title: Timing of wound closure in open fractures based on cultures obtained after debridement.
abstract: BACKGROUND
  The timing of wound closure in open fractures has remained an inexact science. Numerous recommendations have been made for the management of these injuries regarding the optimal time to perform competent wound closure, with all advice based on subjective parameters. The purpose of this study was to determine the utility of a prospective protocol with use of wound cultures obtained after irrigation and debridement as a guide to the timing of wound closure following an open fracture of an extremity.
  
  
  METHODS
  Four hundred and twenty-two open fractures had emergency irrigation and debridement, fracture stabilization, and open wound management. Wound cultures were obtained for aerobic and anaerobic analysis following debridement. At forty-eight hours after debridement, patients were again returned to surgery. If the initial culture results were positive, a repeat irrigation and debridement was carried out, and additional cultures were obtained after debridement. This procedure was repeated, and the wound was not closed until negative culture results were achieved.
  
  
  RESULTS
  Of the 422 open fractures, 346 were available for long-term follow-up. The overall deep infection rate was 4.3%. Gustilo Type-II fractures had a deep infection rate of 4%, and Type-III fractures had an infection rate of 5.7%. Type-III fractures demonstrated differences among the fracture patterns within this type, as infection developed in 1.8% of Type-IIIA injuries, 10.6% of Type-IIIB fractures, and 20% of Type-IIIC fractures. Fractures requiring multiple debridement procedures and those in patients with diabetes or an increased body mass index demonstrated higher rates of infection. With the numbers studied, fractures in which the wound was closed in the presence of positive cultures (a protocol breach) did not have a significantly increased risk of deep infection (p = 0.0501).
  
  
  CONCLUSIONS
  The use of this standardized protocol was shown to achieve a very low rate of deep infection compared with historical controls. An increased number of irrigation and debridement procedures are required to achieve this improved outcome.
  
  
  METHODS
  Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.
authors.affiliation: Department of Orthopaedic Surgery, Saint Louis University, 3635 Vista Avenue, Saint Louis, MO 63110, USA. lenarzcj@slu.edu
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Lenarz
authors.forename: J Tracy
authors.initials: JT
authors.lastname: Watson
authors.forename: Berton R
authors.initials: BR
authors.lastname: Moed
authors.forename: Heidi
authors.initials: H
authors.lastname: Israel
authors.forename: J Daniel
authors.initials: JD
authors.lastname: Mullen
authors.forename: James B
authors.initials: JB
authors.lastname: Macdonald
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D003646:Debridement; D005260:Female; D005597:Fractures, Open / Q000150:complications* / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D018709:Statistics, Nonparametric; D007507:Therapeutic Irrigation; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology*; D014946:Wound Infection / Q000188:drug therapy / Q000209:etiology* / Q000601:surgery
chemical_list: D000900:Anti-Bacterial Agents