title: Delayed wound closure increases deep-infection rate associated with lower-grade open fractures: a propensity-matched cohort study.
abstract: BACKGROUND
  Primary closure of skin wounds after debridement of open fractures is controversial. The purpose of the present study was to determine whether primary skin closure for grade-IIIA or lower-grade open extremity fractures is associated with a lower deep-infection rate.
  
  
  METHODS
  We identified 349 Gustilo-Anderson grade-I, II, or IIIA fractures treated at our level-I academic trauma center from 2003 to 2007. Eighty-seven injuries were treated with delayed primary closure, and 262 were treated with immediate closure after surgical debridement. After application of a propensity score-matching algorithm to balance prognostic factors, 146 open fractures (seventy-three matched pairs) were analyzed.
  
  
  RESULTS
  After application of a propensity score-matching algorithm with adjustment for age, sex, time to debridement, American Society of Anesthesiologists (ASA) class, fracture grade, evidence of gross contamination, and a tibial fracture rather than a fracture at another anatomic site, the two treatment groups were compared with respect to the prevalence of infection. Deep infection developed at the sites of three of the seventy-three fractures treated with immediate closure (infection rate, 4.1%; 95% confidence interval [CI], 0.86 to 11.5) compared with thirteen in the matched group of seventy-three fractures treated with delayed primary closure (infection rate, 17.8%; 95% CI, 9.8 to 28.5) (McNemar test, p = 0.0001).
  
  
  CONCLUSIONS
  Immediate closure of carefully selected wounds by experienced surgeons treating grade-I, II, and IIIA open fractures is safe and is associated with a lower infection rate compared with delayed primary closure.
authors.affiliation: Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Suite MG-321, Toronto, ON M4N 3M5, Canada. E-mail address for R.J. Jenkinson: richard.jenkinson@sunnybrook.ca.
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Jenkinson
authors.affiliation: Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Suite MG-321, Toronto, ON M4N 3M5, Canada. E-mail address for R.J. Jenkinson: richard.jenkinson@sunnybrook.ca.
authors.forename: Alexander
authors.initials: A
authors.lastname: Kiss
authors.affiliation: Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Suite MG-321, Toronto, ON M4N 3M5, Canada. E-mail address for R.J. Jenkinson: richard.jenkinson@sunnybrook.ca.
authors.forename: Samuel
authors.initials: S
authors.lastname: Johnson
authors.affiliation: Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Suite MG-321, Toronto, ON M4N 3M5, Canada. E-mail address for R.J. Jenkinson: richard.jenkinson@sunnybrook.ca.
authors.forename: David J G
authors.initials: DJ
authors.lastname: Stephen
authors.affiliation: Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Suite MG-321, Toronto, ON M4N 3M5, Canada. E-mail address for R.J. Jenkinson: richard.jenkinson@sunnybrook.ca.
authors.forename: Hans J
authors.initials: HJ
authors.lastname: Kreder
mesh_terms: D000328:Adult; D000465:Algorithms; D015331:Cohort Studies; D003646:Debridement; D005260:Female; D005597:Fractures, Open / Q000145:classification / Q000150:complications* / Q000601:surgery*; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D019637:Orthopedic Procedures / Q000379:methods; D057216:Propensity Score; D012189:Retrospective Studies; D013530:Surgical Wound Infection / Q000453:epidemiology* / Q000209:etiology*; D013997:Time Factors; D014945:Wound Healing