Background: Open fractures are one of the leading causes of disability worldwide. The treatment of these injuries has been commissioned by the Lancet Commission for Global Surgery as one of the central three surgical prioritizes to reduce mortality and morbidity globally.
Objective: To identify the optimal timing of the treatment of open fractures.
Methods: In February 2020, we searched PUBMED, Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (including In‐Process & Other Non‐Indexed Citations), Google Scholar, Orthoevidence.com, Ovid Embase, and EBSCO CINAHL Plus. Manual searches of retrieved articles and previous systemic reviews were conducted along with a gray literature search. Observational studies, both prospective and retrospective, as well as randomized trials that evaluated the association between the timing of irrigation and debridement and the development of surgical site infection in open fractures, were included. We then conducted an extensive meta-analysis of observational studies using raw and adjusted outcomes to determine if there was any plausible association between the timing of surgery and infection.
Results: The search resulted in 1148 studies. Three-hundred and sixteen were thoroughly reviewed after title screening, which resulted in 35 observational studies, including 8459 fractures. In unadjusted analyses, there was no association between irrigation and debridement and surgical site infection. If anything, the estimate showed a protective effect of later debridement (OR 0.88, 95% CI 0.72, 1.07, I2 = 24%, p=0.20, 35 studies). This effect was consistent across most subgroups. Adjustment for confounding was only performed in six studies. Aggregating adjusted estimates using the inverse-variance technique with time to debridement as a continuous variable, the risk did not increase significantly for each hour of delay to debridement (OR 1.02, 95% 1.00 to 1.04, I2 =32%, p=0.08, 6 studies). Adjusted estimates using a 6-8 hour cutoff and mostly very low-quality evidence, showed no significant increase in the odds of infection with delay past 6 to 8 hours (random effects, OR 1.08, 95% CI 1.00 to 1.18, 6 to 8-hour cutoff, I2 = 72%, p=0.07, 6 studies and fixed effects, OR 1.02, 95% CI 1.01 to 1.03, I2=45% p=0.005, 6 studies).
Conclusions: This complete review of the evidence consisting of 35 observational studies did not find an association between irrigation and debridement and surgical site infection in open fractures. This was consistent across all subgroups and when deep infection was considered. There is currently no available timepoint where irrigation and debridement is associated with increased rates of infection. Future studies must improve methodological quality to validate this finding.
Patient or healthcare consumer involvement: None