The effect of the timing of antibiotics and surgical treatment on infection rates in open long-bone fractures: a 9-year prospective study from a district general hospital

TIME UNTIL THE START OF ANTIBIOTIC PROPHYLAXIS AND THE RISK OF OPEN FRACTURE INFECTION: A SYSTEMATIC REVIEW

Open fractures are highly incident injuries closely related to the modern life, in which accidents caused by motor vehicles or other machines impart high energy to bone tissue. Individual morbidity is represented by the functional impairment resultant of infection, nonunion, or vicious healing. In terms of public health, there are huge costs involved with the treatment of these fractures, particularly with their complications. One of the critical issues in managing open fractures is the use of antibiotics (ATB), including decisions about which specific agents to administer, duration of use, and ideal timing of the first prophylactic dose. Although recent guidelines have recommended starting antibiotic prophylaxis as soon as possible, such a recommendation appears to stem from insufficient evidence. In light of this, we conducted a systematic review, including studies that addressed the impact of the time to first antibiotic and the risk of infectious outcomes. Fourteen studies were selected, of which only four found that the early initiation of treatment with antibiotics is able to prevent infection. All studies had important risks of bias. The results indicate that this question remains open, and further prospective and methodologically sound studies are necessary in order to guide practices and health policies related to this matter. Level of Evidence II; Therapeutic Studies Investigating the Results Level of Treatment.

Soft tissue coverage for IIIB fractures: from timing to coverage options

Open tibia fractures are the most common open long bone injury. Most of these injuries involve a high-energy mechanism. Many standards for management have been created to provide guidance and a baseline for quality. There are several factors that must be considered when determining the timing of coverage for an open fracture with soft tissue compromise. Understanding the available options for soft tissue coverage, including local/rotational flaps and free tissue transfer, will allow for a tailored approach based on the personality of the injury. The aim of this review was to characterize the critical window of treatment based on the current literature and to provide a review of the available soft tissue coverage options.

Delays in Debridement of Open Femoral and Tibial Fractures Increase Risk of Infection

BACKGROUND

Infection remains a costly, devastating complication following the treatment of open fractures. The appropriate timing of debridement is controversial, and available evidence has been conflicting.

METHODS

This study is a retrospective analysis of the SIGN (Surgical Implant Generation Network) Surgical Database (SSDB), a prospective registry of fracture cases in predominantly low-resource settings. Skeletally mature patients (≥16 years of age) who returned for follow-up at any time point after intramedullary nailing of an open femoral or tibial fracture were included. Patients were excluded if they had delays in debridement exceeding 7 days after the injury. Utilizing a model adjusting for potential confounders, including patient demographic characteristics, injury characteristics, country income level, and hospital type and resources, local logistic regression analysis was performed to evaluate the probability of infection with increasing time to debridement in 6-hour increments.

RESULTS

In this study, 27.3% of patients met the eligibility criteria and returned for follow-up, with a total of 10,651 fractures from 61 countries included. Overall, the probability of infection increased by 0.17% for every 6-hour delay in debridement. On subgroup analysis, the probability of infection increased by 0.23% every 6 hours for Gustilo-Anderson type-III injuries compared with 0.13% for Gustilo-Anderson type-I or II injuries. The infection risk increased every 6 hours by 0.18% for tibial fractures compared with 0.13% for femoral fractures.

CONCLUSIONS

There was a linear and cumulative increased risk of infection with delays in debridement for open femoral and tibial fractures. Such injuries should be debrided promptly and expeditiously. The size and international nature of this cohort make these findings uniquely generalizable to nearly all environments where such injuries are treated.

LEVEL OF EVIDENCE

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

American Academy of Orthopaedic Surgeons Appropriate Use Criteria: Prevention of Surgical Site Infections After Major Extremity Trauma

High-energy extremity trauma rates can be difficult to precisely state given the complexity of contributing combined mechanisms; however, the rate of open fractures in the United States is 11.5 to 13 per 100,000 people. The management of high-energy extremity fractures presents many challenges for treating surgeons, including elevated risk of surgical site infections (SSIs). In recent studies, higher risk closed injuries are associated with deep SSI rates as high as 19% after surgical treatment and for severe open injuries, which rate surpasses 30%. Fracture-related infections are associated with notable costs and decreased long-term functional outcomes. Identified risk factors for the development of deep SSIs are primarily related to the severity of injury and its location. The quality of the vast literature identifying available interventions to decrease the risk of developing SSIs is highly variable, and it is unclear how consistently these interventions are applied.

Antibiotic administration within 1 hour for open lower extremity fractures is not associated with decreased risk of infection

BACKGROUND

Open fractures have a high risk of infection with limited data correlating timing of prophylactic antibiotic administration and rate of subsequent infection. The Trauma Quality Improvement Program has established a standard of antibiotic administration within 1 hour of arrival, but there is a lack of adequately powered studies validating this quality metric. We hypothesize that open femur and/or tibia fracture patients undergoing orthopedic surgery have a decreased risk of infectious complications (osteomyelitis, deep and superficial surgical site infection) if antibiotics are administered within 1 hour of presentation compared with administration after 1 hour.

METHODS

The 2019 Trauma Quality Improvement Program was queried for adults with isolated (Abbreviated Injury Scale <1 for the head/face/spine/chest/abdomen/upper extremity) open femur and/or tibia fractures undergoing orthopedic surgery. Transfer patients were excluded. Patients receiving early antibiotics (EA) within 1 hour were compared with patients receiving delayed antibiotics (DA) greater than 1 hour from arrival.

RESULTS

Of 3,367 patients identified, 2,400 (70.4%) received EA. Patients receiving EA had a higher rate of infections compared with DA (1.1% vs. 0.2%, p = 0.011). After adjusting for age, comorbidities, injury severity, nerve/vascular trauma to the lower extremity, washout of the femur/tibia performed in <6 hours, blood transfusion, and admission vitals, patients in the EA group had a similar associated risk of surgical site infection/osteomyelitis compared with the DA cohort ( p = 0.087). These results remained in subset analyses of patients with only femur, only tibia, and combined femur/tibia open fractures (all p > 0.05).

