ORIGINAL ARTICLE

Current Practice in the Management of Open Fractures

Among Orthopaedic Trauma Surgeons. Part A: Initial
Management. A Survey of Orthopaedic Trauma Surgeons
William Obremskey, MD, MPH,* Cesar Molina, MD,* Cory Collinge, MD, Arvind Nana, MD,
Paul Tornetta III, MD, Claude Sagi, MD, Andrew Schmidt, MD,k Robert Probe, MD,
Jaimo Ahn, MD, PhD,** and Bruce D. Browner, MD, for the Evidence-Based Quality Value and Safety
CommitteeOrthopaedic Trauma Association, Writing Committee

Objectives: Open fractures are one of the injuries with the highest rate
of infection that orthopaedic trauma surgeons treat. The main purpose of
this survey was to determine current practice and practice variation
among Orthopaedic Trauma Association (OTA) members and make
treatment recommendations based on previously published resources.

Design: Survey.
Setting: Web-based survey.
Accepted for publication October 28, 2013.
From the *Orthopaedic Trauma Institute, Vanderbilt University Medical Center, Nashville, TN; Department of Orthopaedic Surgery, John Peter Smith,
Fort Worth, TX; Department of Orthopaedic Surgery, Boston Medical
Center, Boston, MA; Orthopaedic Trauma Service, Florida Orthopaedic
Institute and Department of Orthopaedic Surgery, University of South
Florida, Tampa, FL; kDepartment of Orthopaedic Surgery, Hennepin
County Medical Center, Minneapolis, MN; Department of Orthopaedic
Surgery, Scott & White Healthcare, Temple, TX; **Orthopaedic Trauma
and Fracture Service, Hospital of the University of Pennsylvania, Philadelphia, PA; and Department of Orthopaedics, University of Connecticut
Health Center, Farmington, CT.
W.T.O. receives consulting fees from legal representatives and his institution is
receiving a grant from the Department of Defense. P.T. is salaried and
supported by publication royalties from Smith & Nephew and Wolters Kluwer/
Lippincott William & Wilkins; holds the intellectual property rights/patent and
royalties from Smith & Nephew; and receives consulting fees from Smith &
Nephew. J.A. receives consulting fees from AO and Synthes, and his institution
is currently receiving a grant from the Department of Defense. A.S. is current
board member of the Orthopaedic Trauma Association, receives consulting and
lecture fees from Medtronic, Inc., and his institution is currently receiving
a grant from the Department of Defense. R.P. certies that he has or may
receive payments or benets, during the study period, an amount of US
$10,000 to US $100,000 from Stryker Orthopaedics, Mahwah, NJ. R P. is
on the Board of Trustees of Scott & White Healthcare and Chair, Board of
Directors of Scott & White Memorial Hospital. For the remaining authors none
were declared.
The project described was supported by the National Center for Research
Resources, Grant UL1 RR024975-01, and is now at the National Center
for Advancing Translational Sciences, Grant 2 UL1 TR000445-06. The
content is solely the responsibility of the authors and does not necessarily
represent the ofcial views of the NIH.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF
versions this article on the journals Web site (www.jorthotrauma.com).
Reprints: William Obremskey, MD, MPH, Department of Orthopedics,
Orthopedic Trauma Institute, Vanderbilt University Medical Center,
1215 21st Avenue South, Suite 4200 MCE-South Tower Nashville, TN
37232 (e-mail: william.obremskey@vanderbilt.edu).
Copyright 2013 by Lippincott Williams & Wilkins

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Participants: Three hundred seventy-nine orthopaedic trauma

surgeons.

Methods: A 15-item questionnaire-based study titled OTA Open

Fracture Survey was constructed. The survey was delivered to all
OTA membership categories. Different components of the data
charts were used to analyze numerous aspects of open fracture management, focusing on parameters of initial and denitive treatment.

