Table I.
Characteristics of eligible studies for quantitative analysis
| Study/characteristic | Details |
|---|---|
| 01_Henry et al13 (1990) | |
| Study title | The role of local antibiotic therapy in the management of compound fractures |
| Objective | Effect of tobramycin PMMA beads in open fracture wounds for temporary wound coverage |
| Setting | Single centre in the United States (Humana Hospital, University of Louisville) |
| Level of evidence | Low |
| Study design | Retrospective cohort study |
| Selection of participants | Consecutive |
| Follow-up interval | Control group: 20.9 mths (6 to 50); intervention group: 17.5 mths (6 to 51) |
| Inclusion criteria | Open limb fractures |
| Number of open fractures for analysis | 404 |
| Gustilo–Anderson | I: 127 (31%); II: 153 (39%); III: 124 (31%) |
| Report of relevant prognostic factors | Partially |
| Systemic antibiotics in both groups | Yes, penicillin, cefazolin, tobramycin |
| Intervention group: local antibiotics | Tobramycin PMMA beads |
| Matching of cohorts | Yes |
| Outcome parameter(s) | Wound infection and/or bone infection |
| Definition of infection? | Incomplete; infection = identification of pathogen in culture |
| 02_Ostermann et al14 (1993) | |
| Study title | The role of local antibiotic therapy in the management of compound fractures |
| Objective | Effect of tobramycin PMMA beads in open fracture wounds for temporary wound coverage |
| Setting | Single centre in the United States (University of Louisville) |
| Level of evidence | Low |
| Study design | Retrospective cohort study |
| Selection of participants | Consecutive |
| Follow-up interval | Not reported |
| Inclusion criteria | Open limb fractures |
| Number of open fractures for analysis | 704 |
| Gustilo–Anderson | I: 198 (28%); II: 259 (37%); III: 247 (35%) |
| Report of relevant prognostic factors | Partially |
| Systemic antibiotics in both groups | Yes, penicillin, cefazolin, tobramycin |
| Intervention group: local antibiotics | Tobramycin PMMA beads |
| Matching of cohorts | Similar case-matching reported: grade open fracture, age, gender, fracture location, follow-up interval; no matching in wound closure |
| Outcome parameter(s) | Wound infection and/or bone infection |
| Definition of infection? | Incomplete; infection = identification of pathogen in culture; bone infection = “deep bony infection occurring after 6 weeks” |
| 03_Ostermann et al15 (1995) | |
| Study title | Local antibiotic therapy for severe open fractures. A review of 1085 consecutive cases |
| Objective | Effect of tobramycin PMMA beads in open fracture wounds for temporary wound coverage |
| Setting | Single centre in the United States (University of Louisville) |
| Level of evidence | Low |
| Study design | Retrospective cohort study |
| Selection of participants | Consecutive |
| Follow-up interval | Not reported |
| Inclusion criteria | Open limb fractures |
| Number of open fractures for analysis | 1085 |
| Gustilo–Anderson | I: 279 (26%); II: 364 (34%); III: 442 (41%) |
| Report of relevant prognostic factors | Partially |
| Systemic antibiotics in both groups | Yes, penicillin, cefazolin, tobramycin |
| Intervention group: local antibiotics | Tobramycin PMMA beads |
| Matching of cohorts | Similar case-matching reported: grade open fracture, age, gender, fracture location, follow-up interval; no matching in wound closure |
| Outcome parameter(s) | Wound infection and/or bone infection |
| Definition of infection? | Not reported |
| 04_Keating et al16 (1996) | |
| Study title | Reamed nailing of open tibial fractures: does the antibiotic bead pouch reduce the deep infection rate? |
| Objective | Determine whether addition of the bead pouch to a standard protocol of wound management of open fractures was associated with a concomitant reduction in the rate of deep infection |
| Setting | Single centre in the United Kingdom |
| Level of evidence | Low |
| Study design | Retrospective cohort study |
| Selection of participants | Consecutive: first control (historical group), then intervention group |
| Follow-up interval | 23 mths (12 to 50) |
| Inclusion criteria | Grade II and III open tibial fractures |
| Number of open fractures for analysis | 78 |
| Gustilo–Anderson | II: 38 (49%); III: 40 (51%) |
| Report of relevant prognostic factors | Partially |
| Systemic antibiotics in both groups | For 72 hrs: cefazolin every 8 hrs; grade III fracture: additional gentamicin |
| Intervention group: local antibiotics | Tobramycin PMMA beads |
| Matching of cohorts | Similar case-matching reported: fracture comminution, age, gender, mean time to wound coverage |
| Outcome parameter(s) | Deep infection and/or nonunion |
| Definition of infection? | Incomplete: “presence of a purulent discharge, with bony involvement evident at the time of surgical debridement” |
| 05_Moehring et al17 (2000) | |
| Study title | Comparison of antibiotic beads and intravenous antibiotics in open fractures |
| Objective | Efficacy of antibiotic-impregnated beads compared with conventional intravenous antibiotics in the treatment of open fractures |
| Setting | Single centre in the United States (University of California) |
| Level of evidence | Moderate |
| Study design | Randomized prospective study |
| Selection of participants | Consecutive enrolment not possible because patients declined to consent or inadvertently were omitted |
| Follow-up interval | 15 mths (12 to 27) |
