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Management of soft-tissue coverage of open tibia fractures in Latin America: Techniques, timing, and resources

  • Madeline C. MacKechnie
    Affiliations
    University of California, San Francisco, Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, Zuckerberg San Francisco General Hospital, 2550 23rd St, Building 9, 2nd Fl, San Francisco, CA, 94110, United States of America
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  • Michael J. Flores
    Affiliations
    University of California, San Francisco, Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, Zuckerberg San Francisco General Hospital, 2550 23rd St, Building 9, 2nd Fl, San Francisco, CA, 94110, United States of America
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  • Vincenzo Giordano
    Affiliations
    Serviço de Ortopedia e Traumatologia Prof Nova Monteiro, Hospital Municipal Miguel Couto, Avenida Bartolomeu Mitre, 1080, Rio de Janeiro, 22793-260, Brazil
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  • Michael J. Terry
    Affiliations
    University of California, San Francisco, Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, Zuckerberg San Francisco General Hospital, 2550 23rd St, Building 9, 2nd Fl, San Francisco, CA, 94110, United States of America
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  • Mario Garuz
    Affiliations
    Hospital Santo Tomás, Calle 37 Este, Panamá, Panama
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  • Nicolas Lee
    Affiliations
    University of California, San Francisco, Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, Zuckerberg San Francisco General Hospital, 2550 23rd St, Building 9, 2nd Fl, San Francisco, CA, 94110, United States of America
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  • Luis G. Padilla Rojas
    Affiliations
    Federación Mexicana de Colegios de Ortopedia y Traumatología A.C, Puerta de Hierro Hospital, Avenida Empresarios 150, Zapopan, Jalisco, 45116, Mexico
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  • Michael A. MacKechnie
    Affiliations
    Director of Sports Medicine, Department of Orthopaedic Surgery, Cleveland Clinic Martin Health, 200 Hospital Avenue, Stuart, Florida, 34994, United States of America
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  • Fernando Bidolegui
    Affiliations
    Servicio de Ortopedia y Traumatología, Hospital Sirio Libanes, Campana 4658, C1419, Buenos Aires, Argentina
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  • Kelsey Brown
    Affiliations
    University of California, San Francisco, Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, Zuckerberg San Francisco General Hospital, 2550 23rd St, Building 9, 2nd Fl, San Francisco, CA, 94110, United States of America
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  • Jose Eduardo Quintero
    Affiliations
    Fracturas y Fracturas, Carrera 12 Bis #9-22, Pereira-Risaralda, Colombia
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  • Anthony Ding
    Affiliations
    University of California, San Francisco, Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, Zuckerberg San Francisco General Hospital, 2550 23rd St, Building 9, 2nd Fl, San Francisco, CA, 94110, United States of America
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  • Carlos G. Sanchez Valenciano
    Affiliations
    Centro Médico de Caracas, Avenida Eraso, Plaza El Estanque Urb, Caracas, 1011, Venezuela
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  • Horacio Tabares Neyra
    Affiliations
    Centro de Investigaciones en Longevidad, Envejecimiento y Salud (CITED), Sociedad Cubana de Ortopedia y Traumatologia, Calle G y 27, Vedado GP, 10400, La Habana, Cuba
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  • Julio Segovia
    Affiliations
    Instituto de Prevision Social, Hospital Central, Avenida Sacramento y Dr Manuel Peña
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  • Dino Aguilar
    Affiliations
    Centro de Ortopedia y Traumatología, Hospital Vivian Pellas, Managua, PO Box 2261, Nicaragua
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  • Esther MM van Lieshout
    Affiliations
    Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands
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  • Michael HJ Verhofstad
    Affiliations
    Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands
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  • Theodore Miclau
    Correspondence
    Corresponding author.
    Affiliations
    University of California, San Francisco, Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, Zuckerberg San Francisco General Hospital, 2550 23rd St, Building 9, 2nd Fl, San Francisco, CA, 94110, United States of America
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Open AccessPublished:January 18, 2022DOI:https://doi.org/10.1016/j.injury.2022.01.027

      Highlights

      • Surgeon-respondents in HICs and MICs in Latin America report differences in access to plastic surgeons and timing to definitive coverage of open tibia fractures.
      • In HICs, surgeons treat lower extremity proximal third, middle third, and distal third defects more commonly with free flaps. Surgeons in MICs treat these injuries more frequently with other methods, including fasciocutaneous flaps, local muscle flaps, or direct wound care.
      • Most orthopaedic surgeons reported limited access to all necessary soft-tissue surgical resources and tools, except Negative Pressure Wound Therapy (NPWT or Wound VAC).
      • Most orthopaedic surgeons in Latin America have not received soft-tissue flap coverage, skin grafting, or wound management training. The study’s findings demonstrate a strong interest in additional training.

      Abstract

      Purpose

      This study examined soft-tissue coverage techniques of open tibia fractures, described soft-tissue treatment patterns across income groups, and determined resource accessibility and availability in Latin America.

      Methods

      A 36-question survey was distributed to orthopaedic surgeons in Latin America through two networks: national orthopaedic societies and the Asociación de Cirujanos Traumatólogos de las Américas (ACTUAR). Demographic information was collected, and responses were stratified by income groups: high-income countries (HICs) and middle-income countries (MICs).

