What is the operating room (OR) washout timeline for open fractures?

From the Guidelines

Patients with open fractures should be brought to the OR for débridement and irrigation as soon as reasonable and ideally before 24 hours post injury. This is based on the most recent and highest quality study available, which suggests that the timing of surgery is crucial in preventing surgical site infection after major extremity trauma 1. The study, published in 2023 in The Journal of the American Academy of Orthopaedic Surgeons, provides a moderate strength of recommendation for this guideline.

Key Considerations

• The goal is to perform débridement and irrigation as soon as possible, taking into account the patient's overall condition and the availability of surgical facilities.
• The procedure should include copious irrigation with normal saline or Ringer's lactate solution.
• Antibiotics should be administered as soon as possible after injury, ideally within 3 hours, to reduce the risk of infection.
• The timing of wound closure depends on the degree of contamination, with some clean wounds amenable to primary closure and others requiring delayed closure after repeat debridements.

Important Details

• The traditional teaching of performing debridement within 6 hours (the "6-hour rule") is no longer considered a strict guideline, and the focus should be on performing the procedure as soon as reasonable 1.
• The use of antiseptic solutions like chlorhexidine or povidone-iodine should be avoided as they can damage tissues and impair healing.
• The choice of antibiotics and the timing of administration should be based on the type and severity of the fracture, as well as the presence of any contaminants.

From the Research

OR Washout Timeline for Open Fractures

• The optimal timeline for OR washout in open fractures is a critical aspect of preventing infections and promoting healing.
• According to 2, in type III open extremity fractures, antibiotic therapy should be administered for no more than 24 hours after injury, in the absence of clinical signs of active infection.
• The study 3 suggests that administration of antibiotics should be carried out as early as possible and over 24-72 hours depending on the injury.
• In terms of surgical debridement, 4 states that emergent debridement within 6 hours of injury has long been considered critical, but the current literature suggests no obvious advantage to performing surgical debridement within 6 hours after injury versus doing so between 6 and 24 hours after injury.
• The study 5 found that early antibiotics and debridement independently reduce infection in an open fracture model, and that delaying antibiotics to six or 24 hours had a profoundly detrimental effect on the infection rate regardless of the timing of surgery.
• The optimal timing for OR washout may vary depending on the severity of the injury and the presence of clinical signs of active infection, as noted in 2 and 3.
• Further research is needed to provide stronger corroborating evidence, as noted in 2 and 6.