The management of patients suffering from trauma has advanced rapidly over the past 10 years and it is now accepted that patients with open fractures are best treated jointly by orthopaedic and plastic surgeons working together in specialist and major trauma centres. The importance of this collaborative working is reflected in the Quality Statement published by the National Institute for Health and Care Excellence (NICE) in March 2018 (NICE Quality Standard QS166 for Trauma, https://www.nice.org.uk/guidance/qs166/chapter/Quality-statement-3-Open-fractures#quality-statement-3), which states:
People with open fractures of long bones, the hindfoot or midfoot have fixation and definitive soft tissue coverage within 72 hours of the injury if this cannot be performed at the same time as the debridement.
NICE further recognised that for collaborative management to be attainable requires not just the desire to collaborate but the appropriate infrastructure to be in place. The NICE Complex Fracture Guidelines 2016 defined an orthoplastic centre, which has the following key characteristics:
◆ A combined service of orthopaedic and plastic surgery consultants.
◆ Sufficient combined operating lists with consultants from both specialties to meet the standards for timely management of open fractures.
◆ Scheduled, combined review clinics for severe open fractures.
◆ Specialist nursing teams able to care for both fractures and flaps.
In addition, an effective orthoplastic service will also:
◆ Submit data on each patient to the Trauma Audit and Research Network (TARN).
◆ Hold regular clinical audit meetings with both orthopaedic and plastic surgeons present.
For the past 20 years the British Orthopaedic Association (BOA) and British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) have worked together to produce professional guidelines for the management of severe open tibial fractures, promoting a joint ‘orthoplastics’ approach to care, and this has led to the development of clinical audit standards that have been used both nationally and internationally to improve the care of trauma patients. This book reflects the new NICE guidance and builds on previous work to provide a practical guide based on the available evidence and experience of the authors. The guide covers the entire patient pathway from emergency management through to definitive care and then rehabilitation and psychosocial care. It is essential reading for all orthopaedic and plastic surgeons who manage trauma.
Professor Chris Moran
National Clinical Director for Trauma NHS-England