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.
J Orthop Trauma. 2013 Dec;27(12):722-5. doi: 10.1097/BOT.0b013e31829e7079.
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.
Retrospective review.
Level I and level II trauma centers.
PATIENTS/PARTICIPANTS: 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.
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.
Healing after the primary procedure, requirement for secondary bone grafting procedures, and the presence of deep infection.
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.
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.
Therapeutic level III.
本研究比较了两种不同的清创方案（激进清创与非激进清创）治疗高能量开放性股骨髁上骨折的结果，评估了两种方案在后续骨移植需求和深部感染方面的差异。
回顾性研究。
一级和二级创伤中心。
患者/参与者：29 例连续的高分级开放性（Gustilo Ⅱ和Ⅲ型）股骨髁上骨折患者（OTA/AO 33A 和 C 型）接受清创和锁定钢板内固定治疗。
2 家不同的一级创伤中心的外科医生对开放性股骨髁上骨折采用了不同的清创方案。其中一家中心（MA 组，n=17）采用了更为激进的清创方案，包括彻底清除所有失活骨组织并使用抗生素骨水泥间隔物填充大块骨缺损。另一家中心（LA 组，n=12）采用了相对保守的清创方案，仅彻底清除明显污染的骨组织，保留其他骨碎片，且不使用抗生素骨水泥间隔物。这 2 家中心的其他治疗方案均相似，包括所有病例均采用锁定钢板进行确定性固定，在彻底清创前使用 IV 抗生素，一旦临床和影像学提示骨折愈合即可负重。
初次手术治疗后的愈合情况、是否需要二期骨移植以及是否存在深部感染。
2 家中心的患者在年龄、性别、开放性骨折比例、开放性骨折分级、损伤机制和吸烟史等方面均无显著差异（P>0.05）。但 MA 组患者中糖尿病患者比例更高（P<0.05）。MA 组清创后使用骨水泥间隔物填充骨缺损的比例更高（35%比 0%，P<0.006），且计划二期骨移植的患者比例更高（71%比 8%，P<0.006）。LA 组患者初次手术治疗后愈合比例更高（92%比 35%，P<0.003）。两组的感染率无显著差异：LA 组为 25%，MA 组为 18%（P=0.63）。两组所有患者最终均愈合，在平均 1.8 年的随访中均未出现感染的证据。
在治疗高能量、高分级开放性股骨髁上骨折时，应该切除多少骨组织，这是一个外科医生判断的问题，且这种判断是一个连续的过程。基于本研究的结果，在感染风险和骨愈合潜力之间似乎存在理论上的权衡，在初始治疗中，LA 方法可能更有利于骨清创。
治疗性研究，III 级。
