Retrospective analysis of risk factors for deep infection in lower limb Gustilo–Anderson type III fractures

Abstract

Background: Open fractures are among the most severe injuries observed in orthopedic patients. Treating open fractures is difficult because such patients with infections may require multiple operations and amputations. Furthermore, only a few studies have focused on antibiotic prophylaxis in open fractures and evaluated how to cover lost soft tissue to increase the success rate of reconstruction. We evaluated the risk factors for deep infection in lower limb Gustilo-Anderson (G-A) type III fractures. Materials and methods: This retrospective study investigated patients who underwent surgical procedures for lower limb G-A type III fractures between January 2007 and January 2017 at our institution. We enrolled 110 patients with 114 lower limb G-A type III fractures (77 G-A type IIIA fractures and 37 G-A type IIIB fractures) who were followed up for at least 2 years. We compared patients presenting infections with those without infections by assessing the following factors: severe contamination, diabetes, smoking, Injury Severity Scale, segmental fracture, location of fracture, G-A classification, damage control surgery, methods of surgery, timing of fixation, combination of antibiotics used, duration of antibiotic prophylaxis, timing of wound closure, and soft-tissue reconstruction failure. Results: Eighteen fractures presented deep infections. Compared with patients without infections, patients developing infections differed significantly in terms of severe contamination (P < 0.01), G-A classification (P < 0.01), duration of antibiotic prophylaxis (P < 0.01), timing of wound closure (P < 0.01), and incidence of soft-tissue reconstruction failure (P < 0.01). Skin grafting was associated with significantly higher failure rates than muscle and free flap reconstructions (P = 0.04). Treatment with antibiotics was significantly longer in patients with drug-resistant bacterial infections than in those without infections (P < 0.01). Conclusion: Early flaps rather than skin grafting should be used to cover G-A type IIIB fractures, because skin grafting resulted in the highest failure rate among soft-tissue reconstructions in open fractures. Longer duration of antibiotic use had a significant impact not only on deep infection rates but also on the presence of drug-resistant bacteria. These findings suggest that prolonged use of antibiotics should be avoided in cases of open fractures.

Bacterial Epidemiology of Surgical Site Infections after Open Fractures of the Lower Limb: A Retrospective Cohort Study

“…These results may be related to the small size of our population. Other risk factors have been previously identified: male gender, smoking, polytrauma, Gustilo grade III classification, and contaminated wounds [ 4 , 7 , 20 ].…”

“…The severity of infection, Gustilo classification, smoking, diabetes, time to antibiotic therapy initiation, and shorter duration of antibiotic prophylaxis have been identified as risk factors for the occurrence of postoperative infections [ 4 , 7 ].…”

Impact of Establishing A Level-1 Trauma Center For Lower Extremity Trauma: A 4-Year Experience

“…To assess the severity of open lower leg fractures, we evaluated the Gustilo-Anderson Classi cation of each patient. [11,12]. In the case of bone loss, which is a major condition for amputation, bone loss of 5 cm or more was con rmed by radiological evaluation.…”

Tibial bone and soft-tissue concentrations following combination therapy with vancomycin and meropenem – evaluated by microdialysis in a porcine model

“…1,2 In cases of open tibial fractures, recent studies have found that the combination of vancomycin and meropenem as first-line antibiotic therapy covers up to 93% to 96% of the encountered bacteria causing infection, most frequently being Staphylococcus aureus, Enterococcus spp., Pseudomonas aeruginosa, Enterobacter species, and coagulase-negative staphylococci (CoNS). 1,2,10 Supported by the current European Bone and Joint Infection Society (EBJIS) guidelines on prevention of fracture-related infections, 11 the diverse contamination profile demands a broad antibiotic prophylactic spectrum encompassing both Gram-positive and Gramnegative bacteria. 12 When administering antibiotics to prevent infection of a contaminated open fracture, it is essential that antibiotic target site concentrations, as a minimum, reach and remain above relevant bacteria's minimal inhibitory concentrations (MICs) for a sufficient amount of time.…”