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 Table of Contents  
ORIGINAL ARTICLES
Year : 2021  |  Volume : 36  |  Issue : 3  |  Page : 64-68

Study of early infection in open fractures of long bones


Department of Orthopaedics, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India

Date of Submission04-Oct-2021
Date of Acceptance29-Nov-2021
Date of Web Publication22-Dec-2021

Correspondence Address:
Digvijay Agarwal
Department of Orthopaedics, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun 248140, Uttarakhand.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jbjd.jbjd_17_21

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  Abstract 

Introduction: The complications associated with open fracture make the task of a surgeon difficult and also increase the financial burden. Underlying bone is exposed to contaminating agents due to breakdown of the tissue barrier between the fracture zone and the environment. It leads to an increased risk of complications such as wound infections and nonunion. Materials and Methods: We performed a prospective observational study on 82 patients presenting with open fractures of long bones treated in the year 2019 in the Department of Orthopedics, Himalayan Institute of Medical Sciences. Patients presenting with long bone open fractures within 72 h from injury to the Emergency were included in the study. All patients were clinically and radiologically followed for a period of 6 weeks. Results: Of the 82 cases, 26 developed an infection (31.70%). Fracture classified as Type IIIa had the highest infection rate (50%), whereas Type 1 had the lowest infection rate (14.3%). Infection rate in patients presenting 24 h after injury was higher than those presenting within 24 h from injury but a significant association could not be established between infection rate and late presentation from injury. Enterococcus species were the most commonly identified organism in both intraop and postop swabs (31.57%). Discussion: Trauma patients can present with chest, abdomen, or head injury, which may require emergency intervention precludes early debridement for open fracture. In our study, no significant decrease in infection rate was observed in patients undergoing debridement within 6 h from injury. However, it was also observed that open fractures presenting 24 h after injury had a higher infection rate than those presenting before it, which is in accordance with previous literature. Organisms finally causing established infection in bone were isolated mostly from postop swabs and were gram negative, which further strengthens the fact that most infections are nosocomial in origin. Conclusion: This paper furnishes the literature by validating facts, theories, and guidelines given in the past to manage open fractures. The study has limitation that the numbers of patients presenting with open fractures were less, and especially patients having common risk factors such as diabetes and anemia due to which correlation with infection rate could not be assessed effectively.

Keywords: Debridement, infection, open fracture


How to cite this article:
Maheshwari R, Agarwal D, Ratra R. Study of early infection in open fractures of long bones. J Bone Joint Dis 2021;36:64-8

How to cite this URL:
Maheshwari R, Agarwal D, Ratra R. Study of early infection in open fractures of long bones. J Bone Joint Dis [serial online] 2021 [cited 2022 Jun 25];36:64-8. Available from: http://www.jbjd.in/text.asp?2021/36/3/64/333202




  Introduction Top


Open fracture is one of the serious consequences of trauma. In such cases, no matter how small the soft-tissue lesion is, the fracture segments and its hematoma communicate with the contaminated environment through skin and adjacent soft tissues.[1] Underlying bone is exposed to contaminating agents due to breakdown of the tissue barrier between the fracture zone and the environment. It leads to an increased risk of complications such as wound infections and nonunion.[2] The complications associated with open fracture make the task of a surgeon difficult and also increase the financial burden. It has been estimated that 3.5–6 million fractures occur in the United States annually. Extrapolating from these data, it can be estimated that more than 3%, that is, 150,000, of these are open fractures.[3]

The variations in the infection rate are evident around the globe. The infection rate in open fractures being registered may vary from 0% to 50% according to Weitz Marshall and Boss, whereas Spencer et al.[4] showed the overall incidence of infection in open fractures to be approximately 10.4%. A study conducted by RahimiShorin et al.[5] found infection rate to be 1.89%, whereas a study conducted by ULABRA University, Brazil showed the infection rate to be 18.8%.[1] The possibility of infection in open fracture may depend on on degree of skin loss, soft-tissue injury, and additional risk factors such as age, contamination, any chronic illness, or systemic injury. However, most of the open fractures show changes in wound flora during the hospital stay. It has been observed that infection in open fracture cases is most often nosocomial in origin.[6]

Due to a large number of patients with open fractures and their complexity, it is necessary to study the rates of open fractures in tertiary hospitals to allow better planning and care organization for these patients. A series of 82 patients with open fractures of long bones were prospectively studied to know the incidence of open fractures and the factors associated with infection in such cases.


