dr.

Juanda Raynaldi
Introduction
• Primary wound closure in management of
open tibia fracture has been discourage.
• Several studies suggest that infections are
not caused by initial contamination but are
instead of nosocomial routes
• The current standart of care established by
Gustillo Anderson since 25 years ago,.
Open Fracture Classification
• Gustilo Anderson
• Type 1: wound size < 1 cm, Clean, low energy, simple
fracture
• Type 2: wound size 1 – 10 cm, moderate contamination,
higher energy
• Type 3:
• A: wound size >10cm, high contamination, comminuted, soft
tissue coverage of bone possible
• B: wound size >10cm, high contamination, comminuted, severe
soft tissue lost, need reconstruction
• C: wound size >10cm, high contamination, comminuted, vascular
injury require repair
Methods
• Retrospective analysed ( Jan ‘98 – Des ‘99)
• Followed up min. 12 month ( Roman et al )
• Two Groups
1. Delayed Wound Closure (Johannesburg Hospital)
2. Primary Wound Closure (Halen Josef Hospital)
• Inclusion Criteria: Isolated open tibia fracture ( type 1, 2
and 3A)
• Exclusion Criteria : grade 3B & 3C, politrauma, significant
unrelated co-morbid, delayed presentation (>24 hrs),
admision to ICU
• Current accepted standart Group 1
1. Early surgical debridement
2. Intravenous AB ( Cefazolin 1 g, 3x1)
3. Stabilization in plaster splint
4. Would left open, debridement 48 – 72 hrs repeat until wound
viable
5. IM tibial nail fixation

• Current accepted standart Group 1

1. Early debridement
2. IM tibial nail
3. Primary wound closure
4. Intravenous AB : from ER to 72 hrs post surgery.
Results
• Group 1
• 49 patients
• 1 infection

• Group 2
• 46 patients
• 2 infection
Discussion
• Prompt assasement, early high pulsatile lavage,
debridement, intravenous AB are widely accepted

• Many authors recomanded the wound left open

• Heitmann et al. reported 64% of all open tibial fractures

are contaminated on presentation in the emergency room.
Confirmed by Faisham et al.
• Robson et al. introduced the concept of the “Golden
Period of Opportunity”,referring to the initial 4–12 h period
following the injury.

• Wound infection generaly occur when bacterial count >

105 on initial swab.

• Many of the organisms that cause deep infection 

nosocomial flora.
• 2 potential advantages of primary wound closure
1. Minimized the risk of nosocomial infection prior to delayed
closure

2. Reduction the length of stay  leading to reduction in the overall

cost of treatment

• the wisdom of mandatory, delayed closure for low energy,

minimally contaminated open tibial fractures can
legitimately be reconsidered.
Conclusion

• There is no significant difference in infection rates

between these two groups.