Section 1: Preventing and Managing Infection and Other Complications After Orthopaedic Trauma

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Complications, including infection, flap failure, amputation, nonunion, malunion, loss of reduction, and hardware failure, are common after major extremity trauma. These complications drive high rates of hospital readmission and are linked to poor long-term functional outcomes in both military and civilian settings.1–7 Surgical site infection and osteomyelitis are particularly devastating, with rates ranging as high as 14%–60%.8,9 Over $1.8 billion is spent each year in the treatment of surgical site infections (SSIs) in general10,11; yet these infections are thought to be the most common of all potentially preventable postoperative complications. Any strategy that could improve the diagnosis, prevention, or early treatment of infections, and complications more broadly, would certainly benefit the care of orthopaedic trauma patients, improve outcomes, and reduce overall treatment costs. The Major Extremity Trauma Research Consortium (METRC) targeted the identification and evaluation of these strategies as a priority and initiated 5 prospective studies including one observational study and 4 randomized trials that have the potential for making a difference.
The BIOBURDEN study is the first large multi-institutional study to characterize the contemporary extremity wound “bioburden” of severe open tibia fractures at the time of definitive wound closure using both traditional culture techniques and modern polymerase chain reaction technologies. Seminal work from previous decades determined that culture data from open wounds did not predict the likelihood of infection nor the bacteria present, if infection occurred. However, little work has examined if the bioburden present at the time of wound closure in patients who need multiple irrigation and debridements is useful in predicting infection. Of interest is whether culture or more modern polymerase chain reaction–based techniques can be used to predict the future occurrence of SSI or the pathogens that will occur in these infections. The interaction between this bacterial bioburden and prophylactic antibiotics is of particular interest. This study has the potential to provide clinicians with important information that may guide choices in prophylactic antibiotic selection and provide the foundation for future treatments aimed at reducing infection.
The VANCO and OXYGEN trials evaluate the use of 2 promising approaches for reducing the risk of SSI in high risk fractures. The OXYGEN study is a phase III, double blind, prospective randomized clinical trial designed to assess the efficacy of 2 different concentrations of supplemental perioperative oxygen in the prevention of SSI. Although use of increased levels of supplemental perioperative oxygen has been studied in reducing SSI in nonorthopaedic surgery, little work has been performed to examine its effectiveness in reducing SSI after fracture fixation.12,13 The VANCO study is a phase III, prospective, randomized clinical trial designed to assess the efficacy of locally administered vancomycin powder in the prevention of SSI after fracture surgery. Clinical studies in the spine literature describe the use of local vancomycin powder to reduce SSI.14 However, there is no level I evidence to support its use in treating at-risk extremity fractures. Both studies use low-cost strategies that have few barriers to implementation. If proven efficacious, these 2 approaches have the potential to quickly lower infection rates across military and civilian practice environments.
Multiple studies demonstrate that infection rates tend to increase whenever hardware is placed within a wound, likely because of the difficulty the immune system has in clearing bacteria from the biofilm that develops on metallic surfaces.15 Treatment with modern ring external fixation, which does not place any permanent hardware at the fracture site, may reduce infections and hospital readmissions for other major complications. The FIXIT study is a prospective, multicenter, randomized trial comparing internal fixation to the use of modern ring external fixators in the treatment of severe open tibia fractures.

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