Zdravotnické
nakladatelství
Galén
© Česká společnost
pro ortopedii
a traumatologii 2006
Úvodní strana / Home
Webmaster
Provozovatel webu
AKTUÁLNÍ ČÍSLO
ARCHÍV
PERIODIKUM
REDAKČNÍ RADA
POKYNY PRO AUTORY
INSTRUCTIONS
TO AUTHORS
PŘEDPLATNÉ
SUBSCRIPTION
INZERCE
Souborný referát / Current concepts review
ACTA CHIRURGIAE ORTHOPAEDICAE ET TRAUMATOLOGIAE ČECHOSL.,
73, 2006, p. 301
Open Fractures and Infection
Otevřené zlomeniny a infekce
Th. NEUBAUER1, G. S. BAYER2, M. WAGNER1
1 Department of Traumatology, Wi lhelminenspital der Stadt Wien, Austr ia
2 Department of Plast ic and Reconstruct ive Surgery, Wi lhelminenspital der Stadt Wien,
Austr ia
SUMMARY
Open fractures still represent a major challenge for the treating surgeon and frequently demand
a complex of soft tissue and bone procedures to achieve an undisturbed healing with adequate limb
function. However, despite improvement in operative techniques and antibiotic therapy septic
complications still occur in severe open fracture forms up to 50%. They are still deleterious for the patient
as well as a major economic factor for the treating hospital. Radical (repetitive) debridement of the wound
and coverage of soft tissue defects are of utmost importance in the prophylaxis of septic complications
along with antibiotic therapy. If the local wound requires flap coverage, early performed procedures yield
a clear decrease of infection rates even in most severe fracture forms. Osseous stabilization contributes
to infection prophylaxis, especially when the implants can be inserted in a minimal invasive way and
provide an adequate handling of soft tissues and the wound. Thus, most often intramedullary nails and
external fixators are used today for osteosynthesis. Recently developed plates with angular stability offer
a promising alternative even in open fractures, especially when there is an extension of the fracture into
the meaphyseal area though indications have to be evaluated. Manifest septic complications demand an
early and aggressive approach with radical eradication of the septic topic. While acute infections require
most often only minor surgical procedures and offer the chance to leave implants in situ, chronic
infections usually demand complex reconstructive measures of bones and soft tissues.
Key words: open fractures, classification, soft tissue coverage, infection.
INTRODUCTION
Infection still represents one of the major complications in the treatment of open fractures though results
have improved during the last century. Break down of the tissue barrier between the fracture zone and the
environment leaves the underlying bone prone to direct contact with contaminating agents, mirrored in
positive wound cultures up to 60 %-70 % (22, 57, 58). Figures from the 19th century demonstrate that in
preceding centuries the major concern was the survival of the patient with primary mortality rates of about
50 % and another 40 % mortality in subsequent amputations (24, 42). Due to improved aseptic and
operative techniques, survival rates of the patients increased. However, loss of the injured extremity due
to wound infection and non-union was of major concern, especially when combined with a major vascular
trauma (9). Though survival of the patient as well as salvage of the extremity can be achieved today in
most patients, open fractures are still prone to complications. Ochsner (49) found in ORIF procedures an
over-all infection rate of 6,2 % in open fractures compared to 1,9 % in closed fractures. Depending on the
anatomic site and on the severity of soft-tissue trauma up to 50 % infectious complications have been
reported (15, 22, 73) with the tibia being most often affected (53, 64). Thus, subsequent chronic osteitis
and/or non-union still represent today a major source of disability and decreased quality of life for the
individual patient as well as a socio-ecconomic problem for public health systems.
CLASSIFICATION
As the severity and amount of the soft tissue damage
determine a complex treatment concept of surgical and
conservative measures, classification of these fractures
is of utmost importance. The classification system of
Gustilo et al. was established in 1976 (22) and still
included important parameters like the skin wound,
amount of muscle damage and fracture type (Table 1),
which allowed to draw therapeutic conclusions for an
individual fracture. Gustilo et al. (23) modified the
classification in 1984 by dividing fracture type III into
subclasses A, B and C (Table 2) depending on the
coverage of bone by soft tissues and vascular
compromise, respectively. Though accused of high inter
-observer errors due to subjective influence on injury
description (4), Gustillo's system still represents
a global classification system for open fractures. It's
simplicity makes it prone for the use in clinical routine and it's subgroups allow prognostic conclusions in
respect to possible complications, which increase with Gustillo's classification number (43, 45, 73). Muhr
(47) reported in a survey of the literature the risk of acute infection in open fractures Gustillo's grade I with
0 %-2 %, in type II fractures of 5 % and in type III fractures of up to 10 %-25 %, respectively. Weiz-
页码,1/10(W)w
2011/6/7http://www.achot.cz/detail.php?stat=1
Marschall (73) found a similar distribution in the
American literature with 0 % infection rate in type I, up
to 12 % in type II and up to 50 % in type III fractures.
