Predisposing factors for early infection in patients with open fractures and proposal for a risk score

Abstract

BackgroundThe primary goals of orthopedic treatment of open fractures are to prevent infection, stabilize bone injury and restore limb function. The objective of the current study was to identify risk factors associated with infection in patients suffering from open fractures, using the strength of association of these factors to propose a score that enables risk stratification in initial care.Materials and methodsA retrospective analysis was performed on 122 patients who underwent open fracture treatment. Clinical and demographic data were collected and the results were divided into two groups: those without infection and those with infection. Both groups were evaluated searching for associated factors that could lead to infection.ResultsThirty-one patients out of 122 were infected (25.4 %). Infection was significantly associated with exposure time up to 24 h (mean 30.3 h; p = 0.007). Fractures classified as Gustilo III had a greater chance of infection (74.2 %; p = 0.042), especially type IIIB (41.9 %). Fractures classified as Tscherne II and III had a greater chance of infection (48.4 and 25.8 %, respectively; p = 0.001).ConclusionsIt was possible to show that the exposure time and the types of fracture classified as Gustilo III and Tscherne II and III are associated with the outcome of infection. It was also possible to create a risk score (IRS) for predicting infection in these types of fractures, which can be used in the initial care of the patient, with a sensitivity of 0.840, specificity of 0.544, cut-off of 6.5 and area under the curve of 0.709 (p = 0.002).Level of evidenceLevel III.

Risk factors for infectious complications after open fractures; a systematic review and meta-analysis

“…Internal fixation was compared to external fixation in 16 studies (four RCTs, five prospective, eight retrospective) [8,21,22,24,35,39,50,54,114,115,118,141,[171][172][173][174][175]. Heterogeneity was large (p=<0.00001, I 2 =79%); sensitivity analysis did not change this.…”

“…Thirteen articles mentioned age as a risk factor, most reported mean age (N=10, 1,819 fractures), [8,[17][18][19][20][21][22][23][24][25] others median age (N=3, 1,477 fractures) [26][27][28]. Using those that presented age in means with standard deviations (SD) did not demonstrate significant differences between infected and non-infected patients.…”

“…BMI was only described in two articles [8,19], both reporting mean values with SD. No significant difference was encountered between those with and without infectious complications.…”

“…Patients often require more than one surgical debridement, are prescribed many different antibiotics, and still, the rate of amputation due to chronic osteomyelitis or severe soft tissue infection ranges from 4.2 to 10.6% [5][6][7]. Preventing infection should therefore be one of the main goals in the primary treatment of a patient with a severe soft tissue injury [8].…”

Factors Associated With the Development of Early Infection After Surgical Treatment of Fractures

“…Bowen and Widmaier 6 investigated risk factors for infection after open fractures, and the only predictor for infection they found was tobacco use. Matos et al 16 also looked for risk factors for acute infection in open fractures and found an association between increased time until treatment and risk of infection. Oliveira et al 17 analyzed the risk of infection in 1,103 patients with closed fractures who underwent internal fixation compared with 1,887 open fractures, and found a higher incidence of infection in cases of exposed fractures.…”