Session III - Polytrauma

Deep Septic Complications Associated with the Delayed Management of Open Fractures in the Poly-traumatized Patient

Lisa A. Taitsman, MD, MPH; David P. Barei, MD; Sean E. Nork, MD; Sarah Holt, MA; Bruce J. Sangeorzan, MD; Harborview Medical Center, University of Washington, Seattle, Washington, USA

Purpose: The optimal management of lower extremity open fractures includes early operative debridement. In multiply injured patients requiring significant resuscitation, life-threatening injuries require prioritization, and formal surgical debridement of open fractures is frequently delayed. The purpose of this study was to assess the impact of injury severity and time to surgical debridement on early infection rates in poly-traumatized patients with open fractures.

Methods: A retrospective review of patients treated at a single level-1 trauma center over a 36-month period was performed. Patients were excluded if they died from their injuries prior to definitive orthopaedic management, required amputation for an unsalvageable limb, or underwent operative orthopaedic surgery at another facility. The hospital trauma registries identified 431 patients with open fractures of the femur or tibia or both. Multiply injured patients were defined as having an Injury Severity Score (ISS) higher than or equal to 18. Time, in hours (h), to operative debridement was determined by comparison of the earliest documented time closest to injury (medical evacuation record or emergency department admission time) and surgical start times. All procedures involved pulsatile lavage irrigation and systematic sharp debridement. Systemic antibiotics were uniformly administered. Follow-up endpoints included clinical and radiographic union, the presence of a deep or superficial infection, or the occurrence of nonunion. Infections involving bone, those requiring secondary debridement, or those with bacterial growth from deep operative culture samples, were considered deep infections. Both acute and chronic infections were included.

Results: Sufficient follow-up data were available for 306 patients (71%) with 89 femur fractures and 245 tibia fractures. Twenty-six of these patients had multiple extremity involvement. Fractures were classified according to Gustilo-Anderson as 43 type I, 76 type II, 180 type IIIA, 29 type IIIB, and 6 type IIIC. Overall, deep infections occurred in 7.2% of fractures (N = 24). Infections occurred in 7 open femur fractures (7.9%) and in 17 open tibial fractures (6.9%). Twenty-one of 24 infections occurred in type III fractures. Patients were stratified into six groups according to time to surgical debridement (<8 h, 8 to 18 h, >18 h) and ISS (<18, 18). Comparison of groups was performed using the chi-square test. One hundred and four open fractures occurred in patients with ISS scores of 18 or higher. Thirty-seven (35.6%), 45 (43.3%), and 22 (21.1%) of these fractures were surgically debrided in less than 8 hours, 8 to 18 hours, and more than 18 hours, respectively. Two hundred and one open fractures occurred in patients with ISS scores of less than 18. One hundred and eight (53.7%), 87 (43.3%), and 6 (3%), were surgically debrided less than 8 hours, 8 to 18 hours, and more than 18 hours, respectively. There was no statistical difference in infection rates among any of these groups. Delay to surgical debridement, however, was highly correlated with an increased ISS score. Of the 104 patients with ISS scores of 18 or higher, 10 became infected (9.6%). Fourteen of the 201 patients with ISS scores of less than 18 became infected (6.97%). There was no statistical difference in infection rates between these groups.

Discussion: In this series, delayed surgical debridement in the multiply injured patient did not statistically increase deep infection rates. Increasing time delay and increased injury severity, however, demonstrated a trend toward increased deep infection rates. On the basis of our data, we support the continued practice of urgent irrigation and debridement of open fractures, but this should not take precedence over the management of life-threatening injuries.