Treatment and prevention of osteomyelitis following trauma in adults
- Steven K Schmitt, MD, FIDSA
Steven K Schmitt, MD, FIDSA
- Staff Physician, Department of Infectious Diseases
- Associate Professor of Medicine
- Cleveland Clinic Lerner College of Medicine
Posttraumatic osteomyelitis refers to osteomyelitis that develops as a result of contaminated open fractures or surgical treatment of closed fractures [1,2]. Posttraumatic osteomyelitis can occur in up to 25 percent of open fractures; the risk depends upon the following factors [3-8]:
●Severity of fracture
●Severity of soft tissue injury
●Degree of bacterial contamination
●Presence of underlying vascular insufficiency (eg, peripheral vascular disease or diabetes)
- Hoff WS, Bonadies JA, Cachecho R, Dorlac WC. East Practice Management Guidelines Work Group: update to practice management guidelines for prophylactic antibiotic use in open fractures. J Trauma 2011; 70:751.
- Pasquale M, Fabian TC. Practice management guidelines for trauma from the Eastern Association for the Surgery of Trauma. J Trauma 1998; 44:941.
- Merritt K. Factors increasing the risk of infection in patients with open fractures. J Trauma 1988; 28:823.
- DeLong WG Jr, Born CT, Wei SY, et al. Aggressive treatment of 119 open fracture wounds. J Trauma 1999; 46:1049.
- Gross T, Kaim AH, Regazzoni P, Widmer AF. Current concepts in posttraumatic osteomyelitis: a diagnostic challenge with new imaging options. J Trauma 2002; 52:1210.
- Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wounds. Clin Orthop Relat Res 1989; :36.
- Tsukayama DT. Pathophysiology of posttraumatic osteomyelitis. Clin Orthop Relat Res 1999; :22.
- Lavery LA, Walker SC, Harkless LB, Felder-Johnson K. Infected puncture wounds in diabetic and nondiabetic adults. Diabetes Care 1995; 18:1588.
- Lew DP, Waldvogel FA. Osteomyelitis. Lancet 2004; 364:369.
- Khatod M, Botte MJ, Hoyt DB, et al. Outcomes in open tibia fractures: relationship between delay in treatment and infection. J Trauma 2003; 55:949.
- Mader JT, Ortiz M, Calhoun JH. Update on the diagnosis and management of osteomyelitis. Clin Podiatr Med Surg 1996; 13:701.
- Trampuz A, Zimmerli W. Diagnosis and treatment of infections associated with fracture-fixation devices. Injury 2006; 37 Suppl 2:S59.
- Haas DW, McAndrew MP. Bacterial osteomyelitis in adults: evolving considerations in diagnosis and treatment. Am J Med 1996; 101:550.
- Karam GH, Ackley AM, Dismukes WE. Posttraumatic Aeromonas hydrophila osteomyelitis. Arch Intern Med 1983; 143:2073.
- Lavery LA, Harkless LB, Felder-Johnson K, Mundine S. Bacterial pathogens in infected puncture wounds in adults with diabetes. J Foot Ankle Surg 1994; 33:91.
- Laughlin TJ, Armstrong DG, Caporusso J, Lavery LA. Soft tissue and bone infections from puncture wounds in children. West J Med 1997; 166:126.
- Harkness B, Andresen D, Kesson A, Isaacs D. Infections following lawnmower and farm machinery-related injuries in children. J Paediatr Child Health 2009; 45:525.
- Johnson EN, Burns TC, Hayda RA, et al. Infectious complications of open type III tibial fractures among combat casualties. Clin Infect Dis 2007; 45:409.
- Kindsfater K, Jonassen EA. Osteomyelitis in grade II and III open tibia fractures with late debridement. J Orthop Trauma 1995; 9:121.
- Lee J. Efficacy of cultures in the management of open fractures. Clin Orthop Relat Res 1997; :71.
- Patzakis MJ, Wilkins J, Moore TM. Considerations in reducing the infection rate in open tibial fractures. Clin Orthop Relat Res 1983; :36.
- Mader JT, Cripps MW, Calhoun JH. Adult posttraumatic osteomyelitis of the tibia. Clin Orthop Relat Res 1999; :14.
- Cierny G, Mader JT. Adult chronic osteomyelitis. Orthopedics 1984; 7:1557.
- Gosselin RA, Roberts I, Gillespie WJ. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev 2004; :CD003764.
- Böhm E, Josten C. What's new in exogenous osteomyelitis? Pathol Res Pract 1992; 188:254.
- Meadows SE, Zuckerman JD, Koval KJ. Posttraumatic tibial osteomyelitis: diagnosis, classification, and treatment. Bull Hosp Jt Dis 1993; 52:11.
- Anthony JP, Mathes SJ, Alpert BS. The muscle flap in the treatment of chronic lower extremity osteomyelitis: results in patients over 5 years after treatment. Plast Reconstr Surg 1991; 88:311.
