Current Concept Review: Risk Factors for Infection Following Open Fractures

Return to Sport or Military Duty After Lower Extremity Open Fracture: Systematic Review of Athletes and Active Military

Background

Open fractures are complex injuries with high complication rates and infection risks, often resulting in prolonged recovery and limited return to physical activities. Despite this, data on return to sport (RTS) or return to military duty (RTD) are limited. This study evaluates RTS or RTD in individuals with lower extremity open fractures, hypothesizing extended recovery times and limited return rates, particularly for amateur athletes and military personnel compared with professional athletes.

Methods

A systematic review of studies from 1990 to 2024 was conducted using Embase, Ovid MEDLINE, Clinicaltrials.gov, Cochrane databases, SPORTDiscus, and Scopus. Studies investigating lower extremity open fractures with RTS or RTD outcomes were included. Data extracted included patient demographics, Gustilo-Anderson classifications, recovery timelines, and return rates.

Results

Eleven studies were included, with 10 involving adults and 1 including pediatric patients. The analysis covered 722 open fractures. Two studies reported an average return to sport time of 44.0 weeks (17 individuals) in amateur athletes, whereas 3 studies reported an average return to sport time of 61.8 weeks (26 individuals) in professional athletes. Five studies reported 27.3% of amateur athletes had returned to sports at final follow-up (mean = 19.5 months), and 1 study reported that 18.3% of military members returned to full duty at final follow-up. In the 3 studies reporting on professional athletes, 80.8% returned to playing at the professional level.

Conclusions

Lower extremity open fractures often result in prolonged recovery times and significantly limit RTS or RTD. Although professional athletes demonstrated higher return rates, the outcomes for the general amateur athlete and military populations were substantially poorer. Further research with discrete fracture and treatment details is needed to better understand recovery trajectories for open fractures, disparity in outcomes between professional and amateur athletes, and the influence of resources and motivation on returning to activity.

Severe soft tissue injuries in multiple trauma patients-a challenge we can meet? A matched-pair analysis from the TraumaRegister DGU®

Introduction

Despite tremendous clinical efforts over the past few decades, the treatment of severely injured patients remains still challenging. Concomitant soft tissue injuries represent a particular challenge, as they can lead to complications at any time of trauma care, hold a high risk of infection and often require multiple surgical interventions and interdisciplinary collaboration.

Methods

This retrospective, multicentric study used the TraumaRegister DGU® to examine the effect of open fractures and severe soft tissue injuries on outcome of multiple trauma patients. Primary admitted multiple trauma patients at the age of 16 to 70 years, treated from 2010 to 2021, were included. A Matched pair analysis was performed for better comparability of trauma patients with and without open fractures and/or severe soft tissue injuries.

Results

After applying the matching criteria, 5,795 pairs were created and analyzed. The group with sustained soft tissue injuries/open fractures was found to have a higher ISS ([mean ± SD] 22.1 ± 10.4 vs. 20.6 ± 10.2, p < 0.001). Endotracheal tube insertion (27.7% vs. 30.4%, p = 0.003), catecholamine administration (6.0% vs. 8.4%, p < 0.001) and cardio-pulmonary resuscitation (1.6% vs. 2.1%, p = 0.027) were more frequent in the group with sustained soft tissue injury. Both groups were equally frequent admitted to the intensive care unit (ICU) and length of stay (LOS) at the ICU (median (quartiles) 3 (1-9) versus 3 (1-9)) did not differ significantly. However, total LOS at the hospital was longer for the group with sustained soft tissue injury (median (quartiles) 18 (11-29) versus 17 (10-27)). Sepsis occurred more often in patients with soft tissue injury (4.3% vs. 5.2%, p = 0.034). There was no significant difference in prevalence of multi organ failure, 24 h-mortality (2.1% vs. 2.5%, p = 0.151) and overall-mortality (3.6% vs. 3.9%, p = 0.329) between both groups.

