Improving the care of patients with severe open fractures of the tibia

Wordsworth, Matthew; Lawton, Graham; Nathwani, Dinesh; Pearse, Michael; Naique, S.; Dodds, Anthony J.; Donaldson, Hugo; Bhattacharya, Rajarshi; Jain, Abhilash; Simmons, Jonathan; Hettiaratchy, Shehan

doi:10.1302/0301-620x.98b3.35818

Cited by 59 publications

(48 citation statements)

References 18 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…These findings provide the clinician with a greater evidential basis for advising and counselling patients as to their likely outcomes with each of the two alternative treatment strategies. 39 …”

Section: Discussionmentioning

confidence: 99%

Outcomes following limb salvage after combat hindfoot injury are inferior to delayed amputation at five years

Bennett

Stevenson

Sargeant

et al. 2018

Bone & Joint Research

View full text Add to dashboard Cite

ObjectivesThe surgical challenge with severe hindfoot injuries is one of technical feasibility, and whether the limb can be salvaged. There is an additional question of whether these injuries should be managed with limb salvage, or whether patients would achieve a greater quality of life with a transtibial amputation. This study aims to measure functional outcomes in military patients sustaining hindfoot fractures, and identify injury features associated with poor function.MethodsFollow-up was attempted in all United Kingdom military casualties sustaining hindfoot fractures. All respondents underwent short-form (SF)-12 scoring; those retaining their limb also completed the American Academy of Orthopaedic Surgeons Foot and Ankle (AAOS F&A) outcomes questionnaire. A multivariate regression analysis identified injury features associated with poor functional recovery.ResultsIn 12 years of conflict, 114 patients sustained 134 fractures. Follow-up consisted of 90 fractures (90/134, 67%), at a median of five years (interquartile range (IQR) 52 to 80 months).The median Short-Form 12 physical component score (PCS) of 62 individuals retaining their limb was 45 (IQR 36 to 53), significantly lower than the median of 51 (IQR 46 to 54) in patients who underwent delayed amputation after attempted reconstruction (p = 0.0351).Regression analysis identified three variables associated with a poor F&A score: negative Bohler’s angle on initial radiograph; coexisting talus and calcaneus fracture; and tibial plafond fracture in addition to a hindfoot fracture. The presence of two out of three variables was associated with a significantly lower PCS compared with amputees (medians 29, IQR 27 to 43 vs 51, IQR 46 to 54; p < 0.0001).ConclusionsAt five years, patients with reconstructed hindfoot fractures have inferior outcomes to those who have delayed amputation. It is possible to identify injuries which will go on to have particularly poor outcomes.Cite this article: P. M. Bennett, T. Stevenson, I. D. Sargeant, A. Mountain, J. G. Penn-Barwell. Outcomes following limb salvage after combat hindfoot injury are inferior to delayed amputation at five years. Bone Joint Res 2018;7:131–138. DOI: 10.1302/2046-3758.72.BJR-2017-0217.R2.

show abstract

Section: Discussionmentioning

confidence: 99%

Outcomes following limb salvage after combat hindfoot injury are inferior to delayed amputation at five years

Bennett

Stevenson

Sargeant

et al. 2018

Bone & Joint Research

View full text Add to dashboard Cite

show abstract

“…First, there is no universal definition of a high-energy trauma. The difference between high- and low-energy trauma was based on literature and at the discretion of the investigators [ 10 , 18 ]. Some of the patient charts lacked a detailed description of the mechanism of injury, which impeded the estimation of the energetic force.…”

Section: Discussionmentioning

confidence: 99%

“…High-energy fractures were defined conform the ATLS ® guidelines and caused by; a motor vehicle-related traffic injury, firearm incident, fall from height >2 m, fall at high speed (e.g., fall with bicycle), aircraft accident, a crash with an object at high speed or a crash with a heavy object [ 10 ].…”

Section: Methodsmentioning

confidence: 99%

Two-stage treatment in patients with patients with high-energy femoral fractures does not lead to an increase in deep infectious complications: a propensity score analysis