- May JW Jr, Jupiter JB, Gallico GG 3rd, et al. Treatment of chronic traumatic bone wounds. Microvascular free tissue transfer: a 13-year experience in 96 patients. Ann Surg 1991; 214:241.
- Culliford AT 4th, Spector J, Blank A, et al. The fate of lower extremities with failed free flaps: a single institution's experience over 25 years. Ann Plast Surg 2007; 59:18.
- Clifford RP, Beauchamp CG, Kellam JF, et al. Plate fixation of open fractures of the tibia. J Bone Joint Surg Br 1988; 70:644.
- Clifford RP, Lyons TJ, Webb JK. Complications of external fixation of open fractures of the tibia. Injury 1987; 18:174.
- Chapman MW. The role of intramedullary fixation in open fractures. Clin Orthop Relat Res 1986; :26.
- Etter C, Burri C, Claes L, et al. Treatment by external fixation of open fractures associated with severe soft tissue damage of the leg. Biomechanical principles and clinical experience. Clin Orthop Relat Res 1983; :80.
- Rajasekaran S. Early versus delayed closure of open fractures. Injury 2007; 38:890.
- Seligson D, Henry SL. Treatment of compound fractures. Am J Surg 1991; 161:693.
- Patzakis MJ, Bains RS, Lee J, et al. Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds. J Orthop Trauma 2000; 14:529.
- Vasenius J, Tulikoura I, Vainionpää S, Rokkanen P. Clindamycin versus cloxacillin in the treatment of 240 open fractures. A randomized prospective study. Ann Chir Gynaecol 1998; 87:224.
- Russell GV Jr, King C, May CG, Pearsall AW 4th. Once daily high-dose gentamicin to prevent infection in open fractures of the tibial shaft: a preliminary investigation. South Med J 2001; 94:1185.
- Sorger JI, Kirk PG, Ruhnke CJ, et al. Once daily, high dose versus divided, low dose gentamicin for open fractures. Clin Orthop Relat Res 1999; :197.
- Ostermann PA, Henry SL, Seligson D. The role of local antibiotic therapy in the management of compound fractures. Clin Orthop Relat Res 1993; :102.
- 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; 77:93.
- Henry SL, Ostermann PA, Seligson D. The prophylactic use of antibiotic impregnated beads in open fractures. J Trauma 1990; 30:1231.
- Worlock P, Slack R, Harvey L, Mawhinney R. The prevention of infection in open fractures. An experimental study of the effect of antibiotic therapy. J Bone Joint Surg Am 1988; 70:1341.
- Hake ME, Young H, Hak DJ, et al. Local antibiotic therapy strategies in orthopaedic trauma: Practical tips and tricks and review of the literature. Injury 2015; 46:1447.
- Cierny G 3d, Mader JT. The surgical treatment of adult osteomyelitis. In: Evarts CM, Surgery of the Musculoskeletal System (Ed), Churchill Livingstone, New York 1983. p.15.
- Adams K, Couch L, Cierny G, et al. In vitro and in vivo evaluation of antibiotic diffusion from antibiotic-impregnated polymethylmethacrylate beads. Clin Orthop Relat Res 1992; :244.
- Calhoun JH, Mader JT. Antibiotic beads in the management of surgical infections. Am J Surg 1989; 157:443.
- Henry SL, Seligson D, Mangino P, Popham GJ. Antibiotic-impregnated beads. Part I: Bead implantation versus systemic therapy. Orthop Rev 1991; 20:242.
- Popham GJ, Mangino P, Seligson D, Henry SL. Antibiotic-impregnated beads. Part II: Factors in antibiotic selection. Orthop Rev 1991; 20:331.
- Scott DM, Rotschafer JC, Behrens F. Use of vancomycin and tobramycin polymethylmethacrylate impregnated beads in the management of chronic osteomyelitis. Drug Intell Clin Pharm 1988; 22:480.
- Wilson KJ, Cierny G, Adams KR, Mader JT. Comparative evaluation of the diffusion of tobramycin and cefotaxime out of antibiotic-impregnated polymethylmethacrylate beads. J Orthop Res 1988; 6:279.
- Helgeson MD, Potter BK, Tucker CJ, et al. Antibiotic-impregnated calcium sulfate use in combat-related open fractures. Orthopedics 2009; 32:323.
- Hauser CJ, Adams CA Jr, Eachempati SR, Council of the Surgical Infection Society. Surgical Infection Society guideline: prophylactic antibiotic use in open fractures: an evidence-based guideline. Surg Infect (Larchmt) 2006; 7:379.
- Gillespie WJ, Walenkamp GH. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database Syst Rev 2010; :CD000244.
- Dellinger EP, Caplan ES, Weaver LD, et al. Duration of preventive antibiotic administration for open extremity fractures. Arch Surg 1988; 123:333.
- Weber EJ. Plantar puncture wounds: a survey to determine the incidence of infection. J Accid Emerg Med 1996; 13:274.
- Roesgen M, Hierholzer G, Hax PM. Post-traumatic osteomyelitis. Pathophysiology and management. Arch Orthop Trauma Surg 1989; 108:1.