To the Editor:

We read with interest the article by D'Souza et al.1 We are concerned with a statement in the conclusion that "There is no correlation between the development of infection in open fractures with? the interval between injury and debridement." This may be due to a small sample size (a type-II error). There is evidence that early debridement significantly reduces the rate of infection in open fractures2 and improves outcomes.3-5 In our institutions, patients with open fractures receive primary debridement and stabilisation within 6 hours and this continues until there is sufficient evidence to the contrary.

M Magro, B Ingram, A Mansell

Barts and the London School of Medicine and Dentistry

SS Al-Nammari, S Shankar

Trauma and Orthopaedics,

The Royal London Hospital

REFERENCES

1. D'Souza A, Rajagopalan N, Amaravati RS. The use of qualitative cultures for detecting infection in open tibial fractures. J Orthop Surg (Hong Kong) 2008;16:175-8.

2. Kindsfater K, Jonassen EA. Osteomyelitis in grade II and III open tibia fractures with late debridement. J Orthop Trauma 1995;9:121-7.

3. Crowley DJ, Kanakaris NK, Giannoudis PV. Debridement and wound closure of open fractures: the impact of the time factor on infection rates. Injury 2007;38:879-89.

4. Naique SB, Pearse M, Nanchahal J. Management of severe open tibial fractures: the need for combined orthopaedic and plastic surgical treatment in specialist centres. J Bone Joint Surg Br 2006;88:351-7.

5. A report by the British Orthopaedic Association/British Association of Plastic Surgeons Working Party on the management of open tibial fractures. September 1997. Br J Plast Surg 1997;50:570-83.

Authors' reply:

We agree that early debridement reduces infection rate. In our series, because of unequal distribution and small number of cases, no significant correlation was noted between the time of injury, debridement, and outcome. Nonetheless, the association of infection was higher in pre- than post-debridement cultures.

A D'Souza, N Rajagopalan, RS Amaravati

Department of Orthopaedics,

St John's Medical College Hospital,

Bangalore, India

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