Four moderate quality (Lack 2015, Clegg 2019, Olinger 2018, Hendrickson 2020) and thirteen low quality (Vandenberg 2017, Chua 2014, Hou 2011, Rinker 2008, Arslan 2019, Liu 2012, Whiting 2019, Hohmann 2007, Scharfenberger 2017, Pollak 2000, D’Alleyrand 2014, Philandrianos 2018, Yazar 2006) studies have investigated the risk of deep infection or need for late amputation as a function of the time necessary to achieve definitive wound coverage. However, almost all of these investigations only analyzed the time to coverage data as a secondary outcome within a broader study. There are no Level 1 studies that serve as the basis for this recommendation, with no randomized controlled trials available. Three of the four moderate-quality studies (Lack 2015, Clegg 2019, Olinger 2018) only evaluated timing of definitive coverage as a secondary outcome, limiting their value with respect to the gravitas they carry specific to this recommendation. Regardless, all three fully support the concept of early definitive coverage of open fracture wounds with flaps, local or distant, when necessary. These three studies all report better outcomes when coverage is achieved on or before the 7th day.
The fourth moderate quality study (Hendrickson 2020) and all thirteen of the low quality (Vandenberg 2017, Chua 2014, Hou 2011, Rinker 2008, Arslan 2019, Liu 2012, Whiting 2019, Hohmann 2007, Scharfenberger 2017, Pollak 2000, D’Alleyrand 2014, Philandrianos 2018, Yazar 2006) studies were observational longitudinal cohort studies, and although completed retrospectively they collectively further inform this recommendation. They are all therefore inevitably susceptible to potential confounding and multiple biases, particularly selection bias. The most severe injuries would in fact be less likely suitable for early coverage, and therefore at increased risk of treatment failure independent of the timing of definitive coverage. Nevertheless, almost all these studies support and promote the general principle of early definitive coverage of open fracture wounds with local rotational myoplasties or microvascular free tissue transfers when necessary. The majority of these studies specify 7 days as the defined limit, with worse outcomes consistently reported when coverage is delayed beyond 7 days for any reason.
Benefits & Harms
The available studies consistently demonstrate, with few exceptions, that early coverage of open fractures very likely decreases the risk of deep infection, with a resulting decreased length of stay, fewer procedures during the initial hospitalization, and a diminished risk of later developing both skeletal and soft-tissue specific complications.
Outcome Importance
These injuries are often devastating in severity and are generally at tremendous risk of permanent disability or amputation; minimizing the possibility of deep infection is certainly of paramount importance. Infection almost inevitably results in additional surgery, prolonged hospitalization, and independently increases the probability of treatment failure or late amputation. This potentially condemns the affected individual to a protracted course of further limb-salvage procedures, additional hospitalizations, and prolonged antibiotics, all of which can dramatically delay the rehabilitation process and in many instances permanently remove them from the active workforce. All these considerations have tremendous economic implications, not only for the necessary health care but also additional substantial societal costs in terms of lost wages and workers' compensation.
Cost Effectiveness/Resource Utilization
This timeframe allows for coordination of care with other specialties, including plastic surgeons or other surgeons and nursing staff with microvascular expertise. This definitive procedure can then be scheduled electively, when clinical and logistical conditions have been optimized. This also provides time to complete angiography if necessary to better define the local vascular anatomy, to aid in preoperative planning, selection of donor tissue, and surgical decision-making processes such as choice of anastomotic technique.
Acceptability
Early wound coverage is preferable, and within 7 days appears to strike a reasonable balance between clinical urgency and practicality. The current literature supports this timeframe, and this recommendation should be considered highly acceptable.
Feasibility
Delay of definitive coverage for several days has certain benefits regarding better patient optimization in poly-trauma scenarios, as well as allowing for transfer from rural or regional medical facilities that may lack the necessary resources or expertise. Under most circumstances, the seven-day limit for securing soft-tissue coverage provides the necessary balance between satisfying the dual demands of clinical exigency and what are often complex superimposed logistical issues.
Future Research
Most of the current evidence consists of uncontrolled retrospective longitudinal cohort studies with only small or moderate sample size. These studies are limited by inherent selection bias and other confounding factors, limiting their intrinsic value and generalizability. In some cases, the study population has more than one type of fracture or includes fractures in different anatomical regions. Future studies require a larger sample size, concentration on specific fracture types or anatomical regions, and adherence to strict protocols in the pre-operative, operative, and postoperative periods. Given the wide spectrum of pathology often encountered, the probability of concomitant poly trauma in many cases, and the likelihood of confounding factors characteristic of the trauma population, large prospective randomized studies with a multicenter design would prove difficult to coordinate, but ultimately will be required to answer this question definitively and establish the standard of care.
- Yazar, S., Lin, C. H., Lin, Y. T., Ulusal, A. E., Wei, F. C. Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures. Plastic & Reconstructive Surgery 2006; 7: 2468-75; discussion 2476-7
- Whiting, P. S., Galat, D. D., Zirkle, L. G., Shaw, M. K., Galat, J. D. Risk Factors for Infection After Intramedullary Nailing of Open Tibial Shaft Fractures in Low- and Middle-Income Countries. Journal of Orthopaedic Trauma 2019; 6: e234-e239
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- Scharfenberger, A. V., Alabassi, K., Smith, S., Weber, D., Dulai, S. K., Bergman, J. W., Beaupre, L. A. Primary Wound Closure After Open Fracture: A Prospective Cohort Study Examining Nonunion and Deep Infection. Journal of Orthopaedic Trauma 2017; 3: 121-126
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- Philandrianos, C., Moullot, P., Gay, A. M., Bertrand, B., Legre, R., Kerfant, N., Casanova, D. Soft Tissue Coverage in Distal Lower Extremity Open Fractures: Comparison of Free Anterolateral Thigh and Free Latissimus Dorsi Flaps. Journal of Reconstructive Microsurgery 2018; 2: 121-129
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