Pre-Debridement and Post-Debridement Culture in Open Fractures of the Extremities: A Comparative Study
DOI:
https://doi.org/10.17140/ORTOJ-5-118Keywords:
Open fractures, Debridement, Pre-debridement, Post-debridement, Meta- analysis, Systematic reviewAbstract
Background
Due to contamination, open fractures are considered to be dangerous and thereby require proper management. Through a systematic review and meta-analysis, this study compares the literature on pre-debridement and post-debridement cultures derived
from such fracture sites.
Methods
Data for this review was collected through various online sources such as dataBASE (EMBASE), medical literature analysis and
retrieval system online (MEDLINE) and different citations provided the relevant data.
Results
Twenty articles were included. The desired timing to examine the debridement was six hours post-injury (according to the sixhour rule). Antibiotics including ampicillin, penicillin, cefazolin, cefuroxime, and flucloxacillin were used in some patients. The use
of Ancef I as an antibiotic during the starting hours of fracture helps to reduce the chances of infection in 1.4% of the infected
patients. The infection rate was 3% in pre-debridement culture, while a 2% infection rate was found in post debridement culture.
Gram-negative bacteria were responsible for pre-debridement infection, while gram-positive bacteria were responsible for postdebridement.
Conclusion
The pre-debridement infection rates are reduced as compared to post-debridement when treatment is initiated within a strict time
interval and limited to the specific use of antibiotics. Treatment of gram-negative bacteria helps to reduce the bulk of infectious
material and thereby reduces the infection rate.
References
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(12): 1057-1064. doi: 10.2106/JBJS.K.00582
Pollak AN. Timing of debridement of open fractures. J Am Acad Orthop Surg.. 2006; 14(10): S48-S51. doi: 10.5435/00124635- 200600001-00011
Neubauer T, Bayer G, Wagner M. Open fractures and infection. Acta Chir Orthop Traumatol Cech. 2006; 73(5): 301-312.
Byrd HS, Spicer TE, Cierney G. Management of open tib-ial fractures. Plast Reconstr Surg. 1985; 76(5): 719-730. doi: 10.1097/00006534-198511000-00011
O’Brien C.L, Menon M, and Jomha N.M. Controversies in the management of open fractures. Open Orthop J. 2004; 36: 178-1848. doi: 10.2174/1874325001408010178
Okike K, Bhattacharyya T. Trends in the management of open fractures: A critical analysis. J Bone Joint Surg Am. 2006; 88(12): 2739-2748. doi: 10.2106/JBJS.F.00146
Penn-Barwell J, Murray C, Wenke J. Early antibiotics and de-bridement independently reduce infection in an open frac-ture model. J Bone Joint Surg Br. 2012; 94(1): 107-112. doi: 10.1302/0301-620X.94B1.27026
Gustilo RB, Mendoza R, Williams DN. Problems in the man-agement of type III (severe) open fractures: A new classification of type III open fractures. J Trauma. 1984; 24(8): 742-746. doi: 10.1097/00005373-198408000-00009
Warrender WJ, Lucasti CJ, Chapman TR, Ilyas AM. Antibiotic management and operative debridement in open fractures of the hand and upper extremity: A systematic review. Hand Clin. 2018; 34(1): 9-16. doi: 10.1016/j.hcl.2017.09.001
Parrett BM, Matros E, Pribaz JJ, Orgill DP. Lower extremi-Systematic Review | Volume 5 | Issue 1| Yu B et al ty trauma: Trends in the management of soft-tissue reconstruc-tion of open tibia-fibula fractures. Plast Reconstr Surg. 2006; 117(4): 1315-1322. doi: 10.1097/01.prs.0000204959.18136.36
Crowley D, Kanakaris N, Giannoudis P. Debridement and wound closure of open fractures: The impact of the time factor on infection rates. Injury. 2007; 38(8): 879-89. doi: 10.1016/j.inju-ry.2007.01.012
D’souza A, Rajagopalan N, Amaravati R. The use of quali-tative cultures for detecting infection in open tibial frac-tures. J Orthop Surg (Hong Kong). 2008; 16(2): 175-178. doi: 10.1177/230949900801600209
Lingaraj R, Santoshi JA, Devi S, Najimudeen S, Gnanadoss JJ, Kanagasabai R, et al. Predebridement wound culture in open frac-tures does not predict postoperative wound infection: A pilot study. J Nat Sci Biol Med. 2015; 6(Suppl 1): S63-S68. doi: 10.4103/0976- 9668.166088
Zhu H, Li X, Zheng X. A descriptive study of open fractures contaminated by seawater: Infection, pathogens, and antibiotic re-sistance. BioMed Res Int. 2017; 2017. doi: 10.1155/2017/2796054
Ryan SP, Pugliano V. Controversies in initial management of open fractures. Scand J Surg. 2014; 103(2): 132-137. doi: 10.1177/1457496913519773
Sitati FC, Mosi PO, Mwangi JC. Early bacterial cultures from open fractures-differences before and after debridement. Annals of African Surgery. 2017; 14(2). doi: 10.4314/aas.v14i2.3
Hull P, Johnson S, Stephen D, Kreder H, Jenkinson R. Delayed debridement of severe open fractures is associated with a high-er rate of deep infection. Bone Joint J. 2014; 96(3): 379-384. doi: 10.1302/0301-620X.96B3.32380
Mangala A, Arthi K, Deepa R. Comparison of predebridement and debridement cultures in predicting postoperative infections in compound fractures. Journal of Clinical & Diagnostic Research. 2018; 12(7): DC06-DC09. doi: 10.7860/JCDR/2018/36011.11735
Gupta S, Saini N, Sharma R. A comparative study of efficacy of pre and post-debridement cultures in open fractures. Internet J Orthop Surg. 2012; 19(3): 33-36. doi: 10.13107/jocr.2250-0685.1296
Nusbaum AG, Gil J, Rippy MK, Warne B, Valdes J, Claro A, et al. Effective method to remove wound bacteria: Comparison of various debridement modalities in an in vivo porcine model. J Surg Res. 2012; 176(2): 701-707. doi: 10.1016/j.jss.2011.11.1040
Bhatty S, Rajesh P, Harjit K. Study of microbiological flora and role of primary bacterial cultures in management of open fractures of long bones. Int J Orthop Sci. 2018; 4(2): 91-94. doi: 10.22271/ ortho.2018.v4.i2b.14
Ibrahim T, Riaz M, Hegazy A, Erwin PJ, Tleyjeh IM. Delayed surgical debridement in pediatric open fractures: A systematic re-view and meta-analysis. J Child Orthop. 2014; 8(2): 135-141. doi: 10.1007/s11832-014-0567-2
Ketonis C, Dwyer J, Ilyas AM. Timing of debridement and infection rates in open fractures of the hand: A systematic review. Hand (N Y). 2017; 12(2): 119-126. doi: 10.1177/1558944716643294
Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wounds. Clin Orthop Relat Res. 1989; (243): 36-40.
