Prevention

Host Factors

• Question 1: What is the relationship between smoking and infection in fracture procedures? Is smoking history or only current smoking important? Does nicotine cessation at time of fracture reduce complication rates?
• Question 2: What is the role of nutritional supplementation in avoiding infection in acute fracture cases?
• Question 3: Does preoperative pneumonia/UTI/ trophic ulcers increase PJI/SSI risk in femoral neck fracture patients treated by partial/ total hip arthroplasty?
• Question 4: Are there microorganism specific risk factors for acute infection in trauma patients (i.e., Does being a nasal carrier of MRSA increase the risk for MRSA infection after trauma?)
• Question 5: Is periprosthetic fracture a risk for the development of a PJI?
• Question 6: Are there predictors of the need for allogeneic blood transfusion in arthroplasty for acute hip fractures?

Risk Mitigation

• Question 1: Is there a role for bacterial decolonization (for example, of MRSA in nares) in trauma cases?
• Question 2: What are the ideal strategies to prevent secondary and nosocomial contamination of open fracture wounds which are left open?
• Question 3: Is there a difference in the risk of PJI with use of internal versus external fixation for treatment of periprosthetic fractures?
• Question 4: Should definitive fixation of fracture in a polytrauma patient and open abdomen be delayed until the abdomen is closed?

Diagnosis

• Question 1: Which open fracture classification system currently used, Gustilo-Anderson or OTA open fracture classification (OTA-OFC), is preferred based on interobserver reproducibility and predictiveness of outcomes?
• Question 2: What diagnostic criteria must be fulfilled to diagnose SSI (surgical site infection) in Orthopedic trauma (including external fixators)?
• Question 3: What diagnostic criteria define infected non-union of long bone?
• Question 4: What differentiates acute from chronic osteomyelitis? Is it clinically important to distinguish one from the other?
• Question 5: Is synovial fluid or fracture hematoma always aseptic? If not, could this play a role in acute infection or PJI after ORIF?
• Question 6: What is the relationship between implanted metal and colonization under a VAC in open fractures?

Treatment

Antibiotics & Non-operative Management

• Question 1: What is the most optimal prophylaxtic antibiotic coverage and treatment duration for open fractures of long bones?
• Question 2: What antibiotic should be used for low energy open fractures? — Page: What antibiotic(s) should be used for high energy open and grossly contaminated fractures?
• Question 3: What is the optimal mechanism for delivery of local antibiotics in contaminated or infected wounds?
• Question 4: Is there a role for combination of local and systemic antibiotic delivery systems to treat open fractures with overlying contaminated wounds?
• Question 5: What is the most optimal antibiotic treatment for chronic osteomyelitis?
• Question 6: What is the recommended suppressive antibiotic therapy for the treatment of chronic osteomyelitis after fracture fixation while the implant cannot be removed?
• Question 7: Is there a role for hyperbaric oxygen therapy and other non-antibiotic methods for the treatment of chronic osteomyelitis/implant infections?

Surgeon & Care Team

• Question 1: Should all infected non-unions be treated in specialized septic surgery centers?
• Question 2: Is there a minimum number of complex osteomyelitis procedures a surgeon should perform annually to ensure proper outcomes?
• Question 3: Who are the essential members of the multidisciplinary team required to manage infected fractures and non-unions?

Risk Factors

• Question 1: What are predictors of the need for allogeneic blood transfusion in periprosthetic fractures?
• Question 2: Is acute femoral neck fracture a risk factor for infection in patients undergoing hip arthroplasty?

Procedure-Related

• Question 1: What is the optimal timing of surgical debridement in open fractures?
• Question 2: What is the recommended volume of irrigating fluid in the ED for open fractures?
• Question 3: What is the recommended volume and composition of irrigating fluid in the OR for open fractures and post-traumatic wounds?
• Question 4: What is the most appropriate management of early (prior to complete wound healing) infection after fracture fixation with stable fixation?
• Question 5: What is the most appropriate management of early (before complete wound healing) infection after fracture fixation with unstable fixation?
• Question 6: What is the appropriate timing of conversion to internal fixation following external fixation? How is this altered by pin site infection?
• Question 7: What are the alternatives to segmental resection in septic non-union?
• Question 8: What is the optimal management (Masquelet technique, bone transfer) of post-infective bone defects in different long bones (tibia, femur, humerus, etc.)? How does this vary by type of defect (conical vs. cylindrical)?
• Question 9: What is the optimum waiting time for bone grafting in staged management of septic nonunion?

Management of Hardware

• Question 1: When should hardware be removed when treating SSI (surgical site infection) in Orthopedic trauma?
• Question 2: Which surgical treatment (plate, nail, external fixator) for open tibial shaft fractures results in lower rate of infection?
• Question 3: When performing intramedullary fixation, what is the evidence regarding reaming versus non-reaming and association with infection?
• Question 4: Are antibiotic-coated rods and plates an acceptable alternative to cement only implants?
• Question 5: What is the ideal composition of antibiotic-impregnated intramedullary nails?
• Question 6: What is the ideal composition of antibiotic-impregnated spacers/beads in post-traumatic infections? Is preoperative microbial identification necessary?
• Question 7: Should antibiotic cement rods be left permanently in situ?

Wound Coverage

• Question 1: Is there evidence to support one type of flap coverage over another (muscle over fasciocutaneous flap, for example) after open tibial fractures?
• Question 2: What is the appropriate timing for flap coverage of open fractures and traumatic wound defects?
• Question 3: Should open fracture wounds be closed primarily or closed secondarily? If closed primarily, which ones and under what criteria?
• Question 4: What are the evidence-based recommendations for the use of Negative Pressure Wound Therapy in open fractures and traumatic wounds?

Outcomes

• Question 1: What is the most appropriate outcome measurement (clinical, radiographic, laboratory, etc.) for management of early infection after fracture fixation?