There are many articles comparing the proportion of patients with surgical site infection in open fractures whose surgical debridement took place either before or after 6 hours. One high quality study (Konbaz 2019), nine moderate quality studies (Albright 2020, Enninghorst 2011, Harley 2002, Hendrickson 2020, Hull 2014, Noumi 2005, Olinger 2018, Weber 2014, Westgeest 2016), and twenty low quality studies (Whiting 2019, Pollak 2010, Sagar 1987, Srour 2015, Campbell 2020, Wei 2014, Nobert 2016, Al-Arabi 2007, Hendrickson 2018, Malhotra 2014, Spencer 2004, Arti 2012, Joseph 2020, Fernandes 2015, Reuss 2007, Tripuraneni 2008, Al-Hilli 2010, Charalambous 2005, Crowe 2017, Townley 2010) were reviewed. One high quality (Konbaz 2019) study did not support the 6-hour rule for performing the debridement but demonstrated a correlation of infection with the Gustillo classification, use of external fixation and not closing the wound primarily at the first debridement. Six moderate quality studies did not support the 6-hour rule (Albright 24 hours, Harley no correlation with time to surgery, Hendrickson no correlation with time to antibiotics, Noumi no correlation, Weber no correlation, Westgeest no correlation).
Benefits/Harms of Implementation
The current evidence is insufficient to definitively confirm the importance of early surgical intervention for open fractures, although this might not be true for certain fractures such as tongue-type calcaneus fractures. In some fractures, such as pilon fracture, waiting for final surgical intervention might be more appropriate. More studies are required.
Outcome Importance
This data suggests waiting a few extra hours to perform surgery in most but not all open fractures might have advantages in terms of preparation for surgery, marshalling the necessary resources, staffing, and equipment. However, more evidence is needed.
Cost Effectiveness/Resource Utilization
The current insufficient evidence indicates urgent surgical care might not be necessary for most but not all open fractures. Timely surgical care would be expected to improve the resource allocation and potentially enhance outcomes post-surgery if and when the operative team is better prepared and adequately staffed.
Acceptability
More timely surgery as opposed to urgent surgical care can potentially improve preparation of the surgical team as well as allow for better patient optimization. In certain cases, access to comprehensive medical care is simply not possible within the proposed 6-hour surgery window, particularly in under resourced rural and geographically isolated areas.
Future Research
Most of the current evidence comes from retrospective case series with small cohorts. In many instances, the study population has more than one type of fracture or includes fractures in different anatomical regions. Future studies require larger cohorts, concentration on specific fracture types or anatomical regions, and greater specificity in the operative and postoperative protocols. Prospective randomized studies, particularly if done through multicenter design, are required to more definitively address this issue and establish a widely recognized standard of care.
- Konbaz, F. M., Alassiri, S. S., Al Eissa, S. I., Taha, W. S., Al Helal, F. H., Al Jehani, R. M. Does delay in surgical debridement increase the risk of infection in open tibia fractures in Saudi patients? A retrospective cohort study. Journal of Clinical Orthopaedics & Trauma 2019; 2: 305-309
- Albright, P. D., Ali, S. H., Jackson, H., Haonga, B. T., Eliezer, E. N., Morshed, S., Shearer, D. W. Delays to Surgery and Coronal Malalignment Are Associated with Reoperation after Open Tibia Fractures in Tanzania. Clinical Orthopaedics & Related Research 2020; 0: 05
- Enninghorst, N., McDougall, D., Hunt, J. J., Balogh, Z. J. Open tibia fractures: timely debridement leaves injury severity as the only determinant of poor outcome. Journal of Trauma-Injury Infection & Critical Care 2011; 2: 352-6; discussion 356-7
- Harley, B. J., Beaupre, L. A., Jones, C. A., Dulai, S. K., Weber, D. W. The effect of time to definitive treatment on the rate of nonunion and infection in open fractures. Journal of Orthopaedic Trauma 2002; 7: 484-90
- Hendrickson, S. A., Donovan, R., Harries, L., Wright, T. C., Whitehouse, M. R., Khan, U. Time to intravenous antibiotic administration (TIbiA) in severe open tibial fractures: Impact of change to national guidance. Injury 2020; 4: 1086-1090
- Hull, P. D., Johnson, S. C., Stephen, D. J., Kreder, H. J., Jenkinson, R. J. Delayed debridement of severe open fractures is associated with a higher rate of deep infection. Bone & Joint Journal 2014; 3: 379-84
- Noumi, T., Yokoyama, K., Ohtsuka, H., Nakamura, K., Itoman, M. Intramedullary nailing for open fractures of the femoral shaft: evaluation of contributing factors on deep infection and nonunion using multivariate analysis. Injury 2005; 9: 1085-93
- Olinger, C. R., Carver, D. C., Nolan, V. G., Weinlein, J. C. The Effect of Under-Dosing Prophylactic Antibiotics in the Care of Open Tibial Fractures. Journal of Orthopaedic Trauma 2018; 7: 322-326
- Weber, D., Dulai, S. K., Bergman, J., Buckley, R., Beaupre, L. A. Time to initial operative treatment following open fracture does not impact development of deep infection: a prospective cohort study of 736 subjects. Journal of Orthopaedic Trauma 2014; 11: 613-9
