Orthoplastic Treatment of Open Lower-Limb Fractures Improves Outcomes: A 12-Year Review

Background: The British Orthopaedic Association Standards for Orthopaedics and Trauma 4 (BOAST 4) inform the management of open lower-limb fractures. The authors conducted repeated reviews of performance against these standards over a 12-year period. This latest iteration has shown further improvements in outcomes concomitant with changes in service delivery. Methods: Data on Gustilo-Anderson grade IIIB or IIIC open lower-limb fractures were collected from a prospectively constructed departmental database and analyzed using Excel. Outcomes assessed included time to stabilization, time to definitive soft-tissue coverage, and deep infection rates. Results A total of 69% of patients in our cohort received care that aligned with BOAST 4 guidelines. Median time to stabilization was 14.2 hours and to soft-tissue coverage was 47 hours, with 71% of cases compliant with BOAST 4 guidelines. The overall deep infection rate was 6.5% in our cohort. There was a significantly lower deep infection rate in BOAST 4–compliant cases (2%) versus noncompliant cases (16%), respectively (P = 0.05). A total of 41 of 61 patients had fixation and soft-tissue coverage in a single operation (fix and flap), eight had staged operations, and 12 required local flap closure. There was no significant difference in deep infection rates among these approaches. Conclusions: Compliance with the BOAST 4 guidelines and time to definitive soft-tissue coverage have improved at our center since the last review. Deep infection rates were significantly lower in BOAST 4–compliant cases, further validating this approach. The fix and flap technique was introduced during the study period and reduces operative burden for patients. These results support a joint orthoplastic approach as the optimal management for these complex injuries. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

[1]  J. Singh,et al.  Single-stage “Fix and Flap” gives Good Outcomes in Grade 3B/C Open Tibial Fractures: A Prospective Study , 2020, Malaysian orthopaedic journal.

[2]  A. Pillai,et al.  Adjuvant Local Antibiotic Hydroxyapatite Bio-Composite in the management of open Gustilo Anderson IIIB fractures. Prospective Review of 80 Patients from the Manchester Ortho-Plastic Unit. , 2020, Journal of orthopaedics.

[3]  R. M. Hulick,et al.  What are the Risk Factors for Deep Infection in AO/OTA 43C Pilon Fractures? , 2019, Journal of orthopaedic trauma.

[4]  M. Whitehouse,et al.  Two-stage combined ortho-plastic management of type IIIB open diaphyseal tibial fractures requiring flap coverage: Is the timing of debridement and coverage associated with outcomes? , 2019, Journal of orthopaedic trauma.

[5]  E. Marzetti,et al.  Clinical and radiographic outcomes in patients operated for complex open tibial pilon fractures. , 2019, Injury.

[6]  A. Pillai,et al.  The use of adjuvant local antibiotic hydroxyapatite bio-composite in the management of open Gustilo Anderson type IIIB fractures. A prospective review. , 2019, Journal of orthopaedics.

[7]  D. Tigani,et al.  Orthoplastic surgical collaboration is required to optimise the treatment of severe limb injuries: A multi-centre, prospective cohort study. , 2017, Journal of plastic, reconstructive & aesthetic surgery : JPRAS.

[8]  M. Bhandari,et al.  Incidence of infection following internal fixation of open and closed tibia fractures in India (INFINITI): a multi-centre observational cohort study , 2017, BMC Musculoskeletal Disorders.

[9]  G. Lawton,et al.  Improving the care of patients with severe open fractures of the tibia: the effect of the introduction of Major Trauma Networks and national guidelines. , 2016, The bone & joint journal.

[10]  J. Mathews,et al.  Single-stage orthoplastic reconstruction of Gustilo-Anderson Grade III open tibial fractures greatly reduces infection rates. , 2015, Injury.

[11]  WrightTC,et al.  Role of plastic surgeons in major trauma centres in the UK , 2015 .