Results: Eighty-six percent of participants responded that a period of

time of less than 1 hour is the optimal time to antibiotic administration
after identication of open fracture. Despite concerns with nephrotoxicity, 24.0%76.3% of respondents reported the use of aminoglycosides in management of open fractures. A little over half of survey
respondents continue antibiotics until next debridement in wounds that
were not denitively closed after initial debridement and stabilization.
Conclusions: Rapid administration of antibiotics in open fracture
management is important. Aminoglycoside use is still prevalent
despite evidence questioning efcacy and toxicity concerns. Time to
debridement of open fractures is controversial among OTA members. Antibiotic administration is commonly continued .48 hours
despite concerns raised by Surgical Infection Society and The Eastern Association of the Surgery of Trauma. Regarding study logistics,
survey participation reminders should be used when conducting this
type of study as it can increase data accrual by 50%.
Key Words: open fractures, antibiotic prophylaxis, time to closure

Level of Evidence: Therapeutic Level V. See Instructions for

Authors for a complete description of levels of evidence.
(J Orthop Trauma 2014;28:e198e202)

INTRODUCTION
The current practice patterns of orthopaedic trauma
surgeons treating open long bone fractures and associated
segmental long bone defects are not well known. Open fractures
are one of the injuries with the highest rate of infection that
orthopaedic trauma surgeons treat.1 Prevention of infection is
a high priority for physicians and patients as it negatively affects
patient outcomes and increases both morbidity and costs.24
An additional challenge with some open injuries is the
management of associated long bone defects; the combination
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J Orthop Trauma  Volume 28, Number 8, August 2014

of soft tissue and bone loss is one of the most difcult

problems in posttraumatic limb reconstruction after highenergy extremity trauma. Without reconstitution of a limbs
structural integrity, amputation becomes inevitable. As a solution, segmental defects of long bones are most commonly
reconstructed with stable xation and bone grafting.57 Other
treatment adjuncts have recently become available, such as
the use of bone graft extenders and bone morphogenic protein, but their benet in the treatment of open fractures with
bone loss is unknown.
Currently, there is no literature report evaluating open
fracture practice patterns among orthopaedic trauma surgeons.
Here, we present a 2-part survey (part A and part B) of the
clinical practices of Orthopaedic Trauma Association (OTA)
members regarding several aspects of open fracture initial
management and the reconstruction of segmental long bone
defects. Information from this survey will be helpful in
describing current practices, measuring practice variation,
evaluating guideline implementation, and identication of
knowledge gaps that represent areas for further research. We
hope that the data gathered for this survey will serve as a model
for investigating additional topics that can help provide
information on current practices and be available for reference
to medical students, residents, and all orthopaedic surgeons.

METHODS

A 15-item questionnaire entitled OTA Open Fracture

Survey was used to collect data from members of the OTA
through REDCap,8 a free, secure, web-based application designed to support research studies and data capture. The survey
was delivered, through e-mail, to all OTA membership categories composed of a total of 1545 members. A period of 20 days
was allotted for response of the survey. A reminder was sent out
to all possible respondents after 10 days. Once response accrual
was complete, data were extracted from REDCap and charted
using Microsoft Excel (2010). We analyzed several aspects of
open fracture management as follows: antibiotic prophylaxis and
early interventions to denitive closure. Statistical analysis with
basic descriptive statistics was performed using STATA (Version 12.0 standard edition).

RESULTS
Between the months of July and August 2012, a total of
379 of 1545 OTA orthopaedic trauma surgeons (active,
community, and candidates) responded and completed the
survey titled OTA Current Practice Survey, resulting in
a 24.5% response rate.
Of the 379 respondents, 324 (85.5%) believed that less
than 60 minutes is the ideal time for initiation of antibiotics
after identication of an open fracture in emergency department. Only 1.3% (5/379) reported 12 hours as an acceptable
time to initiation of antibiotics. Distribution of appropriate
time to antibiotics is further depicted in (see Figure, Supplemental Digital Content 1, http://links.lww.com/BOT/A166).
Of the 379 respondents, 9 (2.4%) stated the use of
aminoglycosides for the treatment of Gustilo-Anderson type I
noncontaminated open fractures, 15% (57/379) for type II
fractures, 59% (224/379) for type IIIA fractures, and 66.8%
2013 Lippincott Williams & Wilkins

