Controversies in Initial Management ofOpen Fractures

S. P. Ryan, V. PuglianoDepartment of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, USA

Scandinavian Journal of Surgery 103: 132–137, 2013

Introduction

• Open fractures are one of the most challenging injuries

• higher risk of infection, nonunion,woundhealing complications

• often require multiple surgeries for definitive care

• multidisciplinary approach including teams of orthopedic, trauma, and plastic surgeons is commonly required

• most debated controversies with regard to the initial management of open fractures include: 1)timing of initial operative debridement, 2)choice of antibiotic

3)time to wound coverage

Classification

• Gustilo–Anderson Classification

• based on the

– mechanism of injury

– soft tissue damage,

– length of skin laceration

– fracture pattern

– degree of contamination

Gustilo RB, Mendoza RM, Williams DN: Problems in the management of type III (severe) open fractures: A new classification of type III fractures. J Trauma 1984;24:742–746.

• Type I fractures, the wound is less than 1 cm in length and clean

Type I open fracture

• Type II, the wound is greater than 1 cm and has minimal soft tissue damage and intact periosteum

• I and II can be closed either immediately or delayed

Type II open fracture.

• Type III fractures include

those injuries with 1)significant periosteal stripping

2) Segmental fractures

3)extensive soft tissue wounds

4) Vascular injury requiring repair

5)high-velocity gunshot wounds

• IIIA injuries are those with adequate soft tissue coverage of the bone that does not require a rotational or free flap

• IIIB fractures, there is inadequate soft tissue coverage of the bone and massive contamination, necessitating flap coverage

Type IIIB open tibia fracture requiring rotational/free flap.

• IIIC injuries are those with vascular disruption requiring repair

Type IIIC open femur fracture with vascular injury

• type of open fracture may not be determined until after final debridement

• all Type III open fractures have a higher incidence of gram-negative infection, and the addition of aminoglycosides is commonly used for these fracture types

• no data supporting that the addition of gram negative coverage decreases the infection rate

Antibiotic Coverage in OpenFractures

• strong evidence for using systemic antibiotics in the treatment of open fractures. this has been first established by the landmark study by Patzakis et al.

Patzakis MJ, Harvey P, Ivler D: The role of antibiotics in the management of open fractures. J Bone Joint Surg Am 1974;56:532–541

• Patzakis et al.

– prospective RCT

– 330 open fractures were randomized to either receive a first-generation cephalosporin, penicillin and streptomycin or a placebo

– duration of antibiotic varied from 10 to 14 days depending on whether internal fixation was used

– infection rates between the cephalosporin (2%) and penicillin/streptomycin (10%) or placebo (14%)

Patzakis MJ, Harvey P, Ivler D: The role of antibiotics in the management of open fractures. J Bone Joint Surg Am 1974;56:532–541

What is Controversial?

• In contrast to the use of first-generation cephalosporins, the administration of aminoglycosides for more complex open fractures (Type III) is controversial

• Gustilo et al.

– Type 3 fractures

– 77% of bacteria isolated from wounds was G-veorganisms

– Recommended to add aminoglycosides or 3rd gen. cephalosporins.

– did not study if aminoglycoside decreases the rate of infection in Type III fractures, So,his recommendation to add gram-negative coverage is not valid

Gustilo RB, Mendoza RM, Williams DN: Problems in the management of type III (severe) open fractures: A new classification

of type III fractures. J Trauma 1984;24:742–746.

– Patzakis et al. (1)

• follow-up retrospective study

• reported that the addition of aminoglycosides to cephalosporin decreased infection rate compared to cephalosporin alone (13% vs. 5%).

• However, this study has several flaws affect its validity as duration of Abx. And closure of wounds varied among groups.

– Patzakis et al. (2)

• Recent prospective study

• Ciprofloxacin vs 1st gen. cephalosporin + gentamicin

• 200 open fractures

• In cipro group infection was 4 times higher.

• But this is not statistically significant due to few type 3 fractures (26 cases).

(1)Patzakis MJ, Wilkins J, Moore TM: Use of antibiotics in open tibial fractures. Clin Orthop Relat Res 1983;178:31–35.

(2)Patzakis MJ, Bains RS, Lee J et al: Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds. J Orthop Trauma 2000;14:529–533

– Thus, the addition of aminoglycosides for Type III fractures is not currently supported in the literature.

– despite this, the Eastern ssociation for the Surgery of Trauma (EAST) recommends it.

