An Updated Evidence About the Role of Timing to Debridement on Infection Rate of Open Tibial Fractures: A Meta-Analysis.

Ahmed Elnewishy

doi:10.7759/cureus.10379

Abstract

Background and objectivesRecent experimental and clinical evidence supporting early debridement for open fractures has been questioned. Therefore, this systematic review and meta-analysis aimed to summarize and evaluate the current evidence regarding the timing of surgical debridement of open tibial fractures.MethodsA systematic review and meta-analysis were conducted on studies compared the infection rate following early versus late debridement of open tibial fractures. We performed an online, bibliographic, search through the period from January 2000 to June 2020 in five bibliographic databases: Cochrane Central Register of Controlled Trials (CENTRAL), Medline via PubMed, Web of Science, Scopus, and EBSCO host.ResultsNine retrospective studies and six prospective studies were included in the present meta-analysis study. The pooled effect estimate showed no statistically significant difference between early and late debridement regarding the overall infection rate (RD 0.02, 95% CI [0 - 0.04], p = 0.94); there was no significant heterogeneity in the pooled estimate (I2 = 5%). The subgroup analysis showed that the non-significant difference was consistent regardless of the definition of early and late timing to debridement. Likewise, the pooled effect estimate showed no statistically significant difference between early and late debridement regarding the deep infection rate (RD 0.01, 95% CI [-0.01 - 0.03], p = 0.92); there was no significant heterogeneity in the pooled estimate (I2 = 0%). The pooled effect estimate showed no statistically significant difference between early and late debridement regarding the nonunion rate as well. The funnel lots showed little evidence of asymmetry by visual inspection.ConclusionIn conclusion, the current evidence demonstrates no impact of timing to surgical debridement on the infection rate following open tibial fractures in the adult population. Our results demonstrated that the risks of infection, deep infection, and nonunion were similar between patients who underwent delayed versus early debridement.

Highlights

Tibia fractures are the most common long bone fractures with an infection rate of 20 times higher than other open long bone fractures [1]
The pooled effect estimate showed no statistically significant difference between early and late debridement regarding the deep infection rate (RD 0.01, 95% confidence interval (95% CI) [-0.01 - 0.03], p = 0.92); there was no significant heterogeneity in the pooled estimate (I2 = 0%)
The current evidence demonstrates no impact of timing to surgical debridement on the infection rate following open tibial fractures in the adult population

Summary

Introduction

Tibia fractures are the most common long bone fractures with an infection rate of 20 times higher than other open long bone fractures [1]. Several tissue damage and wound contamination can lead to bone and soft tissue necrosis and infection due to open fractures. In order to reduce the risk of infection and nonunion, it has been recommended that open tibial fractures should be debrided within 6 hours from injury, which is known as the 6-hour rule [7]. The 6-hour rule comes from a study of Friedrich that was conducted on guinea-pigs and showed that all animals remained healthy when debridement of open wounds was performed within 6 hours [8]. This systematic review and meta-analysis aimed to summarize and evaluate the current evidence regarding the timing of surgical debridement of open tibial fractures

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Discussion

Conclusion