The Journal of Bone and Joint Surgery (American). 2010;92:7-15.
doi:10.2106/JBJS.H.00984
© 2010 The Journal of Bone and Joint Surgery, Inc.
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The Relationship Between Time to Surgical Débridement and Incidence of Infection After Open High-Energy Lower Extremity Trauma

Andrew N. Pollak, MD1, Alan L. Jones, MD2, Renan C. Castillo, MS3, Michael J. Bosse, MD4, Ellen J. MacKenzie, PhD3 and the LEAP Study Group

1 University of Maryland School of Medicine, 22 South Greene Street, Suite T3R54, Baltimore, MD 21201. E-mail address: apollak{at}umoa.umm.edu
2 Orthopedic Trauma Associates of North Texas, Sammons Tower, 3409 Worth Street, Suite 320, Dallas, TX 75246
3 Center for Injury Prevention and Research, Johns Hopkins University Bloomberg School of Public Health, 624 North Broadway Street, Room 482, Baltimore, MD 21205
4 Department of Orthopaedic Surgery, Carolinas Medical Center, P.O. Box 32861, Charlotte, NC 28232

A commentary by Andrew H. Schmidt, MD, is available at www.jbjs.org/commentary and as supplemental material to the online version of this article.

Investigation performed at the University of Maryland School of Medicine, Baltimore, Maryland; the University of Texas Southwestern School of Medicine, Dallas, Texas; the Center for Injury Prevention and Research, Johns Hopkins University School of Public Health, Baltimore, Maryland; and Carolinas Medical Center, Charlotte, North Carolina

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the National Institutes of Health—National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS R01-AR42659). Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity in direct or indirect support of this work.

Background Urgent débridement of open fractures has been considered to be of paramount importance for the prevention of infection. The purpose of the present study was to evaluate the relationship between the timing of the initial treatment of open fractures and the development of subsequent infection as well as to assess contributing factors.

Methods Three hundred and fifteen patients with severe high-energy lower extremity injuries were evaluated at eight level-I trauma centers. Treatment included aggressive débridement, antibiotic administration, fracture stabilization, and timely soft-tissue coverage. The times from injury to admission and operative débridement as well as a wide range of other patient, injury, and treatment-related characteristics that have been postulated to affect the risk of infection within the first three months after injury were studied, and differences between groups were calculated. In addition, multivariate logistic regression models were used to control for the effects of potentially confounding patient, injury, and treatment-related variables.

Results Eighty-four patients (27%) had development of an infection within the first three months after the injury. No significant differences were found between patients who had development of an infection and those who did not when the groups were compared with regard to the time from the injury to the first débridement, the time from admission to the first débridement, or the time from the first débridement to soft-tissue coverage. The time between the injury and admission to the definitive trauma treatment center was an independent predictor of the likelihood of infection.

Conclusions The time from the injury to operative débridement is not a significant independent predictor of the risk of infection. Timely admission to a definitive trauma treatment center has a significant beneficial influence on the incidence of infection after open high-energy lower extremity trauma.

Level of Evidence Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.


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