Epidemiology of bacterial infection during management of open leg fractures

Early total reconstruction for a Gustilo type IIIB open forearm fracture associated with avulsion injury of multiple extensor tendons: A case report

Gustilo type IIIB open forearm fractures associated with avulsion injuries of multiple extensor tendons are difficult to reconstruct. Not only are bones, nerves, blood vessels, and soft tissues injured, but also tendons directly related to hand function. A 74-year-old man sustained an injury to his dominant right hand after being hit by a heavy pulley. The patient was diagnosed with a Gustilo type IIIB open forearm fracture, and multiple extensor tendons were avulsed from the musculotendinous junction. On the day of injury, the radius was fixed using a volar locking plate, and the ulnar head was fixed to the radius. On the fourth day, the avulsed extensor tendons were reconstructed using tendon transfer, and the exposed tendons and soft tissue defects were covered using a free anterolateral thigh flap on the seventh day. Three years after the injury, the patient had no difficulty in performing activities of daily living. Single-stage reconstruction allows for early rehabilitation. We believe that the more complex and severe the injury is, the more we should aim to repair the injured tissue as early as possible, that is, early total reconstruction.

What Is the Ideal Duration for Surgical Antibiotic Prophylaxis?

Background: Surgical antibiotic prophylaxis practice became common in the 1970s and has since become almost universal. The earliest articles used three doses over 12 hours with the first being administered before the start of the operation. Conclusions: The duration of prophylaxis has varied widely in practice over time, but an increasing body of evidence has supported shorter durations, most recently with recommendations in influential guidelines to avoid administration after the incision is closed.

Management of open fractures: A narrative review

Open fractures are an emergency where the principal aim of the treatment is to maximise the restoration of limb function while preventing the dreaded consequences of infection and non-union. The decision-making process for open injuries is influenced by a variety of criteria, such as patient age, injury features, systemic response, activity level, comorbidities, and functional requirements. A collaborative orthoplastic approach to treating these injuries is essential for minimizing complications and need to be considered as a single specialty in early and long-term management. It has been shown that early prophylactic systemic antibiotics, wound irrigation, aggressive debridement of contaminated and devitalized tissue, and appropriate fracture fixation decreases the complications in all grades of open fractures. The advantages of Gram-negative antibiotics, the use of local antibiotics, intraoperative wound cultures, the "fix and flap" approach, and Negative Pressure Wound Therapy are few of the treatment options that are still controversial. The aim of this review is to provide a comprehensive review and practice guidelines regarding the management of open fractures.

Single institution retrospective study evaluating the frequency of implant removal and associated risk factors following open fracture fixation in 80 cases (2010-2020)

BACKGROUND

Open fractures occur commonly in small animals and are characterised by contamination of the fracture site. While never quantified, it is believed that open fractures stabilised with internal implants are at a higher risk for requiring explantation. This retrospective study determines the frequency and risk factors for explantation following use of internal fixation. Medical records of client-owned dogs and cats with an open fracture, between 2010 and 2020 stabilised using internal implants, were included. Data retrieved included signalment, cause and characterisation of the fracture, comorbidities, preexisting infections, and all details related to anesthesia and surgery. Pre-, Peri- and post-operative antibiotic use were detailed. All cases were followed to clinical union. Postoperative complications, including requirement for implant removal were recorded and classified as major or minor. Associations between potential risk factors and need for explantation were assessed.

RESULTS

Of 80 cases, 72 (90%) were dogs and eight (10%) cats. Major complications were encountered in 23 (28.75%) cases and minor complications in 16 (20%) cases. Explantation was performed in 17 cases (21.25%). Out of 72 dogs, 13 required explantation (18%) whereas four of the eight cats needed implants removed (50%). Only diagnosis of postoperative infection was associated with an increased risk of explantation (RR 2.77; 95% CI 1.25; 6.15; p = 0.045).

CONCLUSION

Approximately 1 in 5 open fractures stabilised using internal fixation can be anticipated to require explantation, with cats potentially being at a higher risk than dogs. Cases diagnosed with postoperative infection are at a higher risk for requiring implant removal.

Type III Gustilo-Anderson open fracture does not justify routine prophylactic Gram-negative antibiotic coverage

Postoperative surgical site infection (SSI) is common in open long bone fractures, so early administration of prophylactic antibiotics is critical to prevent SSI. However, the necessity of initial broad-spectrum coverage for Gram-positive and -negative pathogens remains unclear. The purpose of this study was to clarify the effectiveness of prophylactic broad-spectrum antibiotics in a large, national-wide sample. We reviewed an open fracture database of prospectively collected data from 111 institutions managed by our society. A retrospective cohort study was designed to compare the rates of deep SSI between narrow- and broad-spectrum antibiotics, which were initiated within three hours after injury. A total of 1041 type III fractures were evaluated at three months after injury. Overall deep SSI rates did not differ significantly between the narrow-spectrum group (43/538, 8.0%) and broad-spectrum group (49/503, 9.8%) (p = 0.320). During propensity score-matched analysis, 425 pairs were analyzed. After matching, no significant difference in the SSI rate was seen between the narrow- and broad-spectrum groups, with 42 SSIs (9.9%) and 40 SSIs (9.4%), respectively (p = 0.816). The probability of deep SSI was not reduced by broad-spectrum antibiotics compared with narrow-spectrum antibiotics in type III open long bone fractures.

Effect of Local Antibiotic Prophylaxis on Postoperative Deep Infection in Fracture Surgery: A Systematic Review and Meta-Analysis

OBJECTIVES

Despite the use of systemic antibiotic prophylaxis, postoperative infection after fracture surgery remains an issue. The purpose of this systematic review and meta-analysis was to evaluate the effect of locally applied antibiotics on deep infection in fracture surgery in both the open and closed fractures.

DATA SOURCES

A comprehensive search of MEDLINE, Embase, and PubMed was performed from the date of inception to April 15, 2021, and included studies in all languages.

STUDY SELECTION

Cohort studies were eligible if they investigated the effect on the infection rate of local antibiotic prophylaxis on deep infection after fracture surgery.

DATA EXTRACTION

This study was conducted according to the Cochrane Handbook for Systematic Reviews and reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Risk of bias was assessed using version 2 of the Cochrane risk-of-bias tool for randomized trials and the Methodological Index for Nonrandomized Studies tool where applicable.

DATA SYNTHESIS

An inverse variance random-effects model was the primary analysis model because of the anticipated diversity in the evaluated populations. Univariate models were used when a single outcome was of interest.

CONCLUSIONS

The risk of deep infection was significantly reduced when local antibiotics were applied compared with the control group receiving systemic prophylaxis only. This beneficial effect was observed in open fractures but failed to reach statistical significance in closed fractures. This meta-analysis suggests that there may be a significant risk reduction in deep infection rate after fracture surgery when local antibiotics are added to standard systemic prophylaxis, particularly in open fractures. Further high-powered Level I studies are needed to support these findings.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The management of fracture related infections: What practices can be supported by high-level evidence?

Fracture related infections (FRIs) are a disabling condition causing significant concern within the orthopaedic community. FRIs have a huge societal and economic burden leading to prolonged recovery times and the potential for becoming chronic conditions or being life-threatening. Despite its importance in our field, the surgical community has just recently agreed on a definition which, added to the lack of surgical trials assessing preventive and treatment interventions have limited our understanding and precipitated wide variations in surgeons' practice. This article aims to review the current practices that can be supported with high-quality evidence. Currently, we have a limited body of high-quality evidence on FRI prevention and treatment. A handful of measures have proven effective, such as the use of prophylactic antibiotics, the use of saline and low pressure as the preferred irrigation solution and the safety of delaying initial surgical débridement more than 6 hours without impacting infection rates for open fracture wounds débridement. Future multicentre trials, properly powered, will shed light on current areas of controversy regarding the benefit of different preoperative and perioperative factors for the prevention and treatment of FRIs. Higher quality evidence is needed to guide surgeons to offer an evidence-based approach to prevent FRI occurrence and to treat patients suffering from them.

