Top

European Journal of Trauma and Emergency Surgery

Published in:

Open Access 30-09-2023 | Tibia Fracture | Original Article

Comparing outcomes following direct admission and early transfer to specialized trauma centers in open tibial fracture treatment: a systematic review and meta-analysis

Authors: Pien Gabriele Francien Joosten, Marieke Paulina Borgdorff, Matthijs Botman, Mark-Bram Bouman, Daphne van Embden, Georgios Fredericus Giannakópoulos

Published in: European Journal of Trauma and Emergency Surgery | Issue 2/2024

Abstract

Introduction

Guidelines on the management of open tibia fractures recommend timely treatment in a limb reconstruction center which offer joint orthopedic-trauma and plastic surgery services. However, patient’s transfer between centers remains inevitable. This review aims to evaluate the clinical outcomes and hospital factors for patients directly admitted and transferred patients to a limb-reconstruction center.

Methods

A research protocol adhering to PRISMA standards was established. The search included databases like MEDLINE, EMBASE, and the Cochrane library up until March 2023. Nine articles met the inclusion criteria, focusing on open tibia fractures. Exclusion criteria were experimental studies, animal studies, and case reports. Outcomes of interest were operation and infection rates, nonunion, limb salvage, and the Enneking limb score.

Results

The analysis involved data from 520 patients across nine studies published between 1990 and 2023, with the majority (83.8%) having Gustilo Anderson type III open tibia fractures. Directly admitted patients showed lower overall infection rates (RR 0.30; 95% CI 0.10–0.90; P = 0.03) and fewer deep infections (RR 0.39; 95% CI 0.22–0.68; P = 0.001) compared to transferred patients. Transferred patients experienced an average five-day delay in soft tissue closure and extended hospital stays by eight days. Patients transferred without initial surgical management underwent fewer total surgical procedures. The direct admission group displayed more favorable functional outcomes.

Conclusion:

Low- to moderate-quality evidence indicates worse clinical outcomes for transferred patients compared to directly admitted patients. Early treatment in specialized limb reconstruction units is essential for improved results in the management of open tibia fractures.

Level of evidence

Therapeutic level IIa.

Court-Brown CM, et al. The epidemiology of open fractures in adults. A 15-year review. Injury. 2012;43(6):891–7.CrossRefPubMed

Lua J, et al. Complications of open tibial fracture management: risk factors and treatment. Malays Orthop J. 2017;11(1):18–22.CrossRefPubMedPubMedCentral

Babhulkar S, Raza HK. Open fractures. Indian J Orthop. 2008;42(4):365–7.CrossRefPubMedPubMedCentral

Schade AT, et al. The economic burden of open tibia fractures: a systematic review. Injury. 2021;52(6):1251–9.CrossRefPubMed

Hoekstra H, et al. Economics of open tibial fractures: the pivotal role of length-of-stay and infection. Health Econ Rev. 2017;7(1):32.CrossRefPubMedPubMedCentral

Naique SB, Pearse M, Nanchahal J. Management of severe open tibial fractures: the need for combined orthopaedic and plastic surgical treatment in specialist centres. J Bone Jt Surg Br. 2006;88(3):351–7.CrossRef

Gopal S, et al. Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Jt Surg Br. 2000;82(7):959–66.CrossRef

National Institute for Health and Care Excellence (NICE), Fractures (complex) assessment and management of complex fractures [NG37]. 2016. https://www.nice.org.uk/guidance/ng37. Accessed 10th Feb 2020.

British Orthopeadic Association, British Association of Plastic Reconstructive and Aesthetic Surgeons (BOA, BAPRAS), Open Fractures. 2017. https://www.boa.ac.uk/uploads/assets/3b91ad0a-9081-4253-92f7d90e8df0fb2c. Accessed 11th Mar 2020.

10.

Nanchahal J, Khan U, Moran C, Barrett S, Sanderson F, et al. Standards for the management of open fractures of the lower limb. London: Royal Society of Medicine Press; 2009.

11.

Ali AM, et al. Experience of managing open fractures of the lower limb at a major trauma centre. Ann R Coll Surg Engl. 2015;97(4):287–90.CrossRefPubMedPubMedCentral

12.

Trickett RW, et al. From guidelines to standards of care for open tibial fractures. Ann R Coll Surg Engl. 2015;97(6):469–75.CrossRefPubMedPubMedCentral

13.

Wordsworth M, et al. Improving the care of patients with severe open fractures of the tibia: the effect of the introduction of Major Trauma Networks and national guidelines. Bone Jt J. 2016;98-B(3):420–4.CrossRef

14.

Ylitalo AAJ, et al. Implementing an orthoplastic treatment protocol for open tibia fractures reduces complication rates in tertiary trauma unit. Injury. 2023;54(8): 110890.CrossRefPubMed

15.

Shah A, Judge A, Griffin XL. Variation in timely surgery for severe open tibial fractures by time and place of presentation in England from 2012 to 2019. Bone Jt Open. 2022;3(12):941–52.CrossRefPubMedPubMedCentral

16.

Wensley K, et al. Using BOAST guidelines to boost standards: an audit of adherence to BOAST open fracture guidelines (abstract 1445). Br J Surg. 2021;108(Supplement_6).

17.

Lin CA, et al. Low adherence to recommended guidelines for open fracture antibiotic prophylaxis. J Bone Jt Surg Am. 2021;103(7):609–17.CrossRef

18.

Chowdhury MM, Dagash H, Pierro A. A systematic review of the impact of volume of surgery and specialization on patient outcome. Br J Surg. 2007;94(2):145–61.CrossRefPubMed

19.

