InternationalOrthopaedics

SICOTaisbl2015
10.1007/s002640152712z

OriginalPaper

Areviewoffortyfiveopentibialfractures
coveredwithfreeflaps.Analysisof
complications,microbiologyandprognostic
factors
UlrikKhlerOlesen 1,RasmusJuul 4,ChristianTorstenBonde 3,ClausMoser 2,MartinMcNally 6,LisaToftJensen 3,
JensJrgenElberg 3andHenrikEckardt 5

(1) DepartmentofOrthopaedicSurgery,Rigshospitalet,Blegdamsvej9,2100Copenhagen,Denmark
(2) DepartmentofClinicalMicrobiology,Rigshospitalet,Copenhagen,Denmark
(3) DepartmentofPlasticSurgery,BreastSurgeryandBurns,Rigshospitalet,Copenhagen,Denmark
(4) DepartmentofOrthopaedicSurgery,SlagelseHospital,Slagelse,Denmark
(5) DepartmentofTraumatology,UniversityHospitalBasel,Basel,Switzerland
(6) NuffieldOrthopaedicCentre,OxfordUniversityHospitals,Oxford,UK
UlrikKhlerOlesen
Email:ulrik.kaehler@gmail.com
Received:31December2014
Accepted:12February2015
Publishedonline:8March2015

Abstract
Purpose
Treatmentofopenfracturesiscomplexandcontroversial.Thepurposeofthepresentstudyisto
addevidencetothemanagementofopentibialfractures,wheretissuelossnecessitatescover
withafreeflap.Weidentifiedfactorsthatincreasetheriskofcomplications.Wequestioned
whetherearlyflapcoverageimprovedtheclinicaloutcomeandwhetherwecouldimproveour

antibiotictreatmentofopenfractures.
Methods
From2002to2013wetreated56patientswithanopentibialfracturecoveredwithafreeflap.
Wereviewedpatientrecordsanddatabasesfortypeoftrauma,smoking,timetotissuecover,
infection,amputations,flaplossandunionoffracture.Weidentifiedfactorsthatincreasethe
riskofcomplications.Weanalysedtheorganismsculturedfromopenfracturestoproposethe
optimalantibioticprophylaxis.Followupwasaminimumofoneyear.Primaryoutcomewas
infection,bacterialsensitivitypattern,amputation,flapfailureandunionofthefracture.
Results
Whensofttissuecoverwasdelayedbeyondsevendays,infectionrateincreasedfrom27to
60%(p
Conclusion
Flapcoverwithinoneweekisessentialtoavoidinfection.Highenergytraumaandsmokingare
importantpredictorsofcomplications.Wesuggestantibioticprophylaxiswithvancomycinand
meropenemuntilthewoundiscoveredinthesecomplexinjuries.
Keywords OpentibialfracturesAntibioticsInfectionMicrobiologyTimingFreeflap
AmputationSmoking

Introduction
Openfractureshaveanincreasedriskofinfectionandnonunion.Thesecomplicationsmay
resultinamputationandsepticshock.Themostseverecases,withsignificantsofttissueinjury,
needbothosteosynthesisoftheboneandaplasticsurgicalprocedure,intheformofafreeflap,
torestorethesofttissue.Furthermore,thefragilesofttissuemantleinthedistaltibiaandthe
lackofreliablelocalflapsinthisareaisachallengefororthopaedicandplasticsurgeons.The
ultimategoalsofthetreatmentaretoavoidamputationandinfection,restoresofttissuecover
andachieveunionofthefracture(Figs.1,2and3).
http://staticcontent.springer.com.scihub.org/image/art%3A10.1007%2Fs002640152712
z/MediaObjects/264_2015_2712_Fig1_HTML.gif
Fig.1

Afreefibulagraftwithmuscleandskinfromtherightlegofthepatient,istransferredtotheleftside,
wherethepatientsustainedanopendistaltibialfracture,withsubstantialboneloss

http://staticcontent.springer.com.scihub.org/image/art%3A10.1007%2Fs002640152712
z/MediaObjects/264_2015_2712_Fig2_HTML.gif
Fig.2
Thefibulaisexposed

http://staticcontent.springer.com.scihub.org/image/art%3A10.1007%2Fs002640152712
z/MediaObjects/264_2015_2712_Fig3_HTML.gif
Fig.3
6monthsafter.Donorandthegraftsite.Thepatientiswalkingunaided,withnopain

