Abstract
Summary
open tibia fractures are best treated in an orthopaedic-plastic surgical multidisciplinary setting.
Introduction
Open fractures of the leg represent a severe trauma. It is often stated that combining the skills of Plastic and Orthopaedic surgeons can optimise the results of limb salvage in complex limb injury. The multidisciplinary approach, shared between plastic and orthopaedic surgeons, is likely to provide the optimal treatment of these injuries, although this mutidisciplinary simultaneous treatment is not routinely performed. Given the relatively low incidence of these traumas, a multicentric recruitment of these patients can contribute in providing an adequately numerous cohort of patients to be evaluated through the long process of soft tissue and bone healing following an open tibia fracture. We compared three centres with different protocols for management of these challenging cases.
Patients & Methods
The following trauma centres, either orthoplastic or orthopaedic, were involved in a prospective observational study: Rizzoli Orthopaedic Institute/University of Bologna (leading centre) and Maggiore Hospital (Bologna), Frenchay Hospital (Bristol, Regno Unito), Jinnah Hospital (Lahore, Pakistan), a centre in the developing world who have adopted an Ortho-Plastic approach. From 01/01/2012, all patients consecutively hospitalised in the mentioned centres due to Gustilo grade 3 tibial open fractures were included in the study and propspectively followed. Demographics, mechanism of the trauma, type of lesion, timing and way of transfer to the trauma centre, as well as timing and techniques of bone and soft tissue treatment were recorded. The considered outcome measures were duration of hospitalization (main outcome measure), rate of reintervention, Enneking score at 3, 6 and 12 months, the incidence of osteomyelitis, non union, amputation and other complications.
Results
The number of patients included in the first 6 months was 42. Mechanism, severity of injury and techniques regarding definitive bone reconstruction were similar accross the three centres. The main difference occured in soft-tissue management with VAC therapy being utilised by the Italian centre compared to vascularised tissue transfer in Pakistan and Britain. The mean duration of hospital stay in the Italian centre was 72 days compared with 24 days in Pakistan and 25 days in Britain. Patients treated in a centre with an orthoplastic team, therefore, spent an average of 46 fewer days in hospital (P<0.005, 95% CI −69 to −24days).
Discussion
From an initial analysis of data, the duration of hospitalization is strongly influenced by the fact that a plastic procedure is performed or not. The first evaluations on the hospital management of these injuries show a relevant advantage deriving from a combined orthoplastic approach, evenwhen applied into a comparatively hostile cohort.