      Results

      The survey was completed by 469 orthopaedic surgeons, representing 19 countries in Latin America (2 HICs and 17 MICs). Most respondents were male (89%), completed residency training (96%), and were fellowship-trained (71%). Only 44% of the respondents had received soft-tissue training. Respondents (77%) reported a strong interest in attending a soft-tissue training course. Plastic surgeons were more commonly the primary providers for Gustilo Anderson (GA) Type IIIB injuries in HICs than in MICs (100% vs. 47%, p<0.01) and plastic surgeons were more available (<24 h of patient presentation to the hospital) in HICs than MICs (63% vs. 26%, p = 0.05), demonstrating statistically significant differences. In addition, respondents in HICs performed free flaps more commonly than in MICs for proximal third (55% vs. 10%, p<0.01), middle third (36% vs. 9%, p = 0.02), and distal third (55% vs. 10%, p<0.01) lower extremity wounds. Negative Pressure Wound Therapy (NPWT or Wound VAC) was the only resource available to more than half of the respondents. Though not statistically significant, surgeons reported having more access to plastic surgeons at their institutions in HICs than MICs (91% vs. 62%, p = 0.12) and performed microsurgical flaps more commonly at their respective institutions (73% vs. 42%, p = 0.06).

      Conclusions

      The study demonstrated that most orthopaedic surgeons in Latin America have received no soft-tissue training, HICs and MICs have differences in access to plastic surgeons and expectations for flap type and timing to definitive coverage, and most respondents had limited access to necessary soft-tissue surgical resources. Further investigation into differences in the clinical outcomes related to soft-tissue coverage methods and protocols can provide additional insight into the importance of timing and access to specialists.

      Keywords

      Introduction

      The burden of musculoskeletal disease poses a significant global health challenge, with low-and middle-income countries (LMICs) being particularly affected, resulting in approximately 90% of trauma-related deaths worldwide [
      • Mock C.N.
      The global burden of musculoskeletal injuries: challenges and solutions.
      ,
      • Moroz P.J.
      • Spiegel D.A.
      The World Health Organization's action plan on the road traffic injury pandemic: is there any action for orthopaedic trauma surgeons?.
      ,
      • Hofman K.
      • Primack A.
      • Keusch G.
      • Hyrnkow S.
      Addressing the growing burden of trauma and injury in low-and middle-income countries.
      ]. Open tibial shaft fractures are one of the most frequently reported traumatic injuries, and are associated with high rates of infection, nonunion, and malunion [
      • Mock C.N.
      The global burden of musculoskeletal injuries: challenges and solutions.
      ]. Road traffic accidents have contributed to the rise in the incidence of open tibia fractures, which has led to over 50,000 open fractures per year in some Latin American countries, with complication rates reaching as high as 20% [
      • Fraser B.
      Traffic accidents scar Latin America's roads.
      ,
      • Orihuela-Fuchs V.A.
      • Fuentes-Figueroa S.
      Infection rate in open fractures adjusted for the degree of exposure.
      ].
      Due to the high-velocity trauma associated with many open tibia fractures, these injuries are often complicated by soft-tissue damage, which can be exacerbated by poor and untimely wound coverage that can lead to further complications including infection, amputation, and death [
      • Gosselin R.
      Injuries: the neglected burden in developing countries.
      ,
      • Carey J.N.
      • Caldwell A.M.
      • Coughlin R.R.
      • Hansen S.
      Building orthopaedic trauma capacity: IGOT international SMART course.
      ]. In high-income countries (HICs), these soft-tissue interventions are often delegated to the expertise of plastic surgeons. However, in LMICs there is a dearth of plastic surgeons available to treat soft-tissue injuries, and therefore these wounds are managed by orthopaedic surgeons or other healthcare providers who often lack sufficient training [
      • Townley W.A.
      • Nguyen D.Q.A.
      • Rooker J.C.
      • Dickson J.K.
      • Goroszeniuk D.Z.
      • Khan M.S.
      • et al.
      Management of open tibial fractures - a regional experience.
      ].
      Multiple measures have been suggested to address this gap in the management of soft-tissue injury following open tibia fractures, such as standard of care protocols, academic partnerships, and international soft-tissue coverage training courses [
      • Wu H.H.
      • Kushal P.R.
      • Caldwell A.M.
      • Coughlin R.R.
      • Hansen S.L.
      • Carey J.N.
      Surgical management and reconstruction training (SMART) course for international orthopedic surgeons.
      ]. However, these measures are not well documented across Latin America. In a recent study, it was reported that few middle-income countries (MICs) had standard of care protocols or guidelines in place for open fracture treatment in Latin America [
      • Miclau T.
      • Hoogervorst P.
      • Shearer D.W.
      • El Naga A.
      • Working Z.
      • Martin C.
      • et al.
      Current status of musculoskeletal trauma care systems worldwide.
      ,
      • Albright P.D.
      • MacKechnie M.C.
      • Jackson J.H.
      • Chopra A.
      • Holler J.T.
      • Flores Biard A.
      • et al.
      Knowledge deficits and barriers to performing soft-tissue coverage procedures: an analysis of participants in an orthopaedic surgical skills training course in Mexico.
      ]. The current paucity of literature on soft-tissue management for open traumatic wounds in this region poses a significant challenge in identifying needs, comparing treatment strategies, and determining effective solutions across a diverse economic landscape. Thus, the purpose of this study was to examine soft-tissue coverage techniques of open tibia fractures, describe soft-tissue treatment patterns across income groups, and determine resource accessibility and availability in Latin America.

