A Reevaluation of the Risk of Infection Based on Time to Debridement in Open Fractures: Results of the GOLIATH Meta-Analysis of Observational Studies and Limited Trial Data. (3rd February 2021)

• Record Type: Journal Article
• Authors: Foote, Clary J.; Tornetta, Paul; Reito, Aleksi; Al-Hourani, Khalid; Schenker, Mara; Bosse, Michael; Coles, Chad P.; Bozzo, Anthony; Furey, Andrew; Leighton, Ross
• Is Part Of: Journal of bone and joint surgery. Volume 103:Number 3(2021)
• Publication Date: 2021-02-03
• Subjects: Bones -- Surgery -- Periodicals; Joints -- Surgery -- Periodicals; Orthopedics -- Periodicals; Orthopedics; General Surgery; Bone Diseases; Joint Diseases; Bones -- Surgery; Joints -- Surgery; Orthopedics; Bot (anatomie); Gewrichten; Chirurgie (geneeskunde); Periodicals; Electronic journals; Periodicals; 617.47005
• DOI: 10.2106/JBJS.20.01103
• Languages: English
• ISSNs: 0021-9355

Abstract

Update: This article was updated on February 9, 2021, because of a previous error. On page 269, in the Note at the end of the article, the surname that had read "Merner" now reads "Mener." An erratum has been published: J Bone Joint Surg Am. 2021 Mar 17;103(6):e25. Background: Open fractures are one of the leading causes of disability worldwide. The threshold time to debridement that reduces the infection rate is unclear. Methods: We searched all available databases to identify observational studies and randomized trials related to open fracture care. We then conducted an extensive meta-analysis of the observational studies, using raw and adjusted estimates, to determine if there was an association between the timing of initial debridement and infection. Results: We identified 84 studies (18, 239 patients) for the primary analysis. In unadjusted analyses comparing various "late" time thresholds for debridement versus "early" thresholds, there was an association between timing of debridement and surgical site infection (odds ratio [OR] = 1.29, 95% confidence interval [CI] = 1.11 to 1.49, p < 0.001, I 2 = 30%, 84 studies, n = 18, 239). For debridement performed between 12 and 24 hours versus earlier than 12 hours, the OR was higher in tibial fractures (OR = 1.37, 95% CI = 1.00 to 1.87, p = 0.05, I 2 = 19%, 12 studies, n = 2, 065), and even more so in Gustilo type-IIIB tibial fractures (OR = 1.46, 95% CI = 1.13 to 1.89, p = 0.004, I 2 = 23%, 12 studies, n = 1, 255). An analysis of Gustilo type-III fractures showed a progressive increase in the risk of infection with time. Critical time thresholds included 12 hours (OR = 1.51, 95% CI = 1.28 to 1.78, p < 0.001, I 2 = 0%, 16 studies, n = 3, 502) and 24 hours (OR = 2.17, 95% CI = 1.73 to 2.72, p < 0.001, I 2 = 0%, 29 studies, n = 5, 214). Conclusions: High-grade open fractures demonstrated an increased risk of infection with progressive delay to debridement. Level of Evidence: Prognostic Level IV . See Instruction for Authors for a complete description of the levels of evidence.