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:

Ashford RU. Injury. 2004;35:411-6. Bednar DA. J Orthop Trauma. 1993;7:532-5. Friedrich PL. Arch Klin Charalambous CP. Injury. 2005;36:656-61. Chir.1898;57:288-310 Harley BJ. J Orthop Trauma. 2002;16:484-90. Khatod M. J Trauma. 2003;55:949-54. Basic science (German) Skaggs DL. J Bone Joint Surg Am. 2005;87:8-12. Kindsfater K. JOT. 1995;9:121-7 Spencer J. Ann R Coll Surg Engl. 2004;86:108- 12. More severe fxs in >6 hr group 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 low- velocity 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 post- operatively 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 1st 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 Salt Water – Aeromonas – Vibrio – Zosyn or the like 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 Pulse Lavage It appears low CONCLUSIONS pressure is The rates of reoperation were similar regardless of irrigation pressure, a better finding that indicates that very low pressure is an acceptable, low-cost alternative for the irrigation of open fractures. The reoperation rate was Less bone and higher in the soap group than in the soft tissue saline group. (Funded by the Canadian Institutes of Health damage 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