| Inclusion criteria | Grade II and IIIA/B open long-bone fracture |
| Number of open fractures for analysis | 62 |
| Gustilo–Anderson | Not reported |
| Report of relevant prognostic factors | No |
| Systemic antibiotics in both groups | Cefazolin + aminoglycoside or anaerobic coverage or both added for Grade IIIA/B fractures |
| Intervention group: local antibiotics | Tobramycin PMMA beads; no further systemic antibiotics |
| Control group: additional antibiotics | Yes, intravenous cephalosporin and gentamicin until wound coverage |
| Matching of cohorts | Similar case-matching reported: fracture comminution, age, gender, time to wound coverage |
| Outcome parameter(s) | Infection |
| Definition of infection? | Incomplete: “Persistent drainage, that was positive on culture, from an open fracture site or wound that had broken down” |
| Further information | A third group of 13 fractures was not randomized and received both local and systemic antibiotics (due to limb saving or other reasons). This group was not taken into consideration for this meta-analysis. |
| 06_Ziran et al20 (2004) | |
| Study title | Intramedullary nailing in open tibial fractures: a comparison of two techniques |
| Objective | Comparison of reamed and unreamed tibial nailing in terms of union and infection rate; subgroup analysis: effect of antibiotic beads in IIIIB open tibial fractures |
| Setting | United States, not reported if single or multicentre trial |
| Level of evidence | Very low |
| Study design | Retrospective cohort study |
| Selection of participants | Consecutive |
| Follow-up interval | Not reported |
| Inclusion criteria | Grade IIIB open tibial fractures for subgroup analysis |
| Number of open fractures for analysis | 28 |
| Gustilo–Anderson | III: 28 (100%) |
| Report of relevant prognostic factors | No |
| Systemic antibiotics in both groups | Penicillin, cefazolin, and gentamicin |
| Intervention group: local antibiotics | Tobramycin PMMA beads |
| Matching of cohorts | Similar case-matching for all 51 fractures stated but no detailed information given |
| Outcome parameter(s) | Infection |
| Definition of infection? | None |
| Further information | In total, 51 open tibial fractures investigated: 22 reamed and 29 unreamed. In reamed IIIB open tibial fractures, PMMA beads were applied to wound. Just 28 IIIB open tibial fractures are considered in this systematic review. Level of evidence rated very low because prophylactic effect of local antibiotics in open fractures was investigated in just a small cohort. |
| 07_Singh et al18 (2015) | |
| Study title | Surgical site infection in high-energy periarticular tibial fractures with intra-wound vancomycin powder: a retrospective pilot study |
| Objective | Assess the efficacy of intraoperative vancomycin powder administration on preventing deep surgical site infection |
| Setting | Single centre in the United States (Vanderbilt Orthopaedic Institute) |
| Level of evidence | Very low |
| Study design | Retrospective cohort study |
| Selection of participants | Consecutive |
| Follow-up interval | Average not reported (minimum 6 mths) |
| Inclusion criteria | Articular tibial fractures, adult, staged fixation with > 5 days after injury |
| Number of open fractures for analysis | 26 |
| Gustilo–Anderson | Not reported |
| Report of relevant prognostic factors | Partially |
| Systemic antibiotics in both groups | Cefazolin every 8 hrs for 24 hrs |
| Intervention group: local antibiotics | 1 g vancomycin powder into surgical wound at time of definitive fixation |
| Matching of cohorts | Similar case-matching for age, gender, smoking, diabetes, fracture location (of all 93 cases) |
| Outcome parameter(s) | Deep surgical site infection |
| Definition of infection? | Surgical site infection not specified |
| Further information | In total, 93 tibial fractures analyzed. For this review, only the 26 open fractures were taken into account. Level of evidence rated very low because prophylactic effect of local antibiotics in open fractures was investigated in just a small cohort. |
| 08_Lawing et al19 (2015) | |
| Study title | Local injection of aminoglycosides for prophylaxis against infection in open fractures |
| Objective | Determine efficacy of local aminoglycosides (gentamicin and tobramycin), in conjunction with systemic antibiotics, to lower the prevalence of infection in patients with open fractures |
| Setting | Single centre in the United States (University of North Carolina) |
| Level of evidence | Moderate |
| Study design | Retrospective cohort study |
| Selection of participants | Consecutive |
| Follow-up interval | Control group: 12.5 mths; intervention group: 11.3 mths |
| Inclusion criteria | Open fractures |
| Number of open fractures for analysis | 351 |
| Gustilo–Anderson | I: 44 (12%); II: 139 (40%); III: 168 (48%) |
| Report of relevant prognostic factors | Yes (very detailed) |
| Systemic antibiotics in both groups | Cefazolin; in grade III fractures gentamicin added; in contaminated fractures penicillin added |
| Intervention group: local antibiotics | Local aminoglycoside injection after wound closure |
| Matching of cohorts | Similar case-matching for age, gender, polytrauma; multivariate analysis was performed to adjust for potential differences for confounding variables |
| Outcome parameter(s) | Infection |
| Definition of infection? | CDC definition of superficial and deep infection |
PMMA, poly(methyl methacrylate); CDC, Centers for Disease Control and Prevention