1445 Using BOAST Guidelines to Boost Standards: An Audit of Adherence to BOAST Open Fracture Guidelines

Abstract Aim Open fractures require prompt management and appropriate infrastructure is required to deliver optimal care. The BOAST Open Fracture guidelines (2017) set out best practice in their management and advocate a combined Orthoplastics approach. Method All patients with open tibial fractures who presented to or were referred to our hospital from January 2018 - March 2020 were included in our audit. The standard used was the BOAST Open Fracture Guidelines. Data was collected retrospectively for cycle one (January – December 2018) then prospectively for cycle two (November 2019 – March 2020). Between cycles, results from cycle one was used to facilitate a business case for the creation of a second scheduled weekly Orthoplastics list in our hospital. Results 61 injuries met inclusion criteria in cycle one and 23 in cycle two. In cycle one, 28% of cases missed the 72-hour soft tissue coverage target, 11% missed the 7-day target. Only 10% of cases had both Orthopaedics and Plastics consultants involved at initial debridement. Following the invention of an additional weekly Orthoplastics list, the percentage of patients missing the 7-day target for soft tissue coverage halved to 5% and the percentage of cases with both Orthopaedics and Plastics consultants involved at initial debridement more than doubled to 26%. Conclusions We advocate multiple weekly Orthoplastics lists to ensure prompt consultant-led management and minimise delays for patients with open fractures. We have demonstrated that audit of current practice is a simple and effective tool to facilitate improvement in guideline compliance.

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Perioperative management of open fractures in the lower limb

Journal of Perioperative Practice ◽

10.1177/17504589211012150 ◽

2021 ◽

pp. 175045892110121

Author(s):

Bryan Loh ◽

Jiang An Lim ◽

Matthew Seah ◽

Wasim Khan

Keyword(s):

Soft Tissue ◽

Lower Limb ◽

Open Fracture ◽

Wound Care ◽

Operative Management ◽

Open Fractures ◽

Soft Tissue Coverage ◽

Non Union ◽

Patient Presentation ◽

British Orthopaedic Association

An open fracture is a fracture which communicates with the external environment through a wound in the skin. Severe open fractures are managed by both orthopaedic and plastic surgeons to address injuries in both the bone and soft tissue. This review outlines the management of open fractures in the lower limb from the initial patient presentation to operative management (including debridement, skeletal fixation, definitive soft tissue coverage) according to the standards jointly published by the British Orthopaedic Association (BOA) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS). Additionally, the decision-making between limb salvage or amputation will be explored. Finally, this review will discuss the patient’s postoperative care including wound care and management of potential complications that may arise such as infection, flap failure and fracture non-union.

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592 Surgical Management of Open Tibia Fractures at A Major Trauma Centre: A Review of Cases Over A One-Year Period

British Journal of Surgery ◽

10.1093/bjs/znab134.153 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

A Khajuria

Keyword(s):

Soft Tissue ◽

Surgical Management ◽

Open Fracture ◽

Major Trauma ◽

Trauma Centre ◽

Soft Tissue Coverage ◽

Internal Stabilization ◽

Major Trauma Centre ◽

Tibia Fractures ◽

One Year

Abstract Introduction The BOAST/BAPRAS updated the open fracture guidelines in December 2017 to replace BOAST 4 Open fracture guidelines; the changes gave clearer recommendations for timing of surgery and recommendations for reducing infection rates. Method Our work retrospectively evaluates the surgical management of open tibia fractures at a Major Trauma Centre (MTC), over a one-year period in light of key standards (13,14 and 15 of the standards for open fractures). Results The vast majority of cases (93%) had definitive internal stabilization only when immediate soft tissue coverage was achievable. 90% of cases were not managed as ‘clean cases’ following the initial debridement. 50% of cases underwent definitive closure within 72 hours. The reasons for definitive closure beyond 72hours were: patients medically unwell (20%), multiple wound debridement’s (33%) and no medical or surgical reason was clearly stated (47%). Conclusions The implementation of a ‘clean surgery’ protocol following surgical debridement is essential in diminishing risk of recontamination and infection. Hence, this must be the gold standard and should be clearly documented in operation notes. The extent of availability of a joint Orthoplastic theatre list provides a key limiting step in definitive bony fixation and soft tissue coverage of open tibia fractures.

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The Use of Engineered Bilayered Skin (MyDermTM) in the Management of Massive Skin Defect in Grade III Gustilo-Anderson Open Fracture

The International Journal of Lower Extremity Wounds ◽

10.1177/1534734617724974 ◽

2017 ◽

Vol 16 (3) ◽

pp. 212-216

Author(s):

Nor Hazla Mohamed Haflah ◽

Min Hwei Ng ◽

Mohd Heikal Mohd Yunus ◽

Amaramalar Selvee Naicker ◽

Ohnmar Htwe ◽

...

Keyword(s):

Soft Tissue ◽

Open Fracture ◽

Wound Closure ◽

Posterior Tibial Artery ◽

Soft Tissue Coverage ◽

Skin Defect ◽

Vascular Repair ◽

Posterior Compartment ◽

Large Defect ◽

Large Skin

Open fracture Gustilo-Anderson grade IIIC is associated with higher risk of infection and problems with soft tissue coverage. Various methods have been used for soft tissue coverage in open fractures with large skin defect. We report a case of a patient who had grade IIIC open fracture of the tibia with posterior tibial artery injury. The patient underwent external fixation and reduction. Because of potential compartment syndrome after vascular repair, fasciotomy of the posterior compartment was performed. This wound, however, became infected and because of further debridement, gave rise to a large skin defect. A tissue engineered skin construct, MyDermTM was employed to cover this large defect. Complete wound closure was achieved 35 days postimplantation. The patient then underwent plating of the tibia for nonunion with no adverse effect to the grafted site. The tibia eventually healed 5 months postplating, and the cosmetic appearance of the newly formed skin was satisfactory.