Dingemans

Sier

Peters

et al. 2017

Eur J Trauma Emerg Surg

View full text Add to dashboard Cite

PurposeIn patients following severe trauma sometimes the physiological condition or soft tissue status may not allow definitive fixation of a femoral fracture. In these patients, an external fixator can be placed to temporarily stabilise the fracture, after which definitive fixation can be performed in a second procedure. The aim of this study was to compare the postoperative wound infection and union rates of patients treated with direct intramedullary nailing (IMN) and patients treated with the ‘two-stage treatment’.MethodsAll patients with high-energy femoral fractures treated with IMN between 2000 and 2016 in a single Level 1 trauma centre were eligible. Electronic charts were reviewed for patient and surgical characteristics; furthermore, the development of complications was noted. A propensity score analysis was performed to assess the attributed risk of the external fixator on the development of postoperative wound infections.ResultsA total of 149 patients were included in this study; 93 underwent direct IMN and 56 underwent the two-stage treatment. Patients who underwent two-stage treatment were more severely injured, reflected by lower EMV and higher ISS on admission. Patients in the two-stage treatment group had a significant higher risk of postoperative wound infections (OR: 4.698, 95% CI: 1.203–18.339) but not a higher risk on deep postoperative wound infections (OR 2.345, 95% CI: 0.439–12.540). Union rate did not differ between the two groups (94% vs 94% NS).ConclusionsThe two-stage treatment is a safe treatment option in patients with a high-energy femoral fracture in terms of postoperative wound infections. Union rates are also comparable between the two treatment groups.

show abstract

“…Several studies reported successful results of major trauma centres (MTC) in the United Kingdom following these standards. A decrease in treatment time, fewer required surgeries per patient, and a higher successful limb reconstruction rate have led to a decrease in deep infection rate [9–11].…”

Section: Introductionmentioning

confidence: 99%

Treating open lower limb fractures successfully; thoughts and current practice on therapy and centralization in The Netherlands

Oflazoglu

Hoogendoorn

Zwaal

et al. 2017

Eur J Trauma Emerg Surg

View full text Add to dashboard Cite

Introduction The British Orthopedic Association (BOA) and British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) updated the evidence-based guidelines for the treatment and care of open lower limb fractures (BOAST 4). Following this, a Dutch version has been developed. The main points are multidisciplinary care, planning, and treatment of these injuries. Early osteosynthesis (within 7-14 days) combined with soft-tissue coverage results in more efficient care and less complications. Aim To study the variation in treatment and thoughts among trauma, orthopedic, and plastic surgeons. Materials and methods In this cross-sectional study 94 surgeons (57 trauma, 23 plastic, and 14 orthopedic surgeons) working at 46 centers completed an online questionnaire, consisting of 5 demographic, 14 hospital-related, 8 BOAST 4-related, and 2 centralization-related questions. Results There was a strong agreement among surgeons about the best moment for multidisciplinary consultation, which was before initial debridement, while in practice, this often does not occur. All surgeons agreed that the initial debridement should be performed immediately by any surgeon, but not solely by trainees. Plastic surgeons responded that the definitive stabilization and wound cover should not exceed 7 days, while half of the trauma and orthopedic surgeons agreed that it should not exceed 14 days. Finally, most surgeons agreed that Gustilo 3 fractures should be centralized. However, there was disagreement on the need for centralization of Gustilo 2 fractures. Discussion Surgeons agree on better and earlier multidisciplinary treatment of open lower limb fractures and the centralization of Gustilo 3 fractures.

show abstract

Improving the care of patients with severe open fractures of the tibia

Abstract: This study demonstrates that a systemised trauma network combined with evidence based practice can lead to improvements in patient care.

Cited by 59 publications

References 18 publications

Outcomes following limb salvage after combat hindfoot injury are inferior to delayed amputation at five years

Outcomes following limb salvage after combat hindfoot injury are inferior to delayed amputation at five years

Two-stage treatment in patients with patients with high-energy femoral fractures does not lead to an increase in deep infectious complications: a propensity score analysis

Treating open lower limb fractures successfully; thoughts and current practice on therapy and centralization in The Netherlands

Contact Info

Product

Resources

About