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Primary Wound Closure After Open Fracture

A Prospective Cohort Study Examining Nonunion and Deep Infection

Scharfenberger, Angela V. MD, FRCS; Alabassi, Khaled MD; Smith, Stephanie MD, FRCP; Weber, Donald MD, FRCS; Dulai, Sukhdeep K. MD, MSc, FRCS; Bergman, Joseph W. MD, FRCS; Beaupre, Lauren A. PT, PhD

Journal of Orthopaedic Trauma: March 2017 - Volume 31 - Issue 3 - p 121–126
doi: 10.1097/BOT.0000000000000751
Original Article

Objectives: Determine the proportion of subjects developing deep infection or nonunion after primary wound closure of open fractures (humerus, radius/ulna, femur, and tibia/fibula). Secondarily, a matched-series analysis compared outcomes with subjects who underwent delayed wound closure.

Design: Prospective cohort between 2009 and 2013 of subjects undergoing primary closure.

Setting: Trauma center.

Participants: Eighty-three (84 fractures) subjects were enrolled. Eighty-two (99%) subjects (83 fractures) provided follow-up data. Matching (age, sec, fracture location, and grade) was performed using study data of delayed wound closure undertaken at the same center between 2001 and 2009 (n = 68 matched subjects).

Intervention: Primary wound closure occurred when the fracture grade was Gustilo grade 3A or lower and the wound deemed clean at initial surgery. Standardized evaluations occurred until the fracture(s) healed; phone interviews and chart reviews were also undertaken at 1 year.

Main Outcome Measurements: Deep infection is defined as infection requiring unplanned surgical debridement and/or sustained antibiotic therapy after wound closure; nonunion is defined as unplanned surgical intervention after definitive wound closure or incomplete radiographic healing 1-year after fracture.

Results: Three (4%) subjects had deep infections, whereas 10 (12%) subjects developed nonunion in the primary closure cohort. In the matched analyses [n = 68 pairs; (136 subjects)], the primary closure cohort had fewer deep infections [n = 3 (4%) vs. n = 6 (9%)] and nonunions [n = 9 (13%) vs. n = 19 (29%)] than the delayed closure cohort (P < 0.001).

Conclusions: Primary wound closure after an open fracture appears acceptable in appropriately selected patients and may reduce the risk of deep infection and nonunion compared with delayed closure; a definitive randomized trial is needed.

Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Departments of *Surgery;

Infectious Diseases; and

Physical Therapy, University of Alberta, Edmonton, AB, Canada.

Reprints: Lauren A. Beaupre, PT, PhD, 2-50 Corbett Hall, University of Alberta, Edmonton, AB T6G 2G4, Canada (e-mail:

This study was funded through unrestricted research grants from the Edmonton Civic Employees Charitable Foundation and the Edmonton Orthopaedic Research Committee.

L. A. Beaupre receives salary support from the Canadian Institutes for Health Research as a New Investigator (Patient Oriented Research) and Alberta Innovates—Health Solutions as a Population Health Investigator. The remaining authors report no conflict of interest.

Presented as a poster at the Annual Meeting of the Orthopaedic Trauma Association, October 7–10, 2015, San Diego, CA.

This study was approved by the regional health ethics board at the University of Alberta (Pro00009272).

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Accepted November 04, 2016

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