Current Practice in the Management of Open Fractures

(253/379) for type IIIB fractures. The stated use of aminoglycosides in contaminated open fractures was high and ranged
from 29.8% (113/179) in type I fractures to 76.3% (289/379) in
type IIIB fractures.
Of the 379 surgeons, 60 (15.8%) believed debridement
should be done as soon as possible in noncontaminated
type IIIA fractures. In contrast, 40.9% (155/179) of surgeons
opted for immediate debridement when presented with a contaminated type IIIA fracture. Most of the respondents, 99.7%
(378/379), believed that less than 12 hours is an acceptable
time for irrigation and debridement in patients diagnosed with
a contaminated type IIIA fracture (see Figure, Supplemental
Digital Content 2, http://links.lww.com/BOT/A167). The
presence of contamination in an open type IIIA fracture seemed
to signicantly impact the urgency of the situation for orthopaedic traumatologists.
Of the 379 respondents, 59 (15.6%) continued antibiotics
for 24 hours and 21.4% (81/379) for 48 hours in wounds that
were left open after debridement. The slight majority of
orthopaedic trauma surgeons, 54.4% (206/379), continued the
use of antibiotics until next debridement (see Figure, Supplemental Digital Content 3, http://links.lww.com/BOT/A168).
In type I fractures, 29% (110/379) of respondents
reported using antibiotics for 48 hours postdebridement,
33% (125/379) in type II fractures, 39% (148/279) in type
IIIA fractures, and 38.5% (146/379) in type IIIB fractures.
Surprisingly, 24% (91/379) of respondents believed that
antibiotic coverage should continue for 72 hours or more in
patients with a type IIIA fracture (see Figure, Supplemental
Digital Content 4, http://links.lww.com/BOT/A169).
Of the 379 surgeons, 131 (34.5%) used negative pressure
wound therapy (NPWT) alone, 23% (87/379) of surgeons used
antibiotic bead pouch only, and 13.2% (50/379) used a combination of NPWT and antibiotic beads in contaminated open
wounds. In noncontaminated open fracture wounds, 70.7% of
surgeons (268/379) reported the use of NPWT alone, 3.9% (15/
379) used antibiotic bead pouch only, and 8.7% (33/379)
reported a combination NPWT and antibiotic beads. Overall,
70.7% of surgeons (268/379) used some sort of NPWT in
contaminated open fractures until denitive closure versus
83.4% (316/379) in noncontaminated open injuries. A total of
32% (121/379) of respondents reported the use of wet-to-dry
dressings in noncontaminated wounds versus 20% (76/379) in
contaminated wounds. Local antibiotics are used by 27% (103/
379) of respondents in noncontaminated wounds versus 66%
(250/379) in contaminated wounds.
The majority of respondents thought that time to
antibiotics (220/379) and the quality of debridement (243/
279) are the 2 most important issues in preventing deep
infection in type I, II, and IIIA fractures. The 2 most
important issues in preventing deep infection in type IIIB
fractures were identied as time to denitive closure (241/
379) and the quality of debridement (218/379).
Of 379 respondents, 131 (34.5%) believed that the most
effective time to closure is within the rst 3 days. A total of
96.8% (367/379) believed that soft tissue coverage for a type IIIB
open tibia fracture should be performed within the rst 7 days.
Further break down of timing is seen in (see Figure, Supplemental Digital Content 5, http://links.lww.com/BOT/A170).
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Obremskey et al

DISCUSSION
Our response rate, 24.5%, does not signicantly differ
from previously reported values in large population online
surveys (17%20% response rate among 13,400 survey participants9). In 2005, Leece et al10 performed a survey among OTA
members regarding the treatment of femoral neck fractures and
found a response rate of 45% (99/221). In our survey, we
noticed that an initial wave of 254 responses in the rst 10 days
was received with a decreasing number of responses toward
days 7 through 10. To maximize survey participation, a response
reminder was sent after 10 days from survey launch. This
attempt provided an additional 125 responses, a 49.2% increase,
in the following 10 days. A literature report evaluated reasons
for survey nonresponse.11 We attribute our response rates to
a number of following reasons: intentional or unintentional deletion of survey invitation, initial reading of invitation then forgetting to respond, infrequently attending to electronic mail, and
failure to notify the OTA when e-mail address is changed.
Nonetheless, 379 expert opinions make for outstanding data
and are currently the best representation of treatment patterns
of open fractures among orthopaedic trauma surgeons.

Time to Antibiotics
Rapid administration of antibiotics in open fracture
management is important. In 1989, Patzakis et al12 identied
the utility of rapid antibiotic administration after injury and
showed a lower infection rate in those receiving antibiotics
within the rst 3 hours from injury. Our results show that
most of the respondents (88%) believe the rst 60 minutes
after identication of an open fracture are crucial for antibiotic initiation.

