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What is the evidence for the current BOAST guidelines for open fractures and in what way would you suggest modifying these?

What is the evidence for the current BOAST guidelines for open fractures and in what way would you suggest modifying these?

Open fracture, or a compound fracture, is a fracture in which the bone communicates with the external environment. These can range from a small puncture wound to a large skin defect with the bone exposed. (1)

In 1993 and then in 1997, the British Orthopaedic Association (BOA) and the British Association of Plastic surgeons (BAPS) published one of the first guidelines on the management of open tibial fractures. (2,3) These emphasized the importance of understanding the management of open fractures and the need for a multidisciplinary approach, as they can be associated with significant morbidity. Over the years, following further research in this field, there have been several updates to these guidelines.

The current BOAST – 4 (British Orthopedic Association Standard for Trauma) guidelines, published in December 2017, provides a useful management tool for open fractures. (4) The main recommendations include the use of antibiotics, thorough examination of the affected limb, the need for early debridement and last but not the least the importance of joint Thermoplastic care.

Below we will discuss some of these recommendations and their current evidence in literature.
3 BOAST – 4 Guidelines
4 Antibiotics

The rate of infection, based on the Gustillo-Anderson Classification (5), is 1.4%, 3.6% and 22.7% for Type I, II and III fractures, respectively. (6) Studies have been published over the years regarding the use of prophylactic antibiotics to lower the rate of infection. (6,7,8) Recent research suggests that sooner you give antibiotics, the lower the chances of infection. Lack et al (9) used a retrospective analysis in his study to find out the effects of giving antibiotics early. He concluded that giving antibiotics within 66 minutes of the injury decreased the rate of infection. The most common organisms are gram-positive but gram-negative organisms have also been grown especially in type III fractures contaminated with soil. (10,11) The guidelines therefore recommend that intravenous antibiotics should be administered ideally within 1 hour of injury, based on local hospital policy.

Arterial injury
Glass et al (12) in his study recommended that open fractures with an associated vascular injury should have their circulation restored with in 3-4 hours of injury. A delay of more than 6 hours can lead to devastating complications. (13,14) These include renal failure, compartment syndrome and death. As high has 86% of lower limb amputation rate has been reported (15), hence the need for prompt diagnosis of arterial injury.

5 Compartment syndrome
Compartment syndrome is a well recognised complication of high energy trauma and more commonly seen after tibial fractures. (16,17) This is a limb threatening injury and therefore BOA recommends a thorough examination of the neurovascular status of the injured limb. Compartment pressure measurement is a useful tool to aid in the diagnosis but some studies have questioned the value of these. (18,19) Therefore, if there is a clinical suspicion of compartment syndrome, immediate decompression should take place using the two-incision technique. (20) A lateral incision to decompress the anterior and lateral compartments and a medial incision for the superficial and deep posterior compartments. These should be done carefully by avoiding the perforators, as demonstrated in the figure below from the BOAST guidelines.

6 Wound debridement
Older guidelines have recommended that wound debridement should be conducted within 6 hours as it increases the chances of infection. (2,3,21) However, Webb et al (22) in his study reviewed open tibial fracture treatment and concluded that the timing of debridement and soft-tissue coverage had no effect on infection rate, union rate or length of hospital stay. Therefore BOAST guidelines recommended that except for wounds with sewage or agriculture contamination, they should be washout out between 12 to 24 hours.

Thermoplastic care
Most high energy open fractures i.e Gustilo type III fractures can be associated with extensive skin loss and tissue damage. A delay in managing these wounds can result in surgical failure and increased infection rates. (23) Gopal et al (24) recommended the ‘fix and flap’ approach for managing lower limb trauma which limits the complications associated with these. Negative pressure wound therapy has also been described for the management of III-B fractures. (25) These are highly skilled procedures and therefore BOAST has recommended the involvement of plastic surgeons as early as possible in the management of open fractures in order to improve outcomes.

7 Recommended modifications
BOAST guidelines are the gold standards that are used nationally in the United Kingdom across all hospitals. In a well-equipped and funded hospital, these can be easily followed. However, circumstances vary across the country.
The timing of initial debridement within 12 hours for a high energy open fracture is not practically possible for most major trauma centres. This can be due to delay in transfer times of the patient to a tertiary centre or the increasing amount of trauma limiting the availability of theatre space or surgeon. Reviewing the literature, many studies recently have shown that there is little to no difference in the infection rates between early or late debridement, given the patient receives antibiotics early. (26,27,28) Therefore, changing the timing to 24 hours for all, except grossly contaminated wounds, would be a more feasible option.
Although high pressure pulse lavage (29) and use of antibiotics or soaps (30) has been recommended in previous literature, following a trial by the FLOW investigators (31) normal saline used at low-pressure lavage has shown to have the same efficacy in removing debris as compared to other pressures. The type of fluid and pressure used for irrigation during debridement could also be mentioned in the guidelines as a useful tool.
Tetanus toxoid administration should be included in the BOAST guidelines together with antibiotics. Heavily contaminated wounds run the risk of being infected with Clostridium tetani which is responsible for tetanus. (32) Any patient who has not received a tetanus toxoid immunisation in the last 5 years should be given a booster dose.

