Practical Guidelines for the Orthoplastic Approach: A Systematic Review of High-Quality Evidence for the Lower Extremity Trauma

Abstract

Abstract Background: The aim of this review is to produce a high-quality evidence-based protocol for lower extremity traumas, from the immediate wound management to the final reconstruction, summarizing only the high-quality evidence present in literature. Methods: Pubmed, EMBASE and Cochrane libraries were searched for high-quality studies on the orthoplastic approach for lower limb traumas. Search terms were: “trauma” OR “fracture”, “lower extremity” OR “lower limb” OR “leg” OR “tibia” OR “fibula”, “bone infection” OR “osteomyelitis”, “orthoplastic”, “flap” OR “reconstruction”. Inclusion criteria were cohort study, clinical trial, randomized controlled trial, systematic review or meta-analysis; lower extremity open fractures; detailed reports about patient and treatment; defined follow-up and outcomes. The PRISMA statement was followed. Exclusion criteria were diabetic foot, open fractures of the foot, not clearly defined protocol of treatment, case series and case reports. Three independent authors (MAB, GC and RC) searched the literature and extracted data from studies, based on eligibility criteria. Results: We summarized the available evidence in three main time settings: fracture management in the emergency department; optimal management during the first 24 hours; optimal management and final goal within 72 hours. Conclusions: The optimal goal is to achieve bone fixation and definitive coverage in a single surgery within 24 hours from injury. If not possible, the main purpose of the orthoplastic team should be the definitive coverage within 72 hours. A dedicated operating room and efficient referral to a specialized trauma center are paramount to reduce infection and costs. Level of evidence: Level II, therapeutic study