      Methods

      A cross-sectional, multi-national survey was conducted between January to July 2021 to identify orthopaedic surgeons’ standards of soft-tissue wound care for open tibia fractures and determine areas for further study and improvement. Inclusion criteria included orthopaedic surgeons that treat traumatic injuries in Latin America. There were no exclusion criteria.
      The survey consisted of 36 questions and was designed based on a literature review, and further assessed by two fellowship-trained orthopaedic and plastic surgeons (NL and MT). It was then translated into Spanish and Portuguese by three bilingual Latin American orthopaedic surgeons using the back translation method (MG, CSV, and VG) [
      • Brislin R.W.
      Back-translation for cross-cultural research.
      ]. Demographic information was collected, including country of practice, years of experience, subspeciality training, practice environment, and soft-tissue training level. In addition, a needs assessment gauged orthopaedic surgeons’ access and availability to various wound care and microsurgical operating room resources and instruments. To optimize the number of survey responses across the region, the survey was distributed through two networks: national orthopaedic societies across Latin America and the Asociación de Cirujanos Traumatólogos de las Américas (ACTUAR) [
      • Miclau T.
      • MacKechnie M.C.
      • Shearer D.W.
      • ACTUAR Group
      Asociación de Cirujanos Traumatólogos de las Américas: development of a Latin American research consortium.
      ], an academic consortium of Latin American orthopaedic trauma surgeons interested in collaborating on clinically-important and regionally-relevant investigative work.
      In addition, survey responses were stratified by income groups (HICs and MICs) categorized by the 2021 World Bank Country and Lending Groups [] data to further evaluate patterns and differences in soft-tissue management of open tibia fractures. Analysis was performed utilizing Fisher's exact tests with p ≤ 0.05 as the significance level with STATA SE version 17 software (StataCorp). The survey was distributed electronically through REDCap (Research Electronic Data Capture) and the study was deemed exempt from review by the University of California, San Francisco Institutional Review Board.

      Results

      The survey was completed by 469 orthopaedic surgeons. Respondents represented 19 countries in Latin America (Fig. 1), two of which were designated as HICs and 17 as MICs. Most survey respondents were male (89%), completed residency training (96%), and were fellowship-trained (71%). The majority of orthopaedic surgeons practiced in an urban environment (94%), most commonly in a public-private dual practice setting (45%). Most survey respondents (59%) personally treated 20 or fewer open tibia fractures each year. Overall, only 44% of the survey respondents had received soft-tissue training, obtained through surgical mentorship (53%) or formal training courses (47%). Seventy-seven percent of respondents reported a strong interest in attending a soft-tissue training course (Table 1).
      Fig. 1
      Fig. 1Map of survey respondents by country and identification of income groups (HICs and MICs) as determined by the 2021 World Bank Country and Lending Groups data.
      Table 1Demographic Data of Survey Respondents.
      Total n (%)
      469 (100)
      Male416 (88.7)
      Years in practice
        0-569 (14.7)
        6-1088 (18.8)
       11-1570 (14.9)
       16-2067 (14.3)
       >21175 (37.3)
      Residency training448 (95.7)
      Fellowship in musculoskeletal trauma333 (71.3)
      Practice setting
       Public-Private (Combination)212 (45.2)
       Public hospital126 (26.9)
       Private practice102 (21.7)
       Academic practice28 (6)
      Practice location
       Urban439 (93.6)
       Suburban25 (5.3)
       Rural5 (1.1)
      Supervise Residents285 (60.8)
      Received soft-tissue training
       Yes207 (44.2)
       No262 (55.8)
      Type of soft-tissue training
        Surgical mentorship108 (52.7)
        Formal training course97 (47.3)
      Number of open tibia fractures personally treated each year
       0-10173 (38.1)
       11-2093 (20.5)
       21-3061 (13.4)
       31-4028 (6.2)
       41-5034 (7.5)
       51-6015 (3.3)
       61-708 (1.8)
       71-803 (1)
       81-901 (.2)
       91-10016 (3.1)
       >1008 (1.8)
      *Various data not reported by all respondents

