Open Limb Research Articles

Plastic surgical operative workload in major trauma patients following establishment of the major trauma network in England: A retrospective cohort study

The introduction of major trauma centres (MTCs) in England has led to 63% reduction in trauma mortality.(1) The role of plastic surgeons supporting these centres has not been quantified previously. This study aimed to quantify plastic surgical workload at an urban MTC to determine the contribution of plastic surgeons to major trauma care. All Trauma Audit and Research Network (TARN)-recorded major trauma patients who presented to an urban MTC in 2013 and underwent an operation were identified retrospectively. Patients who underwent plastic surgery were identified and the type and date of procedure(s) were recorded. The trauma operative workload data of another tertiary surgical specialty and local historical plastics workload data from pre-MTC go-live were collected for comparison. Of the 416 major trauma patients who required surgical intervention, 29% (n=122) underwent plastic surgery. Of these patients, 43% had open lower limb fractures, necessitating plastic surgical involvement according to British Orthopaedic Association Standards for Trauma (BOAST) 4 guidance. The overall plastic surgery operative workload increased sevenfold post-MTC go-live. A similar proportion of the same cohort required neurosurgery (n=115; p=0.589). This study quantifies plastic surgery involvement in major trauma and demonstrates that plastic surgical operative workload is at least on par with other tertiary surgical specialties. It also reports one centre's experience of a significant change in plastic surgery activity following designation of MTC status. The quantity of plastic surgical operative workload in major trauma must be considered when planning major trauma service design and workforce provision, and for plastic surgical postgraduate training.

Monolateral frame external fixators in the definitive management of open limb fractures in North-western Nigeria

Background: The use of external fixators became popular in the last ten years in our environment with the availability and expertise to apply them being popularised by the AO foundation. They have virtually supplanted the application of casts which had high levels of complications and unpredictable outcomes in patients with open fractures. This manuscript describes its use in trauma in our environment. Aims: The aim of this study is to demonstrate that monolateral frame external fixators are a means of definitively treating open limb fractures. Materials and Methods: For a period of nine years (2006-2014), we prospectively studied the use of monoframe external fixation in one hundred and six limbs in three hospitals in the northwest of Nigeria. Gustillo II and III A, B and C patients were included in the study. External fixators from different manufacturers were used. The adherence to the principles of application, duration of application, pin track infection, union and non-union rates were observed for both groups. Results: One hundred and six limbs in were studied. Ninety four males and eleven females in the study group with five of the males being children of less than twelve years. Ninety seven cases had open tibial fractures (one lady had bilateral open tibial fractures) and four cases involved the femur. Union rate of 60% was observed. Pin tack infection rate of 80%, average duration of stay of the patient was three month; fracture union rate of 60% and reoperation rate of 2%were observed. Conclusion: Monolateral external fixators can be used successfully in the management of open diaphyseal fractures of long bones with reasonably high success rates and few complications.

Managementz of limb fractures in a teaching hospital: comparison between Wenchuan and Yushu earthquakes

ObjectiveTo comparatively analyze the medical records of patients with limb fractures as well as rescue strategy in Wenchuan and Yushu earthquakes so as to provide references for post-earthquake rescue MethodsWe retrospectively investigated 944 patients sustaining limb fractures, including 891 in Wenchuan earthquake and 53 in Yushu earthquake, who were admitted to West China Hospital (WCH) of Sichuan University. ResultsIn Wenchuan earthquake, WCH met its three peaks of limb fracture patients influx, on post-earthquake day (PED) 2, 8 and 14 respectively. Between PED 3-14, 585 patients were transferred from WCH to other hospitals outside the Sichuan Province. In Yushu earthquake, the maximum influx of limb fracture patients happened on PED 3, and no one was shifted to other hospitals. Both in Wenchuan and Yushu earthquakes, most limb fractures were caused by blunt strike and crush/burying. In Wenchuan earthquake, there were 396 (396/942, 42.0%) open limb fractures, including 28 Gustilo I, 201 Gustilo II and 167 Gustilo III injuries. But in Yushu earthquake, the incidence of open limb fracture was much lower (6/61, 9.8%). The percent of patients with acute complications in Wenchuan earthquake (167/891, 18.7%) was much higher than that in Yushu earthquake (5/53, 3.8%). In Wenchuan earthquake rescue, 1 018 surgeries were done, composed of debridement in 376, internal fixation in 283, external fixation in 119, and vacuum sealing drainage in 117, etc. While among the 64 surgeries in Yushu earthquake rescue, the internal fixation for limb fracture was mostly adopted. All patients received proper treatment and survived except one who died due to multiple organs failure in Wenchuan earthquake. ConclusionProvision of suitable and sufficient medical care in a catastrophe can only be achieved by construction of sophisticated national disaster medical system, prediction of the injury types and number of injuries, and confirmation of participating hospitals’ exact role. Based on the valuable rescue experiences after Wenchuan earthquake, the rescue was faster, more orderly and effective in Yushu earthquake. Nevertheless, there is still a long way to go in the development of a stronger emergent response to the disasters.

