Time to debridement in open high-grade lower limb fractures and its effect on union and infections: A prospective study in a tropical setting

Abstract

Purpose: To prospectively evaluate whether time to debridement has any correlation with union, infection, and quality of life in high-grade lower limb fractures in a tropical setting. Methods: A prospective cohort study was conducted at a tertiary care center in South India. Two hundred fifty-four adult skeletally mature patients with 301 grade 3 fractures involving the femur, tibia, or fibula were recruited. The cohort was empirically divided into two groups (early and late) based on the time to debridement (less than or more than 12 h from injury). Outcome: The primary outcome was nonunion. Secondary outcomes were deep infection rates and patients’ quality of life. Short form-36 (SF-36) and short musculoskeletal functional assessment (SMFA) questionnaires were also used. Patients were followed up for 9 months. Results: The follow-up rate was 93%. The late group had a significantly higher risk of nonunion (odds ratio(OR): 6.5, 95% confidence interval (CI): 2.82–14.95) and infections (OR: 6.05, 95% CI: 2.85–12.82). There was a 4% increase in the infection risk for each hour of delay for the initial 50 h ( p < 0.0001). SF-36 and SMFA scores were superior in the early group ( p < 0.0001). Conclusion: The study contradicts findings reported in the literature from the West. Our study was in agreement with our hypothesis and proved that debridement within 12 h resulted in significantly lower rates of nonunion and infections and an overall improved quality of life in high-grade open lower limb fractures in a developing country. Level of evidence: Level II Trial registration: German Clinical Trials Register DRKS00015186

Risk factors for nonunion following surgically managed, traumatic, diaphyseal fractures: a systematic review and meta-analysis

“…Among the risk factors that could not be included in the meta-analyses, it was found that fracture gap ( 20 , 24 , 37 ), comminution ( 22 , 32 , 41 ), soft tissue defects ( 15 , 22 ), NSAIDs ( 19 , 20 , 23 , 42 ), and location of the fracture ( 25 , 29 , 32 , 42 , 43 ) were associated with nonunion in more than 50% of the studies. By contrast, polytrauma ( 18 , 19 , 26 , 30 , 31 ), ASA score ( 14 , 19 , 30 , 39 ), injury mechanism ( 25 , 27 , 35 ), hypertension ( 19 , 41 , 42 ), injury severity score ( 33 , 38 , 43 ), comorbidity ( 17 , 28 , 39 ), and time until surgery ( 14 , 15 , 43 ) were associated with nonunion in less than 50% of the studies. Vitamin D deficiency ( 36 ), osteoporosis ( 19 ), and fracture alignment ( 21 ) were also associated with nonunion, but each risk factor was only included in a single study.…”

“…The included studies were designed as follows: one was prospective ( 14 ), one was uncertain ( 15 ), and the remaining 28 were retrospective ( 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ) ( Table 1 ). The studies included 38 465 patients, of which 3,975 suffered from nonunion.…”

“…Thirteen studies included Gustilo classification in their analyses; nine and ten studies were eligible for the meta-analysis comparing type I vs II and type II vs III, respectively. The studies that were not included in the meta-analyses supplied the following evidence: one study stated that Gustilo type was significantly associated with nonunion in the univariate analysis ( P < 0.0001), but not in the multiple logistic regression analysis ( P = 0.085) ( 30 ), another study pooled data into two groups, over and under type IIIc (OR: 2.41, 95% CI: 1.26–4.76) ( 14 ), and the last study pooled type I+II and compared this to type III (OR: 6.06, 95% CI: 1.67–24.50) ( 43 ).…”

“…Vitamin D deficiency ( 36 ), osteoporosis ( 19 ), and fracture alignment ( 21 ) were also associated with nonunion, but each risk factor was only included in a single study. No studies found that alcohol ( 17 , 19 , 41 , 42 ), fracture location (right vs left) ( 19 , 41 ), head injury ( 19 , 26 ), race ( 39 ), cholesterol ( 36 , 42 ), betel nuts ( 42 ), compartment syndrome ( 24 ), cause of injury ( 19 ), fasciotomy ( 18 ), year of injury ( 17 ), rheumatoid arthritis ( 17 ), obliquity ( 19 ), CRP ( 14 ), contamination ( 14 ), or hematocrit ( 14 ) were associated with nonunion.…”

Infection risk in Gustilo and Anderson type III tibia and fibular fractures treated with external fixation in a tertiary hospital of a developing country

“…Evidence have shown no difference between the time of debridement and clinical or functional outcome in type III fractures specifically, whilst a delay from injury to presentation such as in more remote regions has been shown to have acceptable outcomes as long as the main principles of satisfactory debridement, fracture stabilization and soft tissue management are offered. 7,26 Ironically most of their patients presented after a week while some were actually type II injuries.…”