The management of open fractures associated with arterial injury requiring vascular repair.

Seventy-two open fractures associated with arterial injury requiring vascular repair (Gustilo type IIIC injuries) were treated at the University of Louisville from May 1983 and through 1992. The involved anatomic areas were the humerus (four), forearm (ten), femur (eight), tibia (31), ankle (ten), and foot (nine). Fracture management consisted of careful débridement, wound irrigation, fasciotomy, and fracture stabilization. Additionally, 40 wounds (55.6%) were treated with the supplemental use of local antibiotics (tobramycin-PMMA bead chains). Twenty-three patients (32.1%) underwent primary amputation, and 49 (67.99%) of the injured vessels were repaired. There were seven secondary amputations because of infection or poor revascularization, resulting in an overall 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 use of the antibiotic bead chains was of significant benefit in lowering infectious complications. Primary coverage of soft-tissue defects with free tissue transfer had an infection rate of 66%; temporary wound coverage with the "antibiotic bead pouch" technique until wound closure can be obtained in a sterile and viable environment appears to be a better option.