- Westgeest, J., Weber, D., Dulai, S. K., Bergman, J. W., Buckley, R., Beaupre, L. A. Factors Associated With Development of Nonunion or Delayed Healing After an Open Long Bone Fracture: A Prospective Cohort Study of 736 Subjects. Journal of Orthopaedic Trauma 2016; 3: 149-55
- Whiting, P. S., Galat, D. D., Zirkle, L. G., Shaw, M. K., Galat, J. D. Risk Factors for Infection After Intramedullary Nailing of Open Tibial Shaft Fractures in Low- and Middle-Income Countries. Journal of Orthopaedic Trauma 2019; 6: e234-e239
- Pollak, A. N., Jones, A. L., Castillo, R. C., Bosse, M. J., MacKenzie, E. J., Leap Study Group The relationship between time to surgical debridement and incidence of infection after open high-energy lower extremity trauma. Journal of Bone & Joint Surgery - American Volume 2010; 1: 7-15
- Sagar, J. V., Muthukumar, G., Prasannan, C., Sharma, R., Mohanty, P. R. Factors influencing wound infection: time lapse analysis and wound culture studies. Indian Journal of Pathology & Microbiology 1987; 4: 343-7
- Srour, M., Inaba, K., Okoye, O., Chan, C., Skiada, D., Schnuriger, B., Trump, M., Lam, L., Demetriades, D. Prospective evaluation of treatment of open fractures: effect of time to irrigation and debridement. JAMA Surgery 2015; 4: 332-6
- Campbell, S., Dhyani, J., Greenberg, P., Ahmed, N. Outcomes in patients with late debridement of open long bone fractures of the lower extremities in penetrating trauma: a retrospective review of the National Trauma Data Bank. European journal of orthopaedic surgery & traumatologie 2020; 6: 1075-1081
- Nobert, N., Moremi, N., Seni, J., Dass, R. M., Ngayomela, I. H., Mshana, S. E., Gilyoma, J. M. The effect of early versus delayed surgical debridement on the outcome of open long bone fractures at Bugando Medical Centre, Mwanza, Tanzania. Journal of Trauma Management & Outcomes [Electronic Resource] 2016; 0: 6
- Wei, S. J., Cai, X. H., Wang, H. S., Qi, B. W., Yu, A. X. A comparison of primary and delayed wound closure in severe open tibial fractures initially treated with internal fixation and vacuum-assisted wound coverage: a casecontrolled study. International Journal Of Surgery 2014; 7: 688-94
- Al-Arabi, Y. B., Nader, M., Hamidian-Jahromi, A. R., Woods, D. A. The effect of the timing of antibiotics and surgical treatment on infection rates in open long-bone fractures: a 9-year prospective study from a district general hospital. Injury 2007; 8: 900-5
- Hendrickson, S. A., Wall, R. A., Manley, O., Gibson, W., Toher, D., Wallis, K., Ward, J., Wallace, D. L., Lamyman, M., Giblin, A. V., Wright, T. C., Khan, U. Time to Initial Debridement and wound Excision (TIDE) in severe open tibial fractures and related clinical outcome: A multi-centre study. Injury 2018; 10: 1922-1926
- Malhotra, A. K., Goldberg, S., Graham, J., Malhotra, N. R., Willis, M. C., Mounasamy, V., Guilford, K., Duane, T. M., Aboutanos, M. B., Mayglothling, J., Ivatury, R. R. Open extremity fractures: impact of delay in operative debridement and irrigation. The Journal of Trauma and Acute Care Surgery 2014; 5: 1201-7
- Spencer, J., Smith, A., Woods, D. The effect of time delay on infection in open long-bone fractures: a 5-year prospective audit from a district general hospital. Annals of the Royal College of Surgeons of England 2004; 2: 108-12
- Arti, H., Khorami, M., Ebrahimi-Nejad, V. Comparison of negative pressure wound therapy (NPWT) &conventional wound dressings in the open fracture wounds. Pakistan Journal of Medical Sciences 2016; 1: 65-9
- Joseph, C. M., Jepegnanam, T. S., Ramasamy, B., Cherian, V. M., Nithyananth, M., Sudarsanam, T. D., Premkumar, P. S. Time to debridement in open high-grade lower limb fractures and its effect on union and infections: A prospective study in a tropical setting. 2020; 1: 2309499020907558
- Fernandes Mde, C., Peres, L. R., de Queiroz, A. C., Jr., Lima, J. Q., Jr., TurĂbio, F. M., Matsumoto, M. H. Open fractures and the incidence of infection in the surgical debridement 6 hours after trauma. 2015; 1: 38-42
- Reuss, B. L., Cole, J. D. Effect of delayed treatment on open tibial shaft fractures. 2007; 4: 215-20
- Tripuraneni, K., Ganga, S., Quinn, R., Gehlert, R. The effect of time delay to surgical debridement of open tibia shaft fractures on infection rate. Orthopedics 2008; 12: 1195
- Al-Hilli, A. B., Salih, D. S. Early or delayed surgical treatment in compound limb fractures due to high velocity missile injuries: a 5-year retrospective study from Medical City in Baghdad. Iowa Orthopaedic Journal 2010; 0: 94-8
- Charalambous, C. P., Siddique, I., Zenios, M., Roberts, S., Samarji, R., Paul, A., Hirst, P. Early versus delayed surgical treatment of open tibial fractures: effect on the rates of infection and need of secondary surgical procedures to promote bone union. Injury 2005; 5: 656-61
- Crowe, C. S., Luan, A., Lee, G. K. Hospital Transfer of Open Tibial Fractures Requiring Microsurgical Reconstruction Negatively Impacts Clinical Outcomes. Annals of Plastic Surgery 2017; 5: S180-S184
- Townley, W. A., Nguyen, D. Q., Rooker, J. C., Dickson, J. K., Goroszeniuk, D. Z., Khan, M. S., Camp, D. Management of open tibial fractures - a regional experience. Annals of the Royal College of Surgeons of England 2010; 8: 693-6