Surgical outcomes in Patients with Late Debridement of Long Bone Fractures of Lower Extremities in Penetrating Injury

Author(s):
Nasim Ahmed; staurt campbell [email protected]

Background:

The American College of Surgeons’ Committee on Trauma has a quality indicator regarding open long bone fractures in lower extremities that states that the irrigation and debridement (I & D) of the fracture should be performed within 8 hours of the patient’s injury. Therefore, the purpose of this study was to see the impact of the timing of I & D for cases of open femur, tibia, and fibula fractures following penetrating traumatic injury on the occurrence of surgical site infections (SSI), wound disruption, and sepsis.

Hypothesis:

late debridement can lead to increased infection rate

Methods:

Patients from the 2007–2010 National Trauma Data Bank who sustained a penetrating injury and were diagnosed with an open femur, tibia, or fibula fracture and also underwent an I & D within 24 hours of arrival to the hospital were eligible for inclusion in the study. The patients’ characteristics and outcomes were compared between two groups: I & D within 8 hours (Group 1) and between 8-24 hours (Group 2). Initial patient measures and outcomes were compared between the two unmatched groups followed by propensity score matching.

Results:

A total of 1,014 patients qualified for the study and of those, 736 (72.6 %) patients underwent an I & D within 8 hours (Group 1). There were significant baseline differences between the two groups regarding race (white vs. nonwhite, P=0.001) and the mechanism of injury (firearm: 91.8% vs. 96.8%, P=0.01). In order to better balance the groups, 277 patients from each group were pair-matched on age, sex, race, injury severity score (ISS), Glasgow coma scale (GCS), initial systolic blood pressure (iSBP), and the mechanism of injury; after, there were no significant differences observed between the groups for the matching variables. When examining the patient outcomes, no significant differences in the occurrence of SSIs, sepsis, or wound disruptions between the two groups. Additionally, Group 1 had a significantly longer hospital length stay (Median [IQR]: 5.0 [3.0, 10.0] vs. 4.0 [3.0, 7.0], P<0.001).

Conclusions:

For nearly all the patients who were analyzed, a firearm was the cause of the open fracture in their lower extremity, and around 70% of the patients underwent an I & D within 8 hours of hospital arrival per ACS guidelines. There were no significant differences identified in SSI, wound disruption, and sepsis rates, or the proportion of patients who went home without any follow-up services needed. However, the median hospital length of stay was longer for those who had their I & D within 8 hours