Abstract
The management of grade III open fractures remains controversial. While the time tested external fixators have their advantages of ease of application and facilitating repeated debridements in extensive uncovered open wounds, their use has been marred with pin tract infections, delayed union, non-union, joint stiffness and patient discomfort. Advantages of internal fixation include access for soft tissue care, secure control of alignment and rotation and early weight bearing. But surgeons have feared using internal fixators in grade III open wounds for the risk of deep infection. With lack of adequate data regarding time to first debridement, number of debridements, time to definitive fixation, mode of final coverage and time to coverage affecting the final infection rate, this study plans to study these variables in the use of internal fixation in grade III B open fractures of long bones
Introduction
As a result of rapid increase in motor vehicle and industrial accidents open fractures have become very common. A fracture is considered to be open when disruption of the skin and underlying soft tissues results in a communication between the fracture and the outside environment. Open fractures are most commonly classified according to the system developed by Gustilo and Anderson and subsequently modified by Gustilo et al1 The modified classification is based on the size of the wound, periosteal soft-tissue damage, periosteal stripping, and vascular injury.
The great medical discoveries of the past 150 years,2 such as anaesthesia, antisepsis, asepsis, the germ theory of infections, advances in prehospital care, fluid and cardiorespiratory resuscitation, and early fracture stabilization,brought about a revolution in operative wound care. Although in the past success in treating open fractures was measured by the number of lives lost or limbs amputated, attention is now being focused on reducing wound infections and healing times. Ultimately, we aim to restore our patients with the least delay to as close to their preinjury status as possible3.
The rates of infection and nonunion are higher in Gustilo type IIIB than in types I, II, and IIIA open fractures.4 To prevent complications, various treatment regimens have been developed, including acute delivery of intravenous antibiotics, repeated radical debridement followed by early local or free flap closure, 5 rigid stabilization with external fixation8 or interlocking unreamed nailing, 6 and prophylactic bone grafting.7
The primary focus of selection of skeletal fixation methods involves avoiding infection. For many years the concept of immediate application of internal fixation implants for open fracture stabilization was strongly discouraged.8 The presence of metal within a wound is a foreign body that is a potential substrate for biofilm formation, with a theoretical increased risk for acute infection.9 Additionally, the potential bone devitalisation required to apply an extra medullary implant was thought to contribute to development of infection. There remains fear of implanting metal in a contaminated field leading to intramedullary deep infection in massively contaminated wounds where inadequate debridement may further increase the risk10. Several decades ago traditional teaching was that intramedullary nailing, particularly with associated reaming, significantly damaged the osseous blood supply, and was ill-advised in open fractures.11
The advantages of internal fixation include high patient acceptance, cosmesis, access for soft tissue care, secure control of alignment and rotation, early mobilization, and the potential for biomechanically safe early weight bearing.12 The major advantage of unreamed interlocking intramedullary nails is that alignment is maintained without additional periosteal damage and theoretically with minimal disruption of the medullary vasculature.13 Primary plating preserves the integrity of the soft tissues surrounding the fracture site, does not disturb the periosteal and endosteal blood supply, does not produce any osseous debris as in case of reaming, and provides rigid internal fixation which protects against nonunion and malunion14 Over the past 5 decades, improved metallurgy, surgical techniques, antibiotic therapy, and understanding of the pathophysiology of infection have led to the wide-spread use of immediate internal fixation of open fractures. Several sentinel works have demonstrated acceptable infection rates.15 More recent clinical and in vitro data on locking plates indicates that infection rates in open fractures may be even lower than with standard compression plate devices.
While there is ample data supporting the administration of antibiotics after open fracture, evidence indicating an optimal regimen is lacking. In the randomized, controlled trial by Patzakis et al.16 in 1974, patients receiving the first-generation cephalosporin cephalothin were found to have a lower infection rate than those receiving penicillin and streptomycin (2.3% compared with 9.7%). Also of interest is the prospective double-blind study by Benson et al. in 1983 who found clindamycin to be as effective as cefazolin for preventing infection after open fracture17. Ciprofloxacin has also been considered for the management of open fractures, given its activity against both gram-positive and gram-negative organisms. There is currently controversy with regard to the specific antibiotic agent(s) to be given after open fracture. While some have recommended treating all open fractures with a combination of a first-generation cephalosporin and an aminoglycoside18, others have advocated monotherapy with a first- generation cephalosporin for type-I and II fractures with the addition of an aminoglycoside (usually gentamicin) for type- III fractures19. Most agree that penicillin or ampicillin should be added when there is a high risk of anaerobic infection (in association with farm injuries, for example).The available evidence suggests that antibiotic treatment should be initiated as soon as possible following injury.
Although, in the past, cultures were routinely done before and after debridement of open fractures, authors of recent studies have questioned their utility.20 The organisms that are found to be contaminating an open fracture on presentation do not represent the microbes that will eventually cause infection. In fact, there is evidence that most infections at the sites of open fractures are caused by nosocomial bacteria21
Still the issue of primary internal fixation in grade 3B open fractures is controversial. Since Davis22 performed the first immediate internal fixation following timely initial debridement of open fractures in 1948, many surgeons23 have reported the utility of immediate internal fixation. However certain variables like time to give first dose of antibiotic, which antibiotic, for how long, right time to take cultures, whether pre or post debridement and the significance of colony counts remain in the blue which this monologue is trying to enlighten.
Materials and Methods
This study was an uncontrolled interventional study. It was a one year prospective study involving 34 patients with Grade III B Open diaphyseal fractures of long bones including humerus, forearm bones, femur and tibia with or without fibula. The minimum period of follow up was nine months. Patients were evaluated both subjectively and objectively.