Moher D, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339: b2535.CrossRefPubMedPubMedCentral

20.

Ouzzani M, et al. Rayyan-a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210.CrossRefPubMedPubMedCentral

21.

Monsell FP, et al. High-energy open tibial fractures in children: treatment with a programmable circular external fixator. J Bone Jt Surg Br. 2012;94(7):989–93.CrossRef

22.

Townley WA, et al. Management of open tibial fractures—a regional experience. Ann R Coll Surg Engl. 2010;92(8):693–6.CrossRefPubMedPubMedCentral

23.

Crowe CS, Luan A, Lee GK. Hospital transfer of open tibial fractures requiring microsurgical reconstruction negatively impacts clinical outcomes. Ann Plast Surg. 2017;78(5 Suppl 4):S180-s184.CrossRefPubMed

24.

Singh S, Lo SJ, Soldin M. Adherence to national guidelines on the management of open tibial fractures: a decade on. J Eval Clin Pract. 2009;15(6):1097–100.CrossRefPubMed

25.

Chummun S, et al. Delayed presentation of IIIB tibial fractures: outcome following management in a specialist centre. Eur J Plast Surg. 2011;35:25–30.CrossRef

26.

Allison K, et al. The management of compound leg injuries in the West Midlands (UK): are we meeting current guidelines? Br J Plast Surg. 2005;58(5):640–5.CrossRefPubMed

27.

Hendrickson SA, et al. Time to initial debridement and wound excision (TIDE) in severe open tibial fractures and related clinical outcome: a multi-centre study. Injury. 2018;49(10):1922–6.CrossRefPubMed

28.

Higgin R, et al. Outcomes following the delayed management of open tibial fractures. Injury. 2021;52(8):2434–8.CrossRefPubMed

29.

Shammas RL, et al. Identifying predictors of time to soft-tissue reconstruction following open tibia fractures. Plast Reconstr Surg. 2018;142(6):1620–8.CrossRefPubMed

30.

D’Alleyrand JC, et al. Is time to flap coverage of open tibial fractures an independent predictor of flap-related complications? J Orthop Trauma. 2014;28(5):288–93.CrossRefPubMed

31.

Shah A, Judge A, Griffin XL. Incidence and quality of care for open fractures in England between 2008 and 2019. Bone Jt J. 2022;104-B(6):736–46.CrossRef

32.

Green AR. The courage to co-operate: the team approach to open fractures of the lower limb. Ann R Coll Surg Engl. 1994;76(6):365–6.PubMedPubMedCentral

33.

Hay-David A, et al. Motorcyclists and pillion passengers with open lower-limb fractures: a study using TARN data 2007–2014. Ann R Coll Surg Engl. 2018;100(3):203–8.CrossRefPubMedPubMedCentral

34.

Stammers J, et al. The impact of trauma centre designation on open tibial fracture management. Ann R Coll Surg Engl. 2013;95(3):184–7.CrossRefPubMedPubMedCentral

35.

Berner JE, et al. International Lower Limb Collaborative (INTELLECT) study: a multicentre, international retrospective audit of lower extremity open fractures. Br J Surg. 2022;109(9):792–5.CrossRefPubMedPubMedCentral

36.

Moy R, et al. Trauma systems: the potential impact of a trauma divert policy on a regional ambulance service. Emerg Med J. 2012;29(5):404–8.CrossRefPubMed

37.

Hendrickson SA, et al. Plastic surgical operative workload in major trauma patients following establishment of the major trauma network in England: a retrospective cohort study. J Plast Reconstr Aesthet Surg JPRAS. 2016;69(7):881–7.CrossRefPubMed

38.

Prodromidis AD, Charalambous CP. The 6-hour rule for surgical debridement of open tibial fractures: a systematic review and meta-analysis of infection and nonunion rates. J Orthop Trauma. 2016;30(7):397–402.CrossRefPubMed

39.

Morris R, Pallister I, Trickett RW. Measuring outcomes following tibial fracture. Injury. 2019;50(2):521–33.CrossRefPubMed

Title: Comparing outcomes following direct admission and early transfer to specialized trauma centers in open tibial fracture treatment: a systematic review and meta-analysis
Authors: Pien Gabriele Francien Joosten
Marieke Paulina Borgdorff
Matthijs Botman
Mark-Bram Bouman
Daphne van Embden
Georgios Fredericus Giannakópoulos
Publication date: 30-09-2023
Publisher: Springer Berlin Heidelberg
Keyword: Tibia Fracture
Published in: European Journal of Trauma and Emergency Surgery / Issue 2/2024
Print ISSN: 1863-9933
Electronic ISSN: 1863-9941
DOI: https://doi.org/10.1007/s00068-023-02366-x

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Comparing outcomes following direct admission and early transfer to specialized trauma centers in open tibial fracture treatment: a systematic review and meta-analysis

Abstract

Introduction

Methods

Results

Conclusion:

Level of evidence

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusion:

Level of evidence

Please log in to get access to this content

Other articles of this Issue 2/2024

Influence of COVID-19 pandemic on hospitalisations at a paediatric traumatology department during 2020: a single-centre observational study and comprehensive literature review

Reliability of the safety threats and adverse events in trauma (STAT) taxonomy using trauma video review

Comparison of the safety and efficacy for different regimens of pharmaco-prophylaxis among severely burned patients: a randomized controlled trial

Conservative treatment versus transverse pinning in fifth metacarpal neck fractures in active adults: a randomized controlled trial

Independent factors of preventable death in a mature trauma center: a propensity-score analysis

Delta Shock Index and higher incidence of emergency surgery in older adults with blunt trauma