Theliteratureremainsinconclusiveonthetopicofantibiotictreatmentandtimingofsofttissue
cover,probablyduetotherelativelysmallnumberofpatientsineachcentrewiththiscondition
[15,79].Furthermore,hospitallogisticsmaydelaythemostoptimalcourse.Thedelayintime
toskincoverisprobablyrootedinalackofconsensusontiming,differentapproachestothe
treatmentofseverelyinjuredpatientswithotherlifeorlimbthreateninginjuriesandlackof
capacity.Inourhospital,thedelayinflapcoveragewasrootedinacapacityproblemtypically,
anelectivetumourpatientoperationmustbecancelledforthemicrosurgeryteamtooperateon
anopenfracturepatient.
Thepurposeofourstudywastoinvestigatethedeterminingfactorsthatreducetheriskof
amputation,infectionandnonunionandtoidentifyrelevantfirstlineantibiotics.Webelievethat
ourstudyisuniqueinitscombinationofdataonmicrobiologyandtimingofcoverofopen
fractures.Theseaspectshavenotpreviouslybeendiscussedinthesamecontext,althoughthey
arecloselyassociated.

Methods
ThisstudywasconductedattheDepartmentofOrthopaedicSurgeryandTraumaandatthe
DepartmentofPlasticSurgery,CopenhagenUniversityHospital,Rigshospitalet,Denmark.
Rigshospitaletisareferralcentreforfractureswithsofttissuelossandhasacatchment

populationof1.7million.
Thestudyincludedallpatientswithopenfracturesofthetibia,coveredwithfreevascularized
flapsatourinstitutionfromJanuary2002toJune2013.Patientswithinitiallyclosedfractures
andpatientswithchronicosteomyelitiswereexcluded.Thepatientsincludedinthestudywere
identifiedfromourdatabaseofallmicrosurgicalproceduresconductedbytheDepartmentof
PlasticSurgeryduringtheperiod.
Weretrospectivelycollecteddatafrompatientrecords(history,tobaccouse,fracturetype,
fractureunion,timingofsurgicalprocedures,flapfailure,infection,amputation)andfromour
localmicrobiologicaldatabase(samples,species,antibiotics,susceptibilitypatterns)andfrom
themicrosurgicaldatabase(flaptypes,timing).
InjurytypewasrecordedaccordingtoMllerOTAfractureclassificationandtheGustilo
Andersonsofttissuedamageclassification[1,12].Initialwoundtreatmentwasclassifiedas
Openwhennegativepressurewoundtherapy(NPWT),oranyothertypeofopendressingwas
used.Closedwoundtreatmentdenotedcaseswhereprimarysuturingofthewoundproceeded
towoundbreakdownandnecrosis.WedefinedinfectionwhenCRPand/orwhitecellcountwas
elevatedincombinationwithpus,dischargeorwoundbreakdown,provideditwasrelatedtothe
initiallesion,includingtheflap.Superficialsignsofinfectionandexternalfixatorpintract
infectionswereexcluded.Positiveculturesorbloodtestswithoutclinicalsignsofinfectionwere
notincluded.
Unionofthefracturewasevaluatedradiographicallyandwedefinednonunionwhenlessthan
threeoutoffourcorticeshadbridgingcallusinanteroposteriorandlateralviews,oneyearor
later,afterinitialsurgery.Highenergytraumawasdefinedas:polytraumaingeneral,including
fallsfromaheightof2.5m,motorvehicleormotorcycleaccidents,bicycleaccidents,
pedestriansbeinghitbyanyoftheaboveandcrushinginjuries.Lowenergytraumawasdefined
asfallfromstandingheightorupto
Thebacterialspeciesisolatedfromthewoundsandtheirsusceptibilitypatternsweredefined
withrespecttotimefrominjury.Weincludedsampleculturesbetweenthesecondand30thday
afterinjury.Culturesfrominitialwoundrevisionswerenotincluded.Thisavoidedtheearly
woundcontaminationperiod(whichhaspreviouslybeenshowntohavepoorcorrelationwith
laterinfectionpathogens)[22,23].Thesamplesincludedwerebiopsiesharvestedfromdeep
tissueduringsurgicalwoundrevisionsofpatientsthatwereclinicallyinfected.Blood,pinsite
andcathetercultureswerenotincluded.Identicalresultswerecountedonlyonce.The
susceptibilityofidentifiedmicroorganismstorelevantantibioticswastestedbydiscdiffusion.
Weincludedonlypositivesamplesthatwerefullysusceptibletotheantibiotictested.
WeusedFischersExacttestfordichotomousvariablesandsetthelevelofsignificanceatp=

0.05.Wecalculatedtherelativeriskratioforeachoutcomemeasurerelatedtotheenergyof
initialtrauma.Clinicalfollowupwasaminimumofoneyearforallpatients.

