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

Authors

Paul Tornetta, Boston Medical Center
Gregory J. Della Rocca, University of Missouri
Saam Morshed, University of California, San Francisco
Clifford Jones, The University of Arizona
Diane Heels-Ansdell, McMaster University
Sheila Sprague, McMaster University
Brad Petrisor, McMaster University
Kyle J. Jeray, Prisma Health Upstate
Gina Del Fabbro, McMaster University
Sofia Bzovsky, McMaster University
Mohit Bhandari, McMaster University
Gordon H. Guyatt, McMaster University
Stephen D. Walter, McMaster University
Emil H. Schemitsch, St. Michael's Hospital
Jeffrey Anglen, Indiana University
Michael Bosse, Carolinas Health Care System
Susan Liew, International-The Alfred
Parag Sancheti, Sancheti Institute for Orthopaedics and Rehabilitation
Paula McKay, McMaster University
Kim Madden, McMaster University
Kerry Tai, McMaster University
Lisa Buckingham, McMaster University
Aravin Duraikannan, McMaster University
Stephanie L. Tanner, Greenville Hospital System
Rebecca G. Snider, Greenville Hospital System
Douglas Altman, University of Oxford
Rajiv Gandhi, Toronto Western Hospital University of Toronto
Markus Bischoff, McMaster University
Bill Ristevski, Hamilton Health Sciences

Document Type

Article

Publication Date

12-1-2020

Journal

Journal of the American Academy of Orthopaedic Surgeons Global Research and Reviews

Volume

4

Issue

12

URL with Digital Object Identifier

10.5435/JAAOSGlobal-D-20-00188

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.