A Reevaluation of the Risk of Infection Based on Time to Debridement in Open Fractures

Abstract

Update This article was updated on February 9, 2021, because of a previous error. On page 269, in the Note at the end of the article, the surname that had read “Merner” now reads “Mener.” An erratum has been published: J Bone Joint Surg Am. 2021 Mar 17;103(6):e25. Background: Open fractures are one of the leading causes of disability worldwide. The threshold time to debridement that reduces the infection rate is unclear. Methods: We searched all available databases to identify observational studies and randomized trials related to open fracture care. We then conducted an extensive meta-analysis of the observational studies, using raw and adjusted estimates, to determine if there was an association between the timing of initial debridement and infection. Results: We identified 84 studies (18,239 patients) for the primary analysis. In unadjusted analyses comparing various “late” time thresholds for debridement versus “early” thresholds, there was an association between timing of debridement and surgical site infection (odds ratio [OR] = 1.29, 95% confidence interval [CI] = 1.11 to 1.49, p < 0.001, I2 = 30%, 84 studies, n = 18,239). For debridement performed between 12 and 24 hours versus earlier than 12 hours, the OR was higher in tibial fractures (OR = 1.37, 95% CI = 1.00 to 1.87, p = 0.05, I2 = 19%, 12 studies, n = 2,065), and even more so in Gustilo type-IIIB tibial fractures (OR = 1.46, 95% CI = 1.13 to 1.89, p = 0.004, I2 = 23%, 12 studies, n = 1,255). An analysis of Gustilo type-III fractures showed a progressive increase in the risk of infection with time. Critical time thresholds included 12 hours (OR = 1.51, 95% CI = 1.28 to 1.78, p < 0.001, I2 = 0%, 16 studies, n = 3,502) and 24 hours (OR = 2.17, 95% CI = 1.73 to 2.72, p < 0.001, I2 = 0%, 29 studies, n = 5,214). Conclusions: High-grade open fractures demonstrated an increased risk of infection with progressive delay to debridement. Level of Evidence: Prognostic Level IV. See Instruction for Authors for a complete description of the levels of evidence.

Clinical and Radiological Outcomes of Gustilo-Anderson Type IIIB Open Fractures in 125 Patients

“…The BOA/BAPRAS standards replaced this threshold by advising on immediate debridement for grossly contaminated wounds or suspected compartment syndrome, debridement within 12 hours for solitary high-energy open fractures and debridement within 24 hours for all other low-energy open fractures [ 6 ]. A study of 77 open fractures by Patzakis et al and another meta-analysis involving over 18,000 patients by Goliath investigators showed increased risk of infection after 12 hours [ 16 , 17 ]. However, Hendrickson et al, in their retrospective review of 116 GA grade IIIB open fractures, showed no difference in infection rates when debridement is done before or after the 12-hour threshold [ 18 ].…”

Type III Gustilo–Anderson open fracture does not justify routine prophylactic Gram-negative antibiotic coverage

“…We performed one-to-one propensity score-matched analysis for the administration of broad-spectrum antibiotics. We selected patient demographic characteristics and other potential confounding variables derived from previous studies 8 , 21 – 23 . Those factors included age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) class, smoking, diabetes mellitus, time to completion of debridement, open fracture location (i.e., upper vs. lower extremity), Gustilo–Anderson classification, and summative score of the OTA-OFC.…”

Revisiting the Classic Open Fracture Studies to Correct Misperceptions and Errors

“…(2) “All open fractures were treated as emergencies,” whereas today many open fractures are operated in a timely basis but not necessarily as an emergency. As noted in the GOLIATH meta-analysis, 6 current recommendations suggest that open fractures should be surgically addressed within 12 hours, especially type III fractures.…”

“…4,5 (2) “All open fractures were treated as emergencies,” whereas today many open fractures are operated in a timely basis but not necessarily as an emergency. As noted in the GOLIATH meta-analysis, 6 current recommendations suggest that open fractures should be surgically addressed within 12 hours, especially type III fractures.(3) The authors routinely cultured the wounds on admission and again before wound closure. Open fracture wounds are rarely cultured today unless the wound seems infected (not just contaminated).…”