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

Paul Tornetta 3rd; Gregory J Della Rocca; Saam Morshed; Clifford Jones; Diane Heels-Ansdell; Sheila Sprague; Brad Petrisor; Kyle J Jeray; Gina Del Fabbro; Sofia Bzovsky; Mohit Bhandari; FLOW Investigators

doi:10.5435/JAAOSGlobal-D-20-00188

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

J Am Acad Orthop Surg Glob Res Rev. 2020 Dec 8;4(12):e20.00188. doi: 10.5435/JAAOSGlobal-D-20-00188.

Authors

Paul Tornetta 3rd¹, Gregory J Della Rocca, Saam Morshed, Clifford Jones, Diane Heels-Ansdell, Sheila Sprague, Brad Petrisor, Kyle J Jeray, Gina Del Fabbro, Sofia Bzovsky, Mohit Bhandari; FLOW Investigators

Affiliation

¹ From the Department of Orthopedic Surgery, Boston Medical Center, Boston, MA (Dr. Tornetta III); the University of Missouri School of Medicine, Columbia, MO (Dr. Della Rocca); the University of California San Francisco, San Francisco General Hospital, Orthopaedic Trauma Institute, San Francisco, CA (Dr. Morshed); the The CORE Institute, University of Arizona-Phoenix, Phoenix, AZ (Dr. Jones); the Department of Health Research Methods, Evidence, and Impact (Ms. Heels-Ansdell, Dr. Sprague, and Dr. Bhandari) and the Division of Orthopaedic Surgery, Department of Surgery (Dr. Sprague, Dr. Petrisor, Ms. Del Fabbro, Ms. Bzovsky, and Dr. Bhandari), McMaster University, Hamilton, Ontario, Canada; and the Department of Orthopaedic Surgery, Prisma Health-Upstate, Greenville, SC (Dr. Jeray).

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.

MeSH terms

Fractures, Open* / surgery
Humans
Lower Extremity
Risk Factors
Surgical Flaps
Therapeutic Irrigation

Associated data

ClinicalTrials.gov/NCT00788398