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Free tissue transfer instead of rotational flap
1%
73/5348
Flap coverage at four days after injury
3%
149/5348
Use of an intramedullary nail instead of minimally invasive plating
32/5348
Delay in administration of IV antibiotics
89%
4735/5348
Debridement at 15 hours after injury
6%
310/5348
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Intravenous antibiotics are critical to prevent infection in open fractures. Delay in administration of intravenous antibiotics has been linked with increased risk of infection. Open tibia fractures are associated with high rates of infection. Historically, early debridement (within 6-8 hours) and early flap coverage (typically defined as less than 72 hours) were thought to minimize the risk of infection. Recent evidence has challenged these findings, with multiple studies demonstrating no significant link between the timing of debridement and rates of infection. Multiple studies from the Lower Extremity Assessment Project (LEAP) found no significant difference in infection or complication with flap coverage more than 72 hours after injury. Bhattacharyya et al retrospectively evaluated patients with type IIIB tibial fractures treated with extended use of negative pressure wound therapy. The authors found increased rates of infection beyond 7 days despite the use of negative pressure wound therapy. Lack et al evaluated the timing of antibiotic administration on infection rates for type III tibial fractures. The authors found increased rates of infection with administration of antibiotics beyond 66 minutes. The authors discuss the possibility of pre-hospital intervention as many severely injured patients have delayed arrival at treatment centers. Pollak et al prospectively analyzed rates of complication with flap coverage as part of the LEAP study. The authors found no increase in complications with flap coverage beyond 72 hours. The only significant risk for complication was the use of rotational flaps in comminuted or segmental (AO/OTA type C) tibial fractures. Incorrect answers: Answer 1: Lower rates of complication, including infection, were seen with free flaps in AO/OTA type C fractures in the study by Pollak et al. Answer 2: Timing of flap coverage is controversial. Early studies demonstrated increased infection with delay beyond 72 hours, however recent studies using more rigorous statistical analysis do not support these findings. Answer 3: No study has demonstrated lower infection rates with the use of plating versus nailing in open tibial fractures. Answer 5: The timing of debridement with open fractures has been shown not to effect the rate of infection in multiple recent studies.
4.5
(11)
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