Outcomes of early versus late irrigation and debridement of pediatric open long bone fractures

Abstract

BACKGROUND

Open long bone fractures are a major concern for pediatric patients due to the risk of surgical site infection (SSI). Early studies have recommended irrigation and debridement of open fractures within 6 hours-8 hours for the prevention of SSI. According to the American College of Surgeons (ACS) Best Practice Guidelines, in 2015, irrigation and debridement should be done within 24 hours.

AIM

To identify whether early irrigation and debridement, within 8 hours, vs late, between 8 hours and 24 hours, for pediatric open long bone fractures impacts rate of SSI.

METHODS

Using retrospective data review from the National Trauma Data Bank, Trauma Quality Improvement Project (TQIP) of 2019. TQIP database is own by the ACS and it is the largest database for trauma quality program in the world. Propensity matching analysis was performed for the study.

RESULTS

There were 390 pediatric patients with open long bone fractures who were included in the study. After completing propensity score matching, we had 176 patients in each category, irrigation and debridement within 8 hours and irrigation and debridement between 8 hours and 24 hours. We found no significant differences between each group for the rate of deep SSI which was 0.6% for patients who received surgical irrigation and debridement within 8 hours and 1.1% for those who received it after 8 hours [adjusted odd ratio (AOR): 0.5, 95%CI: 0.268-30.909, P > 0.99]. For the secondary outcomes studied, in terms of length of hospital stay, patients who received irrigation and debridement within 8 hours stayed for an average of 3.5 days, and those who received it after 8 hours stayed for an average of 3 days, with no significant difference found, and there were also no significant differences found between the discharge dispositions of the patients.

CONCLUSION

Our findings support the recommendation for managing open long bone fractures from the ACS: Complete surgical irrigation and debridement within 24 hours.

Key Words: Pediatric trauma; Open tibia fracture; Irrigation and debridement; Timing of intervention; Surgical site infection

Core Tip: Using the National Trauma Quality Improvement Project of 2019, data from 390 pediatric patients with open long bone fractures showed no significant difference in the rate of surgical site infection when irrigation and debridement was done within 8 hours vs between 8 hours and 24 hours.

INTRODUCTION

Open long bone fractures are a major concern for pediatric patients due to the risk of surgical site infection (SSI). The most widely used classification system of open fractures is Gustilo-Anderson's classification, which is categorized from minor grade I injuries to severe grade III injuries, and grade III is further classified into three subcategories[1,2]. The higher the grade of the open fracture, the higher the risk of infection. The infection rate for open fractures in children was reported at around 8%[3]. The consequences of infections after open tibial fractures in adults included a longer time for union, non-union of the fracture, the risk for sepsis, and even amputation[4]. Early administration of antibiotics and timely irrigation and debridement of an open fracture resulted in a reduction in the incidence of SSI[5,6].

Studies and guidelines are consistent with the early administration of antibiotics in open long bone fractures to minimize the risk for SSI[7,8]. However, there is no consistency regarding the appropriate timing of irrigation and debridement of the fracture. Early studies have recommended irrigation and debridement of open fractures within 6 hours-8 hours for the prevention of SSI[9]. The arbitrary 6-hour or 8-hour cut of the timing for irrigation was re-evaluated in recent studies, and recommendations were made to perform the irrigation and debridement as early as possible but within 24 hours of injury[10,11]. According to the American College of Surgeons (ACS) Best Practice Guidelines, in 2015, irrigation and debridement should be done within 24 hours[12]. The available literature regarding outcomes of infection rate with pediatric open long bone fractures is limited. Two recent single-center studies had variable outcomes regarding the timing of irrigation and debridement and SSI in pediatric open long bone fractures[3,13]. Therefore, we designed this study to address the SSI in pediatric open tibial fractures in relation to the timing of the irrigation and debridement utilizing the National Trauma Data Bank, Trauma Quality Improvement Project (TQIP) database. The hypothesis is that earlier irrigation and debridement of pediatric open tibial bone fractures will lead to lower infection rates.

MATERIALS AND METHODS

The TQIP database of the calendar year of 2019 data was accessed for the study. All pediatric patients < 18 years of age who sustained blunt mechanism of injury and open tibial fractures who were admitted to the hospital and underwent irrigation and debridement within 24 hours were included in the study. Race, sex, injury severity score (ISS), glasgow coma scale (GCS) score, other regions' abbreviated injury scale (AIS) scores, the timing of antibiotic administration and comorbidities were included in the study. Patients with penetrating mechanisms of injury were excluded from the study. The primary outcome was SSI. The secondary outcomes were hospital length of stay and discharge disposition.

