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Three Part Question

In [patients with simple traumatic lacerations] is [primary closure after 12 hours] associated with [a greater risk of infection] than [primary closure before 12 hours]?

Clinical Scenario

A 32 year old male presents to the Emergency Department with a laceration on his right forearm. He accidentally cut his forearm with the sharp edge of a metal can 14 hours ago. The wound appears clean and there is no evidence of any foreign body. Neuro-vascular and tendon examination are normal. The wound is irrigated with saline and repaired with nylon sutures. You wonder whether this wound is at a higher risk for infection because of the time lapse from injury to repair.

Search Strategy

OVID interface on the world-wide web. 1966-May 2011.

[exp laceration OR exp simple laceration OR laceration OR wounds] AND [exp primary closure OR exp wound repair OR treatment OR infection]

Search Outcome

45 papers were found of which 43 were irrelevant or violated the pre-determined inclusion/exclusion criteria. The remaining 2 papers are shown in the table below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Berk et al 1988 USA	372 patients with simple traumatic lacerations. 204 completed a 7-days follow up. 72 wounds were sutured before 12 hours, and 132 wounds were sutured after 12 hours. Failed healing defined as wound dehiscence or evidence of infection.	Prospective observational study	Failed healing defined as wound dehiscence or evidence of infection.	7/72 (10%, 95% CI, 5–19%) in wounds <12-hours old. 26/132 (20%, 95% CI, 14-27%) in wounds >12-hours old.	No randomization. Infection rate not reported separately. 45% lost to follow up (168/372).
			Overall	Wounds sutured after 12 hours showed a more significant infection rate than those sutured before 12 hours.
Morgan et al 1980 Scotland	155 patients had superficial wounds (deep wounds requiring closure in the operating room were excluded from the total number). 136 wounds were sutured before 12 hours and 19 wounds were sutured after 12 hours. All patients received antibiotics (randomized to a single intramuscular penicillin injection or penicillin injection plus a 5-day course of Clindamycin). Follow up in 7 days.	Prospective study (randomization for type of antibiotics and not based on wound age)	Wound infection	9/136 (6%, 95% CI, 3-12%) in wounds <12-hours old. 6/19 (32%, 95% CI, 15-54%) in wounds >12-hour old.	Non-randomized. 83 patients did not return for follow-up. Sample size was too small for wounds sutured after 12 hours to draw a meaningful conclusion. Patients received different antibiotics.
			Overall	Wounds sutured after 12 hours showed a more significant infection rate than those sutured before 12 hours.

Comment(s)

The quality of the included studies is not optimal since none were randomized trials and the follow-ups were inadequate. More rigorous randomized prospective studies with a larger sample size are required to make definite recommendations.

Clinical Bottom Line

There is not enough evidence to determine if simple lacerations repaired more than 12 hours after infliction are at a higher risk of infection.

References

1. Berk WA, Osbourne DD, Taylor DD. Evaluation of the ‘Golden Period’ for Wound Repair: 204 Cases From a Third World Emergency Department. Annals of Emergency Medicine 1988 May; 17(5):496-500
2. Morgan WJ, Hutchison D, Johnson HM. The delayed treatment of wounds of the hand and forearm under antibiotic cover. British Journal of Surgery 1980; 67: 140-141