Secondary Analyses from the PREP-IT Trial

Surgical site infections (SSIs) pose a perennial challenge to orthopaedic surgeons treating patients with fractures. This month, JBJS is proud to publish a supplement entitled “Secondary Analyses from the PREP-IT Trial,” the result of the collaboration between the Aqueous-PREP (A Pragmatic Randomized Trial Evaluating Preoperative Aqueous Antiseptic Skin Solutions in Open Fractures) and PREPARE (A Pragmatic Randomized Trial Evaluating Preoperative Alcohol Skin Solutions in Fractured Extremities) trials. This combined effort represents one of the largest prospectively collected datasets to measure many aspects of practice variability within modern fracture management. Independently published, the Aqueous-PREP1 and PREPARE trials2 answered the fundamental question of whether an iodine or chlorhexidine aseptic skin solution reduces SSIs and/or unplanned reoperations in patients with a fracture. Aqueous-PREP enrolled 1,683 open fractures of the upper or lower extremities and found no difference in the rate of SSIs or return to the operating room in patients who received aqueous 10% povidone-iodine versus aqueous 4% chlorhexidine gluconate as surgical skin antisepsis. The PREPARE trial compared the effect of surgical skin preparation with 0.7% iodine povacrylex in 74% isopropyl alcohol versus 2% chlorhexidine gluconate in 70% isopropyl alcohol on the rate of SSIs or unplanned reoperations in 6,785 patients with closed fractures and 1,700 patients with open fractures. The trial demonstrated no difference in the risk of infection between the 2 treatments in patients with open fractures. However, among patients with a closed fracture, those who received the iodine povacrylex solution had a significantly lower infection rate. This supplement combines the 2 trial datasets and asks an inclusive, but not exhaustive, number of other questions regarding the modern management of fractures in patients. The supplement is organized to take the reader through many of the daily clinical decision points with which providers are faced, such as: Do hospital-based infection prevention strategies, such as a preoperative scrub and nasal decolonization, impact infection? What impact does the type, duration, and start time of prophylactic antibiotics have on infection rates? Does the use of temporizing external fixators impact infection? Does the preparation solution have an impact on nonunion rates? And, should the patient become infected, what organisms would we see, how soon would they develop, and what is the current practice of medical treatment for these infections? Additionally, we explore other topics such as the impact of socioeconomic factors, race, gender, and food deserts on infection development. Our authors also explore the predictability of the classic Gustilo-Anderson classification system and compare this with the recently modified Orthopaedic Trauma Association Open Fracture Classification system in order to refine the ways in which we communicate about and study these patients. It is our hope that these studies will aid in daily clinical decision-making, spark interest in further lines of research, and, above all, improve fracture care for patients everywhere.