CONCLUSION

In this large national analysis, approximately 70% of isolated open femur or tibia fracture patients undergoing surgery received antibiotics within 1 hour. After adjusting for known risk factors of infection, there was no association between timing of antibiotic administration and infection. Reconsideration of the quality metric of antibiotic administration within 1 hour for open fractures appears warranted.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Delayed Presentation of Seymour Fractures: A Single Institution Experience and Management Recommendations

Background: Seymour fractures in children are prone to complications without prompt and appropriate treatment. This study investigated outcomes of Seymour fractures with delayed presentations; specifically, if deep infection predisposed to operative treatment, if antibiotic administration improved fracture healing, and if oral clindamycin had fewer treatment failures than oral cephalexin. Methods: A single-institution retrospective cohort study was performed of patients with delayed Seymour fracture presentations (defined as greater than 24 hours post-injury) between 2009 and 2017. Data collected included demographics, time to presentation, infection on presentation, operative treatment, antibiotic use and duration, fracture union, and complications. Statistical testing used logistic regression and Fisher's exact test, with results reported as P-values (P), odds ratios (ORs), and 95% confidence intervals (CIs). Results: There were 73 patients with delayed Seymour fracture presentations, with mean age of 11.1 years (standard deviation: 2.9), with 56 (77%) males, and median time to presentation of 7 days (interquartile range: 3-17). Deep infection on presentation was a risk factor for operative intervention (OR = 34.4, P = .0001, CI, 5.5-217.2). Antibiotic administration protected against the development of a nonunion or delayed union (OR = 0.11, P = .008, CI, 0.021-0.57). Time to antibiotics did not protect against nonunion or delayed union (OR = 0.77, P = .306, CI, 0.37-1.3). Clindamycin had fewer treatment failures than cephalexin (P = .039). Conclusions: Deep infection is a risk factor for operative treatment of Seymour fractures with delayed presentations. Clindamycin is a better antibiotic choice for Seymour fractures that present in delayed fashion.

Infection after Open Long Bone Fractures: Can we Improve on Prophylaxis?

INTRODUCTION

Current standards recommend antibiotic prophylaxis administered after open fracture injury. The purpose of this study was to assess culture results in patients with open fracture-associated infections, hypothesizing that cultures obtained do not vary by Gustilo-Anderson (GA) classification.

METHODS

We examined cultured bacterial species from patients with open long bone fractures that underwent irrigation and debridement at a Level 1 trauma center (2008-2016), evaluating our current and two hypothetical antibiotic protocols to assess whether they provided appropriate coverage. The antibiotic protocols included protocols 1 (cefazolin, with gentamicin added for type III fractures), 2 (vancomycin and cefepime) and 3 (ceftriaxone).

RESULTS

GA classification was not associated with bacterial gram stain (P = 0.161), nor was it predictive of mono- versus polymicrobial infection (P = 0.094). Of 42 culture-positive infections, 31 were type III and 11 were type I or II fractures. 27% of the infections for type I or II fractures were caused by organisms targeted by protocol 1 (OR 0.18, 95% CI 0.04-0.82; P = 0.027). There was no difference in coverage by fracture type among protocol 2 (P = 0.771) or protocol 3 (P = 0.891). For type III fractures, protocol 2 provided 94% appropriate coverage compared to 68% and 61% coverage by protocols 1 and 3, respectively.

CONCLUSION

For open fractures complicated by infection, isolated bacterial organisms do not correlate with GA open fracture classification, suggesting that hypothetical protocol 2 should be used for all fracture types. Protocol 2's broad coverage, across all GA fracture types, may prevent infection by organisms not covered by current antibiotic prophylaxis.

Delayed debridement of open tibia fractures beyond 24 and 48 h does not appear to increase infection and reoperation risk

PURPOSE

Surgical debridement is critical to the treatment of open tibia fractures, although the effects of delayed debridement have not been well-established. Other factors such as Gustilo-Anderson type, prompt initiation of antibiotics, and time to definitive closure may be more predictive of infection than time to surgery. We sought to determine the effect of a prolonged delay to surgical debridement with respect to infection and reoperation rates for open tibia fractures.

METHODS

All open diaphyseal tibia fractures with > 12-week follow-up were evaluated. Patient demographics, Gustilo-Anderson type, and rates of deep infection and all-cause reoperation were recorded. Patients were divided into 3 groups based on time to surgery: early (< 24 h), delayed (24-48 h), and late (> 48 h). Univariate and multivariate analyses were performed to evaluate the relationship between time to surgery, fracture type, infection, and reoperation.

RESULTS

In total, 96 open tibia fractures with average follow-up of 59.3 weeks and infection rate of 13.5% were included. Infection rates for the early, delayed, and late groups were 13.3%, 17.2%, and 9.1%, respectively (p = 0.70). Reoperation rates for the early, delayed, and late groups were 29.8%, 31.0%, and 22.7%, respectively (p = 0.80). The groups did not vary in proportion of Gustilo-Anderson fracture types; infection rates between Gustilo-Anderson types were similar (p = 0.57). Type IIIA-C fractures required more reoperations than other fracture types (p = 0.01).

CONCLUSION

Delayed surgical debridement of open tibia fractures did not result in greater rates of infection or reoperation. Gustilo-Anderson classification was more predictive of reoperation, with Type IIIA-C injuries having a significantly higher reoperation rate.

The Effect of Delayed Surgical Debridement in the Management of Open Tibial Fractures: A Systematic Review and Meta-Analysis

Introduction: Open tibial fractures are complex injuries with variable outcomes that significantly impact patients’ lives. Surgical debridement is paramount in preventing detrimental complications such as infection and non-union; however, the exact timing of debridement remains a topic of great controversy. The aim of this study is to evaluate the association between timing of surgical debridement and outcomes such as infection and non-union in open tibial fractures. Materials and Methods: We performed a systematic review and meta-analysis of the literature to capture studies evaluating the association between timing of initial surgical debridement and infection or non-union, or other reported outcomes. We searched the MEDLINE, PubMed Central, EMBASE, SCOPUS, Cochrane Central and Web of Science electronic databases. Our methodology was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane handbook for systematic reviews of interventions. Results: The systematic review included 20 studies with 10,032 open tibial fractures. The overall infection rate was 14.3% (314 out of 2193) and the overall non-union rate 14.2% (116 out of 817). We did not find any statistically significant association between delayed debridement and infection rate (OR = 0.87; 95% CI, 0.68 to 1.11; p = 0.23) or non-union rate (OR = 0.70; 95% CI, 0.42 to 1.15; p = 0.13). These findings did not change when we accounted for the effect of different time thresholds used for defining early and late debridement, nor with the Gustilo–Anderson classification or varying study characteristics. Conclusion: The findings of this meta-analysis support that delayed surgical debridement does not increase the infection or non-union rates in open tibial fracture injuries. Consequently, we propose that a reasonable delay in the initial debridement is acceptable to ensure that optimal management conditions are in place, such that the availability of surgical expertise, skilled staff and equipment are prioritised over getting to surgery rapidly. We recommend changing the standard guidance around timing for performing surgical debridement to ‘as soon as reasonably possible, once appropriate personnel and equipment are available; ideally within 24-h’.

Standards of open lower limb fracture care in the United Kingdom

Open fractures of the lower limb remain a potentially devastating group of injuries that are challenging to manage. The primary aims of treatment are to optimise limb function and avoid serious complications such as infection and non-union, which are costly for both the patient and healthcare system. The management of these fractures has evolved significantly, and this is evident following the creation of national open fracture guidelines and a formal trauma system. These have served to standardise care for these injuries in the United Kingdom. The aim of this review is to update our colleagues on the current standard of lower limb open fracture care in the United Kingdom, and the impact this has had on patient outcomes.