Other classification systems like the classification
system of Tscherne and Oestern (68) (Table 3) and the
AO Müller Classification (63) (Table 4) provide more
refined descriptions of the local situation, as lesions of
bone, soft tissues and neurovascular structures and the
grade of contamination are evaluated seperately. On
the other hand their detailed classification of different
parameters in an open fracture result in a descriptive
complexity, which makes communication in daily routine
more difficult than Gustillo's classification. In many fractures the whole amount of soft tissue damage can
be comprehended yet a few days after the trauma, when demarcation of necroses is delayed (Fig. 1).
Thus, independently on the system used, classification of an open fracture should be re-evaluated after
the initial debridement (68).
PATHOMECHANISM OF INFECTION
Contamination and virulence
Contamination of the wound is dependent on the kind of
accident with rates of primary colonization being
reported as high as 70 %-80 % (23, 37, 58, 59).
Smears reveal most often Gram-positive Staph. aureus
and epidermidis and in Gram-negative species Bacilli,
Pseudomonas, Acinetobacter or Enterobacteriae (22,
40, 45, 51, 52, 61, 64). Though the microbiological
pattern at the wound site may be influenced by
environmental factors (agricultural injury, gun-shot
injury, water injury?) which have to be considered in the
antibiotic management (37, 66, 76) it is well known that
most infections in open fractures are of nosocomial
origin as causative micro-organisms of infection are
different to those found in initial smears (40, 45).
Kindsfater et al. (37) reported that 25 % of infections
were caused by micro-organisms found in initial
examinations and Lee (40) evaluated only 8 % of
microorganisms on pre-debridement cultures to be the
infectious agens. Thus, infection rates can be positively
influenced by prophylactic, hygenic requirements.
Rojcyk et al. (58) demonstrated that coverage of the
wound with a sterile dressing at the accident site and
it's removal under sterile conditions in the operating
room can reduce the infection rate from 19,2 % to 4,3
% (Fig. 2).
In contrast to their number the virulence of inoculated
micro-organisms cannot be influenced in the stadium of
the acute trauma. Only a long lasting and global change
of treatment strategies with avoidance of uncritical and
unexperienced use of antibiotics can provide
a successful reduction of the selection and infection
with problematic micro-organisms like multiresistant
staphylococci (MRSA / MRSE, ORSA / ORSE).
Local and general factors of defence
Vascularity at the fracture site represents the most
important factor in the local defence of inocculated
micro-organisms. It's importance is mirrored in high
rates of infectious complications (11, 64, 66) in
Gustillo's IIIC fractures. Additionally, wound morphology
at the fracture site contributes to the multiplication of
microorganisms when caves, restricted fluids or
hematomas provide an excellent local environment.
From a biological point of view fracture stabilization with
implants increases the local compromise to the soft
tissues by adding a surgical trauma and inserting
a foreign body (45). On the other hand, there is
evidence that fracture stabilization decreases the rate
of septic complications (25, 74). Thus, osteosynthesis
techniques preserving the soft tissues by a minimal
approach while providing a high amount of stability will
contribute to the prophylaxis of infection. For diaphyseal
fractures these techniques include the external fixator,
the unreamed nail and minimal invasively inserted
plates bridging the fracture zone.
