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Timing of Wound Closure in Open Fractures Based on Cultures Obtained After Debridement
Christopher J. Lenarz, MD1; J. Tracy Watson, MD1; Berton R. Moed, MD1; Heidi Israel, PhD, RN1; J. Daniel Mullen, MSPH, BA, BS2; James B. MacDonald, BS2
1 Department of Orthopaedic Surgery, Saint Louis University, 3635 Vista Avenue, Saint Louis, MO 63110. E-mail address for C.J. Lenarz: lenarzcj@slu.edu. E-mail address for J.T. Watson: watsonjt@slu.edu. E-mail address for B.R. Moed: moedbr@slu.edu. E-mail address for H. Israel: israelha@slu.edu
2 1402 South Grand, Saint Louis, MO 63104. E-mail address for J.D. Mullen: jmullen2@slu.edu. E-mail address for J.B. MacDonald: macdonjb@gmail.com
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

A commentary by Marc F. Swiontkowski, MD, is available at www.jbjs.org/commentary and as supplemental material to the online version of this article.
Investigation performed at the Department of Orthopaedic Surgery, Division of Orthopaedic Traumatology, Saint Louis University School of Medicine, Saint Louis, Missouri

Copyright © 2010 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Aug 18;92(10):1921-1926. doi: 10.2106/JBJS.I.00547
A commentary by Marc F. Swiontkowski, MD, is available here
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The timing of wound closure in open fractures has remained an inexact science. Numerous recommendations have been made for the management of these injuries regarding the optimal time to perform competent wound closure, with all advice based on subjective parameters. The purpose of this study was to determine the utility of a prospective protocol with use of wound cultures obtained after irrigation and debridement as a guide to the timing of wound closure following an open fracture of an extremity.


Four hundred and twenty-two open fractures had emergency irrigation and debridement, fracture stabilization, and open wound management. Wound cultures were obtained for aerobic and anaerobic analysis following debridement. At forty-eight hours after debridement, patients were again returned to surgery. If the initial culture results were positive, a repeat irrigation and debridement was carried out, and additional cultures were obtained after debridement. This procedure was repeated, and the wound was not closed until negative culture results were achieved.


Of the 422 open fractures, 346 were available for long-term follow-up. The overall deep infection rate was 4.3%. Gustilo Type-II fractures had a deep infection rate of 4%, and Type-III fractures had an infection rate of 5.7%. Type-III fractures demonstrated differences among the fracture patterns within this type, as infection developed in 1.8% of Type-IIIA injuries, 10.6% of Type-IIIB fractures, and 20% of Type-IIIC fractures. Fractures requiring multiple debridement procedures and those in patients with diabetes or an increased body mass index demonstrated higher rates of infection. With the numbers studied, fractures in which the wound was closed in the presence of positive cultures (a protocol breach) did not have a significantly increased risk of deep infection (p = 0.0501).


The use of this standardized protocol was shown to achieve a very low rate of deep infection compared with historical controls. An increased number of irrigation and debridement procedures are required to achieve this improved outcome.

Level of Evidence: 

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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