A Reevaluation of the Risk of Infection Based on Time to Debridement in Open Fractures: Results of the GOLIATH Meta-Analysis of Observational Studies and Limited Trial Data

BACKGROUND

Open fractures are one of the leading causes of disability worldwide. The threshold time to debridement that reduces the infection rate is unclear.

METHODS

We searched all available databases to identify observational studies and randomized trials related to open fracture care. We then conducted an extensive meta-analysis of the observational studies, using raw and adjusted estimates, to determine if there was an association between the timing of initial debridement and infection.

RESULTS

We identified 84 studies (18,239 patients) for the primary analysis. In unadjusted analyses comparing various "late" time thresholds for debridement versus "early" thresholds, there was an association between timing of debridement and surgical site infection (odds ratio [OR] = 1.29, 95% confidence interval [CI] = 1.11 to 1.49, p < 0.001, I2 = 30%, 84 studies, n = 18,239). For debridement performed between 12 and 24 hours versus earlier than 12 hours, the OR was higher in tibial fractures (OR = 1.37, 95% CI = 1.00 to 1.87, p = 0.05, I2 = 19%, 12 studies, n = 2,065), and even more so in Gustilo type-IIIB tibial fractures (OR = 1.46, 95% CI = 1.13 to 1.89, p = 0.004, I2 = 23%, 12 studies, n = 1,255). An analysis of Gustilo type-III fractures showed a progressive increase in the risk of infection with time. Critical time thresholds included 12 hours (OR = 1.51, 95% CI = 1.28 to 1.78, p < 0.001, I2 = 0%, 16 studies, n = 3,502) and 24 hours (OR = 2.17, 95% CI = 1.73 to 2.72, p < 0.001, I2 = 0%, 29 studies, n = 5,214).

CONCLUSIONS

High-grade open fractures demonstrated an increased risk of infection with progressive delay to debridement.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instruction for Authors for a complete description of the levels of evidence.

Early application of topical antibiotic powder in open-fracture wounds: A strategy to prevent biofilm formation and infections

Despite meticulous surgical care and systemic antibiotics, open fracture wounds have high rates of infection leading to increased morbidity. To reduce infection rates, orthopaedic surgeons may administer local antibiotics using various carriers that may be ineffective due to poor antibiotic release from carriers, subsequent surgery to remove nondegradable carriers, and mismatch between release kinetics and material degradation. Biofilms form rapidly as bacteria that are within the wound multiply quickly and transform from the antibiotic-susceptible planktonic phenotype to the antibiotic-tolerant biofilm phenotype. This tolerance to antibiotics can occur within hours. Currently, local antibiotics are placed in the wounds using a carrier such as polymethylmethacrylate beads; however, this occurs after surgical debridement that can be hours to even a day after initial injury allowing bacteria enough time to form a biofilm that makes the antibiotic containing polymethylmethacrylate beads less effective. In contrast, emerging practices in elective surgical procedures, such as spine fusion, place antibiotic powder (e.g. vancomycin) in the wound at the time of closure. This has been shown to be extremely effective, presumably because of the very small-time period between potential contamination and local antibiotic application. There is evidence that suggests that the ineffectiveness of local antibiotic use in open fractures is primarily due to the delay in application of local antibiotics from the time of injury and propose a concept of topical antibiotic powder application in the prehospital or emergency department setting.

An Updated Evidence About the Role of Timing to Debridement on Infection Rate of Open Tibial Fractures: A Meta-Analysis

Background and objectives Recent experimental and clinical evidence supporting early debridement for open fractures has been questioned. Therefore, this systematic review and meta-analysis aimed to summarize and evaluate the current evidence regarding the timing of surgical debridement of open tibial fractures. Methods A systematic review and meta-analysis were conducted on studies compared the infection rate following early versus late debridement of open tibial fractures. We performed an online, bibliographic, search through the period from January 2000 to June 2020 in five bibliographic databases: Cochrane Central Register of Controlled Trials (CENTRAL), Medline via PubMed, Web of Science, Scopus, and EBSCO host. Results Nine retrospective studies and six prospective studies were included in the present meta-analysis study. The pooled effect estimate showed no statistically significant difference between early and late debridement regarding the overall infection rate (RD 0.02, 95% CI [0 - 0.04], p = 0.94); there was no significant heterogeneity in the pooled estimate (I2 = 5%). The subgroup analysis showed that the non-significant difference was consistent regardless of the definition of early and late timing to debridement. Likewise, the pooled effect estimate showed no statistically significant difference between early and late debridement regarding the deep infection rate (RD 0.01, 95% CI [-0.01 - 0.03], p = 0.92); there was no significant heterogeneity in the pooled estimate (I2 = 0%). The pooled effect estimate showed no statistically significant difference between early and late debridement regarding the nonunion rate as well. The funnel lots showed little evidence of asymmetry by visual inspection. Conclusion In conclusion, the current evidence demonstrates no impact of timing to surgical debridement on the infection rate following open tibial fractures in the adult population. Our results demonstrated that the risks of infection, deep infection, and nonunion were similar between patients who underwent delayed versus early debridement.

Delay of Antibiotic Administration Greater than 2 Hours Predicts Surgical Site Infection in Open Fractures

AIMS

Antibiotic administration, severity of injury, and debridement are associated with surgical site infection (SSI) after internal fixation of open fractures. We sought to validate a time-dependent treatment effect of antibiotic administration.

PATIENTS

Consecutive open fracture patients at a level 1 trauma center with minimum 30-day follow-up were identified from an orthopaedic registry from 2013-2017.

METHODS

The primary endpoint was SSI within 90 days. A threshold time to antibiotic administration associated with SSI was ascertained by receiver-operator analysis. A Cox proportional hazards model adjusted for age, smoking, and drug use determined the treatment effect of antibiotic administration within the threshold period.

RESULTS

Ten percent of 230 patients developed a SSI. There was a trend for patients who did not develop an SSI to receive antibiotics earlier than those who did develop an SSI (61 minutes, IQR 33-107 vs 83 minutes, IQR 40-186), p=0.053). Intravenous antibiotic administration after 120 minutes of presentation of an open fracture to emergency department was significantly associated with a 2.4 increased hazard of surgical site infection (p=0.036) within 90 days.

CONCLUSION

Antibiotic administration greater than 120 minutes after ED presentation of an open fracture was associated with an increased risk of SSI.

Retrospective analysis of risk factors for deep infection in lower limb Gustilo-Anderson type III fractures

Background

Open fractures are among the most severe injuries observed in orthopedic patients. Treating open fractures is difficult because such patients with infections may require multiple operations and amputations. Furthermore, only a few studies have focused on antibiotic prophylaxis in open fractures and evaluated how to cover lost soft tissue to increase the success rate of reconstruction. We evaluated the risk factors for deep infection in lower limb Gustilo–Anderson (G–A) type III fractures.

