Delay in Initial Debridement for Open Tibial Fractures and Its Possible Impact on Patient Outcomes
Authors: Tahir Muhammad , Ahmed Nadeem , Shaikh Saeed Ahmad , Jamali Allah Rakhio , Choudry Usama Khalid , Khan Shoaib 
Published: March 2021

Update
This article was updated on July 21, 2022, because of errors on pages 2, 3, 4, and 5. Specifically, on page 2, in Table I, the values for mean age, diabetes, and smoker that had read “43.60 ± 13.65,” “8.7% (165),” and “23.9% (453)” now read “43.52 ± 15.31,” “8.7% (164),” and “23.8% (451),” respectively.
On page 3, in Table II, all data in the Rates column were incorrect. For infection, the rates for Type-I, Type-II, and Type-III fractures that had read “8.42/10.14/12.32,” “16.74/20.85/16.98,” and “26.57/29.60/26.73” now read “8.8/9.7/13.8,” “13.9/19.3/16.7,” and “20.1/28.4/26.3.” For nonunion, the rates for Type-I, Type-II, and Type-III fractures that had read “6.13/8.53/9.35,” “11.78/15.61/14.56,” and “18.46/22.64/23.44” now read “5.3/9.2/10,” “6.8/19.3/14.2,” and “13.3/22.7/31.7.” Relative risk estimates, 95% confidence intervals, p values, and the conclusions drawn therewith have not been adjusted but may have been affected by the changes in rates.
Additionally on page 3, the sentence that had read “The overall infection rates for the GA type-I, II, and III fractures were 8.42%, 16.74%, and 26.57%, respectively, in the group debrided in the 24 to 48-hour period; 10.14%, 20.85%, and 29.60% for those debrided in the 49 to 72-hour period; and 12.32%, 16.98%, and 26.73% for those debrided in the 73 to 96-hour period” now reads “The overall infection rates for the GA type-I, II, and III fractures were 8.8%, 13.9%, and 20.1%, respectively, in the group debrided in the 24 to 48-hour period; 9.7%, 19.3%, and 28.4% for those debrided in the 49 to 72-hour period; and 13.8%, 16.7%, and 26.3% for those debrided in the 73 to 96-hour period.”
Additionally on page 3, the sentences that had read “The trends for the nonunion rates for GA type-I, II, and III fractures according to the timing of the surgery were similar to those observed for the infection rates. The overall nonunion rates for the type-I, II, and III injuries were 6.13%, 11.78%, and 18.46%, respectively, for those debrided in the 24 to 48-hour period; 8.53%, 15.61%, and 22.64% for those debrided in the 49 to 72-hour period; and 9.35%, 14.56%, and 23.44% for those debrided in the 73 to 96-hour period” now read “The trends for the nonunion rates for GA type-I, II, and III fractures according to the timing of the surgery were similar to those observed for the infection rates. The overall nonunion rates for the type-I, II, and III injuries were 5.3%, 6.8%, and 13.3%, respectively, for those debrided in the 24 to 48-hour period; 9.2%, 19.3%, and 22.7% for those debrided in the 49 to 72-hour period; and 10.0%, 14.2%, and 31.7% for those debrided in the 73 to 96-hour period.”
Additionally on page 3, the sentence that had read “Additionally, our data suggested that a delay of >12 hours between the injury and the first administration of antibiotics was strongly associated with deep infection after surgery, independent of the delay before debridement and the GA classification (RR = 6.183, CI = 4.389 to 8.372, p < 0.05)” now reads “Additionally, our data suggested that a delay of >24 hours between the injury and the first administration of antibiotics was strongly associated with deep infection after surgery, independent of the delay before debridement and the GA classification (RR = 6.183, CI = 4.389 to 8.372, p < 0.05).” On page 4, in Figure 1, the rates of infection and nonunion were incorrect. A new figure has been provided with the correct rates.
The sentence on page 4 (formerly spanning pages 4 and 5) that had read “These data were comparable with our infection rates of 8.4%, 16.7%, and 26.6% in the same time interval for these fracture types” now reads “These data were comparable with our infection rates of 8.8%, 13.9%, and 20.1% in the same time interval for these fracture types.”
The sentence on page 4 (formerly page 5) that had read “Furthermore, the 10%, 15%, and 25% infection rates in the 73 to 96-hour period reported by Duyos et al. were similar to the infection rates of 12.3%, 17.0%, and 26.7% in the same period in our study” now reads “Furthermore, the 10%, 15%, and 25% infection rates in the 73 to 96-hour period reported by Duyos et al. were similar to the infection rates of 13.8%, 16.7%, and 26.3% in the same period in our study.”
Finally, on page 5, in Table IV, the data for deep infection in the 24-48, 48-72, and 72-96-hour cohorts that had read “99,” “122,” and “106,” respectively, now read “98,” “116,” and “111.” Additionally, the data for nonunion in the 24-48, 48-72, and 72-96-hour cohorts that had read “47,” “105,” and “125,” respectively, now read “56,” “112,” and “109.”
Note that relative risk estimates, 95% confidence intervals, p values, and the conclusions drawn therefrom have not been adjusted but may have been affected by the changes in rates. Data for radiographic union score for tibial fracture, treatment type, superficial infection, osteomyelitis, graft failure, amputation, unplanned surgery, and death were also unable to be verified.
An erratum has been published: JBJS Open Access. 2022;7(3):e20.00027ER.

Background:
The current consensus regarding the management of open fracture indicates that the initial debridement should be performed within the first 6 hours after injury. Unfortunately, in Pakistan, the emergency medical services are not well-established and patient arrival at the hospital is delayed the majority of the time. In this study, we present our experience with delayed surgical management of open tibial fractures.

Methods:
A prospective study of patients who presented to the accident and emergency department of the authors’ institution was performed. The duration of the study was 4 years. All patients ≥18 years of age with an isolated open fracture of the tibia were included in the study. Open fractures were graded using the Gustilo-Anderson (GA) classification. The study participants were divided into 3 groups based on the timing of the surgery. Infection and nonunion rates were compared using chi-square analysis. P < 0.05 was considered significant.

Results:
A total of 1,896 patients were included in the study. There was no significant difference between the results of surgery performed before 48 hours and those of surgery performed after 48 hours with regard to the infection rates associated with GA type-I (p = 0.48), type-II (p = 0.70), or type-III (p = 0.87) fractures or the nonunion rates associated with type-I (p = 0.6338), type-II (p = 0.4030), or type-III (p = 0.4808) fractures. A higher GA classification was associated with higher rates of infection and nonunion independent of the timing of the surgery (95% confidence interval [CI] = 1.24 to 1.89, p < 0.01).

Conclusions:
Our study indicates that the risks of infection and nonunion remain acceptable despite delays in the management of open tibial fractures within a 24 to 96-hour window. A delay in the initial time to debridement is acceptable only when early care cannot be provided. Prompt initial debridement remains the best possible treatment for open tibial fractures.

Level of Evidence:
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.