Open ankle fractures: Factors influencing unplanned reoperation.

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Abstract

[Indexed for MEDLINE] Conflict of interest statement: Declaration of Competing Interest None. 8. J Bone Joint Surg Am. 2025 Nov 19;107(22):2541-2553. doi: 10.2106/JBJS.24.01055. Epub 2025 Nov 19. Infection and Nonunion Rates in Open Fractures: Description of 6,042 Fractures from the FLOW and PREP-IT Trials. Natoli RM(1), Marchand LS(2), Bzovsky S(3), Hagen JE(4), Gage MJ(5), Stennett CA(5), O'Hara NN(5), Jeray KJ(6), Petrisor B(3), Sprague S(3)(7), Slobogean GP(5); the FLOW Investigators; the PREP-IT Investigators; the FLOW Investigators and the PREP-IT Investigators. Collaborators: Slobogean GP, Sprague S, Wells J, Bhandari M, Harris AD, Mullins CD, Thabane L, Wood A, Della Rocca GJ, Hebden J, O'Hara LM, Zura R, Lee C, Patterson J, Gardner MJ, Blasman J, Davies J, Liang S, Taljaard M, Devereaux PJ, Guyatt GH, Marvel D, Palmer J, Friedrich J, Grissom F, D'Alleyrand JC, Rivera J, Talbot M, Joshi MG, Mossuto F, Medeiros M, Polk G, Kettering E, Mahal N, Pogorzelski D, Dodds S, Leonard J, Li S, Rojas A, Del Fabbro G, Szasz OP, Heels-Ansdell D, Bzovsky S, McKay P, Minea A, Murphy K, O'Toole RV, O'Hara NN, Schrank G, Eglseder A, Johnson A, Langhammer C, Nascone J, Pensy R, Pollak A, Sciadini M, Hempen E, Degani Y, Howe A, Camara M, Phipps H, Rudnicki J, Holler C, Aumann K, Spelta J, Nieves J, Smetzer B, Dunning J, Krudener K, Lock E, Marineau L, Petrisor BA, Johal H, Ristevski B, Williams D, Denkers M, Rajaratnam K, Al-Asiri J, Gallant J, Pusztai K, MacRae S, Renaud S, Gjorgjievski M, Jeray KJ, Adams JD, Beckish ML, Bray CC, Brown TR, Cross AW, Dew T, Faucher GK, Gurich RW Jr, Lazarus DE, Millon SJ, Moody MC, Palmer MJ, Porter SE, Schaller TM, Sridhar MS, Sanders JL, Rudisill LE Jr, Garitty MJ, Poole AS, Sims ML, Walker CM, Carlisle R, Hofer EA, Huggins B, Hunter M, Marshall W, Ray SB, Smith C, Altman KM, Pichiotino E, Quirion JC, Loeffler MF, Pichiotino ER, Cole AA, Maltz EJ, Parker W, Ramsey TB, Burnikel A, Colello M, Stewart R, Wise J, Anderson M, Eskew J, Judkins B, Miller JM, Tanner SL, Snider RG, Townsend CE, Pham KH, Martin A, Robertson E, Bray E, Sykes JW, Yoder K, Conner K, Abbott H, Natoli RM, McKinley TO, Virkus WW, Sorkin AT, Szatkowski JP, Mullis BH, Jang Y, Lopas LA, Hill LC, Diaz MM, Garst KM, Denari EW, Osborn P, Fowler J, Pierrie S, Morshed S, Miclau T, Marmor M, Matityahu A, McClellan RT, Shearer D, Toogood P, Ding A, Murali J, El Naga A, Tangtiphaiboontana J, Belaye T, Berhaneselase E, Pokhvashchev D, Obremskey WT, Jahangir AA, Sethi M, Boyce R, Stinner DJ, Mitchell P, Trochez K, Rodriguez E, Pritchett C, Hogan N, Moreno AF, Hagen JE, Patrick M, Vlasak R, Krupko T, Talerico M, Horodyski M, Pazik M, Lossada-Soto E, Gary JL, Warner SJ, Munz JW, Choo AM, Achor TS, Chip Routt ML, Kutzler M, Boutte S, Warth RJ, Prayson M, Venkatarayappa I, Horne B, Jerele J, Clark L, Boulton C, Lowe J, Ruth JT, Askam B, Seach A, Cruz A, Featherston B, Carlson R, Romero I, Zarif I, Dehghan N, McKee M, Jones CB, Sietsema DL, Williams A, Dykes T, Guerra-Farfan E, Tomas-Hernandez J, Teixidor-Serra J, Molero-Garcia V, Selga-Marsa J, Porcel-Vazquez JA, Andres-Peiro JV, Esteban-Feliu I, Vidal-Tarrason N, Serracanta J, Nuñez-Camarena J, Villar-Casares