Prospective evaluation of treatment of open fractures: effect of time to irrigation and debridement.

IMPORTANCE: The standard practice of irrigation and debridement (I&D) of open fractures within 6 hours of injury remains controversial.

OBJECTIVE: To prospectively evaluate the effect of the time from injury to the initial I&D on infectious complications.

DESIGN, SETTING, AND PARTICIPANTS: A total of 315 patients who were admitted to a level 1 trauma center with open extremity fractures from September 22, 2008, through June 21, 2011, were enrolled in a prospective observational study and followed up for 1 year after discharge (mean [SD] age, 33.9 [16.3] years; 79% were male; and 78.4% were due to blunt trauma). Demographics, mechanism of injury, time to I&D, operative intervention, and incidence of local infectious complications were documented. Patients were stratified into 4 groups based on the time of I&D (<6 hours, 7-12 hours, 13-18 hours, and 19-24 hours after injury). Univariate and multivariable analysis were used to determine the effect of time to I&D on outcomes.

MAIN OUTCOMES AND MEASURES: Development of local infectious complications at early (<30 days) or late (>30 days and <1 year) intervals from admission.

RESULTS: The most frequently injured site was the lower extremity (70.2%), and 47.9% of all injuries were Gustilo classification type III. There was no difference in fracture location, degree of contamination, or antibiotic use between groups. All patients underwent I&D within 24 hours. Overall, 14 patients (4.4%) developed early wound infections, while 10 (3.2%) developed late wound infections (after 30 days). The infection rate was not statistically different on univariate (<6 hours, 4.7%; 7-12 hours, 7.5%; 13-18 hours, 3.1%; and 19-24 hours, 3.6%; P = .65) or multivariable analysis (<6-hour group [reference], P = .65; 7- to 12-hour group adjusted odds ratio [AOR] [95% CI], 2.1 [0.4-10.2], P = .37; 13- to 18-hour group AOR [95% CI], 0.8 [0.1-4.5], P = .81; 19- to 24-hour group AOR [95% CI], 1.1 [0.2-6.2], P = .90). Time to I&D did not affect the rate of nonunion, hardware failure, length of stay, or mortality.

CONCLUSIONS AND RELEVANCE: In this prospective analysis, time to I&D did not affect the development of local infectious complications provided it was performed within 24 hours of arrival.