LOCAL

ANTIBIOTIC

THERAPY

FOR

SEVERE

OPEN

FRACTURES
A REVIEW OF 1085 CONSECUTIVE CASES

PETER

A. W. OSTERMANN.

DAVID

SELIGSON.

STEPHEN

L. HENRY

Froni

tli(

Uniieisit

of Louisville,

Kentick

USA

We reviewed treated in 914

1085

consecutive at the

compound University

limb

fractures 240 (group and 845 local (PMMA) use

Current
irrigation,

management
serial radical

patients period. systemic managed

of Louisville

over a nine-year 1) received only (group of beads. gender, 2) were

Of these antibiotic

fractures, prophylaxis

tion Ivler

of

broad-spectrum Dellinger

of open fractures includes wound debridement, systemic administraantibiotics (Patzakis. Harvey and et al 1988), stabilisation of the bone provision of soft-tissue 1985: Caudle and Stern 1991 ). Stabilisation nailing or external is now fixation

1974;

by the supplementary differences location or

aminoglycoside-polymethylmethacrylate There were no significant fracture type, fracture the

and, if the wound is sterile, early cover (Byrd. Spicer and Cierney 1987; usually Edwards obtained et al 1988: Muhr by unreamed

in age, follow-up

between irrigation, stabilisation, local preference In group as against infection incidence significant fractures

two groups. All had meticulous debridement but wound management depended on the

copious wound and skeletal and the use of individual rate of 12%

antibiotic

surgeons

(Seligson, Banis and Matheny 1989; Ostermann et al 1993), but low infection rates have been reported after severe open fractures treated by reamed intramedullary nailing (CourtBrown et al 1991). Provision target areas and costly of therapeutic tissue levels of antibiotic to requires high serum levels of potentially toxic antibiotics (Federspil. Schatzle and Tieslen prophylactic have been usc of reported (PM MA)

and there was no randomisation. 1 there was an overall infection 3.7% in group 2 (p 0.001). and local osteomyelitis showed
<

Both acute a decreased

in group only in for acute

2, Gustilo infection,

but

this type-HIB and only

was statistically and type-IIIC in type-I! use of and local

1976). An alternative method is the local antibiotics. Satisfactory results with aminoglycoside-polyrnethylmethacrylate beads Henry oped

type-IIIB fractures for Our review suggests antibiotic-laden of infection

J Bone Reeeieed Joimit 21 Shiv l)eember

chronic osteomyelitis. that the adjuvant may reduce fractures.

(Henry, Ostermann and Seligson and Seligson 1993). These were for the treatment of chronic

1990: Osterniann, originally develthey can

osteomyelitis:

PMMA beads in severe compound

[Br]

the incidence

I995;77-B:93-7. /99.?;
Accepted

provide high local side-effects (Klemm We have reviewed

levels of antibiotics with no systemic 1979). retrospectively the therapeutic effect

after

revision

8 June

1994

of antibiotic-laden PMMA beads in preventing established infection in a series of 1085 consecutive open fractures over a nine-year period. In 845 of these systemic antibiotics were nated supplemented beads; the antibiotics. by the local use other 240 compound of antibiotic-impregfractures had only

Open

fractures

are

often

contaminated

of infection by devitalisation stability. fracture function.

is a major of bone

complication. and soft tissue

the development Infection is favoured

and

parenteral

and

loss of skeletal limb, of

PATIENTS AND METHODS

The aims of treatment are healing without infection

salvage of the and restoration

P. A. W. Ostermann. MD. Trauma Surgeon Department of Surgery. Trauma Center Bergmannsheil. Ciile. University of Hochum. Buerkle-de-la Camp. Platz Gernianv. D. Seligson. MD. Professor and Chief of Fracture Service S. I. Henry. MD. Orthopaedic Surgeon Departnient of Orthopaedic Surgery, School of Medicine, Louisville. Louisville. Kentucky 40292, USA. Correspondence #{174}199SBritish 030 1 -620X/95/ should he sent to Dr P. A. W. Ostermann.
of

School I . 4630

of MediBochum,

We reviewed the records of 1085 consecutive open limb fractures in 914 patients treated from May 1983 to July 1992 at the University of Louisville. a Level I Trauma Center. The mean age of the patients there were 581 males and 333 Using the fracture 279 type (25.7%) II, and classification (1976). (33.5%) was 33.7 females. ol Gustilo years (14 to 91):

and Anderson

University

of

of the fractures 442 (40.8/d type

were type I. 364 III. Of the last. 199

Editorial Society I 901 S2.0()

Bone

and

Joint

Surgery

(45%) were type lilA. 171 (38.7%) type IIIB and 72 (16.3%) type IIIC (Gustilo. Mendoza and Williams 1984). All the fractures were treated by early wound irrigation.
93

\()l..

