Session XI - Tibia
Timing of Operative Management in the Treatment of Open Fractures: Does Delay to OR Increase the Risk of Complications?
Introduction/Objective: Open fractures remain a true orthopaedic emergency with surgical débridement 6 to 8 hours from injury being the standard of care. This timing is based on historical principles and in vitro data. Previous studies have failed to show harm with delayed débridement but lacked sufficient power to formalize statements. This study aims to determine if delay to operative irrigation and débridement is associated with increased deep infections or nonunion in open fractures.
Methods: This is a retrospective study of open long bone fractures treated at a tertiary trauma center between 1990 and 2002. Database review focused on three areas: (1) patient and fracture characteristics, (2) operative management, and (3) complications requiring operative management. Patients who lived away from the center's catchment area or were first débrided beyond 72 hours from injury were excluded. Primary outcomes were defined as infection or nonunion requiring operative management. Case control and cohort study analysis was preformed using STATA statistical software. Odds ratios and confidence intervals were calculated for adverse outcomes when débridement occurred beyond 6, 8, 12, 16, and 24 hours. Matched case control analysis (1 to 4 match) was performed to stratify for lower extremity and high-grade open fractures. Logistic regression with time as a continuous variable was calculated for the matched and unmatched case control study.
Results: 891 open long bone fractures were identified. There were 99 cases of deep infection or nonunion. Case control and cohort study analysis did not demonstrate any increased risk of complication with delayed débridement at the 6, 8, 12, 16, or 24-hour mark; confidence intervals were narrow with odds ratios (OR) and relative risks (RR) of one almost universally included. These OR and RR were respectively for 6, 8, 12, 16, and 24hrs: OR ± CI: 0.59 ± 0.39-1.00, 0.69 ± 0.44-1.09, 0.93 ± 0.58-1.46, 1.02 ± 0.59-1.46, 1.35 ± 0.64-2.65 and RR ± CI: 0.63 ± 0.42-0.96, 0.72 ± 0.50-1.05, 0.93 ± 0.63-1.38, 1.02 ± 0.66-1.58; 1.30 ± 0.75-2.29.
High-energy and lower extremity fractures had increased risk of complications. Matched case control and adjusted cohort study analysis, accounting for energy and extremity, also did not demonstrate any increased risk of infection or nonunion with delayed OR. Finally, logistic regression analysis of time to OR as a continuous variable did not show any increased risk of complication in both the matched and unmatched case control groups (OR = 1. 01 ± 0.99-1.03).
Conclusion/Significance: Multiple statistical analyses were unable to demonstrate any increased risk of nonunion or infection with delayed débridement. Large patient numbers and narrow confidence intervals support strong power of study compared to previous publications. The retrospective nature of the study and the therapeutic intent (ie, to operate as soon as possible) limit the ability to conclude that there is no harm with delayed débridement. However, the cohort size, which is larger than previously published data on the topic, allows the calculation of tight confidence intervals that will assist surgeons in setting priorities in the care of these patients.