Conclusion

Due to database analysis and revision of guidelines, the treatment of severely injured patients has steadily improved in recent years. Patients with severe soft tissue injuries/open fractures required more medical interventions and length of stay at the hospital was longer. In this study, we were able to show that although concomitant severe soft tissue injuries required more ICU interventions and led to a longer length of stay, 24-h and all-cause mortality were not significantly increased.

Association of Surgical Debridement Timings With Infection and Non-union Rates in Open Fractures of Lower Limb Long Bones

BACKGROUND

Open fractures are one of the orthopaedic conditions that require urgent surgical intervention. Managing these fractures remains challenging for orthopaedic surgeons due to the need to transfer polytrauma patients to hospitals with advanced capabilities. Further delays may occur as resuscitative life-saving measures take precedence. Open fractures are frequently complicated by infections, non-unions, and, in rare cases, amputation. Currently, management of compound fractures of long bones of the lower limb requires early surgical debridement followed by limb salvage procedures or amputation (if required), depending on the type, location, and extent of the injury. Early and aggressive debridement of open fractures has always been the rule.

OBJECTIVES

To study the role of timing of surgical debridement of open fractures of the lower limb and its effect on infection and non-union rates and to analyze the impact of increased severity of open fractures on union and infections.

MATERIALS AND METHODS

The study was conducted prospectively in the orthopaedic department of a tertiary care hospital of Patiala with a population of 223 patients who presented to the orthopaedic emergency department with open lower limb fractures. Patients were divided into two groups based on the timing of surgical debridement: Groups A and B. Group A consisted of the patients who were operated on within 24 hours (n=110) and Group B consisted of patients whose surgical debridement was conducted 24 hours after injury (n=113). Infection rates and non-union rates were obtained based on the above data. All the results were summarized in Microsoft Excel (Microsoft Corp., Redmond, WA) and were analyzed with SPSS software 22 (IBM Corp., Armonk, NY) using the ANOVA test, chi-square test, and paired t-test. The Gustilo-Anderson classification (GAC) was used to classify the grades of open fractures. A p-value <0.05 indicated a statistically significant difference.

RESULTS

The mean age in Group A was 39.53±13.25 years (range 18-80) and the mean age in Group B was 42.45±12.64 years (range 18-76) (p=0.0936; not significant) In Group A, infection was present in 30 patients (27.27%) and in Group B, infection was present in 32 patients (28.32%) (p=0.9802; non-significant). Non-union was present in eight patients (7.27%) and 13 patients (11.50%) in Groups A and B, respectively (p=0.2793; non-significant). In Group A, the infection rate was 0% for GAC Grade 1, 10% for Grade 2, 35.89% for Grade 3A, and 66.67% for Grade 3B (p-value < 0.00001; statistically significant). In Group B, the infection rate was 2.86% for GAC Grade 1, 13.79% for Grade 2, 57.69% for Grade 3A, and 52.17% for Grade 3B (p-value < 0.00001; statistically significant). In Group A, the non-union rate was 0% for GAC Grade 1, 0% for Grade 2, 7.69% for Grade 3A, and 23.81% for Grade 3B (p-value < 0.00001; statistically significant). In Group B, the non-union rate was 0% for GAC Grade 1, 6.89% for Grade 2, 19.23% for Grade 3A, and 26.09% for Grade 3B (p-value < 0.00001; statistically significant).

CONCLUSION

The timing of surgical debridement in open fractures of the lower limb does not have a significant role in their management and these fractures can safely be debrided up to several hours after injury. GAC grading of open fractures has a significant association with infection and non-union rate, which increased significantly with increasing grades of open fractures.

Risk of infection and conversion time from external to definitive fixation in open tibial fracture

BACKGROUND

An open fracture of the tibia is one of the most common and dangerous type of open fractures. In the management of these injuries, the primary focus is on reducing the infection rate, as this is crucial for achieving the best clinical outcomes. This study aims to explore how provisional external fixation duration influences the rates of infection and union in open tibial shaft fractures.

METHODS

A retrospective study with a total of 55 patients who received temporary external fixation. Groups A (less than 12 days), B (12-24), C (25-36), and D (more than 36) were the four groups into which they were split according to the conversion time.