77-B.

N.

I. J.-\NLARY

1995

94

P. A. W. OSTERMANN.

D. SELIGSON.

S. L. HENRY

A type-IIIB

compound

fracture

(see

text).

Fig. Ia

serial tures

radical debridement and with severe compounding received systemic

skeletal stabilisation: fracwere managed by external antibiotic prophylaxis.

and provide a sterile wound environment levels of antibiotics (Fig. 4). This pouch times After at 48eight or 72-hour days the intervals. soft-tissue under defect

was

with high changed bone lateral

local three was skin

fixation. All patients using (78%)

sterile over

conditions.

tobramycin, cefazolin, of the fractures were

and penicillin. In addition, 845 treated with chains of tobramydecision to use local antibiotic it was based on the preference
and the availability of mould-

covered by a myocutaneous defect by a split-thickness After five weeks when

free flap. and the skin graft (Fig. 5). soft-tissue healing was

cm-impregnated beads. The chains was not randomised:

of the attending physician

complete, nailing with no

made antibiotic PMMA beads. The 240 fractures not treated with antibiotic chains (group 1) included 67 (27.9%) type-I fractures. 71 (29.6%) III fractures (lIlA: 43, IIIB:
Of the

the external fixator was removed and static locked was performed. The fracture healed uneventfully signs of infection (Fig. 6).

type-Il and 102 (42.5%) 27, IIIC: 32). managed with antibiotic

typechains and IIIC: to

RESULTS

845 open

fractures

There

was

no

statistical

difference

in

age

distribution. or length I). Wound local levels

(group 2) 212 (25. 1%) were type-I. 293 (34.7%) type-lI 340 (40.2%) type-Ill fractures (lIlA: 156. IIIB: 144. 40). We reviewed all hospital charts and clinic records

gender, fracture location, fracture classification, of follow-up between groups I and 2 (Table management differed in each group. since high of antibiotics can only ment. In group I (no primarily and 419 a closed, be preserved beads). 89 had

determine the incidence of acute wound infection and deep bone infection (osteomyelitis). The statistical significance of the data was case assessed report. by chi-squared man analysis sustained with Yates correction. A 30-year-old

in a closed compart(37.1%) wounds were delayed primary closure

98 (40.8%)

in 53 (22.1%) small defects were left open. In group 2. (49.5%) wounds were primarily closed over beads. and (45.1%)
I. Details

Illustrative

in 381
Table

severe
of the

soft-tissue
and

defects
fractures Group in the 1 ( IS
tO

were
two

managed
groups Group 2

by

type-IIIB open fracture of the left lower leg in a helicopter crash. The fracture was unstable, with extensive soft-tissue loss, periosteal stripping, and gross contamination (Fig. 1 ). After copious wound irrigation and meticulous radical debridement the fracture was stabilised with an external fixator (Fig. 2). A drain was brought out through intact skin and tobramycin-PMMA beads were placed in the wound (Fig. 3). An adherent sterile drape ew Medical Ltd, Hull, UK) was (Opsite: Smith & Nephused to cover the defect

patients

Age

in years

(mean:

range)

33.3

90)

34.2

1 14 to 91)

Male:female Follow-up Upper Lower limb limb in months (mean: range)

16 1:89 23.6 (6 to 82 (24.4C/ ( 75.67c )

420:244
19.2 (6 to 76) (16.4C/c)
(83.63-)

59/240 I 8 1/240

139/845 706/845

THE

JOURNAL

OF BONE

AND

JOINT

SURGERY

l.t)(.-\L

ANFIBIt)IIC

THERAPY

R)R

SEVERE

OPEN

FRACRJRFS

95

Fig.

Fig.

Fig. 4 After hap. exiernal

fixation. wound

Fig. fly thorough debridenient. antibiotic-loaded heads in an Opsite pouch.

iii:tiigenient

and

kin

gralting

as

well

as

tree

r?*

TiT==-T:=

___
I,,.

I
6a

:,

\
/A
. -

..

.
Fig. 6h
unnn

Fig.

Fig. and
no

6c

Fig.

6d

Flic

tinal

appearance

with

sound

evidence

of

intectioti.

VUI..

77-B.

Nu.