Current Concept Review: Risk Factors for Infection Following Open Fractures

Infection following open fracture is a significant source of morbidity and mortality. Therefore, a central tenet of treatment is to minimize the risk of infection. The initial risk of infection is determined by wound characteristics, such as size, soft tissue coverage, vascular injury, and contamination. While no consensus exists on optimal antibiotic regimen, early administration of prophylactic antibiotics, within an hour of injury, when possible, has been shown definitively to decrease the risk of infection. Infection risk is further reduced by early irrigation with normal saline and aggressive debridement of devitalized tissue. Patient factors that increase risk of infection following open fracture include diabetes mellitus, smoking, male gender, and lower extremity fracture.

Bacterial infection and antibiotic resistance pattern in open fracture cases in Indonesia

Background

The annual incidence of open fracture in Dr Soetomo Hospital, East Java were 400 cases with chronic infection complications exist in 14% (57 cases). A previous study in this hospital shows the resistance rate of Pseudomonas towards cefazolin and amikacin was 100% and 15%, respectively. The objective of this study was to identify bacterial infection type and antibiotic resistance pattern in infection caused by the open fracture.

Methods

This was an analytic cross-sectional study. Samples were collected from three debridement surgery sites in Mataram Hospital, Mataram University Hospital, and Islamic Mataram Hospital from September 2019 until October 2020. Specimens from wound infection were cultured, and an antibiotic sensitivity test was performed.

Results

Approximately 213 samples were analyzed in this study, comprising open fracture grade 3A (45%) and 3B (39%). The majority of fractures were lower extremity fractures (62%). Bacterial infection were found in 35% cases (80 isolates) in which 62,5% (50 isolates) were gram-positive bacteria and 37,5% (30 isolates) were gram-negative bacteria. Infection in open fracture was equivalent to grading. The predominant bacterial infection was caused by gram-positive bacteria, including Staphylococcus aureus and Staphylococcus negative coagulase. Gram-positive bacteria were sensitive towards Cepoferazone, Sulbactam and Ofloxacin, whereas gram-negative bacteria remains sensitive against Doxicyclin and Amicasin.

Conclusion

Infection in open fracture was equivalent with the grade, and gram-positive were predominantly sensitive with cefoperazone sulbactam.

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This study was to identify bacterial infection type and antibiotic resistance pattern in infection caused by the open fracture.

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This was an analytic cross-sectional study.

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The predominant bacterial infection was caused by gram-positive bacteria, including Staphylococcus aureus and Staphylococcus negative coagulase.

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Infection in open fracture was equivalent with the grade, and gram-positive were predominantly sensitive with cefoperazone sulbactam.

Timing of antibiotic administration, wound debridement, and the stages of reconstructive surgery for open long bone fractures of the upper and lower limbs

BACKGROUND

Open fractures of the major long bones are complex limb-threatening injuries that are predisposed to deep infection. Treatment includes antibiotics and surgery to debride the wound, stabilise the fracture and reconstruct any soft tissue defect to enable infection-free bone repair. There is a need to assess the effect of timing and duration of antibiotic administration and timing and staging of surgical interventions to optimise outcomes.

OBJECTIVES

To assess the effects (risks and benefits) of the timing of antibiotic administration, wound debridement and the stages of surgical interventions in managing people with open long bone fractures of the upper and lower limbs.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and clinical trial registers in February 2021. We also searched conference proceedings and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs that recruited adults with open fractures of the major long bones, comparing: 1) timings of prophylactic antibiotic treatment, 2) duration of prophylactic antibiotic treatment, 3) timing of wound debridement following injury or 4) timing of the stages of reconstructive surgery.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We aimed to collect data for the following outcomes: limb function, health-related quality of life (HRQoL), deep surgical site infection, delayed or non-union, adverse events (in the short- and long-term course of recovery), and resource-related outcomes.

MAIN RESULTS

We included three RCTs of 613 randomised participants with 617 open fractures. Studies were conducted in medical and trauma centres in the USA and Kenya. Where reported, there was a higher proportion of men and a mean age of participants between 30 and 34 years old. Fractures were in the upper and lower limbs in one study, and were tibia fractures in two studies; where reported, these were the result of high-energy trauma such as road traffic accidents. No studies compared the timing of antibiotic treatment or wound debridement. Duration of prophylactic antibiotic treatment (1 study, 77 participants available for analysis) One study compared antibiotic treatment for 24 hours with antibiotic treatment for five days. We are very uncertain about the effects of different durations of antibiotic treatment on superficial infections (risk ratio (RR) 1.19, 95% CI 0.49 to 2.87, favours 5 day treatment; 1 study, 77 participants); this was very low-certainty evidence derived from one small study with unclear and high risks of bias, and with an imprecise effect estimate. This study reported no other review outcomes. Reconstructive surgery: timing of the stages of surgery (2 studies, 458 participants available for analysis) Two studies compared the timing of wound closure, which was completed immediately or delayed. In one study, the mean time of delay was 5.9 days; in the other study, the time of delay was not reported. We are very uncertain about the effects of different timings of wound closure on deep infections (RR 0.82, 95% CI 0.37 to 1.80, favours immediate closure; 2 studies, 458 participants), delayed union or non-union (RR 1.13, 95% CI 0.83 to 1.55, favours delayed closure; 1 study, 387 participants), or superficial infections (RR 6.45, 95% CI 0.35 to 120.43, favours delayed closure; 1 study, 71 participants); this was very low-certainty evidence. We downgraded the certainty of the evidence for very serious risks of bias because both studies had unclear and high risks of bias. We also downgraded for serious imprecision because effect estimates were imprecise, including the possibility of benefits as well as harms, and very serious imprecision when the data were derived from single small study. These studies reported no other review outcomes.

AUTHORS' CONCLUSIONS

We could not determine the risks and benefits of different treatment protocols for open long bone fractures because the evidence was very uncertain for the two comparisons and we did not find any studies addressing the other possible comparisons. Well-designed randomised trials with adequate power are needed to guide surgical and antibiotic treatment of open fractures, particularly with regard to timing and duration of antibiotic administration and timing and staging of surgery.

Type of antibiotic but not the duration of prophylaxis correlates with rates of fracture-related infection

PURPOSE

The issue of optimal prophylactic antibiotic administration for closed and open fracture surgeries remains controversial. The purpose of this study was to assess the role of type and duration longer than 48 h of antibiotic prophylaxis on the rates of fracture-related infection (FRI).

METHODS

This is a single-center, prospective observational cohort study carried out with patients undergoing surgery for implants insertion to fracture stability. Risk estimates were calculated on the variables associated with factors for FRI and reported as a prevalence ratio (PR) with respect to the 95% confidence interval (CI).

RESULTS

Overall, 132 patients were analyzed. The global rate of FRI was 15.9% (21/132), with open and closed fractures accounting for 30.5% (11/36) and 10.4% (10/96), respectively. The FRI rates in patients undergoing orthopedic surgery for fracture stabilization who received prophylactic antibiotic for up to and longer than 48 h were 8.9% and 26.4%, respectively. This difference did not reach statistical significance (prevalence ratio [PR] = 2.6, 95% confidence interval [95% CI]: 0.9-7.3. p = 0.063).

CONCLUSIONS

Duration of antibiotic prophylaxis for surgical orthopedic fractures was not correlated with rates of FRI.

