Orthoplastic Team
Implementation of an orthoplastic team may decrease length of stay, deep infection, and additional operations to bone and also may help improve time to wound healing and time to union.
Prevention of Surgical Site Infection After Major Extremity Trauma (2022)
This guideline was produced in collaboration with METRC, with funding provided by the US Department of Defense. Endorsed by: ASES, POSNA, AOFAS, IDSA, OTA

Rationale

Two low quality studies (Vandenberg 2017, Boriani 2017) investigated implementation of an orthoplastic team when treating patients with open tibial fractures. Boriani (2017) was a multi-center prospective study assessing the effect of an integrated orthoplastic unit compared to an independent orthopaedic only approach. After 12 months follow-up, the authors reported the orthoplastic approach resulted in significantly less cases of deep infection/osteomyelitis than the orthopaedic only approach. Furthermore, the orthoplastic approach had significantly better results in all other assessed outcomes, including bone healing, length of stay, and soft-tissue healing. However, the study as designed was simply not a valid comparison of an integrated orthoplastic unit to an independent orthopaedic unit; this was instead a comparison to a unit without any plastic surgery or microvascular support of any kind. Boriani (2017) presented no data demonstrating their multidisciplinary unit achieved better outcomes compared to results obtained prior to its introduction. Vandenberg (2017) was a smaller, single-center study determining patient outcomes after introducing a combined/integrated orthopaedic trauma and plastics microsurgical team to their institution. They compared a pre-integration cohort to a post-integration cohort to measure changes in post-operative complications. The authors observed no difference in infection or other complication outcomes between the two groups. Although Vandenberg (2017) found no difference between the integrated orthoplastic unit and independent orthopaedic only approaches, Boriani (2017) with a larger sample size and a multi-center design, suggests that the implementation of an orthoplastic approach may improve patient outcomes in certain health care settings. Nevertheless, plastic surgical or microvascular technical expertise are an essential component of contemporary wound management and open fracture treatment, regardless of whether it is integrated into a formal multi-disciplinary unit.

Cost Effectiveness/Resource Utilization

Within major trauma centers that already provide expert orthopaedic services and have the capacity for sophisticated wound care using plastic surgery and microvascular techniques, there is some potential to reduce costs by optimizing resource allocation. Limited data suggests more timely surgery and earlier wound closure can reduce the length of stay and number of surgical procedures required. Coordinating the delivery of care through an integrated orthoplastic unit will probably provide a more cost-effective and efficient model of care for open major extremity trauma.

Acceptability

While gathering momentum in hospitals throughout the United Kingdom and Europe, it remains to be seen whether this practice gains acceptance more widely in North America. Although conceptually attractive, its benefit has not yet been convincingly demonstrated. Nevertheless, there is at this time no reason to believe this approach would encounter resistance if it were to be introduced.

Feasibility

Major trauma centers in contemporary healthcare systems already have the capacity to deliver expert orthopaedic care and use state of the art skeletal stabilization methods, as well as providing sophisticated wound care using plastic surgery and advanced microvascular techniques. Coordinating the delivery of this care as an orthoplastic unit, to optimize resource allocation and ultimately enhance patient outcomes, is not only very feasible, but also a laudable goal that could ultimately improve care. However, in those healthcare systems without plastic surgical support for wound coverage following open major extremity trauma, this remains an unrealistic expectation.

Future Research

The role of an integrated orthoplastic unit, with shared decision-making as part of a coordinated strategy, has simply not been adequately evaluated to date. At this time, it is not possible to make a recommendation here with any confidence regarding the potential benefit of multi-disciplinary management of major extremity trauma. Further prospective evaluation of this approach at the same institution both before and after implementation of an orthoplastic team would be of great interest.