Austin Trauma & Critical Care Conference Open Fracture Update 2018 Dave Laverty MD Orthopedic Trauma Surgeon
Take Home Points We are stuck in the 90 s Time to antibiotics matters most Gram negative bacteria are bad players Antibiotic regimens are evolving Time to debridement less important Modern wound management helps
History 1946 Ellis Proposed parenteral Atbx for open fxs 1974 Patzakis prospective randomized study 13.9% placebo 10% penicillin and streptomycin group 2.3% cephalothin group
Classification Gustillo Anderson 1976, modified 84 Most commonly used system Low inter-observer reliability
Gustilo Anderson Grade I < 1cm clean Grade II < 10cm clean Grade III A > 10cm clean B > 10cm not clean needs flap C vasc injury
Expert Panel 5 essential categories skin injury, muscle injury, arterial injury, contamination, bone loss J Orthop Trauma Volume 24, Number 8, August 2010
OTA-OFC: 5 Categories Skin Muscle Arterial Contamination Bone Loss J Orthop Trauma Volume 24, Number 8, August 2010
OTA-OFC Skin 1. Can be approximated 2. Cannot be approximated 3. Extensive degloving Compliments of Dr. James Kellam
OTA-OFC Muscle 1. No muscle in area, no appreciable muscle necrosis, some muscle injury with intact muscle function 2. Loss of muscle but the muscle remains functional, some localized necrosis in the zone of injury that requires excision, intact muscle-tendon unit 3. Dead muscle, loss of muscle function, partial or complete compartment excision, complete disruption of a muscle - tendon unit, muscle defect does not approximate
OTA-OFC Arterial 1. No injury 2. Artery injury without ischemia 3. Artery injury with distal ischemia
OTA-OFC Contamination 1. None or minimal contamination 2. Surface contamination (easily removed not embedded in bone or deep soft tissues) 3. a. Imbedded in bone or deep soft tissues b. High risk environmental conditions (barnyard,fecal,dirty water etc)
OTA-OFC Bone Loss 1. None 2. Bone missing or devascularized but still some contact between proximal and distal fragments 3. Segmental bone loss
OTA-OFC: Reliability? Yes! Diverse multinational cohort of orthopedic surgeons and residents Reviewed 12 videos of open fracture cases Compared reliability to Gustilo-Anderson System J Orthop Trauma Volume 27, Number 7, July 2013
OTA-OFC Can it predict treatment? Retrospective review of 356 patients at a level 1 trauma center Suggest that the subclassification of 5 categories has potential advantages of determining treatment(s) which may be related to short term outcome Agel et al. JOT Volume 28, Number 5, May 2014
Retrospective review of 512 open fractures Gustilo-Anderson classification did not correlate with outcome OTA-OFC skin injury component was an independent predictor of limb ampuation
Antibiotcs & Gustilo Anderson Gustillo Types I-III I Ancef II Ancef III Ancef and amoinoglycoside Gross dirt or Barnyard - add PCN
Dosing Grade I-III Ancef 2gm IV Grade III Gentamicin single dosing 3-5 mg/kg PCN 2.4 mil units
Obesity and Abx Dosing Data suggest (> 80 kg or BMI >35) need more Cefazolin 3gm Adverse event risk likely not increased with higher dose Dosing of vancomycin can stay the same Bratzler DW, Clin Infect Dis 2004;38:1706-1715 Mangram AJ. Infect Control Hosp Epidemiol 1999;20:250-278.
Issues.. Penicillin allergy: Give ancef (test dose) Cephalosporin allergy Clindamycin Vancomycin Renal insufficiency Fluoroquinolone
Time to Antibiotic Administration Patzakis MJ. Clin Orthop Relat Res. 1989;243:36-40 infection rate 4.7% (17/364) antibiotics within 3 hours infection rate 7.4% (49/661) antibiotics greater than 3 hour Give as soon as possible
Duration of Antibiotics Grade I II 24 hours after last debridement or wound coverage. Longer duration increases risk of nosocomial infection
Time to Debridement of Open Fxs It Matters: It Does Not Matter: Friedrich PL. Arch Klin Chir.1898;57:288-310 Basic science (German) Kindsfater K. JOT. 1995;9:121-7 More severe fxs in >6 hr group Ashford RU. Injury. 2004;35:411-6. Bednar DA. J Orthop Trauma. 1993;7:532-5. Charalambous CP. Injury. 2005;36:656-61. Harley BJ. J Orthop Trauma. 2002;16:484-90. Khatod M. J Trauma. 2003;55:949-54. Skaggs DL. J Bone Joint Surg Am. 2005;87:8-12. Spencer J. Ann R Coll Surg Engl. 2004;86:108-12. Patzakis MJ. Clin Orthop Relat Res. 1989;243:36-40. Rohmiller M. OTA 2002 Taitsman. OTA 2002 Time to debridement LESS important
Alternatives & Current Recommendations
EAST Eastern Association for the Surgery of Trauma Level I: Preoperative prophylaxis as soon as possible for Gram positives Type III add gram negative coverage (i.e. gentamicin) High-dose penicillin - fecal/clostridial contamination Level II: Discontinue 24 hours after wound coverage types I&II Continue for type III fractures for only 72 hours after injury, or 24 hours after wound coverage www.east.org
Surgical Infection Society Level I: No prophylactic antibiotics required for open fractures from lowvelocity GSW w/o surgery first-generation cephalosporin for 24-48 h perioperatively is a safe and effective prophylactic choice for patients with Type I open fractures. Level II: first-generation cephalosporin for 48 h perioperatively is safe and effective prophylactic choice for patients with Type II and III fxs Level III: broad-spectrum agent given pre-operatively and for 48 h postoperatively is a safe and effective option for patients with Type II and III open fractures. Hauser CJ, Surg Infect 2006;7:379 405.
Special Circumstances
Low velocity GSW Marcus retrospective no difference (4.2%) vs (3.8%) Dickey - 63 patients 3% infection rate with or without antibiotics My recommendation: Single dose 1 st gen. cephalosporin ED
High Velocity GSW Treat as other open fractures Continue atbx at least 24-48 hours after wound coverage
Open fracture in Water Fresh water Aeromonas Zosyn or the like Salt Water Vibrio
Local Antibiotic Delivery Adjunct to parenteral Very high local concentration Short duration Foreign body
Local antibiotics - Delivery mechanisms Standard: PMMA bone cement Tobramycin Vancomycin Bead pouch versus block Experimental: - tobramycin impregnated calcium sulphate - gentamicin - collagen strips - others
Does surgical Prep Matter?? Yes chlorhexidine is best
High versus Low Pressure It appears low pressure is better Less bone and soft tissue damage Pulse Lavage CONCLUSIONS The rates of reoperation were similar regardless of irrigation pressure, a finding that indicates that very low pressure is an acceptable, low-cost alternative for the irrigation of open fractures. The reoperation rate was higher in the soap group than in the saline group. (Funded by the Canadian Institutes of Health Research and others; FLOW ClinicalTrials.gov number, NCT00788398.)
Does adding a surfactant help?? The studies are ongoing It appears Castile soap may has no benefit
What about the VAC?? NPWT Decreases some bacterial load in colonized wounds Will not cure an infection
Take Home Points 1. Antibiotics early 2. Gram negatives are a problem 3. More research needed 4. Patient factors still matter