Type of Antibiotics
Surgical Infection Society (SIS) guidelines for prophylactic antibiotic use in open fractures do not recommend
the routine use of aminoglycosides.13 The notable lack of
evidence regarding the use of aminoglycosides in this population was clearly displayed and its concern for toxicity in
patients with intertrochanteric hip fractures.14 Nonetheless,
most of the respondents still hold gentamicin as an option
for antibiotic prophylaxis, with as many as 76.4% of orthopaedic trauma surgeons reporting its use. The East Practice
Management Guidelines15 established by the Eastern Association for the Surgery of Trauma (EAST) state that once-daily
aminoglycoside dosing is safe and effective for types II and
III fractures. The authors also recommend prophylaxis with
penicillin in at-risk fractures. However, a larger multispecialty
review group recommending treatment for worst-case scenario military extremity injuries (skin, soft tissue, and/or
bone) has been endorsed by the Infectious Diseases Society
of America and the SIS. The group recommends high-dose
cefazolin as the antibiotic of choice. Additional recommendations include the use of clindamycin as an alternate agent in
the case of b-lactam antibioticinduced anaphylaxis and elimination of the need for penicillin in the coverage of clostridial
gangrene and group A b-hemolytic Streptococcus infections
and elimination of the use of an aminoglycoside.16 Patzakis
et al17 evaluated the efcacy of a single agent, ciprooxacin,

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and compared it with combination antibiotic therapy, cefamandole and gentamicin, in all types of open fracture
wounds. The infection rate for types I and II open fractures
was 5.8% in the uoroquinolone group and 6% in the combination therapy group. The infection rate for type III open
fractures was 31% versus 7.7% in the ciprooxacin group
versus combination therapy group, respectively. The authors
concluded that single-agent antibiotic therapy with ciprooxacin is a therapeutic alternative in the management of open
type I and II fractures.17 However, this recommendation did
not extend for the treatment of type III fractures. Additionally,
basic science experiments have identied uoroquinolones to
delay fracture healing in several parameters (histology, radiography, and mechanical) and having a dose-dependent
cytotoxicity.18,19

Duration of Antibiotics
The SIS and the EAST group have extensively
reviewed prophylactic antibiosis and its postoperative duration in open fractures.20 Both guidelines recommend the use
of antibiotics for 24 hours in type I fractures and 4872 hours
for a type III fracture. However, these guidelines differ with
regard to duration of antibiotics in type II fractures with
the SIS, advocating antibiotic use for 24 hours and EAST
for 48 hours. Although the slight majority of respondents
say antibiotic duration should last for 24 hours after denitive
xation, there is still a large group of 110 orthopaedic trauma
surgeons who believe antibiotics should continue for 48 hours
in type I open fractures. It is particularly concerning that
almost a quarter of respondents believe antibiotics should
be administered for 72 hours or more in type IIIA fractures
despite several literature reports showing the increased risk of
resistant pneumonia and other systemic bacterial infections
with prolonged antibiotic use.2125

Time to Debridement
Time to debridement of open fractures is controversial
among OTA members. The presence of contamination in an
open type IIIA fracture seemed to signicantly impact the
urgency of the situation for orthopaedic traumatologists with
40.9% opting for debridement to be done as soon as possible
in contaminated type IIIA fractures versus only 15.8% in
noncontaminated type IIIA fractures. A recent meta-analysis
evaluated how timing to debridement affects infectious
complications in open long bone fractures.26 They concluded
that there was no association between delayed debridement
and higher infection rates when only deep infections were
considered, when only more severe open injuries were considered, and when all infections were considered. Response
results from our survey further emphasize this matter with
only 7.9% (30/379) of participants choosing this issue as
the most important factor in types I, II, and IIIA fractures
and 2.64% (10/379) in type IIIB injuries.

Local Antibiotics
The use of local antibiotics doubled among survey
respondents (27%66%) when treating patients with contaminated open wounds. Anecdotal clinical and basic science
evidence supports the use of local antibiotics for open
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fractures. The use of antibiotic beads has been shown to

decrease the incidence of infection after open fractures.2729
Antibiotic beads or spacer are often used as an adjuvant to
parenteral antibiotics. Tobramycin 2.4 g and/or vancomycin 2
g are the most common additions to 1 batch of polymethylmethacrylate. Bioabsorbable carriers such as calcium sulfate,
polylactic acid, and propylene fumarate have been used
experimentally.30,31 In the wound, beads produce high local
levels of antibiotics. Systemic antibiotic levels are low, and
low rates of toxicity are observed.32 The antibiotic bead pouch
technique may decrease the incidence of infection and permits
staged wound closure of severe injuries.33

