New Trauma Study: the ‘Defined Approach’ Rules

Researchers from the University of California Keck School of Medicine in Los Angeles and the University of Arizona College of Medicine in Phoenix have found that a “defined approach” to debriding open tibia fractures is safe and can reduce the need for flap coverage.

Their work, “Use of a Defined Surgical Approach for the Debridement of Open Tibia Fractures,” was published in the January 18, 2018 edition of the Journal of Orthopaedic Trauma.

A co-author on the study, Geoffrey S. Marecek, M.D., assistant professor of Clinical Orthopaedic Surgery at Keck, told OTW, “Open tibia fractures are challenging injuries. So much thought needs to go into each step of treatment from the time the patient arrives in the emergency department.”

“Some of my fellowship mentors taught me to use a ‘defined approach’ when the traumatic wound was in a challenging location like the medial tibia, or when extending it might compromise the vascularity of the skin edges. It’s a thoughtful approach, but medicine and orthopedics is filled with well-intentioned ideas that didn’t work out well. We wanted to verify that it was a safe and effective approach to the debridement of open tibia fractures.”

“In order to try to get a fair comparison we excluded patients who had an OTA [Orthopaedic Trauma Association] Open Fracture Classification skin score of 3. That subset of patients typically goes on to flap coverage and a ‘defined surgical approach’ would not be useful for them.”

“Patients who had debridement through a ‘defined approach’ did not require flap coverage, compared to 19% of patients who had extension of the traumatic wound.”

“Undoubtedly this is partially due to surgeons selecting what they felt was the appropriate treatment. Perhaps as importantly, the rates of infection and unplanned reoperation were similar in both groups, suggesting that this approach is safe and effective.”

“Surgeons should ensure they do a thorough debridement, regardless of what technique they use. That being said, a thoughtful approach to making skin incisions may help some subset of patents avoid a flap.”

“I think the importance of thorough surgical debridement cannot be overstated. It doesn’t seem to matter if it’s done through extension of the traumatic wound or a defined interval—just be sure to expose the entire zone of injury and remove all nonviable tissue and debris. This will hopefully add one more option when surgeons are treating these difficult injuries.”