Abstract
Background
Traditional recommendations suggest that open fractures require urgent surgical debridement to reduce infection. However, this has recently been challenged by a number of investigations. However, in many cases, these studies were not able to control for important confounding factors. The purpose of our study was to evaluate the relationship between delay to definitive surgical debridement while controlling for important confounders.
Method
364 patients with 459 open fractures treated at a level one trauma centre over four years were reviewed. Time to definitive surgical debridement was modelled as a predictor of infection while controlling for fracture grade, anatomic site of fracture, and presence of significant contamination. Time to debridement was modelled as both a continuous variable and a categorical variable with cut off points at 6 and 12 hours of delay.
Results
46 deep infections occurred in 459 fractures(10%). There were no infections among grade one open fractures(0/55). Delay to debridement using cut-points of 6 hours and 12 hours was not associated with an increased infection rate. However, with delay to debridement analyzed as a continuous variable each additional hour of delay was associated with an increase in the odds of infection(OR=1.033 95%CI 1.01–1.057). Multivariable analysis also showed that infection was associated with tibial fractures(OR=2.44 95%CI 1.26–4.73), higher Anderson & Gustillo grade (OR=1.99 95%CI 1.004–3.954), and gross contamination (OR=3.12 95%CI 1.36–7.36).
Among more severe open fractures the impact of delay to debridement translates into a larger absolute increase in probability of infection.
Conclusion
We recommend that higher grade open fractures be treated with definitive debridement as soon as possible given that the risk of infection increases in a linear fashion with time delay. For severe open fractures, especially tibial, we recommend emergent debridement as soon as the patient has been resuscitated and is stable enough to undergo surgery.
