• Juan Enrique Berner, Adele Pope, David Winston Hamilton, Jagdeep Nanchahal, and Abhilash Jain.
• Kellogg College, University of Oxford. Oxford, United Kingdom; Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Health Science Center at San Antonio. San Antonio, United States of America. Electronic address: juan.berner@kellogg.ox.ac.uk.
• Injury. 2024 Nov 9; 55 (12): 112018112018.

BackgroundOrtho-plastic evidence-based clinical guidelines for open fractures have demonstrated to standardise care and improve outcomes for patients admitted following lower extremity trauma. Despite its benefits, very few countries have introduced such guidance. The aim of this study was to explore the attitudes, barriers and limitations to the development and implementation of guidelines for lower limb open fractures METHODS: Twelve renowned orthopaedic and plastic surgeons, based in countries with no guidelines at present, underwent semi-structured interviews. A qualitative appraisal was conducted using reflexive thematic analysis methodology. Systematic coding led to the development and refinement of themes to address the research question.ResultsIndividualistic decision-making, reliance on multidisciplinary interpersonal relationships, and the presence of immobile determinants of open fracture care emerged as three themes that define how patients are currently managed in settings with no guidelines in place. Although guidelines can potentially improve care by presenting evidence-based recommendations, introducing audit practices, establishing pathways for multidisciplinary collaboration, and enhancing effective leadership; if barriers to the implementation are not considered, they may end up as a "piece of paper on the wall that everyone ignores" CONCLUSIONS: This study is the first to explore the challenges of introducing ortho-plastic guidelines for open extremity trauma. The themes presented describe the status quo in settings with no such protocols in place, establishing the foundation for future initiatives aiming to provide a practical strategy to aid the development and introduction of clinical guidelines for open lower limb fractures.Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.

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