The purpose of this study is to help doctors who treat open fractures understand how much fluid is required when cleaning out the wound. Participants will spend about 12 months in this study and will be asked to answer study questions about your recovery at your typical follow up clinic visits with your surgeon. After the surgeon has determined a participant's bone has healed, any remaining study visits can be conducted over the phone, email, and/or mail. Participants will not be asked to attend additional clinic visits as part of this study. Researchers will compare two different fluid volume protocols to determine if one results in better fracture and/or wound healing.

This study compares the two irrigation protocols for Irrigation and Debridement (I&D) of open fractures. Open fractures are classified using the Gustilo-Anderson classification criteria, which divides these fractures into Types I, II, and III. The study protocols being compared differ in the volume of normal sterile saline used during the I&D procedure. Protocol A sets the volume of irrigation to be 1L normal sterile saline for Type I and Type II open fractures and 3L for Type III open fractures. Protocol B uses 3L normal saline for Type I open fractures, 6L for Type II, and 9L for Type III. Irrigation volumes for Protocol A are based on current practice by orthopedic trauma surgeons at Inova. Volumes in Protocol B are based on the FLOW trial study design.

Hypothesis: Decreased irrigation volumes (Protocol A) during surgical I&D will be non-inferior to high irrigation volumes (Protocol B) with respect to the development of surgical site infection.

Study Design: This is a bimonthly cluster randomized trial in which the study. When enrollment begins, the first two-month (60-day) period will be randomly assigned to either Protocol A or B. Thereafter, the study treatment in effect allocation will alternate every two months (60 days). Since investigators will need this information to conduct the study treatment they cannot be blinded to treatment assignments.

This study design is based on the PREP-IT and PREPARE trials, which were national, multicenter RCTs that compared post-surgical infection rates after using different skin sterilization solutions to prepare surgical sites of open and closed fractures.

Patients will receive the protocol in effect at the time they consent to participate in the study, prior to their I&D, unless otherwise clinically indicated by their study surgeon while in the operating room (OR). All open fracture patients will be screened for participation in the study during their initial evaluation and admission to the hospital, based on inclusion and exclusion criteria detailed in the study protocol. A member of the study team will discuss the study with patients meeting the appropriate criteria prior to their first I&D. These patients will either be consented/enrolled or will be screen failed due to lack of consent.

Inclusion Criteria:

• Age 18 or older
• Patient diagnosed with a Type I, II, or III open fracture of the appendicular skeleton by a study surgeon
• For the purposes of this study, an open fracture is a fracture associated with a soft tissue wound which may or may not be contiguous with the fracture.
• Open fractures of the carpals, tarsals, metacarpals, metatarsal, and/or phalanges without the involvement of a long bone or the hindfoot will not be considered.

Exclusion Criteria:

• Patient is unable to understand Informed Consent and/or HIPAA Authorization Form
• Patient does not speak English
• Patient is pregnant
• Patient is unable or (in the judgment of research personnel) unlikely to attend follow-up visits.
• Patient was previously enrolled in a study which has the same primary outcomes or may influence infection rate or bone healing
• Patient declines to participate in study

This is a pilot study taking place at one hospital system. All data analysis is planned to take place in-house and there are currently no established data use agreements for the information to be collected.