Open Lower Limb Fractures Research Articles

Protocol for a randomised controlled trial of standard wound management versus negative pressure wound therapy in the treatment of adult patients with an open fracture of the lower limb: UK Wound management of Open Lower Limb Fractures (UK WOLFF)

IntroductionPatients who sustain open lower limb fractures have reported infection risks as high as 27%. The type of dressing applied after initial debridement could potentially affect this risk. In this...

The impact of a dedicated orthoplastic operating list on time to soft tissue coverage of open lower limb fractures.

An observational study was conducted of 105 patients presenting with an open fracture of the tibia or ankle to determine the impact of a dedicated orthoplastic operating list on our management of these injuries over the time period January 2012 to July 2014. There were 51 patients before and 54 after the introduction of the orthoplastic list. Significant improvements were noted in our ability to deliver a service in line with national guidelines across all Gustilo-Anderson grades of injury. Among patients with the most severe grades of injury (Gustilo types IIIB and IIIC), there was a trend towards an improved time to first skeletal stabilisation (29.5 vs 14.2 hours, p=0.068), an improvement in time to soft tissue coverage (173.6 vs 88.1 hours, p=0.009) and a trend towards a reduced length of inpatient stay (32.6 vs 23.2 days, p=0.138). Where the 72-hour target had been breached, there was a significant improvement in the proportion of patients covered within 7 days of injury (48.2% vs 83.3%, p=0.017). Our compliance with national management standards increased significantly to reflect these improvements in care. These results support the implementation of dedicated orthoplastic operating sessions to meet the growing burden of patients presenting with open fractures at specialist centres.

Experience of managing open fractures of the lower limb at a major trauma centre.

In April 2012 the John Radcliffe Hospital in Oxford became a major trauma centre (MTC). The British Orthopaedic Association and British Association of Plastic, Reconstructive and Aesthetic Surgeons joint standards for the management of open fractures of the lower limb (BOAST 4) require system-wide changes in referral practice that may be facilitated by the MTC and its associated major trauma network. From 2008 to 2013 a multistep audit of compliance with BOAST 4 was conducted to assess referral patterns, timing of surgery and outcomes (surgical site infection rates), to determine changes following local intervention and the establishment of the MTC. Over the study period, 50 patients had soft tissue cover for an open lower limb fracture and there was a significant increase in the proportion of patients receiving definitive fixation in our centre (p=0.036). The median time from injury to soft tissue cover fell from 6.0 days to 3.5 days (p=0.051) and the median time from definitive fixation to soft tissue cover fell from 5.0 days to 2.0 days (p=0.003). The deep infection rate fell from 27% to 8% (p=0.247). However, in 2013 many patients still experienced a delay of >72 hours between injury and soft tissue cover, primarily owing to a lack of capacity for providing soft tissue cover. Our experience may be relevant to other MTCs seeking to identify barriers to optimising the management of patients with these injuries.

Successful reimplantation of extruded long bone segments in open fractures of lower limb – A report of 3 cases

Extruded bone segments are rare complication of high energy open fractures. Routinely these fractures are treated by debridement followed by bone loss management in the form of either bone transport or free fibula transfer. There are very few reports in the literature about reimplantation of extruded segments of bone and there are no clear guidelines regarding timing of reimplantation, bone stabilisation and sterilisation techniques. Reimplantation of extruded bone is a risky procedure due to high chances of infection which determines the final outcome and can result in secondary amputations. We present two cases of successful reimplantation of extruded diaphyseal segment of femur and one case of reimplantation of extruded segment of tibia.

The use of secure anonymised data linkage to determine changes in healthcare utilisation following severe open tibial fractures

