Fig. 1 Photo of an open distal tibial metadiaphyseal fracture at the time of initial debridement in a 38-year-old man injured in a motorcycle accident
Courtesy of Kevin Tetsworth, MD, FAAOS

AAOS Now

Published 8/2/2022
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Terry Stanton

New Clinical Practice Guideline Covers Prevention of Surgical Site Infection after Major Extremity Trauma

During its March meeting, the AAOS Board of Directors approved the Clinical Practice Guideline (CPG) and correlating Appropriate Use Criteria (AUC) on the Prevention of Surgical Site Infections (SSIs) after Major Extremity Trauma.

The CPG and AUC were developed in collaboration with the Major Extremity Trauma Research Consortium (METRC) and funded by a Department of Defense grant. The CPG is intended to help prevent SSIs in adults following major extremity trauma, defined as any of the following: open fractures; major/high-energy closed fractures; degloving injuries; Morel lesions; low- and high-velocity gunshot injuries; crush injuries; blast injuries; and moderate- to high-energy injury mechanisms.

The CPG provides 14 recommendations categorized as strong or moderate based on available evidence about preoperative, perioperative, and postoperative interventions to decrease SSIs following major extremity trauma. The guideline also addresses modifiable factors that are associated with increased risk for SSI following surgery for major extremity trauma.

Furthermore, the CPG offers several recommendations characterized as “options,” or guidance formulated with either low-quality evidence, no evidence, or conflicting evidence. Recommended options include use of incisional negative-pressure wound therapy for high-risk surgical incisions; the implementation of an orthoplastic team; patient outcomes related to the use of hyperbaric oxygen; preoperative skin preparation; and select modifiable and administrative risk factors.

The cochairs of the Development Group for the CPG were Ashton Goldman, MD, FAAOS, representing the Society of Military Orthopaedic Surgeons, and Kevin Tetsworth, MD, FAAOS, FRACS, representing AAOS. In a joint interview with AAOS Now, they explained that METRC and AAOS teamed to develop this guideline because the organizations “have mutual goals to define current and future research to maximize short- and long-term outcomes for patients who sustain major extremity trauma.”

The CPG encompasses specific recommendations regarding initial treatment of traumatic injury and prevention of SSI. For example, the guideline recommends that patients with open fractures be brought to the OR for debridement and irrigation as soon as reasonable, ideally within 24 hours of injury. During initial management of open wounds after major extremity trauma, irrigation with saline (no additives) is preferred.

The guideline includes four recommendations pertaining to use of antibiotics. Three of the recommendations are categorized as moderate strength and favor “early delivery of antibiotics … in the setting of open fracture” and use of antibiotics before surgery for open fractures. The one strong recommendation in this regard calls for antibiotic prophylaxis with systemic cefazolin or clindamycin, except for Type III (and possibly Type II) open fractures, for which additional Gram-negative coverage is preferred. On the question of local antibiotics used during and after surgery, the CPG advises that local antibiotic prophylactic strategies, such as vancomycin powder, tobramycin-impregnated beads, or gentamicin-covered nails, may be beneficial.

“To prevent SSIs after significant extremity trauma, antibiotics are a necessary tool,” Dr. Goldman observed. “Our goal was to provide recommendations at the different time points and routes of antibiotic delivery. Based on current evidence, the working group could only give a strong recommendation for the use of systemic perioperative and postoperative prophylaxis.”

Dr. Tetsworth added: “It is vitally important that we as a community monitor antibiotic usage to remain consistent with best practice, while still respecting the principles of antibiotic stewardship. Inappropriate use and overuse of antimicrobials can contribute to an increase in resistant bacteria and can occasionally result in patient harm.”

The guideline contains recommendations advising against the use of two treatment modalities: negative-pressure wound therapy for open and closed fractures and the use of silver-coated dressings to improve outcomes or decrease pin-site infections. Of the first, Dr. Tetsworth commented, “Additional research is needed to better define the optimal employment of this technology.”

In regard to silver-coated dressings, Dr. Goldman offered a caveat. “Most quality literature surrounding silver-coated dressings after major extremity trauma is related to pin sites,” he said. “There is a clear need for future research evaluating the use of silver-coated dressings on closed wounds.”

