Once daily high-dose gentamicin to prevent infection in open fractures of the tibia shaft: A preliminary investigation. (*).ABSTRACT
Background. Cephalosporin cephalosporin (sĕf'əlōspôr`ĭn), any of a group of more than 20 antibiotics derived from species of fungi of the genus Cephalosporium and closely related chemically to penicillin. Cephalosporins, e.g. and aminoglycoside aminoglycoside /ami·no·gly·co·side/ (-gli´ko-sid) any of a group of antibacterial antibiotics (e.g., streptomycin, gentamicin) derived from various species of Streptomyces antibiotics are currently recommended for infection prophylaxis prophylaxis (prō'fĭlăk`sĭs), measures designed to prevent the occurrence of disease or its dissemination. Some examples of prophylaxis are immunization against serious diseases such as smallpox or diphtheria; quarantine to confine in high-energy open tibial tibial
pertaining to the tibia.
a longitudinal prominence on the cranial border of the proximal tibia. Its proximal end (tibial tubercle) has a growth plate separate from the proximal tibia; hyperflexion injuries to shaft fractures. We evaluated cephalosporin in conjunction with once daily high-dose gentamicin gentamicin /gen·ta·mi·cin/ (jen?tah-mi´sin) an aminoglycoside antibiotic complex isolated from bacteria of the genus Micromonospora, as prophylaxis against infection in Gustilo types II and III open tibial shaft fractures.
Methods. Sixteen patients were identified in whom once daily gentamicin dosing was used as part of an antibiotic prophylaxis regimen in patients with types II and III open tibial shaft fractures. Cefazolin (1 g) and gentamicin (5 mg/kg) were given before operation. Antibiotic therapy was continued for 48 hours after definitive wound closure. Monitoring for gentamicin toxicity consisted of blood urea nitrogen blood urea nitrogen
n. Abbr. BUN
Nitrogen in the form of urea in the blood or serum, used as a indicator of kidney function.
Blood urea nitrogen (BUN) (BUN) and creatinine levels, gentamicin trough levels, and a daily query for signs of prodromal prodromal
the stage of premonitory signs presaging the onset of disease or of specific clinical signs such as seizures. ototoxicity Ototoxicity Definition
Ototoxicity is damage to the hearing or balance functions of the ear by drugs or chemicals.
Ototoxicity is drug or chemical damage to the inner ear. .
Results. Average time to fracture union was 8 months. One superficial and two deep infections were observed. No patient showed signs of nephrotoxicity neph·ro·tox·ic·i·ty
The quality or state of being toxic to kidney cells.
nephrotoxicity(ne·fr or ototoxicity.
Conclusions. Our investigation suggests that this dosing regimen might be safe as prophylaxis against infection in open tibial shaft fractures and that it warrants further study.
THE TIBIA is the most commonly fractured long bone, and many of these fractures are open. (1) The incidence of infection is noted to be 10 to 20 times higher in open tibial fractures than other open fractures. (2) Open tibial fractures are susceptible to infection due to several factors, including the high energy imparted to the leg, the poor blood supply of the tibia, and contamination of the fracture site at injury. (3) Several studies have shown that antibiotics significantly decrease the infection rate associated with open tibial shaft fractures. (2,4-6) It is generally agreed that a cephalosporin should be given in all open tibial shaft fractures. The addition of an aminoglycoside has been advocated for Gustilo types II and III open fractures (4,7) because of the higher incidence of gram-negative organisms contaminating these more severe open fractures. (2,4,8) Gentamicin is an aminoglycoside commonly used in prophylaxis against gram-negative colonization of open tibial fractures; however, institutional differences exist regarding the dose and dosing interval dosing interval Therapeutics The frequency of intermittent drug administration, based on the drug's half-life. See Slow-release drug. . A recent study has shown good results using a large daily dose of gentamicin in open fracture prophylaxis. (9) The purpose of this review was to investigate the efficacy of a 5 mg/kg daily dose of gentamicin in conjunction with a cephalosporin to prevent infection in operatively stabilized Gustilo types II and III open tibial shaft fractures.
MATERIALS AND METHODS
Between May 1, 1995, and May 31, 1999, 52 patients between the ages of 18 and 65 with an operatively treated Gustilo type II or III open tibial shaft fracture were identified using a prospectively gathered trauma registry. Three patients who had primary amputation and 2 who had delayed amputation amputation (ăm'pyətā`shən), removal of all or part of a limb or other body part. Although amputation has been practiced for centuries, the development of sophisticated techniques for treatment and prevention of infection has greatly were excluded from the study. Fifteen patients who received cefazolin only, 4 who received broad spectrum antibiotics, 2 who received twice daily gentamicin, and 2 others with incomplete antibiotic records were also excluded from the study. The remaining 24 patients received a cephalosporin and a once daily gentamicin dose of 5 mg/kg. Of these 24 patients, four were lost to follow-up, and four had follow-up for less than 3 months and were excluded from the study, leaving 16 patients for review (Table). There were 3 type II, 6 type IIIA IIIA Internet Information Infrastructure Architecture
IIIA Integrated Intelligence Information Application
IIIA International Imaging Industry Association , 5 type IIIB, and 2 type IIIC IIIC International Independent Investigation Commission open fractures. There were 15 men and 1 woman, with an average age of 35 years (range, 28 to 65 years). The average Injury Severity Score (10 was 16 (rang e, 9 to 34). Fractures resulted from crushing injury in 2 patients, gunshot wound in 2, motorcycle accident in 3, pedestrian-car accident in 6, and motor vehicle accident motor vehicle accident Public health A morbid condition that kills 45,000/yr–US; 60% are < age 35; MVAs account for 500,000 hospitalizations and most 20,000 spinal cord injuries, at a cost of $75 billion/yr in 3. Follow-up averaged 15 months (range, 3 to 42 months).
Patients were initially assessed and stabilized in the emergency room by the trauma surgery service, which then consulted orthopaedic surgery. A Betadine dampened sponge was placed over the open wound, and the lower extremity lower extremity
The hip, thigh, leg, ankle, or foot. Also called inferior limb, pelvic limb. was splinted to minimize soft tissue damage. Attempts were made to obtain radiographs before splint splint, rigid or semiflexible device for the immobilization of displaced or fractured parts of the body. Most commonly employed for fractures of bones, a splint may be a first-aid measure that allows the patient to be moved without displacing the injured part, or it application. Intravenous cefazolin (1 g) was administered on arrival to the emergency room. Gentamicin (5 mg/kg) was given if the patient had normal BUN and creatine creatine /cre·a·tine/ (kre´ah-tin) an amino acid occurring in vertebrate tissues, particularly in muscle; phosphorylated creatine is an important storage form of high-energy phosphate. levels, no history of either renal disease Renal disease
Mentioned in: Glycogen Storage Diseases
hypertension High blood pressure Cardiovascular disease An abnormal ↑ systemic arterial pressure, corresponding to a systolic BP of > 160 mm Hg or granulocytopenia, and was not pregnant. After clearance by the trauma surgery service, patients were taken to the operating room operating room
n. Abbr. OR
A room equipped for performing surgical operations. for irrigation irrigation, in agriculture, artificial watering of the land. Although used chiefly in regions with annual rainfall of less than 20 in. (51 cm), it is also used in wetter areas to grow certain crops, e.g., rice. , debridement Debridement Definition
Debridement is the process of removing nonliving tissue from pressure ulcers, burns, and other wounds.
Debridement speeds the healing of pressure ulcers, burns, and other wounds. , and fracture stabilization.
Wound debridement was done in a meticulous fashion. The open wound was extended proximally and distally approximately 5 cm to facilitate visualization and wound debridement. After initial debridement, the wound was irrigated with 9,000 mL of pulsed lavage lavage /la·vage/ (lah-vahzh´)
1. the irrigation or washing out of an organ, as of the stomach or bowel.
2. to wash out, or irrigate.
n. (Stryker, Kalamazoo, Mich). Inspection of the open wound was repeated after the irrigation, and debridement was continued as indicated by wound contamination. At completion of debridement, fractures were stabilized using a 4.5 mm plate, 2 reamed nails, 4 external fixators, and 9 unreamed nails. All but one patient, who had a primary wound closure, were returned to the operating room every 48 hours for repeat irrigation and debridement until the wound was clean, at which time the wound was closed. Additional wound closure techniques consisted of 9 delayed primary closures, 4 rotational tissue transfers, and 2 free tissue transfers. Intravenous administration of antibiotics was continued for 48 hours after the definitive wound closure, except in rotational an d free tissue transfers, for which antibiotics were continued until drains were removed.
