Open Tibia Fractures: Timely Debridement Leaves Injury Severity as the Only Determinant of Poor Outcome
Open Tibia Fractures: Timely Debridement Leaves Injury Severity as the Only Determinant of Poor Outcome
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DOI：
10.1097/ta.0b013e31820b4285
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发表时间：
2011-02-01
影响因子：
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通讯作者：
Balogh, Zsolt J.
中科院分区：
文献类型：
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作者：
Enninghorst, Natalie;McDougall, Debra;Balogh, Zsolt J.
背景：最近的回顾性研究表明，开放性胫骨骨折的清创时间并不是预后的主要决定因素。这项前瞻性研究的目的是确定不良预后的可修改的独立预测因素。方法：一项为期36个月的前瞻性观察研究，于2009年12月结束，研究对象是一家一级创伤中心收治的连续开放性胫骨干骨折患者（年龄0 ~ 18岁）。前瞻性记录人口统计学、机制、损伤严重程度评分、骨折类型/分级、局部污染、清创时间、抗生素使用时间和干预措施。结果指标如下：住院时间、深度感染、二次手术以及6个月和12个月时的愈合情况。进行单因素、多因素和逻辑回归分析。结果：89例连续患者（74%男性，年龄41岁+/- 17岁，损伤严重程度评分15 +/- 3分，37%多发损伤）符合纳入标准。手术清创和手术稳定的平均时间为8小时+/- 4小时（48%在6小时内）。平均住院时间为21天±13天。深部感染15例（17%），需要截肢5例（6%）（1例急性，4例晚期感染）。6个月和12个月的愈合率分别为39%和67%。56例（63%）患者需要进一步的手术（总共312例）。多变量回归模型（18个变量）显示，6个月和12个月深度感染或骨不连无独立显著预测因素（多发损伤和吸烟最接近显著，p = 0.08）。结论：及时处理开放性胫骨骨折（平均8小时）消除了清创时间和污染作为预后不良的预测因素。患者因素、局部和全身损伤严重程度决定了结果。以最早的安全时间清创为目标，最大限度地减少可改变因素对结果的负面影响。
Background: Recent retrospective studies suggest that the time to debridement of open tibia fractures is not a major determinant of outcome. The aim of this prospective study was to determine the modifiable independent predictors of poor outcomes.Methods: A 36-month prospective observational study ending in December 2009 was performed on consecutive open tibia shaft fracture patients (age > 18 years) admitted to a Level 1 trauma center. Demographics, mechanism, Injury Severity Score, fracture type/grade, local contamination, time to debridement, time to antibiotics, and interventions were prospectively recorded. Outcome measures were as follows: length of stay, deep infection, secondary procedures, and presence of union at 6 months and 12 months. Univariate, multivariate, and logistic regression analyses were performed.Results: Eighty-nine consecutive patients (74% male, age 41 years +/- 17 years, Injury Severity Score 15 +/- 3, and 37% multiple injured) met inclusion criteria. The mean time to surgical debridement and operative stabilization was 8 hours +/- 4 hours (48% within 6 hours). The average length of stay was 21 days +/- 13 days. Fifteen patients (17%) had deep infection and 5 (6%) required amputation (1 acute and 4 late because of the infection). The 6-month and 12-month union rates were 39% and 67%, respectively. Fifty-six patients (63%) required further procedures (a total of 312). The multivariate regression model (18 variables) showed no independent significant predictors for deep infection or nonunion at 6 months and 12 months (multiple injuries and smoking were closest to reach significance, p = 0.08).Conclusion: Timely management of open tibia fractures (mean, 8 hours) eliminates time to debridement and contamination as predictors of poor outcome. Patient factors and local and general injury severity determine the outcomes. Aiming for the earliest safe time to debridement minimizes the negative effects of modifiable factors on the outcome.