To date it remains unclear if a delayed surgical treatment of open hand injuries after more than 6 h may be detrimental to outcome. Previous investigations by McLain et al. (J Hand Surg Am 16:108-112, 1980 9), Nylen and Carlsson (Scand J Plast Reconstr Surg 14:185-189, 1991 10) could not find statistical proof of correlation between infection rate and delayed surgical treatment after open hand injuries up to 18 h. The current study was designed to investigate the outcome of early versus delayed surgical treatment after open hand injury

Angly, Bernhard

Constantinescu, Mihai A

Juon, Bettina H

Kreutziger, Janett

Vögelin, Esther

Bernhard Angly

Mihai A. Constantinescu

Janett Kreutziger

Bettina H. Juon

Esther Vögelin

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World Journal of Surgery

Early versus Delayed Surgical Treatment in Open Hand Injuries: A Paradigm Revisited

Bern Open Repository and Information System (BORIS)

Early versus Delayed Surgical Treatment in Open HandInjuries: A Paradigm RevisitedBernhard Angly • Mihai A. Constantinescu •Janett Kreutziger • Bettina H. Juon •Esther VögelinPublished online: 7 February 2012 Société Internationale de Chirurgie 2012AbstractBackground To date it remains unclear if a delayed sur-gical treatment of open hand injuries after more than 6 hmay be detrimental to outcome. Previous investigations byMcLain et al. (J Hand Surg Am 16:108–112, 1980 9),Nylen and Carlsson (Scand J Plast Reconstr Surg14:185–189, 1991 10) could not find statistical proof ofcorrelation between infection rate and delayed surgicaltreatment after open hand injuries up to 18 h. The currentstudy was designed to investigate the outcome of earlyversus delayed surgical treatment after open hand injury.Patients and methods A retrospective data analysis of allpatients sustaining an open hand injury between January 1and December 31 2006 was performed. Patients withincomplete data records were excluded. Patients werestratified according to time delay of surgical treatment andinjury complexity. Complications, revision rate, and func-tional outcome were also investigated.Results Between January 1 and December 31 2006 a totalof 458 patients with open hand injuries were treated at theUniversity Hospital of Berne, Switzerland. The records wereretrospectively analyzed and a subgroup of 100 patients wererandomly determined for standardized follow-up evaluation.There were no significant differences regarding infection,complication, and revision rate between early (\6 h) anddelayed (6–24 h) surgical treatment of open hand injuries.Independently from the time point of surgical treatment,patients with complex injuries and longer operative timeshad an increased infection rate (p = 0.05) and revision rate(p = 0.003).Conclusions Delayed surgical treatment (6–24 h) of openhand injuries did not increase infection or revision rates inopen non-devascularizing hand injuries.IntroductionWill the delayed surgical treatment of open hand injuries aftermore than 6 h influence the outcome in a negative manner? Inthe historical literature [1] general surgical treatment wasrequested within 6 h after trauma to prevent wound infections.However, this standard was established before the introduc-tion of prophylactic antibiotic therapy [2]. In general traumastudies, investigations of open lower limb fractures showed nocorrelation between infection rate and delayed surgicaltreatment up to 24 h [3–8]. In more recent hand injury relatedliterature, McLain et al. [9] reported 11% infection rates inopen fractures of the hand, but they found no differencesbetween early and delayed treatment. Neither did NylenBernhard Angly and Mihai A. Constantinescu contributed equally tothis work.B. AnglyOrthopaedic and Hand Surgery, Hirslanden Clinic Birshof,Reinacherstrasse 28, 4142 Münchenstein, Switzerlande-mail: bernhard.angly@sec.hirslanden.chM. A. Constantinescu  B. H. Juon  E. VögelinDepartment of Plastic, Reconstructive and Hand Surgery,Inselspital, University Hospital of Bern, Freiburgstrasse,3010 Bern, Switzerlande-mail: mihai.constantinescu@insel.chB. H. Juone-mail: bettina.juon@insel.chE. Vögeline-mail: esther.voegelin@insel.chJ. Kreutziger (&)Department of Anaesthesia and Critical Care Medicine,Innsbruck Medical University, Anichstrasse 35,6020 Innsbruck, Austriae-mail: janett.kreutziger@uki.at123World J Surg (2012) 36:826–829DOI 10.1007/s00268-012-1455-xand Carlsson and McLain et al. [9, 