Materials and methods

This retrospective study investigated patients who underwent surgical procedures for lower limb G–A type III fractures between January 2007 and January 2017 at our institution. We enrolled 110 patients with 114 lower limb G–A type III fractures (77 G–A type IIIA fractures and 37 G–A type IIIB fractures) who were followed up for at least 2 years. We compared patients presenting infections with those without infections by assessing the following factors: severe contamination, diabetes, smoking, Injury Severity Scale, segmental fracture, location of fracture, G–A classification, damage control surgery, methods of surgery, timing of fixation, combination of antibiotics used, duration of antibiotic prophylaxis, timing of wound closure, and soft-tissue reconstruction failure.

Results

Eighteen fractures presented deep infections. Compared with patients without infections, patients developing infections differed significantly in terms of severe contamination (P < 0.01), G–A classification (P < 0.01), duration of antibiotic prophylaxis (P < 0.01), timing of wound closure (P < 0.01), and incidence of soft-tissue reconstruction failure (P < 0.01). Skin grafting was associated with significantly higher failure rates than muscle and free flap reconstructions (P = 0.04). Treatment with antibiotics was significantly longer in patients with drug-resistant bacterial infections than in those without infections (P < 0.01).

Conclusion

Early flaps rather than skin grafting should be used to cover G–A type IIIB fractures, because skin grafting resulted in the highest failure rate among soft-tissue reconstructions in open fractures. Longer duration of antibiotic use had a significant impact not only on deep infection rates but also on the presence of drug-resistant bacteria. These findings suggest that prolonged use of antibiotics should be avoided in cases of open fractures.

Level of evidence

Level IV retrospective observational study.

Antibiotic utilization in open fractures

Open fractures are complex presentations with elevated risks of infection and nonunion due to a multitude of factors. Along with early surgical debridement, antibiotics have been heavily utilized and have become part of standard of care to reduce the risks of fracture-related infections. Many aspects of their use have been studied and debated. The early administration of intravenous antibiotics has been shown to significantly reduce the incidence of infection. Furthermore, current standards do not recommend prolonged antibiotic administration post wound closure. Recently, an increasing number of studies have assessed the utility of locally administered antibiotics. Clinical and basic science studies have been relatively supportive of their usage, but further studies are still warranted to further delineate their effects.

Surgical timing for open fractures: Middle of the night or the light of day, which fractures, what time?

Controversy exists over the optimal management of open fractures as new clinical studies question open fracture management dogma. Open fractures are complex injuries requiring the orthopaedic surgeon to consider both the bone injury as well as associated soft tissue injury. Early intravenous antibiotics and tetanus prophylaxis remain instrumental in infection prevention. However, the “six-hour rule” for initial open fracture debridement and revascularization has come into question. New evidence supports initial debridement within 24 hours with the appropriate surgical team. Additionally, orthopaedic surgeons and vascular surgeons should collaborate on the sequence of management of open fractures with associated vascular injury. Whereas debates on the optimal irrigation pressure and solution have been answered by multicenter randomized controlled trials, further research is required to determine the optimal irrigation volume and timing of wound closure. With advances in management of open fractures, the utility of well-known classification systems including the Gustilo-Anderson classification and Mangled Extremity Severity Score need to be re-evaluated in favor of up-to-date classification systems which better guide management and predict prognosis.

Timing of antimicrobial initiation and reduced infection risk in open limb fractures: a cohort study

To assess whether early administration of antimicrobials in open fractures of the limbs reduces infection risk. A historical cohort study included all adult patients admitted with an open fracture of the limbs, between January 1, 2012, and December 31, 2016. Epidemiological, clinical, and microbiological data was collected and analyzed. Microbiological infection was defined by positive wound cultures during the first 30 days, and clinical infection as defined by the treating physician. Of 167 patients, microbiological infection was identified in 12 (7%) patients, and clinical infection in 27 (16%) patients. All patients received the first dose of antimicrobials within 15 h of admission (median 1.29 h). Very early administration of the first dose did not reduce the risk of infection (median of 1.06 h and 1.31 h for patients that did vs. did not develop infection, respectively P = 0.58). In multivariate logistic regression, location of fracture in the lower limbs was associated with an increased risk of infection (OR 4.654, CI 1.407-15.398), and Gustilo-Anderson classification grade 1 or 2 was associated with a decreased risk of infection (OR 0.301, CI 0.104-0.872). Very early administration of antimicrobials did not reduce risk of infection in open limb fractures.

The Israeli Defense Forces Point of Injury Antimicrobial Treatment Protocol - A New Protocol and Review of the Literature

INTRODUCTION

Combat wound infection is a common and serious complication, leading to significant morbidity and mortality. In 2005, a point of injury antimicrobial protocol was published by the Israel Defense Forces, in which Moxifloxacin was chosen. During 2016-2017, a revision of this protocol was performed and concluded with the publication of an updated protocol. The purpose of this report is to present this process and the revised protocol, together with a review of the literature.

METHODS

We searched "Medline" and "Google Scholar" for studies dealing with antimicrobial prophylaxis in trauma, for militaries' point of injury antimicrobial protocol protocols and for established surgical antimicrobial prophylaxis protocols.

RESULTS

Point of injury antimicrobial protocol is aimed at preventing early infection and its complications. The choice of Moxifloxacin for this purpose may not be optimal since Moxifloxacin spectrum might be overly broad, there is scant evidence supporting it for this indication, and the available preparation does not meet distinctive technical requirements. Contrarily, Ceftriaxone seemed to have suitable microbiological, pharmacological and technical features.

CONCLUSION

Point of injury antimicrobial protocol should be used especially when evacuation and definitive surgical treatment are delayed. According to present scientific data and operational needs, Ceftriaxone was chosen for most penetrating injuries, with Metronidazole addition for penetrating abdominal and cranial trauma.

Does delay in surgical debridement increase the risk of infection in open tibia fractures in Saudi patients? A retrospective cohort study

BACKGROUND

Infection is the most common and devastating complication of open fractures, with a reported incidence of 3-40%. Tibia bone along its anteromedial surface has relatively thin soft tissue coverage; hence the open tibia fracture incidence rate ranges from 49.4% to 63.2%. Open fractures are usually classified based on the Gustilo & Anderson classification system, which is used by surgeons as an index for the severity of an injury and as a prognostic tool. Our current practice follows the 6-h rule of irrigation and debridement (I&D). Nevertheless, there is little support for this opinion in the literature. Our study concentrates on identifying the risk factors of infection in open tibia fractures and comparing the rate of infection if surgical irrigation and debridement was delayed.

METHODS

The medical records of 389 patients with open fractures were reviewed. Of these cases, 113 patients with open tibia fracture who presented to our Hospital from the period 1997 to 2008 fit the inclusion criteria and were included in a retrospective cohort study.

RESULTS

A total of 113 tibia fractures were reviewed, with an average patient age of 31.70 years; 87.1% of the fractures were high-energy fractures, and the most common mechanism of injury was a motor vehicle accident (62.4%). The data analysis revealed no difference in overall infectious outcome when comparing initial I&D performed within 6 h to when I&D was performed after 6 h (P = 0.201). The data analysis showed a significant relationship between infection and wound closure in first surgery in both univariate and multivariate analysis (P = 0.0003 and P = 0.014), respectively.

