Combined Orthopedic and Plastic Surgical Strategies in Management of Gustilo Grade Iii Open Fractures

Abstract

Objective: To compare functional outcomes, infection rates, and limb salvage rates of integrated ortho-plastic treatment of Gustilo-Anderson Grade III open fractures in a trauma sample.

Materials and Methods: This is a prospective cohort study whereby 187 patients with Gustilo Grade III (GG-III) open fractures (III-A: n=42, III-B: n=118, III-C: n=27) were enrolled in the study to have been treated using a specific orthoplastic service in tertiary care centers in Pakistan during the period between January 2022-December 2024. The main outcomes were a deep infection rate, the time of full coverage of soft tissue, bony fusion, and the salvage of limbs. Secondary outcomes involved functional assessment by the use of Lower Extremity Functional Scale (LEFS) and Disabilities of the Arm, Shoulder and Hand (DASH) scores.

Results: The average time to conclusive soft tissue cover was 5.2 +- 2.8 days. Deep infection was registered in 14.4% of the patients (27/187) which is significantly lower than the historical controls (32.6%, p=0.001). Salvage of the limbs was done in 93.6% (175/187) of the cases. Patients who were covered within 72 hours had significantly lower infection rates (8.7% vs. 24.3%, p=0.003) and had a faster bony union (18.4 +- 4.2 vs. 24.7 +- 5.8 weeks, p<0.001). In 68.4% III-B/III-C injuries the survival rate was 94.2% by using free flaps. Multivariate regression found significant predictors of deep infection of delayed coverage (>7 days), vascular injury and diabetes (p<0.05).

Conclusion: Orthoplastic management is an important intervention in resource-limited Pakistani hospitals that enhances limb salvage and decreases deep infection in Gustilo Grade III fractures. New soft tissue coverage during the first 72 hours becomes the most significant variable that can be modified and shaped. Formation of orthoplastic teams is a cost-efficient approach to complicated limb trauma in developing countries.