1. Highly contaminated lower limb fractures should undergo immediate wound excision in theatre.
2. Wound excision should be performed jointly by consultant orthopaedic and plastic surgeons.
3. High-energy lower limb fractures (likely Gustilo–Anderson Type IIIA and IIIB), which are not highly contaminated, should undergo wound excision within 12 hours of injury and all other lower limb fractures should be excised within 24 hours of injury. The consultant orthoplastic surgical team are best placed to determine the timing for individual patients based on clinical assessment.
The aim of wound excision is to remove contaminating debris and all devitalised tissue. This should reduce both the bacterial burden and available substrate for microbial colonisation, resulting in fewer deep surgical site infections. In turn, this will lead to improved patient outcomes. The timing of wound excision has been the subject of intense debate. In the past, guidelines have favoured wound excision within 6 hours based on historical animal and human studies. However, it is difficult to isolate the effect of timing alone owing to the many confounding factors, including patient characteristics, mechanism of injury, timing and type of antibiotics, and timing of soft tissue reconstruction.
In 2016, the National Institute for Health and Care Excellence (NICE) performed a systematic review of the literature (1) with regard to timing of wound excision when managing open fractures. Two further reviews have followed (2, 3), both with methodological limitations. The NICE review identified no randomised controlled trials. Nine cohort studies were included, two prospective and seven retrospective. Thirty-one studies were excluded owing to inadequate adjustment for confounders and for not meeting the protocol criteria. A subsequent search identified a further retrospective study on timing of excision after 24 hours following injury (4).
The NICE review identified two studies suggesting no clinical difference in deep surgical site infection rates between early and late wound excision (6 or 8 hours or less versus more than 6 or 8 hours, respectively) (5, 6). Another study suggested low deep surgical site infection rate with early wound excision (less than 8 hours) (7). A further three studies suggested timing of wound excision is not a predictor of deep surgical site infection (8, 9, 10). In a large retrospective study of patients with open tibial fractures, primary wound excision beyond the first day of admission was associated with a significantly increased probability of amputation (11).
NICE have recommended that all open fractures should be excised jointly by consultant orthopaedic and plastic surgeons. A series comparing open fractures managed by a specialist centre versus those initially managed at local centres showed that the latter had increased complication rates and revision surgery (12). This is supported by another retrospective study, which found that patients with open ankles, initially treated at peripheral centres, undergo additional, potentially avoidable operations (13).
Using arbitrary time cut-offs rather than analysing time as a continuum reduces statistical power. Hull et al. looked retrospectively at the accumulative effect of delayed wound excision on deep surgical site infection rates (14). They reported a series of 364 consecutive patients with 459 open limb fractures. After controlling for confounding variables and considering all grades of fractures together, they found with each hour passing post-injury there was an increase in the odds ratio for infection of 1.033. When subdivided by fracture severity, a delay in the first wound excision had a greater effect on higher-grade fractures. Open fractures of the tibia had an increased odds ratio for infection of 2.44 compared with non-tibia sites and high-grade (IIIB and IIIC) had higher rates of infection than low-grade (II and IIIA) injuries. Therefore, high-grade fractures of the tibia where excision is delayed are at the greatest risk of developing deep infection. The NICE Guidance Development Group recommended that highly contaminated fractures such as those exposed to the aquatic environment or sustained in the agricultural environment should be excised immediately in theatre. High-grade open fractures (presumed grade IIIA or IIIB) should be excised within 12 hours and all other open fractures, excluding those of the hand, toes, and wrist, within 24 hours of the injury.
No studies consider the economics or cost effectiveness of different timings. The NICE Guidance Development Group performed a cost analysis that explored the timing of initial wound excision with or without the presence of a plastic surgeon, timing of soft tissue cover, and provision of multiple theatre sessions. It found that as the delay to wound excision increased, so did the costs owing to increased complication rates. In addition, the increased staff costs to deliver early wound excision by consultant plastic surgeons alongside consultant orthopaedic surgeons are outweighed by the costs of potential complications if the patient is treated sequentially or inadequately.
The available evidence shows benefits of early wound excision. Timing of wound excision is largely modifiable unlike severity of injury and presence of gross contamination, which are both major risk factors. The NICE guidelines take account of the relative contributions of these risk factors and balance them with the potential risks of out-of-hours surgery alongside the health economic requirements of delivering a service.
1. National Clinical Guideline Centre (UK). Fractures (Complex): Assessment and Management. London: National Institute for Health and Care Excellence (UK); 2016 Feb. NG37. https://www.nice.org.uk/guidance/ng37/chapter/Recommendations#hospital-settings
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13. Chummun S, Wright TC, Chapman TWL, Khan U. Outcome of the management of open ankle fractures in an ortho-plastic specialist centre. Injury Int. J. Care Injured 2015;46:1112–15.Find this resource:
14. Hull PD, Johnson SC, Stephen DJG, Kreder HJ, Jenkinson RJ. Delayed debridement of severe open fractures is associated with a higher rate of deep infection. Bone Joint J. 2014;96-B(3):379–84.Find this resource: