Open fracture dogma has mandated management of these injuries within an 8 hour window. Over the past several years, there has been a growing number of good papers that dispute this fact. As is the norm, many are retrospective in nature, or meta-analyses of retrospective papers.
Recently, a paper was published that detailed a (small) prospective and multi-center study (3 hospitals in Canada) looking at deep infection, Gustillo grade, antibiotics, and time to treatment. My hopes were raised!
Here are the factoids:
- 939 patients were screened, but only 736 were actually enrolled
- Only 482 completed the entire study (>90 days clinical followup and an interview after 1 year). Others with less clinical followup were still included and analyzed.
- Information on fracture grade, time to antibiotic administration, time to OR, and development of deep infections were recorded. Cellulitis and pin site infections were not considered.
- Time to antibiotic administration ranged from 1 hour to 10 hours (!!?)
- Time to OR ranged from 6 to 13 hours
- 46 patients developed deep infections, and 56 had cellulitis or pin site infections
- Of those who developed infections, there was no clear association with time to OR
- Also in those with infections, antibiotics were given after about 3 hours, vs 2.5 hours in those without.
The authors concluded that neither time to antibiotic administration nor time to surgery made any difference on deep tissue infections. But should I believe them?
Bottom line: SLOPPY! If you just read the abstract you might believe the wrong thing. This paper cobbled together surgeons at 3 different centers and let them do their own thing. The researchers just observed the management that these fellowship trained surgeons chose. No guidelines. No protocols. The variability of practice in this study leaves me flabberghasted. The median time to antibiotic administration was 3 hours, with some waiting up to 10 hours! The median time to OR was 9 hours, not so far off the 8 hour mark the everyone seems to look at. No wonder they couldn’t find any differences.
Give antibiotics early. Get to the OR in a reasonable amount of time, preferably using the Gustillo grade to take high grades there sooner. And keep your eye on the literature for papers that are much, much better than this one!
Reference: Time to Initial Operative Treatment Following Open Fracture Does Not Impact Development of Deep Infection: A Prospective Cohort Study of 736 Subjects. J Orthop Trauma 28(11):613-619, 2014.