy after local corticosteroid injection. Korean J Anesthesiol, 65(6 Suppl): S59-S61.
IssueVol 47 No 12 (2018) QRcode
SectionOriginal Article(s)
Skin complication Orthopedic procedures Orthopedic devices

Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
AZIZIAN Z, MANSOURI P, HESAMI Z, EBRAHIMPOUR A, ATTAR B, CHALANGARI R. Skin Complications of Orthopedic Procedures and Devices. Iran J Public Health. 2018;47(12):1937-1944.