Time to Initial Debridement and wound Excision (TIDE) in severe open tibial fractures and related clinical outcome: a multi-centre study

Publication date: Available online 27 July 2018

Source: Injury

Author(s): Susan A. Hendrickson, Rosemary A. Wall, Oliver Manley, William Gibson, Deirde Toher, Katy Wallis, Jayne Ward, David L. Wallace, Michael Lamyman, Anna-Victoria Giblin, Thomas C. Wright, Umraz Khan

Abstract

Background

Recent national (NICE) guidelines in England recommend that initial debridement and wound excision of open tibial fractures take place within 12 hours of the time of injury, a change from the previous target of 24 hours. This study aims to assess the effect of timing of the initial debridement and wound excision on major infective complications, the impact of the new guidance, and the feasibility of adhering to the 12 hour target within the infrastructure currently existing in four major trauma centres in England.

Methods

A retrospective review was performed of Gustilo-Anderson grade 3B open tibial fractures presenting acutely to four Major Trauma Centres (MTCs) in England with co-located plastic surgery services over a ten-month period. The incidence of deep infective complications was compared between patients who underwent initial surgery according to the new NICE guidance and those who did not. Patients warranting emergency surgery for severely contaminated injury, concomitant life-threatening injury and neurovascular compromise were excluded. Multi-variable logistic regression analysis was performed to assess the effect of timing of surgical debridement on development of deep infective complications.

Results

112 patients with 116 fractures were included. Six fractures (5.2%) developed deep infective complications. 38% (n = 44) underwent primary debridement within 12 hours and 90% within 24 hours. There was no significant difference in the incidence of major infective complications if debrided in less than or greater than 12 hours (4.5% vs 5.6%, p = 1.00). Logistic regression found no significant relationship between timing of wound excision and development of deep infection. There was no significant decrease in mean time to debridement following introduction of new national guidance (13.6 vs 16.1 hours) in these four MTCs.

Conclusion

Overall, the rate of deep infection in high energy open tibial fractures managed within the four major trauma centes is low. Achieving surgical debridement within 12 hours is challenging within the current infrastructure, and it is unclear whether adhering to this target will significantly affect the incidence of severe infective complications. Debridement within 24 hours appears achievable. If a 12-hour target is to be met, it is vital to ensure dedicated orthoplastic capacity is adequately resourced.

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