RESULTS

12.8%, 18.2%, 50%, and 100% of the infections were found in Groups A, B, C, and D, respectively. Significant (P < 0.05) differences were found throughout the four groups. The conversion time from external to definitive fixation was found to have a relationship with the occurrence of an infection (P = 0.004). A higher prevalence of infection was observed over time. However, no association was observed between infection and antibiotic duration or initial debridement time (P = 0.689 and P = 0.963, respectively).

CONCLUSIONS

Results of this study demonstrate that the likelihood of infection increases when the change from external fixation to definitive internal fixation is delayed. Therefore, it is important to convert to definitive internal fixation immediately when the local and general conditions are favorable for doing so.

Dependability of Procalcitonin as an Early Predictor of Infection in Open Fractures: An Observational Study

Introduction Open extremity fractures are complex injuries involving soft tissue disruption and bone discontinuity, often associated with significant morbidity and mortality due to complications such as infection. Infection remains a primary concern, exacerbating patient outcomes and increasing healthcare costs. Procalcitonin (PCT) is a biomarker with potential utility for early detection of infection in these cases. Materials and methods This prospective observational study was conducted at Justice K S Hegde Charitable Hospital between October 2022 and April 2024. Forty patients with open fractures who met inclusion criteria were enrolled. PCT levels were measured preoperatively and on postoperative days 1 and 5. Patients were monitored for clinical signs of infection for one month. Data analysis included descriptive and inferential statistics. Results The mean age of the patients was 42.26 ± 16.62 years, with a male predominance of 35 (87.5%) of the total sample size. Preoperative PCT levels were significantly higher in patients who developed infections (mean: 1.02 ng/mL) compared to non-infected patients (mean: 0.13 ng/mL). Postoperative PCT levels continued to rise in all patients but were significantly elevated in the infected group (p < 0.01). Conclusion PCT is a reliable biomarker for the early detection of postoperative infections in open fractures. Elevated preoperative PCT levels (>0.5 ng/mL) predict infection, while non-infected patients showed lower trauma-related increases. Further studies with larger samples are recommended to validate these findings.

Orthoplastics Management of Open Lower Limb Fractures at a Major Trauma Centre: Audit of Adherence to BOAST4 Guidelines

Introduction

The British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guide the optimal management of open lower limb fractures. Adherence of the newly established Orthoplastic service at the Major Trauma Centre covering the Southeast of England was audited in relation to these standards.

Materials and methods

Audit standards were produced. Data were collected using hospital records and the Trauma Audit and Research Network database. All open lower limb fractures managed between August 2020-August 2022 were included. Data collected included patient and injury demographics, and information related to initial and definitive management.

Results

Overall, 133 patients were identified, 70 men and 63 women, with an average age of 58 years. Women had a higher average age (69 years) and ASA grade (71% ASA 3 or higher). Low-energy injuries occurred in 69% of women compared to 78% of high-energy injuries in men (p<0.001). Among them, 108 (81%) were debrided within 24 h. The average time to first debridement was 18.78 h, and 95 (75%) were definitively closed within 72 h, 76 with primary closure, 7 with split-thickness skin graft, 7 with local flap and 36 with free flap. Overall, the post-operative infection rate was 13% with 94% of these fractures definitively closed within 72 h.

Conclusion

Most open lower limb fractures occurred in older women with higher ASA grade, from low-energy mechanisms. Most injuries were definitively managed as per the BOAST guidelines, but further efforts are required to improve the adherence to initial debridement targets, including training, appropriate resource allocation and implementation of procedures and proformas to guide injury management and improve documentation.

Evaluating the duration of antimicrobial therapy for the treatment of orthopedic hardware infections

The optimal duration of antimicrobial therapy for orthopedic hardware infections is unclear. We identified 216 patients with orthopedic hardware infections, of whom 42 (19%) later had relapsed infection. Chronic suppressive antimicrobial therapy beyond 12 weeks was not significantly associated with lower odds of relapse.IMPORTANCEThere is debate about how long to continue antibiotics after initial treatment of bone and joint infections when hardware remains in place. This study found no benefit from continuing antibiotics longer than 12 weeks when trying to prevent recurrent infection.