Dressing Type
An extensive literature review evaluating prevention of
perioperative infection concluded that the rate of postoperative infections associated with occlusive dressings is lower
than that associated with nonocclusive dressings.34 Literature
reports have shown clear benets of the hypoxic environment
that occlusive dressings provide which allow for better
broblast migration, and angiogenesis, leading to faster healing.28,35 Occlusive dressings have also shown to signicantly
decrease the risk of infection from 7.1%2.6%.36 Despite the
multiple literature ndings, a total of 20% of respondents use
wet-to-dry dressings in management of open fractures with
signicant contamination before denitive closure. The high
prevalence of NPWT among survey respondents shows a signicant migration toward the use of this type of dressing in
the management of open fracture wounds.
Godina37 evaluated microsurgical reconstruction of a total
of 532 patients with complex trauma to the extremities. Patients
were then separated into early (,72 hours), delayed (72 hours to
3 months), and late (3 months to 12 years) reconstruction. One
hundred and thirty-four patients were treated early, with 63 of
these patients undergoing immediate debridement and reconstruction (,24 hours) and the remaining patients treated in the
next 2448 hours. Patients treated in the early time point showed
a higher free ap success rate, lower infection rate, hospital stay,
number of microsurgical procedures, and a 50% reduction in
bone healing time when compared with patients treated in the
delayed time frame.37 The author attributed the differences in
free ap failure rate to the posttraumatic brosis affecting the
veins in the vicinity of the injury and that the site for venous
anastomosis is a key component for success in delayed reconstruction of posttraumatic defects with free ap transfers.
Gopal et al38 performed a review of 84 patients with
Gustilo type IIIB or IIIC tibia fractures. All patients underwent radical debridement of the wound, skeletal stabilization,
and soft tissue coverage with a muscle ap. In 33 cases, soft
tissue reconstruction was immediate whereas in 30 patients it
was performed from 24 to 72 hours after injury. The remaining 21 patients were treated beyond 72 hours. Nineteen patients were stabilized with external xation. An overall ap
failure rate of 3.5% was found along with a deep infection
rate of 9.5%. An infection rate of 37% was found in the
external xation group. The majority of these complications
were seen in patients treated beyond 72 hours.38 Patients in
the Godina37and Bhattacharyya et al39 case series did not have
use of a negative pressure wound dressing.
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Current Practice in the Management of Open Fractures

Time to Closure
Bhattacharyya et al39 investigated whether the use of
vacuum-assisted closure (VAC) sponge allowed for a delay
in ap coverage of open Gustilo type IIIB tibia fractures without increasing infection rate. Results showed a rate of infection
of 12.5% and 57% in those who underwent denitive coverage
within and after 7 days, respectively. Authors concluded that
VAC therapy does not allow delay of soft tissue coverage past
7 days without an increase in infection rates.39 Steiert et al40
identied a 2% (1/42) infection rate in patients with Gustilo
and Anderson type III open fractures who underwent delayed
reconstruction at a mean closure time of 28 days. Similar results were found by Fleischmann et al41 with a 6.6% (1/15)
infection rate after the use of wound VAC in patients with
severe open fractures and associated soft tissue injuries. The
average number of days from initial injury to denitive closure
was 7.3 days. Of the survey respondents, 96.8% believe that
soft tissue coverage for a type IIIA fracture should be done
within the rst 7 days. The use of wound VAC may decrease
the risk of infection in injuries undergoing denitive reconstruction 7 days postinjury.

CONCLUSIONS
It is important to note the value of survey-based
investigation for nding and characterizing areas of controversy in any specialty. Survey participation reminders must
be taken into account when conducting this type of study as
they can increase data accrual by 50%. We encourage the use
of this type of resource for shedding light on areas of
controversy among any specialty.
Great variation exists among orthopaedic trauma surgeons in treatment of open fractures by orthopaedic trauma
surgeons. Antibiotic prophylaxes, time to wound debridement, and time to wound closure are among the more
controversial topics identied.
Urgent administration of a high-dose rst-generation
cephalosporin is well supported. Addition of aminoglycosides has not been evaluated and has potential toxicity.
Penicillin use is also not well supported even in contaminated fractures. Addition of gram-negative bacteria coverage
with aminoglycosides or uoroquinolones is an area of
future investigation. Timing of debridement should be based
on patient and system capacity, and quality of debridement
is considered most important to remove contaminated and
necrotic material. Basic science and clinical data support the
efcacy of high-dose local antibiotics and occlusive dressings. Early (,7 days) denitive wound closure is encouraged as early as feasible.
Use of local antibiotics is encouraged in highly
contaminated wounds. Antibiotic prophylaxis .48 hours is
not supported. Repeated debridements every 24 - 48 hours is
recommended if wound is left open and is contaminated. The
use of wet-to-dry dressings is limited to circumstances when
an occlusive dressing is not feasible.
REFERENCES
1. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one
thousand and twenty-ve open fractures of long bones: retrospective and
prospective analyses. J Bone Joint Surg Am. 1976;58:453458.