Duration of Perioperative Antibiotic Prophylaxis in Open Fractures: A Systematic Review and Critical Appraisal

Fracture-related infection (FRI) remains a serious complication in open fracture care. Adequate surgical treatment and perioperative antibiotic prophylaxis (PAP) are key factors influencing the outcome. However, data concerning the optimal duration of PAP is scarce. The aim of this systematic review was to provide an overview of current evidence on the association between PAP duration and FRI in open fractures. A comprehensive search on 13 January 2022, in Embase, Medline, Cochrane, Web of Science and Google Scholar revealed six articles. Most studies compared either 1 day versus 5 days of PAP or included a cut-off at 72 h. Although prolonged PAP was not beneficial in the majority of patients, the variety of antibiotic regimens, short follow-up periods and unclear description of outcome parameters were important limitations that were encountered in most studies. This systematic review demonstrates a lack of well-constructed studies investigating the effect of PAP duration on FRI. Based on the available studies, prolonged PAP does not appear to be beneficial in the prevention of FRI in open fractures. However, these results should be interpreted with caution since all included studies had limitations. Future randomized trials are necessary to answer this research question definitively.

Bacterial Epidemiology of Surgical Site Infections after Open Fractures of the Lower Limb: A Retrospective Cohort Study

Open lower limb fractures are common injuries, and the occurrence of infectious complications after open fractures is a usual problem. The rate of surgical site infections (SSIs) and the nature and resistance of the germs responsible for SSIs remain poorly described. Our aim was to describe the bacterial epidemiology of SSIs after surgical management of an open lower limb fracture. We conducted a retrospective monocentric cohort study from 1 January 2012 to 31 December 2020 based on the analysis of inpatient records in a non-university hospital of Ile de France region. All patients who underwent surgery for an open lower limb fracture were included. A total of 149 patients were included. In our population, 19 (12.7%) patients developed an SSI. Of these 19 patients, the sample was polymicrobial in 9 (47.4%) patients. In 9 (45%) cases, the samples identified a group 3 enterobacteria, Enterobacter cloacae being the main one in 7 (36.9%) cases. Staphylococci were identified in 11 patients, with Staphylococcus aureus in 9 (47.4%). All Staphylococcus aureus were susceptible to methicillin, and all enterobacteria were susceptible to C3G. Among all SSI, 10 (58.8%) contained at least one germ resistant to amoxicillin/clavulanic acid (AMC). The SSIs rate was 12.7%. The main pathogens identified were Enterobacter cloacae and Staphylococcus aureus. The presence of early SSI caused by group 3 Enterobacteriaceae renders current antibiotic prophylaxis protocols inadequate with AMC in half the cases.

Evolution in the Acute Management of Open Fracture Treatment? Part 1

INTRODUCTION

Despite decades of advancement in wound debridement, prophylactic antibiotic therapy, fracture stabilization, and soft tissue reconstruction, infection remains a serious complication after open fracture. Inconclusive historical data and new challenges with resistant organisms and antimicrobial stewardship having created a difficult environment within which to develop sound, evidence-based treatment protocols that can be applied universally. The first part of this 2-part series will synthesize the historical perspective along with the current concepts surrounding bacteriology and antibiotic use/stewardship. Part 2 will analyze and summarize the current literature regarding the management of open fracture and prevention of subsequent infection.Numerous authors from Hippocrates to Larrey noted that superior results were obtained with an early aggressive debridement of necrotic tissue after wounding.1-7 Historically, the usual outcome after open fracture was infection, sepsis, amputation, and death before the introduction of antibiotics.8-11 As recently as the first half of the 20th century, surgeons argued that if an appropriate debridement was performed, antibiotics were not necessary and advocated against their routine use over concern for resistant organisms.The current period of open fracture treatment (starting in the 1970s) heralded a more scientific era with critical evaluation of antibiotics, surgical debridement, and the development of standardized evidence-based protocols. This era began with 3 classic articles by Patzakis and Gustilo that, to this day, remain central to the discussion of infection prevention after open fractures.12-14.

LEVEL OF EVIDENCE

Therapeutic Level V. See Instructions for Authors for a Complete description of levels of evidence.

Diagnosing fracture related infections: Where are we now?

Accurate diagnosis of fracture related infection (FRI) is critical for preventing poor outcomes such as loss of function or amputation. Due to the multiple variables associated with FRI, however, accurate diagnosis is challenging and complicated by a lack of standardized diagnostic criteria. Limitations with the current gold standard for diagnosis, which is routine microbiology culture, further complicate the diagnostic and management process. Efforts to optimize the process rely on a foundation of data derived from prosthetic joint infections (PJI), but differences in PJI and FRI make it clear that unique approaches for these distinct infections are required. A more concerted effort focusing on FRI has dominated more recent investigations and publications leading to a consensus definition by the American Orthopedics (AO) Foundation and the European Bone and Joint Infection Society (EBJIS). This has the potential to better standardize the diagnostic process, which will not only improve patient care but also facilitate more robust and reproducible research related to the diagnosis and management of FRI. The purpose of this review is to explore the consensus definition, describe the foundation of data supporting current FRI diagnostic techniques, and identify pathways for optimization of clinical microbiology-based strategies and data.

The evidence base for 2017 BOAST-4 guidance on open fracture management: Are we due an update?

INTRODUCTION

Open fracture management in the United Kingdom and several other countries is guided by the British Orthopaedic Association's Standards for Trauma Number 4 (BOAST-4). This is updated periodically and is based on the best available evidence at the time. The aim of this study is to evaluate the evidence base forming this guidance and to highlight new developments since the last version in 2017.

METHODS

Searches have been performed using the PubMed, Embase and Medline databases for time periods a) before December 31, 2017 and from 01/01/2018-01/02/2021. Results have been summarized and discussed.

DISCUSSION

Several contentious issues remain within the 2017 guideline. Antibiotic guidance, the use of antibiotic impregnated PMMA beads and intramedullary devices, irrigation in the emergency department, time to theatre and the use of negative pressure dressings and guidance regarding the management of paediatric injuries have all demonstrated no clear consensus.

CONCLUSION

The advent of the BOAST-4 guideline has been of huge benefit, however the refinement and improvement of this work remains ongoing. There remains a need for further study into these contentious issues previously listed.

Comparison of bacteria isolated from open fractures following debridement and subsequent infection

BACKGROUND

One of the major objectives for the management of open fractures is to prevent bone and soft tissue infection. Here, we identified species and drug sensitivities of bacterial isolates recovered during open fracture debridement and after infection and compared the results between the two time points.

METHODS

A total of 61 hospitalized patients with open fractures who developed post-operative wound infection between October 2016 and December 2017 were included in this study. The cohort included 43 males and 18 females aged between 4 and 72 years. Patients were admitted to hospital 1-14 h after injury. Samples were collected after debridement and after infection and submitted for bacterial culture. Resulting isolates were identified using a VITEK 2 Bacterial Identification System and tested for drug sensitivity using the disc diffusion method. Results from the two time points were then compared.

RESULTS

The positive bacterial culture rate following debridement was relatively low (14/61, 22.9%). In addition, bacteria cultured after debridement were generally inconsistent with those cultured after wound infection, with a concordance rate of only 3.3% (2/61). Gram-negative bacteria accounted for 91.3% (63/69) of isolates recovered from wound infections following surgery, among which Acinetobacter baumannii was baumannii was the predominant pathogen, accounting for 49.3% (42/69) of all isolates. Overall, 60.8% (42/69) of postoperative infections were caused by multi-drug resistant bacteria, with A. baumannii isolates accounting for 80.9% (34/42) of these cases. Rates of cefoperazone/sulbactam resistance were relatively low among the isolates (15/34, 44.1%), and most isolates showed a sensitive or intermediate resistance phenotype.

CONCLUSIONS

Results of bacterial culture after debridement could not predict pathogenic bacteria causing postoperative infection. Therefore, we propose that open fracture infections are predominantly nosocomial and are mainly caused by multidrug-resistant Gram-negative bacteria. Further attention should be paid to the control of these pathogens in clinical settings.

