Association of Surgical Debridement Timings With Infection and Non-union Rates in Open Fractures of Lower Limb Long Bones.

BACKGROUND

Open fractures are one of the orthopaedic conditions that require urgent surgical intervention. Managing these fractures remains challenging for orthopaedic surgeons due to the need to transfer polytrauma patients to hospitals with advanced capabilities. Further delays may occur as resuscitative life-saving measures take precedence. Open fractures are frequently complicated by infections, non-unions, and, in rare cases, amputation. Currently, management of compound fractures of long bones of the lower limb requires early surgical debridement followed by limb salvage procedures or amputation (if required), depending on the type, location, and extent of the injury. Early and aggressive debridement of open fractures has always been the rule.

OBJECTIVES

To study the role of timing of surgical debridement of open fractures of the lower limb and its effect on infection and non-union rates and to analyze the impact of increased severity of open fractures on union and infections.

MATERIALS AND METHODS

The study was conducted prospectively in the orthopaedic department of a tertiary care hospital of Patiala with a population of 223 patients who presented to the orthopaedic emergency department with open lower limb fractures. Patients were divided into two groups based on the timing of surgical debridement: Groups A and B. Group A consisted of the patients who were operated on within 24 hours (n=110) and Group B consisted of patients whose surgical debridement was conducted 24 hours after injury (n=113). Infection rates and non-union rates were obtained based on the above data. All the results were summarized in Microsoft Excel (Microsoft Corp., Redmond, WA) and were analyzed with SPSS software 22 (IBM Corp., Armonk, NY) using the ANOVA test, chi-square test, and paired t-test. The Gustilo-Anderson classification (GAC) was used to classify the grades of open fractures. A p-value <0.05 indicated a statistically significant difference.

RESULTS

The mean age in Group A was 39.53±13.25 years (range 18-80) and the mean age in Group B was 42.45±12.64 years (range 18-76) (p=0.0936; not significant) In Group A, infection was present in 30 patients (27.27%) and in Group B, infection was present in 32 patients (28.32%) (p=0.9802; non-significant). Non-union was present in eight patients (7.27%) and 13 patients (11.50%) in Groups A and B, respectively (p=0.2793; non-significant). In Group A, the infection rate was 0% for GAC Grade 1, 10% for Grade 2, 35.89% for Grade 3A, and 66.67% for Grade 3B (p-value < 0.00001; statistically significant). In Group B, the infection rate was 2.86% for GAC Grade 1, 13.79% for Grade 2, 57.69% for Grade 3A, and 52.17% for Grade 3B (p-value < 0.00001; statistically significant). In Group A, the non-union rate was 0% for GAC Grade 1, 0% for Grade 2, 7.69% for Grade 3A, and 23.81% for Grade 3B (p-value < 0.00001; statistically significant). In Group B, the non-union rate was 0% for GAC Grade 1, 6.89% for Grade 2, 19.23% for Grade 3A, and 26.09% for Grade 3B (p-value < 0.00001; statistically significant).

CONCLUSION

The timing of surgical debridement in open fractures of the lower limb does not have a significant role in their management and these fractures can safely be debrided up to several hours after injury. GAC grading of open fractures has a significant association with infection and non-union rate, which increased significantly with increasing grades of open fractures.