Axelrod Daniel, Comeau-Gauthier Marianne, Prada Carlos, Bzovsky Sofia, Heels-Ansdell Diane, Petrisor Brad, Jeray Kyle, Bhandari Mohit, Schemitsch Emil, Sprague Sheila
Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada.
Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.
OTA Int. 2022 Dec 28;6(1):e231. doi: 10.1097/OI9.0000000000000231. eCollection 2023 Mar.
Open fractures represent a major source of morbidity. Surgical site infections (SSIs) after open fractures are associated with a high rate of reoperations and hospitalizations, which are associated with a lower health-related quality of life. Early antibiotic delivery, typically chosen through an assessment of the size and contamination of the wound, has been shown to be an effective technique to reduce the risk of SSI in open fractures. The Gustilo-Anderson classification (GAC) was devised as a grading system of open fractures a complete operative debridement of the wound had been undertaken but is commonly used to help with the choice of initial antibiotics. Incorrect preoperative GAC, leading to less aggressive initial management, may influence the risk of SSI after open fracture. The objectives of this study were to determine (1) how often the GAC changed from the initial to definitive grading, (2) the injury and patient characteristics associated with increases and decreases of the GAC, and (3) whether a change in GAC was associated with an increased risk of SSI.
Using data from the FLOW trial, a large multicenter randomized study, we used descriptive statistics to quantify how frequently the GAC changed from the initial to definitive grading. We used regression models to determine which injury and patient characteristics were associated with increases and decreases in GAC and whether a change in GAC was associated with SSI.
Of the 2420 participants included, 305 participants had their preoperative GAC change (12.6%). The factors associated with upgrading the GAC (from preoperative score to the definitive assessment) included fracture sites other than the tibia, bone loss at presentation, width of wound, length of wound, and skin loss at presentation. However, initial misclassification of type III fractures as type II fractures was not associated with an increased risk of SSI ( = 0.14).
When treating patients with open fracture wounds, surgeons should consider that 12% of all injuries may initially be misclassified when using the GAC, particularly fractures that have bone loss at presentation or those located in sites different than the tibia. However, even in misclassified fractures, it did not seem to increase the risk of SSI.
开放性骨折是发病的主要原因。开放性骨折后的手术部位感染（SSI）与再次手术和住院率高相关，而这又与较低的健康相关生活质量相关。早期使用抗生素，通常通过评估伤口大小和污染情况来选择，已被证明是降低开放性骨折发生SSI风险的有效技术。 Gustilo-Anderson分类法（GAC）是作为开放性骨折的分级系统设计的——伤口已进行了彻底的手术清创，但通常用于帮助选择初始抗生素。术前GAC分类错误，导致初始治疗不够积极，可能会影响开放性骨折后发生SSI的风险。本研究的目的是确定：（1）GAC从初始分级到最终分级的变化频率；（2）与GAC增加和减少相关的损伤和患者特征；（3）GAC的变化是否与SSI风险增加相关。
利用FLOW试验（一项大型多中心随机研究）的数据，我们使用描述性统计来量化GAC从初始分级到最终分级的变化频率。我们使用回归模型来确定哪些损伤和患者特征与GAC的增加和减少相关，以及GAC的变化是否与SSI相关。
在纳入的2420名参与者中，305名参与者的术前GAC发生了变化（12.6%）。与GAC升级（从术前评分到最终评估）相关的因素包括胫骨以外的骨折部位、就诊时的骨丢失、伤口宽度、伤口长度和就诊时的皮肤缺损。然而，III型骨折最初被误分类为II型骨折与SSI风险增加无关（P = 0.14）。
在治疗开放性骨折伤口的患者时，外科医生应考虑到，使用GAC时，所有损伤中约12%可能最初被误分类，特别是就诊时伴有骨丢失的骨折或位于胫骨以外部位的骨折。然而，即使在分类错误的骨折中，似乎也不会增加SSI的风险。