The data was summarized using summary statistics. The continuous variables were presented as a median and interquartile range (IQR) (1^st quartile and 3^rd quartile) and the categorical variables were presented as proportion or percentage. The characteristics and injury of two groups, early irrigation and debridement (≤ 8 hours) and late irrigation and debridement (between 8 hours-24 hours), were compared using the Wilcoxon rank sum test for continuous variables, and the Chi-square test for the categorical variables. When the expected value was less than 5 in a cell of the contingency table of categorical variables, the Fisher exact test was used. The propensity score was calculated for each patient from each group and then one-to-one matching was performed using the “nearest neighbor” approach with a caliper of 0.25 standard deviation as the matching method to pair a patient who was “group = Between 8 hours-24 hours” with a subject who was “group = Within 8 hours”. The propensity score matching was performed using the R package “MatchIt”[14]. The variables used for calculating the propensity score [age, race (white), sex, ISS and GCS]. After matching, standardized mean differences were evaluated to see the improvement. The Wilcoxon signed rank test was used to compare the continuous variables between matched groups. McNemar’s test was used to compare the categorical variables between matched groups. For the length of total hospital stay, the Kaplan-Meier procedure was used to estimate the median time, and the standard error was estimated using the Greenwood’s formula. The Kaplan-Meier curves were generated. The log-rank test was used to compare the time (Kaplan-Meier curves) between groups. The 2-sided P value was reported for each test. P < 0.05 was considered an indication of statistical significance. Statistical analysis was performed using the R language[15].

RESULTS

The total of 390 patients who qualified for the study, 207 (53.1%) patients underwent irrigation and debridement within 8 hours of the patient’s arrival and the remaining 183 (46.9%) patients underwent irrigation and debridement between (8 hours-24 hours). There were no significant differences between the characteristics of these two groups, late vs early, including median age [IQR: 15 years (12-16) vs 14 years (10-16), P = 0.063], median GCS score [IQR: 15 (15-15) vs 15 (15-15), P = 0.732], the median timing (in hours) of antibiotic therapy administration [median IQR: 0.2 (0-0.88) vs 0.3 (0-0.86), P = 0.278]. The only significant difference between the groups was that a higher proportion of black race patients underwent late irrigation and debridement compared to non-black patients (21.9% vs 13%, P = 0.03). No significant differences were found between the groups regarding the comorbidities and an AIS score (Table 1).

Table 1 Showing patient demographics before matching, n (%).

	Irrigation and debridement within 8 hours	Irrigation and debridement after 8 hours	P value
Age (years): Median (Q1, Q3)	14 (10, 16)	15 (12, 16)	0.063
Race
American indian	1 (0.5)	0 (0)	1
Asian	4 (1.9)	1 (0.5)	0.377
Black	27 (13)	40 (21.9)	0.03
Pacific islander	2 (1)	0 (0)	0.501
White	151 (72.9)	121 (66.1)	0.176
Other	19 (9.2)	19 (10.4)	0.819
Sex
Female	64 (30.9)	55 (30.1)	0.941
Male	143 (69.1)	128 (69.9)
Injury severity score	10	9	0.224
Glasgow coma scale	15	15	0.732
Mechanism of Injury
Fall	35 (16.9)	41 (22.4)	0.503
Machinery	1 (0.5)	1 (0.5)
MVT occupant	42 (20.3)	35 (19.1)
MVT motorcyclist	8 (3.9)	7 (3.8)
MVT pedal cyclist	4 (1.9)	5 (2.7)
MVT pedestrian	35 (16.9)	41 (22.4)
MVT other	9 (4.3)	6 (3.3)
Pedal cyclist, other	5 (2.4)	3 (1.6)
Pedestrian, other	4 (1.9)	3 (1.6)
Transport, other	41 (19.8)	20 (10.9)
Natural/ environment, other	0 (0)	1 (0.5)
Overexertion	4 (1.9)	7 (3.8)
Struck by, against	16 (7.7)	11 (6)
Other specified and classifiable	3 (1.4)	2 (1.1)
Antibiotic therapy (hours)	0.3 (0-0.86)	0.2 (0-0.88)	0.278
Comorbidities
Congenital abnormalities	1 (0.5)	3 (1.6)	0.345
Mental health disorder	4 (1.9)	4 (2.2)	1
Substance abuse	2 (1)	1 (0.5)	1
Bleeding	0 (0)	1 (0.5)	0.469
Abbreviated injury score of 3-5
Brain	7 (3.4)	9 (4.9)	0.612
Spine	4 (1.9)	0 (0)	0.126
Chest	12 (5.8)	12 (6.6)	0.92
Abdomen	8 (3.9)	4 (2.2)	0.506
Upper extremity	0 (0)	1 (0.5)	0.469
Lower extremity	193 (93.2)	156 (85.2)	0.016

MVT: Motor vehicle transport.

