A comparison of more and less aggressive bone debridement protocols for the treatment of open supracondylar femur fractures

William M. Ricci, Cory Collinge, Philipp N Streubel, Christopher M. McAndrew, Michael J. Gardner

Research output: Contribution to journalArticle

14 Citations (Scopus)

Abstract

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 2 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 2 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 > 0.05). Patients at the MA center were more often diabetic (P < 0.05). 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 2 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. CONCLUSIONS:: 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 trade-off between infection risk and osseous healing potential seems to favor an LA approach toward bone debridement in the initial treatment. LEVEL OF EVIDENCE:: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Original languageEnglish (US)
Pages (from-to)722-725
Number of pages4
JournalJournal of Orthopaedic Trauma
Volume27
Issue number12
DOIs
StatePublished - Dec 1 2013

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Debridement
Clinical Protocols
Femur
Bone and Bones
Bone Transplantation
Infection
Open Fractures
Trauma Centers
Anti-Bacterial Agents
Fracture Healing
Weight-Bearing
Smoking
Demography
Wounds and Injuries
Therapeutics

Keywords

  • Debridement
  • Infection
  • Nonunion
  • Open Fracture

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine

Cite this

A comparison of more and less aggressive bone debridement protocols for the treatment of open supracondylar femur fractures. / Ricci, William M.; Collinge, Cory; Streubel, Philipp N; McAndrew, Christopher M.; Gardner, Michael J.

In: Journal of Orthopaedic Trauma, Vol. 27, No. 12, 01.12.2013, p. 722-725.

Research output: Contribution to journalArticle

Ricci, William M. ; Collinge, Cory ; Streubel, Philipp N ; McAndrew, Christopher M. ; Gardner, Michael J. / A comparison of more and less aggressive bone debridement protocols for the treatment of open supracondylar femur fractures. In: Journal of Orthopaedic Trauma. 2013 ; Vol. 27, No. 12. pp. 722-725.
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AU - Gardner, Michael J.

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N2 - 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 2 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 2 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 > 0.05). Patients at the MA center were more often diabetic (P < 0.05). 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 2 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. CONCLUSIONS:: 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 trade-off between infection risk and osseous healing potential seems to favor an LA approach toward bone debridement in the initial treatment. LEVEL OF EVIDENCE:: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

AB - 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 2 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 2 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 > 0.05). Patients at the MA center were more often diabetic (P < 0.05). 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 2 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. CONCLUSIONS:: 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 trade-off between infection risk and osseous healing potential seems to favor an LA approach toward 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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KW - Infection

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