MDM, Mestre-Torres J, Lalueza-Broto P, Moreira-Borim F, Garcia-Sanchez Y, Marcano-Fernández F, Martínez-Carreres L, Martí-Garín D, Serrano-Sanz J, Sánchez-Fernández J, Sanz-Molero M, Carballo A, Pelfort X, Acerboni-Flores F, Alavedra-Massana A, Anglada-Torres N, Berenguer A, Cámara-Cabrera J, Caparros-García A, Fillat-Gomà F, Fuentes-López R, Garcia-Rodriguez R, Gimeno-Calavia N, Martínez-Álvarez M, Martínez-Grau P, Pellejero-García R, Ràfols-Perramon O, Peñalver JM, Domènech MS, Soler-Cano A, Velasco-Barrera A, Yela-Verdú C, Bueno-Ruiz M, Sánchez-Palomino E, Andriola V, Molina-Corbacho M, Maldonado-Sotoca Y, Gasset-Teixidor A, Blasco-Moreu J, Fernández-Poch N, Rodoreda-Puigdemasa J, Verdaguer-Figuerola A, Cueva-Sevieri HE, Garcia-Gimenez S, Viskontas DG, Apostle KL, Boyer DS, Moola FO, Perey BH, Stone TB, Lemke HM, Spicer E, Payne K, Hymes RA, Schwartzbach CC, Schulman JE, Malekzadeh AS, Holzman MA, Gaski GE, Ramsey L, Pilson H, Carroll EA, Halvorson JJ, Babcock S, Goodman JB, Holden MB, Williams W, Hill T, Brotherton A, Syme J, Romeo NM, Vallier HA, Vergon A, Levine A, Hirschfeld A, Higgins TF, Haller JM, Rothberg DL, Marchand LS, Olsen ZM, McGowan AV, Hill S, Dauk MK, Bergin PF, Russell GV, Graves ML, Morellato J, McGee SL, Bhanat EL, Yener U, Khanna R, Nehete P, Powe SE, Potter D, VanDemark R 3rd, Seabold K, Staudenmier N, Gitajn IL, Chang G, Wolinsky P, Mullin DS, Chockbengboun TA, Anderson JM, Malskis B, Fisher L, Phelps K, Bosse M, Karunakar M, Kempton L, Sims S, Hsu J, Seymour R, Churchill C, Mayfield A, Sweeney J, Jaeblon T, Beer R, Demyanovich HK, Bauer B, Meredith S, Talwar S, Domes CM, Kuhn G, Gage MJ, Reilly RM, Paniagua A, Dupree J, Weaver MJ, von Keudell AG, Sagona AE, Brameier D, Suneja N, Mehta S, Donegan D, Horan A, To L, Heng M, Harris MB, Lhowe DW, Esposito JG, Alnasser A, McTague M, Shannon SF, Scott AN, Clinch B, Weber B, Beltran MJ, Archdeacon MT, Sagi HC, Wyrick JD, Le TT, Laughlin RT, Thomson CG, Hasselfeld K, Lin CA, Vrahas MS, Moon CN, Little MT, Marecek GS, Dubuclet DM, Garlich JM, Scolaro JA, Learned JR, Lim PK, Demas S, Amirhekmat A, Dela Cruz YM, Abdallah H, Shankar AN, Campbell A, Nauth A, Creek AT, Lawendy AR, Dowrick A, Gupta A, Yee A, Denault A, Al-Ashtari A, Toth A, Hammond A, Liew A, Diane A, Svotelis A, Lippert A, Garza A, Chia A, Evans A, Gong A, Marcantonio AJ, Schmidt A, Rai AK, Brekke AC, Deshaies A, Dubey A, Beardmore A, Johnson A, Rhorer A, Duraikannan A, Stodle A, Patil A, Kreitenberg A, Amundsen A, Moaveni A, Carr A, Patil A, Hill AD, Hoang B, Barden BB, Koch BS, Benoit B, Laliberté B, LaRue B, Flatoy B, Perey B, Ristevski B, Petrisor B, Pilkey B, Crist BD, Brigman B, Drew B, Jolley B, Miller B, Mullis B, Richardson CG, Coady C, Aga C, Coles C, Théorêt C, Harbour C, Metha C, Puram C, Bailey C, Graham C, Tieszer C, Sage C, Moorman CT, Jones CB, Donohue C, Williams D, Rispoli D, Farrell DJ, Whelan D, Viskontas D, Brown D, Volgas DA, Alexander D, Bielema DJ, Johnston D, Conner DM, Nelles D, Pichora D, Goetz DR, Ruch D, Sanders D, Stephen D, Volgas D, Zamorano D, Taylor D, Lawson D, Bartley D, Sietsema DL, Pourmand D, Nassikars D, Mann D, Kwok D, Heels-Ansdell D, Nam D, Tuder D, Rouleau D, Gajewski D, Lopez D, Boyer D, Li D, Altman D, Bednar D, Price DM, Watson DJ, Bogoch E, Harvey E, Vesterhus EB, Langslet E, Edwards E, Schemitsch