immediate primary skin closure in type-iii a

8/9/2019 Immediate Primary Skin Closure in Type-III A

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217 THE JOURNAL OF BONE AND JOINT SURGERY

Immediate primary skin closure in type-III Aand B open fracturesRESULTS AFTER A MINIMUM OF FIVE YEARS

S. Rajasekaran,J. Dheenadhayalan,J. N. Babu,S. R. Sundararajan,H. Venkatramani,S. R. Sabapathy

From Ganga

Hospital,

Coimbatore, India

S. Rajasekaran, MS, FRCS,

PhD, Director and Head

J. Dheenadhayalan, MS,

Consultant Surgeon

J. N. Babu, MS, FNB, Clinical

Fellow

S. R. Sundararajan, MS,

Consultant Surgeon

Department of Orthopaedics,

Traumatology and Spine

H. Venkatramani, MS, MCh,

Consultant Surgeon

S. R. Sabapathy, MCh, DNB,

FRCS, Director and Head

Department of Plastic, Hand

and Reconstructive Surgery

Ganga Hospital, 313

Mettupalayam Road,Coimbatore 641043, India.

Correspondence should be sent

to Dr S. Rajasekaran; e-mail:

[email protected]

2009 British Editorial Society

of Bone and Joint Surgery

doi:10.1302/0301-620X.91B2.

21228 $2.00

J Bone Joint Surg [Br]

2009;91-B:217-24.

Received 28 April 2008;

Accepted after revision 26

September 2008

Between June 1999 and May 2003 we undertook direct primary closure of the skin wounds

of 173 patients with Gustilo and Anderson grade-IIIA and grade-IIIB open fractures. These

patients were selected from a consecutive group of 557 with type-III injuries presenting

during this time. Strict criteria for inclusion in the study included debridement within

12 hours of injury, no sewage or organic contamination, no skin loss either primarily or

secondarily during debridement, a Ganga Hospital open injury skin score of 1 or 2 with a

total score of ten or less, the presence of bleeding skin margins, the ability to approximate

wound edges without tension and the absence of peripheral vascular disease. In addition,

patients with polytrauma were excluded.

At a mean follow-up of 6.2 years (5 to 7), the outcome was excellent in 150 (86.7%), goodin 11 (6.4%) and poor in 12 (6.9%). A total of 33 complications occurred in 23 patients

including superficial infection in 11, deep infection in five and the requirement for a

secondary skin flap in three. Six patients developed nonunion requiring further surgery, one

of whom declined additional measures to treat an established infected nonunion.

Immediate skin closure when performed selectively with the above indications proved to

be a safe procedure.

Debate continues on the timing of closure in

open fractures particularly on the role of

immediate closure in Gustilo and Anderson

type-III injuries.1-7 The common practice of

leaving wounds open after debridement8-12was based on the experience of war wounds

during a period when antibiotics were less

readily available, the principles of surgical

debridement were not fully developed and the

techniques for proper soft-tissue reconstruc-

tion had not been established.13,14 With the

availability of potent antibiotics and refine-

ment in the techniques of surgical debride-

ment, surgeons have slowly advanced towards

early and even immediate closure of the

wound.1-3,15-24

The major concern with immediate closure

is the increased risk of infection on the premisethat the offending organism leading to infec-

tion in open injuries is introduced at the site of

the accident. However, there is ample evidence

that infection is generally the result of hospital

acquired colonisation rather than primary con-

tamination at the time of injury.24-28It has been

shown that there is no correlation between

contaminating organisms and those isolated in

subsequent infection. Pre-operative cultures

rarely grow drug-resistant organisms which

are often found in infected open injuries.27The

rate of infection may in fact be greater in

wounds which are left open in the hospital

environment for closure at a later date.24Leav-

ing wounds open may also lead to avoidabledesiccation of the tissues resulting in increased

secondary loss of tissue, an increase in the

number of surgical procedures required, a

lengthened in-patient stay and extra cost.