      Comparison of soft-tissue management between income groups

      The majority of respondents from both HICs (55%) and MICs (56%) had not received any form of soft-tissue coverage training. Average timing between injury and presentation to the hospital was most commonly reported within 6 h among HICs and MICs (82% vs. 60%, p = 0.63), demonstrating no significant difference between income groups. Similarly, timing between presentation to the hospital and the operating room was most commonly reported within 6 h for both HICs and MICs (64% vs. 63%, p = 0.69). Plastic surgeons were identified as the primary providers for soft-tissue coverage for Gustilo Anderson (GA) Type IIIB fractures in HICs significantly more often than in MICs (100% vs. 47%, p<0.01). While not statistically significant, respondents in HICs had access to plastic surgeons more commonly than in MICs (91% vs. 62%, p = 0.12). Additionally, orthopaedic surgeons in HICs reported increased availability to soft-tissue specialists within 24 h of patient presentation to the hospital in comparison to MICs (63% vs. 26%, p = 0.05). Definitive soft-tissue coverage was performed more commonly within seven days in HICs than in MICs (60% vs. 49%, p = 0.48) and microsurgical flaps were used more frequently at institutions in HICs than in MICs (73% vs. 42%, p = 0.06), although these differences were not statistically (Table 2).
      Table 2Comparison of Soft-Tissue Management in Open Tibia Fractures between Income Groups.
      High-Income Countries n (%)Middle-Income Countries n (%)P Value
      Total11 (100)458 (100)
      Average time between injury and patient presentation to hospital
       <6 hours9 (81.8)274 (60)0.63
        24 hours2 (18.2)173 (37.9)
        48 hours0 (0)10 (2.1)
      Average time between patient presentation and the OR for fracture stabilization
       <6 hours7 (63.7)281 (62.5)0.69
        24 hours4 (36.4)142 (31.6)
        48 hours027 (6)
      Average time to provide soft-tissue coverage after presentation of injury
       <7 days6 (60)194 (48.7)0.48
       >7 days4 (40)204 (51.3)
      Primary soft-tissue coverage provider for GA-IIIB fractures
       Plastic surgeon11 (100)213 (46.9)<0.01
       Orthopaedic surgeon0 (0)205 (45.1)
       No available surgeon036 (7.9)
      How often is a plastic surgeon available at your institution?
         Always10 (90.9)282 (61.7)0.12
        Sometimes1 (9.1)69 (15.1)
        Never0 (0)106 (23.2)
      How available is your soft-tissue coverage provider?
        Inpatient (initial hospitalization) <24 hours7 (63.6)118 (26.2)0.05
        Inpatient (initial hospitalization) <1-3 days3 (27.3)134 (29.7)
        Inpatient (initial hospitalization) >3 days1 (9.1)139 (30.8)
        Transfer or outpatient follow-up only060 (13.3)
      Are microsurgical flaps performed at your institution?
        Yes8 (72.7)192 (42.1)0.06
        No3 (27.3)264 (57.9)
      Have you received soft-tissue coverage training?
       Yes5 (45.4)202 (44.2)1
       No6 (54.5)255 (55.8)
      Are you interested in attending a soft-tissue training course?
        Very interested7 (63.6)353 (77.2)0.13
        Moderately interested2 (18.2)82 (18)
        Not interested2 (18.2)22 (4.8)
      *Various data not reported by all respondents
      *Tests of significance completed with Fisher's exact test (p ≤ 0.05)
      2021 World Bank Country and Lending Groups
      Preference for soft-tissue management of lower extremity wounds following open tibia fractures were treated significantly differently between income groups. Respondents from HICs performed free flaps more often than in MICs for proximal third (55% vs. 10%, p<0.01), middle third (36% vs. 9%, p = 0.02), and distal third lower extremity defects (55% vs. 10%, p<0.01) (Fig. 2).
      Fig. 2
      Fig. 2Survey respondents’ preference for treatment of lower extremity proximal, middle, and distal third defects stratified by income groups (HICs vs. MICs).

      Wound care and operating room resources

      The majority of participants (70%) had access to a Negative Pressure Wound Therapy (NPWT or Wound VAC). Less than half of the participants had access to the following items: magnifying loupes (43%), wall suction outside the OR (41%), manual blade for harvesting skin grafts (Humby blade) (40%), power dermatome (39%), microsurgery instruments (31%), operating microscopes (28%), handheld doppler (22%), and skin graft mesher (19%). Participants reported access to multiple types of dressings, including saline-moistened sterile gauze dressings (76%), occlusive dressings (71%), and anti-microbial dressings (62%). Regarding anti-microbial dressings for wound care, antibiotic ointments were the most commonly accessible (71%), followed by Silvadene (67%), Betadine/Iodine-based dressings (56%), Dakins/Dilute bleach (22%), honey-based dressings (17%), and other supplies (13%) (Table 3).
      Table 3Wound Care and Operating Room Resources.
      Total n (%)
      469 (100)
      Which OR resources do you consistently have access to?
      Participants were able to select multiple responses
       Negative Pressure Wound Therapy (NPWT or Wound VAC)328 (69.8)
       Magnifying loupes201 (42.8)
       Wall suction outside the OR192 (40.8)
       Manual blade for harvesting skin grafts (e.g Humby blade)189 (40.2)
       Power dermatome184 (39.1)
       Microsurgery instruments147 (31.3)
       Operating microscopes130 (27.7)
        Handheld doppler103 (21.9)
        Skin graft mesher91 (19.4)
      Which dressings do you consistently have access to?
      Participants were able to select multiple responses
        Saline-moistened sterile gauze dressing355 (75.5)
        Occlusive dressing332 (70.6)
        Anti-microbial dressing289 (61.5)
      What type of anti-microbial dressings do you have access to?
      Participants were able to select multiple responses
       Antibiotic ointments333 (70.8)
        Silvadene315 (67)
       Betadine/Iodine-based dressing262 (55.7)
        Dakins/Dilute bleach102 (21.7)
       Honey-based dressing82 (17.4)
        Other61 (12.9)
      What type of microsurgical instruments are available at your institution?
      Participants were able to select multiple responses
        Not sure270 (57.4)
        8-0 suture (nylon, proline)183 (38.9)
        9-0 suture131 (27.9)
        Micro needle-holder129 (27.4)
        Curved micro dissecting scissors126 (26.8)
        Straight micro scissors122 (26)
        Micro-pickups112 (23.8)
        10-0 suture107 (22.8)
        Micro vessel dilator99 (21.1)
       *Various data not reported by all respondents
      + Participants were able to select multiple responses

