Prevention of infection in open fractures: Where are the pendulums now?

Injury. 2020 May:51 Suppl 2:S57-S63. doi: 10.1016/j.injury.2019.10.074. Epub 2019 Oct 25.


Soft tissue management and fracture fixation including initial external fixation in Gustilo-Anderson type II and type III open fractures are cornerstones in the treatment but details on timing and type of wound closure, irrigation and debridement, systemic and local antibiotics, antimicrobial-coated implants and the use of Bone Morphogenetic Protein-2 remain controversial. This article looks at current clinical evidence of these items for the management of open fractures. Timing of debridement and wound closure remains critical. Early debridement by an experienced team within 24 h seems adequate while gross contamination, a devascularized limb, a multi-injured patient and compartment syndrome require immediate surgical intervention. Wound closure during the first surgery was shown to result in reduced rates for infections and nonunion. If soft-tissue reconstruction is needed, it should be performed within the first 7 days. Regarding types of irrigation fluid, antiseptic and antibacterial solutions did not prove to be superior to saline. High pressure irrigation has not been demonstrated to be beneficial whereas antibiotic administration as soon as possible has been proven to be favorable. Administration of more than 72 h was not superior to shorter systemic antibiotic intervals. For Gustilo-Anderson type I and II, broad spectrum antibiotic therapy is reasonable. Additional aminoglycosides for broader coverage are recommended in Gustilo-Anderson type III fractures. There is newer literature on the beneficial effects of the use of local antibiotics, e.g. by antibiotic beads. Coating of internal fixation devices is a modern approach to improve infection prophylaxis and gentamicin-coated implants have been demonstrated to be safe in clinical application. Vacuum assisted closure (VAC) could not evidence negative pressure wound therapy to reduce infection risk, improve self-rated disability or quality of life in open fractures, however, enhance treatment costs. Recombinant human bone morphogenetic proteins (rhBMP)-2 showed promising data in Gustilo-Anderson type III open tibial shaft fractures with lower rates of invasive secondary procedures. In conclusion, there is evidence for thorough debridement and irrigation with saline, early soft tissue coverage and the use of systemic and local antibiotics. Except for a short-term soft tissue coverage VAC seems not to be beneficial and rhBMP-2 is an additional tool in Gustilo-Anderson type III open fractures.

Publication types

  • Review

MeSH terms

  • Anti-Bacterial Agents / therapeutic use
  • Antibiotic Prophylaxis
  • Bone Morphogenetic Protein 2 / therapeutic use
  • Coated Materials, Biocompatible / therapeutic use
  • Debridement
  • Fracture Fixation / adverse effects
  • Fracture Fixation / methods*
  • Fractures, Open / surgery*
  • Humans
  • Negative-Pressure Wound Therapy
  • Prostheses and Implants / adverse effects*
  • Prostheses and Implants / microbiology
  • Randomized Controlled Trials as Topic
  • Recombinant Proteins / therapeutic use
  • Surgical Wound Infection / microbiology
  • Surgical Wound Infection / prevention & control*
  • Transforming Growth Factor beta / therapeutic use
  • Treatment Outcome
  • Wound Healing


  • Anti-Bacterial Agents
  • Bone Morphogenetic Protein 2
  • Coated Materials, Biocompatible
  • Recombinant Proteins
  • Transforming Growth Factor beta
  • recombinant human bone morphogenetic protein-2