Severe open fractures of the lower limbs are complex injuries requiring expert multidisciplinary management in appropriate orthoplastic centres. This study aimed to assess the impact of open fractures on healthcare utilisation and test the null hypotheses that there is no difference in healthcare utilisation between the year before and year after injury, and that there is no difference in healthcare utilisation in the year post-injury between patients admitted directly to an orthoplastic centre in keeping with the joint BOA/BAPRAS standards and those having initial surgery elsewhere.This retrospective cohort study utilising secure anonymised information linkage (SAIL), a novel databank of anonymised nationally pooled health records, recruited patients over 18 years of age sustaining severe open lower limb fractures managed primarily or secondarily at our centre and who had data available in the SAIL databank. 101 patients met inclusion criteria and 90 of these had records in the SAIL databank. The number of days in hospital, number of primary care attendances, number of outpatient attendances and number of emergency department attendances in the years prior and subsequent to injury were recorded.Patients sustaining open fractures had significantly different healthcare utilisation in the year after injury when compared with the year before, in terms of days spent in hospital (23.42 vs. 1.70, p=0.000), outpatient attendances (11.98 vs. 1.05, p=0.000), primary care attendances (29.48 vs. 11.99, p=0.000) and emergency department presentations (0.2 vs. 0.01, p=0.025). Patients admitted directly to orthoplastic centres had significantly fewer operations (1.78 vs. 3.31) and GP attendances (23.6 vs. 33.52) than those transferred in subsequent to initial management in other units.There is a significant increase in healthcare utilisation after open tibial fracture. Adherence to national standards minimises the impact of this on both patients and health services.

Management of open lower limb injuries in South West England and Wales.

The joint British Association of Plastic, Reconstructive and Aesthetic Surgeons/British Orthopaedic Association standards define best practice management in open diaphyseal fractures of the lower limb. The aim of our study was to review the regional approach and experience in South West England and Wales. A further objective was to evaluate service provision with regard to the standards' key recommendations. A prospective audit was undertaken of open diaphyseal fracture patients. Compliance with published standards within all orthoplastic services in South West England and Wales was assessed, and facilities were evaluated. A total of 86 patients were managed between October 2012 and March 2013. This was a 56% increase from 2008. Over half (56%) presented directly to the orthoplastic services with all patients undergoing debridement within 24 hours. Two-thirds (66%) of procedures were in daylight hours excluding those requiring immediate surgical intervention. Adherence to correct antibiotic therapy was 88% at admission, 50% at primary surgery and 62% at definitive surgery. Almost two-thirds (60%) of primary procedures were performed with combined senior orthoplastic teams, with 81% achieving definitive soft tissue coverage and fixation within seven days. Compliance improved in units with larger patient caseloads and where there was an early combined approach during daylight hours. Increased open lower limb fracture workload was demonstrated across South West England and Wales, probably owing to centralisation of trauma services. An improvement in early transfer of this patient group to orthoplastic facilities has allowed all patients to be assessed and debrided within the recommended timeframe. Standards were most likely to be met in those centres seeing higher numbers of injuries and when there was a daylight hours procedure by combined orthoplastic teams.

Taylor spatial frameでbone transportを行った後PERI-LOCでMIPOを行った軟部組織欠損を伴う下腿開放骨折

Taylor spatial frameでbone transportを行った後PERI-LOCでMIPOを行った軟部組織欠損を伴う下腿開放骨折

Potential prognostic factors predicting secondary amputation in third-degree open lower limb fractures

With regard to the improved surgical possibilities and the rising tendency of attempted limb salvage, the topic of secondary amputation becomes increasingly important. The aim of this study was to identify potential prognostic factors predicting secondary amputation in third-degree open lower limb fractures. All patients experienced third-degree open fractures of the lower limb without primary amputation (1994-2012). Prognostic factors were investigated to explain the final outcome of these patients (limb salvage vs. secondary amputation). From a total of 408 open diaphyseal tibia fractures, 93 consecutive fractures were identified (Gustilo-Anderson [G/A] type IIIA, n = 38; G/A type IIIB, n = 41; G/A type IIIC, n = 14) including seven patients with primary amputation. Definite limb salvage was achieved in 72 patients (88%), whereas in 10 patients (12%), secondary amputation was necessary. The median time to secondary amputation was 12 days (range, 2-1,573 days). The median Injury Severity Score (ISS) was 11 (range, 9-41), and the median Mangled Extremity Severity Score (MESS) was 4 (range, 2-9). The MESS was significantly higher in the amputation group compared with the limb salvage group (p = 0.0001). Furthermore, statistical testing revealed that the amount of complex fractures (p = 0.0132), the soft tissue damage (p = 0.0050), the vascular injury rate (p = 0.0110) and the fasciotomy rate (p = 0.0468) were significantly higher in the amputation group. In 60%, the limitations for limb salvage were infectious complications and/or, in 40%, was irreversible vessel occlusion after initial vessel reconstruction. The current study findings indicate that MESS is highly prognostic, but considering the significant advances in reconstructive techniques, decision making in patients with an MESS of 7 or greater should be reevaluated for the everyday clinical use. Prognostic study, level III. Therapeutic study, level IV.

