Risk factors for deep infection in secondary intramedullary nailing after external fixation for open tibial fractures

doi:10.1016/j.injury.2005.08.026

Injury

Volume 37, Issue 6, June 2006, Pages 554-560

https://doi.org/10.1016/j.injury.2005.08.026 Get rights and content

Summary

Background

Risk factors for deep infection in secondary intramedullary nailing (IMN) after external fixation (EF) for open tibial fractures were investigated by multivariate analysis following univariate analyses.

Methods

Forty-two open tibial fractures were treated with secondary IMN after EF. The open tibial fractures were classified according to the criteria proposed by Gustilo et al.: type II, 11; type IIIA, 8; type IIIB, 22 and type IIIC, 1. Locked IMNs with limited reaming were performed in 27 patients, and locked IMNs without reaming in 15 patients. The following factors contributing to deep infection were selected for analysis: age, gender, Gustilo type (II or III), fracture grade by AO type (A or B + C), fracture site, existence of multiple trauma (Injury Severity Score, ISS < 18 or ISS ≥ 18), existence of floating knee injury, debridement time (≤6 h or >6 h), reamed (R) versus unreamed (UR) nailing, duration of external fixation (≤3 weeks or >3 weeks), interval between removal of EF and IMN (≤2 weeks or >2 weeks), skin closure time (≤1 week or >1 week), existence of superficial infection (+ or −) and existence of pin tract infection (+ or −). The relationship between deep infection and the above factors was evaluated by univariate analyses.

Results

Seven (16.7%) of the 42 open tibia fractures developed deep infections. All deep infections occurred in Gustilo type III (22.6%, 7/31). Only the skin closure time was a significant factor affecting the occurrence of deep infection on the present analysis (p = 0.006).

Conclusion

The present evaluation showed that early skin closure within 1 week is the most important factor in preventing deep infections when treating open tibial fractures with secondary IMN after EF.

Introduction

In managing severe open tibia fractures, many orthopaedic surgeons have been obliged to use an external fixator in order to gain initial bony and soft-tissue stability. However, external fixation itself has been associated with several problems, such as delayed unions, non-unions, malunions and ankle joint stiffness.¹⁸ For these reasons, external fixators may be converted to intramedullary nailing. This exchange has been associated with intramedullary infection, as previously reported.12, 13, 14

Our aim in designing this retrospective study was to investigate risk factors for deep infection in secondary intramedullary nailing after external fixation for open tibial fractures.

Section snippets

Clinical materials

We treated 46 open tibial fractures with secondary intramedullary nailing (IMN) after external fixation (EF) at the Department of Orthopaedic Surgery and Trauma Center, Kitasato University Hospital, between 1986 January and 2002 February. We retrospectively reviewed 42 patients excluding 4 patients treated with IMN after pinless of EF. Some of these cases were reported previously.25, 26

Thirty-five patients were male and seven patients were female. The mean patients’ age at the time of injury

Results

Seven of the 42 open tibia fractures developed deep infections. Two of these infections were caused by Staphylococcus aureus alone, two were caused by Pseudmonas aeruginosa alone, one was caused by Staphylococcus epidermidis alone, one was caused by gram negative rod and bacillus sp. and one was caused by Serratia sp., and Pseud. Aeruginosa.

Although all deep infections occurred in Gustilo type III (7/31), this was not statistically significant (p = 0.084). The relationship between deep infection

Discussion

To our knowledge, Karlström and Olerud¹² documented the first experience with secondary IMN after external fixation for three open tibia fractures. They reported two deep infections after these procedures, and advised against IMN after EF. McGraw and Lim¹⁴ and Mauer et al.¹³ presented detailed descriptions of the problems associated with secondary IMN after external fixation. They also reported a high incidence of deep infection in secondary or delayed IMN after EF.

