An evaluation of the management of severe open tibial fractures in the United Kingdom's major trauma centres.

AIM: To evaluate the management of patients with severe open tibial fractures at major trauma centres (MTCs) in the UK with respect to BOAST 4 guidelines.

METHODS: Data collected by the Trauma and Audit Research Network (TARN) for all severe open tibial fractures treated at the 23 adult MTCs were evaluated. Key performance indicators (KPIs) included MTC admission under orthoplastics, administration of antibiotics within three hours of injury, initial debridement within 24 h and definitive fixation and soft tissue coverage within 72 h. Outcomes included 30-day infection rate, amputation rate and mortality rate. A score was calculated according to overall attainment of KPIs, and correlated to outcomes.

RESULTS: From 2014 to 2020, 3359 adults with Gustilo-Anderson (GA) IIIB and/or IIIC fractures were admitted to MTCs. Male to female ratio was 2:1 with a mean age of 43 and 65 years respectively. There was a negative correlation between KPI score and mortality rate (r=-0.4929, p = 0.0169). Direct admission to an MTC was positively correlated with receipt of antibiotics within three hours (r = 0.5452, p = 0.0070). Joint orthoplastic plans were documented in 89 % of patients (MTC range 30-95 %). Soft tissue cover was achieved within 72 h for 48 % (MTC range 5.23-89.39 %). Patients over 65 were significantly more likely to have a delay to MTC admission and prophylactic antibiotic administration. Mortality rate in this group was 6% vs 2 % in those under 65. The older cohort were twice as likely to require an amputation.

CONCLUSION: This is the largest cohort of open tibial injuries managed in the UK with wide variation in practice between centres demonstrated and better adherence to BOAST guidelines linked to reduced mortality in those aged 65 and over. The older cohort of patients also had higher rates of infection and amputation. It is unclear whether these poor outcomes are due to the pre-morbid physiological status of the patient or non-compliance to Standards. We present these data to highlight the need for improved adherence to Standards - the adoption of a scoring system provides a simple way to evidence this.