Impact of duration of perioperative antibiotic prophylaxis on development of fracture-related infection in open fractures

INTRODUCTION

Infection is a common complication of open fractures potentially leading to nonunion, functional loss, and even amputation. Perioperative antibiotic prophylaxis (PAP) is standard practice for infection prevention in the management of open fractures. However, optimal duration of PAP remains controversial. The objectives were to assess whether PAP duration is independently associated with infection in open fractures and if administration of PAP beyond the commonly-recommended limit of 72 h has any effect on the infection rate.

MATERIALS AND METHODS

Over a 14-year period from 2003 to 2017, 530 skeletally-mature patients with operatively-treated, non-pathologic, long-bone open fractures were treated at one institution. Twenty-eight patients were excluded because of death or loss to follow-up and the remaining 502 patients (with 559 open fractures) who completed a 24-month follow-up were included in this retrospective study. The outcome was fracture-related infection (FRI), defined by the criteria of a recent consensus definition. A logistic generalized estimating equations regression model was conducted, including PAP duration and variables selected by a least absolute shrinkage and selection operator (LASSO) method, to assess the association between PAP duration and FRI. Propensity score analysis using a 72-h cut-off was performed to further cope with confounding.

RESULTS

PAP duration, adjusted for the LASSO selected predictors, was independently associated with FRI (OR: 1.11 [95%CI, 1.04-1.19] for every one-day increase in PAP duration, p = 0.003). PAP duration longer than 72 h did not significantly increase the odds for FRI compared to shorter durations (p = 0.06, analysis adjusted for propensity score).

CONCLUSIONS

This study found no evidence that administration of prophylactic antibiotics beyond 72 h in patients with long-bone open fractures is warranted. Analyses adjusted for known confounders even revealed a higher risk for FRI for longer PAP. However, this effect cannot necessarily be considered as causal and further research is needed.

Antibiotic prophylaxis in orthopedics-traumatology

When all rules of hygiene have been scrupulously applied, antibiotic prophylaxis (ABP) is the one remaining means of further reducing surgical site infection risk. Its efficacy in major orthopedic surgical procedures is proven. Guidelines for indications and ABP systemic administration have been long established and are able to address many questions. By extrapolation, the same protocols apply in closed fractures, whereas they are less certain in open fractures, where successive and still incomplete reassessments have been made. There are no specific ABP protocols in implant revision for mechanical or infectious causes or in high-grade open fractures, despite the high associated risk of surgical site infection. All means of prophylaxis need exploring in these contexts: various molecule combinations, and various local applications. Although ideas are by no means lacking, levels of evidence are low or undetermined. Awaiting more objective data, the focus has to be on the quality of implementation. It is easy enough to conceive of ABP in terms of the tissue pharmacokinetics of the antibiotic(s), but real-life implementation is a real organizational challenge. Optimizing practices in clearly defined indications is still the prime objective for surgical ABP.

Multidisciplinary management of the bone and joint infection complicating treatment of an open fracture of the lower limb

Bone and joint infections (BJI) of the lower limb can cause functional sequelae and in some cases have an impact on patient's life prognostic. One of the main objectives of multidisciplinary consultation team meetings (MTM) in the treatment of bone and joint infections is to provide an appropriate medical-surgical care, pooling skills of different organ specialists: infectious disease physicians, microbiologists, orthopedic surgeons and plastic surgeons. Treatment is based on aggressive debridement, bone stabilization, adequate antibiotic therapy, long-term coverage of the loss of skin substance and close clinical monitoring. The authors present their multidisciplinary diagnostic and therapeutic approaches to BJI complicating an open fracture at a referent center in the management of complex bone and joint infections.

[Prevention of infections following open fractures]

Open fractures involve a high risk of open fracture-associated infections (OFAIs), and the treatment can often be protracted and complicated. Thus, prevention of OFAIs in the acute and perioperative management of open fractures is of great importance. Through vigilance and thorough treatment planning, between the day of injury and the hospital discharge, the risk of OFAIs can be considerably reduced.

The Novel Role of Healing from Bacterial Infections of Lower Limb Open Fractures by X-Ray Exposure

Objective

To confirm the role of X-ray exposure in treating infected wound fractures at the lower limb and determine X-ray exposure times.

Methods

Fifty-one wound swabs were collected from patients with infected open fractures at the lower limb with grade II, IIIA, B, and C according to the Gustilo and Anderson classification system and then cultured. The bacterial isolates were identified by biochemical tests and the VITEK-2 System and tested against several antibiotics. The X-ray exposure was done for open fractures by radiography (at kV133 and 5 milliambers).

Results

The higher isolation rate was recorded for Staphylococcus aureus with 21 (41.2%) isolates, and most of them (20, 95.2%) were isolated from grade II fractures. The isolation rate of Gram-negative bacteria was 25.5% for Escherichia coli with 13 isolates, 19.6% for Pseudomonas aeruginosa with 10 isolates, and 13.7% for Klebsiella pneumoniae with 7 isolates, most of which were isolated from grade III fractures. The isolation rate of P. aeruginosa was 60% (6 isolates) from grade IIIA and 71.4% (5 isolates) from grade IIIB for K. pneumoniae, while for E. coli it was 69.2% (9 isolates) from grade IIIC. All the bacterial isolates recorded high levels of antibiotic resistance against most tested antibiotics. Wound cultures of grade II fractures appeared sterile after the first X-ray exposure, and these wounds were infected with S. aureus or P. aeruginosa. However, cultures of grade IIIA and IIIB fractures appeared sterile after the second X-ray exposure for all isolated bacteria, except for S. aureus (grade IIIA fractures) (after the third X-ray exposure). Grade IIIC fractures showed sterile culture after the third X-ray exposure for wounds infected with P. aeruginosa and E. coli.

Conclusions

The study concluded that X-ray exposure showed high effectiveness in treating infected open fractures.

Development of the Bacterial Spectrum and Antimicrobial Resistance in Surgical Site Infections of Trauma Patients

Background: While ubiquitously multi-resistant bacteria are on the rise, peri-operative antimicrobial prophylaxis in trauma and near-to-bone surgical procedures has only been changed slightly during the last 25 years. Recent clinical studies concerning the bacterial spectrum and efficacy of antimicrobial treatment in infected trauma surgical patients are rare. The aim of the study was analysis of the contemporary bacterial spectrum and its antimicrobial resistance including the assessment of the appropriateness of peri-operative antimicrobial prophylaxis with cefuroxime. Methods: Patients of a level-I academic trauma center who underwent open or arthroscopic surgery because of a recent trauma necessitating the use of bone-near metal implants were included in the study. All patients in whom a surgical site infection (SSI) had developed during six weeks post-operatively necessitating surgical debridement and had positive microbiologic culture results from an intra-operative surgical site swab were analyzed, retrospectively. In particular, age, gender, date and duration of surgical interventions, and patient's related risk factors were collected, and infecting agents and their minimum inhibitory concentration values for 34 selected antimicrobial agents were evaluated. An SSI occurring later than 6 weeks post-operatively and patients with chronic and septic wounds were excluded. Statistical analysis was performed with SPSS^® (IBM, Armonk, NY). Results: There were 438 pathogens cultured in specimens from 303 enrolled patients (female = 140, male = 163). The most frequent pathogens were Staphylococcus aureus (27.1%), S. epidermidis (20.6%), Enterococcus faecalis (13.6%), Escherichia coli (5.1%), and Pseudomonas aeruginosa (3.7%) accounting for 303 isolates. Of those, 89 (29.4%) were multi-resistant. Of the S. epidermidis isolates, 79.8% (n = 71) were resistant against Oxacillin and thus against most beta-lactam antibiotic agents. Altogether, only 44.1% of the infecting organisms were susceptible to cefuroxime, the antimicrobial agent most often being used for prophylactic purposes. Conclusion: Standardized antimicrobial prophylaxis with cephalosporins has to be reconsidered critically. Multi-resistant species such as S. epidermidis are an increasing challenge in trauma operations.

[Primary soft tissue management in open fracture]

OBJECTIVE

Debridement of soft tissue and bone in an open fracture situation to minimize infection risk and achieve primary skin closure, or to provide conditions for early soft tissue coverage.