Various authors have

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Cited by (60)

Relationship between number of debridements and clinical outcomes in open tibia fractures requiring free flap coverage: A retrospective cohort study
2023, Orthoplastic Surgery
Open fractures with degloving injuries are commonly managed by serial debridements prior to definitive flap coverage in the United States (US). Some international institutions minimize the number of debridements prior to coverage. The purpose of this study was to compare clinical outcomes in patients with open tibia fractures requiring free flap coverage from institutions with differing debridement philosophies.
This was a multi-site retrospective cohort study of patients treated at two US tertiary care facilities (serial debridement cohort) and one in India (early total debridement cohort) with Type IIIB or IIIC open tibia fractures requiring free tissue transfer. The number of debridements prior to flap coverage were recorded and primary outcomes were rates of infection, non-union, and flap failure. Fischer's exact tests were used to compare outcomes between the cohorts.
80 patients were included, 44 from India and 36 from the US. Patients in the serial debridement cohort underwent more debridements prior to flap coverage (mean 3.64 vs 1.84, p < 0.001) and had significantly higher rates of infection and non-union compared to patients in the early total debridement cohort (p < 0.05). There were no differences in rates of flap failure between the cohorts.
Patients with open tibia fractures treated at institutions favoring serial debridements underwent more debridements and had higher rates of infection and non-union compared to patients treated at a center favoring early total debridement. Serial debridements may not be necessary prior to flap coverage for open tibia fractures and the current practice should be further investigated.
Optimum timing of conversion from DCO to definitive fixation in closed fractures of the lower limb: When and how?
2023, Injury
In damage control orthopaedics (DCO), fractures are initially stabilised with external fixation followed by delayed conversion to definitive internal fixation. The aim of this study is to determine whether the timing of the conversion influences the development of deep infection and fracture healing in a cohort of patients treated by DCO after a closed fracture of the lower limb. Furthermore, we wanted to evaluate whether the one-stage conversion procedure is always safe.
A retrospective cohort study was conducted at a single level 1 trauma centre. Ninety-four cases of closed fractures of lower limb treated by DCO subsequently converted to internal fixation from 2012 to 2019 were included. Development of deep infection, superficial infection, non-union and time to union were recorded. Patients were then divided into three groups according to the timing of conversion: Group A (<7 days), Group B (7-13 days), Group C (> 14 days). Comparison between groups was performed to assess intergroup variabilty.
The mean number of days between DCO and conversion was 6.7±4.52 (range 1-22). We observed one case of deep infection (1.1%), one case of non-union (1.1%), four cases of superficial infection (4.3%) and mean time to union was 4.9±1.38 months months. Comparison between groups demonstrated no significant correlation between timing of conversion and development of superficial or deep infection and non-union, while it highlighted that complexity of the fracture and longer surgical time of conversion procedure were significantly higher in Group C.
One-stage conversion to definitive internal fixation within 22 days from DCO is a safe and feasible procedure, which does not influence the incidence of infection or non-union.
Definitive fixation of open tibia fractures: Does reopening the traumatic wound increase complication rates?
2022, Journal of Clinical Orthopaedics and Trauma
It is unknown if surgical approach or use of previous traumatic wounds for open fracture instrumentation has an impact on patient complications or outcomes. This study sought to compare infection and nonunion rates in the staged treatment of open tibia fractures where the traumatic wound was reopened during definitive fixation versus when they were not.
A retrospective review was performed on all patients at a single institution level 1 trauma center. All patients who had a minimum of 1 year clinical and radiographic outcomes were included. Primary outcome measures were incidence of infection and nonunion. Groups of patients were compared based on surgical approach for definitive fixation.
A total of 96 patients were included – 48 patients received definitive treatment and wound closure during initial management of the open fracture (group 1), 22 patients had staged fixation through new incisions (group 2), and 26 patients had their traumatic wound reopened during definitive fixation (group 3). Rates of infection were 10.4%, 31.8% and 11.5% respectively (p = 0.15). Rates of nonunion were 20.8%, 27.3% and 30.8% (p = 1.0). No statistically significant differences in regards to primary outcomes were found between the staged fixation groups. Multiple logistic regression also showed no difference in infection or nonunion when controlling for known risk factors.
