Open Wound Closure

Two high quality (Jenkinson 2014, Konbaz 2019) and four low quality (Wei 2014, Peterson 2020, Russell 1990, Hohman 2007) studies have addressed the topic of primary closure of an open fracture, and all have concluded the practice is safe in selected wounds after adequate formal operative debridement by an experienced surgeon(s). Jenkinson (2014) investigated the risk of developing deep infection after primary closure of the open fracture site in a series of 349 Type 1/2/3A lower extremity injuries treated at a North American academic Level 1 trauma center. Using a propensity-matched cohort model, and after carefully controlling for a number of other confounding variables, they demonstrated the rate of infection was more than four times higher in those managed with delayed primary closure compared to those closed immediately. The remaining four low quality studies were observational longitudinal cohort studies, and they are all therefore inevitably susceptible to potential confounding and multiple biases, therefore are at increased risk of infection independent of the timing of closure. The Hohmann (2007) study from South Africa used a different model, where open fractures at one hospital were closed primarily and open fractures at another hospital underwent delayed primary closure. Although they observed no meaningful difference in infection rates and this result is favorable for advocates of immediate early primary wound closure, in this context it also can be considered equally favorable for delayed wound closure protocols. Nevertheless, most of these low quality studies further support and promote the general principle of early primary closure of open fracture wounds whenever possible. Only the Russell (1990) study reported the risk of infection following primary closure of Type 1/2/3A injuries resulted in a higher risk of deep infection (14%) compared to delayed closure of similar wounds (0%). However, this particular cohort was treated between 1981 and 1985, and perhaps does not adhere to current standards for surgical debridement or antibiotic options.

Benefits & Harms
The contemporary literature consistently indicates that, after thorough operative debridement by an experienced surgeon, primary closure of many open fractures can be considered safe and effective. This action very likely decreases the risk of deep infection, and is associated with a shorter length of stay, fewer procedures during the initial hospitalization, and a reduced risk of later developing further complications.

Outcome Importance
Minimizing the possibility of infection is extremely important because infection almost always leads to additional surgery and prolonged hospitalization. Deep infection may result in chronic osteomyelitis or an infected non-union, and treatment failure may ultimately lead to amputation. These factors all have significant economic implications, including not only the greater health care costs that might accrue but also the substantial additional societal costs in terms of lost wages and workers' compensation. There are additional complex implications regarding the affected individual’s social status, the risk of divorce and disruption of the family unit, and the possibility of depression and isolation.

Cost Effectiveness/Resource Utilization
Primary wound closure for selected open fractures is the more cost-effective approach, and one that utilizes fewer resources. Fewer operative procedures and a decreased length of initial hospitalization inevitably results in more efficient allocation of hospital beds, theatre time, theatre space, and clinical consumables.

Acceptability
Early primary wound closure is preferable, and current literature informs us this can be safely done in selected cases following meticulous operative debridement by an experienced surgeon. Considering the reduction in length of stay and more efficient resource utilization, this recommendation should be considered highly acceptable.

Feasibility
Primary wound closure for selected open fractures is an easily implemented and more cost-effective alternative. It requires an experienced trauma surgeon to make the decision, and this is perhaps not always convenient. However, surgeons can choose this course of action with confidence when the wound is carefully assessed and considered appropriate.

Future Research
This recommendation is largely based on uncontrolled retrospective studies with inadequate sample size, studies that may be diminished by the substantial risk of selection bias and other confounding factors. Future research will 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 tremendous variety of pathology encountered, the probability of additional severe injuries in many cases, and the likelihood of confounding factors typical 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.