Results
FromJanuary2002untilJune2013,56patientsreceivedafreevascularizedflaptocoveran
openfractureofthetibiaatourinstitution.Ofthese,11hadinsufficientorirretrievablepatient
records,leaving45patientstobeincludedinthestudy.Thepatientswithirretrievablerecords
wereallfromtheperiod(20022005),priortotheintroductionofelectronicpatientrecords.
Thestudygroupconsistedof13womenand32men.Theaverageagewas42years(range16
71,SD18).GustiloAndersontypeIIIBfracturesaccountedfor26(57%)ofthelesions,andsix
(13%)wereGustiloAndersonIIIC.Thirtyonepatients(67%)sustainedhighenergytrauma.
Therewere15smokers(33%).Onepatienthadbilateralfractures.
Allpatientswereinitiallydebridedwithcopiouslavage.Theaveragetimetofirstdebridement
was6.8hours(rangeoneto26,SD6.2).Afterdebridement31patients(67%)with32fractures
continuedwithopenwoundcare,typicallywithnegativepressurewoundtherapy(NPWT).The
remainder(15)hadclosedwoundtherapywithsteriledressingsandsuturingofthewound,that
laterwentontowoundbreakdown.
Sixteenpatientswereprimarilystabilizedwithinternalfixation(plates,nailorscrews).The
remaining29patientsweretreatedwithtemporaryexternalfixation,whichwasconvertedto
internalfixationincombinationwiththefreeflap.
Theaveragetimetoflapcoverwas16days(rangetwoto54days,SD13,excludingoneoutlier
at450days).Thefreeflapsconsistedof24latissimusdorsiflaps,13gracilisflaps,three
vascularizedfreefibulas,fiveanterolateralthighflaps(ALT)andasingleradialforearmflap.
Onepatienthadflapstobothtibias(patientno.7)(seeTable1).
Table1
Patientdemographics