A standard treatment protocol was followed. The life-saving assessment and resuscitation of severely injured patients was undertaken first. The involved limb was then examined with careful neurologic and vascular assessment and calculation of MESS score. Early first dose antibiotic was given in the casualty itself. A third generation cephalosporin like Cefperazone/Sulbactum (1.5g q8h) with amikacin (750mg OD) and metronidazole (500 mg q8h) or a combination of Piperacillin /Tazobactum (4.5g q8h) was used.
Tetanus toxoid and tetanus immune globulin according to immunization status and contamination of wound was also given preoperatively. The wound was washed with copious amount of saline and a sterile dressing applied after taking adequate pictures of the wound. Plastic surgery consult was taken for coverage and where ever vascularity was in doubt. The fracture was splinted and adequate x-rays done. The patient was taken to the OT on an urgent basis but not always necessarily within the so called golden period of 6 hours because of the usual delays. In the OR the wound was first washed with copious amount of saline. Minimum 9 liters of normal saline was used. Either bulb syringes or sometimes pulse lavage was used where deep seated dirt or grit was suspected. No additives were used. Then the wound was adequately debrided. All dead and damaged tissues and foreign bodies were removed.
When the wound looked appreciably clean the limb was redraped and painted. All the fractures were internally fixed in the primary sitting either with a plate or a nail. Diaphyseal fractures usually require relative stability to heal and healing by secondary intention is found to be stronger. So most commonly a plate in a bridge mode or an interlocking nail was used. Both reamed and unreamed nails were used to stabilize the fractures. If the wound looked adequately clean and margins opposable it was closed in the primary sitting. If it was felt that the wound will need further debridements before final closure, it was either dressed or preferably a negative pressure dressing was applied. Patient was taken for a redebridement usually within 48-72 hours. Deep tissue cultures were taken after each wash and debridement. When the wound looked clean enough and the last cultures came out to be negative the wound was either closed or covered with a split thickness skin graft if adequate granulation tissue was present or covered with a local fasciocutaneous or a muscle flap.
Wounds were covered at the earliest, but where ever delay was anticipated because of unhealthy condition of the wound or doubtful vascularity or absence of granulation tissue preferably a VAC dressing was applied. VAC dressings were changed in 4-5 days till adequate granulation had appeared which took on an average around 3-4 dressings. IV Antibiotics were continued for 72 hours after the initial procedure and for 48 hours after each additional procedure and were continued till 3 days after wound coverage or closure. Post op immediate joint ROM and strengthening exercises were started. NWB gait training was also started immediately once the wounds were covered. PWB was started usually around 6 weeks when a good soft callus had well formed. FWB was started usually around 3 months when at least 3 cortices had united in 2 views. Follow up with clinical and radiological assessment was obtained at immediately post op, at discharge, at 3 weeks, 6 weeks, 3 months, 6 months and 9 months.
Observations, Results and Analysis
34 diaphyseal fractures of long bones were fixed primarily within 24 hours of presentation. Leg bone fractures were most common (16 cases or 47.06%). Mean age was 31.62 years. 94.12 % of patients were males. Road traffic accidents (52.94%) was the most common mode of injury. 52.94% patients presented within 6 hours and antibiotics were also started within 6 hours. Mean time to presentation was 8 hours and the Range was 2-20 hours. 20.62% cases had a MESS score of 2. None had a score of 7 or more. Mean MESS score was 3.17 and the Range was 2-6. 61. 76% fractures were fixed with a nail. 38.24% fractures were fixed with a plate. The single case of humerus was fixed with a locked plate. 46.67% of forearm fractures were fixed with a LC-DCP. 26.67% forearm fractures were fixed with a TENS nail. Both the femur fractures were fixed with a reamed hollow nail. 43.75% of tibia fractures were fixed with an unreamed solid nail. 37.5% of tibia fractures were fixed with a reamed cannulated nail. In 61.76% of patients a combination of cefperazone/sulbactum + amikacin + metronidazole was used. In 61.76% of patients a combination of cefperazone/sulbactum + amikacin + metronidazole was used. In 38.24% patients Piperacillin/Tazobactum was used. Average duration of antibiotics was 7.41 days. 35.29% patients had no growth. MSSA was the most common organism grown in cultures (17.65%). Out of the culture positive cases 44.12% patients had a colony count of 102. 2.94% cases had a superficial infection. 2.94% cases had a deep infection. Of all the culture positive cases infection was seen in only in 9% of the cases. No correlation could be proven between mode of injury and resulting infections. Infection rate increased as the Time to Presentation/Initiation of Antibiotics increased. The case of deep infection was found when MESS score was 6. Duration of antibiotics given had no correlation with infection. Staph aureus was found to be the culprit in both the infections MSSA in superficial and MRSA in deep. It was found that contamination does not always becomes infection but a high colony count correlates more with infection.
Recommendations from this study
Primary Internal fixation a good modality of fracture stabilisation even in open 3B fractures. Early first dose of broad spectrum antibiotic should be given as soon as possible after presentation as it has been found to be the single most important factor in preventing infection. Starting a broad spectrum antibiotic according to grade of fracture and wound contamination and crushing is better and later de-escalating it according to the post debridement cultures. There is no role of IV antibiotics for more than 48 hr. after each procedure. There is not much role of pre or post debridement cultures. Post debridement cultures are relatively more valuable but often are the result of contamination rather than true infection. Contamination does not always becomes infection but a high colony count correlates more with infection. Relative but stable fixation with a bridge locked plate or a locking nail after limited reaming is becoming the treatment of choice in open grade III B fractures these days in centres which have facility for wound coverage
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