Exploring versatile applications of a vacuum-assisted bone harvester in orthopedic surgery

BACKGROUND

Orthopedic procedures often require removing bone or pathological tissue, with traditional methods involving instruments like curettes and rongeurs. However, these methods can be time-consuming and lead to increased blood loss. To mitigate these side effects, vacuum-assisted tools have been developed to aid in tissue removal. These devices enable surgeons to suction tissue without discarding it, potentially improving outcomes in conditions such as osteomyelitis or tumor removal while enabling collection of the material for downstream applications. Despite limited research, vacuum-assisted devices show promise beyond bone marrow harvesting. This study assesses infection and clearance rates, estimated blood loss, and total procedure time associated with the use of vacuum-assisted tissue removal, with a goal to understand if these devices can be used for tissue removal across a variety of pathologic conditions.

METHODS

A retrospective cohort study was conducted on patients undergoing orthopedic procedures with the Avitus® Bone Harvester repurposed from its original design from December 1, 2021, to July 1, 2023. Procedures were categorized into oncology, and debridement for infection cases. Infection cases were further categorized into those secondary to trauma and those involving primary infections (osteomyelitis and periprosthetic joint infection). Clinical variables, including demographics, intraoperative details, complications, and follow-up, were reviewed. Statistical analysis included descriptive statistics computed with R Studio.

RESULTS

The study included 44 patients, with debridement for infection cases being the most common (primary infection: 45.5%; infection secondary to trauma: 18.1%), followed by oncology cases (36.4%). In all oncology cases, a definitive diagnosis was established using the device, and no post-operative infections were reported. The infection clearance rate was 85.0% for primary infection cases and 50.0% for cases of infection following trauma. Across the entire cohort, the average blood loss was 314.52 mL (sd: 486.74), and the average total procedure time was 160.93 min (sd: 91.07). The overall reoperation rate was 47.7%, with an unplanned reoperation rate of 11.4%.

CONCLUSION

The vacuum-assisted bone harvester was effectively utilized in a wide range of debridement and curettage procedures across diverse orthopedic surgeries. In oncology cases, the device enabled effective tissue removal with comparable recurrence rates, demonstrating its potential to minimize contamination while preserving tissue for accurate diagnoses. Additionally, a high rate of osteomyelitis eradication was observed in debridement for primary infection cases (85%). Despite the relatively high reoperation rate of 47.7%, it is crucial to interpret this figure within the context of the varied reasons for reoperation. Many of these reoperations were planned as part of a staged approach to treatment or were unrelated to the device's performance. It is crucial to acknowledge that isolating the device's contribution to these results can be difficult. The utilization of the device should be guided by considerations of cost-effectiveness and patient-specific risk factors.

Fracture-Related Infection of a Distal Femur Open Fracture Treated With a Supracutaneous Locking Plate

Fracture-related infection (FRI) is a challenging complication in open fractures. It can cause major disability to patients and a burden to the public health sector. A multidisciplinary approach is required to eradicate infection and improve the quality of life for patients. We present a case of an FRI in an open fracture of the distal femur treated using a supracutaneous locking plate, which is an uncommon technique. This technique yields excellent outcomes in controlling local infection and providing satisfactory stability, especially for a peri-articular distal femur fracture with FRI. Therefore, supracutaneous plating using a locking plate can be considered an alternative option to conventional external fixations in managing FRIs.

