SLR - April 2023 - John Paul Sevcik, DPM PGY3
Title: Orthoplastic Treatment of Open Lower-Limb Fractures Improves Outcomes: A 12-Year ReviewReference: D’Cunha EM, Penn-Barwell JG, McMcaster J, Fries CA. Orthoplastic Treatment of Open Lower-Limb Fractures Improves Outcomes: A 12-Year Review. Journal of Plastic and Reconstructive Surgery. 2022 Feb 23;151(2), 308e-314e.
Level of Evidence: IV – Retrospective Case Series
Reviewed By: John Paul Sevcik, DPM PGY3
Residency Program: Mercy Health – St. Rita’s Medical Center, Lima, Ohio
Podiatric Relevance: Open fractures of the foot and leg can be very debilitating injuries, with significant risk for infection and need for amputation. Effective initial management of the open fracture is necessary to avoid potential future adverse outcomes. The BOAST 4 guidelines provide guidance on initial management of open lower-limb fractures, with an emphasis on definitive fracture stabilization within 24 hours and definitive soft tissue coverage within 72 hours. This study is the most recent iteration in a 12-year review of outcomes that evaluates the compliance of Oxford University Hospital with the BOAST 4 guidelines, reviews the rate of deep infection, and compares current outcomes with previous results.
Methods: The study is a Level IV retrospective review of patients presenting from 2016-2018 with Gustilo-Anderson IIIB-IIIC open fractures of the lower extremity. These were classified according to demographics, mechanism of injury, fracture classification, time to and type of stabilization, time to and type of soft-tissue coverage, and incidence of surgical site infection.
Results: 61 patients were included in this review. 59% met BOAST 4 guidelines. 41 patients had concomitant fracture stabilization and soft tissue coverage, 8 patients had staged operations, and 12 patients had local flap coverage of their wounds. There was no significant difference in rate of deep infection among these groups. As time to definitive soft-tissue coverage was increased, a significantly increased rate of non-compliance with BOAST 4 guidelines was observed (p=0.001). There was a significant increased rate of deep infections in the BOAST 4 non-compliant versus the compliant group (p=0.05). In comparison to previous reviews, time to soft tissue coverage has decreased, as well as the rate of deep infection.
Conclusions: This study demonstrated an improvement in time to definitive soft tissue coverage of lower extremity open fractures in comparison to prior iterations of this study, as a part of maintaining compliance with BOAST 4 guidelines. This has aided in reducing the rate of deep infection. Additionally, the vast majority of patients had definitive fracture stabilization and soft tissue coverage performed in the same procedure without increased rate of deep infection. The authors relate that with more “fix and flap” procedures being performed, this has allowed for more compliance with BOAST 4 guidelines, and a decreased infection rate compared with prior time periods in this study. These results are limited due to it being a retrospective review, having a small and heterogenous sample size, lack of inclusion of patient comorbidities, and lack of blinding of groups. Regardless, the article demonstrates that the improvement of outcomes with timely fracture stabilization and soft tissue coverage of open fractures. Podiatric surgeons who treat patients with open fractures should be competent in orthoplastic techniques for both the stabilization of open fractures and coverage of exposed bone.