8 References

1) Wheeless C, Nunley J, Urbaniak J. Wheeless’ textbook of orthopaedics.
2) The Early Management of Severe Tibial Fractures: The Need for Combined Plastic and Orthopaedic Management. BOA/BAPS, London, January 1993.
3) CM Court-Brown, AT Cross, DM Hahn, DR Marsh, K Willett, AAWF Quaba, et al. A report by the British Orthopaedic Association/British Association of Plastic Surgeons Working Party on the management of Open Tibial Fractures. Brit Jour Plas Surg. 1997;50(8):570-583
4) BOAST – 4 guidelines. Open fractures. Available from https://www.boa.ac.uk/uploads/assets/uploaded/6418c4a3-d355-4f15a258cfef62b4729f.pdf
5) Gustilo RB, Gruninger RP, Davis T. Classification of type III (severe) open fractures relative to treatment and results. Orthopedics. 1987;10:1781–8
6) Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wounds. Clin Orthop Relat Res. 1989;243:36–40.
7) Hoff WS, Bonadies JA, Cacheco R, Dorlac W. East practice management guidelines work group: Update to practice management guidelines for prophylactic antibiotic use in open fractures. J Trauma. 2011;70(3):751–4.
8) Melvin S, Dombroski D, Torbert J, Kovach SJ, Esterhai JL, Mehta S. Tibial shaft fractures: I. Evaluation and initial wound management. J Am Acad Orthop Surg. 2010;18:10–19.
9) Lack WD, Karunakar MA, Angerame MR, et al Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection. J Orthop Trauma 2015;29:1–6
10) Templeman DC, Gulli B, Tsukayama DT, Gustilo RB. Update on the management of open fractures of the tibial shaft. Clin Orthop Relat Res. 1998;350:18–25
11) Patzakis MJ, Wilkins J, Moore TM. Use of antibiotics in open tibial fractures. Clin Orthop Relat Res. 1983;178:31–5.
12) Glass GE, Pearse MF, Nanchahal J. Improving lower limb salvage following fractures with vascular injury: A systematic review and new management algorithm. J Plast Reconstr Aesthet Surg. 2009; 62:571-9
13) Howard PW, Makin GS. Lower limb fractures with associated vascular injury. J Bone Joint Surg Br. 1990; 72:116-20
14) Lange RH, Bach AW, Hansen ST Jr, Johansen KH. Open tibial fractures with associated vascular injuries: Prognosis for limb salvage. J Trauma. 1985; 25:203-8
15) Green NE, Allen BL: Vascular injuries associated with dislocation of the knee. J Bone Joint Surg Am 1977;59(2):236-239. 16) E. Stark, C. Stucken, G. Trainer, P. Tornetta III Compartment syndrome in Schatzker type VI plateau fractures and medial condylar fracture-dislocations treated with temporary external fixation J Orthop Trauma, 23 (2009), pp. 502506
17) M.M. McQueen, A.D. Duckworth, S.A. Aitken, R.A. Sharma Court-Brown CM: Predictors of compartment syndrome after tibial fracture J Orthop Trauma, 29 (2015), pp. 451-455
18) I.A. Harris, A. Kadir, G. Donald Continuous compartment pressure monitoring for tibia fractures: does it influence outcome? J Trauma, 60 (2006), pp. 13301335
19) O.Q. Al-Dadah, C. Darrah, A. Cooper, S.T. Donell, A.D. Patel Continuous compartment pressure monitoring vs: clinical monitoring in tibial diaphyseal fracture Injury, 39 (2008), pp. 1204-1209
20) Mubarak SJ, Owen CA. Double-incision fasciotomy of the leg for decompression in compartment syndromes. J Bone Joint Surg Am. 1977; 59:184-7
21) Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58:453–8.
22) Webb LX, Bosse MJ, Castillo RC, MacKenzie EJ. Analysis of surgeoncontrolled variables in the treatment of limb-threatening type-III open tibial diaphyseal fractures. J Bone Joint Surg Am. 2007; 89:923-8
23) Melvin JS , Dombroski DG , Torbert JTet al. . Open tibial shaft fractures: II. Definitive management and limb salvage. J Am Acad Orthop Surg 2010;18:108-17.
24) Gopal S , Majumder S , Batchelor AGet al. . Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg [Br] 2000;82-B:959-66.
25) Schlatterer DR , Hirschfeld AG , Webb LX . Negative pressure wound therapy in grade IIIB tibial fractures: fewer infections and fewer flap procedures? Clin Orthop Relat Res2015;473:1802-11.
26) Halawi MJ , Morwood MP . Acute management of open fractures: an evidence-based review. Orthopedics 2015;38:e1025-33.
27) Werner CML , Pierpont Y , Pollak AN . The urgency of surgical débridement in the management of open fractures. J Am Acad Orthop Surg 2008;16:369

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