Propensity score matching created 176 pairs of patients. After propensity score matching, there was an improvement in all the matching variables. There were no significant differences found between the groups, late vs early, regarding median age [IQR: 15 years (12-16) vs 14 years (11-16), P = 0.418], median GCS score [IQR: 15 (15-15) vs 15 (15-15), P > 0.99), the median timing ( in hours) of antibiotic therapy administration (median IQR: 0.2 (0-0.88) vs 0.3 (0-0.87), P = 0.428]. There was no significant difference between the groups regarding the black race patients who underwent late irrigation and debridement compared to non-black patients (21% vs 14.8%, P = 0.153) (Table 2).

Table 2 Showing patient demographics after matching, n (%).

	Irrigation and debridement within 8 hours	Irrigation and debridement after 8 hours	P value
Age (years): Median (Q1, Q3)	14 (11, 16)	15 (12, 16)	0.063
Race
American Indian	1 (0.6)	0 (0)
Asian	4 (2.3)	1 (0.6)	0.371
Black	26 (14.8)	37 (21)	0.153
Pacific islander	2 (1.1)	0 (0)
White	121 (68.8)	120 (68.2)	1
Other	19 (10.8)	16 (9.1)	0.71
Sex
Female	54 (30.7)	54 (30.7)	1
Male	122 (69.3)	122 (69.3)
Injury severity score	9.5	9	0.748
Glasgow coma scale	15	15	1
Mechanism of injury
Fall	33 (18.8)	40 (22.7)
Machinery	0 (0)	0 (0)
MVT occupant	35 (19.9)	33 (18.8)
MVT motorcyclist	8 (4.5)	7 (4)
MVT pedal cyclist	4 (2.3)	5 (2.8)
MVT pedestrian	29 (16.5)	40 (22.7)
MVT other	8 (4.5)	6 (3.4)
Pedal cyclist, other	3 (1.7)	3 (1.7)
Pedestrian, other	2 (1.1)	3 (1.7)
Transport, other	33 (18.8)	20 (11.4)
Natural/ environment, other	0 (0)	1 (0.6)
Overexertion	4 (2.3)	5 (2.8)
Struck by, against	15 (8.5)	11 (6.2)
Other specified and classifiable	2 (1.1)	2 (1.1)
Antibiotic therapy (hours)	0.3 (0-0.87)	0.2 (0-0.88)	0.428
Comorbidities
Congenital abnormalities	0 (0)	3 (1.7)
Mental health disorder	3 (1.7)	3 (1.7)	1
Substance abuse	1 (0.6)	1 (0.6)	1
Bleeding	0 (0)	1 (0.6)
Abbreviated injury score of 3-5
Brain	4 (2.3)	8 (4.5)	0.386
Spine	2 (1.1)	0 (0)
Chest	7 (4)	11 (6.2)	0.48
Abdomen	4 (2.3)	4 (2.3)	1
Upper extremity	0 (0)	1 (0.6)
Lower extremity	164 (93.2)	152 (86.4)	0.067

MVT: Motor vehicle transport.

The rate of deep SSI was 0.6% for patients who received surgical irrigation and debridement within 8 hours and 1.1% for those who received it after 8 hours (AOR: 0.5, 95%CI: 0.268-30.909, P > 0.99) (Table 3).

Table 3 Showing patient outcomes after matching, n (%).

	Irrigation and debridement within 8 hours	Irrigation and debridement after 8 hours	P value	Odds ratio	Absolute risk difference
Deep surgical site Infection	1 (0.6)	2 (1.1)	1	0.5 (0.268- 30.909)	-0.006 (-0.031 to 0.019)
Length of stay in hospital (days)	3.5 (3,4)	3 (3,4)	0.911
Discharge dispositions
Home with care	12 (6.8)	10 (5.7)	0.534
Home without care	145 (82.4)	152 (86.4)
Rehabilitation	12 (6.8)	11 (6.2)
Short-term through long-term care facility	5 (2.8)	1 (0.6)
Skilled nursing facility	1 (0.6)	2 (1.1)
Other	1 (0.6)	0 (0)

Patients who received irrigation and debridement within 8 hours stayed for an average of 3.5 days, and those who received it after 8 hours stayed for an average of 3 days, with no significant difference found (Figure 1).

