Gaps in knowledge

In order to acquire an evidence base for these guidelines, a systematic literature search was carried out which gave a comprehensive picture of the evidence base for various treatment options. In summary, it can be contended that the evidence concerning treatment options in patients with a grade III open fracture of the lower limb is very limited. None of the clinical questions could be answered by a high or moderate level of evidence. In many cases recommendations were supported on the basis of a very low level of evidence, augmented by the expertise of the working party and patient preferences.

 

The very low level of evidence is a consequence of the low incidence of these types of fracture. Additionally, the complexity and the acute character of the pathology play a role. A study protocol requires a clearly described treatment protocol, but the degree of complexity (depending on type of fracture and contamination) demands a specific approach in each individual case. The acute nature of the issues that often surround multitrauma patients makes it difficult to include patients in trials whereby their permission for participation must be requested prior to treatment.

 

If a new study were to be planned, the working party is of the opinion that this should ideally be at an international level. Multicentre research in which a number of countries participate would generate more power. Nonetheless, one of the challenges faced in this sort of research is reaching agreement on an unambiguous approach to care so that the results could be combined in a reliable manner.

 

The main knowledge gaps in these guidelines apply to:

1. Risk stratification in order to find out what type of treatment is best for what type of trauma, i.e. the question of the possibility of  stratifying the various clinical questions in these guidelines in order to be able to develop more focused recommendations for various situations.
2. The effectiveness of primary bone grafting in open fractures.
3. The timing of definitive coverage could be more strongly supported with evidence.
4. The time point and indication that an amputation should be carried out.
5. The timing and implementation of exercise therapy to promote return to work.
6. The correct antibiotic regimen in terms of timing, duration and drug.

 

Regarding future research, it is important that is only carried out if enough power can be obtained and the results can be unambiguously obtained. The working party prioritises treatment with antibiotics.