Background. Open fracture wounds are well known to be associated with infection & prolonged healing. Activity in scientific research to improve wound healing has often provided variable results. This study was done to question the de facto nature of Normal Saline as best irrigant in management of such wounds and to find out a better irrigant, if so, that does exist with due consideration to the mechanism by which saline dressings act. Material and methods. 30 patients with Grade 3 open fracture wounds were assessed over a period of three months according to Ganga Hospital Injury severity Score and were divided equally in study and control groups after adequate matching. A standard dressing protocol consisting of debridement and external fixation within 6 hours, avoidance of any antiseptic or surfactant agent, high-volume low-pressure pulsatile lavage irrigation and saline soaked gamgee pad packings with concerned solutions changed twice daily was done in respective groups. Follow-up was done by colour of healing granulation tissue, pus culture and soft tissue biopsy at Day 1, 3,7,10 & 14. Results. 6 out of 15(40%) wounds in study group were observed to have reached pink healthy granulation with low exudate by Day 14 as compared to only 3 out of 15(20%) in control group. The time taken to traverse from each stage of healing granulation was also observed to be smaller with 3% NaCl as compared to 0.9% NaCl. Although once healthy granulation stage was reached, further dressing with 3% NaCl in study group was shown to have worsening of granulation in about 33% of cases with none such observed in control. Conclusion. 3% NaCl is a better irrigant than 0.9% NaCl for dressing of Open trauma wounds during initial stages of dressing. Their effectivity in maintaining advanced granulation is although questionable, probably owing to its desiccative action

Aim. Fracture-related infection (FRI) is an important complication following surgical fracture management. Key to successful treatment is an accurate diagnosis. To this end, microbiological identification remains the gold standard. Although a structured approach towards sampling specimens for microbiology seems logical, there is no consensus on a culture protocol for FRI. The aim of this study is to evaluate the effect of a structured microbiology sampling protocol for fracture-related infections compared to ad-hoc culture sampling. Method. We conducted a pre-/post-implementation cohort study that compared the effects of implementation of a structured FRI sampling protocol. The protocol included strict criteria for sampling and interpretation of tissue cultures for microbiology. All intraoperative samples from suspected or confirmed FRI were compared for culture results. Adherence to the protocol was described for the post-implementation cohort. Results. In total 101 patients were included, 49 pre-implementation and 52 post-implementation. From these patients 175 intraoperative culture sets were obtained, 96 and 79 pre- and post-implementation respectively. Cultures from the pre-implementation cohort showed significantly more antibiotic use during culture sampling (P = 0.002). The post-implementation cohort showed a tendency more positive culture sets (69% vs. 63%, P = 0.353), with a significant difference in open wounds (86% vs. 67%, P = 0.034). In all post-implementation culture sets causative pathogens were cultured more than once per set, in contrast to pre-implementation (P <0.001). Despite stricter tissue sampling and culture interpretation criteria, the number of polymicrobial infections was similar in both cohorts, approximately 29% of all culture sets and 44% of all positive culture sets. Significantly more polymicrobial cultures were found in early infections in the post-implementation cohort (P = 0.048). This indicates a better yield in the new protocol. Conclusions. A standardised protocol for intraoperative sampling for bacterial identification in FRI is superior than an ad-hoc approach. This was the combined effect of no antibiotics around sampling, more tissue samples with the ‘no touch-technique, increased awareness for both surgeon and microbiologist and stricter criteria for diagnosis. It resulted in more microbiologically confirmed infections and more certainty when identifying causative pathogens

We have conducted a case-control study over a period of ten years comparing both deep infection with methicillin-resistant staphylococcus aureus (MRSA) and colonised cases with a control group. Risk factors associated with deep infection were vascular diseases, chronic obstructive pulmonary disease, admission to a high-dependency or an intensive-care unit and open wounds. Those for colonisation were institutional care, vascular diseases and dementia. Older age was a risk factor for any MRSA infection. The length of hospital stay was dramatically increased by deep infection. These risk factors are useful in identifying higher-risk patients who may be more susceptible to MRSA infection. A strategy of early identification and isolation may help to control its spread in trauma units