Systemic factors
As most open fractures are caused by considerable trauma, the percentage of associated injuries in these
patients is high and polytrauma not uncommon. Muhr (48) reported in a survey of the literature 30
页码,2/10(W)w
2011/6/7http://www.achot.cz/detail.php?stat=1
Fig. 1. Z. W., 39 years, motorcycle accident, male,
sustained open tibial fracture Gustillo IIIc, with traumatic
dissection of the posterior tibial artery:
a) Osseous lesion represented an irregular 43-C.3
fracture with an associated segmental fibula fracture at
three levels.
b) Dorsomedial laceration of the skin with distinct
subcutaneous degloving injury, local muscle destruction
and disruption of the posterior tibial artery; (AO - class.:
43 C3, IO4, MT4, NV3).
% polytrauma patients among open fractures and Schandelmeier et al. (60) found in a group of IIIB tibia
fractures only 18 % isolated injuries. Therefore additional systemic compromise due to multiorgan failure
or a suppressed immune system may influence the local situation in these patients. In elderly patients and
low-energy trauma pre-existing vascular disease may add further compromise to the local situation,
especially in certain anatomic areas - like the tibia - with preexisting critical vascularity.
THERAPY OPTIONS
Open fractures are emergencies and require prompt and adequate treatment including a complex of
combined bone and soft tissue procedures. The aim of treatment in open fractures is the restoration of the
limb's full function by an adequate healing of soft tissues and bone without infection (26, 66). By
respecting the established therapeutic principles complications, especially infection rates, can be
improved dramatically (Table 5).
Local debridement and soft-t issue care
The quality of the initial debridement represents the key
-point in the treatment of open fractures and their
infection prophylaxis (66). Radical removal of all
devitalized tissues along with a copious irrigation of the
wound are of paramount importance (22, 35, 48) as the
nutritial basis for micro-organisms is removed and the
number of inoculi can be reduced by 80 % (47).
However, one has to consider that irrigation with high
pressure pulsatile systems can add tissue damage and
propagate foreign bodies or bacteria deeper into the
wound (27). Debridement must include all bone areas
of uncertain vascularity, which can decrease infection
rates dramatically by 33 % (12).
The time elapsing between injury and the start of
operative wound debridement is considered as an
important factor contributing to the prophylaxis of
wound infections (11, 26, 31, 36, 37). Though not
proofed by evidenced data, a positive influence on bone
healing and wound infections can be observed when
initial debridement is started within 6 hours from injury.
In most severe soft tissue damage even primary
amputation has to be considered, to avoid prolonged
disability and a limb without function after many
reconstruction attempts. Especially in polytrauma
patients with a critical general state the rule "limb for
life" still has it's values. Objective and absolute criterias
for primary amputation in open tibia fractures were defined by Lange et al. (39) as a prolonged ischemia
of more than 6 hours in IIIC fractures and a complete destruction of the posterior tibial nerve with loss of
protective sensation in adults. Discrimination between a salvagable or non-salvagable extremities may be
supported by the MESS-score (28). It represents a relative easily assessable scoring system, where
values of >7 pts. being absolute predictable for amputation (Table 6).
Antibiotic treatment
Systemic administration of antibiotics represented one
key-point in Gustilo's treatment concept (22) and it has
been proofed that the infection rate in open fractures
can be reduced by it. Patzakis et al. (51) demonstrated
in a prospective, randomized trial of 333 open fractures
that infection rates decreased to 2,3 % by the
administration of cephalothin compared to 13,9
% infections in the group without antibiotic treatment.
The selection of antibiotics should be based on the
microbiological findings and must especially cover
nosocomial pathogens like Staphylococcus aureus,
Gram negative bacilli or Pseudomonas aeruginosa (22,
51, 57, 66, 74). A widely used combination, covering
Gram positive as well as Gram negative
microorganisms, includes a first generation cephalosporine and aminoglycosides (45, 76); it can be
adapted to special injury patterns and environmental situations like farmyard accidents, water injury or
wounds with fecal contamination (66). Antibiotic treatment should be started as soon as possible after the
injury and maintained long enough to destroy all micro-organisms. On the other hand development of
resistant pathogens and secondary infections under a prolonged therapy have to be avoided. Therefore, it
seems reasonable to limit antibiotic treatment for three days with repeated three days administrations for
major surgical procedures and for wound closure (52, 66, 76).
Local antibiotic carriers
Local antibiotic carriers provide high tissue levels of the drugs and almost no systemic toxicity, which is
especially useful in severe soft-tissue damage and gross contamination and/or impaired vascularity. Most
often gentamycin augmented beads are used to support the antimicrobic activity of parenteral
administered antibiotics (46, 50). Ostermann et al. (50) observed a decrease of the over all infection rate
of open fractures from 12 % down to 3,7 % when an antibiotic therapy with tobramycin,l cefazolin and
penicillin was supplemented by local antibiotic beads. This differences seem to be especially significant in
severe fracture forms (62). Antibiotic beads can fill contaminated primary or secondary bone defects till
they can be definitively operated on.
