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

© 2018 Elsevier Ltd Background: Recent national (NICE) guidelines in England recommend that initial debridement and wound excision of open tibial fractures take place within 12 h of the time of injury, a change from the previous target of 24 h. 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 h 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 h and 90% within 24 h. There was no significant difference in the incidence of major infective complications if debrided in less than or greater than 12 h (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 h) 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 h 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 h appears achievable. If a 12-h target is to be met, it is vital to ensure dedicated orthoplastic capacity is adequately resourced

The Distally Based Peroneus Brevis Flap: The 5-Step Technique

The peroneus brevis flap was first described as proximally based by Mathes et al (Surg Clin North Am. 1974;54:1337-1354) and later by Jackson and Scheker (Injury. 1982;13:324-330). A distally based version of this flap by Mathes and Nahai (Reconstructive Surgery: Principles, Anatomy and Technique. 1997:1437e46) was subsequently described in 1997. The first case series of distally based flaps was published by Eren et al (Plast Reconstr Surg. 2001;107:1443-1448).In our experience, the distally based flap is a useful muscle flap to reconstruct small defects in the lateral distal third of the leg. Initial interest and confidence in the use of this flap in our unit were hindered by lack of direct experience and descriptive detail in the literature. We have now developed a systematic approach to harvest the distally pedicled peroneus brevis muscle flap in 5 reproducible, safe steps. This has allowed the flap to become adopted as a standard technique of limb reconstruction in our unit with no cases of flap loss