Session III - Polytrauma

Management of Open Fractures of the Lower Extremity: Do Timing of Operative Treatment and Primary Wound Closure Really Matter?

Michael T. Rohmiller, MD; Sharat Kusuma, BS, MBA; Gordon M. Blanchard, MD; John R. Edwards, MD; Mark P. McAndrew, MD; Marcus F. Sciadini, MD; Kenneth D. Johnson, MD; Vanderbilt University Medical Center, Nashville, Tennessee, USA

Purpose: The appropriate management of open fractures remains one of the most controversial topics in orthopaedic surgery. Historically, open fracture treatment consisted of immediate irrigation and debridement, delayed wound closure, and repeat irrigation and debridement. However, at our institution, we have delayed treatment of open fractures (except grade IIIc) and closed open fracture wounds primarily since 1997. This study attempts to address three primary questions: What is the maximum allowable time to debridement without increasing the risk of infection? Is it practical to perform definitive fixation of the fracture at the index procedure? Is primary closure of the open fracture wound acceptable?

Methods: The medical records of 9500 patients treated by the adult orthopaedic trauma service between 1997 and 2001 at our institution were reviewed. The review was initially performed by query of the orthopaedic trauma database (data collected prospectively at the time of injury and adjusted at each follow-up) and augmented with examination of patient charts. Of those patients, there were 717 records that identified an open fracture of the lower extremity. Further review discovered 475 patients with an open fracture of the femur, tibia, or fibula. Patients were excluded from the study if one of the following criteria were met: death during initial hospitalization, amputation during initial hospitalization, or failure to return for any follow-up. The study group consisted of 370 patients with 390 open fractures (98 grade I, 144 grade II, 96 grade IIIa, 43 grade IIIb, and 9 grade IIIc, according to the Gustillo-Anderson classification) who met the inclusion criteria. A review of the medical records of each patient was performed with specific attention given to the following criteria: time >from injury to initial debridement, time from injury to initial antibiotic dose, presence of preliminary irrigation prior to formal operative irrigation and debridement, fracture grade using the Gustillo-Anderson grading system, type of fixation used, wound closure at index procedure, postoperative antibiotic use, complications at any time, infections, fracture healing, and additional procedures needed. The data were then examined to determine significance of these variables in terms of wound and fracture healing.

Results: The average time from arrival in the emergency department to formal operative debridement was more than 8 hours (range, 0.5 to 120). Primary wound closure was performed for 338 of the 390 fractures (no primary closure in grade IIIb or IIIc fractures). We noted 21 infections (5 superficial, which were treated by antibiotics alone, and 16, which required additional operative procedures). There were 38 cases of delayed union or nonunion which required additional operative procedures.

Discussion and Conclusion: Our figures are comparable to those of historical controls evaluating immediate treatment of open fractures. Patients did not experience increased complications as a result of our management. Therefore, we believe that delayed treatment of open fractures combined with definitive treatment at the index procedure and primary wound closure does not increase complication rates in patients with open fractures.