Patient

Age

Year

Smoker

Fracture

GA
class

High
energy

Wound
treatment

Flap
type

43

2005

Yes

44A

GA3B

Yes

Open

LD

39

2009

No

42A

GA3B

Yes

Open

ALT

43

2013

Yes

41C3

GA3B

Yes

Open

LD

25

2012

No

42C3

GA3C

Yes

Open

LD

72

2011

No

42A

GA3B

Yes

Open

Grac

45

2002

Yes

42A3

GA3B

Yes

Closed

LD

71

2011

No

42B1

GA3B

Yes

Open

LD

71

2011

No

42A2

GA3B

Yes

Open

LD

22

2008

Yes

42A3

GA3B

Yes

Open

LD

44

2012

No

41C3

GA3B

Yes

Open

LD

10

49

2011

No

42B2

GA3C

Yes

Open

LD

11

52

2011

No

44B3

GA3B

Yes

Open

ALT

12

16

2005

Yes

42A3

GA3B

No

Open

LD

13

46

2012

Yes

44BC

GA3B

Yes

Open

LD

14

39

2009

Yes

43B2

GA3A

No

Open

Grac

15

27

2011

No

41A1

GA3B

No

Open

LD

16

61

2007

No

42C1

GA3B

No

Closed

Grac

17

59

2007

Yes

43C3

GA3B

Yes

Closed

LD

18

35

2010

No

42B2

GA3B

No

Open

Grac

19

31

2005

No

43B2

GA3B

Yes

Closed

Grac

20

17

2006

No

42C1

GA3B

Yes

Closed

Grac

21

38

2011

No

42A1

GA3A

No

Open

ALT

22

80

2011

No

44B2

GA3A

No

Open

Radialis

23

64

2010

No

43C3

GA3C

Yes

Open

ALT

24

30

2009

Yes

43B2

GA3C

Yes

Open

LD

25

29

2004

Yes

42A2

GA2

Yes

Closed

LD

26

34

2005

Yes

42B2

GA2

No

Closed

LD

27

77

2012

No

44B2

GA3B

No

Open

LD

28

59

2012

No

41A3

GA3B

Yes

Closed

LD

29

24

2003

Yes

44B1

GA3B

Yes

Open

LD

30

56

2007

Yes

42C2

GA2

Yes

Closed

Grac

31

67

2011

No

44C1

GA2

No

Open

LD

32

21

2010

No

43A3

GA3C

Yes

Open

Fib

33

42

2009

No

43B2

GA3B

Yes

Open

LD

34

56

2013

No

41C1

GA3B

Yes

Open

alt

35

41

2005

No

42C3

GA3B

Yes

Open

Grac

36

35

2002

Yes

42B2

GA2

Yes

Closed

LD

37

67

2012

No

43B3

GA3B

No

Open

Fib

38

15

2002

No

44B3

GA2

No

Closed

Grac

39

42

2005

No

42A2

GA3A

Yes

Closed

LD

40

22

2013

No

43B2

GA2

No

Open

Grac

41

16

2002

No

42A2

GA3B

Yes

Closed

Grac

42

19

2009

No

44C2

GA3A

Yes

Closed

LD

43

29

2009

Yes

42C3

GA3C

Yes

Open

Fib

44

28

2013

Yes

43C2

GA1

No

Closed

Grac

44

28

2013

Yes

43C2

GA1

No

Closed

Grac

45

35

2012

No

42B3

GA2

No

Open

Grac

FracturetypeaccordingtoAO
LDLatissimusdorsiALTanterolateralthighGracGracilisFibfasciomyocutaneousfibulaflapGA
GustiloAndersonclassificationExfixexternalfixation

SciHub
Infection

Twentytwofractures(48%)becameinfectedatanaverageof21daysfromtheinitialtrauma
(rangefourto83days,SD21days,excludinganoutlierat360days).Inthegroupreceiving
flapcoverbeforedayseven(earlycover),fiveoutof18becameinfected(27%),andinthe
groupofpatientsreceivingtheflapafterdayseven(latecover),17outof28becameinfected
(60%).Thedifferencebetweeninfectionratesinthetwogroupswasstatisticallysignificant(p
Nonunion
Nineteen(41%)fractureswerenotunitedoneyearafterosteosynthesis.Nonunionoccurredin
tenoutof16patientsinthesmokinggroup(63%),comparedtonineoutof30patients(30%)
inthenonsmokinggroup.Thedifferencebetweennonunionratesinthesmokingandthenon
smokinggroupwasalmostsignificant(p
Limbsalvage
Infourpatients(9%),continuinginfectionrequiredtreatmentwithabelowtheknee
amputation.Twoofthesehadaninfectednonunion.Meantimetoamputationwas17.2months
(0.4,14,14and40months).Theassociationbetweenamputationandinfectionwasstatistically
significant(p
Flapfailure
Sevenpatients(19%)sustainedpartialorcompletelossofthefreeflap,resultinginasecondary
procedure.Noneofthesepatientswereamputatedandallofthemunderwenteithersuccessful
repairorreplacementoftheirflaps.Flapfailurewassignificantlyassociatedwithsmoking,with
fiveoutofseven(71%)flapfailuresoccurringinthesmokinggroup(p
Injuryseverity
Allfourpatientswhowereamputatedwereinthehighenergytraumagroup.Seventeenof22
infectedpatients(77%)wereinthehighenergygroup.Furthermore,sixoutofseven(86%)

flapfailuresand14of19(74%)nonunioncaseswereinthehighenergygroup.When
comparinghighenergytraumawithlowenergytrauma,therelativeriskratiosforamputation,
flapfailure,infectionandnonunionwere3.8,2.9,1.6and1.4,respectively.
Cultureresults
Weisolated43differentbacterialspeciesin22infectedpatientsfromdaytwoto30.Sixofthe
infectionsweremonomicrobial,ninehadtwodifferentbacteriaandtherestwerepolymicrobial.
Sevenbacteriaaccountedfor75%oftheinfections,enterococcusspeciesandcoagulase
negativestaphylococcus(CoNs)beingthemostfrequent.Thepatternsofsensitivityareseenin
Table2.