Figure 1  Hospital length of stay between the two groups, early vs late irrigation and debridement.

Analysis of the discharge dispositions of the patients amongst the options of home with care, home without care, rehabilitation, short-term stay at a long-term care facility, skilled nursing facility, or other, there was no significant difference found between the two groups regarding discharge dispositions (Table 3).

Comparing pediatric patients with open tibial fracture injuries who received surgical irrigation and debridement within 8 hours vs after 8 hours-24 hours, we found no significant difference in the occurrence of deep SSI. The length of stay in the hospital and discharge dispositions were similar between the groups.

DISCUSSION

The literature regarding pediatric open long bone fracture management is relatively limited regarding the occurrence of infections; however, our results are concordant with the available data. Kuhn et al[3] conducted a retrospective study at a level 1 trauma center at Vanderbilt University Medical Center looking at open long bone fractures in 303 pediatric patients and found that infection rates were unrelated to the timing of operative debridement when patients were divided into two groups, within 6 hours and after 6 hours[3]. Additionally, Kelly et al[16] also conducted a retrospective study of 288 open fractures in pediatric patients at a level 1 trauma center in tennessee and found no significant association between the development of infection and time to surgical debridement; however, this data was not specific to long bone fractures. Another study by Skaggs et al[17] analyzed data from 536 pediatric patients who sustained open fractures across six tertiary pediatric referral centers in North America. They also found no significant difference between infection rates for patients treated within 6 hours vs after 6 hours, but this data was also not specific to long bone fractures. Our data on pediatric open long bone fractures, tibial fractures, concordant with these studies' conclusions; the timing of operative debridement within 24 hours is not directly predictive of SSI risk for pediatric open long bone fracture management.

Kuhn et al[3] studied several factors within pediatric open long bone fractures associated with the risk for deep infection, including the type of long bone, the Gustilo-Anderson type, the time of presentation to the hospital after the injury occurred, the number of operative debridement and the number of operative procedures. The only statistically significant variable in terms of increasing the risk of deep infection was the time between the injury and presentation to the hospital[3]. Wang et al[18] studied the management of Gustilo-Anderson type II and IIa pediatric open long bone fractures comparing early primary wound closure, which was closure during the initial operation, vs delayed wound closure, on subsequent return to the operating room, and found no significant associations between the rates of complications including infection, delayed compartment syndrome, nonunion, growth arrest, and the length of stay at the hospital. Chan et al[13] studied 60 patients with pediatric open tibial fractures at a level 1 trauma center in the United Kingdom. They found no significant association with outcomes of infection rate, time to union, problems with the union, and any additional unplanned surgery when comparing independent variables of time at which antibiotics were given, time to index surgery, type of skeletal fixation, and time to definitive cover[13]. Our study establishes that there were no significant differences in deep SSI, length of stay in the hospital, and discharge disposition when comparing pediatric open long bone fractures specifically tibial fractures patients who received surgical irrigation and debridement within 8 hours vs after 8 hours.

The main limitation of our study was its retrospective nature. Additionally, since the data is obtained from the TQIP, we could not account for differences between the hospitals regarding protocol and how each one specifically manages pediatric open long bone fractures. The surgical irrigation and debridement methodology at these different hospitals was unknown in terms of how they conducted the procedure, how much fluid was used during the irrigation, when the antibiotics were administered, and which antibiotics were administered. Unfortunately, TQIP data set does not provide information about the Gustilo-Anderson’s classification of the fractures but provides information about the severity of the fracture on AIS scores. Propensity score matching balanced the higher severity (AIS 3-5) of the fractures between the two groups (Table 2). These variables could have impacted our results in ways we cannot currently analyze. Nonetheless, the TQIP database is extremely beneficial in analyzing larger trends across the country. Future research with prospective studies can address these limitations.

CONCLUSION

Our study showed more than half of the open long bone fractures underwent irrigation and debridement within 8 hours of the patient’s arrival at the hospital. Performing the irrigation and debridement within 8 hours or between 8 hours-24 hours showed no significant differences in deep SSI, hospital length of stay or discharge to home. Our data supports the recommendation for managing open long bone fractures from the ACS: Complete surgical irrigation and debridement within 24 hours.