  Materials and Methods Top


We performed a prospective observational study on 82 patients presenting with open fractures of long bones treated in the year 2019 in the Department of Orthopedics, Himalayan Institute of Medical Sciences. Patients presenting with long bone open fractures within 72 h from injury to the emergency were included in the study. Patients who had some active source of infection such as respiratory or urinary infection or any other septic foci were excluded from the study. All patients were clinically and radiologically followed for a period of 6 weeks. All fractures were classified using Gustilo–Anderson classification.[7]

All open fractures presenting to the emergency were treated according to a fixed protocol. The wounds were clinically evaluated, subjected to surgical cleaning, and placement of sterile dressing. Temporary stabilization of the fracture was done and the first dose of antibiotic was administered as soon as the patient landed to the emergency. Gram-negative coverage in the form of aminoglycosides (e.g., Amikacin) was added for Grade III open fractures, whereas a second-generation cephalosporin (e.g., Cefuroxime) was administered to all patients presenting with open fracture. Antibiotics were continued for 24 h for Grade I, 48 h for Grade II, and 72 h for Grade III open fractures.

Depending on patient’s clinical condition, first debridement and surgical cleaning were performed as early as possible for all Grade II and III open fractures. Grade I open fractures were managed with surgical cleaning, antiseptic dressing, and temporary stabilization of fracture in emergency. First culture was taken preoperatively for Grade II and III open fractures, whereas for Grade I open fracture culture swab was taken from the punctured wound in emergency. First dressing was done on second postop day or if required earlier. Subsequent culture was taken postdebridement if the patient has been discharged from suture line or symptoms/signs of infection. Antibiotics were continued as per protocol or changed if discharge or signs of infection are present according to sensitivity. Second debridement was planned if symptoms/signs of infection persist, most importantly discharge from the suture line. All cases were followed for a period of 6 weeks to study if infection develops.


  Results Top


In the year 2019, 86 patients with open fractures of long bones were admitted by the Orthopedics team and were analyzed for inclusion in the study. Four patients were excluded because they did not have 6-week follow-up, and thus 82 patients were included in the study. The mean age was 39.18 years ranging from 5 to 84 years and most of the patients belonged to the 21–40 years age group (43.9%). Most of the patients were male (n = 69; 84.1%). The most prevalent type of fracture according to Gustilo–Anderson classification was Type III, accounting for 42.68% of all cases (35 patients). Of these, 24 patients were Type IIIa, 10 patients IIIb, and 1 patient IIIc. Type I was least prevalent, with 25.60% (21 patients) followed by 31.70% (26 patients) with Type II injury [Table 1].
Table 1: Distribution according to Gustilo–Anderson classification

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Lower limb was more frequently involved than upper limb with 78% (64 patients) of fractures involving lower limb long bones. Rate of infection was found to be higher in lower limb fractures as 25% of cultures were positive in lower limb fractures as compared to 16.7% in upper limb fractures. Patient-related factors such as diabetes, smoking, anemia, and immunosuppressive disease were evaluated as risk factors contributing to infection. None of the diabetics developed an infection, and thus no significant association could be established (P = 1.000). Similarly, of 11 smokers, 3 developed an infection but no statistically significant association could be established (P = 0.711).

Of the 82 cases, 26 developed an infection (31.70%). Of these, 3 were of Type I fracture (14.3%), 7 had Type II fracture (26.92%), and 16 had Type III fracture (45.71%). Fracture classified as Type IIIa had the highest infection rate (50%), whereas Type 1 had the lowest infection rate (14.3%) [Table 2]. A correlation was observed between the increasing grades of fracture and infection rate however an association could not be established (P = 0.612).
Table 2: Relationship between infection rate and grade of open fracture

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The time of presentation from injury ranged from 1 to 72 h, whereas emergency debridement was planned within 6 h from presentation for all Grade II and Grade III open fractures, depending on the patient’s clinical condition and associated injuries requiring emergency intervention. Grade I open fractures were treated electively depending on the availability of operation theatre but surgical cleaning with saline and aseptic dressing was done in emergency. Wound debridement of 49 patients (59.75%) was done within 24 h from injury, 21 patients (25.60%) 24–72 h from injury, and 12 patients (14.63%) 72 h after injury [Table 3]. Infection rate in patients presenting 24 h after injury was higher (33.3%) than those presenting within 24 h from injury (27.65%) but a significant association could not be established between infection rate and late presentation from injury [Table 4].
Table 3: Distribution of open fractures according to time of debridement from injury

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Table 4: Incidence of infection in open fracture wounds in comparison with time interval from trauma to first debridement

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We noted that 19 of the 82 intraop cultures grew bacteria (23.17%), whereas 14 postop cultures grew bacteria (17.07%). It was observed that only 7 of these 14 patients had bacterial growth in their intraop cultures, whereas the other 7 had no bacterial growth in their previous culture [Table 5].
Table 5: Distribution of intraop and postop swabs growing bacteria according to Gustilo–Anderson classification