There is growing interest in the possibility

of primary closure in open injuries.1-3,15-24

However, studies on this subject have

included a wide variation in wound manage-

ment such as direct skin closure, skin grafting

and early application of skin flaps.28No study

has evaluated the long-term results of direct

skin suturing performed immediately in type-

III injuries or the appropriate indications forthis approach.

It has been our practice since 1992 to per-

form immediate skin closure of open injuries,

including type-III injuries, during the initial

reconstruction, if certain criteria were met.

The encouraging results achieved prompted

us to carry out a prospective study on the out-

come of the immediate closure of type-III

injuries and to develop safe indications for the

procedure.


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IMMEDIATE PRIMARY SKIN CLOSURE IN TYPE-III A AND B OPEN FRACTURES 218

VOL. 91-B, No. 2, FEBRUARY 2009

Patients and MethodsThe study was approved by the institutional review board

and all patients included in it were counselled regarding the

implications and outcome of our protocol.

Between June 1999 and May 2003, we treated 738 open

injuries. Of the salvaged 707 injuries, 557 were type-III A

or B injuries. Of this group, 185 patients satisfied the crite-

ria and had immediate closure (Fig. 1). Eight of these werelost to follow-up and four died during the study period,

leaving 173 available for evaluation. There were 151 men

and 22 women with a mean age of 36.6 years (3 to 75).

Motor-vehicle accidents accounted for 133 injuries, domes-

tic accidents for 15, work-place injuries for 19 and indus-

trial accidents for six. The lower limb was involved in 134

and the upper limb in 39 (Fig. 2). The wound length was

less than 5 cm in 59 patients, between 6 cm and 10 cm in 81

and more than 11 cm in 33. There were inherent difficulties

in classifying the injuries as type IIIA or type IIIB because

from the time it was originally proposed,28the definition

has been modified many times with frequent changes and

there is no longer a uniformly accepted definition.29-33

Accordingly, the wounds were also assessed using the

Ganga Hospital open injury score34,35which analyses the

severity of injury to the skin, bone and musculotendon

units individually and also gives a total score (Table I). All

173 injuries had a skin score of two or less and a total score

of ten or less.

Management protocol. The hospital protocol involved deb-

ridement at the first opportunity by a senior member of the

orthopaedic and plastic surgical team who assessed the ful-

filment of the criteria for primary closure.35 These

comprised debridement within 12 hours of the injury and

no loss of skin either primarily or during debridement.

Additionally, stable skeletal fixation had to be achieved

either by internal or by external fixation during the initial

738 open injuries(from 1999-2003)Excluded

Excluded

Excluded

Excluded

Salvaged: 707

Type IIIA or B: 557

Immediate closure: 185

Study population: 173

Primary amputation: 31

Inclusion criteria

not fulfilled: 309

Injury severity scoreof > 25 and/or

Ganga Hospital TotalScore of > 10 and/or

Ganga Hospital SkinScore of 3 and above

Lost to follow-up: 8Died: 4

Type I: 70Type II: 65Type IIIC: 15

Exclusion criteria: (63)

Hand and foot injuries:15 Shock: 13 Sewage contamination/

farmyard injuries: 20 Peripheral vascular diseases: 5 Drug dependent diabetes mellitus: 7 Connective tissue disorders and

peripheral vasculitis: 3

Fig. 1

Flow chart summarising the study population.

Fig. 2

Diagram showing the distribution in the upper and lowerlimbs of the 173 type-III A and B open injuries managed byimmediate direct skin closure.


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219 S.RAJASEKARAN, J. DHEENADHAYALAN, J .N. BABU, S.R. SUNDARARAJAN, H.VENKATRAMANI, S.R. SABAPATHY

THE JOURNAL OF BONE AND JOINT SURGERY

procedure and the skin margins closed by direct apposition

without tension. When there was vascular involvement,

associated hand and foot injuries or a polytrauma with an

injury severity score of > 25,36other methods of skin cover

were provided and the patients were excluded. Patients

were also excluded from immediate closure if they had

presented with shock, had sewage or organic contamina-

tion, had peripheral vascular disease or diseases compro-

mising wound healing such as connective-tissue disorders

and peripheral vasculitis (Table II).

