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Infections in Orthopaedic Trauma Minimizing Infections After Open Fractures,Barnaby Dedmond, MD,GUSTILO & ANDERSON 19761 Types 1, 2, 3 Updated 19842 Types 3A, 3B, 3C,1. Gustilo RB, Anderson JT. “Prevention of Infection in the Treatment of One Thousand and Twenty-five Open Fractures of Long Bones.” JBJS-A 1976. 58(4): 453-458.,2. Gustilo RB, Mendoza RM, Williams DN. “Problems in the Management of Type III (Severe) Open Fractures: A New Classification of Type III Open Fractures.” J Trauma 1984. 24(8): 742-746.,Classification Why do we care?,Classification correlates with prognosis,Antibiotics in Open Fractures,The use of antibiotics in open fractures has a protective effect against early infection compared with no antibiotics or placebo (Relative risk 0.41),Gosselin RA, Roberts I, Gillespie WJ. “Antibiotics for preventing infection in open limb fractures.” Cochrane Database System Review 2004. 1: CD003764.,Choice of Antibiotics in Open Fractures,No difference in infection rates between clindamycin and cefazolin (anything vs S. aureus will work),Benson DR, Riggins RS, Lawrence RM, Hoeprich PD, Huston AC, Harrison JA. “Treatment of Open Fractures: A Prospective Study.” J Trauma 1983. 23: 25-30.,Choice of Antibiotics in Open Fractures,Due to gram negative contamination, add aminoglycoside for Grade 3 Farm injuries and Vascular injuries, give ampicillin or penicillin Dont forget tetanus,Duration of Antibiotics in Open Fractures,In a double blind, prospective trial, no difference in infection rates between 1 and 5 days of post operative antibiotics in open fractures,Dellinger EP, Caplan ES, Weaver LD, Wertz MJ, Droppert BM, Hoyt N, Brumback R, Burgess A, Poka A, Benirschke SK. “Duration of preventive antibiotic administration for open extremity fractures.” Arch Surg. 1988 Mar. 123(3): 333-339.,Initial I&D,Timing Classic: within 6 hours Recently being challenged No infections in 91 isolated open Type 1 fractures treated without I&D (except at time of fixation on avg 5 days after injury)1 No difference in infection rate in children will all types of open fractures treated 0-6 hours and 7-24 hours from time of injury2 I still consider all open fractures emergencies,Yang EC, Eisler J. “Treatment of Isolated Type 1 Open Fractures: Is Emergent Operative Debridement Necessary?” CORR 2003. 410: 289-294. Skaggs DL, Friend L, Alman B, Chambers HG, Schmitz M, Leake B, Kay RM, Flynn JM. “The Effect of Surgical Delay on Acute Infection Following 554 Open Fractures in Children.” JBJS-A 2005. 87:8-12,The Irrigation,Amount No good data Animal studies show improved removal of particulate matter and bacteria but effect plateaus at a level dependent on the system Anglen recommends 3L for Gr 1, 6L for Gr 2, 9L for Gr 3,Anglen JO. “Wound Irrigation in Musculoskeletal Injury.” JAAOS 2001. 9: 219-226.,The Irrigation,The Delivery Method Bulb Syringe vs. Pulsatile Lavage Animal study shows pulsatile lavage has a detrimental effect on early bone healing, but this effect is no longer present at 2 weeks1 Animal study shows more soft tissue destruction with pulsatile lavage2 Animal study shows pulsatile lavage to be more effective in removing particulate matter and bacteria3 Low pressure pulsatile lavage may result in fewer infections (ongoing study),Dirschl DR, Duff GP, Dahners LE, Edin M, Rahn BA, Miclau T. “High Pressure Pulsatile Lavage Irrigation of Intraarticular Fractures: Effects on Fracture Healing.” JOT 1998. 12(7): 460-463. Boyd JI, Wongworawat MD. “High-Pressure Pulsatile Lavage Causes Soft Tissue Damage.” CORR 2004. 