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Of the 82 patients included in the study, 7 patients went on to develop an established infection in bone (8.5%). Similar organism grew in subsequent postoperative period and these patients had radiological signs on infection at 6-week follow-up. However, the organism that went on to develop an established infection was similar to intraop culture in just two cases, whereas the other five cases had a growth different from intraop culture. Enterococcus species were the most commonly identified organism in both intraop and postop swabs (31.57%). Except Staphylococcus species, all organisms identified were gram-negative bacteria [Figure 1].
Figure 1: Distribution of bacteria identified in both intra and postop swabs

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  Discussion Top


Breakdown of skin and tissue barrier exposes the fracture site to pathogens. Wound infection is a common entity with open fractures, which further can lead to chronic bacterial colonization in injured extremities. Osteomyelitis secondary to open fracture not only affects a person physically but also puts a financial burden on the patient and his family.

Gustilo–Anderson type III fractures were found to be most prevalent (42.68%), which is consistent with some previous studies on open fractures. Guerra et al.[1] in their study of 154 patients showed that 46.70% of patients were Grade III open fractures. Similar results were given by Kale et al.[6] and Matos et al.[8] with maximum number of Grade III open fractures. The values found with other fracture types (Grades I and II) were also similar to these studies reported in the past.[1],[7],[8] Bowen and Widmaier[9] showed that tobacco use and other immunological conditions are risk factors for development of infection in open fractures. Kortram et al.[10] in their meta-analysis showed that diabetes was an important risk factor for development of infection in both closed and open fractures. In our study, we had only 3 diabetic, 5 anemic, and 11 smokers. Although 27.3% smokers developed infection, association could not be established due to low sample size (P = 0.711). Similarly, with risk factors such as diabetes and anemia a significant association with infection was not confirmed (P = 1.000). In a similar study, Pollak et al.[11] did not find any association between smoking and infection.

The infection rate has varied widely in the literature. In our study, we found the overall infection rate to be 31.70%. Infection rate in our study is a bit higher as compared to other studies in the past. Spencer et al. showed an infection rate of 14.6%, Singh et al.[4] found an infection rate of 14.9%, Kamat[12] found an infection rate of 11%, and Guerra et al.[1] showed an infection rate of 18.9%. Approximately 93% of Gustilo Type III fractures were treated within 12 h in the study by Spencer et al., 69% patients were treated within 6 h in the report by Singh et al., and in the study by Kamat there were only 21.70% Grade III open fractures. However, in our study 40.24% of patients presented 24 h after injury and 42.68% of patients had Grade III open fractures. This may be the reason for the higher infection rate.

Trauma patients can present with chest, abdomen, or head injury which may require emergency intervention precludes early debridement for open fracture. There have been several studies in the past evaluating effect of early debridement in open fractures. Historical 6-h rule of doing debridement within 6 h of injury has not been supported in the recent articles. Patzakis and Wilkins[13] in their study of 1104 patients concluded that there was no significant effect of time to debridement on infection rate for greater and less than 12 h. Similar results were given by more recent studies. Kasman and Albar[14] published a study in 2019 of 56 subjects concluding that there was no significant association between infection and onset of debridement in patients with open fractures. In our study, no significant decrease in infection rate was observed in patients undergoing debridement within 6 h from injury. However, it was also observed that open fractures presenting 24 h after injury had a higher infection rate than those presenting before it which is in accordance with previous literature.[15] Thus, we suggest that although open fracture should not be considered as an emergency and emergency debridement of the wound can be delayed for up to 24 h from injury, it would give beneficial time to the operating surgeon to plan out his treatment, arrange his resources effectively, and include a plastic surgeon for wound management.

In our study we found Enterococcus and Staphylococcus species to be the most prevalent cause of infection, which is in accordance with the literature. D’Souza et al.[16] conducted their study on 108 patients with open fractures and found that the maximum number of infections were nosocomial in origin caused by Enterococcus and Staphylococcus species. Previous studies do suggest that most of the infections in open fractures are nosocomial in origin based on the fact that most of the microorganism finally causing infection is different from perop or intraop swabs. Lee[17] in his study on management of open fractures found that only 8% of microorganisms on predebridement cultures were to be an infectious agent. Our study also shows that organisms finally causing established infection in bone were isolated mostly from postop swabs and were gram negative, which further strengthens the fact that most infections are nosocomial in origin. Considering the high prevalence of gram-negative bacteria, our study supports the protocol of adding a prophylactic antibiotic covering gram-negative bacteria for all Grade III open fractures.