All patients received tetanus prophylaxis and 1.5 g of

cefuroxime intravenously on admission. Whenever the

Table I. Details of the Ganga Hospital Open Injury Score34

Score

Covering structures: skin and fascia

Wounds without skin loss

Not over the fracture 1

Exposing the fracture 2

Wounds with skin loss

Not over the fracture 3Over the fracture 4

Circumferential wound with skin loss 5

Skeletal structures: bone and joints

Transverse/oblique fracture/butterfly fragment < 50% circumference 1

Large butterfly fragment > 50% circumference 2

Comminution/segmental fractures without bone loss 3

Bone loss < 4 cm 4

Bone loss > 4 cm 5

Functional tissues: musculotendinous (MT) and nerve units

Partial injury to MT units 1

Complete but repairable injury to MT units 2

Irreparable injury to MT units/partial loss of a compartment/complete injury to posterior tibial nerve 3

Loss of one compartment of MT units 4

Loss of two or more compartments/subtotal amputation 5

Comorbid conditions: add 2 points for each condition present

Injury - debridement interval > 12 hours

Sewage or organic contamination/farmyard injuries

Age > 65 years

Drug-dependent diabetes mellitus/cardiorespiratory diseases leading to increased anaesthetic risk

Polytrauma involving chest or abdomen with injury severity score > 25/fat embolism

Hypotension with systolic blood pressure < 90 mmHg at presentation

Another major injury to the same limb/compartment syndrome

Table II. Inclusion and exclusion criteria used in the study

Inclusion criteriaType-III A and B open injuries of limbs without vascular deficit

Wounds without skin loss either primarily or secondarily during debridement

Ganga Hospital skin score of 1 or 2 and a total score of 10 or less

Injury to debridement interval less than 12 hours

Presence of bleeding wound margins which could be apposed without tension

Stable fixation achieved either by internal/external fixation

Exclusion criteria

Grade-I, -II and -IIIC injuries

Ganga Hospital skin score of 3 or more and a total score of > 10

Isolated hand and foot injuries

Polytrauma involving chest or abdomen with injury severity score > 25

Hypotension with systolic blood pressure < 90 mmHg at presentation

Sewage or organic contamination/farmyard injuries

Peripheral vascular diseases/Thrombo angitis obliteransDrug-dependent diabetes mellitus/connective-tissue disorders/peripheral vasculitis


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surgeons were satisfied with the adequacy of debridement,

a decision was taken for primary closure if the inclusion cri-

teria were fulfilled. Wounds were closed with intermittent

skin sutures over a suction drainage.

Collection of data and outcome assessment. The patients

were assessed for wound healing infection, union of the frac-

ture and the need for additional procedures. The outcome

assessment of wound healing, infection and bony union was

done at each follow-up on a data sheet by two of the authors

(JD, JNB). All the wounds were assessed on the second and

fourth post-operative days and at the time of removal sutures.After discharge, the patients were reviewed at monthly inter-

vals until union and then annually. Wound healing was

assessed according to predefined criteria (Table III). Infection

was classified according to the criteria set by the Centre for

Disease Control (CDC)37and recommended by Nosocomial

Infection National Surveillance Scheme (NINSS).37

The outcome was defined as excellent when the wound

had type-A or type-B wound healing, with no wound

infection and union without the need for secondary pro-

cedures (Table IV). A good outcome was considered to be

a wound which had type-C healing with superficial infec-

tion and uneventful bone union. A poor outcome was one

which had a type-D healing requiring flap cover or deep

infection requiring secondary procedures to treat infection

and nonunion.