Table2
Thenumberofculturesfrainfectedwoundsandtheirsensitivitypattern

Bacteria

Number

Vanco

Mero

Linez

Genta

Sulfa

Amp

Moxi

Enterococcus
species

11

11

Coagulaseneg.
staphylococci
(CoNS)

Enterobacteriaceae

Miscellaneous

Other
pseudomonas

Anaerobic
bacteria

Staphylococcus
aureus

Haemolytic
streptococci

Corynebacterium
species

Pseudomonas
aeruginosa

Total

43

29

24

24

15

14

13

13

Onlysampleswithfullsensitivitywereincluded.
VancoVancomycinMeroMeropenemLinezLinezolidGentagentamycinSulfasulphonamideAmp
AmpicillinMoximoxifloxacinEryErythromycinRifrifampicinCiprociprofloxacinCefurcefuroximAzit
azitromycinMetrometronidazol

Discussion
Theimportanceoftimingofcoverinopenfractureshasbeeninvestigatedbyanumberof
authors,mostnotablyGodina,whowasthefirsttoreporttheimportanceofearlyskincoverto
reducetheriskofinfection[19].Later,anumberofotherobservershavecometosimilar
conclusions,butmanyotheraspectsoftraumacaremayalsoplayaroleinpreventinginfection
andsecuringunionintheseinjuries.
Alleuyrandetal.foundthatpatientsreceivingflapcoverbeforedaysevenhadabetteroutcome
intermsofflapfailureandinfection,evenwhencontrollingforknownriskfactorssuchas
severityoftrauma[2].Choudyetal.alsofoundahighernonunionrateandinfectionratein
patientswithflapcoverafterdayseven[20].
Gopaletal.andSinclairetal.reportedseriesofopentibialfractureswithveryearlyskincover
(beforedaythree)anddefinitivestabilization9095%ofthesepatientshadsuccessfulflap
cover,withnoinfection,unionofthefractureandexcellentoutcomewithoutpainorwalking
disability[4,5].Suchresultsareexceptional.Inanotherseries,infectionrates,flapfailurerates
andnonunionratesexceed3050%.Otherauthors,inlinewiththeguidelinesoftheBritish
OrthopaedicAssociation,havereachedsimilarconclusions,albeitatvariousbreakpoints[25,
711].
Ourstudysamplesizedidnotpermitamultivariateanalysisofallpossibleconfounders,butit
confirmedunequivocallythatpatientscoveredbeforedaysevenhadasignificantlylower
infectionandnonunionrate,irrespectiveoftraumadegree.
Theseresultsshouldencouragesurgeonstostriveforanorthoplasticserviceenablingrapid
freeflapcoveranddefinitivestabilizationwithinoneweekaftertrauma.Weacceptthatnoneof
thesestudiesarerandomizedtrialsofearlyandlatecover,whichisageneralweaknessofthe
literature.
Inourstudy,flapfailurewasnotapredictorofamputation.Thisisanimportantpoint,also
observedbyChoudryetal.,illustratingthataflaprevisionorasecondflapcanoftenallowlimb
salvage[20].Atourinstitution,localmuscleflapsarenotusedforimmediatesofttissuecover
afterlowerextremitytraumaduetohighcomplicationandrevisionrates[3,18,20].Choudryet
al.alsofoundthatcoverlaterthanoneweekusingsoleuspedicledflapsforopentibiafractures
resultedinhighernonunionrates,higherflapfailureratesandmoreinfectionwhencomparedto
freemuscleflaps[20].Useoftobaccowasasignificantpredictorofflapfailure,awellknown
probleminplasticsurgery,alsodescribedbyChristyetal.,[17].Hence,smokerswithcomplex
injuriesshouldbecounseledonquittingsmoking.

PatzakisandWilkins(in1989)wereamongthefirsttoobservethatimmediateantibiotic
prophylaxisinpatientswithopenfracturesisthesinglemostimportantfactorthatwillreduce
theriskofinfections[6].Furthermore,gradeIIIopenfracturesinneedoftissuecoverposea
problemfortheclinician.Thewoundmaybeopenforseveraldaysallowingcolonizationand
adherenceofselectedbacteriathatareresistanttotheantibioticsgiven.Inlinewiththese
observations,ithasbeenshownthatculturesobtainedatinitialdebridementscorrelatepoorly
withlaterinfections,whichiswhyweonlyincludedculturesfrompatientsthatwereclinically
infected,andnotculturesfromdayzerototwo[22,23].Thus,antibiotictreatmentshouldbe
broad,targetbothGrampositiveandnegativeorganisms,andtheriskofgeneratingresistance
shouldbesmall[1316].Theriskcanbefurtherreducedbyusingantibioticsthatarerenally
excretedwithminorimpactonthenormalflora,asproposedbySullivanetal.[21].Also,
reducedselectionforresistantpathogenscanbeexpectedduetothereducedtimetosofttissue
coverage,andtheresultingdecreasedperiodwithneedforantibiotictreatment.
Gopaletal.,incommonwithPollacketal.,haveproposedtheuseofCefuroximeand
metronidazoleforopentibiafractures.Thiswasthecombinationofantibioticsusedatour
institution,butinonly12of43(28%)caseswouldtheseantibioticshavebeeneffectiveagainst
thebacteriaculturedfromourpatientsbeforeflapcover[3,4].
AsdepictedinTable3,vancomycin,whichisbacteriocidal,waseffectiveagainst29of43
isolatedculturesandwasactiveagainstallGrampositivebacteriaidentifiedinthestudy.