Negative Pressure Wound Therapy versus Conventional Dressing in Lower Limb Fractures: Systematic Review and Meta-analysis

Gustilo 3 lower limb fractures represent a significant challenge because of high complication risk. Two management strategies are commonly used for wound coverage until final closure: negative pressure wound therapy (NPWT) and conventional wound dressing (CWD), also described as standard wound coverage without subatmospheric pressure. Understanding their relative effectiveness is essential to improve patient outcomes. The aim of this systematic review and meta-analysis was to compare the efficacy of NPWT and CWD in Gustilo 3 lower limb fracture management, with a focus on overall rates, superficial infection, and deep infection rates. A systematic review of medical research databases was conducted in accordance with PRISMA guidelines. Studies comparing NPWT with CWD for Gustilo 3 fractures were included. Data extraction and quality assessment were performed. Treatment with CWD was associated with significantly higher rates of overall infection [pooled risk ratio (RR): 0.33; 95% confidence interval (CI): 0.14-0.51] and pooled risk difference (RD: 0.27; 95% CI: 0.15-0.38), superficial infection (pooled RR: 0.35; 95% CI: 0.04-0.66), and deep infection (pooled RR: 0.20; 95% CI: 0.02-0.38) compared with NPWT treatment. Overall infection rate remained significantly higher in the CWD group after analyzing only open tibia fractures (pooled RR: 0.35; 95% CI: 0.21-0.48). Nonunion rate was significant higher in the CWD group (pooled RR: 0.30; 95% CI: 0.00-0.59). Flap failure rate was similar in both groups (pooled RR: 0.09; 95% CI: -0.05 to 0.23). NPWT appears to be a reasonable option for wound management in Gustilo 3 lower limb fractures in terms of infection rates.

Comparative evaluation of small molecules reported to be inhibitors of Staphylococcus aureus biofilm formation

IMPORTANCE

Because biofilm formation is such a problematic feature of Staphylococcus aureus infections, much effort has been put into identifying biofilm inhibitors. However, the results observed with these compounds are often reported in isolation, and the methods used to assess biofilm formation vary between labs, making it impossible to assess relative efficacy and prioritize among these putative inhibitors for further study. The studies we report address this issue by directly comparing putative biofilm inhibitors using a consistent in vitro assay. This assay was previously shown to maximize biofilm formation, and the results observed with this assay have been proven to be relevant in vivo. Of the 19 compounds compared using this method, many had no impact on biofilm formation under these conditions. Indeed, only one proved effective at limiting biofilm formation without also inhibiting growth.

Early Reconstruction Delivered Better Outcomes for Severe Open Fracture of Lower Extremities: A 15-Year Retrospective Study

Background: The principle of early flap reconstruction for high-grade traumatic lower-extremity injuries established in 1986 by Godina has been widely accepted. However, the lack of an orthoplastic center in China makes early reconstruction not accessible for all patients with a Gustilo IIIB fracture. This study aimed to analyze the impact of timing on outcomes in lower-extremity traumatic free-flap reconstruction. Methods: A retrospective review identified 394 free-flap reconstructions performed from January 2005 to January 2020 for Gustilo IIIB tibial fractures. Patients were stratified based on the number of debridements: two times or less (early) and more than two times (delayed). The interval between injury and reconstruction, surgery time, hemorrhage volume, length of hospitalization (LoS), wound and bone healing time, flap outcomes, and function restoration were examined based on times of debridement. Results: The mean interval between injury and flap reconstruction in the early-repair group with 6.15 ± 1.82 postoperative days (PODs) was significantly shorter than that of the delayed-repair group with 16.46 ± 4.09 PODs (p < 0.001). The flap harvest time, reconstructive time, and intraoperative blood loss were also significantly less in the early-repair group compared to the delayed-repair group. Interestingly, we observed an 8.20% enlargement of wound size due to multiple debridements in the delayed-repair group. Most importantly, the early-repair group had better outcomes with a decreased risk of total or partial flap necrosis, lower incidence of flap complications, and fewer overall late complications than the delayed-repair group. In addition, the LoS, as well as wound and bone healing time, were notably shorter in the early-repair group. Furthermore, 4.85% of cases in the delayed-repair group experienced additional operations on bone, while no additional operations were performed in the early-repair group. All cases in both groups obtained satisfying functional results, while the early-repair group showed better functional recovery. Conclusions: Early repair with free flaps performed within two instances of debridement had superior outcomes when compared with delayed reconstruction after multiple debridements, consistent with Godina’s findings. We recommended early referral to a higher-level hospital with orthoplastic capabilities after an aggressive and thorough initial debridement carried out by senior surgeons.