SLR - August 2021 - Rabeea Abbas

Risk Factors for Infectious Complications After Open Fractures: A Systemic Review and Meta-Analysis

Reference: Kortram K, Bezstarosti H, Metsemakers WJ, Raschke MJ, Van Lieshout EMM, Verhofstad MHJ Risk Factors for Infectious Complications After Open Fractures: A Systemic Review and Meta-Analysis. International Orthopaedics. 2017 Jul; 41:1965-1982.

Level of Evidence: Level II

Scientific Literature Review

Review By: Rabeea Abbas, DPM
Residency Program: Kaiser Permanente Vallejo Medical Center – Vallejo, CA

Podiatric Relevance: Open fractures are a commonly encountered foot and ankle surgical emergency. Recognizing risk factors for the development of infection after open fracture fixation is critical in managing patients and potential surgical outcomes. Soft tissue injuries associated with open fractures can progress into severe deeper tissue infection, if not properly managed. The purpose of this study was to provide an overview of the patient related and treatment related risk factors for infectious complications in open fractures following fixation. 

Methods: One hundred sixteen manuscripts analyzing a total of 20,367 fractures were included. A meta-analysis was completed based on patient, trauma, and treatment course-related factors for risk of infection development. A study was included if it was published within the last 30 years and contained data regarding infectious complications in relation to one or more risk factors. The authors also compared open versus closed fractures in order to isolate the open fracture as a potential risk factor for infection development. Articles solely reporting on long term osteomyelitis occurring greater than 90 days, or treatment of non- or mal-unions were not included. Studies reporting on less than 50 patients were also excluded. 

Results: Risk factors associated with higher infectious complications included Gustilo-Anderson grade III fractures vs. grades I/II (15.9 percent vs 5.1 percent), lower extremity fractures versus upper extremity (11.8 percent vs. 5.4 percent), smokers (17.7 percent vs. 13.8 percent in nonsmokers), diabetes mellitus (25.3 percent vs. 13.8 perent), systemic vascular disease (37.8 percent vs. 18.1 percent), male gender (16.1 percent vs. 11.6 percent), farmyard injuries (compared with all other mechanisms of injuries.), and use of pulsatile lavage versus a higher volume lower pressure irrigation (24 percent vs. 9 percent). The timing of antibiotic prophylaxis and wound debridement, use of internal fixation versus external fixation (20.7 percent infections vs. 23.6 percent), and immediate vs. delayed wound closure had no apparent statistical difference in rates of infectious complications after open fracture fixation. 

Conclusions: The male gender, Diabetes Mellitus, systemic vascular disease, lower extremity fractures, smoking, Gustilo-Anderson grade III fractures, farmyard injuries, and use of pulsatile lavage are associated with higher risk of infectious complication. There are many limitations, including selection bias for certain risk factors such as use of external fixation versus internal fixation, retrospective nature of many studies, and lack of larger study populations to accurately evaluate factors like BMI and use of alcohol/drugs. Several other risk factors were not reviewed, like renal or hepatic disease, poor nutritional status, length of hospital stay and level of experience/training of the medical team. A larger, prospective study incorporating several of these potential risk factors will be required in order to construct a risk-assessment model of clinical and surgical benefit in the management of open fractures.

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