EH, Keener E, Lenczner E, Meinberg E, Ritchie E, Torres EG, Nott E, Ek E, Wai E, Moola F, Adamsahib F, Houghton F, Howells F, Cabana F, Vézina F, Leversedge F, Frihagen F, Balg F, Nilsen F, Laflamme GY, Gudger GK Jr, Johnson G, Hjorthaug G, Reardon G, Moatshe G, Ortega G, Guyatt GH, Garrigues G, Bennett GW, Berry G, Etherington G, Maytok G, Della Rocca GJ, Flugsrud G, Ekås G, Lemke HM, Curry H, Kreder H, Malempati H, Bedi H, Furunes H, Côté H, Ahn H, Broekhuyse HM, Apold H, Sletten I, Tarkin I, Wong I, Smitherman JA, Trenholm JA, Amirault JD, Broderick JS, Ficke J, Stannard JP, Ringler JR, Waddell J, Brattgjerd JE, Walker JE, Ertl J, Lowe J, Stoneback J, Vourazeris J, Lamontagne J, Joncas JF, Anglen J, Anglen J, Leary J, Downey J, Hidy JT, Westberg JR, Hall JA, Goldstein J, Finkelstein J, Tanksley JA Jr, Clarke-Jenssen J, Adams JD Jr, Garfi J, Hoseth JM, Murnaghan J, Sadler J, Tilzey J, Rydinge J, Kwong J, Foret JL, Alderete J, Cox J, Hsu J, O'Neill J, Baumfeld J, Bradford-Johnson JM, Foxall J, Lee J, Sernik J, Fournier J, Langan JW, Rai KN, Tardif K, Shively K, Moon K, Bedigrew KM, Markley K, Hornbuckle K, Milner K, Lefaivre KA, Apostle K, Sullivan KM, Trask K, Tai K, Gurr K, Kruse KK, Kirk K, Kuhn K, Hemlock K, Madden K, Doshi KM, Rajaratnam K, Walick K, Reid K, Jeray KJ, Nordsletten L, Nastoff LA, Leffler LC, Barron L, O'Malley LK, Barnes L, Dillender L, Anderson LK, Lépine L, Blackrick L, Buckingham L, Cannada LK, Clark LK, Wood L, Sharp LM, Ton L, Bédard L, Lemire L, Petitclerc L, Jackson LT, Bhatia M, Magalhaes-Grave MA, Manson M, Roger ME, Molund M, Burman M, Glazebrook M, Lemos M, Macleod M, Nousiainen M, Bischoff M, Bédard M, Tynan M, Fan M, Russ M, Mammen M, Denkers M, Karam M, Robinson M, Ross M, Zomar M, Esser M, Talbot M, Marmor M, Leonard M, MacNevin M, Earles MM, Andersen M, Biddulph M, Bolognesi M, Bosse M, Charlton M, Connally M, McKee MD, Dunbar M, Ford M, Gross M, Maughon MJ Jr, Prayson MJ, Kain M, Beckish ML, Jabara MR, Tanzer M, Malo M, Arakgi M, Cho M, Weber M, Vicente MR, Bhandari M, Moore M, Kunz M, Smedsrud M, Pekmezci M, Karne NJ, Jhangiani N, Jain N, Patenaude N, Sultana N, Malone NH, Leontaritis N, Bhatia N, Shadmi N, Muller O, Wang O, Sancheti P, Lévesque-Bernier P, Henry P, Osborn P, Yoon P, Martineau P, Tornetta P 3rd, McKay P, Bogsti P, O'Brien PJ, Jarzem P, Siska P, Iversen P, Beaumont P, Lavallée P, Ranger P, Blachut PA, Patel P, Murphy RL Jr, Saravana R, Reilly R, Moon R, Gandhi R, Johal R, Andreson R, Rai R, Topp R, Snider RG, Dumais R, Stewart R, De Gorter R, Mather RC 3rd, Coughlin R, Freeman R, Holtby R, Jenkinson R, Laughlin RT, Gurich RW Jr, Wilk R, Harman RL, Worman R, Teasdall RJ, Lark R, Marien R, McCormack R, Turcotte R, Zura R, Richards R, Trimba R, Leighton R, Reindl R, Miller R, Bicknell RT, McClure SB, Hollenbeck SM, Morshed S, Adams S, Bederman S, Agnew SG, Porter SE, Watson ST, Rodriguez-Elizalde S, Ramasunder S, Bielby SA, Sprague S, MacDonald S, Sayeed S, Knuts S, Clawson S, Leduc S, Pelet S, Ricard S, Tanner SL, Walter SD, Doig S, Finley SH, Kingwell S, Csongvay S, Rocha S, Olson S, Papp S, Liew S, Nix T, Vlack T, Tufescu TV, Endres TJ, Axelrod T, Schaller TM, Varecka T, Belaye T, Dwyer T, Carey T, Daniels T, Miller TJ, Gerlinger T, Treseder T, Nicolaysen T, Ianssen T, Fjalestad T, Burns T, Stone T, McClellan