The CPG addresses two main categories of risk factors—modifiable and administrative—and their implications for patient counseling. A strong recommendation advises that patients be counseled that risk for SSI is increased by diabetes and smoking, and moderate recommendations similarly caution regarding obesity and significant alcohol use.

For administrative risk factors, the guideline notes that minimal evidence indicates that race or socioeconomic status affects risk of SSI, and that there is no significant difference in risk of SSI when a person is treated as an inpatient or outpatient.

“Despite the heterogeneity of patients and injury patterns, the recommendations related to modifiable and administrative risk factors summarize the best available evidence to counsel patients while also providing potential avenues to explore for future research,” Dr. Tetsworth noted.

Overall, Dr. Goldman said, when considering the specific recommendations in the guideline and the strengths of the evidence supporting them, surgeons may view this CPG as both a foundation of current knowledge and a launching point for reflection about one’s own clinical practices. “Many of the recommendations are based upon current best evidence; however, some controversial topics, such as topical antibiotics and negative-pressure wound therapy, may go against providers’ experience or training biases,” Dr. Goldman said. “Therefore, readers should be encouraged to thoroughly examine the rationales and associated literature to determine how best to apply this CPG to their practice.”

Speaking of the CPG process and resulting product, Dr. Tetsworth commented: “As a group, we are especially grateful for the support provided by AAOS and the organizational skills and resources they graciously provided. In our opinion, CPGs play a critically important role in clarifying the current state of best practice in various strategic clinical areas. By providing effective consensus statements, high-quality care can be delivered more consistently to the greatest possible number of individuals.”

The CPG and accompanying documentation are available through AAOS’ OrthoGuidelines website, www.orthoguidelines.org, and free mobile app.

Terry Stanton is the senior medical writer for AAOS Now. He can be reached at tstanton@aaos.org.

AUC on SSIs Provides Tool in Management of Major Extremity Trauma

The new Appropriate Use Criteria (AUC) on Prevention of Surgical Site Infections (SSIs) after Major Extremity Trauma, released in tandem with a Clinical Practice Guideline (CPG) on the topic, offers orthopaedic surgeons guidance for lowering the risk of infection in patients with open fractures and other traumatic injuries.

As with previously issued AUCs, this app-based resource provides clinicians with algorithm-style guidance for appropriate, patient-specific interventions for patients presenting with high-energy extremity trauma who are being considered for surgical intervention. This AUC offers recommendations for treatment scenarios based on evidence and conclusions issued in the CPG. The AUC applies only to patients without the presence of SSI at the extremity trauma site.

When using this AUC, a clinician selects from the following patient indication: Injury Classification, Soft Tissue Characteristic(s), Host Factors/Medical Status, and Surgical Treatment Administered. Once that is selected, the online tool responds with “Appropriate” interventions marked with green checkmarks, “May Be Appropriate” interventions with yellow triangles, and “Rarely Appropriate” interventions marked with a red circle with an X.

If, for example, a clinician is evaluating a patient with a closed injury with significant soft-tissue compromise; no or limited comorbidities (healthy, American Society of Anesthesiologists classification 1–2, Charlson Comorbidity Index <3); and acute definitive internal fixation (open reduction–internal fixation intramedullary nailing), “appropriate” treatments include:></3);>

  • prophylactic antibiotics at the time of fixation surgery
  • standard surgical skin preparation with povidone iodine
  • standard surgical skin preparation with chlorhexidine
  • perioperative normothermia
  • perioperative glucose control
  • supplemental perioperative oxygenation
  • change of gloves at regular intervals

Treatments that “may be appropriate” are:

  • debridement and primary closure or soft-tissue coverage
  • local antimicrobial therapy
  • negative-pressure wound therapy inclusive of incisional negative pressure

“Rarely appropriate” treatment options are prophylactic antibiotics with or without anaerobic coverage upon initial presentation to the medical center, early debridement and irrigation with additives (such as Castile soap), and multiple debridements and secondary closure or soft-tissue coverage.

The AUC and accompanying documentation are available through AAOS’ OrthoGuidelines website, www.orthoguidelines.org, and free mobile app.