I. JANtARY

995

96

P. A. W. OSTERMANN.

D. SELIGSON.

S. L. HENRY infection type Group Per

3.0 8.5 20.6 12.0

the

antibiotic-bead-pouch

technique

described

by

Oster-

mann, Henry and Seligson were loosely

and Seligson (I 989) and Henry, Ostermann (1993). In 45 fractures (5.4%), the wounds closed over beads as a temporary measure could rate was 12% be achieved. for acute infection in group 1 (29/240) and/or and

Table II. Infection rates for acute in both groups related to fracture Group Fracture type Number 1

and/or

chronic

osteomyelitis

2 Per
0.5

cent

Number 1/212 8/293 22/340 3 1/845

cent

p value NS NS
<

until final wound closure The overall infection chronic osteomyelitis

I
II

2/67
6/71

2.7
6.5

3.7% in group 2 (3 1/845). This difference nificant (p < 0.001). There was a reduction of infection statistically
II).

is highly sigin the incidence was (Table

III
I to III

21/102
29/240

0.001 0.001

in all fracture types, but the difference significant only for type-Ill fractures

3. 7

<

Table

III.

Acute

infection Group 1

rates

in both

groups Group 2

related

to fracture

type

Acute wound infection showed lower rates in group 2 than in group 1 , but this difference was statistically significant only for type III, and by further subdivision for the types also
IV);

Fracture

type

Number

Per
1.5 1.4 18.6

cent

Number 0/212 2/293 16/340

Per

cent

p value NS

IIIB reduced

and

IIIC

(Table

III). showed

Chronic

osteomyelitis with group reduction III

was 1 (Table in the sig-

I
II

1/67
1/71

in group analysis

2 in comparison

0.7 4.7

NS
<

statistical

a significant

both type-Il and reduced incidence nificant only

type-Ill fractures. of osteomyelitis fractures.

Within type was statistically

III lIlA
IIIB IIIC

19/102 0/43
11/27 8/32

0.001

4/156
40.7
25.0 10/144

2.6
6.9
5.0

NS
<0.0()l < 0.05

in type-IIIB

2/40

DISCUSSION

Table type

IV.

Chronic

osteomyelitis

in

both

groups

related

to

fracture

Infection ture and a higher

is the

most

severe

complication

of an open

fracGroup 1 Per
1.5 8.5 9.8 29.6 6.3

the higher incidence

Gustilo types have been of this complication.

shown to have Type-IIIB and

Group cent Number 1/212 7/293 13/340 3/156 9/144 1/40

2 Per
0.5

Fracture
I II III lIlA

type

Number 1/67 6/71 10/102 0/43

cent

p value NS
<

type-IIIC open critical injuries Fischer, Gustilo

fractures have been described as the most (Ostermann, Henry and Seligson 1992), and and Varecka (1991) reported an incidence

2.4 3.8
1.9

0.t)5 0.05

of 48.8% of deep bony infections after type-IIIB fractures, although others have achieved much better results (CourtBrown et al 1991). Current management includes the early administration of a short course of parenteral antibiotics (Patzakis et al 1974; Dellinger et al 1988), copious wound irrigation, (Edwards soft-tissue within Russell, Our one serial radical debridement and bony stabilisation et al 1988; Muhr 1991). The establishment coverage or wound closure is recommended week (Byrd et al 1985; Caudle and Stern Henderson investigation and Arnett has shown 1990). that, in our of

<

NS
<0.001

IIIB
IIIC

8/27
2/32

6.3 2.5

NS

tion

and meticulous radical debridement. Our review has raised interesting and provocative tions: Are systemic antibiotics. with their possible effects, essential? alone be sufficient open fractures? We recognise trials sary in a large to provide Can the local application to prevent the evolution that population the answers.
have been directly received or will or indirectly to be received the subject

quesside-

1987;

of antibiotics of infections in randomised will be necesfrom a of this

hands,

adjuvant

local antibiotic therapy reduced the incidence of late infection in comparable treatment groups, but we recognise that there were also different soft-tissue managements and no attempt The at randomisation. positive effect of local antibiotic therapy appeared to with or

prospective, of open

properly fractures

be valid for all fracture types, and especially for those severe soft-tissue damage and gross contamination impaired myelitis (almost vascularity. The very high which we found for type-IIIB 30%) may also be related

No benefits commercial article.

in any form party related

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JOURNAL

OF BONE

AND

JOINT

SURGERY

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ANTIBIOTIC

THERAPY

FOR SEVERE

OPEN

FRACTURES

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VOL.

77-B.

No.

I. JANUARY

1995