For open tibia fractures that underwent staged fixation, no significant differences in infection or nonunion were observed between procedures that involved reopening the traumatic wound versus procedures performed through new incisions. The presence of a distal tibia periarticular fracture was found to be independently associated with infection risk.
AO external fixator for definitive treatment of an open distal tibia fracture during the COVID-19 pandemic
2021, Fuss und Sprunggelenk
Citation Excerpt :
The gold standard for the treatment of open fractures of the long bones consists of aggressive debridement, irrigation and temporary external fixation accompanied by antibiotic prophylaxis [1,2,6,7,9–11]. Subsequent removal of external fixation and definite fixation with intramedullary nailing or plating is generally recommended within 2 weeks to achieve better stability for bone healing and diminish the risk of infection [12,13]. However, under several circumstances this type of treatment may not be feasible, and external fixator has to be used as a definitive mode of fixation.
The accepted gold standard for primary treatment of long bone open fractures consists of aggressive debridement, irrigation and temporary external fixation. Removal of the external fixator followed by definite internal fixation is recommended within the first two weeks after the injury to obtain a more stable fixation, alleviate rehabilitation and to avoid pin infection.
Here, we report a case of a Gustilo IIIB open tibia fracture with extended soft tissue degloving of the distal tibia. Following removal of the AO external fixator, plate fixation and soft tissue coverage with a free flap, implant loosening occurred warranting a return to external fixation. The patient did not return for follow-up due to a prolonged COVID-19-quarantine and no further treatment was installed.
The patient returned after 6 months with the fractures and soft tissues fully healed. In specific situations, the external fixator may be used as a definitive form of treatment.
Der allgemein anerkannte Goldstandard für die primäre Therapie offener Frakturen der langen Röhrenknochen besteht in einem aggressiven Wunddébridement, ausgiebiger Spülung und temporärer Anlage eines Fixateurs externe. Die Abnahme des Fixateurs externe und eine anschließende definitive interne Osteosynthese werden allgemein innerhalb von 2 Wochen empfohlen, um eine stabile Fixierung und erleichterte Mobilisierung bei niedriger Rate an Pininfekten zu erzielen.
Dieser Falbericht schildert die initiale Therapie einer Gustilo IIIB offenen distalen Unterschenkelfraktur mit ausgedehntem Weichteilschaden bei großflächigem Degloving der distalen Tibia. Nach Abnahme des AO Fixateur externe Plattenosteosynthese und Weichteildeckung mit einem freien Lappen kam es zu einer Implantatlockerung, weswegen ein erneuter Verfahrenswechsel auf Fixateur externe notwendig wurde. Die Patientin erschien im Anschluss nicht mehr zur Nachuntersuchung und Planung weiterer Maßnahmen aufgrund einer prolongierten Quarantäne im Rahmen der COVID-19-Pandemie.
Die Patientin erschien nach 6 Monaten zur Nachkontrolle mit vollständig konsolidierten Frakturen und Weichteilen. In speziellen Situationen kann der Fixateur externe auch als definitive Form der Osteosynthese eingesetzt werden.
Clinical outcome of conversion from external fixation to definitive internal fixation for open fracture of the lower limb
2019, Journal of Orthopaedic Science
Citation Excerpt :
Third, open fractures of the femur and tibia were analyzed simultaneously. Our infection rate was 9.4%, lower than those reported in previous studies [9,11,27], even though analyses included both femur and tibia. In addition, the number of patients was small and investigation was performed in single institution.
Few reports have examined the outcomes and complications of temporary bridging external fixation (EF) in open fracture of the lower limb followed by conversion to open reduction internal fixation (ORIF). The purpose of this study was to evaluate healing rates and complications in patients treated with conversion from external fixation to definitive internal fixation for open fracture of the lower limb.
Patients who underwent temporary bridging EF and subsequent conversion to internal fixation (IF) for open fracture of the lower limb, with follow-up period ≥12 months were included in this study. Demographic data, Gustilo-Anderson classification, fracture type, duration to definitive surgery, surgical procedure, perioperative complications, and additional procedures for cases with complications were obtained.
In total, 58 patients (43 males, 15 females), 63 fractures were included in this study. Four fractures (6.3%) were Gustilo grade I, 11 fractures (17.5%) were grade II, 34 fractures (54.0%) were grade IIIa, 12 fractures (19.0%) were grade IIIb, and two fractures (3.2%) were grade IIIc. Mean duration of the application of EF was 12.4 days (range, 3–45 days) until conversion to definitive IF. Rates of deep infection and nonunion were both 9.5%, with two cases showing concomitant infection and nonunion. Rates of infection were 8.8% (3/34) in grade IIIa and 25% (3/12) in grade IIIb. Rates of nonunion were 9.1% (1/11) in grade II, 2.9% (1/34) in grade IIIa and 33% (4/12) in grade IIIb.
