The 6-Hour Rule for Surgical Debridement of Open Tibial Fractures: A Systematic Review and Meta-Analysis of Infection and Nonunion Rates

Prodromidis, Apostolos D.; Charalambous, Charalambos Panayiotou

doi:10.1097/bot.0000000000000573

Cited by 91 publications

(31 citation statements)

References 25 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Treatment protocols advocate for expedient surgical debridement and IV antibiotics to reduce the risk of infection. However, over time, a "six-hour rule" seems to have evolved based mainly on historical tradition rather than scientific evidence [1,5,6,[9][10][11][12][13] .…”

Section: Discussionmentioning

confidence: 99%

“…Current open fracture treatment protocols aim to reduce the risk of infection through emergent intravenous (IV) antibiotics and surgical debridement [5] . Over time, an unwritten "six-hour rule" has developed within the orthopaedic community; it is widely advocated that initiating treatment within six hours of injury reduces the rate of morbidity and mortality [6][7][8][9] . While the literature agrees that urgent care is essential, there is little scientific evidence to support this "sixhour rule" [1,5,6,[9][10][11][12][13] .…”

Section: The Effect Of Treatment Delay On Infection In Open Tibia Framentioning

confidence: 99%

See 1 more Smart Citation

The Effect of Treatment Delay on Infection in Open Tibia Fractures: A Retrospective Study in Ethiopia

Kantor

Gallagher

Rosario

et al. 2019

International Journal of Orthopaedics

View full text Add to dashboard Cite

BACKGROUND: Infection is a devastating complication of open fractures. Historically, treatment protocols advocated that initial treatment of open fractures within six hours reduced the risk of infection. Little scientific evidence has supported this "six-hour rule" but the exact time in which the risk of infection increases remains unknown. AIM: Assess the effect of delay in treatment greater than 6 and 24 hours on the development of infection for open tibia fractures. METHODS: A retrospective review of all patients was conducted to identify skeletally mature patients with an open tibia fracture treated with the Surgical Implant Generation Network (SIGN) intramedullary nail from February 2006 and June 2015. Descriptive data, time to treatment, fracture characteristics, and presence of infection were collected and analyzed. RESULTS: Infection occurred in 19 (11%) patients (Gustilo I 1/44, 2%; Gustilo II 6/39, 15%, Gustilo IIIa 9/44, 21%; Gustillo IIIb 3/44, 7%). Sixty patients received treatment within six hours of their injury, while 93 did not. One hundred forty-four patients were treated within 24 hours from injury (mean, 8.2 hours) and 28 were treated after 24 hours (mean, 41.1 hours). There was no significant difference in the rates of infection for fractures treated before or after six hours from the time of injury (15% vs. 11%, p = 0.621). Infection rate was similar in patients treated within 24 hours and beyond 24 hours (10% vs. 14%, p = 0.518). The average time to treatment of patients with and without infectious outcome were not significantly different (15.6 vs 13.4 hours, p = 0.700). There was an association between more severe Gustilo types and infection, yet this did not reach significance (p = 0.402). CONCLUSION: Our results show that initial treatment beyond 24 hours did not lead to a significant increase in the rate of infection. While not significant, a greater proportion of infections occurred in higher Gustilo types. Our results suggest that fracture type rather than time to treatment may be a more important predictor of infection.

show abstract

Section: Discussionmentioning

confidence: 99%

Section: The Effect Of Treatment Delay On Infection In Open Tibia Framentioning

confidence: 99%

The Effect of Treatment Delay on Infection in Open Tibia Fractures: A Retrospective Study in Ethiopia

Kantor

Gallagher

Rosario

et al. 2019

International Journal of Orthopaedics

View full text Add to dashboard Cite

show abstract

“…1 ). Based on the principles of open fracture management [ 9 , 10 ], urgent debridement of wound and talus reduction, along with early administration of preventive antibiotics as well as a tetanus toxoid booster, was planned as soon as possible. Two hours later, with the patient under general anesthesia, the injured ankle was cleaned and irrigated copiously with sterile normal saline in the operating room.…”

