A Comparison of More and Less Aggressive Bone Debridement Protocols for the Treatment of Open Supracondylar Femur Fractures

*Washington University School of Medicine #Harris Methodist Fort Worth Hospital, Fort Worth, TX †Mayo Clinic, Rochester, MN.
Journal of orthopaedic trauma (Impact Factor: 1.8). 06/2013; 27(12). DOI: 10.1097/BOT.0b013e31829e7079
Source: PubMed


OBJECTIVES:: This study compared results of aggressive and nonaggressive debridement protocols for the treatment of high energy open supracondylar femur fractures after the primary procedure, with respect to the requirement for secondary bone grafting procedures, and deep infection. DESIGN:: Retrospective review SETTING:: Level I and Level II Trauma Centers PATIENTS/PARTICIPANTS:: Twenty-nine consecutive patients with high grade open (Gustilo Types II and III) supracondylar femur fractures (OTA/AO 33A and C) treated with debridement and locked plating. INTERVENTION:: Surgeons at two different Level I trauma centers had different debridement protocols for open supracondylar femur fractures. One center used a More Aggressive (MA)protocol in their patients (n=17) that included removal of all devitalized bone and placement of antibiotic cement spacers to fill large segmental defects. The other center used a Less Aggressive (LA) protocol in their patients (n=12) that included debridement of grossly contaminated bone with retention of other bone fragments and no use of antibiotic cement spacers. All other aspects of the treatment protocol at the two centers were similar: definitive fixation with locked plates in all cases; IV antibiotics were used until definitive wound closure; and weight bearing was advanced upon clinical and radiographic evidence of fracture healing. MAIN OUTCOME MEASUREMENTS:: Healing after the primary procedure, requirement for secondary bone grafting procedures, and the presence of deep infection. RESULTS:: Demographics were similar between included patients at each center with regard to: age; gender; rate of open fractures; open fracture classification; mechanism; and smoking (p>.05). Patients at the MA center were more often diabetic (p<.05). Cement spacers to fill segmental defects were used more often after MA debridement (35% vs 0%, p<0.006) and more patients had a plan for staged bone grafting after MA debridement (71% vs 8%, p<0.006). Healing after the index fixation procedure occurred more often after LA debridement (92% vs 35%, p<0.003). There was no difference in infection rate between the two protocols: 25% with the LA protocol; and 18% with the MA protocol, (p=0.63). All patients in both groups eventually healed and were without evidence of infection at an average of 1.8 years of follow-up. CONCLUSION:: The degree to which bone should be debrided after a high energy, high grade, open supracondylar femur fracture is a matter of surgeon judgment and falls along a continuous spectrum. Based on the results of the current study, the theoretic tradeoff between infection risk and osseous healing potential , seems to favor a less aggressive approach towards bone debridement in the initial treatment. LEVEL OF EVIDENCE:: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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    • "Aggressive debridement protocols that remove all tissue of questionable viability may create problems due to segmental bone loss, delayed union, and commit the patient to further surgical interventions [75]. A retrospective review of 29 open supracondylar femur fractures compared more and less aggressive debridement protocols, and found that retaining marginal viability fragments whilst still removing grossly contaminated or completely devitalized bone fragments was favoured to balance the outcomes of osseous healing and infection risk [75]. Serial debridement every 48 hours, with delay of closure until achievement of negative post-debridement cultures, can produce low rates of deep infections (5.7% in Grade III injuries; 1.3% in IIIA, 10.6% in IIIB, 20% in IIIC) and avoid the problems of excessive debridement [76]. "
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    ABSTRACT: Open fractures are a common problem encountered by orthopaedic surgeons and comprise a broad spectrum of trauma. Management is guided by principle-based steps aimed at reducing the risk of gas gangrene or suppurative infections, whilst maintaining viability in a favourable soft tissue environment to reduce the risk of delayed or non-union of bone. Aspects of these principles, however, create discussion around several areas of controversy. The specific antimicrobial regimen and its duration are questions that have been evaluated for decades. Like the ever-evolving nature of the bacterial pathogens, the answer to this is dynamic and changing. The "six-hour rule" is a hotly debated topic with fervent perseverance of this dogma despite a gross lack of support from the literature. The most appropriate soft tissue management approach for open fractures - immediate definitive soft tissue closure versus leaving wounds open for delayed closure or definitive management - is also an area of debate. Exploration of these controversies and consideration for the historical context of the supporting literature furthers our understanding of the critical elements.
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    No preview · Article · Apr 2015 · Journal of orthopaedic trauma
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