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

Hendrickson, Susan A.; Wall, Rosemary A.; Manley, Oliver; Gibson, William; Toher, Deirdre; Wallis, Katy L.; Ward, Jennifer; Wallace, David; Lamyman, Michael; Giblin, Anna‐Victoria; Wright, Thomas C.; Khan, Umraz

doi:10.1016/j.injury.2018.07.023

Cited by 28 publications

(28 citation statements)

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“…Nine retrospective studies [ 4 , 6 , 11 , 12 , 19 - 23 ] and six prospective studies [ 3 , 5 , 10 , 15 , 24 , 25 ] were included in the present meta-analysis study. The number of fractures ranged from 41 to 383 fractures.…”

Section: Resultsmentioning

confidence: 99%

An Updated Evidence About the Role of Timing to Debridement on Infection Rate of Open Tibial Fractures: A Meta-Analysis

El-Hussein

2020

Cureus

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Background and objectives Recent experimental and clinical evidence supporting early debridement for open fractures has been questioned. Therefore, this systematic review and meta-analysis aimed to summarize and evaluate the current evidence regarding the timing of surgical debridement of open tibial fractures. Methods A systematic review and meta-analysis were conducted on studies compared the infection rate following early versus late debridement of open tibial fractures. We performed an online, bibliographic, search through the period from January 2000 to June 2020 in five bibliographic databases: Cochrane Central Register of Controlled Trials (CENTRAL), Medline via PubMed, Web of Science, Scopus, and EBSCO host. Results Nine retrospective studies and six prospective studies were included in the present meta-analysis study. The pooled effect estimate showed no statistically significant difference between early and late debridement regarding the overall infection rate (RD 0.02, 95% CI [0-0.04], p = 0.94); there was no significant heterogeneity in the pooled estimate (I2 = 5%). The subgroup analysis showed that the non-significant difference was consistent regardless of the definition of early and late timing to debridement. Likewise, the pooled effect estimate showed no statistically significant difference between early and late debridement regarding the deep infection rate (RD 0.01, 95% CI [-0.01-0.03], p = 0.92); there was no significant heterogeneity in the pooled estimate (I2 = 0%). The pooled effect estimate showed no statistically significant difference between early and late debridement regarding the nonunion rate as well. The funnel lots showed little evidence of asymmetry by visual inspection. Conclusion In conclusion, the current evidence demonstrates no impact of timing to surgical debridement on the infection rate following open tibial fractures in the adult population. Our results demonstrated that the risks of infection, deep infection, and nonunion were similar between patients who underwent delayed versus early debridement.

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Section: Resultsmentioning

confidence: 99%

An Updated Evidence About the Role of Timing to Debridement on Infection Rate of Open Tibial Fractures: A Meta-Analysis

El-Hussein

2020

Cureus

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“…Likewise, open fractures are typically debrided and fixated, either with definitive internal fixation or temporizing external fixators, within a 12-to 24-hour period. 10 For some patients with significant tissue loss but relatively clean wounds who are otherwise stable, the decision to proceed with an early free tissue transfer is straight forward. However, other patients have significant delays to free flap that result from failure of initial attempts to close a wound with local muscle flaps, medical instability of the patient, delay in referral to our center, or the late breakdown of native tissues covering fractures.…”

Section: Discussionmentioning

confidence: 99%

Timing of Free Flaps for Traumatic Wounds of the Lower Extremity: Have Advances in Perioperative Care Changed the Treatment Algorithm?