T, Kandemir U, Frizzell V, Halvorsen V, Place V, Wadey V, Yadav V, Arora V, Tyagi V, Jabade VV, Gofton W, Kactmas W, Lackey WG, Ghent W, Fisher W, Min W, Oxner W, Murtha YM, Murdoch Z. Author information: (1)Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana. (2)Department of Orthopaedics, University of Utah, Salt Lake City, Utah. (3)Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada. (4)Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, Florida. (5)Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland. (6)Department of Orthopedic Surgery, Prisma Health-Upstate, Greenville, South Carolina. (7)Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada. Comment in doi: 10.2106/JBJS.25.00175. BACKGROUND: Infection and nonunion are common sequelae of open fractures. Studies have shown infection and nonunion rates ranging from 2% to 52% and 12% to 17%, respectively. The present article describes the rates of surgical site infection (SSI) and delayed union/nonunion following open fractures in a large contemporary series of patients from prospective clinical trials with adjudicated outcomes. METHODS: A descriptive analysis was performed with use of patient data from the FLOW, Aqueous-PREP, and PREPARE-Open studies. These studies, published within the past 10 years, included multiple international trauma centers and shared definitions for SSI and delayed union/nonunion. SSI and delayed union/nonunion rates were stratified by the OTA/AO fracture and Gustilo-Anderson open fracture classification systems. Kaplan-Meier estimators were utilized to obtain point estimates, and the log-log transformation approach was utilized to calculate 95% confidence intervals (CIs) for outcome rates. RESULTS: A total of 6,042 open fractures were included. The cumulative SSI rates at 12 months for Gustilo-Anderson Types 1, 2, 3A, 3B, and 3C were 5.1%, 9.7%, 13.8%, 28.9%, and 26.2%, respectively. The cumulative rates of delayed union/nonunion at 12 months for Gustilo-Anderson Types 1, 2, 3A, 3B, and 3C were 3.0%, 5.2%, 8.0%, 14.0%, and 17.0%, respectively. Utilizing the OTA/AO fracture classification to increase the point estimate granularity, the estimated 12-month SSI and delayed union/nonunion rates in 156 Gustilo-Anderson type 3B open tibial shaft fractures (OTA/AO 42) were 34.7% (95% CI, 26.7% to 41.9%) and 18.4% (95% CI, 12.0% to 24.4%), respectively. A companion website with SSI and delayed union/nonunion rates was developed to supplement this article. CONCLUSIONS: Open fractures are a substantial problem with complications that include infection and nonunion. The present data are useful for prognosis, research study design, and informing public awareness and policy. These results show that, despite current treatment approaches, the rates of SSI and delayed union/nonunion following treatment of open fractures remain high at 1 year and are not substantially improved from historical rates spanning several decades. Although open fracture sequelae remain a burden for patients, orthopaedic surgeons, and health-care systems, there may be opportunities for improvement in outcomes. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence. Copyright © 2025 The Author(s). Published by The Journal of Bone and Joint Surgery, Incorporated. DOI: 10.2106/JBJS.24.01055 PMCID: PMC12614385