INDICATIONS

Indications are Gustilo-Anderson grade I-III A-C open fractures.

CONTRAINDICATIONS

Contraindications are injuries requiring amputation, burns, and life-threatening injuries which make appropriate treatment temporarily impossible.

SURGICAL TECHNIQUE

Removal of gross contamination and macroscopic contaminants; debridement of the wound; complete resection of contaminated and dirty tissue; sparse step-by-step resection of contaminated or non-vital wound and bone margins until vital, bleeding tissue begins; low-pressure irrigation with isotonic irrigation fluid; diagnostic biopsies for microbiological testing; reduction of dead space by interpositioning of muscle or cement spacers loaded with local antibiotics; primary wound closure if tension-free closure possible; otherwise, if resources and knowhow permit and satisfactory clean debridement was achieved, local flap; if flap impossible, debridement not satisfactory, secondary tissue necrosis likely, potential remaining contamination or contamination with fecal matter, then vacuum-assisted closure therapy.

POSTOPERATIVE MANAGEMENT

Wound inspection on the second postoperative day, generous indication for second-look surgery after 36-48 h, wound inspection on the second postoperative day, wound inspection every other day, primary antibiotic prophylaxis with a first- or second-generation cephalosporin (e. g., cefuroxime), and adaptation of antibiotic therapy according to susceptibility screening.

RESULTS

Infection rates of 2-4.7% are reported for immediate primary wound closure in Gustilo-Anderson grade I, II, and III A open fractures. For Gustilo-Anderson grade III B, good wound healing, bony consolidation, and no need for secondary surgery was reported in 86.7% when primary wound closure was achieved.

Effects of Antibiotic Prophylaxis in Patients with Open Fracture of the Extremities: A Systematic Review of Randomized Controlled Trials

BACKGROUND

The purpose of the present study was to perform a systematic review and meta-analysis of the use of alternative antibiotic regimens-including (A) antibiotic prophylaxis versus no prophylaxis, (B) longer versus shorter duration of antibiotic prophylaxis, and (C) alternative drugs-for patients with open fracture of the extremities.

METHODS

Data sources included CINAHL, EMBASE, MEDLINE, the Cochrane Central Registry of Controlled Trials (CENTRAL), and the Cochrane database of systematic reviews from 1965 to December 2013. All randomized controlled trials comparing the effectiveness of antibiotic prophylaxis in patients with open fracture of the extremities were eligible.

RESULTS

We identified 329 potentially eligible articles, of which seventeen proved to be eligible. In four randomized controlled trials involving 472 patients, we found a significantly lower infection rate in patients receiving antibiotic prophylaxis compared with those not receiving antibiotic prophylaxis (risk ratio = 0.37 [95% confidence interval, 0.21 to 0.66]; absolute risk reduction = 9.6% [95% confidence interval, 5.2% to 12.1%]). In three studies involving 1104 patients, we found no difference in the infection rate when a longer duration of antibiotics (three to five days) was compared with a shorter duration (one day) (risk ratio = 0.97; 95% confidence interval, 0.69 to 1.37). Confidence in the estimates for both questions was low to moderate. Individual comparisons of alternative drugs yielded estimates warranting only low to very low confidence.

CONCLUSIONS

Results of randomized controlled trials performed to date provide evidence that antibiotic prophylaxis reduces subsequent infection and that courses as short as one day are as effective as courses of three to five days, although the evidence warrants only low to moderate confidence. Given current practice, a large, multicenter, low risk of bias, randomized controlled trial enrolling representative populations and addressing the duration of antibiotics may be the next optimum step in investigation.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

"Iatrogenic" Segmental Defect: How I Debride High-Energy Open Tibial Fractures

High-energy, open tibial shaft fractures may result in significant comminution, bone loss, and soft tissue injuries. Early, thorough debridement of all nonviable tissue is of critical importance in treating these fractures as an inadequate initial debridement increases the risk of infection and nonunion. Large iatrogenic bone and soft tissue defects can result from debridement and will require subsequent reconstruction by both orthopaedic and plastic surgeons. Although a variety of approaches exist to address these reconstructions, successful management of bone defects remains a considerable challenge. In this article, we detail our approach to debridement and reconstruction of segmental tibial defects and provide a review on the literature on this topic.

Complex Foot Injury: Early and Definite Management

Complex foot injuries occur infrequently, but are life-changing events. They often present with other injuries as the result of a high-energy trauma. After initial stabilization, early assessment should be regarding salvagability. All treatment strategies are intensive. The initial treatment includes prevention of progression ischemia/necrosis, prevention of infection, and considering salvage or amputation. Definitive treatment for salvage includes anatomic reconstruction with stable internal fixation and early soft tissue coverage followed by aggressive rehabilitation. Prognosis after complex injuries is hard to predict. The various stages of the treatment are reviewed and recommendations are made.

Primary Wound Closure After Open Fracture: A Prospective Cohort Study Examining Nonunion and Deep Infection

OBJECTIVES

Determine the proportion of subjects developing deep infection or nonunion after primary wound closure of open fractures (humerus, radius/ulna, femur, and tibia/fibula). Secondarily, a matched-series analysis compared outcomes with subjects who underwent delayed wound closure.

DESIGN

Prospective cohort between 2009 and 2013 of subjects undergoing primary closure.

SETTING

Trauma center.

PARTICIPANTS

Eighty-three (84 fractures) subjects were enrolled. Eighty-two (99%) subjects (83 fractures) provided follow-up data. Matching (age, sec, fracture location, and grade) was performed using study data of delayed wound closure undertaken at the same center between 2001 and 2009 (n = 68 matched subjects).

INTERVENTION

Primary wound closure occurred when the fracture grade was Gustilo grade 3A or lower and the wound deemed clean at initial surgery. Standardized evaluations occurred until the fracture(s) healed; phone interviews and chart reviews were also undertaken at 1 year.

MAIN OUTCOME MEASUREMENTS

Deep infection is defined as infection requiring unplanned surgical debridement and/or sustained antibiotic therapy after wound closure; nonunion is defined as unplanned surgical intervention after definitive wound closure or incomplete radiographic healing 1-year after fracture.

RESULTS

Three (4%) subjects had deep infections, whereas 10 (12%) subjects developed nonunion in the primary closure cohort. In the matched analyses [n = 68 pairs; (136 subjects)], the primary closure cohort had fewer deep infections [n = 3 (4%) vs. n = 6 (9%)] and nonunions [n = 9 (13%) vs. n = 19 (29%)] than the delayed closure cohort (P < 0.001).

CONCLUSIONS

Primary wound closure after an open fracture appears acceptable in appropriately selected patients and may reduce the risk of deep infection and nonunion compared with delayed closure; a definitive randomized trial is needed.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Impact of Body Mass Index and Bacterial Resistance in Osteomyelitis after Antibiotic Prophylaxis of Open Lower-Extremity Fractures

BACKGROUND

We investigated the clinical effectiveness of antimicrobial prophylaxis in lower-extremity open fractures following the Eastern Association for the Surgery of Trauma Guidelines.

METHODS

This observational, retrospective, single-center study included adults with lower-extremity open fractures of the ankle, tibia, fibula, or femur. The primary endpoint was the incidence of osteomyelitis within 12 months of the fracture. Secondary endpoint comparisons were the time of antibiotic initiation and drug selection.

RESULTS

A total of 90 patients were included. Patients suffered from Gustilo and Anderson grades I (14%), II (54.7%), and III (31.3%) fractures. Almost all patients received cefazolin (98%). Among grade III fractures, 59.3% (16/27) of patients received additional gram-negative coverage as recommended by the guidelines. The osteomyelitis rate was 8.9%. There was no difference in osteomyelitis rates among patients with grade III fractures who received or did not receive additional gram-negative coverage: 18.8% (3/16) and 0 (0/11) (p = 0.248), respectively. There was no correlation between median antibiotic start time or antibiotic stop time after closure and the development of osteomyelitis, respectively. Resistant organisms caused 50% (4/8) of the osteomyelitis cases. On univariate analysis, obesity had the most significant association with osteomyelitis (p = 0.026).