Skeletal stabilisation. The choice of implant for stabilisa-

tion of the fracture was decided by the surgical team and

reflected the fracture pattern with consideration of the site

of injury and the age of the patient. Fractures of the lower

limb were mainly treated by locked intramedullary nails,

while those of the upper limb predominantly had plate fix-

ation. In eight patients definitive internal fixation was per-formed after temporary external fixation.

Considering tibial fractures separately, since these are

special challenges in management, there were 79 type-III

open tibial injuries. The wound size was less than 5 cm in

35 and more than 6 cm in 44 patients. The injury was in the

upper proximal metaphyseal region in 11, was diaphyseal

in 32 and in the lower metaphysis in 36. Of these, intra-

articular extension into the knee was seen in seven fractures

and into the ankle in five. The method of stabilisation used

was a locked intramedullary nail in 56 patients, a limb

reconstruction system in eight, hybrid fixation in five, a

dynamic compression plate in seven and screws alone in

three patients who had fractures of the plateau.

ResultsThe mean follow-up was for 6.2 years (5 to 7). Of the

173 patients, 150 (86.7%) had an excellent outcome, 11

(6.4%) a good outcome and 12 (6.9%) a poor outcome. All

39 injuries to the upper limb had an excellent outcome. Of

the 134 injuries to the lower limb 111 (82.8%) had an

excellent outcome (Fig. 3). Primary wound healing was

observed irrespective of the size of the wound or the site.

The presence of bleeding from the wound margins which

Table III. Details of the assessment of wound healing

Wound assessment Patients

Type A primary wound healing

143

Skin edges well approximated

Epithelialising normally with no signs or symptoms of wound infection

Wound heals by primary intention

Type B: marginal wound necrosis not requiring surgical intervention 26Skin edges remain approximated but the margins show necrosis

No signs or symptoms of infection

Wound heals by secondary intention

No surgical intervention required

Type C: wound necrosis requiring surgical intervention 1

Necrosis of skin edges with or without infection

Requires redebridement and secondary suturing

Type D: wound dehiscence requiring flap cover 3

Necrosis of skin edges with or without infection

Requires redebridement and flap cover

Table IV. Details of assessment of final outcome

Grade

Excel lent Type-A or type-B wound healing

No infection

Bony union without intervention

Good Type-C wound healing or superficial infection

Bony union without intervention

Poor Type-D wound healing

Deep infection

Nonunion


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could be apposed without tension was found to be more

important than the size, nature, site of the wound or the

method of internal fixation. A good outcome was observed

in 11 patients in the whole series because of the presence of

type-C wound healing in one, a superficial infection in eight

and both superficial infection and delayed union in two.However, these patients did not require any surgical inter-

vention when erythema developed during healing since they

responded to antibiotic treatment and daily dressing. All

these patients also had satisfactory union of the fracture

without the need for further intervention. In the 12 patients

with a poor outcome, this was due to failure of wound heal-

ing (type D) alone in one, nonunion alone in five, deep

infection and delayed union in four and infective nonunion

with type-D wound healing in one patient. The other

patient had type-D wound healing with superficial

infection and delayed union.Complications. At the final follow-up, a total of 33 compli-

cations were observed in 23 patients. Of these, eight hadinfection alone, two had problems of wound healing alone,

five had delayed union or nonunion, six had infection and

delayed union and two had all three complications of

wound necrosis, infection and nonunion.

Wound healing. Wounds healed without further intervention

in 169 patients (97.7%). Wound healing was assessed as type

A in 143 injuries (82%), type B in 26 (15%), type C in one

(1%) and type D in three (2%) (Table III). Complications in

wound healing requiring surgical intervention were observed

in four patients (2.3%), two in the tibia (2 of 79), one in the

femur (1 of 40) and one in the knee (1 of 12). The nature of the

complication was that of marginal necrosis requiring re-

debridement and secondary suturing in one patient and

wound necrosis requiring debridement and flap cover in three.

While three of these wounds healed subsequently, one patient

with a supracondylar fracture of the femur had persistent deepinfection and osteomyelitis. The patient had a persistent sinus

for three years before it closed and was left with a nonunion.

