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Time to initial operative treatment following open fracture does not impact development of deep infection: a prospective cohort study of 736 subjects.

OBJECTIVES: To evaluate the association between time to surgery, antibiotic administration, Gustilo grade, fracture location, and development of deep infection in open fractures.

DESIGN: Prospective cohort between 2001 and 2009.

SETTING: Three Level 1 Canadian trauma centers.

PARTICIPANTS: A total of 736 (791 fractures) subjects were enrolled and 686 subjects (93%; 737 fractures) provided adequate follow-up data (1-year interview and/or clinical follow-up >90 days).

INTERVENTION: Demographics, injury information, time to surgery, and antibiotics were recorded. Subjects were evaluated using standardized data forms until the fracture(s) healed. Phone interviews were undertaken 1 year after the fracture.

MAIN OUTCOME MEASURES: Infection requiring unplanned surgical debridement and/or sustained antibiotic therapy.

RESULTS: Tibia/fibula fractures were most common (n = 413, 52%), followed by upper extremity (UE) (n = 285, 36%), and femoral (n = 93, 12%) fractures. Infection developed in 46 fractures (6%). The median time to surgery was 9 hours 4 minutes (interquartile range, 6 hours 39 minutes to 12 hours 33 minutes) and 7 hours 39 minutes (interquartile range, 6 hours 10 minutes to 9 hours 54 minutes) for those without and with infection, respectively (P = 0.04). Gustilo grade 3B/3C fractures accounted for 17 of 46 infections (37%) (P < 0.001). Four UE (1.5%), 7 femoral (8%), and 35 tibia/fibula (9%) fractures developed infections (P = 0.001). Multivariate regression found no association between infection and time to surgery [odds ratio (OR), 0.97; 95% confidence interval (95% CI), 0.90-1.06] or antibiotics (OR, 1.0; 95% CI, 0.90-1.05). Grades 3A (OR, 6.37; 95% CI, 1.37-29.56) and 3B/3C (OR, 12.87; 95% CI, 2.72-60.95) relative to grade 1 injuries and tibia/fibula (OR, 3.91; 95% CI, 1.33-11.53) relative to UE fractures were significantly associated with infection.

CONCLUSION: Infection after open fracture was associated with increasing Gustilo grade or tibia/fibula fractures but not time to surgery or antibiotics.

LEVEL OF EVIDENCE: Prognostic level I. See instructions for authors for a complete description of levels of evidence.

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