Session X1 - Tibia

Sat., 10/22/05 Tibia, Paper #46, 10:45 am

Safety of Primary Closure of Soft Tissue Wounds in Open Fractures

Farhad O. Moola, MD (n); Duncan Jacks, MD (n);
Rudolph Reindl, MD, FRCSC (n); Greg K. Berry, MD, FRCSC (n);
Edward J. Harvey, MD, MSc, FRCSC (a-Synthes);
McGill University Health Centre, Montreal, Quebec, Canada

Background: The current standard of care is to leave traumatic wounds open after initial emergent surgical debridement. Treatment at our institution has evolved to immediate closure of all open wounds after adequate irrigation and debridement. Reasons for this approach include advancements in orthopaedic surgery that provide the ability to provide safe and efficient treatment of open fractures as well as limitations in operating room resources.

Purpose: Is immediate primary closure of open fracture wounds a safe practice or does this practice increase the incidence of deep infections and delayed unions/nonunions?

Methods: The study reviewed all open fractures presenting to a level 1 trauma center over a 5-year study period. The patients were followed until fracture union or resolution of their complication. Multiple variables were examined, including patient demographics, mechanism of injury, fracture location, Gustilo classification, time to antibiotic administration, surgical debridement and wound closure, and, finally, method of wound closure. Outcome measurement included infection or union problems.

Results: Of the 297 open fractures, 255 (86 %) were closed immediately after irrigation and debridement. Grades 3a, 3b, and 3c open fractures accounted for 24.2% of cases. The superficial infection rate of primary closure was 10.9%. All cases resolved with oral antibiotics. The combined deep infection and osteomyelitis rate was 4.7%. Neither region of injury, Gustilo grade, velocity of trauma, nor time to primary closure had a significant influence on the incidence of infection.

Conclusion: There was neither an increase in deep infection nor delayed union/nonunion with immediate primary closure. The benefits of immediate primary closure include a decreased requirement for repeat debridements and soft-tissue procedures, thereby minimizing surgical morbidity, hospital stay, and cost of treatment. Primary closure may be a safe practice and could be accepted as a viable treatment plan in the care of open fractures.

If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.