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Risk factors for infectious complications after open fractures; a systematic review and meta-analysis

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Abstract

Purpose

The purpose of this study was to identify risk factors for the development of infection after open fracture fixation.

Methods

A comprehensive search in all scientific literature of the last 30 years was performed in order to identify patient-, trauma-, diagnosis- and treatment-related risk factors. Studies were included when infectious complications were assessed in light of one or more risk factors. A meta-analysis was performed. Risk ratios (RR) or risk differences (RD) with 95% confidence intervals were calculated.

Results

A total of 116 manuscripts were included. Male gender (RR 1.42), diabetes mellitus (DM) (RR 1.72), smoking (RR1.29), a lower extremity fracture (RR 1.94), Gustilo-Anderson grade III open fracture (RR 3.01), contaminated fracture (RR 7.85) and polytrauma patients (RR 1.49) were identified as statistically significant risk factors for the development of infectious complications. Of the treatment-related risk factors, only pulsatile lavage was associated with a higher infectious complication rate (RR 2.70).

Conclusion

A number of risk factors for the development of infections after open fractures have been identified in the available literature. These factors should still be tested for independence in a multivariable model. Prospective, observational studies are needed to identify and quantify individual risk factors for infection after open fracture fixation.

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Acknowledgements

The authors thank Mr. Wichor M. Bramer, biomedical information specialist (Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands), for his help in conducting the systematic literature search.

Author information

Authors and Affiliations

  1. Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Room H820, PO Box 2040, 3000CA, Rotterdam, The Netherlands

    Kirsten Kortram, Hans Bezstarosti, Esther M.M. Van Lieshout & Michael H.J. Verhofstad

  2. Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium

    Willem-Jan Metsemakers

  3. Department of Trauma Surgery, University Hospital Münster, Waldeyerstrasse 1, 48149, Münster, Germany

    Michael J. Raschke

Authors
  1. Kirsten Kortram
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  2. Hans Bezstarosti
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  3. Willem-Jan Metsemakers
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  4. Michael J. Raschke
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  5. Esther M.M. Van Lieshout
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  6. Michael H.J. Verhofstad
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Corresponding author

Correspondence to Michael H.J. Verhofstad.

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The authors have no conflicts of interest to disclose.

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There is no funding source.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

Informed consent was not applicable in this study.

Electronic supplementary material

Appendix I. Search strings used in the different databases

Appendix I. Search strings used in the different databases

Cochrane

((((open OR compound) NEAR/3 fracture*)):ab,ti) AND ((infect*):ab,ti)

Embase.com

('open fracture'/exp OR (((open OR compound) NEAR/3 fracture*)):ab,ti) AND (infection/exp OR 'infection risk'/exp OR 'infection complication'/de OR (infect*):ab,ti) NOT ([Conference Abstract]/lim OR [Letter]/lim OR [Note]/lim OR [Editorial]/lim) AND [english]/lim

Google scholar

"open|compound fracture|fractures"|"open|compound * fracture|fractures"|"open|compound ** fracture|fractures" infection|infections|infected

Medline (OvidSP)

(Fractures, Open/ OR (((open OR compound) ADJ3 fracture*)).ab,ti.) AND (exp infection/ OR (infect*).ab,ti.) NOT (letter OR news OR comment OR editorial OR congresses OR abstracts).pt. AND english.la.

PubMed publisher

(Fractures, Open[mh] OR (((open[tiab] OR compound[tiab]) AND fracture*[tiab]))) AND (infection[mh] OR (infect*[tiab])) NOT (letter[pt] OR news[pt] OR comment[pt] OR editorial[pt] OR congresses[pt] OR abstracts[pt]) AND english[la] AND publisher[sb]

Web-of-science

TS=(((((open OR compound) NEAR/3 fracture*))) AND ((infect*))) AND DT=(article)

