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Adeel Husain PGY 3 Loma Linda University Dept of Orthopaedic Surgery

Open Fractures. Adeel Husain PGY 3 Loma Linda University Dept of Orthopaedic Surgery. Definition. Break in the skin and underlying soft tissue leading directly into or communicating with the fracture and its hematoma. History. Last century, high mortality with open fractures of long bones

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Adeel Husain PGY 3 Loma Linda University Dept of Orthopaedic Surgery

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  1. Open Fractures Adeel Husain PGY 3 Loma Linda University Dept of Orthopaedic Surgery

  2. Definition • Break in the skin and underlying soft tissue leading directly into or communicating with the fracture and its hematoma

  3. History • Last century, high mortality with open fractures of long bones • Early amputation in order to prevent death • WWI, mortality of open femur fractures > 70% • 1939 Trueta “closed treatment of war fractures” • Included open wound treatment and then enclosure of the extremity in a cast • “Greatest danger of infection lay in muscle, not bone” Trueta J: "Closed" treatment of war fractures, Lacet 1939;1:1452-1455

  4. History • 1943 PCN on the battlefield quickly reduced rate of wound sepsis • Delayed closure of wounds • Hampton: closure btwn 4th and 7th day • Larger defects continued to be left open to heal by secondary intention Hampton OP Jr: Basic principles in management of open fractures; JAMA 1955; 159:417-419

  5. History • Advances shifted the focus • Preservation of life and limb  preservation of function and prevention of complications • However, amputation rates still exceed 50% in the most severe open tibial fractures assoc with vascular injury* Lange RH, Bach AW, Hansen ST et al: Open tibial fractures with associated vascular injuries: prognosis for limb salvage. J Trauma; 25(3):203-208

  6. Epidemiology • 3% of all limb fractures • 21.3 per 100,000 per year

  7. Open fracture classification • Allows comparison of results • Provides guidelines on prognosis and treatment • Fracture healing, infection and amputation rate correlate with the degree of soft tissue injury • Gustilo upgraded to Gustilo and Anderson • AO open fracture classification • Host classification of open fractures

  8. Gustilo and Anderson Classification • Model is tibia, however applied to all types of open fractures • Emphasis on wound size • Crush injury assoc with small wounds • Sharp injury assoc with large wounds • Better to emphasize • Degree of soft tissue injury • Degree of contamination

  9. Type 1 Open Fractures • Inside-out injury • Clean wound • Minimal soft tissue damage • No significant periosteal stripping

  10. Type 2 Open Fractures • Moderate soft tissue damage • Outside-in • Higher energy • Some necrotic muscle • Some periosteal stripping

  11. Type 3a Open Fractures • High energy • Outside-in • Extensive muscle devitalization • Bone coverage with existing soft tissue

  12. Type 3b Open Fractures • High energy • Outside in • Extensive muscle devitalization • Requires a flap for bone coverage and soft tissue closure • Periosteal stripping

  13. Type 3c Open Fractures • High energy • Increased risk of amputation and infection • Any grade 3 with major vascular injury requiring repair

  14. Why use this classification? • Grades of soft tissue injury correlates with infection and fracture healing

  15. Gustilo and AndersonBowen and Widmaier* • 2005 Host classification predicts infection after open fracture • Gustilo and Anderson classification and the number of comorbidities predict infection risk • 174 patients with open fractures of long bones • Sorted into three classes based on 14 immunocompromising factors • Age>80, current nicotine use, DM, malignancy, pulmonary insufficiency, systemic immunodeficiency, etc Bowen TR, Widmaier JC. Host classification predicts infection after open fracture. Clin Orthop Relat Res. 2005;433:205-11.

  16. What they found… • Patients with any compromising risk factor has increased risk of infection • May benefit from additional therapies that decrease the risk of infection. Bowen TR, Widmaier JC. Host classification predicts infection after open fracture. Clin Orthop Relat Res. 2005;433:205-11.

  17. Gustilo Classification: a simple and useful tool, but is it accurate? • 1994 Brumback et al. • 125 randomized open fractures • 245 surgeons of various levels of training • 12 cases of open tibia fractures, videos used • Interobserver agreement poor • Range 42-94% for each fracture • Ortho attendings - 59% agreement • Ortho Trauma Fellowship trained attendings - 66% agreement Brumback RJ, Jones AL (1994) Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two hundred and forty-five orthopaedic surgeons. J Bone and Joint Am; 76(8):1162–1166.

