title: A comparison of more and less aggressive bone debridement protocols for the treatment of open supracondylar femur fractures.
abstract: OBJECTIVE
  This study compared results of aggressive and nonaggressive debridement protocols for the treatment of high-energy, open supracondylar femur fractures after the primary procedure, with respect to the requirement for secondary bone grafting procedures, and deep infection.
  
  
  METHODS
  Retrospective review.
  
  
  METHODS
  Level I and level II trauma centers.
  
  
  METHODS
  Twenty-nine consecutive patients with high-grade, open (Gustilo types II and III) supracondylar femur fractures (OTA/AO 33A and C) treated with debridement and locked plating.
  
  
  METHODS
  Surgeons at 2 different level I trauma centers had different debridement protocols for open supracondylar femur fractures. One center used a more aggressive (MA) protocol in their patients (n = 17) that included removal of all devitalized bone and placement of antibiotic cement spacers to fill large segmental defects. The other center used a less aggressive (LA) protocol in their patients (n = 12) that included debridement of grossly contaminated bone with retention of other bone fragments and no use of antibiotic cement spacers. All other aspects of the treatment protocol at the 2 centers were similar: definitive fixation with locked plates in all cases, IV antibiotics were used until definitive wound closure, and weight bearing was advanced upon clinical and radiographic evidence of fracture healing.
  
  
  METHODS
  Healing after the primary procedure, requirement for secondary bone grafting procedures, and the presence of deep infection.
  
  
  RESULTS
  Demographics were similar between included patients at each center with regard to age, gender, rate of open fractures, open fracture classification, mechanism, and smoking (P > 0.05). Patients at the MA center were more often diabetic (P < 0.05). Cement spacers to fill segmental defects were used more often after MA debridement (35% vs. 0%, P < 0.006), and more patients had a plan for staged bone grafting after MA debridement (71% vs. 8%, P < 0.006). Healing after the index fixation procedure occurred more often after LA debridement (92% vs. 35%, P < 0.003). There was no difference in infection rate between the 2 protocols: 25% with the LA protocol and 18% with the MA protocol (P = 0.63). All patients in both groups eventually healed and were without evidence of infection at an average of 1.8 years of follow-up.
  
  
  CONCLUSIONS
  The degree to which bone should be debrided after a high-energy, high-grade, open supracondylar femur fracture is a matter of surgeon judgment and falls along a continuous spectrum. Based on the results of the current study, the theoretic trade-off between infection risk and osseous healing potential seems to favor an LA approach toward bone debridement in the initial treatment.
  
  
  METHODS
  Therapeutic level III.
authors.affiliation: Department of Orthopaedic Surgery, *Washington University School of Medicine, St Louis, MO; †Harris Methodist Fort Worth Hospital, Fort Worth, TX; and ‡Mayo Clinic, Rochester, MN.
authors.forename: William M
authors.initials: WM
authors.lastname: Ricci
authors.forename: Cory
authors.initials: C
authors.lastname: Collinge
authors.forename: Philipp N
authors.initials: PN
authors.lastname: Streubel
authors.forename: Christopher M
authors.initials: CM
authors.lastname: McAndrew
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Gardner
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001860:Bone Plates / Q000009:adverse effects; D001863:Bone Screws / Q000009:adverse effects; D003646:Debridement / Q000009:adverse effects / Q000379:methods*; D005260:Female; D005264:Femoral Fractures / Q000000981:diagnostic imaging / Q000601:surgery*; D005269:Femur / Q000000981:diagnostic imaging / Q000601:surgery; D005593:Fracture Fixation, Internal / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D017102:Fracture Healing; D005597:Fractures, Open / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016459:Prosthesis-Related Infections / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control; D011859:Radiography; D012189:Retrospective Studies; D016896:Treatment Outcome; D014481:United States