Sat., 10/6/12 Femur/Tibial Fx/Knee Injuries, PAPER #73, 8:35 am OTA-2012
A Comparison of More and Less Aggressive Bone Débridement Protocols for the Treatment of Open Supracondylar Femur Fractures
William M. Ricci, MD1; Cory A. Collinge, MD2; Philipp N. Streubel, MD1;
Christopher M. McAndrew, MD1; Michael J. Gardner, MD1;
1Washington University School of Medicine, Saint Louis, Missouri, USA;
2Harris Methodist Fort Worth Hospital, Fort Worth, Texas, USA
Background/Purpose: Modern treatment of high-energy open fractures calls for one or more initial débridements followed by definitive fixation. Aggressive débridement of devitalized or marginally vital bone theoretically minimizes infection risk but may lead to segmental bone defects that require staged bone grafting. Less aggressive bone débridement may increase the risk of infection, but leaves behind more bone for potential healing. This study compared results of aggressive and nonaggressive débridement protocols for the treatment of high-energy open supracondylar femur fractures with regard to deep infection, healing after the primary procedure, and requirement for secondary bone-grafting procedures.
Methods: Surgeons at two different Level I trauma centers had different débridement protocols for open supracondylar femur fractures. One center utilized a More Aggressive protocol that included removal of all devitalized bone and placement of antibiotic cement spacers to fill large segmental defects. The other center usd a Less Aggressive protocol that included débridement of only grossly contaminated bone with retention of other bone fragments and no use of antibiotic cement spacers. Other aspects of treatment protocols at the two centers were similar: definitive fixation was with locked plates in all cases; IV antibiotics were used until definitive wound closure; and weight bearing was advanced upon clinical and radiographic evidence of fracture healing. 17 consecutive patients treated at the More Aggressive protocol center (average age, 50 years; range, 30-78) and 12 at the Less Aggressive protocol center (average age, 53 years; range, 27-80) were retrospectively reviewed. Demographics were similar (P >0.05) between included patients at each center with regard to age, gender, frequency of open and closed fractures, open fracture grade, mechanism, and smoking. Patients at the More Aggressive center were more often diabetic and had higher body mass index (P >0.05).
Results: Cement spacers to fill segmental defects were used more often after More Aggressive débridement (47% vs 0%) and more patients had a plan for staged bone grafting after More Aggressive débridement (71% vs 8%) (P <0.006). Healing after the index fixation procedure occurred more often after Less Aggressive débridement (92% vs 35%) (P <0.003). There was no difference in infection rate between the two protocols: 25% with the Less Aggressive protocol; and 18% with the More Aggressive protocol (P = 0.63). All patients in both groups eventually healed and were without evidence of infection at an average of 1.8 years of follow-up.
Conclusion: The degree to which bone should be débrided after open fracture is a matter of surgeon judgment. The theoretic tradeoff between infection risk and osseous healing potential, based on the results of the current study, seems to favor less aggressive débridement for the initial treatment of high-energy, high-grade, open supracondylar femur fractures treated with locked plating. Leaving devitalized bone in the face of open fracture may be considered heresy, but may also provide better results than aggressive débridement.
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• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.