[Optimal timing of wound closure in severe open fractures with temporary coverage by skin substitute]

In a consecutive series of 1085 open fractures treated at the University of Louisville Level I Trauma Center from May 1983 to July 1992, 381 severe compound fractures in 335 patients were managed with the antibiotic bead pouch technique. There were 27 grade I (marked swelling, compartment syndrome), 115 grade II and 239 grade III open fractures (94 type IIIA, 114 type IIIB and 31 type IIIC). These fractures were managed with early administration of broad spectrum antibiotics, copious wound irrigation, serial debridements and external skeletal stabilization. Tobramycin-PMMA-beads were placed in the wound and porous plastic film (Opsite) covered the soft tissue defect. This dressing was changed every 48 to 72 hours until wound coverage/closure could be obtained. Infection rate either on an acute or chronic basis was 2.6% in grade II open fractures and 8.4% in grade III compound fractures. There was no infected wound or bone in the grade I category. Those fractures which did not develop an infection were closed at a mean time of 7.6 days; those which developed an infection were closed at a mean time of 17.9 days. The difference was statistically highly significant (p < 0.001). When severe open fractures are managed with the antibiotic bead pouch technique, wound closure should be obtained within one week to prevent infectious complications.