Open tibia fractures: timely debridement leaves injury severity as the only determinant of poor outcome

Recent retrospective studies suggest that the time to debridement of open tibia fractures is not a major determinant of outcome. The aim of this prospective study was to determine the modifiable independent predictors of poor outcomes.

A 36-month prospective observational study ending in December 2009 was performed on consecutive open tibia shaft fracture patients (age >18 years) admitted to a Level 1 trauma center. Demographics, mechanism, Injury Severity Score, fracture type/grade, local contamination, time to debridement, time to antibiotics, and interventions were prospectively recorded. Outcome measures were as follows: length of stay, deep infection, secondary procedures, and presence of union at 6 months and 12 months. Univariate, multivariate, and logistic regression analyses were performed.

Eighty-nine consecutive patients (74% male, age 41 years±17 years, Injury Severity Score 15±3, and 37% multiple injured) met inclusion criteria. The mean time to surgical debridement and operative stabilization was 8 hours±4 hours (48% within 6 hours). The average length of stay was 21 days±13 days. Fifteen patients (17%) had deep infection and 5 (6%) required amputation (1 acute and 4 late because of the infection). The 6-month and 12-month union rates were 39% and 67%, respectively. Fifty-six patients (63%) required further procedures (a total of 312). The multivariate regression model (18 variables) showed no independent significant predictors for deep infection or nonunion at 6 months and 12 months (multiple injuries and smoking were closest to reach significance, p=0.08).

Timely management of open tibia fractures (mean, 8 hours) eliminates time to debridement and contamination as predictors of poor outcome. Patient factors and local and general injury severity determine the outcomes. Aiming for the earliest safe time to debridement minimizes the negative effects of modifiable factors on the outcome.