Immediate primary skin closure in type-III A and B open fractures

Abstract

Between June 1999 and May 2003 we undertook direct primary closure of the skin wounds of 173 patients with Gustilo and Anderson grade-IIIA and grade-IIIB open fractures. These patients were selected from a consecutive group of 557 with type-III injuries presenting during this time. Strict criteria for inclusion in the study included debridement within 12 hours of injury, no sewage or organic contamination, no skin loss either primarily or secondarily during debridement, a Ganga Hospital open injury skin score of 1 or 2 with a total score of ten or less, the presence of bleeding skin margins, the ability to approximate wound edges without tension and the absence of peripheral vascular disease. In addition, patients with polytrauma were excluded. At a mean follow-up of 6.2 years (5 to 7), the outcome was excellent in 150 (86.7%), good in 11 (6.4%) and poor in 12 (6.9%). A total of 33 complications occurred in 23 patients including superficial infection in 11, deep infection in five and the requirement for a secondary skin flap in three. Six patients developed nonunion requiring further surgery, one of whom declined additional measures to treat an established infected nonunion. Immediate skin closure when performed selectively with the above indications proved to be a safe procedure.

Attempting primary closure for all open fractures: the effectiveness of an institutional protocol

“…Furthermore, use of this simple protocol leads to a higher percentage of primary closures and equivalent postoperative complication rates for type III injuries compared with a more complex protocol previously suggested. 13 In our series, only open femur fractures and deep infections were independently correlated with delayed union and nonunion. These findings are understandable given that open femur fractures are associated with high-energy mechanisms and soft tissue disruption, while deep infection compromises bone formation.…”

“…The only published prospective study evaluating a wound closure protocol for open fractures is by Rajasekaran and colleagues, 13 who used a combination of the injury severity score, Ganga Hospital total and several other specific criteria to determine whether to perform primary closure in 557 patients with Gustillo-Anderson type III open fractures. Additional criteria that ruled out primary closure included hand and foot injuries; hemodynamic compromise; sewage or farmyard contamination; and several preexisting conditions, such as peripheral vascular disease, drug-dependent diabetes mellitus and connective tissue disorders.…”

“…12 Despite the accumulation of literature evaulating the benefits of different treatment strategies, very little information exists regarding effective protocols involving primary closure for open fractures. Although evaluation of immediate skin closure has been previously reported, 13 this study was limited to Gustillo-Anderson 14 type III injuries and used a complex list of inclusion criteria. The present study evaluates the effectiveness of a simplified treatment protocol advocating the immediate closure of all types of open fractures when possible.…”

Outcomes of intramedullary nailing for open fractures of the tibial shaft

“…[43][44][45] Evidence suggests that nosocomial infections are the cause of osteomyelitis rather than the index traumatic event. 46 Open fractures were traditionally left open so as to allow for wound drainage and inspection, and primary wound closure was forbidden due to the fear of osteomyelitis.…”

Early versus Late Flap Coverage for Open Tibial Fractures

“…5 Immediate skin closure for Gustilo grade-IIIA and -IIIB open tibial fractures achieved good results. 20 Patients with severe open tibial fractures tend to have multiple injuries. 21 Haemodynamically unstable patients are unable to withstand the long operation required for immediate 'fix and flap' procedures.…”