[12]  A. Brent,et al.  Experience of managing open fractures of the lower limb at a major trauma centre. , 2015, Annals of the Royal College of Surgeons of England.

[13]  M. Aboutanos,et al.  Open extremity fractures: Impact of delay in operative debridement and irrigation , 2014, The journal of trauma and acute care surgery.

[14]  H. Kreder,et al.  Delayed debridement of severe open fractures is associated with a higher rate of deep infection. , 2014, The bone & joint journal.

[15]  M. Raschke,et al.  Systematic review and meta-analysis of the additional benefit of local prophylactic antibiotic therapy for infection rates in open tibia fractures treated with intramedullary nailing , 2014, International Orthopaedics.

[16]  I. Tarkin,et al.  Open supracondylar femur fractures with bone loss in the polytraumatized patient - Timing is everything! , 2013, Injury.

[17]  P. Giannoudis,et al.  Prevalence of complications of open tibial shaft fractures stratified as per the Gustilo-Anderson classification. , 2011, Injury.

[18]  J. Nanchahal,et al.  Reconstructive surgery in limbs: the case for the orthoplastic approach. , 2011, Annals of plastic surgery.

[19]  J. Nanchahal,et al.  Standards for the Management of Open Fractures of the Lower Limb , 2010 .

[20]  E. Mackenzie,et al.  The relationship between time to surgical debridement and incidence of infection after open high-energy lower extremity trauma. , 2010, The Journal of bone and joint surgery. American volume.

[21]  E. Mackenzie,et al.  The impact of trauma-center care on functional outcomes following major lower-limb trauma. , 2008, The Journal of bone and joint surgery. American volume.

[22]  J. Nanchahal,et al.  Management of severe open tibial fractures: the need for combined orthopaedic and plastic surgical treatment in specialist centres. , 2006, The Journal of bone and joint surgery. British volume.

[23]  R. M. Smith,et al.  The functional outcome of severe, open tibial fractures managed with early fixation and flap coverage. , 2004, The Journal of bone and joint surgery. British volume.

[24]  R. Sanders,et al.  A staged protocol for soft-tissue management in the treatment of complex pilon fractures , 1999, Journal of orthopaedic trauma.

[25]  P. Giannoudis,et al.  Early internal fixation and soft tissue cover of severe open tibial pilon fractures , 2003, International Orthopaedics.

[26]  C. A. Jones,et al.  The Effect of Time to Definitive Treatment on the Rate of Nonunion and Infection in Open Fractures , 2002, Journal of orthopaedic trauma.

[27]  R. M. Smith,et al.  Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. , 2000, The Journal of bone and joint surgery. British volume.

[28]  Y. Tropet,et al.  Emergency management of type IIIB open tibial fractures. , 1999, British journal of plastic surgery.

[29]  J. Sampalis,et al.  Trauma care regionalization: a process-outcome evaluation. , 1999, The Journal of trauma.

[30]  L. Levin.  The Reconstructive Ladder , 1995 .

[31]  R. Brumback,et al.  Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two hundred and forty-five orthopaedic surgeons. , 1994, The Journal of bone and joint surgery. American volume.

[32]  D. Bednar,et al.  Effect of Time Delay from Injury to Primary Management on the Incidence of Deep Infection After Open Fractures of the Lower Extremities Caused by Blunt Trauma in Adults , 1993, Journal of orthopaedic trauma.

[33]  R. Gustilo,et al.  The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury. , 1991, The Journal of bone and joint surgery. American volume.

[34]  M. Godina.  Early microsurgical reconstruction of complex trauma of the extremities , 1986, Plastic and reconstructive surgery.

[35]  D. N. Williams,et al.  Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. , 1984, The Journal of trauma.

[36]  T. Moore,et al.  Considerations in reducing the infection rate in open tibial fractures. , 1983, Clinical orthopaedics and related research.

[37]  R. Gustilo,et al.  OTD classic article review - Gustillo RB, Anderson JT (1976) Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses , 2002, The Journal of bone and joint surgery. American volume.