TY - JOUR
T1 - A Reevaluation of the Risk of Infection Based on Time to Debridement in Open Fractures
T2 - Results of the GOLIATH Meta-Analysis of Observational Studies and Limited Trial Data
AU - Foote, Clary J.
AU - Tornetta, Paul
AU - Reito, Aleksi
AU - Al-Hourani, Khalid
AU - Schenker, Mara
AU - Bosse, Michael
AU - Coles, Chad P.
AU - Bozzo, Anthony
AU - Furey, Andrew
AU - Leighton, Ross
AU - GOLIATH Investigators
N1 - Publisher Copyright:
Copyright © 2020 by The Journal of Bone and Joint Surgery, Incorporated.
PY - 2021/2/3
Y1 - 2021/2/3
N2 - BACKGROUND: Open fractures are one of the leading causes of disability worldwide. The threshold time to debridement that reduces the infection rate is unclear. METHODS: We searched all available databases to identify observational studies and randomized trials related to open fracture care. We then conducted an extensive meta-analysis of the observational studies, using raw and adjusted estimates, to determine if there was an association between the timing of initial debridement and infection. RESULTS: We identified 84 studies (18,239 patients) for the primary analysis. In unadjusted analyses comparing various "late" time thresholds for debridement versus "early" thresholds, there was an association between timing of debridement and surgical site infection (odds ratio [OR] = 1.29, 95% confidence interval [CI] = 1.11 to 1.49, p < 0.001, I2 = 30%, 84 studies, n = 18,239). For debridement performed between 12 and 24 hours versus earlier than 12 hours, the OR was higher in tibial fractures (OR = 1.37, 95% CI = 1.00 to 1.87, p = 0.05, I2 = 19%, 12 studies, n = 2,065), and even more so in Gustilo type-IIIB tibial fractures (OR = 1.46, 95% CI = 1.13 to 1.89, p = 0.004, I2 = 23%, 12 studies, n = 1,255). An analysis of Gustilo type-III fractures showed a progressive increase in the risk of infection with time. Critical time thresholds included 12 hours (OR = 1.51, 95% CI = 1.28 to 1.78, p < 0.001, I2 = 0%, 16 studies, n = 3,502) and 24 hours (OR = 2.17, 95% CI = 1.73 to 2.72, p < 0.001, I2 = 0%, 29 studies, n = 5,214). CONCLUSIONS: High-grade open fractures demonstrated an increased risk of infection with progressive delay to debridement. LEVEL OF EVIDENCE: Prognostic Level IV. See Instruction for Authors for a complete description of the levels of evidence.
AB - BACKGROUND: Open fractures are one of the leading causes of disability worldwide. The threshold time to debridement that reduces the infection rate is unclear. METHODS: We searched all available databases to identify observational studies and randomized trials related to open fracture care. We then conducted an extensive meta-analysis of the observational studies, using raw and adjusted estimates, to determine if there was an association between the timing of initial debridement and infection. RESULTS: We identified 84 studies (18,239 patients) for the primary analysis. In unadjusted analyses comparing various "late" time thresholds for debridement versus "early" thresholds, there was an association between timing of debridement and surgical site infection (odds ratio [OR] = 1.29, 95% confidence interval [CI] = 1.11 to 1.49, p < 0.001, I2 = 30%, 84 studies, n = 18,239). For debridement performed between 12 and 24 hours versus earlier than 12 hours, the OR was higher in tibial fractures (OR = 1.37, 95% CI = 1.00 to 1.87, p = 0.05, I2 = 19%, 12 studies, n = 2,065), and even more so in Gustilo type-IIIB tibial fractures (OR = 1.46, 95% CI = 1.13 to 1.89, p = 0.004, I2 = 23%, 12 studies, n = 1,255). An analysis of Gustilo type-III fractures showed a progressive increase in the risk of infection with time. Critical time thresholds included 12 hours (OR = 1.51, 95% CI = 1.28 to 1.78, p < 0.001, I2 = 0%, 16 studies, n = 3,502) and 24 hours (OR = 2.17, 95% CI = 1.73 to 2.72, p < 0.001, I2 = 0%, 29 studies, n = 5,214). CONCLUSIONS: High-grade open fractures demonstrated an increased risk of infection with progressive delay to debridement. LEVEL OF EVIDENCE: Prognostic Level IV. See Instruction for Authors for a complete description of the levels of evidence.
U2 - 10.2106/JBJS.20.01103
DO - 10.2106/JBJS.20.01103
M3 - Review Article
C2 - 33298796
AN - SCOPUS:85099621754
VL - 103
SP - 265
EP - 273
JO - JOURNAL OF BONE AND JOINT SURGERY: AMERICAN VOLUME
JF - JOURNAL OF BONE AND JOINT SURGERY: AMERICAN VOLUME
SN - 0021-9355
IS - 3
ER -