  18. So………. • Fracture type should not be classified in the ER • Most reliably done in the OR at the completion of primary wound care and debridement

  19. Microbiology • Most acute infections are caused by pathogens acquired in the hospital • 1976 Gustilo and Anderson • most infections in their study of 326 open fxs developed secondarily • When left open for >2wks, wounds were prone to nocosomial contaminants such as Pseudomonas and other GN bacteria • Currently most open fracture infections are caused by GNR and GP staph Gustilo RB, Anderson JT: Prevention of Infection in the Treatment of One Thousand and Twenty-five Open Fractures of Long Bones; JBJS, 58(4):453-458, June 1976

  20. Nocosomial infection?!!!! Cover the wounds quickly • Only 18% of infections were caused by the same organism initially isolated in the perioperative cultures* • Carsenti-Etesse et al. 1999 • 92% of open fracture infections were caused by bacteria acquired while the patient was in the hospital** *Patzakis MJ, Wilkins J, Moore TM: Considerations in reducing the infection rate in open tibial fractures. Clin Orthop Relat Res. 1983 Sep;(178):36-41. *Patzakis MJ, Bains RS, Lee J, Shepherd L, Singer G, Ressler R, Harvey F, Holtom P: Prospective, randomized, double-blind study comparing single antibiotic therapy, ciprofloxacin, to combo antibiotic therapy in open fracture wounds. J Orthop Trauma. 2000 Nov;14(8):529-33. **Carsenti-Etesse H, Doyon F, Desplaces N, Gagey O, Tancrede C, Pradier C, Dunais B, Dellamonica P. Epidemiology of bacterial infection during management of open leg fractures. Eur J Clin Microbiol Infect Dis. 1999;18:315-23.

  21. Common bacteria encountered with open fractures

  22. What systemic antibiotic? (Gustilo, et al; JBJS 72A 1990)

  23. Antibiotic comparisons • No difference btwn clindamycin and cefazolin* • Patzakis et al. ** • For type 1&2, cipro = cefamandole+gentamicin • For type 3, cipro worse (31% vs 7.7% infection) • Cipro and other fluoroquinolones inhibit osteoblast activity and fracture healing*** *Benson DR, Riggins RS, Lawrence RM, Hoeprich PD, Huston AC, Harrison JA. Treatment of open fractures: a prospective study. J Trauma. 1983;23:25-30. **Patzakis MJ, Bains RS, Lee J, Shepherd L, Singer G, Ressler R, Harvey F, Holtom P. Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds. J Orthop Trauma. 2000;14:529-33. ***Holtom PD, Pavkovic SA, Bravos PD, Patzakis MJ, Shepherd LE, Frenkel B. Inhibitory effects of the quinolone antibiotics trovafloxacin, ciprofloxacin, and levofloxacin on osteoblastic cells in vitro. J Orthop Res. 2000;18:721-7. ***Huddleston PM, Steckelberg JM, Hanssen AD, Rouse MS, Bolander ME, Patel R. Ciprofloxacin inhibition of experimental fracture healing. J Bone Joint Surg Am. 2000;82:161-73.

  24. When and for how long? • Start abx as soon as possible* • Less than 3 hours  4.7 % infection rate • Greater than 3 hours  7.4% • No difference btwn 1 and 5 days of post op abx treatment** • Mass Gen recommended treatment:*** • Cefazolin Q 8 until 24 hours after wound closed • Gentamicin or levofloxacin added for type 3 *Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wounds. Clin Orthop Relat Res. 1989;243:36-40. **Dellinger EP, Caplan ES, Weaver LD, Wertz MJ, Brumback R, Burgess A, Poka A, Benirschke SK, Lennard S, Lou MA. Duration of preventive antibiotic administration for open extremity fractures. Arch Surg. 1988;123:333-9. ***Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg. 2006 Dec;88(12):2739-48.

  25. Local antibiotic therapy • High abx conc within the wound and low systemic conc • Reduces risk of systemic side effect • Vancomycin or aminoglycosides • Heat stable • Available in powder form • Active against suspected pathogens Eckman JB Jr, Henry SL, Mangino PD, Seligson D. Wound and serum levels of tobramycin with the prophylactic use of tobramycin-impregnated polymethylmethacrylate beads in compound fractures. Clin Orthop Relat Res. 1988; 237:213-5.