CONCLUSIONS

Bacterial resistance was common among cases of osteomyelitis in our cohort. Obesity was associated with a higher rate of osteomyelitis.

Institutional and Seasonal Variations in the Incidence and Causative Organisms for Posttraumatic Infection following Open Fractures

OBJECTIVES

The current literature focuses on wound severity, time to debridement, and antibiotic administration with respect to risk of infection after open fracture. The purpose of this analysis was to determine if either the incidence of posttraumatic infection or causative organism varies with treating institution or the season in which the open fracture occurred.

DESIGN

Retrospective review.

SETTING

Seven level 1 regional referral trauma centers located in each of the 7 climatic regions of the continental United States (Northwest, High Plains, Midwest/Ohio Valley, New England/Mid-Atlantic, Southeast, South, and Southwest).

PATIENTS/PARTICIPANTS

Five thousand one hundred twenty-seven skeletally mature patients with open extremity fractures treated between 2008 and 2012 at one of the 7 institutions.

INTERVENTION

Open reduction and internal fixation of fracture following institutional protocol for antibiotic prophylaxis, debridement, and soft-tissue management.

MAIN OUTCOME MEASUREMENTS

Seasonal variation on the incidence of infection and the causative organism after treatment for open fracture as recorded by each individual treating institution. Charts were analyzed to extract information regarding date of injury, Gustilo-Anderson type of open fracture, subsequent treatment for a posttraumatic wound infection, and the causative organisms. Patients were placed into one of the 4 groups based on the time of year that the injury occurred: spring (March-May), summer (June-August), fall (September-November), and winter (December-February). Univariate/multivariate analyses and Fisher test were used to assess whether any observed differences were of statistical significance.

RESULTS

The overall incidence of infection for all open fractures across the 7 different institutions was 7.6% and this did not vary significantly by season. There were, however, significant differences in overall infection rates between the different institutions: Southeast 4.3%, Northwest 13%, Northeast 7.7%, Southwest 9.3%, Midwest/Ohio Valley 5.5%, High Plains 14.6%, and South 7.4%. The following institutions demonstrated a significant seasonal variation in the incidence of infection: Northwest = fall 11% versus winter 18.5%, Southwest = winter 1.5% and fall 17.3%, Northeast = winter 5.2% and spring 9.7%, and Southeast = fall 2.8% and spring 6.0%. The High Plains, Midwest/Ohio Valley, and Southern institutions did not demonstrate a significant seasonal variation in infection rates. Finally, the most commonly encountered causative organism varied not only by region, but by season as well. Staphylococcus aureus (both methicillin sensitive and resistant) continues to be the most prevalent organism in the continental United States.

CONCLUSIONS

A substantial seasonal and institutional variation exists regarding the incidence of infection and causative organisms for posttraumatic wound infection after open fractures. Although this may represent a difference in treatment regimens between individual surgeons and institutions, a decades-old general nation-wide empiric antibiotic prophylaxis regimen for all open fractures may in fact be outdated and suboptimal. We recommend that surgeons consult with their infectious disease colleagues to better understand the seasonal variation of infection and causative organism for their individual hospital, and adjust their prophylactic and treatment regimens accordingly.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Emergency Soft Tissue Reconstruction Algorithm in Patients With Open Tibia Fractures

Introduction:

Tactic of emergency closing of soft tissue defect allows to significantly improve the treatment results concerning patients with severe open fractures. However, a number of certain factors make the implementation of this tactic rather difficult. Injured people’s unstable conditions are mong these crucial factors which include, polytrauma in lots of cases, absence of exact recommendations for recovery terms, choice of definite tissue flaps and a type of circulation.

The Aim of Study:

is to develop exact, usable and in practice algorithm of emergency reconstruction of leg soft tissues in patients with severe open tibia fractures, based on the usage of the most foolproof and simple methods.

Data (Patients) and Methods:

85 patients with open tibia fractures complicated by soft tissue defects were included in our study. Patients were divided into two groups. The control group consisted of 56 patients. Soft tissue reconstruction in this group was provided without an exact algorithm, after continuous attempts on local healing. After analyzing the treatment process and the treatment results we have developed the algorithm of emergency soft tissue reconstruction. It was used in 29 patients (the study group). This algorithm allows choosing optimal timing for tissue reconstruction and appropriate method to be applied, depending on the patient’s condition, the mechanism of soft tissue defect formation, and its square and localization.

Results:

We observed a statistical decrease in deep wound infection frequency, partial tibia necrosis frequency, chronic osteomyelitis frequency, duration of hospitalization in patients with severe open tibia fractures because of using our algorithm.

The effect of early versus delayed surgical debridement on the outcome of open long bone fractures at Bugando Medical Centre, Mwanza, Tanzania

BACKGROUND

Urgent surgical debridement of open long bone fractures is of paramount importance for prevention of subsequent infection. Due to limited information on the timing of this surgical procedure in Mwanza, Tanzania; the present study was conducted to evaluate the effect of early versus delayed surgical debridement on the outcome of open long bone fractures.

METHODS

A prospective cohort study involving 143 patients with open long bone fractures admitted at Bugando Medical Centre (BMC) between December 2014 and April 2015 was conducted. Patients were stratified into two main groups basing on whether they presented at BMC and operated early (within 6 h) or late (more than 6 h). Socio-demographic and clinical information were collected using structured questionnaire. Analysis was done using STATA software version 11.

RESULTS

The male to female ratio was 1.6: 1, with most of the patients being in their third decade of life (30.8 %). Road traffic accident (RTA) was the most common cause of fractures (67.8 %). Majority of patients, 91 (63.6 %) had Gustillo-Anderson grade II and the timing of debridement was significantly associated with this grading (p-value = 0.05). Nine (6.3 %) patients developed surgical site infection (SSI) and the median length of hospital stay (LOS) (interquartile range) was 7 (5-10) days, ranging from 3 to 35 days. SSI was found more in the late group compared to the early group [7.5 % (6/80) versus 4.8 % (3/63) respectively, p-value = 0.503)] and LOS was also longer in the late group compared to the early group [7 (6-11.5) days and 6 (5-10) days respectively, p-value = 0.06]. Pseudomonas aeruginosa was the predominant bacteria causing SSI.

CONCLUSIONS

Open long bone fracture injuries due to RTA are common at BMC. The risk of developing SSI in this setting is low and comparable to many other countries. Despite the fact that there was no statistical significant difference between early versus delayed debrided groups on SSI and LOS stays; the need for prompt surgical intervention in both groups should be an enduring focus to maintain these favorable outcomes.

Seasonal variations in posttraumatic wound infections after open extremity fractures

BACKGROUND

The vast majority of the orthopedic trauma literature has dealt with risk of infection as a function of time to debridement and severity of open fracture. The goal of this analysis was to determine if either the incidence or causative organism of posttraumatic infection varies with the season in which the open fracture occurred. No such study has been previously published.

METHODS

This is a retrospective chart review of all skeletally mature patients sustaining an open fracture of either the upper or the lower extremity long bones from 2007 to 2012. Charts were reviewed to extract information regarding date of injury, Gustilo-Anderson grade of open fracture, Injury Severity Score (ISS), time to surgical debridement, any posttraumatic wound infection (deep or superficial), and the causative organisms. Patients were placed into one of four groups based on the time of year: spring (March to May), summer (June to August), fall (September to November), and winter (December to February). Patients were excluded if they were skeletally immature, smokers, or also diagnosed with a condition that would increase risk of infection. Statistical analysis was performed to assess whether any observed differences were of significance.

