Time to initial operative treatment following open fracture does not impact development of deep infection: a prospective cohort study of 736 subjects.

OBJECTIVES To evaluate the association between time to surgery, antibiotic administration, Gustilo grade, fracture location, and development of deep infection in open fractures. DESIGN Prospective cohort between 2001 and 2009. SETTING Three Level 1 Canadian trauma centers. PARTICIPANTS A total of 736 (791 fractures) subjects were enrolled and 686 subjects (93%; 737 fractures) provided adequate follow-up data (1-year interview and/or clinical follow-up >90 days). INTERVENTION Demographics, injury information, time to surgery, and antibiotics were recorded. Subjects were evaluated using standardized data forms until the fracture(s) healed. Phone interviews were undertaken 1 year after the fracture. MAIN OUTCOME MEASURES Infection requiring unplanned surgical debridement and/or sustained antibiotic therapy. RESULTS Tibia/fibula fractures were most common (n = 413, 52%), followed by upper extremity (UE) (n = 285, 36%), and femoral (n = 93, 12%) fractures. Infection developed in 46 fractures (6%). The median time to surgery was 9 hours 4 minutes (interquartile range, 6 hours 39 minutes to 12 hours 33 minutes) and 7 hours 39 minutes (interquartile range, 6 hours 10 minutes to 9 hours 54 minutes) for those without and with infection, respectively (P = 0.04). Gustilo grade 3B/3C fractures accounted for 17 of 46 infections (37%) (P < 0.001). Four UE (1.5%), 7 femoral (8%), and 35 tibia/fibula (9%) fractures developed infections (P = 0.001). Multivariate regression found no association between infection and time to surgery [odds ratio (OR), 0.97; 95% confidence interval (95% CI), 0.90-1.06] or antibiotics (OR, 1.0; 95% CI, 0.90-1.05). Grades 3A (OR, 6.37; 95% CI, 1.37-29.56) and 3B/3C (OR, 12.87; 95% CI, 2.72-60.95) relative to grade 1 injuries and tibia/fibula (OR, 3.91; 95% CI, 1.33-11.53) relative to UE fractures were significantly associated with infection. CONCLUSION Infection after open fracture was associated with increasing Gustilo grade or tibia/fibula fractures but not time to surgery or antibiotics. LEVEL OF EVIDENCE Prognostic level I. See instructions for authors for a complete description of levels of evidence.