  26. Antibiotics - locally • Prevents secondary contamination by nocosomial pathogens • Useful adjunct to systemic abx • Potential for abx impregnated bone graft, bone graft substitute, and abx coated IMN Ostermann PA, Seligson D, Henry SL: Local antibiotic therapy for severe open fractures. A review of 1085 consecutive cases; J Bone Joint Surg Br. 1995 Jan;77(1):93-7.

  27. Pros Very high levels of antibiotics locally Dead space management Cons Requires removal Limited to heat stable antibiotics Increased drainage from wound Antibiotic Beads

  28. Goals of treatment • 1. preserve life • 2. preserve limb • 3. preserve function • Also…. • Prevent infection • Fracture stabilization • Soft tissue coverage

  29. Stages of care for open fractures

  30. Initial assessment & management • ABC’s • Assess entire patient • Careful PE, neurovasc • Abx and tetanus • Local irrigation 1-2 liters • Sterile compressive dressings • Realign fracture and splint • Do not culture wound in the ED* • 8% of bugs grown caused deep infection • cultures were of no value and not to be done • Recheck pulse, motor and sensation Lee J. Efficacy of cultures in the management of open fractures. Clin Orthop Relat Res. 1997;339:71-5.

  31. Can I take pictures with my phone and send it to my senior? • Documents characteristics accurately • Prevents multiple examinations • Decreases contamination* • Communication via digital photography was more useful than verbal communication** • 1.3-megapixel camera is comparable with higher resolution cameras when viewing color images on computer desktop*** *Tscherne H, Gotzen L, editors Fractures with soft tissue injuries. New York: Springer; 1984 **Tipmongkol V, Thepkamnoet H, Tangtrakulwanich B: Using Digital Wound Photography to Improve Communication among Orthopaedic Health Care Professionals in Orthopeadic Patients. The Thai Journal of Orthopaedic Surgery: 33 No.2: S16-20 AAOS 2010 Podium Present ***Andres BM. Response to letter to the editor re: A comparison of digital cameras -- features essential for the orthopaedic surgeon. Clin Orthop 2004; 428:309.

  32. Primary surgery • Objectives of initial surgical management • Preservation of life and limb • Wound debridement • Definitive injury assessment • Fracture stabilization Stages of open fracture management in the OR

  33. Surgical emergency! • 1898 Friedrich guinea pigs • Take to the OR within 6-8 hours* • 1973 Robson: bacteria multiply in contaminated wounds ** • 105 organisms/gram of tissue is the infection threshold • Reached at 5.17 hours • 1995 Kindsfater et al: • 47 G2/3 fxs at 4.8 months out…. • Less than 5 hrs  7% infection • Greater than 5 hrs  38% infection • However G3 fxs were treated later *Friedrich PL. Die aseptische Versorgung frischer Wundern. Arch Klin Chir. 1898;57:288-310. **Robson MC, Duke WF, Krizek TJ. Rapid bacterial screening in the treatment of civilian wounds. J Surg Res. 1973;14:426-30.

  34. Or not?.... Calling the “6 hour rule” into question No significant difference before or after 6 hours!!! • 1993 Bednar and Parikh…. No significant difference * • 3.4% vs 9%; 82 open femoral/tibial fxs • 2004 Ashford et al…. No significant difference ** • 11% vs 17%; pts from the austrailian outback • 2004 Spencer et al.... No significant difference *** • 10.1% vs 10.9%; 142 open long bone fxs from UK • 2003 Pollack and the LEAP investigators…. No correlation**** • 315 open long bone fxs • 2005 Skaggs et al….No significant difference ***** • children with all types of open fractures; 554 open fractures *Bednar DA, Parikh J. Effect of time delay from injury to primary management on the incidence of deep infection after open fractures of the lower extremities caused by blunt trauma in adults. J Orthop Trauma. 1993;7:532-5. **Ashford RU, Mehta JA, Cripps R. Delayed presentation is no barrier to satisfactory outcome in the management of open tibial fractures. Injury. 2004;35:411-6. ***Spencer J, Smith A, Woods D. The effect of time delay on infection in open long-bone fractures: a 5-year prospective audit from a district general hospital. Ann R Coll Surg Engl. 2004;86:108-12. ****Pollack AN, Castillo RC, Jones AL, Bosse MJ, MacKenzie EJ, and the LEAP Study Group. Time to definitive treatment significantly influences incidence of infection after open high-energy lower-extremity trauma. Read at the Annual Meeting of the Orthopaedic Trauma Association; 2003 Oct 9-11; Salt Lake City, UT. *****Skaggs DL, Friend L, Alman B, Chambers HG, Schmitz M, Leake B, Kay RM, Flynn JM. “The Effect of Surgical Delay on Acute Infection Following 554 Open Fractures in Children.” JBJS-A 2005. 87:8-12

