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Delay in Initial Debridement for Open Tibial Fractures and Its Possible Impact on Patient Outcomes: A Single-Center
Muhammad Tahir1, Nadeem Ahmed1, Saeed Ahmad Shaikh1
1Department of Orthopedic Surgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan.
Insights
Delayed surgical management of open tibial fractures showed acceptable infection and nonunion rates, even beyond the recommended 6-hour window. Higher Gustilo-Anderson (GA) classification correlated with increased risks, irrespective of surgical timing.
Area of Science:
- Orthopedic surgery
- Trauma management
Background:
- The consensus for open fracture management emphasizes debridement within 6 hours.
- Pakistan faces challenges with emergency medical services, leading to delayed hospital arrival.
- This study investigates outcomes of delayed surgical intervention for open tibial fractures.
Purpose of the Study:
- To evaluate the safety and efficacy of delayed surgical management for open tibial fractures.
- To compare infection and nonunion rates based on surgical timing.
- To assess the impact of Gustilo-Anderson (GA) classification on outcomes.
Main Methods:
- Prospective study of 1,896 adult patients with isolated open tibial fractures over 4 years.
- Fractures were graded using the Gustilo-Anderson (GA) classification.
- Patients were grouped by surgical timing; infection and nonunion rates were compared using chi-square analysis.
Main Results:
- No significant difference in infection or nonunion rates between surgery before and after 48 hours for any GA type.
- Higher GA classification was independently associated with increased infection and nonunion rates (CI = 1.24-1.89, p < 0.01).
Conclusions:
- Delayed surgical management (24-96 hours) of open tibial fractures is acceptable when early care is unavailable.
- Risks of infection and nonunion remain within acceptable limits despite delays.
- Prompt initial debridement is still the optimal treatment for open tibial fractures.
Abstract:
The current consensus regarding the management of open fracture indicates that the initial debridement should be performed within the first 6 hours after injury. Unfortunately, in Pakistan, the emergency medical services are not well-established and patient arrival at the hospital is delayed the majority of the time. In this study, we present our experience with delayed surgical management of open tibial fractures.
Methods:
A prospective study of patients who presented to the accident and emergency department of the authors' institution was performed. The duration of the study was 4 years. All patients ≥18 years of age with an isolated open fracture of the tibia were included in the study. Open fractures were graded using the Gustilo-Anderson (GA) classification. The study participants were divided into 3 groups based on the timing of the surgery. Infection and nonunion rates were compared using chi-square analysis. P < 0.05 was considered significant.
Results:
A total of 1,896 patients were included in the study. There was no significant difference between the results of surgery performed before 48 hours and those of surgery performed after 48 hours with regard to the infection rates associated with GA type-I (p = 0.48), type-II (p = 0.70), or type-III (p = 0.87) fractures or the nonunion rates associated with type-I (p = 0.6338), type-II (p = 0.4030), or type-III (p = 0.4808) fractures. A higher GA classification was associated with higher rates of infection and nonunion independent of the timing of the surgery (95% confidence interval [CI] = 1.24 to 1.89, p < 0.01).
Conclusions:
Our study indicates that the risks of infection and nonunion remain acceptable despite delays in the management of open tibial fractures within a 24 to 96-hour window. A delay in the initial time to debridement is acceptable only when early care cannot be provided. Prompt initial debridement remains the best possible treatment for open tibial fractures.
Level Of Evidence:
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