Aim. Antibiotic prophylaxis is critical for the prevention of fracture related infection (FRI) in trauma patients, particularly those with open wounds. Administration of prophylactic antibiotics prior to arrival at the hospital (e.g. by paramedics) may reduce intraoperative bacterial load and has been recommended; however scientific evidence for pre-hospital administration is scarce. Methods. The contaminated rabbit humeral osteotomy model of Arens was modified to resemble the sequence of events in open fractures. In an initial surgery representing the “accident”, a 2mm mid-diaphyseal hole was created in the humerus and the wound was contaminated with a clinical Staphylococcus aureus strain (mean 1.6×106 Colony Forming Units, CFU). The animals were allowed recover for 4 hours mimicking the period from trauma to debridement. At this time, a second procedure was performed in order to debride and irrigate the wound, and to fix a complete osteotomy that was made through the initial defect. Three test groups were included (n=8 rabbits per group): 1) no antibiotic therapy; 2) standard “in-hospital” antibiotic prophylaxis (24 hours therapy starting 30 minutes before surgery); 3) “pre-hospital” antibiotics (single dose 15 minutes after the “accident”). The antibiotic used was cefuroxime and was administered in a weight-adjusted dosage. Results. In the absence of any antibiotic administration (group 1), high bacterial counts were identified at fixation (1.89×106 CFU) and at euthanasia (day 7, 7.70×107 CFU) in all rabbits. When 24 hours of antibiotics were administered commencing “in hospital” (group 2), the bacterial load during fixation surgery was slightly reduced (CFU 9.88×105) and 50% of animals were infected at euthanasia. When one single shot of antibiotics was administered in the “pre-hospital” setting (group 3), the bacterial load during fixation surgery was significantly lower than for both groups 1 and 2(CFU 2.34×103) yet all animals were infected at euthanasia. Conclusions. Early pre-hospital administration of antibiotics significantly reduced the bacterial load in the operative field at the time of debridement compared to regular prophylaxis. However, continuation of systemic antibiotics is necessary in order to prevent infection in this model

The optimal choice of irrigating solution or irrigating pressure in the initial management of open fracture wounds remains controversial. FLOW compared the effect of castile soap versus normal saline, and low versus high pressure pulsatile lavage on one year re-operation rates in patients with open fracture wounds. We conducted a multicentre, blinded, two-by-two factorial, pilot randomised trial of 111 patients with open fracture wounds receiving either castile soap solution or normal saline and either high or low pressure pulsatile lavage. The primary outcome, re-operation within one year, included infections, wound healing problems, and nonunions. Secondary outcomes included all operative and non-operative infections, wound healing problems, nonunion and functional outcomes. We followed the intention to treat principle. Eighty-nine patients (80.2%) completed the 12-month follow-up. As anticipated in this small-sample-size pilot study, results were compatible with substantial benefit and substantial harm. The hazard ratio (HR) for re-operation with castile soap was 0.77 (95% Confidence Interval (CI) 0.35 to 1.69, p=0.52). With low pressure lavage, the hazard ratio for the risk of re-operation was 0.56, 95% CI 0.25 to 1.27, p=0.17. Secondary outcomes showed a significant relative risk reduction for nonunion of 63% in favour of castile soap (p=0.036), and a trend for a relative risk reduction for nonunion of 44% in favour of low pressure lavage (p=0.22). Functional outcome scores showed no significant differences at any time point between groups. The FLOW pilot randomised controlled trial demonstrated the possibility that the use of low pressure may decrease the re-operation rate for infection, wound healing problems, or nonunion. Our findings provide compelling rationale for continued investigation in a pivotal FLOW trial of 2280 patients

