Despite decades of advancement in wound debridement, prophylactic antibiotic therapy, fracture stabilization, and soft tissue reconstruction, infection remains a serious complication after open fracture. Inconclusive historical data and new challenges with resistant organisms and antimicrobial stewardship having created a difficult environment within which to develop sound, evidence-based treatment protocols that can be applied universally. The first part of this 2-part series will synthesize the historical perspective along with the current concepts surrounding bacteriology and antibiotic use/stewardship. Part 2 will analyze and summarize the current literature regarding the management of open fracture and prevention of subsequent infection.
Numerous authors from Hippocrates to Larrey noted that superior results were obtained with an early aggressive debridement of necrotic tissue after wounding.1–7 Historically, the usual outcome after open fracture was infection, sepsis, amputation, and death before the introduction of antibiotics.8–11 As recently as the first half of the 20th century, surgeons argued that if an appropriate debridement was performed, antibiotics were not necessary and advocated against their routine use over concern for resistant organisms.
The current period of open fracture treatment (starting in the 1970s) heralded a more scientific era with critical evaluation of antibiotics, surgical debridement, and the development of standardized evidence-based protocols. This era began with 3 classic articles by Patzakis and Gustilo that, to this day, remain central to the discussion of infection prevention after open fractures.12–14
Level of Evidence:
Therapeutic Level V. See Instructions for Authors for a Complete description of levels of evidence.