Timing of debridement of open tibial fractures during the COVID-19 lockdown in India

Abstract

Introduction and Purpose: Open tibia fracture is a common orthopedic emergency, requiring management with adequate surgical debridement, fracture stabilization, and the administration of intravenous antibiotics to ensure good outcome. They are more prone for non-union due to poor soft-tissue coverage, blood supply and increased risk of post-operative infection. The 6-hour golden rule for debridement has been the norm, despite lacking strong evidence to support it. The COVID -19 pandemic has challenged this age-old dictum due to resource constraints. Early debridement may preclude COVID testing and pose unjustified risks to patient and hospital staff. Delayed surgery in these times might be a more pragmatic approach.Aim: The primary focus of this study was to analyse the outcomes of open tibial fractures at 5months post-operatively with respect to infection and fracture union.Material and Methods: Study was designed as a prospective cohort study with convenience sampling during the period of 54 days of lockdown starting from 25 March 2020 at a tertiary care trauma centre in Kerala, India. All patients with open tibial fractures were managed with advanced trauma Life Support (ATLS) protocol. Intravenous antibiotics were administered within 6 hours. Adequate surgical debridement and low pressure irrigation was done after COVID testing (TRU-NAT/CB-NAAT/RTPCR) as per hospital protocol.Results: Of a total two hundred forty four patients, thirty two patients satisfying inclusion criteria with unilateral open tibial fracture were considered. Average time to surgical debridement was 5hr 52min + 2hr 58min. Majority of the patients being brought to the referral center within 12 hours. Four (13 %) patients were brought after 12 hours but within 3 days of the incident. All had deep infection and nonunion at end of 5 months. Those debrided