Abstract
Purpose
Traditional recommendations suggest that open fractures require urgent surgical debridement to reduce infection. Although many papers comparing early vs late debridement have found no difference in infection rates, these papers have not taken into account important confounding factors. We attempt to answer whether delay between injury and surgical debridement in open fractures is associated with a higher infection rate after accounting for these important confounders.
Method
Five hundred and twenty three open extremity fractures in 417 patients were identified using the Sunnybrook trauma and orthopaedic department registries. Thirty patients (36 fractures) did not have complete follow-up. Seven patients were excluded due to incomplete data (complete follow-up rate=91%). A further 14 patients died during their hospitalization. A total of 459 fractures in 364 patients were reviewed. Data was collected on demographics, ISS score, ASA, time to initial operative debridement, timing of antibiotic administration, mechanism of injury, presence of significant contamination, and Gustillo-Anderson fracture grade. Deep infection was defined as an unplanned return to the operating room for treatment of infection. The influence of time to initial debridement was examined in an unadjusted analysis as a continuous variable and at thresholds of 6 and 12 hours of delay. A multivariable logistic regression was used to analyze the effect of delay while controlling for important confounding variables.
Results
46 deep infections occurred in 459 fractures (10%). In an unadjusted analysis, infection was associated with male sex(p=0.038), higher fracture grade(p=0.007), tibial fractures(p=0.027) and gross contamination (p=0.0001). In an unadjusted analysis, delay to debridement was not associated with deep infection (p=0.08) however, higher grade fractures, tibial fractures and grossly contaminated fractures were debrided earlier than less severe open fractures. Multivariable analysis showed infection was associated with each additional hour of delay (OR=1.033 95%CI 1.01 to 1.057), tibial fractures (OR=2.44 95%CI 1.26 to 4.73), higher Anderson & Gustillo grade (OR=1.99 95%CI 1.004 to 3.954), and gross contamination (OR=3.12 95%CI 1.36 to 7.36).
Conclusion
Among more severe open fractures the impact of delay to debridement translates into a larger absolute increase in probability of infection. For example, a grade 2 injury of the forearm without contamination will have a predicted infection rate increase from 2.38% to 2.86% with an additional 6 hours of delay. However, a grade 3b tibial fracture with contamination will have a predicted infection rate increase from 35.6% to 43.3% with 6 hours of further delay. We recommend severe open fractures be debrided emergently while less severe open fractures be debrided urgently.
