The Effect of Delayed Surgical Debridement in the Management of Open Tibial Fractures: A Systematic Review and Meta-Analysis

Abstract

Introduction: Open tibial fractures are complex injuries with variable outcomes that significantly impact patients’ lives. Surgical debridement is paramount in preventing detrimental complications such as infection and non-union; however, the exact timing of debridement remains a topic of great controversy. The aim of this study is to evaluate the association between timing of surgical debridement and outcomes such as infection and non-union in open tibial fractures. Materials and Methods: We performed a systematic review and meta-analysis of the literature to capture studies evaluating the association between timing of initial surgical debridement and infection or non-union, or other reported outcomes. We searched the MEDLINE, PubMed Central, EMBASE, SCOPUS, Cochrane Central and Web of Science electronic databases. Our methodology was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane handbook for systematic reviews of interventions. Results: The systematic review included 20 studies with 10,032 open tibial fractures. The overall infection rate was 14.3% (314 out of 2193) and the overall non-union rate 14.2% (116 out of 817). We did not find any statistically significant association between delayed debridement and infection rate (OR = 0.87; 95% CI, 0.68 to 1.11; p = 0.23) or non-union rate (OR = 0.70; 95% CI, 0.42 to 1.15; p = 0.13). These findings did not change when we accounted for the effect of different time thresholds used for defining early and late debridement, nor with the Gustilo–Anderson classification or varying study characteristics. Conclusion: The findings of this meta-analysis support that delayed surgical debridement does not increase the infection or non-union rates in open tibial fracture injuries. Consequently, we propose that a reasonable delay in the initial debridement is acceptable to ensure that optimal management conditions are in place, such that the availability of surgical expertise, skilled staff and equipment are prioritised over getting to surgery rapidly. We recommend changing the standard guidance around timing for performing surgical debridement to ‘as soon as reasonably possible, once appropriate personnel and equipment are available; ideally within 24-h’.

Current pathogens infecting open fracture tibia and their antibiotic susceptibility at a tertiary care teaching hospital in South East Asia

“…However, in our research, injury to debridement time greater than 6 hours, or even greater than 12 hours, was not shown to be a risk factor in either the bivariate or multivariate analyses. A recent systematic review and meta-analysis reported debridement time even up to 24 hours did not affect the infection rate; furthermore, it was found that competent debridement was preferred over rapid and poor debridement [ 26 ].…”

Clinical and Radiological Outcomes of Gustilo-Anderson Type IIIB Open Fractures in 125 Patients

“…Nicolaides et al's systemic review, which included 20 studies with 10,032 open tibial fractures and similarly didn't find any statistically significant association between delayed debridement and infection rate or non-union rate[26].A comparison of the outcomes of GA IIIB open fractures of historical studies from available literature with the current study is given in Table8.…”

“…It’s obvious that this result cannot be used to advocate for delayed debridement, but it can guide us to understand the higher relevance of Getting It Right First Time (GIRFT) and prioritising the availability of surgical expertise, skilled staff, and equipment over rushing the patient to the theatre for a rapid operation aiming to adhere to these time thresholds. This was also recommended by Nicolaides et al's systemic review, which included 20 studies with 10,032 open tibial fractures and similarly didn’t find any statistically significant association between delayed debridement and infection rate or non-union rate [ 26 ].…”

Unsupervised Machine Learning Reveals a Vulvodynia-Predominant Subtype in Bladder Pain Syndrome/Interstitial Cystitis

“…The etiology of BPS/IC is multifactorial, and the condition often presents with various comorbidities, such as pelvic organ inflammation, vulvodynia, and pelvic floor myofascial pain, which have been reported to be highly prevalent [3][4][5][6]. Furthermore, inflammation in the BPS/IC may extend to other pelvic organs, potentially contributing 1 to the complex symptomatology of this condition [7,8]. Among these comorbidities, vulvodynia has gained attention in recent years.…”