Issue: July 2013
July 01, 2013
2 min read
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Early treatment remains the best way to prevent infection in open fractures

The importance of immediate antibiotic therapy vs. timing of surgical debridement is controversial.

Issue: July 2013
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Early wound debridement and antibiotic administration are both important steps surgeons can take to prevent infections in patients with open fractures, according to Andrew H. Schmidt, MD.

“Immediate antibiotics are important,” Schmidt,of the University of Minnesota, said in a recent presentation. “Aggressive, thorough debridement by an experienced surgeon is important as well, and then soft tissue reconstruction, biological fixation and early movement.”

The open nature of these fractures invites infection, Schmidt said, but loss of fracture-site hematoma and bone loss also contribute to healing problems. Infection rates for these cases range from 5% to 40%, and nonunions may result from bone loss.

New approaches needed

Andrew H. Schmidt

Andrew H. Schmidt

Current antibiotic treatment regimens for open fractures do not meet current standards of evidence-based practice. Schmidt highlighted work from the Surgical Infection Society and Carl J. Hauser, MD, FACS, FCCM, indicating that most evidence supporting prophylactic antibiotic administration for open fractures is more than 30 years old. For example, Schmidt noted that the use of first-generation cephalosporin to treat type 1 and 2 open fractures remains the gold standard for antibiotic treatment despite its introduction 40 years ago.

However, he said that knowledge of the microbiology and the pathophysiology of surgical site infections has grown tremendously in the last decade, suggesting that new approaches are necessary. “These virulent strains of Staphylococcus aureus and other organisms have specific receptors for proteins that are found on the surfaces of bone and cartilage,” he said. “We need to prevent these bacteria from having access to the soft tissue. You can do that by using antibiotics and performing your debridement.”

An open femur fracture, which had been impaled in mud, is shown. At the time of initial surgical debridement, the mud can be seen on the surgical instrumentation. Because of the gross contamination, external fixation was initially employed to allow for repeated debridement, before intramedullary nailing was eventually performed.

An open femur fracture, which had been impaled
in mud, is shown. At the time of initial surgical
debridement, the mud can be seen on the surgical
instrumentation. Because of the gross
contamination, external fixation was initially
employed to allow for repeated debridement,
before intramedullary nailing was eventually
performed.

Image: Schmidt AH

LEAP study

In a Lower Extremity Assessment Project study, Pollack and colleagues showed that antibiotics may be more important for infection prevention than time to surgery. The researchers studied time to debridement and infection in 315 patients with open fractures at eight level-1 trauma centers. The study revealed that time to surgery was not a significant factor for infection.

“But, they did find that time to from injury to admission at the definitive treating institution did matter, and they suspect that that was a surrogate description of how quickly the patients were given antibiotics,” Schmidt said.

The surgeon should debride the wound “at the earliest possible opportunity and involve both an experienced orthopedic surgeon and plastic surgeon,” he said. Type 1 and 2 open wounds can usually be closed immediately. Type 3 open fractures may require more than one debridement, but should still be closed or covered within a few days. Grossly contaminated fractures that occurred in stagnant water or on farms remain the most problematic.

“Early soft tissue coverage remains the tenet of treatment for these injuries,” Schmidt said. – by Renee Blisard Buddle

References:
Hauser CJ. Surg Infect (Larchmt). 2006;7(4):379-405.
Pollak AN. J Bone Joint Surg Am. 2010;doi:10.2106/JBJS.H.00984.
Schmidt AH. Open fractures – Timing and debridement: What’s new. Presented at: Orthopedics Today Hawaii; Jan. 13-16, 2013; Kohala Coast, Hawaii.
For more information:
Andrew H. Schmidt, MD, can be reached at Hennepin County Medical Center, Department of Orthopaedic Surgery, 701 Park Ave., mailcode G2, Minneapolis, MN 55415; email: schmi115@umn.edu.
Disclosure: Schmidt is on the Board of Directors of the Orthopaedic Trauma Association, receives royalties from Thieme Inc.; is a consultant for Medtronic Inc.; is a contracted researcher for the Department of Defense and Twin Star Medical Inc.; and owns interest in Conventus Orthopaedics, Anthem VAN, International Spine & Orthopaedic Institute and Twin Star Medical.