What Factors Increase Risk of Reoperation Following Open Fracture?

By: Peter Pollack

Early débridement, washing may help prevent infection

"The treatment of open fractures is often made more complicated by infection, wound healing problems, and failure of a fracture to heal properly,” noted Paul Tornetta III, MD. “These issues may require surgical management and result in a delay of return to function for the patient.”

Dr. Tornetta is a coauthor of “Prognostic Factors for Predicting Reoperations after Operative Management of Open Fractures,” which was presented on Tuesday. Dr. Tornetta and his colleagues sought to identify factors that may be associated with detrimental outcomes in order to optimize the care of open fractures.

The research team reviewed data on 2,447 patients with open extremity fractures from the Fluid Lavage of Open Wounds (FLOW) study—a multinational, randomized, controlled trial that compared the use of soap against standard irrigation for open fractures. Overall, 323 participants in the dataset required reoperation.

Based on biologic rationale and previous reports in the literature, the researchers identified 23 potential prognostic factors from the baseline, fracture characteristics, and surgical data collected. They used a multivariable Cox proportional hazards regression analysis to investigate factors that may be associated with increased risk of reoperation within 1 year due to infection, wound healing, or fracture healing.

The research team found the following fracture characteristics to be associated with increased risk of reoperation:

  • lower extremity fractures (hazard ratio [HR] 2.93)
  • Gustilo-Anderson type III fractures (HR 1.49)
  • moderate to severe wound contamination (HR 1.33)

In addition, the researchers noted that patients who received a surgical preparation solution in the emergency department (ED) and those who received an iodine-based preparation solution in the operating room were at reduced risk of reoperation (HR 0.66 and HR 0.53, respectively). They also found that delaying the initial surgery to 6 hours or longer after injury was not associated with an increased risk of reoperation.

“We found that the most important predictors of reoperation were having a lower vs. an upper extremity injury, having the débridement delayed by more than 6 hours, having a Gustilo type III injury, and not having the wound treated in the emergency department,” explained Dr. Tornetta.

“Washing the wound in the ED as an important factor in avoiding reoperation has not been validated previously,” he said. “Most centers do this as a matter of routine, but our data confirm the practice. In addition, several previous studies have identified a time cutoff within the first 24 hours for initial operative débridement, but we found improved outcomes when débridement was performed within 6 hours.

“Some of the predictors of reoperation are not modifiable, such as injury location and soft-tissue health, but others are, such as time to débridement and general cleaning of the wound in the ED,” he continued. “Also, we know that urgent use of antibiotics reduces infection, but the centers in the study all did really great with this so it did not show up as a predictor.

“Further analysis of the data suggests that choice of skin preparation solution and use of a skin preparation solution in the ED may also impact reoperation rates following an open fracture, and this warrants further investigation,” said Dr. Tornetta.          

Dr. Tornetta’s coauthors are Jeffrey Anglen, MD, FACS; Mohit Bhandari, MD, FRCSC, PhD; Gregory J. Della Rocca, MD, PhD, FACS; PJ Devereaux, MD, MSc; Gordon H. Guyatt, MD; Diane Heels-Ansdell, MSc; FLOW Investigators: Kyle J. Jeray, MD; Clifford B. Jones, MD, FACS; Hans J. Kreder, MD; Susan Liew; Kim Madden, MSc; Sun Makosso-Kallyth, MSc, PhD; Paula McKay; Steven R. Papp, MD; Brad Petrisor, MD; Parag Sancheti, MD; Emil H. Schemitsch, MD; Sheila Sprague, PhD; Stephanie L. Tanner, MS; Ted Tufescu, FRCSC, MD; and Stephen Walter.

Details of the authors’ disclosure as submitted to the Orthopaedic Disclosure Program can be found in the Final Program; the most current disclosure information may be accessed electronically at www.aaos.org/disclosure