Monitoring for gentamicin serum levels consisted of gentamicin trough determination 30 minutes before the third dose. For patients with an elevated gentamicin trough level, the dosage was decreased, and the trough measurement was repeated before the subsequent third dose. Gentamicin-associated nephrotoxicity was assessed by serologic se·rol·o·gy
n. pl. se·rol·o·gies
1. The science that deals with the properties and reactions of serums, especially blood serum.
2. monitoring of renal function consisting of BUN and creatinine levels examined every 2 days. Each patient who was responsive was queried about prodromal signs of ototoxicity (hearing loss, tinnitus Tinnitus Definition
Tinnitus is hearing ringing, buzzing, or other sounds without an external cause. Patients may experience tinnitus in one or both ears or in the head. , and dizziness). Audiograms were not obtained.
After discharge from the hospital, patients were examined 2 weeks postoperatively and every 4 to 6 weeks thereafter until fracture union. Further follow-up was arranged on an independent basis. Signs and symptoms of infection were carefully sought. Superficial infections were defined as infections superficial to bone not requiring surgical intervention. (3) Deep infections were defined as those that communicated with the site of the fracture, necessitating operative irrigation and debridement. (3) Serologic examinations of renal function were not done. Audiograms were not done, but patients were asked about possible prodromal signs of ototoxicity during return clinic examinations.
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 iliac crest
The long, curved upper border of the wing of the ilium. bone grafting Bone Grafting Definition
Bone grafting is a surgical procedure by which new bone or a replacement material is placed into spaces between or around broken bone (fractures) or holes in bone (defects) to aid in healing. 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 ne·crose
intr. & tr.v. ne·crosed, ne·cros·ing, ne·cros·es
To undergo or cause to undergo necrosis.
[Back-formation from necrosis.] . The wound ultimately healed with dressing changes. Our 2 patients who had deep infections required 6 subsequent debridements and a nail removal Nail Removal Definition
Nail removal is a form of treatment that is sometimes necessary following traumatic injuries or recurrent infections in the area of the nail. There are nonsurgical as well as surgical methods of 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 Staphylococcus au·re·us
A bacterium that causes furunculosis, pyemia, osteomyelitis, suppuration of wounds, and food poisoning.
Staphylococcus aureus Staphylococcus pyogenes infection. At 6 months postoperatively, the patient returned with drainage from the abscess abscess, localized inflamation associated with tissue necrosis. Abscesses are characterized by inflamation, which is due to the accumulation of pus in the local tissues, and often painful swelling. location with evidence of a nonunion nonunion /non·union/ (non-un´yun) failure of the ends of a fractured bone to unite.
The failure of a fractured bone to heal normally. . A reamed exchange nailing was done, and the patient was treated with intravenous cefazolin and oral ofloxacin for combined S aureus The aureus (pl. aurei) was a gold coin of ancient Rome valued at 25 silver denarii. The aureus was regularly issued from the 1st century BC to the beginning of the 4th century AD, when it was replaced by the solidus. and Serratia marcescens Serratia marcescens Microbiology The type-species of the gram-negative Serratia, widely present in the environment, and occasional cause of hospital-acquired infections Asssociations Contaminated fluids, equipment, cleaning solutions, hands, ↓ 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).
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 gastrocnemius muscle
see Table 13.
gastrocnemius muscle rupture, gastrocnemius muscle avulsion
the muscle may have torn away from its insertion, in which case the tendon will be slack, or it may be a complete or partial separation transfer. Six weeks after wound closure, a deep infection due to S marcescens and Staphylococcus epidermidis Staphylococcus epidermidis Microbiology A coagulase-negative staphylococcus that comprises up to 80% of clinical isolates Infections by S epidermidis developed. The patient required four subsequent debridements and a modification of antibiotic therapy to intravenous ceftriaxone ceftriaxone /cef·tri·ax·one/ (cef?tri-ak´son) a semisynthetic, ß–resistant, third-generation cephalosporin effective against a wide range of gram-positive and gram-negative bacteria, used as the sodium salt. and vancomycin vancomycin (văn'kōmī`sĭn), antibiotic resembling penicillin in the way it acts. It is derived from the bacterium Streptomyces orientalis, which was isolated from soil of India and Indonesia. to eradicate the infection. The fracture healed 12 months after injury.
