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Scientific Articles   |    
Does Timing to Operative Debridement Affect Infectious Complications in Open Long-Bone Fractures?A Systematic Review
Mara L. Schenker, MD1; Sarah Yannascoli, MD1; Keith D. Baldwin, MD, MSPT, MPH1; Jaimo Ahn, MD, PhD1; Samir Mehta, MD1
1 Department of Orthopaedic Surgery, University of Pennsylvania, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA 19104. E-mail address for S. Mehta: samir.mehta@uphs.upenn.edu
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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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Department of Orthopaedic Surgery, University of Pennsylvania, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA 19104. E-mail address for S. Mehta: samir.mehta@uphs.upenn.edu
Investigation performed at the Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
This article was chosen to appear electronically on May 9, 2012, in advance of publication in a regularly scheduled issue.
A commentary by Jason H. Calhoun, MD, is linked to the online version of this article at jbjs.org.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Jun 20;94(12):1057-1064. doi: 10.2106/JBJS.K.00582
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Abstract

Background: 

Existing guidelines recommend emergency surgical debridement of open fractures within six hours after injury. The aim of this study was to systematically review the association between time to operative debridement of open fractures and infection.

Methods: 

Searches of the MEDLINE, EMBASE, and Cochrane computerized literature databases and manual searches of bibliographies were performed. Randomized controlled trials and cohort studies (retrospective and prospective) evaluating the association between time to operative debridement and infection after open fractures were included. Descriptive and quantitative data were extracted. A meta-analysis of patient cohorts who underwent early or delayed debridement was performed with use of a random effects model.

Results: 

The initial search identified 885 references. Of the 173 articles inspected further on the basis of the title, sixteen (six prospective and ten retrospective cohort studies with a total of 3539 open fractures) were included. No significant difference in the infection rate was detected between open fractures debrided early or late according to any of the time thresholds used in the included studies. Sensitivity analyses demonstrated no difference in infection rate between early and late debridement in subgroups defined according to the Gustilo-Anderson classification, level of evidence, depth of infection, or anatomic location.

Conclusions: 

The data did not indicate an association between delayed debridement and higher infection rates when all infections were considered, when only deep infections were considered, or when only more severe open fracture injuries were considered. On the basis of this analysis, the historical “six-hour rule” has little support in the available literature. It is important to realize that additional carefully conducted studies are needed and that elective delay of treatment of patients with open fractures is not recommended.

Level of Evidence: 

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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