  35. Do we even need to do operative debridement? Do we even need to debride low grade open fractures? • Orcutt et al... No significant difference, BUT…* • 50 type 1 &2 open fractures • less infection in nonoperative group (3% vs 6%) • Less delayed union in nonop group (10% vs 16%) • Yang et al….0% infections ** • 91 type 1 open fractures treated without I&D *Orcutt S, Kilgus D, Ziner D. The treatment of low-grade open fractures without operative debridement. Read at the Annual Meeting of the Orthopaedic Trauma Association; 1988 Oct 28; Dallas, TX. **Yang EC, Eisler J. “Treatment of Isolated Type 1 Open Fractures: Is Emergent Operative Debridement Necessary?” Clin Orthop Relat Res 2003. 410: 289-294.

  36. However, after review of all literature….…. Operative debridement is the standard of care!!!! • Okike et al. states…. • “Thorough operative debridement is the standard of care for all open fractures.” • “Even if the benefits of formal I&D were insignificant for low grade fractures, operative debridement is still required for proper wound classification.” • “Open fractures graded on the basis of superficial characteristics are often misclassified.” • Huge risk not to explore and debride! Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg Am. 2006 Dec;88(12):2739-48.

  37. URGENTLY debride, not EMERGENTLY Within 24 hours Within 6 hours • Time to OR is probably less important than:* • Adequacy of debridement • Time to soft tissue coverage • Timing depends on….** • Is patient stable? • Is the OR prepared? • Is appropriate assistance available? • Ortho trained scrub techs, assistant surgeons, xray techs, and other OR staff • 2005 Skaggs et al:*** • If after 10pm, keep until the morning! Or at least within 24 hours. • Unless…. • neurovasc compromise • horrible soft tissue contamination • compartment syndrome *Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg. 2006 Dec;88(12):2739-48. **Werner CM, Pierpont Y, Pollak AN: The urgency of surgical débridement in the management of open fractures. J Am Acad Orthop Surg. 2008 Jul;16(7):369-75. ***Stewart DJ, Kay RM, Skaggs DL: Open Fractures in Children. Principles of Evaluation and Management. JBJS-A. 2005;87:2784-2798.

  38. I&D in the OR • Trauma scrub • Soap and saline to remove gross debris • “Zone of injury” • Skin wound is the window through which the true wound communicates with the exterior • Extend the traumatic wound • Excise margins • Resect muscle and skin to healthy tissue • color, consistency, capacity to bleed and contractility • Bone ends are exposed and debrided • Irrigate • Serial debridements? • If needed, 2nd or 3rd debridement after 24-48 hours should be planned

  39. The Irrigation • Amount • No good data, copious is better • Animal studies show improved removal of particulate matter and bacteria but effect plateaus • Irrigation bags typically contain 3 L of fluid • Anglen recommends:* • 3L (one bag) for type 1 • 6L (two bags) for type 2 • 9L (three bags) for type 3 *Anglen JO. “Wound Irrigation in Musculoskeletal Injury.” JAAOS 2001. 9: 219-226.

  40. How to deliver the irrigation?(what animal studies show) • Bulb Syringe vs Pulsatile Lavage • Pulsatile lavage • Detrimental for early bone healing • this is no longer present at 2 wks* • More soft tissue destruction** • More effective in removing particulate matter and bacteria*** • High or low pressure? • Higher pressure • Better bone cleaning • Worse soft tissue cleaning • Slows bone healing *Dirschl DR, Duff GP, Dahners LE, Edin M, Rahn BA, Miclau T. “High Pressure Pulsatile Lavage Irrigation of Intraarticular Fractures: Effects on Fracture Healing.” JOT 1998. 12(7): 460-463. **Boyd JI, Wongworawat MD. “High-Pressure Pulsatile Lavage Causes Soft Tissue Damage.” CORR 2004. 427: 13-17 ***Bhandari M, Schemitsch EH, Adili A, Lachowski RJ, Shaughnessy SG. “High and Low Pressure Pulsatile Lavage of Contaminated Tibial Fractures: An in vitro Study of Bacterial Adherence and Bone Damage.” JOT 1999. 13: 526-533.

