THE MANAGEMENT OF OPEN FRACTURES ASSOCIATED WITH ARTERIAL INJURY REQUIRING VASCULAR REPAIR

Seventy-two open fractures associated with arterial injury requiring v ascular repair (Gustilo type IIIC injuries) were treated at the Univer sity of Louisville from May 1983 and through 1992. The involved anatom ic areas were the humerus (four), forearm (ten), femur (eight), tibia (31), ankle (ten), and foot (nine). Fracture management consisted of c areful debridement, wound irrigation, fasciotomy, and fracture stabili zation. Additionally, 40 wounds (55.6%) were treated with the suppleme ntal use of local antibiotics (tobramycin-PMMA bead chains). Twenty-th ree patients (32.1%) underwent primary amputation, and 49 (67.99%) of the injured vessels were repaired. There were seven secondary amputati ons because of infection or poor revascularization, resulting in an ov erall amputation rate of 41.6%. The wound infection rate was 13.9% (10 of 72) and the rate for osteomyelitis was 4.2% (3 of 72). The local u se of the antibiotic bead chains was of significant benefit in lowerin g infectious complications. Primary coverage of soft-tissue defects wi th free tissue transfer had an infection rate of 66%; temporary wound coverage with the ''antibiotic bead pouch'' technique until wound clos ure can be obtained in a sterile and viable environment appears to be a better option.