Infection after open tibial shaft fractures has been reported in up to 50% of patients. (3-5,8,11) On the basis of several studies showing high levels of staphylococcal staphylococcal
pertaining to Staphylococcus spp.
staphylococcal clumping test
used as a means of measuring the quantity of fibrinogen-split products in a sample of blood. species as well as gram-negative species, treatment of high-energy open fractures has evolved to include cephalosporin and aminoglycoside antimicrobial prophylaxis. (6,8) Most institutions use 1 or 2 g of cefazolin as prophylaxis against gram-positive organisms; however, many institutional differences exist regarding the type, the dose, and dosing interval of aminoglycosides. (3,6,8,11)
Unlike [beta]-lactam antibiotics, aminoglycoside antibiotics have concentration-dependent bactericidal bactericidal /bac·te·ri·ci·dal/ (bak-ter?i-si´d'l) destructive to bacteria.
An agent that destroys bacteria (e.g. activity. As the ratio of peak concentration to minimum inhibitory concentration minimum inhibitory concentration Lab medicine The minimum antibiotic concentration needed to inhibit bacterial growth from a clinical isolate–eg, a bloodborne infection, which is a form of antimicrobial susceptibility testing. Cf Minimum bactericidal concentration. increases, bactericidal activity of aminoglycosides increases. (12,13) Aminoglycosides also show persistent suppression of bacterial growth after antimicrobial exposure, commonly termed the postantibiotic effect postantibiotic effect
the period after antibiotic serum levels have dropped below the minimum inhibitory concentration when no bacterial growth occurs. . The precise mechanism is unknown; however, it has been postulated that aminoglycosides bind irreversibly to bacterial ribosomal subunits, inducing damage to bacteria. (13,14) Furthermore, evidence suggests that the postantibiotic effect is potentiated by increased antibiotic concentrations up to 10 times the minimum inhibitory concentration. (14,15)
Elevated serum trough levels are responsible for the nephrotoxic nephrotoxic /neph·ro·tox·ic/ (nef´ro-tok?sik) destructive to kidney cells.
Toxic, or damaging, to the kidney. effects of aminoglycosides. Nephrotoxicity, the most common adverse effect seen with aminoglycoside usage, results from accumulation of drug in the renal cortex renal cortex
The part of the kidney containing the glomeruli and the proximal and distal convoluted tubules. , causing proximal tubular necrosis tubular necrosis See Acute tubular necrosis. . (15) It has been shown that short-term infusions of aminoglycosides (once daily dosing) result in significantly decreased levels of renal cortical accumulation. (16,17) Ototoxicity is another commonly cited complication associated with aminoglycoside use. In animal studies, uptake of aminoglycosides in inner ear tissues was greater with continuous infusion than with single injection. (18) However, the clearance rate of aminoglycosides is slow, and it is possible that the prolonged exposure time of the sensory hair cells Hair cells
Sensory receptors in the inner ear that transform sound vibrations into messages that travel to the brain.
Mentioned in: Cochlear Implants makes the dosage less important in the etiology of ototoxicity as compared with nephrotoxicity. (18) These findings have been corroborated cor·rob·o·rate
tr.v. cor·rob·o·rat·ed, cor·rob·o·rat·ing, cor·rob·o·rates
To strengthen or support with other evidence; make more certain. See Synonyms at confirm. in clinical studies in which the incidence of ototoxicity was equivalent between once daily dosin g versus multiple dosing of aminoglycosides. (19,20)
Clinical studies using large daily doses of aminoglycosides to treat established infections have shown good clinical responses without an increased complication profile. Koo et al, (21) in a randomized ran·dom·ize
tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es
To make random in arrangement, especially in order to control the variables in an experiment. study evaluating elderly patients with various infections treated with once daily doses (4 mg/kg) of gentamicin or tobramycin tobramycin /to·bra·my·cin/ (to?brah-mi´sin) an aminoglycoside antibiotic derived from a complex produced by Streptomyces tenebrarius, compared with twice daily doses (2 mg/kg) of the same antibiotics, found no statistically significant difference in the clinical effectiveness between the two doses. Also, there was no difference in the incidence of nephrotoxicity between the two groups; however, in patients treated with once daily dosing, there was an increased incidence of nephrotoxicity in those patients whose initial peak serum concentration serum concentration Therapeutics The amount of a drug or other compound in the circulation, both bound to proteins and unbound, the latter of which generally corresponds to the theraepeutically active fraction was greater than 12 mg/L. (21) Prins et al (19) compared once daily dosing of gentamicin (4 mg/kg) with thrice thrice