      Discussion

      Determining the ideal protocol for open fracture treatment in Latin America is considered one of the top health research priorities in musculoskeletal care [
      • Roberts H.J.
      • MacKechnie M.C.
      • Shearer D.W.
      • Segovia Altieri J.
      • de la Huerta F.
      • Rio M.W.
      • et al.
      Orthopaedic trauma research priorities in Latin America: developing consensus through a modified delphi.
      ], with timeliness and method of treatment being critical to the function and outcome of these injuries [
      • Cross III, W.
      • Swiontkowski M.F.
      Treatment principles in the management of open fractures.
      ,
      • Hertel R.
      • Lambert S.M.
      • Muller S.
      • Ballmer F.T.
      • Ganz R.
      On the timing of soft-tissue reconstruction for open fractures of the lower leg.
      ]. This study adds to recent research on open tibia fracture management in Latin America by identifying soft-tissue coverage techniques, timing, and available resources across HICs and MICs.
      Countries in Latin America have large disparities in healthcare expenditures in relation to their Gross Domestic Product (GDP) per capita, ranging from 3.5%−11.2%, resembling similar percentages to those observed in low, middle, and high-income countries [

      Statista. Healthcare expenditure as percentage of GDP in Latin America and the Caribbean in 2019, by country. Accessed October 26, 2021. https://www.statista.com/statistics/899278/latin-america-health-expenditure-share-gdp-country/.