– penicillin has been used in heavily contaminated or farm wounds to prevent clostridium infection• no hard data supports this recommendation

• Gustilo and Anderson in their original study reported no cases of gas gangrene infection in their original study of over 1000 patients.

• duration of antibiotic therapy in open fractures has also been the subject of much debate

• Merritt et al.

– Retrospective study

– Infection was higher in pateints received Abx. More than 3 days to pt. who received abx. For 24 hrs. only !!

– This could be due to that worse fracture received Abx for longer time.

Merritt K: Factors increasing the risk of infection in patients with open fractures. J Trauma 1988;28:823–827.

• Dellinger et al.

– Prospective randomized trial

– Evaluate time and duration of Abx.

– 240 Pt

– similar infection rate was noted in patients receiving antibiotics for 24 h or greater than 24 h after admission

– Type of fracture was more predictive for infection than abx. Duration.

Dellinger EP, Miller SD, Wertz MJ et al: Risk of infection after open fracture of the arm or leg. Arch Surg 1988;123:1320–1327.

• Recently, Al-Arabi et al:

– Six defferent groups

– Less than 2, 4, 6, 8, 12 h and greater than 12 h

– no correlation between timing of antibiotic administration and infection rate

A l-Arabi YB, Nader M, Hamidian-Jahromi AR et al: 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. Injury 2007;38:900–905.

• Patzakis and Wilkins:

– reported a difference in infection rate in antibiotics delivered in less than 3 h (4.7%) and greater than 3 h (7.4%)

– However, they did not mentioned if this is statistically segnificant

– And they did not control the fracture type

Patzakis MJ, Wilkins J: Factors influencing infection rate in open fracture wounds. Clin OrthopRelat Res 1989;243:36–40.

• In Practice

– Surgical Infection Society guideline: prophylactic antibiotic use in open fractures: an evidence-based guideline:

• first-generation cephalosporin (or clindamycin) should be administered upon arrival to the emergency room

• ((Although there is no consensus on whether 24 h of antibiotics after each debridement prevents infection, it has been our current practice to administer 24 h of antibiotics after each debridement until wound closure or coverage)).

H auser CJ, Adams CA Jr, Eachempati SR; Council of the Surgical Infection Society: Surgical Infection Society guideline: Prophylactic antibiotic use in open fractures: An evidence-based guideline. Surg Infect (Larchmt) 2006;4:379–405.

• SIS– short course of first-generation cephalosporins,

begun as soon as possible after injury, significantly lowers the risk of infection

– There is insufficient evidence to support other common management practices, such as • prolonged courses

• repeated short courses of antibiotics

• the use of antibiotic coverage extending to gram-negative bacilli or clostridial species

• the use of local antibiotic therapies such as beads.

H auser CJ, Adams CA Jr, Eachempati SR; Council of the Surgical Infection Society: Surgical Infection Society guideline: Prophylactic antibiotic use in open fractures: An evidence-based guideline. Surg Infect (Larchmt) 2006;4:379–405.

The Utility of Cultures in OpenWounds

• Patzakis et al

– also evaluated the use of preoperative culture data of the wound

– They found less than 20% of initial cultures predicted the infecting organism

– routine preoperative cultures should not be pursued.

Patzakis MJ, Bains RS, Lee J et al: Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds. J Orthop Trauma 2000;14:529–533.

• many of the infecting organisms in severe open fracture are hospital acquired

Roth AI, Fry DE, Polk JC Jr: Infections morbidity in extremity fractures. J Trauma 1986;26:757–761.

• In contrast, positive cultures at the time of closure did correlate with infection and may have clinical usefulness (Caesenti-Ettesse)

– It correlates with development of infection but not with infecting organism

Carsenti-Etesse H, Doyon F, Desplaces N et al: Epidemiology of bacterial infection during management of open leg fractures.

Eur J Clin Microbiol Infect Dis 1999;18:315–323.

Timing to Debridement

• The most heavily debated topic

• In their original article, Gustilo and Anderson concluded that “open fractures require emergency treatment …

• ” Nevertheless, this statement is not supported by data and seems to represent his expert opinion only

Gustilo RB, Anderson JT: Prevention of infection in the treatment of one thousand and twenty-five open fractures of long

bones. J Bone Joint Surg Am 1976;58:453–458.

• practice trends have been to perform urgent rather than emergent debridement of open fractures (Namdariet) 2011

– They found 40% infection if debridement done after 6 hrs. And 25% done after 24 hrs.

