Marissa Srour1, Kenji Inaba1, Obi Okoye1, Carney Chan1, Dimitra Skiada1, Beat Schnüriger1, Mark Trump2, Lydia Lam1, Demetrios Demetriades1. 1. Division of Acute Care Surgery, Department of Surgery, Keck School of Medicine, Los Angeles County and University of Southern California Medical Center, Los Angeles. 2. Department of Orthopedic Surgery, Keck School of Medicine, Los Angeles County and University of Southern California Medical Center, Los Angeles.
Abstract
IMPORTANCE: The standard practice of irrigation and debridement (I&D) of open fractures within 6 hours of injury remains controversial. OBJECTIVE: To prospectively evaluate the effect of the time from injury to the initial I&D on infectious complications. DESIGN, SETTING, AND PARTICIPANTS: A total of 315 patients who were admitted to a level 1 trauma center with open extremity fractures from September 22, 2008, through June 21, 2011, were enrolled in a prospective observational study and followed up for 1 year after discharge (mean [SD] age, 33.9 [16.3] years; 79% were male; and 78.4% were due to blunt trauma). Demographics, mechanism of injury, time to I&D, operative intervention, and incidence of local infectious complications were documented. Patients were stratified into 4 groups based on the time of I&D (<6 hours, 7-12 hours, 13-18 hours, and 19-24 hours after injury). Univariate and multivariable analysis were used to determine the effect of time to I&D on outcomes. MAIN OUTCOMES AND MEASURES: Development of local infectious complications at early (<30 days) or late (>30 days and <1 year) intervals from admission. RESULTS: The most frequently injured site was the lower extremity (70.2%), and 47.9% of all injuries were Gustilo classification type III. There was no difference in fracture location, degree of contamination, or antibiotic use between groups. All patients underwent I&D within 24 hours. Overall, 14 patients (4.4%) developed early wound infections, while 10 (3.2%) developed late wound infections (after 30 days). The infection rate was not statistically different on univariate (<6 hours, 4.7%; 7-12 hours, 7.5%; 13-18 hours, 3.1%; and 19-24 hours, 3.6%; P = .65) or multivariable analysis (<6-hour group [reference], P = .65; 7- to 12-hour group adjusted odds ratio [AOR] [95% CI], 2.1 [0.4-10.2], P = .37; 13- to 18-hour group AOR [95% CI], 0.8 [0.1-4.5], P = .81; 19- to 24-hour group AOR [95% CI], 1.1 [0.2-6.2], P = .90). Time to I&D did not affect the rate of nonunion, hardware failure, length of stay, or mortality. CONCLUSIONS AND RELEVANCE: In this prospective analysis, time to I&D did not affect the development of local infectious complications provided it was performed within 24 hours of arrival.
IMPORTANCE: The standard practice of irrigation and debridement (I&D) of open fractures within 6 hours of injury remains controversial. OBJECTIVE: To prospectively evaluate the effect of the time from injury to the initial I&D on infectious complications. DESIGN, SETTING, AND PARTICIPANTS: A total of 315 patients who were admitted to a level 1 trauma center with open extremity fractures from September 22, 2008, through June 21, 2011, were enrolled in a prospective observational study and followed up for 1 year after discharge (mean [SD] age, 33.9 [16.3] years; 79% were male; and 78.4% were due to blunt trauma). Demographics, mechanism of injury, time to I&D, operative intervention, and incidence of local infectious complications were documented. Patients were stratified into 4 groups based on the time of I&D (<6 hours, 7-12 hours, 13-18 hours, and 19-24 hours after injury). Univariate and multivariable analysis were used to determine the effect of time to I&D on outcomes. MAIN OUTCOMES AND MEASURES: Development of local infectious complications at early (<30 days) or late (>30 days and <1 year) intervals from admission. RESULTS: The most frequently injured site was the lower extremity (70.2%), and 47.9% of all injuries were Gustilo classification type III. There was no difference in fracture location, degree of contamination, or antibiotic use between groups. All patients underwent I&D within 24 hours. Overall, 14 patients (4.4%) developed early wound infections, while 10 (3.2%) developed late wound infections (after 30 days). The infection rate was not statistically different on univariate (<6 hours, 4.7%; 7-12 hours, 7.5%; 13-18 hours, 3.1%; and 19-24 hours, 3.6%; P = .65) or multivariable analysis (<6-hour group [reference], P = .65; 7- to 12-hour group adjusted odds ratio [AOR] [95% CI], 2.1 [0.4-10.2], P = .37; 13- to 18-hour group AOR [95% CI], 0.8 [0.1-4.5], P = .81; 19- to 24-hour group AOR [95% CI], 1.1 [0.2-6.2], P = .90). Time to I&D did not affect the rate of nonunion, hardware failure, length of stay, or mortality. CONCLUSIONS AND RELEVANCE: In this prospective analysis, time to I&D did not affect the development of local infectious complications provided it was performed within 24 hours of arrival.
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