      ,]. Socioeconomic factors, as well as diverse national healthcare systems in this region, contribute to the uneven distribution of musculoskeletal trauma care across centers, disproportionately impacting those in resource-limited settings [
      • Gosselin R.
      Injuries: the neglected burden in developing countries.
      ,
      • Padilla Rojas L.G.
      • Lopez Cervantes R.E.
      • Perez Atanasio J.M.
      • Martinez Sanchez M.
      • Gomez Acevedo J.M.
      • Kojima K.E
      Latin America trauma systems - Mexico and Brazil.
      ,
      • Rossiter N.D.
      Trauma - the forgotten pandemic?.
      ,
      • Arreola-Risa C.
      • Mock C.N.
      • Lojero-Wheatly L.
      • de la Cruz O.
      • Garcia C.
      • Canavati-Ayub F.
      • et al.
      Low-cost improvements in prehospital trauma care in a Latin American City.
      ,
      • Arreola-Risa C.
      • Mock C.
      • Vega Rivera F.
      • Romero Hicks E.
      • Guzmán Solana F.
      • Porras Ramírez G.
      • et al.
      Evaluating trauma care capabilities in Mexico with the World Health Organization's guidelines for essential trauma care.
      ,
      • Mock C.
      • Joshipura M.
      • Goosen J.
      • Maier R.
      Overview of the essential trauma care project.
      ].
      In this study, plastic surgeons in HICs were more commonly cited as the primary providers responsible for performing soft-tissue coverage than in MICs. Of note, a small percentage of respondents reported no access to orthopaedic or plastic surgeons to provide soft-tissue coverage for GA Type IIIB open tibia fractures, likely requiring the patient to be referred to a more well-equipped hospital with specialists and resources. Plastic surgeons were also reportedly more accessible in HICs than MICs, consistent with prior literature citing lack of access to specialists as a major barrier to performing wound coverage in LMICs [
      • Gosselin R.
      Injuries: the neglected burden in developing countries.
      ,
      • Albright P.D.
      • MacKechnie M.C.
      • Jackson J.H.
      • Chopra A.
      • Holler J.T.
      • Flores Biard A.
      • et al.
      Knowledge deficits and barriers to performing soft-tissue coverage procedures: an analysis of participants in an orthopaedic surgical skills training course in Mexico.
      ,
      • Albright P.D.
      • MacKechnie M.C.
      • Roberts H.J.
      • Shearer D.W.
      • Padilla Rojas L.G.
      • Quintero J.E.
      • et al.
      Open tibial shaft fractures: treatment patterns in Latin America.
      ,
      • Grimes C.E.
      • Bowman K.G.
      • Dodgion C.M.
      • Lavy C.B.
      Systematic review of barriers to surgical care in low-income and middle-income countries.
      ,
      • Ngcelwane M.
      Expanding the orthopaedic training programme to improve the management of lower extremity trauma.
      ,
      • Mishra B.
      • Koirala R.
      • Tripathi N.
      • Raj Shrestha K.
      • Adhikary B.
      • Shah S
      Plastic surgery - myths and realities in developing countries: experience from eastern Nepal.
      ]. Indeed, in Latin America, a prior study reported that soft-tissue flaps are not performed in nearly one-third of GA Type IIIB fractures due to these barriers [
      • Albright P.D.
      • MacKechnie M.C.
      • Roberts H.J.
      • Shearer D.W.
      • Padilla Rojas L.G.
      • Quintero J.E.
      • et al.
      Open tibial shaft fractures: treatment patterns in Latin America.
      ]. Although the orthopaedic surgeon-respondents across HICs and MICs in this study received similar levels of soft-tissue training, the greater availability and access to specialist coverage in HICs was associated with timelier definitive treatment (within seven days) than in MICs, supporting the advantages of a combined orthoplastic team. Other barriers that may factor into time to definitive soft-tissue coverage between income groups include individual surgeon expertise, medical cost, implant and equipment availability, hospital resources, and infrastructure [
      • Holler J.T.
      • Albright P.
      • Challa S.
      • Ali S.H.
      • Keys K.
      • et al.
      Barriers to performing soft tissue reconstruction procedures among orthopedic surgeons in low- and middle-income countries: results of a surgical skills training course.
      ].
      Multidisciplinary management between orthopaedic and plastic surgery teams is advantageous for the treatment of severe open tibia fractures, as it is associated with timelier treatment, quicker recovery, and less complications [
      • Naique S.B.
      • Pearse M.
      • Nanchahal J.
      Management of severe open tibial fractures: the need for combined orthopaedic and plastic surgical treatment in specialist centres.
      ,
      • Gopal S.
      • Majumder S.
      • Batchelor A.G.
      • et al.
      Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia.
      ,
      • Kuripla C.
      • Tornetta III, P.
      • Foote C.J.
      • Koh J.
      • Sems A.
      • Shamaa T.
      • et al.
      Timing of flap coverage with respect to definitive fixation in open tibia fractures.
      ,
      • VandenBerg J.
      • Osei D.
      • Boyer M.I.
      • Gardner M.J.
      • Ricci W.M.
      • Spraggs-Hughes A.
      • et al.
      Open tibia shaft fractures and soft-tissue coverage: the effects of management by an orthopaedic trauma/microsurgical team.
      ]. Plastic surgeons play a critical role in trauma centers performing limb-saving flap procedures, skin grafts, and microsurgery. Given these benefits, combined specialty teams are recognized in national open fracture treatment guidelines in Europe and North America [
      The management of skeletal trauma in the United Kingdom.
      ,
      • Orthopaedic Trauma Association
      American College of Surgeons
      Best practices in the management of orthopaedic trauma.
      ,
      • Nanchahal J.
      • Nayagam S.
      • Khan U.
      • Moran C.
      • Barrett S.
      • Sanderson F.
      • et al.
      Standards for the management of open fractures of the lower limb (British association of plastic reconstructive and aesthetic surgeons).
      ]. Yet, many guidelines in Latin America are neither well-described nor standardized across the region [
      • Padilla Rojas L.G.
      • Lopez Cervantes R.E.
      • Perez Atanasio J.M.
      • Martinez Sanchez M.
      • Gomez Acevedo J.M.
      • Kojima K.E
      Latin America trauma systems - Mexico and Brazil.
      ,
      • Albright P.D.
      • MacKechnie M.C.
      • Roberts H.J.
      • Shearer D.W.
      • Padilla Rojas L.G.
      • Quintero J.E.
      • et al.
      Open tibial shaft fractures: treatment patterns in Latin America.
      ]. Using evidence-based standardized guidelines, such as the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) [
      • Nanchahal J.
      • Nayagam S.
      • Khan U.
      • Moran C.
      • Barrett S.
      • Sanderson F.
      • et al.
      Standards for the management of open fractures of the lower limb (British association of plastic reconstructive and aesthetic surgeons).
      ], could help guide the development of regional protocols that include definitive soft-tissue coverage within seven days, “fix and flap” soft-tissue coverage with concomitant definitive fixation, and NPWT as an adjunct to open fracture management, all of which surgeons in HICs and MICs could work towards to improve outcomes and decrease complications [
      • Elniel A.R.
      • Giannoudis P.V.
      Open fractures of the lower extremity: current management and clinical outcomes.
      ]. Some principles of lower extremity management outlined in these guidelines, including wound debridement within 24 h of injury and antibiotic administration within 3 h of injury for GA Type I-III fractures, are already reported as common practice among orthopaedic surgeons in Latin America [
      • Albright P.D.
      • MacKechnie M.C.
      • Roberts H.J.
      • Shearer D.W.
      • Padilla Rojas L.G.
      • Quintero J.E.
      • et al.
      Open tibial shaft fractures: treatment patterns in Latin America.
      ].