  Conclusion Top


This paper furnishes the literature by validating facts, theories, and guidelines given in the past to manage open fractures. Recent literature abolishes the 6-h rule regarding timing of debridement which is supported by our study. However, infection rate was found to be higher with patients presenting 24 h after injury, which concluded the fact that although the first debridement can be delayed, it should be performed as soon as the patient’s medical condition permits and the surgeon has planned his treatment protocol along with a plastic surgeon. The most common organism identified was Enterococcus species, which strengthens the fact that antibiotic coverage for gram-negative species should be added to the prophylactic antibiotic protocol. Our study also gives strength to the fact that postop swabs are more specific than intraop swabs as the final organism causing infection was mostly identified from postop cultures rather than intraop bacterial cultures.

The study has limitation that the numbers of patients presenting with open fractures were less, and especially patients having common risk factors such as diabetes and anemia due to which correlation with infection rate could not be assessed effectively.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Guerra MTE, Gregio FM, Bernardi A, Castro CC. Infection rate in adult patients with open fractures treated at the emergency hospital and at the ULBRA university hospital in Canoas, Rio Grande do Sul, Brazil. Rev Bras Ortop 2017;52:544-8.  Back to cited text no. 1
    
2.
Neubauer T, Bayer GS, Wagner M. Open fractures and infection. Acta Chir Orthop Traumatol Cech 2006;73:301-12.  Back to cited text no. 2
    
3.
Cross WW 3rd, Swiontkowski MF. Treatment principles in the management of open fractures. Indian J Orthop 2008;42:377-86.  Back to cited text no. 3
    
4.
Singh J, Rambani R, Hashim Z, Raman R, Sharma HK. The relationship between time to surgical debridement and incidence of infection in grade III open fractures. Strategies Trauma Limb Reconstr 2012;7:33-7.  Back to cited text no. 4
    
5.
RahimiShorin H, GharehDaghi M, Mirkazemi M, Assadian M, Ashraf H, Izanloo A. Antibiotic prophylaxis in bacterial infection of type IIIA open fracture of tibia shaft with or without fibula fracture. RazaviInt J Med 2016;4:e37811.  Back to cited text no. 5
    
6.
Kale AR, Sonawane CS, Waghmare VU, Kalambe H. Open fractures and incidence of infection in tertiary care government hospital. Int J Sci Stud 2017;5:24-8.  Back to cited text no. 6
    
7.
Gustilo RB, Anderson JT. Prevention of infection in treatment of one thousand and twenty-five open fractures of long bones: Retrospective and prospective analyses. J Bone Surg Am 1976;58:453-8.  Back to cited text no. 7
    
8.
Matos MA, Lima LG, de Oliveira LA. Predisposing factors for early infection in patients with open fractures and proposal for a risk score. J Orthop Traumatol 2015;16:195-201.  Back to cited text no. 8
    
9.
Bowen TR, Widmaier JC. Hast classification predicts infection after open fracture. Clin Orthop Relat Res 2005;433:205-11.  Back to cited text no. 9
    
10.
Kortram K, Bezstarosti H, Metsemakers WJ, Raschke MJ, Van Lieshout EMM, Verhofstad MHJ. Risk factors for infectious complications after open fractures: A systematic review and meta-analysis. Int Orthop 2017;41:1965-82.  Back to cited text no. 10
    
11.
Pollak AN, Jones AL, Castillo RC, Bosse MJ, MacKenzie EJ; LEAP Study Group. The relationship between time to surgical debridement and incidence of infection after open high-energy lower extremity trauma. J Bone Joint Surg Am 2010;92:7-15.  Back to cited text no. 11
    
12.
Kamat AS. Infection rates in open fractures of the tibia: Is the 6-hour rule fact or fiction? Adv Orthop 2011;2011:943495.  Back to cited text no. 12
    
13.
Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wounds. ClinOrthop 1989;243:36-40.  Back to cited text no. 13
    
14.
Kasman RO, Albar HF. Correlation between early infection and onset of debridement in open diaphysis fracture patient. Glob J Res Anal 2019;8:242-44.  Back to cited text no. 14
    
15.
Srour M, Inaba K, Okoye O, Chan C, Skiada D, Schnüriger B, et al. Prospective evaluation of treatment of open fractures: Effect of time to irrigation and debridement. JAMA Surg 2015;150:332-6.  Back to cited text no. 15
    
16.
D’Souza A, Rajagopalan N, Amaravati RS. The use of qualitative cultures for detecting infection in open tibial fractures. J Orthop Surg (Hong Kong) 2008;16:175-8.  Back to cited text no. 16
    
17.
Lee J. Efficacy of cultures in the management of open fractures. Clin Orthop Relat Res 1997;339:71-5.  Back to cited text no. 17
    


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