What do we need in open fracture research?

Randomized clinical trials are quite rare in open fracture research. Hence, Albright et al. should be commended about their work published in the Clinical Orthopaedics and Related Research. They compared external fixator and intramedullary nail in the treatment of open tibia fractures in Tanzania.

This study was further discussed in a CORR Insight which are frequently published among original research articles in the journal. Professor DeCoster writes in that piece:

We also need to identify the best and acceptable time to debridement for those open fractures that are shown to benefit from operative debridement. […] The timeframes studied should include less than 6 hours, less than 12 hours, less than 24 hours, and more than 24 hours.

I might disagree on this one. Dichotomization and categorizing continuous variables is something which should be forbidden by the law. It leads to loss of power and study results are hard to interpret. These topics have been discussed for decades, see eg. this, this and this for a starter.

Continuous variables needs to be analyzed continuously. We need studies which analyze the effect of time to debridement as continous and preferably with advanced modelling techniques such as estimating nonlinear relationships and possible interactions with other important variables. Even if we had a study of 10 000 patients, saying that time to debridement less/more than 6, 12 or 24 hours changes the odds in infection X amount has no clinical relevance. We need per hour estimates and answer to questions like “What if this patient is debrided now or at some other time?”. Cutting time to random blocks donĀ“t give as relevant information for patient care.

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