      While standard orthopaedic residency training typically does not include soft-tissue flap coverage techniques as part of their core curriculum, this study's findings provide perspective on current training and practices in this region, which can aid in the development of solutions to address treatment gaps. Efforts to train orthopaedic surgeons that acutely manage open tibia fractures with wound defects has been shown to be a cost-effective way of addressing these complex injuries in lesser-resourced settings [
      • Grimes C.E.
      • Henry J.A.
      • Maraka J.
      • Mkandawire N.C.
      • Cotton M.
      Cost-effectiveness of surgery in low-and middle-income countries: a systematic review.
      ,
      • Carlson L.A.
      • Slobogean G.P.
      • Pollak A.N.
      Orthopaedic trauma care in Haiti: a cost-effectiveness analysis of an innovative surgical residency program.
      ]. Specifically, hands-on reconstructive training courses in these environments, led by both orthopaedic and plastic surgeons, can augment surgeons’ knowledge and skill in managing rotational flaps, skin grafts, and wound management [
      • Wu H.H.
      • Kushal P.R.
      • Caldwell A.M.
      • Coughlin R.R.
      • Hansen S.L.
      • Carey J.N.
      Surgical management and reconstruction training (SMART) course for international orthopedic surgeons.
      ,
      • Holler J.T.
      • Albright P.
      • Challa S.
      • Ali S.H.
      • Keys K.
      • et al.
      Barriers to performing soft tissue reconstruction procedures among orthopedic surgeons in low- and middle-income countries: results of a surgical skills training course.
      ,
      • Challa S.
      • Conway D.
      • Hao Hua Wu
      • Bisht R.
      • Sherchan B.
      • Lamichhane A.
      • et al.
      Can a 2-day course teach orthopaedic surgeons rotational flap procedures? An evaluation of data from the Nepal SMART course over 2 years.
      ,
      • Peter N.A.
      • Pandit H.
      • Le G Nduhiu M.
      • Moro E.
      • Lavy C.
      Delivering a sustainable trauma management training programme tailored for low-resource settings in East, Central and Southern Africa countries using a cascading course.
      ,
      • Singh J.
      • Dhillon M.S.
      • Dhatt S.S.
      Single-Stage “Fix and Flap” Gives Good Outcomes in Grade 3B/C Open Tibial fractures: a prospective study.
      ].
      Less than half of the study participants reported having access to various instruments in the operating room, including magnifying loupes, wall suction, Humby blades, and power dermatomes. NPWT was the only resource available to the majority of orthopaedic surgeons. Though previously believed to decrease infection rates of severe open wounds, a 2018 Cochrane review and a large randomized controlled trial showed no clear differences in healing or infection rates in open fractures in comparison to conventional dressings [
      • Iheozor-Ejiofor Z.
      • Newton K.
      • Dumville J.C
      • Costa M.L.
      • Normal G.
      • Bruce J.
      Negative pressure wound therapy for open traumatic wounds.
      ,
      • Costa M.L.
      • Achten J.
      • Bruce J.
      • Tutton E.
      • Petrou S.
      • Lamb S.
      • et al.
      Effect of negative pressure wound therapy versus standard wound management on 12-month disability among adults with severe open fracture of the lower limb: the WOLFF randomized clinical trial.
      ]. While NPWT is widely available in the operating room, this method of wound coverage may not be an adequate substitute to soft-tissue coverage [
      • Coles C.P.
      Open fractures with soft-tissue loss: coverage options and timing of surgery.
      ]. Further, this survey did not distinguish between industry manufactured and improvised NPWT devices, the latter of which is used in some public hospitals in Latin America and has an efficacy that has not been well described. Additional investigation on the differences between NPWT devices would be beneficial. In HICs, surgeons in Latin America were predisposed to treat lower extremity proximal third, middle third, and distal third defects more commonly with free flaps, likely due to the greater access to plastic surgeons at their institutions. Conversely, surgeons in MICs more commonly treated these injuries with various other methods, including fasciocutaneous flaps, local muscle flaps, or direct wound care. While there is evidence to support that free flaps can lead to less wound complications for fractures with high grade osseus injuries [
      • Pollak A.N.
      • McCarthy M.L.
      • Burgess A.R.
      Short-term wound complications after application of flaps for coverage of traumatic soft-tissue defects about the tibia. The Lower Extremity Assessment Project (LEAP) Study Group.
      ], Cho et al. reported no differences in healing or infection rates between fasciocutaenous and muscle flaps, describing both as suitable procedures for wound coverage [
      • Godina M.
      Early microsurgical reconstruction of complex trauma of the extremities.
      ,
      • Parikh P.M.
      • Hall M.M.
      • Attinger C.E.
      • Masden D.L.
      • Steinberg J.S.
      External fixation: indications in lower extremity reconstruction and limb salvage.
      ]. Though the decision for type of flap coverage is dependent on the location and severity of the defect [
      • Elniel A.R.
      • Giannoudis P.V.
      Open fractures of the lower extremity: current management and clinical outcomes.
      ], further examination of the regional differences in soft-tissue treatment selection could help to identify areas of change to improve clinical outcomes.
      This large-scale multi-national study describes orthopaedic surgeons’ soft-tissue coverage techniques of open tibia fractures in Latin America, with the intent to provide insight into region-specific knowledge gaps. Nineteen countries were represented in this study, providing a broad overview of regional treatment patterns and availability of wound care resources. The study demonstrated that most respondents had limited access to necessary soft-tissue coverage surgical tools and resources, most orthopaedic surgeons in this region have received no soft-tissue training, and HICs and MICs have different access to plastic surgeons and expectations for flap type and timing to definitive coverage.
      This study had several limitations. First, a chain-referral sampling method was utilized to improve the number of responses, precluding the ability to estimate a survey response rate. However, this method allowed the survey to be distributed more widely and to a more diverse group of orthopaedic surgeons across the region. Second, the overall number of 469 survey responses was low in comparison to the actual number of practicing orthopaedic surgeons in Latin America, limiting the generalizability of the results. Though it is difficult to provide an absolute number of practicing orthopaedic surgeons across the region, a total of 30,000 orthopaedic surgeon-members have been estimated across 20 Latin American national societies. [
      • Albright P.D.
      • MacKechnie M.C.
      • Roberts H.J.
      • Shearer D.W.
      • Padilla Rojas L.G.
      • Quintero J.E.
      • et al.
      Open tibial shaft fractures: treatment patterns in Latin America.
      ]. Nevertheless, the survey represented participants from 19 countries in Latin America, providing for a regional evaluation of soft-tissue treatment techniques . Third, there were few responses collected overall from the HICs, which may not adequately reflect the treatment practices across this entire income group and may affect statistical inferences. These fewer responses are due, in large part, to the fact that there are only two countries designated as HICs in Latin America (Chile and Uruguay); it is valuable, however, to include these data to fully understand management differences in the region.
      In summary, this study's findings support the need for soft-tissue training courses, including rotational flaps, skin graft, and wound management, as well as better allocation of surgical tools and resources for orthopaedic surgeons in this region. Further investigation into differences in the clinical outcomes related to soft-tissue coverage methods and protocols can provide additional insight into the importance of timing and access to specialists.

