Implementing an orthoplastic treatment protocol for open tibia fractures reduces complication rates in tertiary trauma unit

• Published in: Injury 2023-08, Vol.54 (8), p.110890-110890, Article 110890
• Main Authors: Ylitalo, Antti A.J., Hurskainen, Hanna, Repo, Jussi P., Kiiski, Juha, Suomalainen, Piia, Kaartinen, Ilkka
• Format: Article
• Language: English
• Subjects: BOAST 4; Complications; Gustilo-Andersson classification; Infection; Nonunion; Open fracture; Orthoplastic; Soft tissue coverage; Tibia; Trauma
• ISSN: 0020-1383; 1879-0267
• DOI: 10.1016/j.injury.2023.110890

•Open tibia fracture (OTF) causes a considerable increase in morbidity and risk for complications compared to closed fractures.•The incidence of reoperation due to nonunion decreased from 27.7% to 9.7% after implementing BOAST 4 based OTF treatment protocol.•A structured OTF treatment protocol reduced the incidence of fracture related infection from 20.6% to 1.6% in a tertiary trauma unit.•Definitive fixation and soft tissue coverage performed in separate operations increased the risk for both FRI and reoperation due to nonunion. Open tibia fracture (OTF) causes a considerable increase in morbidity and risk for complications compared to closed fractures. The most significant OTF complication leading to morbidity is commonly considered to be fracture-related infection (FRI). In September 2016, Tampere University Hospital (TAUH) introduced a treatment protocol for OTFs based on the BOAST 4 guideline. The aim of this study is to investigate the outcomes before and after implementation of the OTF treatment protocol. A retrospective cohort study was conducted using handpicked data from the patient record databases of TAUH from May 1, 2007, to May 10, 2021. For patients with OTF, we collected descriptive information, known risk factors for FRI and nonunion, bony fixation method, possible soft tissue reconstruction method, information about the timing of internal fixation and soft tissue coverage, and timing of primary operation. As outcome measures, we collected information on FRI, reoperation due to non-union, flap failure, and secondary amputation. We then compared the incidence of complications before and after the implementation of the OTF treatment protocol at TAUH. After predefined exclusions, a total of 203 patients with OTF were included. Of these, 141 were treated before and 62 after the implementation of the OTF treatment protocol. The FRI rate in the pre-protocol group was significantly higher compared to the protocol group (20.6% vs 1.6%, p = 0.0015). The incidence of reoperation due to nonunion was also significantly higher in the pre-protocol group (27.7% vs 9.7%, p = 0.0054). According to multivariable analysis, definitive fixation and soft tissue coverage performed in separate operations was an independent risk factor for both FRI and reoperation due to nonunion. After implementation, the BOAST 4 based OTF treatment protocol reduced the rate of FRI and reoperation due to nonunion in patients with OTF treated at TAUH during the study period. We, t