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Open fracture severity correlated with in amputation rate
Recently published results showed a correlation between the increase in the severity of injury according to the Orthopaedic Trauma Association-Open Fracture Classification and the increase in the rate of amputation and infection requiring intravenous antibiotics.
Researchers recorded patient age, AO/Orthopaedic Trauma Association (OTA) fracture classification, number of operative debridements, negative pressure wound dressing use and antibiotic bead use for 359 patients with a total of 403 open fractures. Researchers obtained outcomes of amputation within the first 90 days, infection requiring intravenous antibiotics during initial or subsequent hospitalizations, and surgical or traumatic wound healing from subsequent follow-up. Researchers also grouped fractures by upper and lower extremity regions for analysis.
Results showed development of infection in 24% of fractures which necessitated admission for intravenous antibiotics, as well as amputation that occurred in 7% of fractures in the first 90 days. Researchers found 65 wounds did not heal, of which 10 underwent subsequent amputation.
Increasing severity of a skin injury was the most significant predictor of additional debridements, while additional predictors included muscle injury in the upper extremity population, and arterial injury and wound contamination in the lower extremity population. Researchers noted skin injury was the most significant predictor of amputation.
Additional significant predictors of amputation for the overall population included arterial injury and muscle injury, while arterial injury was an additional significant predictor for the lower extremity population. For both the overall population and the lower extremity population, researchers found skin injury and bone loss were significant predictors of IV antibiotics for infection.
According to results, skin injury was a significant predictor of vacuum-assisted closure use for the overall population, the upper extremity population and the lower extremity population. Muscle injury was also a significant predictor of vacuum-assisted closure use in the overall population and the lower extremity population, researchers found. Results showed skin injury in the upper extremity was the significant predictor of the OTA-Open Fracture Classification for a non-healing wound. – by Casey Tingle
Disclosure: The researchers report no relevant financial disclosures.
Perspective
Back to TopFor many years orthopedic surgeons have been trying to devise a classification scheme for open fractures that is reproducible (an injury is classified similarly by different surgeons or by the same surgeon at different times), valid (measures what it is supposed to measure, ie, injury severity) and prognostic (can predict complications and guide treatment to prevent these). The data reported by Johnson and colleagues is from a large, prospective, clinical trial evaluating the qualities of the Orthopaedic Trauma Association’s Open Fracture Classification system (OTA-OFC).
The good news is that the OTA-OFC (which has previously been shown to have good to excellent reproducibility) was predictive of a number of clinically important early (90-day) outcomes, such as the risk of amputation or readmission for intravenous antibiotics. The bad news is that it did not predict which wounds would not heal, an outcome that is increasingly important from a number of clinical and economic standpoints. It would have been valuable to include patient comorbidities, such as diabetes or smoking, that may well have as important an effect on wound healing as the actual wound itself.
Somewhat surprising were the high overall infection (24%) and non-healing wound (16%) rates at the 10 centers involved, many of which are national leaders in the trauma field. This study is an important step forward in this field, but there is still work to be done.