CONCLUSION

This study showed no significant evidence to support the 6-h rule, but it did demonstrate a significant relationship between the Gustilo stage and infection, as well as an increased infection rate if external fixation was used or if the wound was left open during the initial irrigation and debridement. We believe that more studies are required to identify the relationship between infection and the delay in irrigation and debridement; a meta-analysis of the currently available data may provide an answer to this question.

Prehospital Antibiotic Prophylaxis for Open Fractures: Practicality and Safety

OBJECTIVE

Early antibiotic administration has been associated with a significant decrease in infection following open fractures. However, antibiotics are most effective at a time when many patients are still being transported for care. There is limited evidence that antibiotics may be safely administered for open fractures when being transported by life-flight personnel. No such data exists for ground ambulance transport of patients with open fractures. The purpose of the study was to assess the safety and feasibility of prophylactic antibiotic delivery in the prehospital setting.

METHODS

We performed a prospective observational study between January 1, 2014 and May 31, 2015 of all trauma patients transferred to a level 1 trauma center by a single affiliated ground ambulance transport service. If open fracture was suspected, the patient was indicated for antibiotic prophylaxis with 2 g IV Cefazolin. Exclusion criteria included penicillin allergy, higher priority patient care tasks, and remaining transport time insufficient for administration of antibiotics. The administration of antibiotics was recorded. Patient demographics, associated injuries, priority level (1 = life threatening injury, 2 = potentially life threatening injury, 3 = non-life threatening injury), and timing of transport and antibiotic administration were recorded as well.

RESULTS

EMTs identified 70 patients during the study period with suspected open fractures. Eight reported penicillin allergy and were not eligible for prophylaxis. The patient's clinical status and transport time allowed for administration of antibiotic prophylaxis for 32 patients (51.6%). Total prehospital time was the only variable assessed that had a significant impact on administration of prehospital antibiotics (<30 minutes = 29% vs. >30 minutes = 66%; p < 0.001). There were no allergic reactions among patients and no needle sticks or other injuries to EMT personnel related to antibiotic administration.

CONCLUSIONS

EMT personnel were able to administer prehospital antibiotic prophylaxis for a substantial portion of the identified patients without any complications for patients or providers. Given the limited training provided to EMTs prior to implementation of the antibiotic prophylaxis protocol, it is likely that further development of this initial training will lead to even higher rates of prehospital antibiotic administration for open fractures.

Open Distal Radius Fractures: Timing and Strategies for Surgical Management

Open distal radius fractures are rare injuries with few studies to guide treatment. Degree of soft tissue injury and contamination may be a primary consideration to dictate timing and operative intervention. Antibiotics should be started as early as possible and include a first-generation cephalosporin. Surgical fixation remains a matter of surgeon preference: although studies support the use of definitive internal fixation, many surgeons address contaminated injuries with external fixation. Although postoperative outcomes are similar to closed injuries for low-grade open distal radius fractures, high-grade injuries with more complex fracture patterns carry a high risk of complications, poor outcomes, and repeat surgical procedures.

Comparing hospital outcomes between open and closed tibia fractures treated with intramedullary fixation

INTRODUCTION

Tibial shaft fractures comprise a large portion of operatively treated long bone fractures, and present with the highest rate of open injuries. Intramedullary fixation has become the standard of care for both open and closed injuries. The rates of short term complications and hospital length of stay for open and closed fractures treated with intramedullary fixation is not fully known. Previous series on tibia fractures were performed at high volume centers, and data were not generalizable, further they did not report on length of stay and the impact of preoperative variables on infections, complications and reoperation. We used a large surgical database to compare these outcomes while adjusting for preoperative risk factors.

METHODS

Data were extracted from the ACS-NSQIP database from 2005 to 2014. Cases were identified based on CPT codes for intramedullary fixation and categorized as closed vs open based on ICD9 code. In addition to demographic and case data, primary analysis examined correlation between open and closed fracture status with infection, complications, reoperation and hospital length of stay. Secondary analysis examined preoperative variables including gender, race, age, BMI, and diabetes effect on outcomes.

RESULTS

There were 272 cases identified. There were no significant demographic differences between open and closed tibia fracture cases. Open fracture status did not increase the rate of infection, 30day complications, reoperation, or length of stay. The only preoperative factor that correlated with length of stay was age. There was no correlation between BMI, presence of insulin dependent and nondependent diabetes, and any outcome measure.

DISCUSSION

When considering the complication rates for open and closed tibial shaft fractures treated with intramedullary fixation, there is no difference between 30-day complication rate, length of stay, or return to the operating room. Our reported postoperative infection rates were comparable to previous series, adding validity to our results. The heterogeneity of the hospitals included in ACS-NSQIP database allow our data to be generalizable. These methods may underrepresent the true occurrence of infection as operatively treated tibia infections may present late, requiring late revision. Despite limitations, the data reflect on the current burden of managing these once devastating injuries.

Noncontact plating technique in an open fracture

AIM

In comparison with closed fractures, open fractures have an increased risk of infection, there are soft tissue-related problems, and difficulties are experienced in union. The aim of this study was to evaluate and discuss the results of osteosynthesis applied with a noncontact plate in Gustilo-Anderson Type 2, 3a, and 3b fractures.

METHOD

The study included 23 patients applied with debridement + noncontact plate osteosynthesis + soft tissue procedures in a single session for the treatment of an open fracture. A follow-up card was created to evaluate the patients in respect of age, gender, fracture level, fracture etiology, open fracture type, preoperative and postoperative sedimentation and C-reactive protein values, antibiotics used and duration of use, time to union, and complications.

RESULTS

In all 23 patients, full bone union was obtained at mean 22.5 weeks (range: 16-36 weeks). Complications developed in 9 patients. Implant failure occurred in 3 patients. In 5 patients, infection developed which required repeated debridements.

CONCLUSION

In open fractures, noncontact plating following debridement seems to be a good alternative treatment method to intramedullar nailing, especially in metaphyseal and metaphyseo-diaphyseal fractures and in spiral oblique diafiz fractures. Noncontact plating may also be a good alternative to intramedullar nailing for open fracture treatment if the patients have additional pathologies such as contusion and thoracic injury.

Role of Systemic and Local Antibiotics in the Treatment of Open Fractures

The orthopedic community has learned much about the treatment of open fractures from the tremendous work of Ramon Gustilo, Michael Patzakis, and others; however, open fractures continue to be very difficult challenges. Type III open fractures continue to be associated with high infection rates. Some combination of systemic and local antibiotics may be most appropriate in these high-grade open fractures. Further research is still necessary in determining optimal systemic antibiotic regimens as well as the role of local antibiotics. Any new discoveries related to novel systemic antibiotics or local antibiotic carriers will need to be evaluated related to cost.

