This post comes from Roman M. Natoli, MD, PhD. He is a co-author of the Prognostic Level I multicenter study in the new issue of JBJS, Infection and Nonunion Rates in Open Fractures: Description of 6,042 Fractures from the FLOW and PREP-IT Trials.
Dr. Natoli shares what led him to get involved in this important investigative work, key highlights of the research, and his thoughts on future directions. His post is part of a new series on OrthoBuzz, “Author 360,” providing insights and author perspectives on featured JBJS content.
The first law of orthopaedic trauma: keep your bones in your skin. For those of us who treat open fractures, we understand all too well the devastating consequences these injuries can have—particularly when complications like infection and nonunion arise. My involvement with this research began in 2018, as a site investigator for the PREP-IT studies, although the data presented in our recent study also include findings from the FLOW trial, which dates back to 2009.
While preparing grants and manuscripts over the years, I often found myself searching for citations on infection and nonunion rates in fractures. Most available studies were retrospective, limited to a small number of centers, and varied widely in outcome definitions and sample sizes. It became clear that the PREP-IT dataset addressed many of these limitations through 2 robust trials (Aqueous-PREP and PREPARE-Open). The fact that the FLOW trial was coordinated by the same methods center using consistent outcome definitions was a fortunate alignment—and from there, the project gained momentum.
We ultimately compiled data on 6,042 fractures from multiple centers, all prospectively collected and analyzed using standardized, contemporary definitions. This allowed us to generate accurate point estimates and confidence intervals for infection and nonunion rates across various anatomical locations and fracture classifications. With the help of my co-authors, we developed intuitive data visualizations, including detailed tables, a skeletal heat map, and an interactive online tool. This tool enables clinicians to input fracture location and type to receive estimated risks of infection and nonunion up to 1-year post-injury.
One of the most clinically relevant findings is that infection and nonunion rates have remained relatively unchanged over the past several decades. This doesn’t necessarily mean our treatments haven’t improved—it may reflect the increasing complexity of cases due to aging populations, comorbidities, and more severe injuries. Read the study here.
Looking ahead, I see this research as a foundation for future studies aimed at reducing complications. Yet, from a population health perspective, I’m increasingly drawn to the question: how can we prevent these injuries in the first place? Ultimately, the goal remains simple—keep the bones in the skin.
R
oman M. Natoli, MD, PhD is an orthopaedic surgeon at Indiana University School of Medicine in Indianapolis. He also serves as JBJS Associate Editor for Infection.
Read the study at JBJS.org: Infection and Nonunion Rates in Open Fractures. Description of 6,042 Fractures from the FLOW and PREP-IT Trials
Additional perspective on this study is provided by Thomas A. DeCoster, MD in a new commentary at JBJS.org: Open Fractures. Still Risky After All These Years
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