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Deep infection associated with nonunion, delayed healing after treatment for open fracture
Further surgical intervention to facilitate healing was carried out in 90% of these fractures.
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Nonunion and delayed healing following open fracture were associated with deep infection and higher Gustilo grade, according to study results.
“The biggest factor in term of developing a nonunion was if the patient developed a deep infection, but on top of that, we were also able to demonstrate smoking had a weak association with developing a nonunion,” Lauren A. Beaupre, PT, PhD, professor of physical therapy and an adjunct professor in the Division of Orthopedic Surgery at the University of Alberta, in Edmonton, Canada, told Orthopedics Today.
Nonunion, delayed healing
Beaupre and her colleagues recorded patient, fracture and injury information, time to surgery and antibiotics for 736 patients with 791 open fractures. The main outcome measure was nonunion and delayed healing.
Researchers found no difference in median time to surgery between fractures that developed nonunion which was 17% of patients, 90% of which required further surgical intervention to facilitate healing and those that did not. Deep infection, grade 3A fractures and smoking were significantly associated with developing a nonunion while deep infection and grade 3B/C fractures were significantly associated with delayed healing. In multivariate regression, no association was observed between nonunion and time to surgery or antibiotics.
“Looking at nonunion, it was not the exact same factors that predicted an infection, which was interesting,” Beaupre said. “When [a patient is] going to develop an infection, this has to do with having a fracture in [their] lower leg and also having a higher grade fracture. Whereas the development of nonunion, the development of infection was undeniably important, but the location of the fracture did not seem to matter in terms of development of nonunion.”
Clinical bias
Beaupre noted the study had some clinical bias in that investigators could not control for how quickly surgeons chose to take patients to the OR and how many times patients returned to the OR for management of the fracture or wound.
“One of the reasons we did this study was, where we reside in Edmonton, we have a large geographic catchment area, which means we had a huge variation in time to the OR because it sometimes took a long time to get the patients to the surgical site, but we also could not control for that. This allowed us to look at the impact of timing on outcomes because we could not control this factor at the surgical site,” Beaupre said.
Although Beaupre and her colleagues found higher grade fractures had more adverse outcomes, surgeons are aware of this risk. As a result, they are taking these patients to the OR faster instead of delaying surgery, which may have reduced the reported adverse outcomes.
“[Patients] who waited longer did not have these adverse outcomes because surgeons were already trying to get those they believed to be at higher risks for adverse outcomes to the OR as soon as possible. This was a clinical bias we could not control,” she said. – by Casey Tingle
- Reference:
- Westgeest J, et al. J Orthop Trauma. 2016;doi:10.1097/BOT.0000000000000488.
- For more information:
- Lauren A. Beaupre, PT, PhD, can be reached at the University of Alberta, 2-50 Corbett Hall, Edmonton, AB, Canada T6G 2G4; email: lauren.beaupre@ualberta.ca.
Disclosure: Beaupre reports salary support from Alberta Innovates Health Solutions and the Canadian Institute of Health Research.