Negative pressure wound therapy (NPWT) is commonly used to manage severe open fracture wounds. The recently completed X randomized controlled trial (RCT) evaluated the effect of NPWT versus standard wound management on 12-month disability and rate of deep infection among patients with severe open fractures of the lower limb and reported no differences. Using data from the Y trial of open fracture patients, we aimed to evaluate the impact of NPWT on the odds of having deep infections and health-related quality of life (HRQL). Our analyses included participants from the Y trial who had Gustilo II and III lower extremity fractures. To adjust for the influence of injury characteristics on type of dressing received, a propensity score was developed from the dataset. A one-to-one matching algorithm was then used to pair patients with a similar propensity for NPWT. Mixed effects logistic regression was used to evaluate the association between type of wound dressing and development of a deep infection requiring operative management (dependent variable) in the matched cohort. Gustilo type, irrigation solution, fracture location, mechanism of injury, and degree of contamination were included as adjustment variables. To determine any differences in HRQL between the NPWT and standard wound dressing groups, we conducted two multi-level models with three levels (centre, patient, and time) and included Short Form-12 (SF-12) Physical Health Component (PCS) and SF-12 Mental Health Component (MCS) as dependent variables. Gustilo type, irrigation solution, fracture location, mechanism of injury, degree of contamination, and pre-injury SF-12 scores were included as adjustment variables. All tests were 2-tailed with alpha=0.05. After applying propensity score-matching to adjust for the influence of injury characteristics on type of dressing used, there were 270 matched pairs of patients available for comparison. The odds of developing a deep infection requiring operative management within 12 months of initial surgery was 4.22 times higher in patients who received NPWT compared to those who did not receive NPWT (Odds Ratio (OR) 4.22, 95% Confidence Interval (CI) 2.26–7.87. 1,329 participants were included in our HRQL analysis and those treated with NPWT had significantly lower SF-12 PCS at all follow-up visits (6w, 3m, 6m, 12m) post fracture (p=0.01). Participants treated with NPWT had significantly lower SF-12 MCS at 6-weeks post-fracture (p=0.03). Unlike the X trial, our analysis found that patients treated with NPWT had higher odds of developing a deep infection requiring operative management and that being treated with NPWT was associated with lower physical quality of life in the 12 months post-fracture. While there may have been other potential adjustment variables not controlled for in this analysis, our results suggest that the use of this treatment should be re-evaluated

Infection and re-fracture are well-described complications following open paediatric forearm fractures. The purpose of this paper is to determine if patient, injury, and treatment characteristics can be used to predict the occurrence of these complications following the surgical management of paediatric open forearm fractures. This is an IRB-approved retrospective review at a single-institution paediatric level 1 trauma centrefrom 2007–2013 of all open forearm fractures. Medical records were reviewed to determine the type of open fracture, time to administration of initial antibiotics, time from injury to surgery, type of fixation, length of immobilisation, and complications. Radiographs were studied to document fracture characteristics. 262 patients with an average age of 9.7 years were reviewed. There were 219 Gustillo-Anderson Type 1 open fractures, 39 Type 2 fractures, and 4 Type 3 fractures. There were 9 infections (3.4%) and 6 re-fractures (2.3%). Twenty-eight (10.7%) patients returned to the operating room for additional treatment; 21 of which were for removal of implants. Contaminated wounds, as documented within the medical record, had a greater chance of infection (21% vs 2.2%, p=0.002). No difference in infection rate was seen with regard to timing of antibiotics (p=0.87), timing to formal debridement (p=0.20), Type 1 versus Type 2 or 3 open fractures (3.4% vs 5.0%, p=0.64), 24 hours vs. 48 hours of post-operative IV antibiotics (5.2% vs 3.5%, p=0.53), or when comparing diaphyseal, distal, and Monteggia fracture patterns (3.6 vs 2.9% vs 5.9%, p=0.81). There was no difference in infection rate when comparing buried or exposed intramedullary implants (3.5% vs 4.2%, p>0.99). Rate of re-fracture was not increased based on type of open wound (p>0.99) or fracture type (0.4973), although 5 of the 6 re-fractures were in diaphyseal injuries. In this series of open paediatric both bone forearm fractures, initial wound contamination was a significant risk factor for subsequent infection. The rate of infection did not vary with timing of antibiotics or surgery, type of open fracture, or length of post-operative antibiotics. A trend to higher re-fracture rates in diaphyseal injuries was noted. Surgeons should consider planned repeat irrigation and debridement for open forearm fractures with obviously contaminated wounds to reduce the subsequent infection risk