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Techniques of Soft Tissue Coverage in Open Fractures

The Poly-Traumatized Patient with Fractures ◽

10.1007/978-3-642-17986-0_21 ◽

2011 ◽

pp. 243-263 ◽

Cited By ~ 1

Author(s):

Norbert Pallua ◽

Ahmet Bozkurt

Keyword(s):

Soft Tissue ◽

Open Fractures ◽

Soft Tissue Coverage

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Radical treatment of severe open fractures of extremities by orthoplastic surgery: a 10-year retrospective study

10.21203/rs.3.rs-114827/v1 ◽

2020 ◽

Author(s):

Zhao Yang ◽

Chao Xu ◽

Yong-Gang Zhu ◽

Jun Li ◽

Zi-Xiang Wu ◽

...

Keyword(s):

Soft Tissue ◽

Open Fracture ◽

Aesthetic Surgery ◽

Open Fractures ◽

Soft Tissue Reconstruction ◽

Central Unit ◽

Chinese Characteristics ◽

Tissue Reconstruction ◽

The Mean

Abstract Orthoplastic treatment based on the collaboration of orthopedic and plastic surgeons in an “orthoplastic” central unit has been recommended by the British Association of Plastic Reconstructive and Aesthetic Surgery. However, this approach is not used worldwide especially in most developing countries. Based on the aggressive orthoplastic management, orthoplastic experience with Chinese characteristics has been carried out in last 10 years. The clinical data of 41 consecutive patients with severe open fracture (Gustilo IIIb or IIIc) of the limb, who underwent successful surgical debridement, fixation, and soft tissue reconstruction in one stage between January 2008 and April 2019, were retrospectively reviewed. Postoperative indicators, including infection rate and union time, were acquired by a regular follow-up and analyzed. The mean (±SD) age of the patients was 38±16 years. The soft tissue cover was achieved within 72 h. The overall rate of infection was 14.6% (6/41). Sex and the Mangled Extremity Severity Score were associated with infection. The median union time of 40 patients (one amputation) was 32 weeks. The overall rate of infection exhibited a lower tendency in this study. These results indicated that the single-stage radical orthoplastic treatment was an effective and reliable option for reconstructing severe open fractures.

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Simultaneous internal fixation and soft tissue coverage by soleus muscle flap and variances: a reproducible strategy for managing open fractures of tibial shaft

European Journal of Orthopaedic Surgery & Traumatology ◽

10.1007/s00590-020-02786-0 ◽

2020 ◽

Author(s):

Surasak Jitprapaikulsarn ◽

Chawanan Patamamongkonchai ◽

Arthit Gromprasit ◽

Witoon Thremthakanpon

Keyword(s):

Soft Tissue ◽

Internal Fixation ◽

Soleus Muscle ◽

Muscle Flap ◽

Open Fractures ◽

Soft Tissue Coverage ◽

Tibial Shaft

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The principles of managing open fractures

Journal of The Royal Naval Medical Service ◽

10.1136/jrnms-100-20 ◽

2014 ◽

Vol 100 (1) ◽

pp. 20.1-25

Author(s):

R Walker ◽

S Middleton ◽

S A Stapley

Keyword(s):

Soft Tissue ◽

Lower Limb ◽

Open Fracture ◽

Open Fractures ◽

Improvised Explosive Device ◽

Limb Fracture ◽

Explosive Device ◽

Improvised Explosive

AbstractAny fracture of a bone which communicates with the outside environment via a wound in the skin is classified as an open fracture. This may be from penetration by sharp objects from the exterior, laceration caused by the fracture fragments, or shearing forces that tear or de-glove soft tissue from a limb. These injuries vary in mechanism and severity, ranging from a broken finger caught in a bulkhead door to a catastrophic lower limb fracture suffered from an improvised explosive device (IED). We address the management principles that can be applied to all open fractures regardless of cause.

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Soft Tissue Reconstruction

Standards for the Management of Open Fractures ◽

10.1093/med/9780198849360.003.0008 ◽

2020 ◽

pp. 63-74

Keyword(s):

Soft Tissue ◽

Lower Limb ◽

Donor Site ◽

Free Flaps ◽

Donor Site Morbidity ◽

Open Fractures ◽

Soft Tissue Coverage ◽

Soft Tissue Reconstruction ◽

Tissue Reconstruction ◽

Wound Excision

Soft tissue coverage of open fractures with well-vascularised tissues should be performed within 72 hours of injury or at the same time as internal fixation. It may be in the form of local or free flaps, and may comprise muscle, fasciocutaneous tissues, or both. Flap selection depends on multiple factors, including the size and location of the defect following wound excision, availability of flaps, and donor site morbidity. Local flaps are usually used to cover defects with a limited zone of injury. Anastomoses for free flaps should be performed outside the zone of injury. Experimental data suggest that coverage with muscle leads to improved healing of fractures. However, there is currently little clinical evidence to support the use of one form of soft tissue cover over another for open fractures of the lower limb. The plastic surgeon must always consider the donor site morbidity of the flap(s) chosen.

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