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Outcomes after implementation of an open fracture clinical pathway

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Abstract

Introduction

Open fractures are associated with high rates of complication, morbidity and high economic costs. To improve outcomes, an open extremity fracture clinical pathway that protocolized surgical management and encouraged multidisciplinary collaboration was implemented in our institution. This study evaluates the clinical outcomes before and after the implementation of the pathway.

Methodology

Retrospective review of open tibial and femur fractures covering the 2 year periods before and after pathway implementation was conducted. Patient demographics, fracture location, fixation methods and Gustilo–Anderson classification type were recorded. Primary outcomes include complications of wound infection, implant infection, delayed/non-union and flap failure occurring in a 1 year follow-up period. Secondary outcomes include length of hospital stay, time from emergency department (ED) entrance to first wound debridement, time from ED to flap coverage and total number of operations required.

Results

A total of 43 pre-pathway and 46 post-pathway patients were included in this study. There was a significant reduction in length of hospital stay, a 37.5% decrease from a median of 11.2 to 7 days after pathway implementation. There was also a significant decrease in the number of fractures fixed with external fixators from 47 to 26%. No significant differences were found for the other secondary variables. In a subgroup analysis of type III fractures, there was a significant decrease in length of hospital stay as well as the number of operations required. Median length of hospital stay decreased by 46.7% from 15 to 8 days and total number of operations decreased by 50% from a median of four operations to two operations.

Conclusion

This study demonstrates that the implementation of an open extremity fracture clinical pathway significantly reduces the proportion of external fixation surgeries, length of hospital stay, and number of operations in patients with open tibial and femur fractures, without compromising complication rates.

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References

  1. 1.

    Kim PH, Leopold SS (2012) Gustilo–Anderson classification. Clin Orthop Relat Res 47011:3270–3274

  2. 2.

    Papakostidis C, Kanakaris NK, Pretel J, Faour O, Morell DJ, Giannoudis PV (2011) Prevalence of complications of open tibial shaft fractures stratified as per the Gustilo & Anderson classification. Injury 4212:1408–1415

  3. 3.

    Giannoudis PV, Papakostidis C, Roberts C (2006) A review of the management of open fractures of the tibia and femur. J Bone Joint Surg Br 88-B3:281–289

  4. 4.

    Bhandari M, Tornetta P 3rd, Sprague S, Najibi S, Petrisor B, Griffith L et al (2003) Predictors of reoperation following operative management of fractures of the tibial shaft. J Orthop Trauma 175:353–361

  5. 5.

    Harris I, Lyons M (2005) Reoperation rate in diaphyseal tibia fractures. ANZ J Surg 7512:1041–1044

  6. 6.

    Cheah TS (1998) Clinical pathways—the new paradigm in healthcare? Med J Malays 531:87–96

  7. 7.

    Kinsman L, Rotter T, James E, Snow P, Willis J (2010) What is a clinical pathway? Development of a definition to inform the debate. BMC Med 81:31

  8. 8.

    Rotter T, Kinsman L, James E, Machotta A, Gothe H, Willis J et al (2010) Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev 3:CD006632

  9. 9.

    Nanchahal J, Nayagam S, Khan U, Moran C, Barrett S, Sanderson F et al (2009) Standards for the management of open fractures of the lower limb. In: Laing H (ed) Royal Society of Medicine Press, London

  10. 10.

    Melvin SJ, Dombroski DG, Torbert JT, Kovach SJ, Esterhai JL, Mehta S (2010) Open tibial shaft fractures: II. Definitive management and limb salvage. J Am Acad Orthop Surg 182:108–117

  11. 11.

    Neuman MD, Archan S, Karlawish JH, Schwartz JS, Fleisher LA (2009) The relationship between short-term mortality and quality of care for hip fracture: a meta-analysis of clinical pathways for hip fracture. J Am Geriatr Soc 5711:2046–2054

  12. 12.

    Rotter T, Kugler J, Koch R, Gothe H, Twork S, van Oostrum JM et al (2008) A systematic review and meta-analysis of the effects of clinical pathways on length of stay, hospital costs and patient outcomes. BMC Health Serv Res 81:265

  13. 13.

    Noumi T, Yokoyama K, Ohtsuka H, Nakamura K, Itoman M (2005) Intramedullary nailing for open fractures of the femoral shaft: evaluation of contributing factors on deep infection and nonunion using multivariate analysis. Injury 369:1085–1093

  14. 14.

    Wood T, Sameem M, Avram R, Bhandari M, Petrisor B (2012) A systematic review of early versus delayed wound closure in patients with open fractures requiring flap coverage. J Trauma Acute Care Surg 724:1078–1085

  15. 15.

    Moda SK, Kalra GS, Gupta RS, Maggu NK, Gupta RK, Kalra MK (1994) The role of early flap coverage in the management of open fractures of both bones of the leg. Injury 252:83–85

  16. 16.

    Byrd HS, Cierny G 3rd, Tebbetts JB (1981) The management of open tibial fractures with associated soft-tissue loss: external pin fixation with early flap coverage. Plast Reconstr Surg 681:73–82

  17. 17.

    Chua W, Murphy D, Siow W, Kagda F, Thambiah J (2012) Epidemiological analysis of outcomes in 323 open tibial diaphyseal fractures: a nine-year experience. Singap Med J 536:385–389

  18. 18.

    National Clinical Guideline C (2016) National Institute for Health and Care Excellence: Clinical Guidelines. Fractures (Complex): assessment and management. National Institute for Health and Care Excellence (UK), London, p 137

  19. 19.

    Schenker ML, Yannascoli S, Baldwin KD, Ahn J, Mehta S (2012) Does timing to operative debridement affect infectious complications in open long-bone fractures? A systematic review. J Bone Joint Surg Am 9412:1057–1064

  20. 20.

    Crowley DJ, Kanakaris NK, Giannoudis PV (2007) Debridement and wound closure of open fractures: the impact of the time factor on infection rates. Injury 388:879–889

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Author information

Correspondence to Wei Jie Tan.

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Appendix

Appendix

See Fig. 1.

Fig. 1
figure1

Open extremity clinical pathway (estimated LOS = 10 days)

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Tan, W.J., Kwek, E.B.K. Outcomes after implementation of an open fracture clinical pathway. Arch Orthop Trauma Surg (2020). https://doi.org/10.1007/s00402-020-03363-0

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Keywords

  • Open fractures
  • Tibial fractures
  • Femoral fractures
  • Critical pathways
  • Outcome assessment (health care)
  • Wound infection
  • Length of stay
  • Debridement
  • Surgical flaps