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. 2022 Apr 1;4(4):CD013555.
doi: 10.1002/14651858.CD013555.pub2.

Timing of antibiotic administration, wound debridement, and the stages of reconstructive surgery for open long bone fractures of the upper and lower limbs

James K-K Chan  1   2   3 , Alexander L Aquilina  2 , Sharon R Lewis  4 , Jeremy N Rodrigues  1   5 , Xavier L Griffin  4 , Jagdeep Nanchahal  6
Affiliations

Timing of antibiotic administration, wound debridement, and the stages of reconstructive surgery for open long bone fractures of the upper and lower limbs

James K-K Chan et al. Cochrane Database Syst Rev. .

Abstract

Background: Open fractures of the major long bones are complex limb-threatening injuries that are predisposed to deep infection. Treatment includes antibiotics and surgery to debride the wound, stabilise the fracture and reconstruct any soft tissue defect to enable infection-free bone repair. There is a need to assess the effect of timing and duration of antibiotic administration and timing and staging of surgical interventions to optimise outcomes.

Objectives: To assess the effects (risks and benefits) of the timing of antibiotic administration, wound debridement and the stages of surgical interventions in managing people with open long bone fractures of the upper and lower limbs.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and clinical trial registers in February 2021. We also searched conference proceedings and reference lists of included studies.

Selection criteria: We included randomised controlled trials (RCTs) or quasi-RCTs that recruited adults with open fractures of the major long bones, comparing: 1) timings of prophylactic antibiotic treatment, 2) duration of prophylactic antibiotic treatment, 3) timing of wound debridement following injury or 4) timing of the stages of reconstructive surgery.

Data collection and analysis: We used standard methodological procedures expected by Cochrane. We aimed to collect data for the following outcomes: limb function, health-related quality of life (HRQoL), deep surgical site infection, delayed or non-union, adverse events (in the short- and long-term course of recovery), and resource-related outcomes.

Main results: We included three RCTs of 613 randomised participants with 617 open fractures. Studies were conducted in medical and trauma centres in the USA and Kenya. Where reported, there was a higher proportion of men and a mean age of participants between 30 and 34 years old. Fractures were in the upper and lower limbs in one study, and were tibia fractures in two studies; where reported, these were the result of high-energy trauma such as road traffic accidents. No studies compared the timing of antibiotic treatment or wound debridement. Duration of prophylactic antibiotic treatment (1 study, 77 participants available for analysis) One study compared antibiotic treatment for 24 hours with antibiotic treatment for five days. We are very uncertain about the effects of different durations of antibiotic treatment on superficial infections (risk ratio (RR) 1.19, 95% CI 0.49 to 2.87, favours 5 day treatment; 1 study, 77 participants); this was very low-certainty evidence derived from one small study with unclear and high risks of bias, and with an imprecise effect estimate. This study reported no other review outcomes. Reconstructive surgery: timing of the stages of surgery (2 studies, 458 participants available for analysis) Two studies compared the timing of wound closure, which was completed immediately or delayed. In one study, the mean time of delay was 5.9 days; in the other study, the time of delay was not reported. We are very uncertain about the effects of different timings of wound closure on deep infections (RR 0.82, 95% CI 0.37 to 1.80, favours immediate closure; 2 studies, 458 participants), delayed union or non-union (RR 1.13, 95% CI 0.83 to 1.55, favours delayed closure; 1 study, 387 participants), or superficial infections (RR 6.45, 95% CI 0.35 to 120.43, favours delayed closure; 1 study, 71 participants); this was very low-certainty evidence. We downgraded the certainty of the evidence for very serious risks of bias because both studies had unclear and high risks of bias. We also downgraded for serious imprecision because effect estimates were imprecise, including the possibility of benefits as well as harms, and very serious imprecision when the data were derived from single small study. These studies reported no other review outcomes.

Authors' conclusions: We could not determine the risks and benefits of different treatment protocols for open long bone fractures because the evidence was very uncertain for the two comparisons and we did not find any studies addressing the other possible comparisons. Well-designed randomised trials with adequate power are needed to guide surgical and antibiotic treatment of open fractures, particularly with regard to timing and duration of antibiotic administration and timing and staging of surgery.

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Conflict of interest statement

JC: Cochrane UK Fellow 2017 to 2018. AA: none SL: none. SL was not involved in the editorial process. JR: funded by the NIHR. This represents independent research funded by the NIHR. The views expressed are the author's own, and are not necessarily those of the NIHR, NHS or the Department of Health and Social Care. XG: works within a research group that has been funded for several trials of negative pressure dressings and has published trials that may be relevant to this review. He has ongoing expert consultancy with several companies. XG is fully funded by the NIHR. The views expressed are the author's own and are not necessarily those of the NIHR, NHS or the Department of Health and Social Care. XG was not involved in the editorial process. JN: co‐applicant on an NIHR‐funded trial for negative pressure wound therapy for closed incisions in people with major trauma of the lower limb ‐ Wound Healing in Surgery for Trauma (WHIST). He has also lectured on courses on the management of open fractures, sponsored by orthopaedic implant manufacturers. JN is member of the NICE Guidance Development Group for Complex and Non‐Complex Fractures. JN is an expert witness providing medico‐legal reports including on open fractures.

Figures

1
1
Flow diagram showing key stages in the management of open fractures.
2
2
PRISMA Study flow diagram.
3
3
Risk of bias summary
4
4
Risk of bias graph
1.1
1.1. Analysis
Comparison 1: Duration of prophylactic antibiotic treatment, Outcome 1: Adverse events: superficial infection
2.1
2.1. Analysis
Comparison 2: Timing of wound closure, Outcome 1: Deep infection
2.2
2.2. Analysis
Comparison 2: Timing of wound closure, Outcome 2: Delayed union or non‐union
2.3
2.3. Analysis
Comparison 2: Timing of wound closure, Outcome 3: Adverse events: superficial infection
See this image and copyright information in PMC

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References to other published versions of this review

Chan 2020
    1. Chan JK-K, Aquilina AL, Rodrigues JN, Griffin XL, Nanchahal J.Timing and staging of antibiotic administration and surgery for open long bone fractures of the upper and lower limbs. Cochrane Database of Systematic Reviews 2020, Issue 3. Art. No: CD013555. [DOI: 10.1002/14651858.CD013555] - DOI - PMC - PubMed

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