Temporary EF for open fracture of the lower limb followed by conversion to IF, as early as soft tissue and general condition permit, may be a safe and effective procedure for patients with lower-limb open fracture of Gustilo grade IIIa or less.
Level IV, Case series.
Incidence and risk factors associated with infection after intramedullary nailing of femoral and tibial diaphyseal fractures: Prospective study
2018, Injury
Citation Excerpt :
The risk factors associated with these infections may include general SSI risk factors as well as those specifically related to fracture fixation [12]. Retrospective studies suggest that open fractures, previous use of external fixation, clinical instability in initial care and the need for soft-tissue reconstruction may be associated with the occurrence of infection after IMN, although no prospective studies have assessed these potential risk factors [10,13–16]. Thus, the objective of this study was to prospectively assess the incidence and potential risk factors related to the occurrence of infection following IMN for fixation of femoral and tibial diaphyseal fractures.
Diaphyseal fractures of femur and tibia are prominent due to its high incidence and high economic and social impact. Intramedullary nailing (IN) is the surgical procedure of choice. Surgical site infection (SSI) related to this procedure is considered a difficult to treat complication.
Determine the incidence of SSI after IN of femoral and tibial diaphyseal fractures and evaluate possible risk factors. METHODS: Prospective observational cohort study. SSI was defined according to CDC-NHSN criteria and surveillance period for the occurrence of infection was 12 months. Incidence of SSI was calculated as the ratio between the number of patients with SSI and total number of patients. Analysis of potential risk factors included patients-related factors (age, gender, body mass index, active foci of infection, immunosuppressive conditions, ASA score, alcohol or illicit drug abuse, smoking, polytrauma, etiology of fracture, type of fracture if closed or open, classification of fracture according to Müller AO, Tcherne classification for closed fractures, Gustilo-Anderson classification for open fractures, previous surgical manipulation, use of blood products); environmental and surgical-related factors (surgical wound classification, duration of surgery, hair removal, intraoperative contamination, antimicrobial use, presence of drains, hypothermia or hypoxia in the perioperative period, type of IN used, reaming, need for soft tissue reconstruction, use of negative pressure therapy) and microbiota-related factors (cultures of nasopharyngeal swabs forStaphylococcus aureus and axillary/inguinal/perineal swab for Acinetobacter baumannii).
221 patients were included and completed the 12-month follow-up period. Incidence of SSI was 11.8%. In the initial analysis by unadjusted logistic regression, following factors were associated SSI: Müller AO classification of the fracture morphology groups 2 or 3, previous use of external fixator, presence of drains, use of negative pressure therapy and need for muscle or skin flap repair. In the multiple logistic regression-adjusted analysis, previous use of external fixator and need for muscle or skin flap repair remained associated with SSI.
Incidence of SSI associated with IN for femoral and tibial diaphyseal fractures was 11.8%. Previous use of external fixators and need for muscle or skin flap repair were factors associated with occurrence of infection.

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Risk factors for deep infection in secondary intramedullary nailing after external fixation for open tibial fractures

Summary

Background

Methods

Results

Conclusion

Introduction

Section snippets

Clinical materials

Results

Discussion

J Orthop Res

Injury

External fixation and secondary intramedullary nailing of open tibial fractures: a randomized, prospective trial

J Bone Joint Surg Br

The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care

J Trauma

Intramedullary nailing following external fixation in femoral and tibial shaft fractures

J Orthop Trauma

External fixation and delayed intramedullary nailing of open fractures of the tibial shaft

J Bone Joint Surg

Early prophylactic bone grafting of high-energy tibial fractures

Clin Orthop

Prospective study of union rate of open tibial fractures treated with locked, unreamed intramedullary nails

J Orthop Trauma

Risk of infection after open fracture of the arm or leg

Arch Surg

Problems in the management of type III (severe) open fractures

J Trauma

Stable osteosynthesis by interlocking cylinder nailing for fractures of the femur and tibia

J Jpn Orthop Assoc

Delayed intramedullary nailing after failed external fixation of the tibia

Clin Orthop

External fixation of severe open tibial fractures with the Hoffmann frame

Clin Orthop