Background:. Severe kyphosis in myelomeningocoele patients results in seating problems, early satiety and ultimately pressure sores over the prominence. Kyphectomy and sagittal correction can improve these morbidities. Aim:. To evaluate the outcome of kyphectomy surgery in meningomyelocoele children. Methods:. A retrospective review was performed of a single surgeon series of paediatric myelomeningocele patients who underwent kyphectomy surgery. All the patients had posterior fusion, employing pedicle screws and sub laminar wiring. All the posterior fusions extended to the pelvis either to include S1 or the ilium. Prior to surgery, three children had open wounds over the apex of the deformity. Despite prone nursing, these failed to heal. These were closed primarily intra-operatively without the requirement of flaps. Results:. Seven children (four males, three females) were identified with an average age of 9.5 (8–13) years. The kyphosis was corrected from a mean range of 110° (88°–180°) to post-operative range of 5°–45°. The operative time averaged 240 min (165–284 min) with an estimated blood loss average of 957 ml (500–2550 ml). All the patients recovered well and no short-term complications were experienced except one transient CSF leak intra operatively. Two patients presented with sub-acute delayed infection requiring removal of instrumentation once the spine had fused. There was one case of instrumentation failure. All patients had improved wheel chair seating. Conclusion:. Kyphectomy in myelomeningocele is an infrequently required procedure which is effective in sagittal correction and improved seating with an acceptable complication rate

Infection is a potentially disastrous complication of total knee arthroplasty (TKA). Although advances in surgical technique and antibiotic prophylaxis have reduced the incidence of infection to approximately 1% in primary TKA, there is still a substantial number of patients. Treatment options include antibiotic suppression, irrigation and debridement with component retention (with or without polyethylene exchange), one-stage or two-stage revision, resection arthroplasty and rarely arthrodesis or amputation. Salvage of prostheses has always been associated with low rates of success. It was reported a success rate of 27% for open debridement. It is suitable for selective cases where infection occurs within the first 4–6 weeks of primary TKA or in the setting of acute hematogenous gram positive infection with stable implants. With the advances in arthroscopic technique, arthroscopy after TKA has become an accepted method to assess and manage the complications of TKA. Arthroscopic treatment for infected TKA was reported and the successful rate was similar or better than open debridement in selected situations. We used arthroscopic debridement combined with continuous antibiotic irrigation and suction to treat acute presentation of infected TKA with acceptable result. From 2010∼2013, we has performed arthroscopic debridement and continuous antibiotic irrigation system for seven patients with infected TKA. All of the seven patients had no open wounds nor sinuses and no radiological evidence of prosthetic instability or evidence of osteomyelitis. Most of the surgical intervention was performed within two weeks from the onset of symptoms. Arthroscopic debridement was performed with a shaver using a multiportal technique (anterolateral, anteromedial, superolateral, superomedial, posterolateral, posteromedial) and a continuous antibiotic irrigation system was used to dilutes concentration of the causative microorganism and keep high local bactericidal concentration of antibiotics. We evaluated the efficacy by using follow up of the C-reactve protein (CRP) test, erythrocyte sedimentation rate (ESR) test and physical examination. Successful treatment was defined as prosthesis retention without recurrent infection by the final follow-up. Six of seven infected TKA were cured without recurrence at a mean follow-up of 23 months (range, 6–41 months). One case with rheumatoid arthritis under long-term steroid therapy had recurred after episode of upper respiratory tract infection for 3 times. However, the infection was controlled by arthroscopic debridement and retention of the prosthesis was achieved. We emphasize the importance of posterior portal to ensure adequate arthroscopic debridement. It is imperative to make early diagnosis and treatment for infected TKA. We should make more effort to preserve the prosthesis in acute infection(within 2 weeks). With the advantage of minimal morbidity, arthroscopic treatement shoulder be an alternative to open debridement

