Once Daily High-Dose Gentamicin to Prevent Infection in Open Fractures of the Tibial Shaft: A Preliminary Investigation

George V. Russell, Jr., MD, Chantaé King, Carmen G. May, RN, BSN, MSN, Albert W. Pearsall IV, MD

Disclosures

South Med J. 2001;94(12) 

In This Article

Results

Fracture union was achieved in all patients an average of 8 months from the index procedure (range, 3 to 28 months). Seven patients required 9 subsequent procedures to obtain bony union, including 1 external fixator adjustment, 3 iliac crest bone grafting procedures, 2 nail dynamizations (removal of locking screws from the nail on one side of the fracture, thereby allowing francture compression), and 3 nail exchanges. Seven other procedures in 3 patients were required for soft tissue management or to control infections after initial wound closure. One patient who had a free tissue muscle transfer required an operative debridement for removal of the flap after it necrosed. The wound ultimately healed with dressing changes. Our 2 patients who had deep infections required 6 subsequent debridements and a nail removal to control the infections. No patient had either nephrotoxicity or ototoxicity (Table).

One patient treated with external fixator had a superficial pin tract infection. This infection was treated on an outpatient basis with oral antibiotics and vigilant pin care. Two patients had deep infections. One of these patients (No. 5, Table) sustained a type IIIA open fracture from multiple low-velocity gunshot wounds (Fig 1). This fracture was stabilized on the night of admission with a reamed intramedullary nail after irrigation and debridement (Fig 2). After 48 hours, irrigation and debridement were repeated, accompanied by delayed primary wound closure. Four months postoperatively, after one previous follow-up examination, fluctuation occurred at the most proximal gunshot wound. Local irrigation and debridement were done, and the patient was given oral antibiotics for a Staphylococcus aureus infection. At 6 months postoperatively, the patient returned with drainage from the abscess location with evidence of a nonunion. A reamed exchange nailing was done, and the patient was treated with intravenous cefazolin and oral ofloxacin for combined S aureus and Serratia marcescens infections. Three months after the exchange nail, the patient returned with a questionable fracture union and drainage from the proximal locking screw wounds, for which local irrigation and debridement were done in the office. Four months after exchange nailing, drainage occurred from the proximal locking screw sites. The patient had nail removal with reaming of the intramedullary canal and was again given oral ofloxacin. The patient was last seen in our hospital for an unrelated admission 17 months after injury. At that time, the patient's leg was healed, without evidence of further infection (Fig 3).

(Patient 5) Preoperative anteroposterior radiograph of patient who had type IIIA open tibia and fibular shaft fractures, resulting from gunshot wounds.

(Patient 5) Postoperative anteroposterior and lateral radiographs show fracture stabilization with intramedullary implants of both tibia and fibula.

(Patient 5) Healed fracture with secondary varus malalignment 17 months after injury. Lateral film shows fracture union with secondary procurvatum deformity.

The other patient with a deep infection (No. 1, Table) sustained a type IIIC open fracture resulting from a crush injury. The patient was treated with immediate revascularization, irrigation and debridement, and bony stabilization with an external fixator. The patient required four additional debridements before a local gastrocnemius muscle transfer. Six weeks after wound closure, a deep infection due to S marcescens and Staphylococcus epidermidis developed. The patient required four subsequent debridements and a modification of antibiotic therapy to intravenous ceftriaxone and vancomycin to eradicate the infection. The fracture healed 12 months after injury.

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