Outcomes after implementation of an open fracture clinical pathway



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.


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.


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.


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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Correspondence to Wei Jie Tan.

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See Fig. 1.

Fig. 1

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 140, 1373–1379 (2020). https://doi.org/10.1007/s00402-020-03363-0

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