Late irrigation, debridement of open fractures did not increase reoperation rates

Prospective studies should focus on time of injury, time to the OR and time to antibiotics.

Irrigation and debridement performed more than 6 hours after the occurrence of an open fracture did not increase the risk of reoperation, based on research presented at a meeting.

“The old dogma that open fractures need to be addressed within 6 hours of injury needs to be revisited,” Herman Johal, MD, orthopedic traumatologist and clinical scholar with the Centre for Evidence-Based Orthopaedics (CEO) and department of surgery at McMaster University in Hamilton, Ontario, told Orthopedics Today. “We found that, as long as the open fracture is treated within 24 hours, there was no additional benefit of getting the patients to the OR within the 6-hour time frame that has been traditionally recommended.”

Timing of irrigation and debridement

Johal and his colleagues collected factors related to patients, injuries and treatment among more than 2,300 patients with open fractures who underwent irrigation and debridement either within or beyond 6 hours of injury.

“We adjusted for the fact that more severe open fracture received earlier surgical management using a propensity score relating injury factors to the timing of irrigation and debridement based on injury severity alone,” Johal said at the meeting.

The investigators then used a logistic regression to adjust for patient-related factors.

Prior to using propensity adjusting, researchers found that patients who received earlier irrigation and debridement were more likely to be younger and have higher energy injuries, type III open fractures, more severely contaminated wounds, more lower extremity injuries and more open tibial fractures.

“They also were more likely to receive staged fixation and definitive treatment utilizing an external factor,” Johal said.

Of the patients studied, the researchers found 319 patients underwent reoperation for infection and complications related to healing.

“Using our unadjusted analysis, we found patients who received earlier irrigation and debridement were more likely to require reoperation,” Johal said. “However, that did not account for the fact that these tended to be more severe injuries leading to earlier treatment.”

According to Johal, after adjusting for patient and injury characteristics, patients who received irrigation and debridement within 6 hours had no difference in reoperation rate compared with patients who received later irrigation and debridement. Furthermore, the increase in time to irrigation and debridement within 24 hours after injury did not cause an increase in reoperations, even when considering type III open fractures alone.

Impact of time on fracture management

Johal and colleagues are now collecting more data through a large randomized controlled trial looking further into open fracture management. The PREP-IT study, led by the McMaster University CEO and University of Maryland R. Adams Cowley Shock Trauma Center, looks primarily at preparation solutions used for open fracture management and will provide a large, rigorous and prospectively collected dataset that can re-examine the impact of timing on reoperation.

“While we were able to look at timing relative to the 6-hour benchmark, and as a continuous variable, the impact of injury characteristics was substantial. Those who were more severely injured were taken to the OR sooner, whether due to their open fracture or other commonly associated life or limb threatening injuries. These patients are at higher risk of developing complications independent of timing to irrigation and debridement, making it even more challenging to discern if there is a benefit to expedited surgery,” Johal told Orthopedics Today. “Having another large, prospective dataset to look at timing, with careful attention paid to the time of injury, time to the OR and time to antibiotics, would help increase the confidence of our findings.” – by Casey Tingle

Reference:

Johal H, et al. Abstract 84. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 12-16, 2019; Las Vegas.

For more information:

Herman Johal, MD, can be reached at 1280 Main St. West, Hamilton, Ontario, L8S 4L8 Canada; email: pyealex@hhsc.ca.

Disclosure: Johal reports no relevant financial disclosures.