Since the time of Hippocrates, the goal of management of an open fracture has been to limit infection. Infection dramatically increases the risk of amputation, and thus this has been an appropriate focus. The role of cultures obtained during initial and subsequent wound debridement procedures has long been studied in the orthopaedic community. This Level-IV study endeavors to evaluate the role of serial cultures following wound debridement in improving the long-term outcomes for open fractures. As is the case with most retrospective series, substantial loss to follow-up is apparent, with complete data available for only 346 of the 422 open fractures. The overall deep infection rate of 4.3% is laudable in this group of seriously injured patients. The finding that fractures requiring multiple wound debridement procedures because of serial positive cultures and those in patients with diabetes or obesity have higher infection rates is confirmatory. Of note is the somewhat surprising fact that when wounds were closed in the presence of positive cultures, there was no significantly increased risk of deep infection.
Level-IV studies are frequently most valuable in producing a hypothesis for further study under controlled trial regimens. Hopefully, this study will produce such a prospective randomized investigation. The value of intraoperative serial cultures in limiting the deep infection rate remains unknown. On the basis of this retrospective analysis of data, however, it seems that this treatment plan used by a highly qualified group of surgeons at a Level-I center is appropriate for dissemination into other high-volume centers. Certainly, the resulting overall rate of deep infection of 4.3%, with a rate of 4.1% for Gustilo Type-II fractures, an overall rate of 5.7% for Type-III fractures, 1.8% for Type-IIIA fractures, 10.6% for Type-IIIB fractures, and 20% for Type-IIIC fractures, is excellent and very much on the favorable side of optimum outcomes in the peer-reviewed literature. This reviewer hopes that these investigators will work with like-minded colleagues in similar settings to produce the Level-I evidence that will further clarify these associations for the orthopaedic community.