J Trauma Acute Care Surg. 2014 May;76(5):1201-7. doi: 10.1097/TA.0000000000000205.
Early (<8 hours) operative debridement and irrigation (D&I) of open fractures are considered essential to reduce the risk of deep infection. With the advent of powerful antimicrobials, this axiom has been challenged. The current study evaluates the rates of deep infections of open fractures in relation to the time to the first D&I.
A list of all blunt open fractures during a 6-year period was obtained from the trauma registry. Patients were evaluated for age, Injury Severity Score (ISS), physiologic derangement (systolic blood pressure, lactate, Revised Trauma Score [RTS]), and fracture type (Gustilo). Time to the first D&I was calculated. All patients received appropriate prophylactic antimicrobials. Infection rates were calculated and correlated to the time to the first D&I (<8 hours vs. >8 hours). Regression analysis was performed to identify independent predictors of infection.
During the 72-month study period, 404 patients met entry criteria, with 415 open extremity fractures (upper, 129; lower, 287). Early (<8 hours) and delayed (>8 hours) groups were well matched, although the age was lower and ISS was higher in the group with greater than 8 hours. The rates of infection were 35 (11%) of 328 (<8 hour) and 17 (19%) of 87 (>8 hours) (p < 0.05). When fractures were subgrouped by extremity, for the lower extremity, both a delay of greater than 8 hours and higher Gustilo type correlated with the development of infection. In the upper extremity, only higher Gustilo type correlated, and a delay to the first D&I did not increase the incidence of infection. Regression analysis revealed that higher ISS (odd ratio [OR], 1.052; 95% confidence interval [CI], 1.019-1.086), Gustilo grade, and a delay of greater than 8 hours (OR, 2.035; 95% CI, 1.022-4.054) were independent predictors of infection for the all-extremity model. Separate models for upper and lower extremities showed that the same three parameters were independent predictors for the lower extremity (ISS: OR, 1.045; 95% CI, 1.004-1.087; Gustilo type and >8-hour delay: OR, 3.006; 95% CI, 1.280-7.059), but none for the upper extremity.
Delay of greater than 8 hours to the first D&I for open fractures of the lower extremity increases the likelihood of infection but not for the upper extremity. Higher Gustilo type open fractures have a higher incidence of infection for both upper and lower extremities. The results have important implications in an era of decreasing surgeon availability, especially in off hours.
Therapeutic study, level IV.
早期（<8 小时）对开放性骨折进行清创和灌洗（D&I）被认为是降低深部感染风险的关键。随着强效抗菌药物的出现，这一公理受到了挑战。本研究评估了开放性骨折的深部感染率与首次 D&I 时间之间的关系。
从创伤登记处获得了 6 年期间所有钝性开放性骨折的清单。根据年龄、损伤严重程度评分（ISS）、生理紊乱（收缩压、乳酸、修订创伤评分[RTS]）和骨折类型（Gustilo）对患者进行评估。计算首次 D&I 的时间。所有患者均接受了适当的预防性抗菌药物治疗。计算感染率并与首次 D&I 时间（<8 小时与>8 小时）相关联。进行回归分析以确定感染的独立预测因素。
在 72 个月的研究期间，404 名患者符合入选标准，其中 415 例开放性四肢骨折（上肢 129 例，下肢 287 例）。早期（<8 小时）和延迟（>8 小时）组之间匹配良好，尽管年龄较小，ISS 较高的患者组>8 小时。感染率为 35（11%）例（<8 小时）和 17（19%）例（>8 小时）（p<0.05）。当按肢体分组时，对于下肢，>8 小时的延迟和更高的 Gustilo 类型均与感染的发展相关。在上肢，只有更高的 Gustilo 类型相关，而首次 D&I 的延迟并没有增加感染的发生率。回归分析显示，更高的 ISS（比值比[OR]，1.052；95%置信区间[CI]，1.019-1.086）、Gustilo 分级和>8 小时的延迟（OR，2.035；95%CI，1.022-4.054）是所有肢体模型感染的独立预测因素。上下肢的单独模型显示，相同的三个参数是下肢（ISS：OR，1.045；95%CI，1.004-1.087；Gustilo 类型和>8 小时延迟：OR，3.006；95%CI，1.280-7.059）的独立预测因素，但对上肢则不是。
下肢开放性骨折首次 D&I 延迟>8 小时会增加感染的可能性，但对上肢则不然。更高 Gustilo 类型的开放性骨折在上肢和下肢的感染发生率更高。在外科医生可用性减少的时代，特别是在非工作时间，这一结果具有重要意义。
治疗研究，IV 级。