There have been a worldwide change in the susceptibility patterns of antibiotics by many community-acquired microorganisms including those associated to wound infection after open fractures. However, the current antibiotic prophylaxis practice adopted by orthopedic surgeons to prevent infectious complications following open fractures has not changed, since Gustilo and Andersen classification was published several decades ago. Few studies have addressed the current pattern of infectious organisms identified in open fracture wounds and its susceptibility to antibiotics that have been empirically used. We aim to study the incidence of community-acquired resistant organisms isolated in lower extremities open fracture and analyze if antibiotic therapy based upon identified resistant pathogens, would decrease surgical site infection (SSI) rates. In a prospective, single center cohort study, from August 2013 to March 2015 at a tertiary public university institution, 136 subjects presenting Gustilo type II or III lower extremities open fractures were randomly assigned in two arms. Both arms were submitted to surgical debridement, fracture stabilization, and empirical antibiotic therapy, but subjects on Group II had at least three samples of tissue cultures collected during debridement. Patients previously treated at an emergency department other them ours were excluded. When resistant bacteria was identified, antibiotic therapy was modified according to antibiogram tests. The primary outcome was to compare the infection rates between these two groups, after early 60-days follow up. We included 136 patients with Gustilo-II (43.4%), –III, (34.5%) open fractures, of which 86% were male, with median age of 33.7 years, and 69.1% presented no comorbidities. Group II (collection of tissue cultures) accounted 36.7% of patients, and among them bacterial growth were detected in 36% (16/50). Microorganism resistant to empirical antibiotic therapy was identified in 18% (9/50), including Staphylococcus aureus, coagulase-negative Staphylococci, Enterococcus sp, Pseudomonas aeruginosa, Klebsiella sp, Serratia sp, Escherichia coli, and Enterobacter sp. Median duration of antibiotic treatment was eleven days. During 60-days of follow up, 71 patients (52.2%) were evaluated for signs of infection using the Centers for Disease Control and Prevention criteria, of which 63.4% (45/71) and 36.6% (26/71) were on Group I and II, respectively. No significant difference in the rates of SSI was observed between the study arms (19.2% vs 22.2%, respectively, P = 0.95). We detected higher rates of bacterial resistance on Gustilo type II and III open fracture wounds, but adjusting antibiotic therapy towards these contaminants did not affected the rates of infection afterwards

Reports of infection by Clostridium sordellii associated with allograft transplantation have generated considerable interest. We report our experience in recognising clostridial contamination in cadaver donors of musculoskeletal tissue. Tissues obtained from 795 consecutive donors were excised using standard surgical techniques. Samples of blood and bone marrow were also obtained. Donors with clostridia recovered from any site were matched with the preceding donor without clostridia as a procedural and environmental control. The histories of the donors were analysed to determine which variables had a relationship to contamination by running a contingency table and chi-squared test on the variables against the event of a donor being contaminated. Sixty-four donors (8.1%) had clostridia, most commonly C. sordellii. Clostridia were grown from the blood, marrow and tissue samples of 52, 37 and 30 donors, respectively. In eight cases, they were cultured from the tissue samples alone. There was no significant difference in age or gender between the contaminated donors and the control group. Open wounds were more common in control than in contaminated subjects, but only death by drowning in the contaminated group was statistically significant (p = 0.02). The time between death and the excision of tissue which was contaminated (16 hrs 10 mins) compared with control (11 hrs 10 mins) donors was also significant (p < 10. −6. ). We conclude that there is clostridial contamination in a significant number of tissue donors, particularly with increasing time between death and tissue excision. Among the most commonly encountered species is C. sordellii. Multiple microbiological cultures, including blood, are necessary in order to identify clostridial contamination

Aims

Chronic osteomyelitis may recur if dead space management, after excision of infected bone, is inadequate. This study describes the results of a strategy for the management of deep bone infection and evaluates a new antibiotic-loaded biocomposite in the eradication of infection from bone defects.

Post-discharge surveillance of surgical site infection is necessary if accurate rates of infection following surgery are to be available. We undertook a prospective study of 376 knee and hip replacements in 366 patients in order to estimate the rate of orthopaedic surgical site infection in the community. The inpatient infection was 3.1% and the post-discharge infection rate was 2.1%. We concluded that the use of telephone interviews of patients to identify the group at highest risk of having a surgical site infection (those who think they have an infection) with rapid follow-up by a professional trained to diagnose infection according to agreed criteria is an effective method of identifying infection after discharge from hospital.