SLR - February 2020 - Catherine Jacobs

Clostridial Infection after Open Fractures of the Lower Extremity - Report of Two Cases and Discussion of Pathomechanism and Treatment

Reference: Tremp M, Oranges CM, Majewski M, Schaefer DJ, Kalbermatten DF, Bloch-Infanger C, Ochsner PE. Clostridial Infection After Open Fractures of the Lower Extremity - Report of Two Cases and Discussion of Pathomechanism and Treatment. In Vivo. 2020 Jan-Feb;34(1):291-298

Scientific Literature Review

Reviewed By: Catherine Jacobs
Residency Program: Saint Francis Hospital & Medical Center – Hartford, CT

Podiatric Relevance: Open fractures one of the most devastating injuries faced by podiatric surgeons. The treatment usually includes antibiotic coverage, and most adhere to the guidelines set by the updated Gustilo and Anderson classification. This article describes the author’s experience with open fractures involving a clostridial infection, an organism not usually covered with our usual antibiotic selection.

Methods: The article describes two cases, the first of a 43-year-old female farmer. She suffered a Gustilo grade two open dislocated trimalleolar fracture. She had immediate ORIF but due to recurrent signs of infection, revision was performed six days later. The patient had two further revisions which left her with 6 centimeters bone defect, and an external fixator was applied for ankle fusion and callus distraction. She later had arthrosis of the ankle joint requiring subtalar fusion and supramalleolar osteotomy correction. The second case involves a 58-year-old woman which fell into a cesspool sustaining a bimalleolar fracture with Gustilo type two injury. Stabilization of the fracture was performed with application of external fixation and four days later formal ORIF was performed with application of a negative pressure device. Twenty-five days later, an abscess was discovered. A gracilis free flap was used for the soft tissue defect and the external fixator was removed 11 weeks later and exchanged for an IM nail. MRI was performed and a sequestrum was identified. The patient was brought back to the operating room for ankle fusion with external fixator using the fibula as a bone bridge.

Results: Both patients underwent many surgeries that ultimately required ankle fusion. The patients were ultimately treated with Metronidazole with good effect once Clostridium was isolated by culture. Both patients are now fully weightbearing.

Conclusions: This article cautions podiatrists treating open fracture to consider alternative organisms and to be vigilant if a current antibiotic regimen is not adequately treating the patient. Clostridium is an uncommon organism isolated in open fracture cases, but one could consider an antibiotic regimen with appropriate coverage if injury was sustained in a dirty area.

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