Primary Wound Closure After Open Fracture: A Prospective Cohort Study Examining Nonunion and Deep Infection
Angela V Scharfenberger1, Khaled Alabassi, Stephanie Smith
1Departments of *Surgery; †Infectious Diseases; and ‡Physical Therapy, University of Alberta, Edmonton, AB, Canada.
Objectives:
Determine the proportion of subjects developing deep infection or nonunion after primary wound closure of open fractures (humerus, radius/ulna, femur, and tibia/fibula). Secondarily, a matched-series analysis compared outcomes with subjects who underwent delayed wound closure.
Design:
Prospective cohort between 2009 and 2013 of subjects undergoing primary closure.
Setting:
Trauma center.
Participants:
Eighty-three (84 fractures) subjects were enrolled. Eighty-two (99%) subjects (83 fractures) provided follow-up data. Matching (age, sec, fracture location, and grade) was performed using study data of delayed wound closure undertaken at the same center between 2001 and 2009 (n = 68 matched subjects).
Intervention:
Primary wound closure occurred when the fracture grade was Gustilo grade 3A or lower and the wound deemed clean at initial surgery. Standardized evaluations occurred until the fracture(s) healed; phone interviews and chart reviews were also undertaken at 1 year.
Main Outcome Measurements:
Deep infection is defined as infection requiring unplanned surgical debridement and/or sustained antibiotic therapy after wound closure; nonunion is defined as unplanned surgical intervention after definitive wound closure or incomplete radiographic healing 1-year after fracture.
Results:
Three (4%) subjects had deep infections, whereas 10 (12%) subjects developed nonunion in the primary closure cohort. In the matched analyses [n = 68 pairs; (136 subjects)], the primary closure cohort had fewer deep infections [n = 3 (4%) vs. n = 6 (9%)] and nonunions [n = 9 (13%) vs. n = 19 (29%)] than the delayed closure cohort (P < 0.001).
Conclusions:
Primary wound closure after an open fracture appears acceptable in appropriately selected patients and may reduce the risk of deep infection and nonunion compared with delayed closure; a definitive randomized trial is needed.
Level Of Evidence:
Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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