Systematic Reviews A Reevaluation of the Risk of Infection Based on Time to Debridement in Open Fractures

Q: What is the main purpose of this reevaluation of open fracture infection risk?

To determine whether the timing of initial surgical debridement is associated with the risk of infection in open fractures, reducing confounding from mixed fracture types.

Q: How was the evidence gathered and analyzed?

The study searched available databases for observational studies and randomized trials, then performed an extensive meta-analysis using both raw and adjusted estimates.

Q: What time thresholds were identified as critical for infection risk?

For high-grade injuries, critical thresholds included 12 hours and 24 hours, with infection risk increasing as debridement was progressively delayed.

Jul 3, 2026

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Open fractures remain a major global cause of disability, and the time-to-debridement threshold that lowers infection risk has been uncertain. A systematic review and meta-analysis searched observational studies and limited trial data on open fracture care, assessing whether initial debridement timing is associated with subsequent infection. Across 84 studies, later debridement showed higher surgical site infection risk, with clear critical thresholds at 12 and 24 hours, especially for high-grade fractures.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages9

Reading Time23 min

Background

Methods

Results

Conclusions

Materials and Methods

COPYRIGHT 􀀁 2020 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED A commentary by Patrick C. Schottel, MD, is linked to the online version of this article [at jbjs.org](at jbjs.org). 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 Clary J. Foote, MD, MSc, Paul Tornetta III, MD, Aleksi Reito, MD, PhD, Khalid Al-Hourani, MD, Mara Schenker, MD, Michael Bosse, MD, Chad P. Coles, MD, Anthony Bozzo, MD, MSc, Andrew Furey, MD, Ross Leighton, MD, and the GOLIATH Investigators* Investigation performed at McMaster University, Hamilton, Ontario, Canada 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, I2 = 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, I2 = 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, I2 = 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, I2 = 0%, 16 studies, n = 3,502) and 24 hours (OR = 2. 17, 95% CI = 1. 73 to 2 . 72, p < 0 .001, I2 = 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. An epidemic rise in the number of open fractures is occurring worldwide, particularly in low and middle income countries (LMICs) 1-4. Because of their health and economic impact, open fractures were recognized by the Lancet Commission on Global Surgery in 2015 as 1 of the top 3 surgical priorities, known as the “bellwether procedures.”5-7 Approximately 6 billion people have limited access to these procedures, leading to 1.2 million potentially preventable complications each year that could be reduced with better access to surgery8-16. The treatment of open fractures involves removal of contamination, excision of devitalized tissue, and irrigation of the wound in an attempt to reduce the risk of subsequent infection. Investigating time to surgical debridement of open fractures as an independent risk factor in the etiology of infection is challenging17-27. Current reports and systematic reviews have pooled all open fracture types, leading to a potential confounding effect on reported estimates28-30. It is possible that the most severe fractures with the worst prognosis are debrided earlier, and less severe injuries are debrided later, leading to *The GOLIATH Investigators are listed in a Note at the end of the article. Disclosure: On the Disclosure of Potential Conﬂicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked“yes” to indicate that the author had a relevant ﬁnancial relationship in the biomedical arena

FAQs

What is the main purpose of this reevaluation of open fracture infection risk?

To determine whether the timing of initial surgical debridement is associated with the risk of infection in open fractures, reducing confounding from mixed fracture types.

How was the evidence gathered and analyzed?

The study searched available databases for observational studies and randomized trials, then performed an extensive meta-analysis using both raw and adjusted estimates.

What time thresholds were identified as critical for infection risk?

For high-grade injuries, critical thresholds included 12 hours and 24 hours, with infection risk increasing as debridement was progressively delayed.

Jul 3, 2026

Upload by Levi