Surgery Timing
It is suggested that patients with open fractures are brought to the OR for debridement and irrigation as soon as reasonable, and ideally before 24 hours post injury.
Prevention of Surgical Site Infection After Major Extremity Trauma (2022)
This guideline was produced in collaboration with METRC, with funding provided by the US Department of Defense. Endorsed by: ASES, POSNA, AOFAS, IDSA, OTA

Rationale

There are many articles comparing the proportion of patients with surgical site infection in open fractures whose surgical debridement took place either before or after 6 hours. One high quality study (Konbaz 2019), nine moderate quality studies (Albright 2020, Enninghorst 2011, Harley 2002, Hendrickson 2020, Hull 2014, Noumi 2005, Olinger 2018, Weber 2014, Westgeest 2016), and twenty low quality studies (Whiting 2019, Pollak 2010, Sagar 1987, Srour 2015, Campbell 2020, Wei 2014, Nobert 2016, Al-Arabi 2007, Hendrickson 2018, Malhotra 2014, Spencer 2004, Arti 2012, Joseph 2020, Fernandes 2015, Reuss 2007, Tripuraneni 2008, Al-Hilli 2010, Charalambous 2005, Crowe 2017, Townley 2010) were reviewed. One high quality (Konbaz 2019) study did not support the 6-hour rule for performing the debridement but demonstrated a correlation of infection with the Gustillo classification, use of external fixation and not closing the wound primarily at the first debridement. Six moderate quality studies did not support the 6-hour rule (Albright 24 hours, Harley no correlation with time to surgery, Hendrickson no correlation with time to antibiotics, Noumi no correlation, Weber no correlation, Westgeest no correlation).

Benefits/Harms of Implementation
The current evidence is insufficient to definitively confirm the importance of early surgical intervention for open fractures, although this might not be true for certain fractures such as tongue-type calcaneus fractures. In some fractures, such as pilon fracture, waiting for final surgical intervention might be more appropriate. More studies are required.

Outcome Importance
This data suggests waiting a few extra hours to perform surgery in most but not all open fractures might have advantages in terms of preparation for surgery, marshalling the necessary resources, staffing, and equipment. However, more evidence is needed.

Cost Effectiveness/Resource Utilization
The current insufficient evidence indicates urgent surgical care might not be necessary for most but not all open fractures. Timely surgical care would be expected to improve the resource allocation and potentially enhance outcomes post-surgery if and when the operative team is better prepared and adequately staffed.

Acceptability
More timely surgery as opposed to urgent surgical care can potentially improve preparation of the surgical team as well as allow for better patient optimization. In certain cases, access to comprehensive medical care is simply not possible within the proposed 6-hour surgery window, particularly in under resourced rural and geographically isolated areas.

Future Research
Most of the current evidence comes from retrospective case series with small cohorts. In many instances, the study population has more than one type of fracture or includes fractures in different anatomical regions. Future studies require larger cohorts, concentration on specific fracture types or anatomical regions, and greater specificity in the operative and postoperative protocols. Prospective randomized studies, particularly if done through multicenter design, are required to more definitively address this issue and establish a widely recognized standard of care.