Delayed debridement of severe open fractures is associated with a higher rate of deep infection.

This study explores the relationship between delay to surgical debridement and deep infection in a series of 364 consecutive patients with 459 open fractures treated at an academic level one trauma hospital in North America. The mean delay to debridement for all fractures was 10.6 hours (0.6 to 111.5). There were 46 deep infections (10%). There were no infections among the 55 Gustilo-Anderson grade I open fractures. Among the grade II and III injuries, a statistically significant increase in the rate of deep infection was found for each hour of delay (OR = 1.033: 95% CI 1.01 to 1.057). This relationship shows a linear increase of 3% per hour of delay. No distinct time cut-off points were identified. Deep infection was also associated with tibial fractures (OR = 2.44: 95% CI 1.26 to 4.73), a higher Gustilo-Anderson grade (OR = 1.99: 95% CI 1.004 to 3.954), and contamination of the fracture (OR = 3.12: 95% CI 1.36 to 7.36). These individual effects are additive, which suggests that delayed debridement will have a clinically significant detrimental effect on more severe open fractures. Delayed treatment appeared safe for grade 1 open fractures. However, when the negative prognostic factors of tibial site, high grade of fracture and/or contamination are present we recommend more urgent operative debridement.

Determinants of functional outcome after simple and complex acetabular fractures involving the posterior wall.

We have evaluated the functional, clinical and radiological outcome of patients with simple and complex acetabular fractures involving the posterior wall, and identified factors associated with an adverse outcome. We reviewed 128 patients treated operatively for a fracture involving the posterior wall of the acetabulum between 1982 and 1999. The Musculoskeletal Functional Assessment and Short-Form 36 scores, the presence of radiological arthritis and complications were assessed as a function of injury, treatment and clinical variables. The patients had profound functional deficits compared with the normal population. Anatomical reduction alone was not sufficient to restore function. The fracture pattern, marginal impaction and residual displacement of > 2 mm were associated with the development of arthritis, which related to poor function and the need for hip replacement. It may be appropriate to consider immediate total hip replacement for patients aged > 50 years with marginal impaction and comminution of the wall, since 7 of 13 (54%) of these required early hip replacement.

Open fractures of the calcaneus: a review of treatment and outcome.

OBJECTIVES: The aim of this study was to evaluate the functional and clinical outcome of patients with open calcaneus fractures and to determine what factors were associated with these outcomes. DESIGN: Retrospective review of 2 level 1 prospective databases. SETTING/PATIENTS/PARTICIPANTS: All patients admitted with an open calcaneal fracture to 2 level 1 trauma units between January 1, 1987 and April 1, 1996 were identified. Data regarding demographics, injury characteristics, and treatment and complications were documented using a standardized data abstraction form. Radiographs were reviewed to document the fracture type according to Essex-Lopresti. For those patients who had computed tomography scans available, the Sanders et al classification was applied and documented. Patients were contacted and asked to return for follow-up evaluation including the American Orthopaedic Foot and Ankle Society ankle/hindfoot score, the Maryland Foot Score, and the Short Form 36 (SF-36). For patients not willing to return for examination, the questionnaires were completed over the telephone, and the objective scoring components were assigned to lowest score possible. RESULTS: Of 177 calcaneal fractures in patients treated as inpatients during the study period, we identified 30 open fractures in 29 patients. Twenty-seven patients had associated injuries. Two patients underwent amputation within 24 hours due to severe crush injury. Following urgent debridement, soft tissues were closed primarily (22 fractures) or with split thickness skin grafting (4 fractures) and free flap coverage (2 fractures); temporary spanning external fixation was used in 3 patients. Definitive fracture care was at the discretion of the treating surgeon and consisted of closed reduction without fixation (10 fractures), open reduction and bone grafting (1 fracture), minimal Kirschner wire (K wire) fixation (12 fractures), and formal lateral open reduction and internal fixation (5 fractures). There were no late amputations. There were no deep infections. Twenty-one of the 28 patients with salvaged limbs returned for follow-up evaluation, and 3 additional patients agreed to be interviewed by telephone. The average time to follow-up was 49 months with a range of 25 to 106 months. The overall American Orthopaedic Foot and Ankle Society ankle/hindfoot scores and Maryland Foot Scores were fair to poor. The average SF-36 results were within 1 standard deviation of published Canadian norms. Worse function was observed in patients with plantar wounds. Severely comminuted fractures had the worst function, whereas single joint depression injuries had the best functional outcome. CONCLUSION: Infection is uncommon following open calcaneus fractures treated with aggressive soft tissue management. Patients with plantar wounds and comminuted fractures are expected to have particularly poor functional results.