Evolution in the Acute Management of Open Fracture Treatment? Part 2

Abstract

Introduction: In the first installment of this two-part series, we explored the history of open fracture treatment focusing primarily on bacteriology and antibiotic selection/stewardship. In this follow-up segment, we will analyze and summarize the other aspects of open fracture care such as time to debridement, pulsatile lavage, and open wound management (including time to closure)-finishing with summative statements and recommendations based on the current most up-to-date literature.

Type III Gustilo–Anderson open fracture does not justify routine prophylactic Gram-negative antibiotic coverage

“…The wounds in type III fractures have thus been managed by delayed wound closure until several days post-injury to allow drainage of any slowly accumulating infectious materials 34 , 35 . Naturally, the profiles of the causative organisms differ, with a higher proportion of Gram-negative species being associated with wounds closed in a delayed fashion 7 . Jenkinson et al clearly demonstrated that Gram-negative pathogens increased more in a delayed wound closure group compared with a primary closure group, even for open fractures with the same severity 35 .…”

“…Early intravenous administration of prophylactic antibiotics in open fractures is currently the standard of care for prevention of surgical site infection (SSI) 1 – 7 . Antibiotics should be initiated as soon as possible after injury 8 , 9 , and specifically within 3 h at the latest 3 , 7 , 9 , 10 .…”

“…Early intravenous administration of prophylactic antibiotics in open fractures is currently the standard of care for prevention of surgical site infection (SSI) 1 – 7 . Antibiotics should be initiated as soon as possible after injury 8 , 9 , and specifically within 3 h at the latest 3 , 7 , 9 , 10 . In particular, Gustilo–Anderson type III open fractures have the highest risk of infection compared with the less severe type I and II fractures 11 – 13 .…”

“…Gustilo et al reported that 77% of cultures isolated from infected type III fractures showed Gram-negative pathogens, leading to the suggestion that a first-generation cephalosporin with addition of an aminoglycoside should be administered 12 . Over the last decade, there has been renewed interest in aminoglycoside-sparing regimens to reduce adverse effects, including acute kidney injury 3 , 4 , 7 . Most studies have reported no significant differences in infection rate compared with the use of aminoglycosides 4 .…”

Traumatic soft tissue defects: a perspective review on reconstruction and communication priorities from the orthopaedic trauma surgeon as a partner in care

“…Li et al [40] found NPWT was associated with reduced surgical site infections in meta-analysis of 45 randomized-control trials compared with soft dressings. However, the WOLFF study, a multicenter randomized trial in patients with severe open lower limb fractures, did not identify differences in the rate of infection or self-rated disability compared to standard dressings [41] . Recent literature comparing NPWT to antibiotic bead pouches suggests that NPWT may be overutilized, provide inferior results, and cost more than antibiotic bead pouches in the management of open fractures pending soft tissue reconstruction [42] .…”