This patient preferred to be mobilised with a brace and did not

favour any further surgical procedures.Infection. Infection was observed in 16 of the 173 patients

(9.2%). It was superficial in 11 (6.4%) and resolved after

treatment with intravenous antibiotics. The other five

(2.9%) patients had deep infection (Table V). Debridement

had to be performed within one week in two injuries, at

three weeks in two and at four weeks in one. Two injuries

required only a single debridement, two required debride-

ment twice and one required debridement on three occa-

sions. This final patient also required revision with removalof the implant and stabilisation using a limb reconstruction

system and a transposition flap. This resulted in an infected

nonunion and a sinus for six months. During this period,

the patient was mobilised using a moulded functional cast-

brace. The sinus closed, but the patient declined further

treatment for the nonunion. All patients with deep infection

had removal of the implant after consolidation of the frac-

ture. No infection occurred in injuries of the upper limb.

Bony union. In total 160 of the 173 (92.5%) fractures

united uneventfully. Delayed union was observed in

Table V. Details of five patients with deep infection

Case Region Infective organism Initial managementTime of presentationof infection

Secondaryprocedures Course of infection

1 Tibia, middle third Staph. aureus Primary closure,locked intramedullarynail

Immediate - United at 20 weeksintermittent dischargefrom a sinus

Implant removal at 32weeks

2 Tibia, lower third Streptococcus viridans Primary closure,locked intramedullarynail

3 weeks Debridement, antibiot-ics and walking cast

Union delayed until36 weeks

Implant removal afterone year

3 Femur, lower third Staph. aureus Primary closure,dynamic condylarscrew

3 weeks Debridement, anti-biotics, implantremoval and seques-trectomy

United at 22 weekswith a sinus resolvingafter one year

4 Femur, lower third Pseudomonas Primary closure,dynamic condylarscrew

Immediate Debridement, anti-biotics, transpositionflap, implant removaland externalfixator

Persistent infectivenonunionMobilised with caliper

5 Tibial plateau Staph. aureus Primary closureButtress plating

4 weeks Debridement Prolonged anti-biotics, united at 20weeksIntermittent dischargefrom a sinus


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seven patients (4%) and nonunion in six (3.5%). All seven

patients with delayed union went on to union without any

open interventional procedure. However, two patients with

fractured tibiae required dynamisation, one patient

required injection of bone marrow and others had a period

of functional cast bracing. All the six patients with non-

union required secondary intervention. Bone grafting was

required in five patients and in three of these revision of thefixation was also needed. As described, the sixth patient

with an infected nonunion refused further treatment.

DiscussionRecently, the traditional concept that wounds in open frac-

tures must be left open at the initial surgery has been chal-

lenged.1-3,15-24In order to determine a realistic protocol the

advantages and disadvantages of both methods of manage-

ment must be reviewed critically.

Undoubtedly, the major concern of closing a wound

which is contaminated is the fear of severe local infection or

the development of tetanus or gas gangrene.38Russell et al9

in a study of 90 of 110 consecutive open tibial fracturesreviewed retrospectively, reported a rate of deep infection

of 20.7% (12 of 58) in primary skin closure compared with

3.1% (1 of 32) after delayed closure. In addition, eight of

the nonunions also followed primary closure and they

advised against this.

The suggestion that primary closure may lead to an

increased rate of infection seems, however, to be inappro-

priate, since there is now growing evidence that most

acute infections after open injuries are the result of patho-

gens acquired in the hospital rather than from the site of

injury.24-27In a prospective study of 326 open fractures,

Gustilo and Anderson29reported that eight patients devel-

oped infection of which five were acquired secondarily in

the hospital. They concluded that during the long inter-

vals when such wounds were open, secondary infection

usually with Gram-negative organisms may be a problem

since these organisms are usually difficult to control by

antibiotics alone.It is evident that the infection is acquired in hospital since

it is difficult to predict the subsequent infective pathogen on

the basis of the initial wound culture.25-27In a prospective

study, Patzakis et al27 found that only 18% of infections

were caused by the organism which was initially isolated in

the peri-operative period. The enormity of the problem of

hospital-acquired infection in open injuries is a strong indi-

cation for primary closure.24Since the site of the fracture

and soft-tissue wound are probably most sterile after an

adequate debridement by an experienced surgeon this is an

opportune time to approximate the skin margins.