American College of Foot and Ankle Surgeons® Clinical Consensus Statement: Perioperative Management

A wide range of factors contribute to the complexity of the management plan for an individual patient, and it is the surgeon's responsibility to consider the clinical variables and to guide the patient through the perioperative period. In an effort to address a number of important variables, the American College of Foot and Ankle Surgeons convened a panel of experts to derive a clinical consensus statement to address selected issues associated with the perioperative management of foot and ankle surgical patients.

Timing of Operative Debridement in Open Fractures

The optimal treatment of open fractures continues to be an area of debate in the orthopedic literature. Recent research has challenged the dictum that open fractures should be debrided within 6 hours of injury. However, the expedient administration of intravenous antibiotics remains of paramount importance in infection prevention. Multiple factors, including fracture severity, thoroughness of debridement, time to initial treatment, and antibiotic administration, among other variables, contribute to the incidence of infection and complicate identifying an optimal time to debridement.

Current management of open fractures: results from an online survey

BACKGROUND

Open fractures are orthopaedic emergencies that carry a high risk for infection, non-union and soft tissue complications. Evidence-based treatment is impeded by the lack of high-quality evidence-based studies. The aim of this investigation was to elucidate the current practice of open fracture management in Germany and to determine major differences in treatment.

METHODS

Surgeons were asked to complete an online questionnaire consisting of 45 items developed by an expert consensus. The first part covered questions on general principles of open fracture management. The second part included questions on soft tissue management, the preferred method of initial surgical stabilisation, microbiological testing, employment of pulsatile lavage and local antibiotics, antibiotic regimen, second-look operations, and blood testing.

RESULTS

Of 653 respondents, 364 (65 %) completed the first part and 314 (48 %) completed the second part of the online survey. 55 % answered that a standard operating procedure for the diagnosis and treatment of patients with open fractures exists in their hospital. Only 25 % leave pre-hospitalisation applied dressings intact until arrival of the patient in the operating room, and 40 % make this decision depending on information provided by pre-hospitalisation emergency personnel. 84 % participants exclude the use of antibiotic-coated implants in the treatment of open fractures. The favoured stabilisation method in Gustilo type I fractures is definitive internal osteosynthesis and primary wound closure for 61 % of respondents. In Gustilo type II (74 %) and type III fractures (93 %), temporary external fixation is preferred. High-pressure pulsatile lavage is used by 22 % responding surgeons in Gustilo type I fractures, 53 % for type II fractures and 67 % for type III fractures.

CONCLUSIONS

Open fracture management differs considerably among surgeons in Germany. Further studies are needed to deliver high-quality evidence concerning primary fracture stabilisation, soft tissue management and second-look operations. Existing evidence-based recommendations for general treatment, antibiotic prophylaxis and soft tissue management should be followed more strictly in clinical practice.

Unblinded randomized control trial on prophylactic antibiotic use in gustilo II open tibia fractures at Kenyatta National Hospital, Kenya

OBJECTIVE

To determine the difference in infection rate between 24h versus five days of prophylactic antibiotic use in management of Gustilo II open tibia fractures.

DESIGN

Unblinded randomized control trial.

SETTING

Accident and Emergency, orthopedic wards and outpatient clinics at Kenyatta National Hospital (KNH).

PATIENTS

The study involved patients aged 18-80 years admitted through accident and emergency department with Gustilo II traumatic open tibia fractures.

INTERVENTION

Patients were randomized into either 24hour or five day group and antibiotics started for 24hours or five days after surgical debridement. The wounds were exposed and scored using ASEPSIS wound scoring system for infection after 48h, 5days and at 14days.

OUTCOME MEASURES

The main outcomes of interest were presence of infection at days 2, 5 and 14 and effect of duration to antibiotic administration on infection rate.

RESULTS

There was no significant difference in infection rates between 24-hour and 5-day groups with infection rates of 23% (9/40) vs. 19% (7/37) respectively (p=0.699). The infection rate was significantly associated with time lapsed before administration of antibiotics (p=0.004).

CONCLUSION

In the use of prophylactic antibiotics for the management of Gustilo II traumatic open tibia fractures, there is no difference in infection rate between 24hours and five days regimen but time to antibiotic administration correlates with infection rate. Antibiotic use for 24hours only has proven adequate prophylaxis against infection. This is underlined in our study which we hope shall inform practice in our setting. A larger, more appropriately controlled study would be useful.

The 6-Hour Rule for Surgical Debridement of Open Tibial Fractures: A Systematic Review and Meta-Analysis of Infection and Nonunion Rates

OBJECTIVES

The aim of this study was a systematic review and meta-analysis of studies comparing early (<6 hours) versus late (>6 hours) surgical debridement of open tibial fractures, with regards to infection and nonunion rates.

METHODS

A systematic literature search of MEDLINE, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature (1961 to present), Allied and Complementary Medicine, and COCHRANE databases was conducted using any combination of the key words: "open," "tibial," and "fractures." After appropriate screening, 7 studies were included for analysis. Inclusion criteria were studies assessing the relation between time to debridement from injury and infection and/or nonunion rates.

RESULTS

Three studies (n = 365) evaluated overall infection rates that varied from 7.7% to 8.9% in the early group versus 1%-18.5% in the late group. Three studies (n = 197) evaluated deep infection rates that varied from 13% to 18.5% in the early group versus 7.1%-18.6% in the late group. Four studies (n = 245) evaluated nonunion rates that varied from 13.2% to 26.1% in the early group versus 0%-32.6% in the late group. Meta-analysis showed no statistical difference between groups with regards to overall infection rates (risk ratio = 1.32; 95% CI, 0.54-3.23; P = 0.55), deep infection rates (risk ratio = 0.99; 95% CI, 0.48-2.07; P = 0.98), and nonunion rates (risk ratio = 1.49; 95% CI, 0.64-3.49; P = 0.36).

CONCLUSIONS

The available literature suggests that there is no obvious difference in the overall/deep infection and nonunion rates between open tibial fractures debrided within 6 hours and those debrided at more than 6 hours. The findings presented here would appear to indicate that judicious delays of greater than 6 hours may not result in a significantly increased risk of adverse events or peri-operative morbidity.

LEVEL OF EVIDENCE

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

Antibiotic related acute kidney injury in patients treated for open fractures

OBJECTIVE

Antibiotic administration during the treatment of open fractures has been shown to reduce infection rates and is considered a critical step in the management of these injuries. The purpose of this study was to determine if aminoglycoside administration during the treatment of open fractures leads to acute kidney injury.

METHODS

Patient records at a level I trauma centre were reviewed for adult patients who presented in 2014 with open fractures were screened for inclusion. Patients were excluded with fractures of the phalanges, metatarsals, and metacarpals, with isolated traumatic arthrotomies, or pre-existing renal dysfunction. Charts were reviewed for patient age, gender, race, past medical history, medication history, injury severity score, intravenous dye studies and fracture type. Patients were divided into those given cefazolin (Group A) and cefazolin with gentamicin (Group B). Laboratory values were used to determine which patients developed kidney dysfunction as measured using the RIFLE criteria. Wilcoxon-Mann-Whitney test and Chi-square were used to compare interval and categorical variables, respectively. Significance was set at P<0.05.