1. Three times.
2. In a threefold quantity or degree.
3. Archaic Extremely; greatly. daily dosing (1.33 mg/kg) for various infections. The once daily regimen proved significantly less nephrotoxic (59% vs 24%), while preserving bacteriologic bac·te·ri·ol·o·gy
The study of bacteria, especially in relation to medicine and agriculture.
bac·te efficacy. Als o, high-tone audiometry showed no significant differences in hearing between the two groups. (19)
While the use of once daily gentamicin has proven effective in the treatment of established infections, its use as a prophylactic agent in open fractures has been described infrequently. Sorger et al (9) used 6 mg/kg of gentamicin given either once daily or twice daily, combined with cefazolin, for upper and lower extremity Gustilo types II and III open fractures. They found a decreased incidence of infections in patients who received the once daily dose of gentamicin; however, this finding did not reach statistical significance. Two patients who received twice daily gentamicin had transient elevation of serum creatinine, which returned to normal after discontinuance Cessation; ending; giving up. The discontinuance of a lawsuit, also known as a dismissal or a non-suit, is the voluntary or involuntary termination of an action.
DISCONTINUANCE, pleading. A chasm or interruption in the pleading.
2. of antibiotics. No patient showed signs of ototoxicity.
The use of high, once daily dosing of gentamicin has been shown effective in our series of type II and type III open tibial shaft fractures in the prophylaxis against infection. The one superficial pin tract infection in a patient with a type II open fracture responded rapidly to oral antibiotics and improved pin care. Deep infections were seen in two patients (12.5%), one in a type IIIA fracture and one in a type IIIC fracture. There were no deep infections in patients with type II open fractures.
Many factors contribute to infections after open tibial shaft fractures, but higher infection rates are more commonly associated with higher energy injuries. (1,3,11,22-26) Both of our patients who had deep infections sustained high-energy injuries. One patient with a type IIIC open fracture stabilized with an external fixator had a deep wound infection necessitating multiple surgical debridements and intravenous antibiotics. The infection was not unexpected, and the postoperative course was not unusual. Several authors have reported series of open tibial fractures treated with external fixators. Court-Brown et al (22) reported infection in 6 of 37 patients with type IIIA open fractures treated with an external fixator. Other studies of high-energy tibial shaft fractures stabilized with external fixators reported infection rates of 7% to 15%. (23,25)
Our other patient with a deep wound infection sustained a type IIIA open fracture resulting from a gunshot wound and stabilized with a reamed intramedullary nail. The role of reamed intramedullary nails in the treatment of open tibial shaft fractures is controversial; however, several recent studies have shown acceptable infection rates using reamed intramedullary nails for open fractures. Court-Brown et al (22) reported infection in 2 of 27 patients with type III open tibial shaft fractures treated with reamed intramedullary nails. Keating et al, (24) in a randomized study comparing reamed nailing with unreamed nailing, found a slightly higher infection rate in the reamed nail group (4%) than in the unreamed group (2%), though the difference did not reach statistical significance.
Our study has several limitations. It is a retrospective review retrospective review,
a posttreatment assessment of services on a case-by-case or aggregate basis after the services have been performed. of patients given prophylaxis with once daily high-dose gentamicin without a well-established enrollment protocol. During the period under review, patients were given once daily, twice daily, or thrice daily gentamicin as ordered by the different physicians who treated these patients. While this series consists of a fairly homogeneous patient population, multiple surgeons and multiple implants were used. Patient follow-up was also problematic but merely reflects our transient trauma patient population.