  41. Antibiotics in the irrigation? No proven benefit! • Antibiotics (bacitracin and/or neomycin) • Mixed results, controversial • Costly • bacitracin alone around $500/washout • ?? Causing resistance • Wound healing problems? • Few reported cases of anaphylaxis • Anglen: “No proven value in the care of open fracture wounds…some risk, albeit small.” *Anglen JO. “Wound Irrigation in Musculoskeletal Injury.” JAAOS 2001. 9: 219-226.

  42. Soaps in the irrigation? • Surfactants (i.e. Soaps) • Less bacteria adhesion • Emulsify and remove debris • No significant difference in infection or bone healing compared to bacitracin solution, but more wound healing problems in bacitracin group Anglen JO. “Comparison of Soap and Antibiotic Solutions for Irrigation of Lower-Limb Open Fracture Wounds: A Prospective, Randomized Study.” JBJS-A 2005. 87(7):1415-1422.

  43. Level 4 evidence based recommendations • 1st washout, highly contaminated  Soap solution • Repeat washout of clean wounds  Saline • Infected wounds  Soap, then antibiotic *Anglen JO. “Wound Irrigation in Musculoskeletal Injury.” JAAOS 2001. 9: 219-226.

  44. Dubunked! Wound closure after contaminated fracture • Timing and technique is controversial OPEN WOUND should be left OPEN! • Prevents anaerobic conditions in wound: Clostridium • Facilitates drainage • Allows repeat debridement Zalavras CG, Patzakis MJ:Open fractures: evaluation and management. J Am Acad Orthop Surg. 2003 May-Jun;11(3):212-9.

  45. To close or not to close? • Recently, renewed interest in primary closure • Collinge, OTA 2004 • Moola, OTA 2005 • Russell, OTA 2005 • DeLong, J Trauma 2004/ • Bosse, JAAOS 2002 • Improved abx management • Better stabilization • Less morbidity • Shorter hospital stay, lower cost • NO increase in wound infection • These wounds are at higher risk of clostridia perfringens if they do get infected. • 1999 Delong et al: 119 open fxs • No significant difference • delayed/nonunion and infection rates btwn immediate and delayed closure • Immediate closure is a “viable option” DeLong WG Jr, Born CT, Wei SY, Petrik ME, Ponzio R, Schwab CW: Aggressive treatment of 119 open fracture wounds. J Trauma. 1999 Jun;46(6):1049-54.

  46. Contraindications to primary closure • Inadequate debridement • Gross contamination • Farm related or freshwater immersion injuries • Delay in treatment >12 hours • Delay in giving abx • Compromised host or tissue viability

  47. When to cover the wound? • ASAP after wound adequately debrided • Only 18% of infections are caused by the same organism isolated in initial perioperative culture* • Suggests hospital acquired etiology of infection • “Fix and Flap”** • For Type IIIB & IIIC open tibia fractures • Early if not immediate flap coverage Patzakis MJ, Bains RS, Lee J, et al. “Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds.” JOT 2000. 14: 529-533. **Gopal S, Majumder S, Batchelor A, Knight S, De Boer P, Smith RM. “Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia.” JBJS-B 2000. 82(7): 959 – 966.

  48. Dressings • Temporary closures – rubber bands • Wet to dry dressings • Semi-permeable membranes • Antibiotic bead pouch • VAC

  49. VAC • Vacuum assisted wound closure • Recommended for temporary management • Mechanically induced negative pressure in a closed system • Removes fluid from extravascular space • Reduced edema • Improves microcirculation • Enhances proliferation of reparative granulation tissue • Open cell polyurethane foam dressing ensures an even distribution of negative pressure -Webb LX: New techniques in wound management: vacuum-assisted wound closure. J Am Acad Orthop Surg. 2002 Sep-Oct;10(5):303-11. -Dedmond BT, Kortesis B, Punger K, Simpson J, Argenta A, Kulp B, Morykwas M, Webb L. “The use of Negative Pressure Wound Therapy in the Temporary Treatment of Soft Tissue Injuries associated with High Energy Open Tibial Shaft Fractures.” JOT. 2007

  50. Types of fracture stabilization • Splint • Good option if operative fixation not required • Internal fixation • Wound is clean and soft tissue coverage available • External fixation • Dirty wounds or extensive soft tissue injury

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