Treating open lower limb fractures successfully; thoughts and current practice on therapy and centralization in The Netherlands

Abstract

Introduction The British Orthopedic Association (BOA) and British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) updated the evidence-based guidelines for the treatment and care of open lower limb fractures (BOAST 4). Following this, a Dutch version has been developed. The main points are multidisciplinary care, planning, and treatment of these injuries. Early osteosynthesis (within 7-14 days) combined with soft-tissue coverage results in more efficient care and less complications. Aim To study the variation in treatment and thoughts among trauma, orthopedic, and plastic surgeons. Materials and methods In this cross-sectional study 94 surgeons (57 trauma, 23 plastic, and 14 orthopedic surgeons) working at 46 centers completed an online questionnaire, consisting of 5 demographic, 14 hospital-related, 8 BOAST 4-related, and 2 centralization-related questions. Results There was a strong agreement among surgeons about the best moment for multidisciplinary consultation, which was before initial debridement, while in practice, this often does not occur. All surgeons agreed that the initial debridement should be performed immediately by any surgeon, but not solely by trainees. Plastic surgeons responded that the definitive stabilization and wound cover should not exceed 7 days, while half of the trauma and orthopedic surgeons agreed that it should not exceed 14 days. Finally, most surgeons agreed that Gustilo 3 fractures should be centralized. However, there was disagreement on the need for centralization of Gustilo 2 fractures. Discussion Surgeons agree on better and earlier multidisciplinary treatment of open lower limb fractures and the centralization of Gustilo 3 fractures.

Manejo de Fraturas Expostas decorrentes de Traumas: Revisão de Literatura

“…O uso de antibiótico como profilaxia na ocorrência de fratura exposta foi abordado em nove (90%) dos artigos selecionados, discutindo elementos como qual a classe antimicrobiana utilizada (60%), tempo de administração de terapia profilática (80%), espectro antimicrobiano (20%) e quando iniciar o tratamento (20%) [7][8][9][10][11][12][13][14][15][16] .…”

“…O desbridamento foi discutido em metade dos estudos selecionados, e a fixação da fratura externa em uma minoria (20%) 7,8,10,13,15,16 . Os artigos encontram-se disponíveis na Tabela 2.…”

“…As cefalosporinas de primeira geração e os aminoglicosídeos são os medicamentos de escolha [7][8][9][10][11][12][13][14][15][16] .…”

“…Isto acarretando atraso do início do tratamento adequado, incluindo o desbridamento inicial, acarretando resultados inferiores. Os estudos apontam que o antibiótico deve ser realizado imediatamente, após a admissão hospitalar [7][8][9][10][11][12][13][14][15][16] .…”

“…O desbridamento foi discutido em metade dos estudos, sendo preconizado em no máximo seis horas, aceitável até 24 horas, e pouco tolerável após 48 horas. 7,10,13,15,16 Contudo, não houve diferença significativa na incidência de complicações infecciosas profundas em fraturas desbridadas utilizando o ponto de corte como 12 horas 16 . Mas houve um aumento da taxa de infecção quando realizado após 24 horas.…”