title: The 6-Hour Rule for Surgical Debridement of Open Tibial Fractures: A Systematic Review and Meta-Analysis of Infection and Nonunion Rates.
abstract: OBJECTIVE
  The aim of this study was a systematic review and meta-analysis of studies comparing early (<6 hours) versus late (>6 hours) surgical debridement of open tibial fractures, with regards to infection and nonunion rates.
  
  
  METHODS
  A systematic literature search of MEDLINE, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature (1961 to present), Allied and Complementary Medicine, and COCHRANE databases was conducted using any combination of the key words: "open," "tibial," and "fractures." After appropriate screening, 7 studies were included for analysis. Inclusion criteria were studies assessing the relation between time to debridement from injury and infection and/or nonunion rates.
  
  
  RESULTS
  Three studies (n = 365) evaluated overall infection rates that varied from 7.7% to 8.9% in the early group versus 1%-18.5% in the late group. Three studies (n = 197) evaluated deep infection rates that varied from 13% to 18.5% in the early group versus 7.1%-18.6% in the late group. Four studies (n = 245) evaluated nonunion rates that varied from 13.2% to 26.1% in the early group versus 0%-32.6% in the late group. Meta-analysis showed no statistical difference between groups with regards to overall infection rates (risk ratio = 1.32; 95% CI, 0.54-3.23; P = 0.55), deep infection rates (risk ratio = 0.99; 95% CI, 0.48-2.07; P = 0.98), and nonunion rates (risk ratio = 1.49; 95% CI, 0.64-3.49; P = 0.36).
  
  
  CONCLUSIONS
  The available literature suggests that there is no obvious difference in the overall/deep infection and nonunion rates between open tibial fractures debrided within 6 hours and those debrided at more than 6 hours. The findings presented here would appear to indicate that judicious delays of greater than 6 hours may not result in a significantly increased risk of adverse events or peri-operative morbidity.
  
  
  METHODS
  Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: *School of Medicine and Dentistry, University of Central Lancashire, Preston, United Kingdom; †Orthopaedic department, Blackpool Victoria Hospital, Blackpool, United Kingdom; and ‡Institute of Inflammation and Repair, School of Medical and Human Sciences, University of Manchester, Manchester, United Kingdom.
authors.forename: Apostolos D
authors.initials: AD
authors.lastname: Prodromidis
authors.forename: Charalambos P
authors.initials: CP
authors.lastname: Charalambous
mesh_terms: D003646:Debridement / Q000009:adverse effects / Q000379:methods / Q000592:standards*; D005260:Female; D005500:Follow-Up Studies; D005593:Fracture Fixation, Internal / Q000009:adverse effects / Q000379:methods; D005597:Fractures, Open / Q000175:diagnosis / Q000601:surgery*; D005599:Fractures, Ununited / Q000453:epidemiology* / Q000503:physiopathology; D006801:Humans; D015994:Incidence; D008297:Male; D018570:Risk Assessment; D013530:Surgical Wound Infection / Q000453:epidemiology* / Q000503:physiopathology; D013978:Tibial Fractures / Q000175:diagnosis / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology