Compliance with international guidelines in the management of Gustilo-Anderson III fractures in multi-trauma patients. A perspective from a level 1 trauma center

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IntroductionThe GA classification(GAC)is the most used for open fractures. The real-world compliance with published guidelines (GL) for GAC fractures is not well explored. We aimed to assess the adherence to the GL on orthopedic injuries in trauma published in the Journal of Trauma in 2020 and study the clinical impact of non-adherence.MethodsWe included trauma patients with long bone GAC grade III fractures treated in 2018-20 at Niguarda Level-1 Trauma Center,Milan,Italy.We selected five points from GL for compliance assessment: application of GAC;x-rays performed in stable patients or after stabilization in unstable ones; antibiotic administration within 3 hours from trauma;soft tissue coverage within 72 hours from trauma for GACIIIA and within 7 days for GACIIIB-C.We performed a group comparison considering compliance to GL to explore differences in infectious complications(IC)or need for amputation(AMP).ResultsWe included 107 patients.The GAC was applied in58%;79.4% underwent X-rays of the extremities. Soft tissue debridement was performed in all patients within 24 hours.The prophylactic antibiotic was administered within 3 hours in75.7%; Soft tissue coverage was performed within 72 hours for GAC IIIA in44% and within seven days for GAC IIIB-C in16.2%.The rate of IC was higher after delayed closure in GAC IIIA.The AMP rate was higher after delayed GAC III A and B-C coverage.The occurrence of IC delayed access to definitive care.ConclusionsWe report sub-optimal compliance with GL,due to delayed coverage for any GAC III with an impact on IC rates,delaying definitive treatment,and AMP. The absence of an ortho-plastic team is a major flaw in our center with clinical effects. Future clinical GL should focus on optimal strategies for compliance and standardize the creation of institutional ortho-plastic teams.Multicenter studies are necessary to investigate factors related to poor compliance with GL.References JTraumaAcuteCareSurg2020Feb;88(2):e53-e76.

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