      Funding

      This study was supported by funding from the Wyss Medical Foundation.

      Conflict of interest

      No conflict of interest related to the research or manuscript for the listed authors.

      Acknowledgements

      This study was supported by funding from the Wyss Medical Foundation.

      Corporate Authors

      RafaelAmadei, MD1 ([email protected]),Fernando Baldy dos Reis, MD2([email protected]), Paulo R. Barbosa Lourenco, MD3([email protected]), Renny Cárdenas Quintero, MD4([email protected]), Fernando de la Huerta, MD5([email protected]), Bibiana Dello Russo, MD6([email protected]), Igor A. Escalante Elguezabal, MD7([email protected]), Robinson Esteves Pires, MD8([email protected]), Diego Abraham Estrada Tellez, MD9([email protected]), Nicolas Gaggero, MD10([email protected]), Germán Garabano, MD11 ([email protected]), Erika Guerrero Rodriguez, MD12 ([email protected]), Gustavo Hernández Vivas, MD13 ([email protected]), Jose María Jiménez Avila, MD, PhD14([email protected]), Kodi E. Kojima, MD, PhD15([email protected]), Leonardo López Almejo, MD16 ([email protected]), Roberto López Cervantes, MD17 ([email protected]), Aramíz López Durán, MD18 ([email protected]), Gerardo López Mejia, MD19 ([email protected]), Ricardo Madrigal Gutiérrez, MD20 ([email protected]), Jose Martínez Ruíz, MD21 ([email protected]), Claudia Medina, MD22([email protected]), Edgar E. Mercado Salcedo, MD23 ([email protected]), Saúl Mingüer Vargas, MD24([email protected]), Tomás Minueza, MD25 ([email protected]), Eduardo Octaviano Navarro Martínez, MD26 ([email protected]), Maura Ocampo Vega, MD27 ([email protected]), María Elena Pérez Carrera, MD28 ([email protected]), César Pesciallo, MD29([email protected]), Luiz Henrique Penteado da Silva, MD30([email protected]), Claudia Ramirez, MD31 ([email protected]), Marcelo Rio, MD32 ([email protected]), Jesús Rodriguez López, MD33 ([email protected]), Alberto J Serrano F, MD34 ([email protected]), Santiago Svarzchtein, MD35 ([email protected]), Victor Toledo-Infanson, MD36 ([email protected]), Miguel Triana, MD37 ([email protected]), Jorge Verlarde, MD38 ([email protected]), Eduardo Vilensky, MD39 ([email protected]), Mauricio Zuluaga, MD40 ([email protected]).
      1Hospital Cuenca Alta Cañuelas, Argentina, 2EPM-UNIFESP, 3Hospital Quinta D'or, Rio de Janeiro, Brazil, 4Sociedad Venezolana de Cirugía Ortopédica y Traumatología, Hospital Central de San Cristóbal, 5Hospital Country 2000, 6Hospital Nacional de Pediatría, Profesor J.P. Garrahan, Argentina, 7Hospital Universitario de Caracas, Venezuela, 8Universidade Federal de Minas Gerais, Belo Horizonte, Brazil, 9Hospital Civil Fray Antonio Alcalde, Mexico, 10Hospital del Trabajador, 11Hospital Británico de Buenos Aires, Buenos Aires, Argentina, 12Hospital Universitario José Eleutario Gonzalez, 13IHSS, Hospital Fundación Ruth Paz, 14Institute Tecnológico y de Estudios Superiores de Monterrey, Campus Guadalajara, Guadalajara, Jalisco, México, 15Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil, 16Federación Mexicana de Colegios de Ortopedia y Traumatología A.C, Hospital Star Médica, Aguascalientes, Mexico, 17Hospital de Especialidades San Francisco de Asis, 18Instituto Nacional de Pediatria, 19Hospital Christus Muguerza Saltillo, 20Hospital Puerta de Hierro, Mexico, 21Hospital Civil Fray Antonio Alcade, Mexico, 22IPS Universitaria Clinica Leon XIII, Colombia, 23Instituto Mexicano del Seguro Social, Mexico, 24Hospital Regional Presidente, Juárez del ISSSTE, Oaxaca, Mexico, 25Hospital Fundación Ruth Paz, 26Hospital General Dr. Aurelio Valdivieso, 27Hospital General, Regional Número 20, Tijuana BC, México, 28Clínica Tramatología y Ortopedia Pediatrica, Universidad de la República Uruguay, 29Hospital Británico de Buenos Aires, 30Clínica IOT e HSVP de Passo Fundo, RS, Brazil, 31Puerta de Hierro, 32Clínica Zabala, Argentina, 33Centro de Investigación y Docencia en Ciencias de la Salud, Universidad Autonoma de Sinaloa, Mexico, 34Universidad Central de Venezuela, Facultad de Medicina, Escuela de Medicina José María Vargas, Caracas, Venezuela, 35Centro Médico Integral Fitz Roy, Argentina, 36Hospital General Gua Prieta, SSA, 37Fundación Cardioinfantil, Hospital Infantil de San José y Clínica la Colina, Colombia, 38Hospital Santo Tomás, Panama, 39CASMUS, Asociación Española, Uruguay, 40Clínica Imbanaco.

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