Ng T, Unadkat J, Bilonick RA, Wollstein R. The importance of early operative treatment in open fractures of the fingers. Ann Plast Surg. 2014; 72(4): 408-410. doi: 10.1097/SAP.0b013e318264fcd5
Capo JT, Hall M, Nourbakhsh A, Tan V, Henry P. Initial man-agement of open hand fractures in an emergency department. Am J Orthop. 2011; 40(12): E243-E8.
Bannasch H, Heermann AK, Iblher N, Momeni A, Schulte-Mönting J, Stark GB. Ten years stable internal fixation of metacarpal and phalangeal hand fractures—risk factor and out-come analysis show no increase of complications in the treatment of open compared with closed fractures. J Trauma. 2010; 68(3): 624-628. doi: 10.1097/TA.0b013e3181bb8ea0
Kömürcü M, Alemdaroğlu B, Kürklü M, Özkan H, Basboz-kurt M. Handgun injuries with metacarpal and proximal phalangeal fractures: Early definitive treatment. Int Orthop. 2008; 32(2): 257- 262. doi: 10.1007/s00264-006-0312-7
Stevenson J, McNaughton G, Riley J. The use of prophylactic flucloxacillin in treatment of open fractures of the distal phalanx within an accident and emergency department: a double-blind ran-domized placebo-controlled trial. J Hand Surg Br. 2003; 28(5): 388- 394. doi: 10.1016/s0266-7681(03)00175-x
Almeida Matos M, Catro-Filho RN, Pinto da Silva BV. Risk factors associated with infection in tibial open fractures. Rev Fac Cien Med Univ Nac Cordoba. 2013; 70(1): 14-18.
Pollak AN, Jones AL, Castillo RC, Bosse MJ, MacKenzie EJ, Group LS. The relationship between time to surgical debridement and incidence of infection after open high- energy lower extrem-ity trauma. J Bone Joint Surg Am. 2010; 92(1): 7-15. doi: 10.2106/ JBJS.H.00984 Submit your article to this journal | https://openventio.org/submit-manuscript/
McLain RF, Steyers C, Stoddard M. Infections in open fractures of the hand. J Hand Surg Am. 1991; 16(1): 108-112. doi: 10.1016/ s0363-5023(10)80022-x
Glueck DA, Charoglu CP, Lawton JN. Factors associated with infection following open distal radius fractures. Hand. 2009; 4(3): 330-334. doi: 10.1007/s11552-009-9173-z
Naique S, Pearse M, Nanchahal J. Management of severe open tibial fractures: The need for combined orthopaedic and plastic surgical treatment in specialist centres. J Bone Joint Surg Br. 2006; 88(3): 351-357. doi: 10.1302/0301-620X.88B3.17120
Skaggs DL, Friend L, Alman B, Chambers HG, Schmitz M, Leake B, et al. The effect of surgical delay on acute infection fol-lowing 554 open fractures in children. J Bone Joint Surg Am. 2005; 87(1): 8-12. doi: 10.2106/JBJS.C.01561
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(2): 108-112. doi: 10.1308/003588404322827491
Khatod M, Botte MJ, Hoyt DB, Meyer RS, Smith JM, Akeson WH. Outcomes in open tibia fractures: Relationship between de-lay in treatment and infection. J Trauma. 2003; 55(5): 949-954. doi: 10.1097/01.TA.0000092685.80435.63
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(7): 484-490. doi: 10.1097/00005131-200208000-00006
Skaggs D, Kautz S, Kay R, Tolo V. Effect of delay of surgical treatment on rate of infection in open fractures in children. J Pedi-atr Orthop. 2000; 20(1): 19-22. doi: 10.1097/01241398-200001000-
Kindsfater K, Jonassen E. Osteomyelitis in grade II and III open tibia fractures with late debridement. J Orthop Trauma. 1995; 9(2): 121-127. doi: 10.1097/00005131-199504000-00006
Bednar DA, Parikh J. Effect of time delay from injury to pri-mary 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(6): 532-535. doi: 10.1097/00005131- 199312000-00008
Downloads
Published
How to Cite
Issue
Section
License
This work is licensed under a Creative Commons Attribution 4.0 International License.
All content published in Orthopedics Research and Traumatology (ORT) is licensed under the Creative Commons Attribution 4.0 International License (CC BY 4.0). This license allows anyone to copy, distribute, transmit, and adapt the work — including for commercial purposes — provided appropriate credit is given to the original author(s) and source.