www.jorthotrauma.com |

e201

Obremskey et al

2. Yusof NM, Halim AS. Outcomes of infected grade IIIB open tibial
fractures. Singapore Med J. 2012;53:591594.
3. Burnett JW, Gustilo RB, Williams DN, et al. Prophylactic antibiotics in
hip fractures. A double-blind, prospective study. J Bone Joint Surg Am.
1980;62:457462.
4. Carlsson AK, Lidgren L, Lindberg L. Prophylactic antibiotics against
early and late deep infections after total hip replacements. Acta Orthop
Scand. 1977;48:405410.
5. Stafford PR, Norris BL. Reamer-irrigator-aspirator bone graft and bi
Masquelet technique for segmental bone defect nonunions: a review of
25 cases. Injury. 2010;41(suppl 2):S72S77.
6. McCall TA, Brokaw DS, Jelen BA, et al. Treatment of large segmental
bone defects with reamer-irrigator-aspirator bone graft: technique and
case series. Orthop Clin North Am. 2010;41:6373; Table of contents.
7. Apard T, Bigorre N, Cronier P, et al. Two-stage reconstruction of posttraumatic segmental tibia bone loss with nailing. Orthop Traumatol Surg
Res. 2010;96:549553.
8. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture
(REDCap)a metadata-driven methodology and workow process for
providing translational research informatics support. J Biomed Inform.
2009;42:377381.
9. Bethell C, Fiorillo J, Lansky D, et al. Online consumer surveys as a methodology for assessing the quality of the United States health care system.
J Med Internet Res. 2004;6:e2.
10. Leece P, Bhandari M, Sprague S, et al. Internet versus mailed questionnaires: a controlled comparison (2). J Med Internet Res. 2004;6:e39.
11. Pealer LN, Weiler RM, Pigg RM Jr, et al. The feasibility of a web-based
surveillance system to collect health risk behavior data from college
students. Health Educ Behav. 2001;28:547559.
12. Patzakis MJ, Wilkins J. Factors inuencing infection rate in open fracture
wounds. Clin Orthop Relat Res. 1989;243:3640.
13. Hauser CJ, Adams CA Jr, Eachempati SR. Surgical Infection Society
guideline: prophylactic antibiotic use in open fractures: an evidencebased guideline. Surg Infect (Larchmt). 2006;7:379405.
14. Solgaard L, Tuxoe JI, Ma M, et al. Nephrotoxicity by dicloxacillin and
gentamicin in 163 patients with intertrochanteric hip fractures. Int Orthop.
2000;24:155157.
15. Hoff WS, Bonadies JA, Cachecho R, et al. East Practice Management
Guidelines Work Group: update to practice management guidelines
for prophylactic antibiotic use in open fractures. J Trauma. 2011;70:
751754.
16. Hospenthal DR, Murray CK, Andersen RC, et al. Executive summary: guidelines for the prevention of infections associated with combat-related injuries:
2011 update: endorsed by the Infectious Diseases Society of America and the
Surgical Infection Society. J Trauma. 2011;71:S202S209.
17. Patzakis MJ, Bains RS, Lee J, et al. Prospective, randomized, doubleblind study comparing single-agent antibiotic therapy, ciprooxacin, to
combination antibiotic therapy in open fracture wounds. J Orthop
Trauma. 2000;14:529533.
18. Huddleston PM, Steckelberg JM, Hanssen AD, et al. Ciprooxacin
inhibition of experimental fracture healing. J Bone Joint Surg Am.
2000;82:161173.
19. Holtom PD, Pavkovic SA, Bravos PD, et al. Inhibitory effects of the
quinolone antibiotics trovaoxacin, ciprooxacin, and levooxacin on
osteoblastic cells in vitro. J Orthop Res. 2000;18:721727.
20. Luchette FA, Bone LB, Born CT, et al. EAST practice management
guidelines work group: practice management guidelines for prophylactic
antibiotic use in open fractures. Available at: http://www.east.org/tpg/
openfrac.pdf. Accessed February 15, 2013.