Appendix II. Quality of evidence, as assessed using the GRADE-tool

1. Patient-related risk factors

Quality assessment

Quality

Factor

Number of studies

Study design

Risk of bias

Inconsistency

Indirectness

Imprecision

Other considerations

Age

7

1 RCT

2 Pros

4 Retro

Not serious

Serious

Not serious

Not serious

None

⨁◯◯◯ VERY LOW

BMI

2

2 Retro

Serious

Not serious

Not serious

Not serious

None

⨁◯◯◯ VERY LOW

Gender

10

1 RCT

3 Pros

7 Retro

Not serious

Not serious

Not serious

Not serious

None

⨁⨁◯◯ LOW

DM

2

2 Retro

Serious

Not serious

Serious

Serious

None

⨁◯◯◯ VERY LOW

HIV

2

2 Pros

Serious

Serious

Serious

Serious

None

⨁◯◯◯ VERY LOW

Smoking

7

3 Pros

4 Retro

Serious

Not serious

Serious

Serious

None

⨁◯◯◯ VERY LOW

Alcohol/Drugs

1

1 Pros

Very serious

Serious

Serious

Serious

None

⨁◯◯◯VERY LOW

2. Fracture-related risk factors

Factor

Quality assessment

Quality

Number of studies

Study design

Risk of bias

Inconsistency

Indirectness

Imprecision

Other considerations

Location

24

2 RCT

6 Pros

16 Retro

Not serious

Serious

Serious

Not serious

None

⨁◯◯◯VERY LOW

Open vs closed fractures

51

3 RCT

6 Pros

42 Retro

Not serious

Serious

Serious

Serious

None

⨁◯◯◯

VERY LOW

Open vs closed fractures - pros

9

3 RCT

6 Pros

Not serious

Not serious

Serious

Not serious

None

⨁◯◯◯

VERY LOW

Gustilo-Anderson grade

74

4 RCT

13 Pros

57 Retro

Not serious

Serious

Serious

Serious

None

⨁◯◯◯

VERY LOW

Gustilo-Anderson grade - RCT

4

4 RCT

Not serious

Not serious

Not serious

Not serious

None

⨁⨁⨁◯

MODERATE

Contamination

3

1 Pros

2 Retro

Serious

Serious

Serious

Serious

None

⨁◯◯◯VERY LOW

3. Trauma-related risk factors

 

Quality assessment

Quality

Number of studies

Study design

Risk of bias

Inconsistency

Indirectness

Imprecision

Other considerations

Mechanism

3

2 Pros

1 Retro

Serious

Serious

Serious

Serious

None

⨁◯◯◯

VERY LOW

Polytrauma

3

1 RCT

1 Pros

1 Retro

Not Serious

Not Serious

Serious

Not Serious

None

⨁◯◯◯

VERY LOW

ISS

4

1 Pros

3 Retro

Serious

Serious

Serious

Not Serious

None

⨁◯◯◯

VERY LOW

4. Treatment-related risk factors

 

Quality assessment

Quality

Number of studies

Study design

Risk of bias

Inconsistency

Indirectness

Imprecision

Other considerations

Antibiotics

2

2 RCT

Not Serious

Not serious

Serious

Not serious

None

⨁⨁⨁◯

MODERATE

Antibiotic timing

3

1 Pros

2 Retro

Serious

Serious

Serious

Not serious

None

⨁◯◯◯

VERY LOW

Debridement

18

3 Pros

15 Retro

Serious

Serious

Serious

Not serious

None

⨁◯◯◯

VERY LOW

Fixation

16

4 RCT

5 Pros

7 Retro

Very serious

Not serious

Serious

Very serious

None

⨁◯◯◯

VERY LOW

Closure

4

2 Pros

2 Retro

Serious

Serious

Serious

Serious

None

⨁◯◯◯

VERY LOW

Transfusion

2

2 Pros

Not serious

Not serious

Serious

Not serious

None

⨁◯◯◯

VERY LOW

Splenectomy

1

1 Retro

Not serious

Not serious

Not serious

Not serious

None

⨁⨁◯◯

LOW

  1. RCT randomized controlled trial, Pros prospective, Retro retrospective, BMI body mass index, DM diabetes mellitus, HIV human immunodeficiency virus, ISS injury severity score

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Kortram, K., Bezstarosti, H., Metsemakers, WJ. et al. Risk factors for infectious complications after open fractures; a systematic review and meta-analysis. International Orthopaedics (SICOT) 41, 1965–1982 (2017). https://doi.org/10.1007/s00264-017-3556-5

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  • DOI: https://doi.org/10.1007/s00264-017-3556-5

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