Time to Initial Operative Treatment Following Open Fracture Does Not Impact Development of Deep Infection: A Prospective Cohort Study of 736 Fractures

SLR - March 2015 - Amanda Quisno

Podiatric Relevance:  The understanding of appropriate management of open fractures is very important to podiatric surgeons, especially those encountering large volumes of foot and ankle trauma. Contemporary guidelines for managing open fracture dictate urgent surgical debridement within six hours, irrigation, administration of antibiotics, and fracture stabilization.  Recently, several studies have called into question the factors surrounding deep infection of open fractures, and whether in fact time to surgical debridement and/or administration of antibiotics truly influence the rate of infection. The purpose of this prospective cohort study was to evaluate the association between time to surgery, antibiotic administration, Gustilo grade, and fracture location in the development of deep infection in open fractures.

Methods: Seven-hundred-thirty-six patients with 791 open fractures were prospectively enrolled and followed, with 686 patients and 737 fractures meeting the final follow-up criteria of 1-year interview or >90 day clinical follow-up. The main outcome analyzed was infection requiring unplanned surgical debridement and/or sustained antibiotic therapy. Rate of infection was compared across various demographics, type/severity of open injury according to Gustilo grade, fracture location, time to surgery, and time to administration of antibiotics.

Results: The most common fractures were tibia/fibula fractures at 52 percent of 413 fractures, followed by upper extremity fractures at 36 percent or 285 fractures. Infection developed in 46 fractures (6 percent); the time to surgical debridement in the cases that developed infection was 7 hours 39 minutes, compare to 9 hours 4 minutes in that that did not. The median time to antibiotic administration was 3 hours 5 minutes for those without and 2 hours 37 minutes for those who did develop deep infection.  Increasing Gustilo grade was associated with a higher rate of infection, with grade 3B/3C fractures accounting for 17 of 46 infections or 37 percent.

Conclusions: There was no association between infection and time to surgery or antibiotic administration. Grades 3A and 3B/C relative to grade 1 injuries were significantly associated with increased infection rate, as were tibia/fibular injuries as compared to upper extremity injuries. These findings suggest that with low numbers of infections seen in Gustilo grade 1 and 2 fractures and upper extremity open fractures, there may be reason or justification for delaying these fracture in the middle of the night if the appropriate personnel or a trauma room are available in the morning.