427: 13-17 Bhandari M, Schemitsch EH, Adili A, Lachowski RJ, Shaughnessy SG. “High and Low Pressure Pulsatile Lavage of Contaminated Tibial Fractures: An in vitro Study of Bacterial Adherence and Bone Damage.” JOT 1999. 13: 526-533.,The Irrigation,The Additive Antibiotics (typically bacitracin and/or neomycin) Mixed animal and human results Costly (for bacitracin alone around $500/washout) ? Causing resistance Reported cases (few) of anaphylaxis Anglen: “No proven value in the care of open fracture woundssome risk, albeit small.”,The Irrigation,The Additive Surfactants (i.e. Soaps) Interfere with bacterial adhesion Emulsify and remove debris No significant difference in infection or bone healing compared to bacitracin solution, but more wound healing problems in bacitracin group,Anglen JO. “Comparison of Soap and Antibiotic Solutions for Irrigation of Lower-Limb Open Fracture Wounds: A Prospective, Randomized Study.” JBJS-A 2005. 87(7):1415-1422.,The Debridement,Remove all devitalized tissue 4Cs of muscle viability Color Contractility Consistency Capacity to Bleed High Velocity Parallel Fluid Flow Compared to scalpel and pulsatile lavage, “equally effective in removing bacteria and particulate matter from the wounds as determined by quantitative bacteriology, x-ray and histologic analysis.”,Webb LX, Morykwas MJ, Smith TL, Banwell PE, Bapst J, Waite AM. “High Velocity Parallel Fluid Flow for Debridement of Contaminated Wounds in a Pig Model.” Poster Presentation 2000 OTA Annual Meeting.,Implants in Open Fractures,Site Specific Forearms immediate plating OK1 Femur in adults, reamed IM Nail2 Tibia some controversy,Jones JA. “Immediate Internal Fixation of High-Energy Open Forearm Fractures.” JOT 1991. 5(3): 272-279. Lhowe DW, Hansen ST. “Immediate Nailing of Open Fractures of the Femoral Shaft.” JBJS-A 1988. 70(6): 812-820.,Implants in Open Fractures,Tibia Unreamed nail (UTN) versus Exfix in Grade II, IIIA, and IIIB UTN with fewer subsequent procedures, less infections No difference in healing rates Reamed (RTN) vs. Unreamed (UTN) for Grade I, II, and IIIA RTN with trend toward decreased number of secondary procedures with no increased complications,Henley MB, Chapman JR, Agel J, Harvey EJ, Whorton AM, Swiontkowski MF. “Treatment of Type II, IIIA, and IIIB Open Fractures of the Tibial Shaft: A Prospective Comparison of Unreamed Interlocking Intramedullary Nails and Half-Pin External Fixators.” JOT 1998. 12(1): 1-7.,Finkemeier CG, Schmidt AH, Kyle RF, Templeman DC, Varecka TF. “A Prospective, Randomized Study of Intramedullary Nails inserted with and withouth Reaming for the Treatment of Open and Closed Fractures of the Tibial Shaft.”,Timing of Wound Coverage/Closure,ASAP after wound adequately debrided Only 18% of infections caused by same organism isolated in initial perioperative culture Suggests hospital acquired etiology of infection “Fix and Flap” For Type IIIB & IIIC open tibia fractures, 6% deep infection with flaps perfomed 72 hours Wound VAC may play a role until coverage,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.” JOT 2000. 14: 529-533.,Gopal S, Majumder S, Batchelor A, Knight S, De Boer P, Smith RM. “Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia.” JBJS-B 2000. 82(7): 959 966.,Dedmond BT, Kortesis B, Punger K, Simpson J, Argenta A, Kulp B, Morykwas M, Webb L. “The use of Negative Pressure Wound Therapy in the Temporary Treatment of Soft Tissue Injuries associated with High Energy Open Tibial Shaft Fractures.” JOT. 2007,The Latest Word,BMPs Approx 40% decreased infection rate with use of BMP in Type III ope