Antimicrobial prophylaxis using once daily high-dose gentamicin in conjunction with cefazolin was found to be efficacious in our patients with high-energy open tibial shaft fractures. Once daily dosing of gentamicin permits higher serum peak concentrations and increased bactericidal action due to its concentration-dependent killing and the associated postantibiotic effect. (12-15) Once daily dosing of gentamicin leads to decreased renal accumulation of the drug, potentially decreasing the risk of nephrotoxicity. (16,17) No patient in this review had nephrotoxicity according to serologic monitoring of BUN and creatinine during hospitalization, and no patient showed any prodromal signs of ototoxicity.
We believe that in cases of open tibial shaft fractures, once daily high-dose gentamicin as prophylaxis against infection may be safely administered in patients who have a normal renal panel, are not pregnant, and have no renal disease, hearing loss, or granulocytopenia, without increased risk of nephrotoxicity or ototoxicity. On the basis of these results, we plan to initiate a prospective, multicenter study to further evaluate the role of once daily gentamicin for antimicrobial prophylaxis in open tibial shaft fractures.
(*.) Presented in part at the 17th Annual Meeting of the Southern Orthopaedic Association, Southampton, Bermuda, July 20, 2000.
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A warm drink consisting of wine or ale mixed with sugar, eggs, bread, and various spices, sometimes given to ill persons.
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PTB Partido Trabalhista Brasileiro (Brazilian Labor Party)
PTB Powers That Be
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A tubular endoscope that is inserted through the mouth and into the larynx and that is used for examining the interior of the larynx.
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The fixation of a fractured bone by a splint or plastic dressing.
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TABLE Patient Data in 16 Cases of Open Fractures of the Tibial Shaft Gustilo Fracture Wound Fracture Patient Type Injury Closure Treatment 1 IIIC Crush Rotation External flap fixator 2 IIIA Gunshot Delayed primary Unreamed closure nailing 3 IIIA Pedestrian- Delayed primary Unreamed auto closure nailing 4 II Motorcycle Rotation Unreamed accident flap nailing 5 IIIA Gunshot Delayed primary Reamed closure nailing 6 IIIB Pedestrian- Delayed primary Unreamed auto closure nailing 7 IIIA Motorcycle Delayed primary Unreamed accident closure nailing 8 II Motor vehicle Delayed primary Unreamed accident closure nailing 9 IIIC Pedestrian- Delayed primary External auto closure fixator 10 IIIA Motorcycle Primary Unreamed accident closure nailing 11 IIIB Crush Free flap Reamed nailing 12 II Motor vehicle Delayed primary Unreamed accident closure nailing 13 IIIB Motor vehicle Rotation 4.5 mm accident flap plate 14 IIIB Pedestrian- Free flap External auto fixator 15 IIIB Pedestrian- Rotation Unreamed auto flap nailing 16 IIIA Pedestrian- Delayed primary External auto closure fixator Union Injury Wound Follow-up Time Severity Patient Infection (no) (mo) Score 1 Staphylococcus 42 12 9 epidermidis, Serratia marcescens 2 None 40 2 22 3 None 34 28 13 4 None 17 12 9 5 Staphylococcus 17 9 13 aureus, Serratia marcescens 6 None 15 15 10 7 None 12 4 27 8 None 12 4 13 9 None 11 4 9 10 None 9 8 22 11 None 8 7 9 12 None 7 3.5 34 13 None 5 4 13 14 Pin tract 4 4 9 infection 15 None 3.5 3.5 22 16 None 3 3 22 Subsequent Patient Procedures 1 Irrigation and debridement x 4 2 None 3 Iliac crest bone grafting Exchanged nail Posterolateral iliac crest bone grafting 4 Dynamization Exchanged nail 5 Irrigation and debridement x 2 Exchanged nail Removed nail 6 Dynamization 7 None 8 None 9 None 10 Iliac crest bone grafting 11 Failed free flap with debridement 12 None 13 None 14 Adjusted external fixator 15 None 16 None
RELATED ARTICLE: KEY POINTS
* Once daily high-dose gentamicin in combination with Cefazolin was found to be an effective infection prophylaxis in high-energy open tibial shaft fractures.
* No patient sustained either ototoxicity or nephrotoxicity from once-daily high-dose gentamicin.