Patterson

Stalder

Richardson

et al. 2019

J reconstr Microsurg

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Background Despite the landmark study by Godina 30 years ago, opinions still vary within the literature about the management of complex traumatic wounds in the lower extremity. We present a large series of lower extremity reconstructions with vascularized free tissue and examine the perioperative factors that influenced the success of these cases. Methods We reviewed 88 patients with free flap reconstruction of traumatic lower extremity wounds over 8 years. Primary outcomes were flap infections, flap loss, total flap-specific complications, and total recipient site complications. Independent variables specific to perioperative care including time to flap coverage, injury classification, exposed or infected hardware, prior osteomyelitis, use of wound vacuum-assisted closure (VAC) therapy, and concurrent polytrauma were investigated to establish their influence on primary outcomes. Each independent variable was assessed using Chi-square or Fisher's exact test and was included in a logistic regression analysis to establish significance. Results Of the 88 patients, 8 had flap loss, 8 had flap infections, and a total of 23 had primary adverse outcomes. Timing of the reconstruction, VAC use, injury classification, prior hardware or wound status, or presence of polytrauma had no statistically significant impact on the primary outcomes. Injury classification/severity on total recipient site complications (p = 0.051) and flap-specific complications (p = 0.073) trended toward significance; however, subgroup analysis did not achieve significance. Logistic regression of any recipient site complication including all independent variables similarly showed no significance. Conclusion Although the original study by Godina suggests early coverage is critical to optimize outcomes, in the modern era of advanced wound care, our study adds to a growing body of evidence that supports the de-emphasis of the 72-hour reconstruction interval. Our current management is focused on more effectively coordinating efficient peritraumatic and perioperative care on an individualized basis in the often very complicated polytrauma patient.

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“…Of the 20 included studies, only 5 provided a description of the debridement carried out [26][27][28][29][30]. Only three studies specified that an Orthoplastic approach was used in the management of fractures [31][32][33]. Six studies did not specify the method of skeletal fixation [32,[34][35][36][37][38], whereas the rest used various methods for the management of the reported fractures.…”

Section: Characteristics Of Included Studiesmentioning

confidence: 99%

“…Only three studies specified that an Orthoplastic approach was used in the management of fractures [31][32][33]. Six studies did not specify the method of skeletal fixation [32,[34][35][36][37][38], whereas the rest used various methods for the management of the reported fractures. Furthermore, only two studies specified the method of soft tissue reconstruction [28,31].…”

Section: Characteristics Of Included Studiesmentioning

confidence: 99%

The Effect of Delayed Surgical Debridement in the Management of Open Tibial Fractures: A Systematic Review and Meta-Analysis

et al. 2021

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Introduction: Open tibial fractures are complex injuries with variable outcomes that significantly impact patients’ lives. Surgical debridement is paramount in preventing detrimental complications such as infection and non-union; however, the exact timing of debridement remains a topic of great controversy. The aim of this study is to evaluate the association between timing of surgical debridement and outcomes such as infection and non-union in open tibial fractures. Materials and Methods: We performed a systematic review and meta-analysis of the literature to capture studies evaluating the association between timing of initial surgical debridement and infection or non-union, or other reported outcomes. We searched the MEDLINE, PubMed Central, EMBASE, SCOPUS, Cochrane Central and Web of Science electronic databases. Our methodology was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane handbook for systematic reviews of interventions. Results: The systematic review included 20 studies with 10,032 open tibial fractures. The overall infection rate was 14.3% (314 out of 2193) and the overall non-union rate 14.2% (116 out of 817). We did not find any statistically significant association between delayed debridement and infection rate (OR = 0.87; 95% CI, 0.68 to 1.11; p = 0.23) or non-union rate (OR = 0.70; 95% CI, 0.42 to 1.15; p = 0.13). These findings did not change when we accounted for the effect of different time thresholds used for defining early and late debridement, nor with the Gustilo–Anderson classification or varying study characteristics. Conclusion: The findings of this meta-analysis support that delayed surgical debridement does not increase the infection or non-union rates in open tibial fracture injuries. Consequently, we propose that a reasonable delay in the initial debridement is acceptable to ensure that optimal management conditions are in place, such that the availability of surgical expertise, skilled staff and equipment are prioritised over getting to surgery rapidly. We recommend changing the standard guidance around timing for performing surgical debridement to ‘as soon as reasonably possible, once appropriate personnel and equipment are available; ideally within 24-h’.

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

Cited by 28 publications

References 10 publications

An Updated Evidence About the Role of Timing to Debridement on Infection Rate of Open Tibial Fractures: A Meta-Analysis

An Updated Evidence About the Role of Timing to Debridement on Infection Rate of Open Tibial Fractures: A Meta-Analysis

Timing of Free Flaps for Traumatic Wounds of the Lower Extremity: Have Advances in Perioperative Care Changed the Treatment Algorithm?

The Effect of Delayed Surgical Debridement in the Management of Open Tibial Fractures: A Systematic Review and Meta-Analysis

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