The management of severe open lower limb fractures at a major trauma centre

To audit adherence to the British Orthopaedic Association and British Association of Plastic, Reconstructive and Aesthetic Surgeons 2009 review of the acute management of severe open lower limb fractures (BOAST4). Audit: Retrospective study of adherence to BOAST4 standards of 37 cases treated at Derriford Hospital between March 2010 and 2011. Intervention: a multidisciplinary approach towards the management of such injuries. Assigning department-specific roles across all specialities involved and establishing an early patient transfer pathway from non-specialist centres in the region. Re-audit: Prospective data collection of adherence to BOAST4 of 18 cases between October 2011 and April 2012. Eleven of 15 standards were comparable. Statistical analysis was performed using Fisher9s exact test (p≤0.05). Six standards showed statistically significant improvement: antibiotic therapy; regular assessment of neurovascular status; urgent surgery for contaminated wounds; initial wound care; appropriate splinting and early patient transfers. One standard was adhered to in all cases. 3 standards showed improvement, although not statistically significant and 1 standard remained consistently low in adherence. Although doctors are familiar with BOAST4, many are not aware of the specific details. A coordinated and informed multidisciplinary team has enabled the successful application of an evidenced-based approach to the management these injuries.

Management of open fractures of the lower limb

This article gives a practical guide for the management of open lower limb fractures. It outlines the referral criteria and pathway for definitive care in a specialist centre, the initial management steps that should be taken in the emergency department, and the principles of fixation, soft tissue coverage and antibiotic therapy.

Reconstruction des pertes de substance de membres inférieurs par lambeau libre en urgence. À propos de 35 ans d’expérience

Authors analyzed 89 cases (86 patients) of lower limb extensive soft tissue defects reconstruction during 1978 to 2013. The mean age is 37 years and 2 months old (range: 5-84 years old). A total of 71 males and 15 female were included. Free flaps were used in emergency in 23 cases for principally covering Gustilo 3B open lower limb fracture and in a later stage for 66 cases all referred from their center for coverage of exposed bone, with frequently osteomyelitis. About the selection of free flaps, in 47 cases we used a latissimus dorsi flaps, 12 cases of epiploon free transfer (in septic area), 10 cases of gracilis transfer and 10 serratus anterior flaps. There are one medial gastrocnemius flap, 2 composite soleus and fibular free flap, 2 antebrachial flap, one inguinal myoosteocutaneous flap, 1 transferred from the other lower limb and one inguinal cutaneous flap. There are 18 free flap losses: one in emergency and 17 after delayed reconstruction. Authors retrospectively analyzed the results (complications, osteomyelitis) according to the timing for lower extremity reconstruction. They found a low infection and flap failure rates (4%) when the coverage is made in the same operating time than initial fracture fixation, they increase to 60% for osteomyelitis and to 23% for flap failure when the reconstruction is delayed.

Orthopedic Injuries Following the East Azerbaijan Earthquake

BackgroundEvaluating demographic characteristics, distribution and types of orthopedic injuries following major earthquakes may be helpful in future planning for disasters.ObjectivesThis study aimed to analyze data from trauma patients with extremity injury resulting from the earthquakes of East Azerbaijan, Iran.Patients and MethodsMedical records of 686 patients admitted to Shohada hospital, Trauma Center of Tabriz University of Medical Sciences were reviewed. There were 200 patients with extremity injury assessed. Demographic characteristics and patterns of injuries in these patients were evaluated.ResultsIn this study, there were 105 females (52.5%) and 95 males (47.5%), out of which, 6 (3%) patients with associated severe head injuries died. The most common sites of injury were lower extremities (81 patients, 41.5% of total victims) while 32 patients (16%) suffered from both upper and lower extremity injuries. Open Fractures were seen in lower extremities of 26 (13%) patients. Compartment syndrome was observed in 3 (1.5%) patients with lower limb fractures. Also, 42 (21%) patients living in Tabriz were injured while they were running away (falling down the stairs and jumping out of windows).ConclusionsExtremity injuries especially open fractures of lower limbs account for the majority of hospitalized victims. Compartment syndrome is one of the main problems that should be addressed. Our study demonstrates that people still need more education regarding earthquakes and the government should direct more attention to this issue.