Facture stabil ization
Most open fractures - especially of higher grade (GII/GIII) - are unstable and require surgical fixation.
Apart from facilitated nursing and early mobilization of the patient the mechanic stability achieved by
页码,3/10(W)w
2011/6/7http://www.achot.cz/detail.php?stat=1
c) After emergency debridement and surgery of the soft
tissues the resulting skin defects were left open and
covered temporarily with Epigard?. The tibia was fixed
with a LCP-distal tibia plate inserted via minimal
invasive approach while the segmental fibula fracture
was stabilised with ESIN rod.
d) End - end anastomosis of the posterior tibial artery at
emergency surgery.
e) Follow-up debridements resulted in distinct skin and
soft tissue defects dorsomedially, though arterial repair
was still covered by vital tissues.
f) Proximal defect was covered by a gastrocnemius flap
and healed uneventful. Distal defect was covered by
a free vascularized gracilis flap, which was lost due to
venous thrombosis. Revision surgery after flap removal
and covarage with microvascular latissimus dorsi flap
osteosynthesis contributes to the prophylaxis of bone /
soft-tissue infections (74). The choice of implant must
be adapted to the "personality of the fracture",
especially the anatomic site, the amount of soft tissue
damage and the degree of contamination. Implant
selection in the acute situation sometimes has to find
a compromise between an optimal biomechanic
solution and a possible implant-interference with local
wound management. So external fixators,
intramedullary nails (IMN) and percutaneously inserted
plates are viable options in open fractures. However,
definitive stabilization must not be achieved initially at
all costs as temporary administration of an external
fixator with conversion to internal fixation after soft
tissues recovery represents a reasonable treatment
concept (2).
External f ixator (E. F.)
Application of an E. F. is usually quickly achieved with
no implant material submerged beneath the skin. Thus,
heavily contaminated fractures, extensive soft tissue
damage or selected situations of polytraumatized
patients are prone to the treatment with external fixators
as the fixator pins usually do not interfere with local
wound care. However, the pin positions have to be
considered when a flap coverage is planned, to avoid
irridation of the flap design. Furthermore, external
fixation alone till osseous union is affected by
complications at the pin sites, malunion, refractures,
deep infection and non-union. Septic complications
often originate from pintrack infections (12, 21, 29)
when conversion to intramedullary stabilization is
delayed (15) where infection rates of nearly 50 % are reported (44). On the other hand Blachut et al. (2)
yielded excellent functional results with only 5 % septic complications, when conversion to IMN was
performed as early as two weeks after injury. Schandelmayer et al. (60) reported in Gustilo IIIb fractures
of the tibia the functional impairment due to a reduced mobility of the ankle joint and toes clearly
increased in the group of external fixator compared to IMN.
Intramedullary nails
Nailing as the golden standard for the treatment of shaft
fractures can be also used in open fractures of type I-III
(2, 3, 38, 67). Krettek et al. (38) evaluated in a meta-
analysis of open tibia fractures with 341 UTN
stabilizations an over-all infection rate of 4 %-9 %, with
7 %-24 % infections in grade G III fractures. In
comparison to external fixation no significant difference
can be found in the time required for bone healing and
in the rate of deep infection (Table 7). However,
Bhandari et al. (1) reported in a survey of randomised
studies with 396 patients and open tibia fractures
a significant lower incidence of reoperations, superficial
infections and malunions when the treatment consisted
of unreamed nails.
页码,4/10(W)w
2011/6/7http://www.achot.cz/detail.php?stat=1
showed successful healing without infection. Soft tissue
situation 6 months after coverage.
g) Radiographs 18 months after trauma reveal osseous
bridging of the fracture zone on the lateral side, though
medial bridging is uncertain.
h) 18 months after trauma patient works in preinjury
occupation and shows unlimited range in knee and
ankle joint, though some pains are reported in the lower
leg after long distance walking (a, b).
Though experimental evidence exists, that unreamed
nailing results in less endosteal vascular compromise
than reamed procedures, prospective randomized studies comparing both nailing techniques did not show
a significant difference in infection rates (14, 3