Risk Factors Associated With Infection in Open Fractures of the Upper and Lower Extremities

Abstract

Introduction: Open fractures are associated with a high risk of infection. The prevention of infection is the single most important goal, influencing perioperative care of patients with open fractures. Using data from 2,500 participants with open fracture wounds enrolled in the Fluid Lavage of Open Wounds trial, we conducted a multivariable analysis to determine the factors that are associated with infections 12 months postfracture.

Methods: Eighteen predictor variables were identified for infection a priori from baseline data, fracture characteristics, and surgical data from the Fluid Lavage of Open Wounds trial. Twelve predictor variables were identified for deep infection, which included both surgically and nonoperatively managed infections. We used multivariable Cox proportional hazards regression analyses to identify the factors associated with infection. Irrigation solution and pressure were included as variables in the analysis. The results were reported as adjusted hazard ratios (HRs), 95% confidence intervals (CIs), and associated P values. All tests were two tailed with alpha = 0.05.

Results: Factors associated with any infection were fracture location (tibia: HR 5.13 versus upper extremity, 95% CI 3.28 to 8.02; other lower extremity: HR 3.63 versus upper extremity, 95% CI 2.38 to 5.55; overall P < 0.001), low energy injury (HR 1.64, 95% CI 1.08 to 2.46; P = 0.019), degree of wound contamination (severe: HR 2.12 versus mild, 95% CI 1.35 to 3.32; moderate: HR 1.08 versus mild, 95% CI 0.78 to 1.49; overall P = 0.004), and need for flap coverage (HR 1.82, 95% CI 1.11 to 2.99; P = 0.017).

Discussion: The results of this study provide a better understanding of which factors are associated with a greater risk of infection in open fractures. In addition, it can allow for surgeons to better counsel patients regarding prognosis, helping patients to understand their individual risk of infection.

Trial registration: ClinicalTrials.gov NCT00788398.

Conflict of interest statement

Dr. Tornetta or an immediate family member has received IP royalties from Smith & Nephew, outside the submitted work. Dr. Della Rocca or an immediate family member has received IP royalties from Wright Medical Technology; has stock or stock options held in Mergenet and the Orthopaedic Implant Company; has received grants from the US Department of Defense, during the conduct of the study; and serves as a board member, owner, officer, or committee member of AAOS, the American College of Surgeons, the American Orthopaedic Association, AOTrauma, and the Orthopaedic Trauma Association, outside the submitted work. Dr. Morshed or an immediate family member serves as a board member, owner, officer, or committee member of the Orthopaedic Trauma Association, outside the submitted work. Dr. Jones or an immediate family member has received IP royalties from Lippincott and OsteoConcentric; is a member of a speakers' bureau or has made paid presentations on behalf of Stryker; is an employee of Dignity Health; serves as a paid consultant to OsteConcentric and Stryker; has received research or institutional support from the Orthopaedic Trauma Association; has received grants from FLOW, during the conduct of the study; and serves as a board member, owner, officer, or committee member of the Arizona Orthopaedic Society, outside the submitted work. Ms. Heels-Ansdell or an immediate family member has received grant from the Canadian Institutes of Health Research and the Association Internationale pour l'Osteosynthese Dynamique, during the conduct of the study. Dr. Sprague or an immediate family member has received grant from the Canadian Institutes of Health Research and the Association Internationale pour l'Osteosynthese Dynamique, during the conduct of the study and has employment from Global Research Solutions and McMaster University, outside the submitted work. Dr. Petrisor or an immediate family member has received grant from the Canadian Institutes of Health Research and the Association Internationale pour l'Osteosynthese Dynamique, during the conduct of the study; has received grants and personal fees from Stryker; and has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research–related funding (such as paid travel) from Pfizer, outside the submitted work. Dr. Jeray or an immediate family member has received personal fees from Radius and Zimmer; and serves as a board member, owner, officer, or committee member of the American Board of Orthopaedic Surgery, the American Orthopaedic Association, the Orthopaedic Trauma Association, and the Southeastern Fracture Consortium, outside the submitted work. Dr. Bhandari or an immediate family member has received research or institutional support Acumed, Aphria, Ferring Pharmaceuticals, Pendopharma, Sanofi-Aventis; has received grants from the Canadian Institutes of Health Research and the Association Internationale pour l'Osteosynthese Dynamique, during the conduct of the study; and has received personal fees from Pendopharma, Sanofi-Aventis, outside the submitted work. Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Ms. Del Fabbro and Ms. Bzovsky.

Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.