Reports of good results after early closure are not new.1-3,15-25

The concept was advocated as early as 1948.39Hope andCole40in a series of tibial fractures in children reported an

infection rate of 7.8% (4 of 51) with primary closure

compared with 14.6% (6 of 41) with secondary closure.

Cullen et al41reviewed the records of 83 children with open

fractures of the tibial metaphysis and diaphysis in which

57 wounds were closed primarily. Only two children devel-

oped superficial infection.

Similar good results have been described in the adult

population. De Long et al21 reported the results of

119 open fractures treated by six forms of wound manage-

Fig. 3a

Photograph (a) and radiograph (b) showing a type-IIIB open fracture of the tibia with a wound 10 cm4 cm in size on the anteromedial aspect ofthe tibia. The wound was (c) debrided and (d) stabilised with an intramedullary nail with ten hours of injury. At the end of the debridement andskeletal stabilisation, the skin edges could be approximated without tension and satisfied the inclusion and exclusion criteria of our study (e). Thewound was managed by immediate direct skin closure with an excellent outcome (f).

Fig. 3b Fig. 3c Fig. 3d Fig. 3e Fig. 3f


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ment and concluded that immediate primary closure, with

or without a second look was a viable option.

The indications for primary closure which we followed

were very strict and were formed from the experience of

treating a large number of open injuries. The senior surgical

team was able to assess the adequacy of the debridement

and to judge the viability of the tissues.

Extension of the wounds for proper inspection and

debridement was undertaken in a longitudinal fashion to

avoid jeopardising closure in appropriate cases. Care was

taken to avoid creating a dead space using large suction

drains so that no collection which might form a nidus for

infection could accumulate.

Assessment of the skin margins requires good judgement

and experience. The Ganga Hospital score was particularly

useful in assessing the status of the skin and judging the suit-

ability of wounds for immediate closure since the scoring sys-

tem is weighted towards loss of skin rather than the size of

the wound. Irrespective of the size of the wound we found it

was safe to close wounds with a skin score of 1 or 2.We acknowledge that the patients in our study were not

randomised, but our previous experience has shown that it

was inappropriate to delay closure of a wound when this was

possible since this increased the chances of complications.

An increase in the rate of complications by adopting a

delayed closure has been noted by others.15-24,40,41Our pri-

mary aim was not only to prove the advantage of selective

closure of open injuries, but also to verify the indications

which were evolved following our previous experience. The

results of this prospective study have shown that these indi-

cations are appropriate and can be used as a guideline in

deciding to undertake immediate closure.

Although infection was noted in 16 patients, deep infec-tion occurred in five. This is less than has been previously

reported.15,28,29Similarly, the requirement of a subsequent

soft-tissue flap due to failure of wound healing only arose

in three patients. We attribute this to immediate closure

which protected the normal internal environment and pre-

vented the additional loss of soft tissue.

However, we emphasise that closure of all wounds with-

out adequate debridement and in the absence of tension will

be disastrous. While advocating immediate closure in certain

open injuries, the criteria for this treatment were met only in

185 of the 557 injuries (33%) which we managed.

We would like to thank Mr K. Ganesh, Physician Assistant, for help in the collec-

tion and analysis of the data. This study was supported and funded by Ganga

Orthopaedic Research and Education Foundation.

Although none of the authors has received or will receive benefits for per-

sonal or professional use from a commercial party related directly or indirectlyto the subject of this article, benefits have been or will be received but will be

directed solely to a research fund, foundation, educational institution, or other

non-profit organisation with which one or more of the authors are associated.

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immediate primary skin closure in type-iii a

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