Volume 7 | Issue 2 | May – August 2019 | Page: 11- 16 | Monappa Naik A, Raviteja Jampani, Mahesh Suresh Kulkarni, Sandeep Vijayan, Sourabh Shetty, Sharath K Rao, Nirish Reddy
Authors: Monappa Naik A , Raviteja Singasani , Mahesh Suresh Kulkarni* , Sandeep Vijayan , Sourabh Shetty , Sharath K Rao , Nirish Reddy .
 Department of Orthopaedics, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Manipal, Udupi, Karnataka 576104, India.
Address of Correspondence
Dr. Mahesh Suresh Kulkarni*,
Department of Orthopaedics, Kasturba Medical College,
Manipal Academy of Higher Education (MAHE), Manipal, Udupi, Karnataka 576104, India.
Background: Open fractures are known to have a multitude of complications. In general, open fractures have been considered as a surgical emergency and treated accordingly with emergency debridement and fixation. Previous animal studies emphasized the need for early debridement and antibiotic administration. However, similar results are not observed and translated in the clinical setting. Hence, we designed an observational study in which our aim was to evaluate the factors which determine union and infections following open long-bone fractures.
Materials and Methods: This is a retro prospective study conducted in a tertiary care hospital from 2015 to 2017. All the open fractures of long bones presented to the casualty not later than 48 h of the injury who were skeletally mature included in the study after obtaining informed consent. All the patients who were presented with the open long-bone injuries were treated as per the institution protocol. Patients were followed up regularly and evaluated.
Results: 59 patients with 69 open fractures were considered for the analysis. Type IIIB and C open fractures were significantly more common in lower-limb injuries. There was no significant difference found between the mean age, gender, involved limb, affected side, presence of the comorbidities, mean time between the injury and the presentation, mean time between injury, and the start of the antibiotics between infected/non-infected and united/non-united open fractures. High-grade injuries took significantly higher number of procedures and time to achieve wound closure. Furthermore, cases with infection and non-union have taken significantly more number of procedures to achieve wound closure. An associated bone loss had a significant increase in the infection, bone grafting, and non-union.
Conclusion: In our study, we noted that open fracture severity and bone loss are the main factors which determine the chances of culture-proven infection. Early antibiotics and wound debridement will not necessarily translate into a decrease in infection rates and non-union.
Keywords: Open fractures, non-union, osteomyelitis, infection, long-bone fractures, bone grafting, soft-tissue injuries.
1. Antonova E, Le TK, Burge R, Mershon J. Tibia shaft fractures: Costly burden of nonunions. BMC MusculoskeletDisord2013;14:42.
2. Soni A, Tzafetta K, Knight S, Giannoudis PV. Gustilo IIIC fractures in the lower limb: Our 15-year experience. J Bone Joint Surg Br 2012;94:698-703.
3. Kim PH, Leopold SS. In brief: Gustilo-anderson classification. [corrected]. Clin OrthopRelat Res 2012;470:3270-4.
4. Papakostidis C, Kanakaris NK, Pretel J, Faour O, Morell DJ, Giannoudis PV, et al. Prevalence of complications of open tibial shaft fractures stratified as per the Gustilo-Anderson classification. Injury 2011;42:1408-15.
5. Hu R, Ren YJ, Yan L, Yi XC, Ding F, Han Q, et al. Analysis of staged treatment for gustiloanderson IIIB/C open tibial fractures. Indian J Orthop2018;52:411-7.
6. Harley BJ, Beaupre LA, Jones CA, Dulai SK, Weber DW. The effect of time to definitive treatment on the rate of nonunion and infection in open fractures. J Orthop Trauma 2002;16:484-90.
7. 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 Engl2004;86:108-12.
8. Crowley DJ, Kanakaris NK, Giannoudis PV. Debridement and wound closure of open fractures: The impact of the time factor on infection rates. Injury 2007;38:879-89.
9. Webb LX, Bosse MJ, Castillo RC, MacKenzie EJ, LEAP Study Group. Analysis of surgeon-controlled variables in the treatment of limb-threatening type-III open tibial diaphyseal fractures. J Bone Joint Surg Am 2007;89:923-8.
10. Yokoyama K, Itoman M, Uchino M, Fukushima K, Nitta H, Kojima Y, et al. Immediate versus delayed intramedullary nailing for open fractures of the tibial shaft: A multivariate analysis of factors affecting deep infection and fracture healing. Indian J Orthop2008;42:410-9.
11. Schenker ML, Yannascoli S, Baldwin KD, Ahn J, Mehta S. Does timing to operative debridement affect infectious complications in open long-bone fractures? A systematic review. J Bone Joint Surg Am 2012;94:1057-64.
12. Hull PD, Johnson SC, Stephen DJ, Kreder HJ, Jenkinson RJ. Delayed debridement of severe open fractures is associated with a higher rate of deep infection. Bone Joint J 2014;96-B:379-84.
13. Singh A, Jiong Hao JT, Wei DT, Liang CW, Murphy D, Thambiah J, et al.Gustilo IIIB open tibial fractures: An analysis of infection and nonunion rates. Indian J Orthop2018;52:406-10.
14. Brown KV, Walker JA, Cortez DS, Murray CK, Wenke JC. Earlier debridement and antibiotic administration decrease infection. J Surg Orthop Adv 2010;19:18-22.
15. Penn-Barwell JG, Murray CK, Wenke JC. Early antibiotics and debridement independently reduce infection in an open fracture model. J Bone Joint Surg Br 2012;94:107-12.
16. Al-Arabi YB, Nader M, Hamidian-Jahromi AR, Woods DA. The effect of the timing of antibiotics and surgical treatment on infection rates in open long-bone fractures: A 9-year prospective study from a district general hospital. Injury 2007;38:900-5.
17. 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 Reconstr2012;7:33-7.
18. Crowley DJ, Kanakaris NK, Giannoudis PV. Irrigation of the wounds in open fractures. J Bone Joint Surg Br 2007;89:580-5.
19. Halawi MJ, Morwood MP. Acute management of open fractures: An evidence-based review. Orthopedics 2015;38:e1025-33.
20. Leow JM, Clement ND, Tawonsawatruk T, Simpson CJ, Simpson AH. The radiographic union scale in tibial (RUST) fractures: Reliability of the outcome measure at an independent centre. Bone Joint Res 2016;5:116-21.
21. Whelan DB, Bhandari M, Stephen D, Kreder H, McKee MD, Zdero R, et al. Development of the radiographic union score for tibial fractures for the assessment of tibial fracture healing after intramedullary fixation. J Trauma 2010;68:629-32.
22. Morshed S. Current options for determining fracture union. Adv Med 2014;2014:708574.
23. Kulkarni MS, Aroor MN, Vijayan S, Shetty S, Tripathy SK, Rao SK, et al. Variables affecting functional outcome in floating knee injuries. Injury 2018;49:1594-601.
24. Fong K, Truong V, Foote CJ, Petrisor B, Williams D, Ristevski B, et al. Predictors of nonunion and reoperation in patients with fractures of the tibia: An observational study. BMC MusculoskeletDisord2013;14:103.
25. Rajasekaran S, Dheenadhayalan J, Babu JN, Sundararajan SR, Venkatramani H, Sabapathy SR, et al. Immediate primary skin closure in type-III A and B open fractures: Results after a minimum of five years. J Bone Joint Surg Br 2009;91:217-24.
|How to Cite this article: Naik M A, Singasani R, Kulkarni M S*, Vijayan S, Shetty S, Rao S K, Reddy N. Timing of Antibiotic and Wound Debridement: Does it Matters in Open Fractures of Long. Journal of Karnataka Orthopaedic Association May – Aug 2019 ; 7(2): 11-16.|