SLR - July 2014 - David Larson
Reference: Jenkinson RJ, Kiss A, Johnson S, Stephen DJG, Kreder HJ. Delayed Wound Closure Increases Deep-Infection Rate associated with Lower-Grade Open Fractures. J Bone Joint Surg Am. 2014;96:380-6
Scientific Literature Review
Reviewed By: David Larson, DPM
Residency Program: Franciscan Health System-St Francis Hospital
Podiatric Relevance: For some podiatrists, open fractures are often encountered and whether to primarily close an open fracture or not is an important clinical decision that can affect the outcome for the patient. This study examines this situation and hypothesis that in the right patient and in certain fractures, primarily closing the wound after adequate surgical debridement would reduce the incidence of deep infection.
Methods: In this propensity-matched cohort study, 146 open fractures (73 pairs) were compared between primary closure after surgical debridement and delayed closure after repeat debridement and the incidence of infection between the two groups was analyzed. The data was collected from January 1, 2003 to January 1, 2007 at the author’s institution. A propensity-score algorithm was used which included factors considered important in contributing to deep infection. These factors included age, sex, time to debridement, fracture grade, evidence of contamination in the wound, tibial vs. non-tibial fracture sites, and ASA scores; then a one-to-one matching algorithm was used to pair fractures with a similar propensity for delayed wound closure. The algorithm process identified 73 matched pairs of patients with similar injury characteristics. One person in the pair was closed primarily and the second had a delayed primary closure. Open fractures were included in the study if they were Gustilo-Anderson grade-I, II, or IIIA fractures and had a follow up of at least 12 months. Exclusions included Gustilo-Anderson grade IIIB and IIIC fractures, open hand and pelvic fractures, and death during hospitalization. The Gustilo-Anderson grade was assigned intra-operatively following initial debridement. A deep infection was defined as an infection to the injured bone and deep tissue that required an unplanned surgical incision and drainage greater than two weeks from the injury date. The protocol for antibiotic administration at this institution was IV cefazolin upon arrival to the emergency department and clindamycin for a penicillin allergy. Gentamicin was added for grade III open fracture. Antibiotics were administered for at least 24 hours after final wound closure. Debridement of the wound was performed once an operating room was available and normal saline was used for irrigation via gravity or pulse lavage.
Results: The group that was closed primarily after initial debridement was found to have a total of three deep infections (4.1 percent infection rate) out of the 73 open fractures closed primarily. The delayed closure group had a total of 13 deep infections (17.8 percent infection rate) out of the 73 open fractures with delayed closures. The study demonstrated that patients that were closed primarily at the time of the initial debridement were at a 13.7 percent risk reduction for the development of a deep infection. The patients with the delayed closure had an overall odds ratio of 11 times more likely of developing a deep infection when compared to being closed primarily.
Conclusions: This study demonstrated that in the right patients and patients with low grade Gustilo-Anderson fractures can be closed primarily safely and with less risk of infection. It is important that clinical judgment is used when deciding to close primarily or not, but in the right circumstances this may be safer for the patient and negate the need for a second surgery, especially in a trauma situation.