10], who reported anoverall infection rate of 16% when investigating tidy anduntidy hand injuries. As a consequence, an overall outcomeassessment of both simple and complex hand injuries with adelay to surgery of up to 24 h appears necessary.The goal of the present study was to retrospectivelyinvestigate the outcome of early versus delayed surgicaltreatment after open, non-devascularizing hand injuries upto 24 h post-trauma.Patients and methodsAnalysis of all patients treated for open hand injuries at theUniversity Hospital of Bern, Switzerland, between 1 Jan-uary and 31 December 2006 was performed according toregulations of the Institutional Review Board. Exclusioncriteria were incomplete records, amputation or devascu-larizing injuries, and minor age patients. Records wereretrospectively analyzed and a prospective, standardizedtelephone lead patient survey, relying on Patient-RatedWrist Evaluation (PRWE) [11], was conducted in 100randomly determined patients.The following parameters were recorded: demographicdata, injury localization and type, number of injuredstructures, time point of trauma and start of operation,operative time, infections, complications, number of revi-sions, and follow-up period. ‘‘Simple injuries’’ weredefined by injury of the skin and just one additionalstructure (i.e., tendon or nerve); ‘‘complex injuries’’ weredefined by two or more injured structures. Patients werestratified according to time delay of surgical treatment,injury complexity, and causes of injury.Following admission to the emergency department, allpatients were treated with an immersion hand bath (50%Octenisept, 50% normosaline). Furthermore, all patientsexcept those with simple, clean cuts received antibioticcoverage: amoxicillin/clavulanic acid 2.2 g or cefuroxime750 mg intravenously on admission, and that dose wasrepeated every 8 h until the operative procedure. A seconddose was administered intravenously if the operative timeexceeded 240 min, followed by oral therapy for 5–7 days.The affected hand was immobilized upon admission untilsurgery and postoperatively depending on the repairedstructures. Depending on injury severity, the follow-uptime varied between 3 and 6 months.Statistical analysis was performed with SPSS (Release18.0.03, 2010). Group differences were analyzed withFisher’s exact test and Student’s t test, as appropriate.Pearson’s correlation coefficient or the Spearman correla-tion test and linear and logistic regression analysis wereperformed. A p value of 0.05 was deemed to be statisticallysignificant throughout the study.ResultsDuring the study phase 458 patients met the inclusion cri-teria. The included subgroup of 100 patients underwentstandardized follow-up evaluation with no exclusion. Themean age of the patients was 52 years (range: 20–81 years).Eighty-two patients were men (82%) and 18 women (18%).Among the recorded mechanism leading to open handinjury, sharp lacerations were the most frequent (35%),followed by 26 injuries with milling machines or saws(26%), 24 blunt traumata (24%), and 15 other injuries(15%). Neither the mechanism of injury nor the area ofinjury had an influence on any of the outcome parameters.According to the above definition, 41 injuries weresimple (41%) and 59 injuries were complex (59%); 52% ofinjuries were treated within 6 h (Table 1).The overall observed infection rate including woundhealing disorders was 14%. There was no significant dif-ference in infection rate in early (\6 h) versus delayed([6 h) surgical treatment of open hand injuries, both insimple and complex injuries (Table 2). Neither age nornumber of injured structures influenced the incidence ofTable 1 Number of patients in dependency of time delay of surgicaltreatment and injury severityTime delay (h) All patients SimpleinjuriesComplexinjuriesn = 100 n = 41 n = 59\6 52 23 29[6–12 28 11 17[12–24 14 4 10[24 6 3 3Table 2 Infection and woundhealing disorder rate independency of time delay ofsurgical treatment and injuryseverityTime delay (h) p Value, all patients p Value, simple injuries p Value, complex injuries p Value,simple vscomplexn = 100 (%) n = 41 (%) n = 59 (%)\6 8 (15.4) 4 (17.4) 4 (13.8) ns[6–12 2 (7.1) ns 1 (9.1) ns 1 (5.9) ns ns[12–24 2 (14.3) ns 0 (0) ns 2 (20.0) ns ns[24 2 (33.3) ns 1 (33.3) ns 1 (33.3) ns nsWorld J Surg (2012) 36:826–829 827123infection. An increase in infection rate related to theduration of the operative procedure was observed in