RESULTS

One-hundred and fifty-nine patients met inclusion criteria. Forty-one (25%) patients were given cefazolin alone and 113 (68%) patients were given cefazolin with gentamicin. Ten (18%) patients with Gustilo-Anderson type III fractures were given cefazolin alone and 67 (67%) patients with types I or II fractures were given a cefazolin with gentamicin. Baseline characteristics and risk factors for renal dysfunction did not vary between groups. Two (4.8%) patients in Group A and 5 (4%) patients in Group B developed acute kidney injury (P=0.599).

CONCLUSIONS

Gentamicin use during the treatment of open fractures does not lead to increased rates of renal dysfunction when used in patients with normal baseline renal function.

[Treatment concept for a traumatic lesion of the prepatellar bursa]

OBJECTIVE

Rapid recovery of the skin and soft tissue of the affected knee joint with surgical debridement of the wound and gentle, as well as risk-balanced partial resection of the traumatic lacerated prepatellar bursa. Functional aftercare with directed administration of antibiotics only.

INDICATIONS

Acute, traumatic laceration of the prepatellar bursa.

CONTRAINDICATIONS

Heavy contamination of the wound. Large, not closable skin defect or deep abrasion. Preexisting local infection. Additional fracture of the patella. Limited patient's cooperation, e. g., alcohol addiction or dementia.

SURGICAL TECHNIQUE

Subdermal application of local anesthesia through the exposed wound margins. Exploration of the wound and excision of the wound margins. Dissection of the boundary layer between the bursa and the subcutaneous fat. Debridement of the wound and excision of the bruised and contaminated bursa tissue. Repetitive rinsing. Insertion of loop drainage. Single-layer wound closure. Crepe bandage.

POSTOPERATIVE MANAGEMENT

Crepe bandage until the first wound inspection. Wound inspection on postoperative day 2 with removal of the loop. Pain-adapted functional treatment. Antithrombotic therapy until full weight-bearing. Removal of the stitches on postoperative day 14. Antibiotic prophylaxis (1st generation cephalosporin) for immunocompromised or polymorbid patients or heavily contaminated wounds.

RESULTS

In 2013, we treated 50 traumatic lacerations of the prepatellar bursa. Four had to undergo further surgical treatment after primary care. In two other patients, one infected and one non-infected wound healing complication developed, which could be treated conservatively.

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.

Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection

OBJECTIVE

To examine the association between antibiotic timing and deep infection of type III open tibia fractures.

DESIGN

Retrospective prognostic study.

SETTING

Level 1 Trauma Center.

PATIENTS

The study population included 137 patients after exclusions for missing data (13), nonreconstructible limbs (9), and/or absence of 90-day outcome data (3).

INTERVENTION

An observational study of antibiotic timing.

MAIN OUTCOME MEASUREMENT

Deep infection within 90 days.

RESULTS

Age, smoking, diabetes, injury severity score, type IIIA versus 3B/C injury, and time to surgical debridement were not associated with infection on univariate analysis. Greater than 5 days to wound coverage (P < 0.001) and greater than 66 minutes to antibiotics (P < 0.01) were univariate predictors of infection. Multivariate analysis found wound coverage beyond 5 days [odds ratio, 7.39; 95% confidence interval (CI), 2.33-23.45; P < 0.001] and antibiotics beyond 66 minutes (odds ratio, 3.78; 95% CI, 1.16-12.31; P = 0.03) independently predicted infection. Immediate antibiotics and early coverage limited the infection rate (1 of 36, 2.8%) relative to delay in either factor (6 of 59, 10.2%) or delay in both factors (17 of 42, 40.5%).

CONCLUSIONS

Time from injury to antibiotics and to wound coverage independently predict infection of type III open tibia fractures. Both should be achieved as early as possible, with coverage being dependent on the condition of the wound. Given the relatively short therapeutic window for antibiotic prophylaxis (within an hour of injury), prehospital antibiotics may substantially improve outcomes for severe open fractures.

LEVEL OF EVIDENCE

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

The effect of the timing of antibiotics and surgical treatment on infection rates in open long-bone fractures: a 6-year prospective study after a change in policy

Our current protocol in treating open long-bone fractures includes early administration of intravenous antibiotics and surgery on a scheduled trauma list. This represents a change from a previous protocol where treatment as soon as possible after injury was carried out. This review reports the infection rates in the period 6 years after the start of this protocol. Two hundred and twenty open long-bone fractures were reviewed. Data collected included time of administration of antibiotics, time to theatre and seniority of surgeon involved. The patients were followed up until clinical or radiological union occurred or until a secondary procedure for non-union or infection was performed. Clinical, radiological and haematological signs of infection were documented. If present, infection was classified as deep or superficial. Surgical debridement was performed within 6 h of injury in 45 % of cases and after 6 h in 55 % of cases. Overall infection rates were 11 and 15.7 %, respectively (p = 0.49). The overall deep infection rate was 4.3 %. There was also no statistically significant difference in the subgroups of deep (p = 0.46) and superficial (p = 0.78) infection. Intravenous antibiotics were administered within 3 h of injury in 80 % of cases and after 3 h in 20 % of cases. The infection rates were 14 and 12.5 %, respectively (p = 1.0). There was no statistically significant difference in the subgroups of deep (p = 0.62) and superficial (p = 0.73) infection. Further statistical analysis did not reveal a significant difference in infection rates for any combination of timing of antibiotics and surgical debridement. Infection rates where the most senior surgeon present was a consultant were 9.5 % as opposed to 16 % with the consultant not present, but this trend was not statistically significant. These results suggest that the change in policy may have contributed to an improvement of the deep infection rate to 4.3 % from the previous figure of 8.5 % although this decrease is not statistically significant. Surgeons may have had concerns that delaying theatre may lead to an increased infection rate, but these results do not substantiate this concern.

Impact of high prevalence of pseudomonas and polymicrobial gram-negative infections in major sub-/total traumatic amputations on empiric antimicrobial therapy: a retrospective study

Introduction

Emergency treatment of major sub-/total traumatic amputations continue to represent a clinical challenge due to high infection rates and serious handicaps. Effective treatment is based on two columns: surgery and antimicrobial therapy. Detailed identification of pathogen spectrum and epidemiology associated with these injuries is of tremendous importance as it guides the initial empiric antibiotic regimen and prevents adverse septic effents.

Methods

In this retrospective study 51 patients with major traumatic amputations (n = 16) and subtotal amputations (n = 35) treated from 2001 to 2010 in our trauma center were investigated. All patients received emergency surgery, debridement with microbiological testing within 6 h after admission and empircic antimicrobial therapy. Additionally to baseline patient characteristics, the incidence of positive standardized microbiologic testing combined with clinical signs of infection, pathogen spectrum, administered antimicrobial agents and clinical complications were analyzed.

Results

70.6% of the patients (n = 36) acquired wound infection. In 39% wounds were contaminated on day 1, whereas the mean length of duration until first pathogen detection was 9.1 ± 13.4 days after injury. In 37% polymicrobial colonization and 28% Pseudomonas were responsible for wound infections during hospitalization. In 45% the empirc antimicrobial therapy focussed on Gram positive strains did not cover the detected bacteria, according antimicrobial resistogram. It was significantly more often found in infections associated with Pseudomonas (p 0.02) or polymicrobial wound infections.

Conclusions

This epidemiologic study reveals a pathogen shift from Gram-positive to Gram-negative strains with high incidence of Pseudomonas and polymicrobial infections in sub-/total major traumatic amputations. Therefore, empiric antimicrobial treatment historically focussing on Gram-positive strains must be adjusted. We recommend the use of Piperacillin/Tazobactam for these injuries. As soon as possible antimicrobial treatment should be changed from empiric to goal directed therapy according to the microbiological tests and resistogram results.

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.

Infection and combat injuries

Blast and ballistic weapons used on the battlefield cause devastating injuries rarely seen outside armed conflict. These extremely high-energy injuries predominantly affect the limbs and are usually heavily contaminated with soil, foliage, clothing and even tissue from other casualties. Once life-threatening haemorrhage has been addressed, the military surgeon’s priority is to control infection.

Combining historical knowledge from previous conflicts with more recent experience has resulted in a systematic approach to these injuries. Urgent debridement of necrotic and severely contaminated tissue, irrigation and local and systemic antibiotics are the basis of management. These principles have resulted in successful healing of previously unsurvivable wounds. Healthy tissue must be retained for future reconstruction, vulnerable but viable tissue protected to allow survival and avascular tissue removed with all contamination.

While recent technological and scientific advances have offered some advantages, they must be judged in the context of a hard-won historical knowledge of these wounds. This approach is applicable to comparable civilian injury patterns. One of the few potential benefits of war is the associated improvement in our understanding of treating the severely injured; for this positive effect to be realised these experiences must be shared.

Does timing to operative debridement affect infectious complications in open long-bone fractures? A systematic review

BACKGROUND

Existing guidelines recommend emergency surgical debridement of open fractures within six hours after injury. The aim of this study was to systematically review the association between time to operative debridement of open fractures and infection.

METHODS

Searches of the MEDLINE, EMBASE, and Cochrane computerized literature databases and manual searches of bibliographies were performed. Randomized controlled trials and cohort studies (retrospective and prospective) evaluating the association between time to operative debridement and infection after open fractures were included. Descriptive and quantitative data were extracted. A meta-analysis of patient cohorts who underwent early or delayed debridement was performed with use of a random effects model.

RESULTS

The initial search identified 885 references. Of the 173 articles inspected further on the basis of the title, sixteen (six prospective and ten retrospective cohort studies with a total of 3539 open fractures) were included. No significant difference in the infection rate was detected between open fractures debrided early or late according to any of the time thresholds used in the included studies. Sensitivity analyses demonstrated no difference in infection rate between early and late debridement in subgroups defined according to the Gustilo-Anderson classification, level of evidence, depth of infection, or anatomic location.

CONCLUSIONS

The data did not indicate an association between delayed debridement and higher infection rates when all infections were considered, when only deep infections were considered, or when only more severe open fracture injuries were considered. On the basis of this analysis, the historical “six-hour rule” has little support in the available literature. It is important to realize that additional carefully conducted studies are needed and that elective delay of treatment of patients with open fractures is not recommended

The relationship between time to surgical debridement and incidence of infection in grade III open fractures

Objective

The purpose of this study was to determine the association between time to initial debridement and infection rate in high-energy (grade III) open fractures of tibia.

Methods

All patients presenting with open fractures were included in the study. The inclusion criteria were Gustilo III A, B and C open fractures of tibia. Time of injury, time of arrival to the hospital, time of initial debridement and subsequent soft tissue procedures were recorded. The primary outcome measure was a diagnosis of infection or osteomyelitis at 1 year. Secondary outcome measure was fracture union at 1 year.

Results

Sixty-seven (67) patients with grade III open fractures were included; the mean age was 32.4 years (54 males and 13 females). Eight patients (12 %) in this study went on to develop a deep infection, and there were 6 (8.4 %) non-unions. The infection rate for patients in the group who underwent debridement in less than 6 h and those greater than 6 h was 13.1 and 10.8 %, respectively. No statistically significant difference could be demonstrated between the two groups (p = 0.56). While there was no significant relationship between grade of fracture and infection rate (p = 0.07), the relationship between grade of fracture and non-union was significant (p = 0.02).

Conclusion

Our study shows that the risk of developing an infection was not increased if the primary surgical management was delayed more than 6 h after injury. Therefore, reasonable delays in surgical treatment for patients with open fractures may be justified in order to provide an optimal operating environment.

Early antibiotics and debridement independently reduce infection in an open fracture model

Most animal studies indicate that early irrigation and debridement reduce infection after an open fracture. Unfortunately, these studies often do not involve antibiotics. Clinical studies indicate that the timing of initial debridement does not affect the rate of infection but these studies are observational and fraught with confounding variables. The purpose of this study was to control these variables using an animal model incorporating systemic antibiotics and surgical treatment.

We used a rat femur model with a defect which was contaminated with Staphylococcus aureus and treated with a three-day course of systemic cefazolin (5 mg/kg 12-hourly) and debridement and irrigation, both of which were initiated independently at two, six and 24 hour time points. After 14 days the bone and hardware were harvested for separate microbiological analysis.

No animal that received antibiotics and surgery two hours after injury had detectable bacteria. When antibiotics were started at two hours, a delay in surgical treatment from two to six hours significantly increased the development of infection (p = 0.047). However, delaying surgery to 24 hours increase the rate of infection, but not significantly (p = 0.054). The timing of antibiotics had a more significant effect on the proportion of positive samples than earlier surgery. Delaying antibiotics to six or 24 hours had a profoundly detrimental effect on the infection rate regardless of the timing of surgery. These findings are consistent with the concept that bacteria progress from a vulnerable planktonic form to a treatment-resistant biofilm.

Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: endorsed by the Infectious Diseases Society of America and the Surgical Infection Society

Despite advances in resuscitation and surgical management of combat wounds, infection remains a concerning and potentially preventable complication of combat-related injuries. Interventions currently used to prevent these infections have not been either clearly defined or subjected to rigorous clinical trials. Current infection prevention measures and wound management practices are derived from retrospective review of wartime experiences, from civilian trauma data, and from in vitro and animal data. This update to the guidelines published in 2008 incorporates evidence that has become available since 2007. These guidelines focus on care provided within hours to days of injury, chiefly within the combat zone, to those combat-injured patients with open wounds or burns. New in this update are a consolidation of antimicrobial agent recommendations to a backbone of high-dose cefazolin with or without metronidazole for most postinjury indications, and recommendations for redosing of antimicrobial agents, for use of negative pressure wound therapy, and for oxygen supplementation in flight.