Does delay in surgical debridement increase the risk of infection in open tibia fractures in Saudi patients? A retrospective cohort study.

Background: Infection is the most common and devastating complication of open fractures, with a reported incidence of 3-40%. Tibia bone along its anteromedial surface has relatively thin soft tissue coverage; hence the open tibia fracture incidence rate ranges from 49.4% to 63.2%. Open fractures are usually classified based on the Gustilo & Anderson classification system, which is used by surgeons as an index for the severity of an injury and as a prognostic tool. Our current practice follows the 6-h rule of irrigation and debridement (I&D). Nevertheless, there is little support for this opinion in the literature. Our study concentrates on identifying the risk factors of infection in open tibia fractures and comparing the rate of infection if surgical irrigation and debridement was delayed.

Methods: The medical records of 389 patients with open fractures were reviewed. Of these cases, 113 patients with open tibia fracture who presented to our Hospital from the period 1997 to 2008 fit the inclusion criteria and were included in a retrospective cohort study.

Results: A total of 113 tibia fractures were reviewed, with an average patient age of 31.70 years; 87.1% of the fractures were high-energy fractures, and the most common mechanism of injury was a motor vehicle accident (62.4%). The data analysis revealed no difference in overall infectious outcome when comparing initial I&D performed within 6 h to when I&D was performed after 6 h ( = 0.201). The data analysis showed a significant relationship between infection and wound closure in first surgery in both univariate and multivariate analysis ( = 0.0003 and  = 0.014), respectively.

Conclusion: This study showed no significant evidence to support the 6-h rule, but it did demonstrate a significant relationship between the Gustilo stage and infection, as well as an increased infection rate if external fixation was used or if the wound was left open during the initial irrigation and debridement. We believe that more studies are required to identify the relationship between infection and the delay in irrigation and debridement; a meta-analysis of the currently available data may provide an answer to this question.