Update on the management of open lower limb fractures.

Open lower limb fractures pose a significant challenging pathology for orthopaedic and plastic surgeons to manage due to the combined soft tissue damage, bone loss and potential vascular compromise. These fracture require extensive team-work and expertise between several surgical specialties and the advice of non-surgical specialties to ensure good clinical outcomes. Extensive research has improved the outcomes of open lower limb fractures and current recommendation on the optimal management is always being updated to enhance patient outcomes. This review serves to provide an overview of the management of open tibial fractures using current evidence and recently updated UK guidelines. The optimal time for surgical debridement, surgical intervention, providing antibiotics and soft tissue coverage will be outlined as well as the indications for amputation.

Does the co-location of orthopaedic and plastic surgeons optimise the management of open lower limb fractures?

Does the co-location of orthopaedic and plastic surgeons optimise the management of open lower limb fractures?

Microbial Isolates in Early Swabs of Patients With Lower Limb Open Fractures

Fracture of lower limb is one of the most common orthopedic problems in emergency department. These fractures and particularly the open fractures have complications that among them, infection is most important and dangerous because lead to defect in functional outcomes of limb. Based on above mentioned; in this study we isolate and identified types of microbial that cause infection in lower limb’s open fractures. In this cross sectional study, 32 patients with open lower limb fractures were enrolled. Open fracture’s specimens were collected by swab and sent to the laboratory for microbial culture immediately. Then patients were compared based on type of isolated microbial contaminant and results of antibiogram. The most frequent was Klebsiella (15.5%), Gram negative bacteria (15.5%), negative coagulase Staphylococcus (12.5%), Staphylococcus Aurous (6.5%).

Experiences of lower limb open fracture management at the Royal United hospital, Bath

Experiences of lower limb open fracture management at the Royal United hospital, Bath

Multi drug resistant pseudomonas infection in open fractures post definitive fixation leading to limb loss: A report of three cases

Introduction: Infection is a common complication in multiply traumatized patients with the majority being nosocomial in origin. We report a series of three patients with open fractures of lower limb which were initially debrided and stabilized with external fixation. Subsequent conversion to definitive internal fixation was performed. All three patients subsequently suffered limb loss as a result of multiple drug resistant pseudomonas aeroginosa infection. Case report: We report three cases. Case 1 is a 48-year-old alcoholic male who sustained a Gustilo grade 3 (a) open fracture of the right tibia and Gustilo grade 1 open fracture on the contralateral tibia. He underwent definitive fixation but subsequently developed a multiple drug resistant pseudomonas aeroginosa infection of the wound. Failure to eradicate the infection and deteriorating soft tissue conditions with infected non-union lead to a final outcome of below knee amputation and secondary stump closure. Case 2 is a 62-year-old male with no significant medical history who sustained a right grade 3 (a) supracondylar femur fracture and a left grade 3 (c) supracondylar femur fracture. He underwent definitive fixation after negative culture results but later developed

The Management of Open Lower Limb Fractures: The Journey From Amputation to Evidence-Based Reconstruction and Harpsichords

The Management of Open Lower Limb Fractures: The Journey From Amputation to Evidence-Based Reconstruction and Harpsichords

Combined management of open tibial fractures course

Lower limb trauma can present complex problems, and early correct management is crucial to optimise outcome. This can be difficult, however, especially in non-specialist centres where people with these injuries sometimes present. In an attempt to improve the delivery of surgical care, the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) and the British Orthopaedic Association (BOA) have recently published updated management guidelines, the Standards for the Management of Open Fractures of the Lower Limb (2009; www.bapras.org.uk/downloaddoc.asp?id=141). The aims of these guidelines, and of the course, are to encourage cooperation between plastic surgeons and orthopaedic surgeons and to provide an evidence based rationale for treatment. This course complements the recent updated guidelines, and four of its authors teach the course. They are recognised for their expertise in the field and come from a background of orthopaedics, plastic surgery, and infectious diseases. The course …

Availability of “in hours” trauma theatres and its effect on the management of open lower limb fractures: experience from a level 1 trauma centre

Availability of “in hours” trauma theatres and its effect on the management of open lower limb fractures: experience from a level 1 trauma centre