Namdari S, Baldwin KD, Matuszewski P et al: Delay in surgical debridement of open tibia fractures: An analysis of national

practice trends. J Orthop Trauma 2011;25:140–144.

What is Agreed Upon?

• most important aspect of managing open fractures is the delivery of systemic antibiotics and performing an adequate debridement of nonviable tissue.

• many surgeons believe that an open fracture without vascular compromise is not an emergency (Namdari)

Delay in surgical debridement of open tibia fractures: An analysis of national practice trends. J Orthop Trauma 2011;25:140–144.

• Some surgeons continue to treat open fractures immediately upon presentation.

• Thus, there is no absolute time which is agreed upon by all surgeons, by which open fractures should be debrided.

What is Controversial?

• debridement within 6 h has propagated throughout the literature and became the standard of care for many years

• poor evidence supporting this practice

• “6-hour rule” likely originated from a study in the 1890s

• Experimental study

• garden mold and dust were used as infecting agents in a guinea pig model of open fracture

• early phases of bacterial growth stopped after 6–8 h from injury

• difficult to obtain a clean wound after 6–8 h of being contaminated

riedrich PL: Die aseptische Versorgung frischer Wunden.Arch Klin Chir 1898;57:288–310.

• Main studies evaluating the association between timing of initial debridement and infection in open fractures are flawed by design– 1) These studies compared the complication

rate in fractures receiving debridement in less than or greater than 6 h only

– 2) Types of open fractures between groups were not equal ..… these studies are retrospective.

– 3) many of the earlier studies were underpowered, and solid conclusions cannot be reached

• In a well-powered study, Pollak et al. (2010)

• 300 lower extremity Type III

• 27% infection rate and no relationship between timing of initial operative debridement and infection

• They did find, time from injury to arrival at the definitive trauma center was an independent risk factor for infection

Pollak AN, Jones AL, Castillo RC et al: The elationship between time to surgical bridement and incidence of infection after high-energy lower extremity trauma. J Bone Joint Surg Am 2010;92:7–15.

• Schenker et al. 2012

– systematic review

– evaluated the relationship between timing of initial operative debridement and infection

– Authors collected data from previously reported retrospective studies

– over 3500 open fractures

– controlled these cases for type of open fracture

– analysis did not identify a difference in infection between early (<6 h) or late (>6 h) debridement

– “6-hour rule” has little support in the literature.

Schenker ML, Yannascoli S, Baldwin KD et al: Does timing to operative debridement affect infectious complications in open

long-bone fractures? J Bone Joint Surg Am 2012;94:1057–1064.

• In conclusion

– no absolute recommendations regarding the optimal timing of open fracture debridements

– “6-hour rule” has little support in the literature

– we recommend urgent debridement of open fractures, while the safety of waiting more than 24 h needs to be determined.

Timing of Wound Closure/Coverage

• Type I and II open fracture wounds can be safely closed after initial thorough debridement, if there is no concern for ongoing muscle necrosis or contamination

• Controversy is focused on Type III

• These wounds usually require a repeat debridement at 48–72 h after initial debridement.

Wound coverage

• Webb et al. (2007)

– 150 patients with Type III open tibia fractures

– no difference in infection rate in those patients receiving early (<3 days) or late (>3 days) wound coverage

Webb LX, Bosse MJ, Castillo RC et al; LEAP Study Group: Analysis of surgeon-controlled variables in the treatment of limbthreatening type III open tibial diaphyseal fractures. J Bone Joint Surg Am 2007;89:923–928

• Pollak et al. (2000)

– No difference in infection rate when comparing wound coverage at less than 3, 4–7, or greater than 7 days.

– They did report, however, a 32% complication rate in those wounds covered at greater than 7 days

Pollak AN, McCarthy ML, Burgess AR: Short-term wound complications after application of flaps for coverage of traumatic soft-tissue defects about the tibia. J Bone Joint Surg Am 2000;82:1681–1691.

• D’Alleyrand et al

– no difference in wound complications in those covered in less than 7 days

– but every day afterward, complication rate increased 15% per day

D ’Alleyrand JC, Dancy L, Castillo R et al: Is time to flap coverage an independent predictor of flap complication? Presented at 2010 OTA Annual Meeting, October 13–16, Baltimore, MD, 2010.

• Recommendation• closure within 7 days of wounds associated with open

fractures once the soft tissues have stabilized, and all nonviable tissues have been removed

Thank You