Jang Yohan, Natoli Roman M, Della Rocca Gregory J, Zura Robert D, Phelps Kevin D, Potter G David, Scolaro John A, Gage Mark J, Saiz Augustine M, O'Hara Nathan N, Stennett Christina A, Sprague Sheila, Slobogean Gerard P
Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana.
Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.
J Bone Joint Surg Am. 2025 Jun 18;107(Suppl 1):51-59. doi: 10.2106/JBJS.24.01223.
Initial surgical management of Gustilo-Anderson type-I to IIIA open fractures varies from surgical fixation of the fracture with immediate closure of the traumatic wound to various combinations of staged fracture and wound management. The decision to choose staged management has historically been based on wound contamination and the severity of the open fracture. The purpose of this study was to compare the rates of surgical site infection (SSI), wound complication, nonunion, and 1-year reoperation between patients with type-I to IIIA open fractures who underwent fix-and-close treatment and those who underwent planned, staged treatment.
This is a secondary analysis of participants who were enrolled in the Aqueous-PREP and PREPARE-Open studies, excluding those with type-IIIB and IIIC open fractures. Participants were divided into fix-and-close or planned, staged groups and were matched using propensity scores that were computed with multiple variables, including patient and injury characteristics. Associations between treatment type and outcomes were analyzed.
A total of 3,170 participants (staged, 872: 70% White, 20% Black, and 10% other or unknown race; fix-and-close, 2,298: 62% White, 21% Black, and 17% other) with Gustilo-Anderson type-I to IIIA open fractures were identified. Eight hundred and thirty-six participants who underwent planned, staged treatment were propensity score-matched to 836 participants who underwent fix-and-close treatment. Staged treatment was significantly associated with increased odds of deep SSI within 90 days (odds ratio [OR], 2.0 [95% confidence interval (CI), 1.15 to 3.47]; p = 0.01) and reoperation specifically for infection within 1 year (OR, 1.47 [95% CI, 1.06 to 2.04]; p = 0.02) but was not associated with increased odds of wound dehiscence (OR, 0.85 [95% CI, 0.49 to 1.49]; p = 0.57), wound necrosis or failure of the wound to heal (OR, 1.37 [95% CI, 0.83 to 2.25]; p = 0.21), reoperation requiring any free or local flap coverage (OR, 0.96 [95% CI, 0.55 to 1.68]; p = 0.89), or reoperation for delayed union or nonunion (OR, 1.30 [95% CI, 0.92 to 1.83]; p = 0.14).
Fix-and-close treatment of open fractures of type IIIA and lower was associated with decreased odds of deep SSI within 90 days and reoperation for infection within 1 year without an increased risk of wound complications or nonunion and may be considered even in fractures with embedded contamination provided that adequate debridement is performed.
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Gustilo-Anderson I型至IIIA型开放性骨折的初始手术治疗方式多样，从骨折手术固定并立即闭合创伤伤口到分期骨折和伤口处理的各种组合。历史上，选择分期治疗的决定基于伤口污染情况和开放性骨折的严重程度。本研究的目的是比较接受一期固定闭合治疗和计划分期治疗的I型至IIIA型开放性骨折患者的手术部位感染（SSI）率、伤口并发症、骨不连和1年再次手术率。
这是对参加Aqueous-PREP和PREPARE-Open研究的参与者的二次分析，排除IIIB型和IIIC型开放性骨折患者。参与者分为一期固定闭合组或计划分期组，并使用倾向评分进行匹配，该评分由多个变量计算得出，包括患者和损伤特征。分析治疗类型与结局之间的关联。
共确定了3170例Gustilo-Anderson I型至IIIA型开放性骨折患者（分期治疗组872例：70%为白人，20%为黑人，10%为其他或种族不明；一期固定闭合组2298例：62%为白人，21%为黑人，17%为其他）。836例接受计划分期治疗的参与者与836例接受一期固定闭合治疗的参与者进行倾向评分匹配。分期治疗与90天内深部SSI几率增加显著相关（优势比[OR]，2.0[95%置信区间（CI），1.15至3.47]；p = 0.0l）以及1年内专门因感染进行再次手术显著相关（OR，1.47[95%CI，1.06至2.04]；p = 0.02），但与伤口裂开几率增加无关（OR，0.85[95%CI，0.49至1.49]；p = 0.57），与伤口坏死或伤口愈合失败无关（OR，1.37[95%CI，0.83至2.25]；p = 0.2l），与需要任何游离或局部皮瓣覆盖进行再次手术无关（OR，0.96[95%CI，0.55至1.68]；p = 0.89），与因骨延迟愈合或骨不连进行再次手术无关（OR，1.30[95%CI，0.92至1.83]；p = 0.14）。
IIIA型及以下开放性骨折的一期固定闭合治疗与90天内深部SSI几率降低以及1年内因感染进行再次手术几率降低相关，且伤口并发症或骨不连风险未增加，即使在有嵌入污染的骨折中，只要进行充分清创，也可考虑采用。
治疗性II级。有关证据水平的完整描述，请参阅作者须知。