Section: Case Presentationmentioning

confidence: 99%

Six-year survival of reimplanted talus after isolated total talar extrusion: a case report

Kwak

Heo²,

Jung

2017

J Med Case Reports

View full text Add to dashboard Cite

BackgroundOpen total extrusion of the talus without concomitant fracture is an extremely rare injury. We present 6-year follow-up data of a patient treated using a temporary spanning external fixator and less invasive single K-wire fixation.Case presentationA 55-year-old Asian man who had a totally extruded talus without fracture underwent immediate reimplantation surgery. A spanning external fixator with single antegrade K-wire fixation was applied to maintain the reimplanted talus. During 6 years of follow-up, he could walk without aids and could squat, corresponding to an American Orthopaedic Foot and Ankle Society score of 85. We found that the suspect lesion that was evident at 6 months after surgery had disappeared at 12 months postoperatively on the basis of sequential follow-up magnetic resonance imaging. There was no evidence of osteonecrosis of the dislocated talus at the final follow-up.ConclusionsIn patients with a totally extruded talus, a surgical strategy including immediate reimplantation of the talus and a temporary spanning fixator with single K-wire fixation might be useful to allow early mobilization around the ankle joint and to prevent additional damage of the foot without significant complications.

show abstract

“…Tibia fractures are the most common long bone fractures with an infection rate of 20 times higher than other open long bone fractures [1]. According to the epidemiologic studies, the incidence rate of open long bone fractures is 11.5 per 100,000 persons annually [2].…”

Section: Introductionmentioning

confidence: 99%

An Updated Evidence About the Role of Timing to Debridement on Infection Rate of Open Tibial Fractures: A Meta-Analysis

El-Hussein

2020

Cureus

View full text Add to dashboard Cite

Background and objectives Recent experimental and clinical evidence supporting early debridement for open fractures has been questioned. Therefore, this systematic review and meta-analysis aimed to summarize and evaluate the current evidence regarding the timing of surgical debridement of open tibial fractures. Methods A systematic review and meta-analysis were conducted on studies compared the infection rate following early versus late debridement of open tibial fractures. We performed an online, bibliographic, search through the period from January 2000 to June 2020 in five bibliographic databases: Cochrane Central Register of Controlled Trials (CENTRAL), Medline via PubMed, Web of Science, Scopus, and EBSCO host. Results Nine retrospective studies and six prospective studies were included in the present meta-analysis study. The pooled effect estimate showed no statistically significant difference between early and late debridement regarding the overall infection rate (RD 0.02, 95% CI [0-0.04], p = 0.94); there was no significant heterogeneity in the pooled estimate (I2 = 5%). The subgroup analysis showed that the non-significant difference was consistent regardless of the definition of early and late timing to debridement. Likewise, the pooled effect estimate showed no statistically significant difference between early and late debridement regarding the deep infection rate (RD 0.01, 95% CI [-0.01-0.03], p = 0.92); there was no significant heterogeneity in the pooled estimate (I2 = 0%). The pooled effect estimate showed no statistically significant difference between early and late debridement regarding the nonunion rate as well. The funnel lots showed little evidence of asymmetry by visual inspection. Conclusion In conclusion, the current evidence demonstrates no impact of timing to surgical debridement on the infection rate following open tibial fractures in the adult population. Our results demonstrated that the risks of infection, deep infection, and nonunion were similar between patients who underwent delayed versus early debridement.

show abstract

The 6-Hour Rule for Surgical Debridement of Open Tibial Fractures: A Systematic Review and Meta-Analysis of Infection and Nonunion Rates

Abstract: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cited by 91 publications

References 25 publications

The Effect of Treatment Delay on Infection in Open Tibia Fractures: A Retrospective Study in Ethiopia

The Effect of Treatment Delay on Infection in Open Tibia Fractures: A Retrospective Study in Ethiopia

Six-year survival of reimplanted talus after isolated total talar extrusion: a case report

An Updated Evidence About the Role of Timing to Debridement on Infection Rate of Open Tibial Fractures: A Meta-Analysis

Contact Info

Product

Resources

About