com-plex injuries but not in simple injuries (p = 0.02).There was no influence of early versus delayed surgicaltreatment on the incidence of revisions (Table 3) in bothsimple and complex injuries. The frequency of revisionwas, however, significantly higher in complex injuries thanin simple injuries (17 of 59 = 28.8% vs. 4 of 41 = 9.8%;p = 0.03, OR 3.74 [confidence interval 1.16–12.13]).Longer initial operative times were associated with ahigher number of revisions (p = 0.006) in complex injuriesbut not in simple injuries.The frequency of all complications (including infectionsand revisions) was higher in complex injuries than insimple injuries (22 of 59 = 37.3% vs. 9 of 41 = 22.0%),but this difference did not reach statistical significance.There was no influence of early versus delayed surgicaltreatment, nor injury localization, or causes of injury, orage on the incidence of complications. Complex regionalpain syndrome was diagnosed in two patients (2%) and wasunrelated to the treatment time point.The recorded operative time was significantly longer incomplex injuries than in simple injuries (156 vs. 52 min;p \ 0.0001) and was associated with the number of injuredstructures (p \ 0.0001, R2 = 0.441), but not with the timepoint of surgical treatment.The overall outcome, as measured by the PRWE score,was independent of early or delayed surgical treatment.Mean PRWE score was significantly lower in simple versuscomplex injuries (6.2 vs. 12.2; p = 0.03). Operative time(R2 = 0.231), age (R2 = 0.3), and number of injured struc-tures (R2 = 0.380) predicted the PRWE score (p \ 0.001).The semiquantitative analysis of hand function followingopen hand surgery revealed statistically an influence ofoperative time (p \ 0.0001, R2 = 0.439), age (p = 0.009,R2 = 0.208), and number of injured structures (p \ 0.0001,R2 = 0.240).DiscussionThe historically conveyed time limit of less than 6 h forsurgical treatment of open injuries still has worldwideacceptance [1]. However, routine prophylactic antibiotictherapy, improved suture and osteosynthesis material, aswell as perioperative management and improved knowl-edge of soft tissue handling has decreased the infection ratedramatically [2, 4, 5]. Delayed treatment of open handinjuries may occur for a number of reasons, like delay intransportation to a tertiary treatment center, importantco-morbidities in multiple trauma patients, or limitations ofoperating room availability, in which hand trauma has alower priority than life-threatening conditions. Becausethese factors are unlikely to change in the future, currentquality management concepts and patient safety require aninvestigation into the paradigm of 6 h limit to hand sur-gery. That was the basis for the current evaluation.This retrospective single-center study revealed no out-come-disadvantage between the classical early surgicaltreatment (\6 h) and delayed surgical treatment ([6 h) inpatients with open hand injuries in terms of infection rates,complication rates, and functional outcome. Unrelated tothe delay of surgery, the outcome was found to be signif-icantly influenced by the patient’s age, number of injuredstructures, as well as duration of surgery.The main features of the study population were com-parable to other hand injury studies [9, 10]. The observedoverall infection rate was 14% in this study and thuscomparable to the above-reported infection rates (16 and11%).The current observations on time-dependent surgicaltreatment of open hand injuries paralleled the findings ofNylen and Carlsson, which showed no differences ininfection rates by delayed surgical treatment up to 24 hpost-trauma. Nylen and Carlsson [10] investigated delay-dependent bacterial counts and infection rates in tidy ver-sus untidy hand injuries, but they did not stratify by injurycomplexity or examine the functional outcome. Theinvestigations of McLain et al. [9] were limited to openhand fractures but did not include simple or complex softtissue injuries, which occur more frequently. The potential‘‘cut-off’’ point in the benefit/deficit calculation of delayedsurgery could not be precisely deduced statistically becauseof the small number of patients in their study who weretreated after 18 h, which is comparable to treatment after24 h delay in the present study. The presented observationsTable 3 Revision rate in dependency of time delay of surgical treatment and injury severityTimedelay (h)p Value, all patients p Value, simple injuries p Value, complex injuries p Value, simpleversus complexn = 100 (%) n = 41 (%) n = 59 (%)\6 13 (25) 2 (8.7) 11 (37.9) 0.01[6–12 6 (21.4) ns 2 (18.2) ns 4 (23.5) ns ns[12–24 1 (7.1) ns 0 (0) ns 1 (10.0) ns ns[24 1 (16.7) ns 0 (0.0) ns 1 (33.3) ns ns828 World J Surg (2012) 36:826–829123are further supported by other studies on delayed treatmentof open fractures [7, 8].The additional value of the present study lies in theassessment of two important outcome parameters (revisionrates and the functional outcome as measured by thePRWE score). These too, remained independent of thetime-point of surgical treatment, showing thus no overalldisadvantage in delayed surgical treatment. The clinicalimpact of the observed statistically significantly pooreroutcome in three patients undergoing extremely delayedsurgery ([24 h) is difficult to ascertain due to the very lowpatient numbers in this group. This result requires futurein-depth, prospective investigation.Further results of this study revealed a statistical cor-relation between poorer outcome and complexity of theinjury, also reflected in the length of the operation. Thiswas true also for the functional outcome measured byPRWE, which was significantly poorer in complex injuriesthan in simple ones, independent of the delay to surgery.The limitations of the present study are the retrospectivesetting and the low number of patients—especially in thelong delay treatment groups ([24 h). Both limitationsaffect the statistical power of observations made beyond24 h post-trauma. Nevertheless, the results of this explor-atory retrospective study are encouraging, showing so farno outcome disadvantage for patients undergoing delayedtreatment of open, non-devascularizing hand injuries.These observations may well improve prioritization algo-rithms, avoid unnecessary rush, and allow patient transferto centers where optimal therapeutic conditions are avail-able and specialized surgeons can perform the necessaryprocedures.ConclusionsIn the present study, the delayed surgical treatment of open,non-devascularizing hand injuries showed no disadvantagein measured outcome variables including infection, revi-sion and function as compared to early treatment. Theseobservations support the concept of specialized centertreatment for these injuries, for which an unavoidable delayof up to 24 h may be accepted. Further prospectiveinvestigations into the changing paradigm of the 6 h limitto surgery are warranted.References1. Friedrich PL (1898) Die aseptische Versorgung frischer Wunden.Arch Klin Chir 57:288–3102. Gustilo RB, Anderson JT (1976) Prevention of infection in thetreatment of one thousand and twenty-five open fractures of longbones: retrospective and prospective analyses. J Bone Joint SurgAm 58:453–4583. Harley BJ, Beaupre LA, Jones CA et al (2002) The effect of timeto definitive treatment on the rate of nonunion and infection inopen fractures. J Orthop Trauma 16:484–4904. Patzakis MJ, Wilkins J (1989) Factors influencing infection ratein open fracture wounds. Clin Orthop Relat Res 243:36–405. Patzakis MJ, Harvey JP Jr, Ivler D (1974) The role of antibioticsin the management of open fractures. J Bone Joint Surg Am56:532–5416. Merritt K (1988) Factors increasing the risk of infection inpatients with open fractures. J Trauma 28:823–8277. Pollak AN, Jones AL, Castillo RC et al (2010) The relationshipbetween time to surgical debridement and incidence of infectionafter open high-energy lower extremity trauma. J Bone Joint SurgAm 92:7–158. Skaggs DL, Friend L, Alman B et al (2005) The effect of surgicaldelay on acute infection following 554 open fractures in children.J Bone Joint Surg Am 87:8–129. McLain RF, Steyers C, Stoddard M (1991) Infections in openfractures of the hand. J Hand Surg Am 16:108–11210. Nylen S, Carlsson B (1980) Time factor, infection frequency andquantitative microbiology in hand injuries: a prospective study.Scand J Plast Reconstr Surg 14:185–18911. MacDermid JC, Turgeon T, Richards RS et al (1998) Patientrating of wrist pain and disability: a reliable and valid measure-ment tool. J Orthop Trauma 12:577–586World J Surg (2012) 36:826–829 829123

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Early versus delayed surgical treatment in open hand injuries: a paradigm revisited

Early versus delayed surgical treatment in open hand injuries: a paradigm revisited

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