RESULTS

All four groups were similar with respect to Gustilo grade, ISS, and time to surgical debridement. A total of 1,128 open fractures were treated between 2007 and 2012. There were 58 total infections for an overall incidence of 4.3%. The incidence of infection based on season was 6.0% for spring, 4.9% for summer, 2.8% for fall, and 3.6% for winter (p < 0.05). The incidence of infection was 5.5% for spring and summer combined and 3.9% for winter and fall combined (p < 0.05). Gram-positive organisms were more prevalent in the spring and summer seasons (p < 0.05). Although gram-negative organisms were cultured more commonly in the fall and winter seasons (52%) compared with the spring and summer seasons (36%), they were evenly distributed with gram-positive organisms during the winter and fall.

CONCLUSION

A seasonal variation exists regarding the incidence of infection and causative organisms for posttraumatic wound infection following open extremity fractures. The incidence of infection is significantly higher in the spring and summer months with a preponderance of gram-positive organisms. Patients with infection after injuries sustained in the fall and winter months are more likely to have a Gustilo Grade 3 injury and gram-negative bacteria as the causative organism.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Predebridement wound culture in open fractures does not predict postoperative wound infection: A pilot study

BACKGROUND

There is confusion in the current literature regarding the value of obtaining predebridement wound cultures in the management of open fractures with several studies reporting contrasting results. We undertook a pilot study to determine the initial bacterial flora of open fractures in our environment and determine the correlation between subsequent wound infection if any, and the initial bacterial flora.

MATERIALS AND METHODS

Initial/predebridement wound swabs were obtained for 32 patients with open fractures. Patients underwent a debridement of the open wound and preliminary stabilization of fracture in the operating room within 24 h. Postdebridement wound cultures were obtained at 48 h and repeated subsequently, if indicated, during the follow-up period. The antibiotic therapy was modified based on the culture reports.

RESULTS

Initial wound swab culture showed bacterial contamination in 18 patients (56%); 14 patients (44%) developed an infection in the immediate postoperative period or during follow-up. Age, gender, co-morbid medical condition, delay in presentation, and grade of open fracture were not found to be predictors of postoperative infection. No patient had an infection with the same organism, which was present in the initial culture.

CONCLUSION

The findings of this study suggest that the initial flora are not the infecting organisms in the open fracture wounds, and predebridement wound cultures have no value in predicting postdebridement wound infection.

Local Injection of Aminoglycosides for Prophylaxis Against Infection in Open Fractures

BACKGROUND

The purpose of this study was to determine the efficacy of local wound cavity injections of aqueous aminoglycosides (gentamicin and tobramycin), in conjunction with systemic antibiotics, to lower the prevalence of infection in patients with open fractures.

METHODS

Three hundred and fifty-one open fractures were identified by Current Procedural Terminology codes 11011 and 11012. Data on patient demographic characteristics, injury characteristics, infection, and fracture union were obtained from the electronic medical records. Patients in the control group (183 fractures) received systemic antibiotics only. Patients in the intervention group (168 fractures) received, in addition to systemic antibiotics, a locally administered aminoglycoside (2 mg/mL) at the time of the index surgical procedure. At the discretion of the attending surgeon, some wounds also received postoperative irrigations of aqueous aminoglycoside (n = 34). For wounds that could not be closed and wounds that received postoperative irrigations, negative pressure dressings were used.

RESULTS

The deep and superficial infection rate in the control group was 19.7% (thirty-six of 183 fractures), but it was significantly lower (p = 0.010) in the intervention group at 9.5% (sixteen of 168 fractures). When comparing only the deep infections, the infection rate in the control group was 14.2% (twenty-six of 183 fractures) compared with 6.0% (ten of 168 fractures) in the intervention group (p = 0.011). After multivariate analysis to adjust for possible confounding factors, the administration of local antibiotics was found to be an independent predictor of lower infection rates in both deep and superficial infections (odds ratio, 2.6 [95% confidence interval, 1.2 to 5.6]; p = 0.015) and deep infections only (odds ratio, 3.0 [95% confidence interval, 1.1 to 8.5]; p = 0.034). The use of local antibiotics did not have an impact on nonunion rate (p = 0.881), with a type-I error rate of α = 0.05 and 0.8 power.

CONCLUSIONS

This study suggests that local aqueous aminoglycoside administration as an adjunct to systemic antibiotics may be effective in lowering infection rates in open fractures; further research with higher-level research designs are needed.

Acute Management of Open Fractures: An Evidence-Based Review

Open fractures are complex injuries associated with high morbidity and mortality. Despite advances made in fracture care and infection prevention, open fractures remain a therapeutic challenge with varying levels of evidence to support some of the most commonly used practices. Additionally, a significant number of studies on this topic have focused on open tibial fractures. A systematic approach to evaluation and management should begin as soon as immediate life-threatening conditions have been stabilized. The Gustilo classification is arguably the most widely used method for characterizing open fractures. A first-generation cephalosporin should be administered as soon as possible. The optimal duration of antibiotics has not been well defined, but they should be continued for 24 hours. There is inconclusive evidence to support either extending the duration or broadening the antibiotic prophylaxis for type Gustilo type III wounds. Urgent surgical irrigation and debridement remains the mainstay of infection eradication, although questions persist regarding the optimal irrigation solution, volume, and delivery pressure. Wound sampling has a poor predictive value in determining subsequent infections. Early wound closure is recommended to minimize the risk of infection and cannot be substituted by negative-pressure wound therapy. Antibiotic-impregnated devices can be important adjuncts to systemic antibiotics in highly contaminated or comminuted injuries. Multiple fixation techniques are available, each having advantages and disadvantages. It is extremely important to maintain a high index of suspicion for compartment syndrome, especially in the setting of high-energy trauma.

Negative pressure wound therapy in grade IIIB tibial fractures: fewer infections and fewer flap procedures?

BACKGROUND

Grade IIIB open tibia fractures are devastating injuries. Some clinicians advocate wound closure or stable muscle flap coverage within 72 hours to limit complications such as infection. Negative pressure wound therapy was approved by the FDA in 1997 and has become an adjunct for many surgeons in treating these fractures. Opinions vary regarding the extent to which negative pressure wound therapy contributes to limb salvage. Evidence-based practice guidelines are limited for use of negative pressure wound therapy in Grade IIIB tibia fractures. This systematic literature review of negative pressure wound therapy in Grade IIIB tibia fractures may substantiate current use and guide future studies.

QUESTIONS/PURPOSES

We sought to answer the following: (1) Does the use of negative pressure would therapy compared with gauze dressings lead to fewer infections? (2) Does it allow flap procedures to be performed safely beyond 72 hours without increased infection rates? (3) Is it associated with fewer local or free flap procedures?

METHODS

We conducted a systematic review of six large databases (through September 1, 2013) for studies reporting use of negative pressure wound therapy in Grade IIIB open tibia fractures, including information regarding infection rates and soft tissue reconstruction. The systematic review identified one randomized controlled trial and 12 retrospective studies: four studies compared infection rates between negative pressure wound therapy and gauze dressings, 10 addressed infection rates with extended use, and six reported on flap coverage rates in relation to negative pressure wound therapy use beyond 72 hours. None of the 13 studies was eliminated owing to lack of study quality.

RESULTS

Negative pressure wound therapy showed a decrease in infection rates over rates for gauze dressings in two of four studies (5.4% [two of 35] versus 28% [seven of 25], and 8.4% [14 of 166] versus 20.6% [13 of 63]), an equivalent infection rate in one study (15% [eight of 53] versus 14% [five of 16]), and an increased infection rate in the fourth study (29.5% [23 of 78] versus 8% [two of 25]). In terms of the second question regarding infection rates with negative pressure wound therapy beyond 72 hours, eight of 10 studies concluded there was no increase in infection rates, whereas two of 10 reported an increase in infection rates associated with negative pressure wound therapy use beyond 72 hours. Infection rates varied from 0% to 57% in these 10 studies. Five studies reported low infection rates of 0% to 7% and five reported rates of 27% to 57%. The third question (addressed by six studies) regarded the potential decreased use of a soft tissue flap in patients treated with extended negative pressure wound therapy. Flap rates were reduced by 13% to 60% respectively compared with those of historical controls. Grade IIIB tibia fractures by definition required soft tissue procedures. The patients in these six studies had Grade IIIB tibia fractures after the first débridement. However, after extended negative pressure wound therapy, fewer patients required flaps than grading at the first débridement would have predicted.

CONCLUSIONS

There is an increasing body of data supporting negative pressure wound therapy as an adjunctive modality at all stages of treatment for Grade IIIB tibia fractures. There is an association between decreased infection rates with negative pressure wound therapy compared with gauze dressings. There is evidence to support negative pressure wound therapy beyond 72 hours without increased infection rates and to support a reduction in flap rates with negative pressure wound therapy. However, negative pressure wound therapy use for Grade IIIB tibia fractures requires extensive additional study.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Open fractures of the foot and ankle: an evidence-based review

Open fractures have been associated with high rates of morbidity and mortality. Morbidity and mortality rates have improved with the advancements in infectious disease, plastic and reconstructive surgery, as well as damage control orthopaedics. Despite these advancements, few reports have focused on management of open foot and ankle fractures. This review outlines evidence-based principles for open fracture management and how these principles are applied to the foot and ankle.

LEVELS OF EVIDENCE

Level V, Expert Opinion.

Controversies in the management of open fractures

Open fractures are a common problem encountered by orthopaedic surgeons and comprise a broad spectrum of trauma. Management is guided by principle-based steps aimed at reducing the risk of gas gangrene or suppurative infections, whilst maintaining viability in a favourable soft tissue environment to reduce the risk of delayed or non-union of bone. Aspects of these principles, however, create discussion around several areas of controversy. The specific antimicrobial regimen and its duration are questions that have been evaluated for decades. Like the ever-evolving nature of the bacterial pathogens, the answer to this is dynamic and changing. The “six-hour rule” is a hotly debated topic with fervent perseverance of this dogma despite a gross lack of support from the literature. The most appropriate soft tissue management approach for open fractures – immediate definitive soft tissue closure versus leaving wounds open for delayed closure or definitive management – is also an area of debate. Exploration of these controversies and consideration for the historical context of the supporting literature furthers our understanding of the critical elements.

Controversies in Initial Management of Open Fractures

BACKGROUND

Treatment of open fractures continues to be a challenge for orthopedic and trauma surgeons, and early treatment recommendations, which persist in the literature for decades, often do not have supporting data.

METHODS

This is a critical review of the literature surrounding controversies in the initial management of open fractures. It also focuses on the utility of negative pressure dressings in the care of associated complex wounds. Studies were selected based on their relevance to the treatment of open fractures.

RESULTS

A total of 40 studies were included. The following topics were critically discussed: timing of initial debridement, antibiotic coverage, utility of obtaining cultures, and timing of wound closure.

CONCLUSION

The majority of open fractures require urgent, not emergent, irrigation and debridement. Antibiotics are essential in preventing infection in open fractures. Timely wound closure after all necrotic tissue has been debrided decreases complications in open fractures. Finally, negative pressure wound therapy has dramatically changed the care of associated complex wounds.

Delayed wound closure increases deep-infection rate associated with lower-grade open fractures: a propensity-matched cohort study

BACKGROUND

Primary closure of skin wounds after debridement of open fractures is controversial. The purpose of the present study was to determine whether primary skin closure for grade-IIIA or lower-grade open extremity fractures is associated with a lower deep-infection rate.

METHODS

We identified 349 Gustilo-Anderson grade-I, II, or IIIA fractures treated at our level-I academic trauma center from 2003 to 2007. Eighty-seven injuries were treated with delayed primary closure, and 262 were treated with immediate closure after surgical debridement. After application of a propensity score-matching algorithm to balance prognostic factors, 146 open fractures (seventy-three matched pairs) were analyzed.

RESULTS

After application of a propensity score-matching algorithm with adjustment for age, sex, time to debridement, American Society of Anesthesiologists (ASA) class, fracture grade, evidence of gross contamination, and a tibial fracture rather than a fracture at another anatomic site, the two treatment groups were compared with respect to the prevalence of infection. Deep infection developed at the sites of three of the seventy-three fractures treated with immediate closure (infection rate, 4.1%; 95% confidence interval [CI], 0.86 to 11.5) compared with thirteen in the matched group of seventy-three fractures treated with delayed primary closure (infection rate, 17.8%; 95% CI, 9.8 to 28.5) (McNemar test, p = 0.0001).

CONCLUSIONS

Immediate closure of carefully selected wounds by experienced surgeons treating grade-I, II, and IIIA open fractures is safe and is associated with a lower infection rate compared with delayed primary closure.

What is the rate of methicillin-resistant Staphylococcus aureus and Gram-negative infections in open fractures?

BACKGROUND

There have been increasing reports of methicillin-resistant Staphylococcus aureus (MRSA) infections in the community, but it is unclear whether infectious organisms in open fracture infections have changed and if our current regimen of antibiotic prophylaxis is therefore obsolete.

QUESTIONS/PURPOSES

We determined the recent incidence of MRSA and Gram-negative organism infections after open fractures.

METHODS

We performed a retrospective cohort study on 189 patients with 202 open fractures treated from 2009 to 2010. During the followup, patients were evaluated for signs of infection using the Centers for Disease Control and Prevention criteria. We determined the organisms using routine microbiology culture. The minimum followup was 3 months (median, 47 months; range, 3-108 months).

RESULTS

Of the 202 open fractures, 20 (10%) developed infections. The most common organism was Staphylococcus, whereas five (25%) of those infected were positive for MRSA, and 11 (55%) of those with infection were cultured for at least one Gram-negative organism. Six (30%) open fractures had infections that grew out multiple organisms. The incidence of MRSA infections in our open fracture population was 2.5%.

CONCLUSIONS

There is a high incidence of MRSA and Gram-negative infections after open fractures, which may indicate that current antibiotic regimens need to be changed.

LEVEL OF EVIDENCE

Level IV, retrospective case-series. See the Guidelines for Authors for a complete description of levels of evidence.

Prophylactic antibiotics in open fractures: a pilot randomized clinical safety study

OBJECTIVE

To develop preliminary data on Staphylococcus aureus colonization and surgical site infections (SSIs) in patients with open fractures who received standard antibiotic prophylaxis compared with a regimen including targeted methicillin-resistant Staphylococcus aureus (MRSA) coverage.

DESIGN

Randomized prospective clinical trial.

PATIENTS

Adult patients who presented to the emergency department with an open fracture between April 2009 and July 2011.

INTERVENTIONS

One hundred thirty patients were randomized to receive prophylaxis with either cefazolin alone (control arm) or vancomycin and cefazolin (experimental arm) from presentation to the emergency department until 24 hours after the surgical intervention. Screening for S. aureus carriage was performed with nares swabs and predebridement and postdebridement open fracture wound swabs. Patients underwent prospective assessment for the development of SSI for no less than 30 days and up to 12 months.

RESULTS

Nasal colonization of methicillin-sensitive S. aureus and MRSA among the sample was 20% and 3%, respectively. No significant difference in the rates of SSI was observed between the study arms (15% vs 19%, respectively, P = 0.62). Staphylococcus aureus caused 55% of the deep incisional/organ space SSI, with 18% attributed to MRSA. A significantly higher rate of MRSA SSIs was observed among MRSA carriers compared with noncarriers (33% vs 1%, respectively, P = 0.003).

CONCLUSIONS

Staphylococcus aureus nasal colonization in trauma patients with open fractures is similar to that of the general community. In this pilot study, the addition of vancomycin to standard antibiotic prophylaxis was found safe, but its efficacy should be evaluated in a larger multiinstitutional trial.