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Osteomyelitis Risk Factors Related to Combat Trauma Open Femur Fractures

A Case–Control Analysis

Lewandowski, Louis R., MD*; Potter, Benjamin K., MD*; Murray, Clinton K., MD; Petfield, Joseph, MD; Stinner, Daniel J., MD; Krauss, Margot, MD, MPH; Weintrob, Amy C., MD§,‖,¶; Tribble, David R., MD, DrPH§ the Trauma Infectious Disease Outcomes Study Group

doi: 10.1097/BOT.0000000000001397
Original Article
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Objectives: To identify the risk factors for osteomyelitis development in US military personnel with combat-related, open femur fractures?

Design: Retrospective observational case–control study.

Setting: US military regional hospital in Germany and tertiary care hospitals in United States (2003–2009).

Patients/Participants: One hundred three patients with open femur fractures who met diagnostic osteomyelitis criteria (medical record review verification) were classified as cases. Sixty-four patients with open femur fractures who did not meet osteomyelitis diagnostic criteria were included as controls.

Main Outcome Measurements: The main outcome measurements were multivariable odds ratios (ORs) and 95% confidence interval (CI).

Results: Among patients with surgical implants, osteomyelitis cases had significantly longer time to definitive orthopaedic surgery compared with controls (median: 21 vs. 13 days). Independent predictors for osteomyelitis risk were Gustilo–Anderson classification (transfemoral amputation OR: 19.3; CI: 3.0–123.0) and Orthopaedic Trauma Association Open Fracture Classification for muscle loss (OR: 5.7; CI: 1.3–25.1) and dead muscle (OR: 32.9; CI: 5.4–199.1). Being injured between 2003 and 2006, antibiotic bead use, and foreign body plus implant(s) at fracture site were also risk factors.

Conclusions: Patients with open femur fractures resulting in significant muscle damage have the highest osteomyelitis risk. Foreign body contamination was only significant when an implant was present. Increased risk with antibiotic bead use is likely a surrogate for clinical suspicion of contamination with complex wounds. The timeframe association is likely due to changing trauma system patterns around 2006–2007 (eg, increased negative pressure wound therapy, reduced high-pressure irrigation, decreased crystalloid use, and delayed definitive internal fixations).

Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

*Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD. Dr. Lewandowski is now with the Department of Orthopaedics, United States Naval Hospital, Okinawa, Japan;

Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX;

Westat, Rockville, MD;

§Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD;

The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD; and

Infectious Disease, Walter Reed National Military Medical Center, Bethesda, MD.

Reprints: David R. Tribble, MD, DrPH, Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814-5119 (e-mail: David.Tribble@usuhs.edu).

Supported by the Infectious Disease Clinical Research Program, a DoD program executed through the Uniformed Services University of the Health Sciences, Department of Preventive Medicine and Biostatistics. This project is funded by the National Institute of Allergy and Infectious Diseases, National Institutes of Health, under Inter-Agency Agreement Y1-AI-5072, and Department of the Navy under the Wounded, Ill, and Injured Program.

The authors report no conflict of interest.

The views expressed are those of the authors and do not reflect the official views or policies of the Uniformed Services University of the Health Sciences, the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, the National Institutes of Health or the Department of Health and Human Services, Brooke Army Medical Center, Walter Reed National Military Medical Center, Landstuhl Regional Medical Center, US Army Medical Department, the US Army Office of the Surgeon General, the Department of Defense, or the Departments of the Army, Navy or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the US Government.

Accepted November 06, 2018

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