Table3
Outcomeofpatientdemographicsandcomplications

Outcome

Late
cover
(61%)

Early
cover

High
energy
(67%)

Low
energy

Open
wound
(67%)

Closed
wound

Proximal
fracture
(59%)

Amputation
(9%)

No
amputation

27

15

27

15

28

14

25

pvalue

0.280

Infection
(48%)

17

17

12

10

12

No
infection

11

13

14

10

19

15

pvalue

0.038*

Flapfailure
(15%)

Nofailure

22

17

25

14

27

12

24

pvalue

0.220

Nonunion
(41%)

13

11

12

Union

15

12

17

10

20

15

pvalue

0.540

0.290

1.000

0.217

1.00

0.146

0.399

0.770

0.660

0.539

0.340

0.424

0.763

*Statisticallysignificantassociationsaremarkedwithanasterisk

Meropenemwaseffectiveagainst24of43organisms,withparticulareffectagainstthe
miscellaneousgroup,enterobacteriacaeandotherGramnegativerods,enterococcusand
anaerobes.Gentamicincovered15of43organisms,butnoneoftheimportantenterococcus

species.
LinezolidalsocoveredtheGrampositiveorganismsinoursamples,andhasgoodpenetration
intotissues,butisonlylicensedforalimitedperiodoftimeandisverycostly.
Basedontheseresults,wesuggestacombinationofvancomycinandmeropenemasfirstline
antibioticprophylaxis.Incombination,theseantibioticsseldomleadtoresistance,aregenerally
welltolerated,andsupplementeachotherwell.Theyarebothmainlyrenallyexcreted.Inthis
series,vancomycinandmeropenemwouldhavecovered40of43(93%)organismscultured.
Thishasalsobeendemonstratedinaseriesof166patientswithchronicosteomyelitisoccurring
mainlyafterfracturewithinternalfixation,inwhichSheehyetal.recommendedvancomycin
andmeropenemforempiricalinitialtreatmentoftheorganismsidentifiedatexcisionofthe
boneinfection[13].
Thepatternsofresistancemaydiffergeographicallyandshouldalsobeconsideredinaregional
context.Weareawarethatprophylaxiswithbroadspectrumantibioticscouldresultin
unwantedresistancepatterns,butthisproblemshouldbeseeninthelightofaverysmall
numberofpatientspresentingwithopenfractureswithcompromisedsofttissue.However,short
durationtreatmentwitheffectiveantibioticregimesshouldalsominimizethedevelopmentof
resistanceandpreventlaterinfectionthatwillinevitablyrequiremuchlongerantibiotictherapy
withrisksforresistance.

Conclusion
Weconcludethatadelayinsofttissuecoverbeyonddaysevenfromtheinitialtraumais
associatedwithanincreasedinfectionandnonunionrate.Smokingmarkedlyincreasestherisk
ofnonunionandflapfailure.Highenergytraumaincreasestherelativeriskofflapfailure,
infection,nonunionandamputation.
Wealsoconcludethatcurrentlyproposedantibioticshavelimitedeffectonbacteriainfecting
grade3openfractures.
Wehavechangedthestandardantibioticprophylaxisatourinstitutiontovancomycinand
meropenem,thusimprovingtheexpectedcoverageoforganismsfrom28to93%.
Acknowledgments
TheauthorswishtothankMDMariaPetersenforvaluableacademicfeedbackandITconsultantChristian
E.Forrestalforassistancewithdatacollection,spreadssheetsandfigures.

Conflictofinterest
Noconflictsofinterestdeclared.

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