e202

| www.jorthotrauma.com

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21. Rello J, Ausina V, Ricart M, et al. Impact of previous antimicrobial

therapy on the etiology and outcome of ventilator-associated pneumonia.
Chest. 1993;104:12301235.
22. Koulenti D, Rello J. Hospital-acquired pneumonia in the 21st century:
a review of existing treatment options and their impact on patient care.
Expert Opin Pharmacother. 2006;7:15551569.
23. Rello J, Sa-Borges M, Correa H, et al. Variations in etiology of ventilator-associated pneumonia across four treatment sites: implications for
antimicrobial prescribing practices. Am J Respir Crit Care Med. 1999;
160:608613.
24. Trouillet JL, Chastre J, Vuagnat A, et al. Ventilator-associated pneumonia caused by potentially drug-resistant bacteria. Am J Respir Crit Care
Med. 1998;157:531539.
25. Chastre J, Wolff M, Fagon JY, et al. Comparison of 8 vs 15 days of
antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial. JAMA. 2003;290:25882598.
26. Schenker ML, Yannascoli S, Baldwin KD, et al. Does timing to operative
debridement affect infectious complications in open long-bone fractures?
A systematic review. J Bone Joint Surg Am. 2012;94:10571064.
27. Ostermann PA, Seligson D, Henry SL. Local antibiotic therapy for severe
open fractures. A review of 1085 consecutive cases. J Bone Joint Surg
Br. 1995;77:9397.
28. Holm C, Petersen JS, Gronboek F, et al. Effects of occlusive and conventional gauze dressings on incisional healing after abdominal operations. Eur J Surg. 1998;164:179183.
29. Keating JF, Blachut PA, OBrien PJ, et al. Reamed nailing of open tibial
fractures: does the antibiotic bead pouch reduce the deep infection rate?
J Orthop Trauma. 1996;10:298303.
30. Felix Lanao R, Jonker AM, Wolke J, et al. Phyciochemical properties
and applications of Poly(lactic-co-glycolic acid) for use in bone regeneration. Tissue Eng Part B Rev. 2013;19:380390.
31. Kempen DH, Lu L, Kim C, et al. Controlled drug release from a novel
injectable biodegradable microsphere/scaffold composite based on poly
(propylene fumarate). J Biomed Mater Res A. 2006;77:103111.
32. Eckman JB Jr, Henry SL, Mangino PD, et al. Wound and serum levels of
tobramycin with the prophylactic use of tobramycin-impregnated polymethylmethacrylate beads in compound fractures. Clin Orthop Relat Res.
1988;237:213215.
33. Henry SL, Ostermann PA, Seligson D. The antibiotic bead pouch technique. The management of severe compound fractures. Clin Orthop Relat
Res. 1993;295:5462.
34. Fletcher N, Soanos D, Berkes MB, et al. Prevention of perioperative
infection. J Bone Joint Surg Am. 2007;89:16051618.
35. Cho CY, Lo JS. Dressing the part. Dermatol Clin. 1998;16:2547.
36. Hutchinson JJ, McGuckin M. Occlusive dressings: a microbiologic and
clinical review. Am J Infect Control. 1990;18:257268.
37. Godina M. Early microsurgical reconstruction of complex trauma of the
extremities. Plast Reconstr Surg. 1986;78:285292.
38. Gopal S, Majumder S, Batchelor AG, et al. Fix and ap: the radical
orthopaedic and plastic treatment of severe open fractures of the tibia.
J Bone Joint Surg Br. 2000;82:959966.
39. Bhattacharyya T, Mehta P, Smith M, et al. Routine use of wound vacuum-assisted closure does not allow coverage delay for open tibia fractures. Plast Reconstr Surg. 2008;121:12631266.
40. Steiert AE, Gohritz A, Schreiber TC, et al. Delayed ap coverage of open
extremity fractures after previous vacuum-assisted closure (VAC) therapy
worse or worth? J Plast Reconstr Aesthet Surg. 2009;62:675683.
41. Fleischmann W, Strecker W, Bombelli M, et al. Vacuum sealing as treatment
of soft tissue damage in open fractures. Unfallchirurg. 1993;96:48892.

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