SLR - April 2017 - Russell Carlson

A Randomized Controlled Study to Compare Conventional and Evidence-Based Treatment Protocols in Fresh Compound Fractures

Reference: Mahajan K, Verma V, Singh GK, Kumar S, Avasthi S. A Randomized Controlled Study to Compare Conventional and Evidence-Based Treatment Protocols in Fresh Compound Fractures. J Clin Diagn Res. 2016 Sept; 10(9): RC01–RC05.

Reviewed By: Russell Carlson, DPM
Residency Program: St. Joseph Medical Center, Houston, TX

Podiatric Relevance: The majority of acute infections after compound fractures are due to hospital-acquired pathogens. It has been reported that most of the infections develop secondarily. Eighteen percent of acute infections following compound fractures were due to the same pathogen as reported in the prior perioperative cultures. This shows that hospital-acquired bacteria have a prominent role and that a protocol for in-hospital management is important. Previous studies have focused on individual measures to prevent infection, such as antibiotics, cement beads, use of first-generation cephalosporins, not removing hair, scrubbing with chlorhexidine, occlusive drapes, solution used for irrigation, use of surgical drains, subcuticular wound closure over skin closure, three-layered dressing and UV light in the operating room. There is no study in literature that has studied the combined effect of individual measures mentioned. Applying the same principle to any hospitalization may also help with time taken for a wound to heal and prevent future infections.

Methods: This randomized controlled study was conducted at the orthopaedics department of King George Medical University trauma center. Patients presenting with Gustillo Anderson Grade I and II compound fractures, both bone leg fractures aged 12 to 70, were included. Grade III and patients with systemic diseases were excluded. Two hundred twenty-six patients of compound fractures of both bone leg were randomized to two groups. One group received standard treatment. The difference between the control and experimental group are as listed. 1) IV cephalosporin and an aminoglycoside given at arrival and again within one hour of surgery as well as intraoperatively if half-life was exceeded. 2) Cement beads placed where dead space in bone was present. 3) Chlorhexidine and alcohol scrub was used on a > 8” area surrounding the wound. 4) Irrigation using one liter each of castile soap–saline–benzalkonium chloride–saline and brush were used. 5) No drains were used. 6) Wounds were closed using subcuticular monofilament suture. 7) A triple-antibiotic ointment was applied to the wound with a three-layered occlusive dressing. 8) The dressing was repeated at 24 hours if not closed in a plaster cast. 9) Beards and ears were completely covered. 10) The doors remained closed, and a maximum of four times opening was permitted during the duration of surgery. 11) Implants were kept in their packing until their time of use.

Results: Experimental group reported significantly lesser time to a negative culture report from wound (1.9 weeks vs. 4.6 weeks), lesser time to bony union (22.81 vs. 23.84 weeks), lesser time to wound healing (10.45 weeks vs. 14.44 weeks) and a lesser duration of hospital stay (4.5 days vs. 6.6 days) and achieved full range of motions (23.94 vs. 24.21 weeks).

Conclusion: The authors concluded that combining guidelines for controlling perioperative infections on important measurable outcomes proved superior to conventional methods. They cited several paper results focusing on several individual of the methods and believe that using them all together as a new guideline will provide superior outcomes.

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