Higher Reoperation Rates in Planned, Staged Treatment of Open Fractures Compared with Fix-and-Close: A Propensity Score-Matched Analysis.

Abstract

BACKGROUND 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. METHODS 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. RESULTS 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). CONCLUSIONS 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. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.