The causes of delay in lower limb reconstruction for severe open lower limb fractures: Highlighting the importance of dedicated orthoplastic operative lists

The causes of delay in lower limb reconstruction for severe open lower limb fractures: Highlighting the importance of dedicated orthoplastic operative lists

Management of open lower limb fractures at RSUH: An audit of compliance with national BOA/BAPRAS guidelines

Management of open lower limb fractures at RSUH: An audit of compliance with national BOA/BAPRAS guidelines

The role of primary plastic surgery in the management of open fractures.

A study was undertaken to determine the requirement for primary plastic surgery in the treatment of open fractures. We reviewed 3297 consecutive open fractures in a 22-year period in a defined population. Analysis showed that 12.6% of patients required primary plastic surgery with 5.6% being treated with split skin grafting and 7.2% with a flap. Only 3.5% of open upper limb fractures required primary plastic surgery compared to 27.9% of open lower limb fractures. The fractures that required most primary plastic surgery were those of the femoral diaphysis and all fractures between the proximal tibia and the midfoot. The incidence of open fractures that require primary plastic surgery was 28/10(6)/year. The incidence in open upper and lower limb fractures was 5.3/10(6)/year and 22.7/10(6)/year respectively. Using these figures it is possible to estimate the numbers of open fractures that will require primary plastic surgery each year in the United Kingdom.

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.

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.

Tree and habitat preferences for open limb and cavity roosts of the spotted owletAthene brama(Temminck, 1821) in southern India

Knowledge about habitat requirements of wildlife is a basic need for conservation. We characterized the roost sites of the spotted owlets Athene brama evaluating 134 open limb and 95 cavity roost trees during 2007–2009 from Madurai district, southern India. Roosts occurred most often in banyan trees Ficus benghalensis (47.0% of open limb and 36.8% of cavity roosts). Number of cavity openings and height of lowest limb differed significantly between open limb and cavity roosts (Mann–Whitney U test, P < 0.05). The spotted owlets used larger trees with a wider basal circumference and canopy volume for open limbs, while roost height, diameter at breast height, total limbs, number cavity openings, and height of lowest limb were larger in cavity roosts. The roost trees were closer to human settlements than other habitat types. Based on our results, we concluded that the spotted owlets preferred roost trees closer to foraging areas and large tree with dense canopy because the roosts located in larger trees are pr...

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.

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.

Retinervus luffae fructus (RLF): a novel material for use in negative pressure wound therapy

To describe a modified negative pressure wound therapy (NPWT) apparatus, made mainly of an environmentally-friendly material derived from the retinervus luffae fructus (RLF; or loofah) plant. We retrospectively reviewed the charts of patients with skin defects on their limbs who underwent treatment with the RLF-NPWT device from September 2012 to October 2012. The endpoint of the study was healing by secondary intention; the time (days) to endpoint was evaluated. The RLF-NPWT device was used in 16 patients. The age of the patients ranged from 15-82 years, with a mean age of 43 ± 17 years. Six patients sustained crush injuries, nine patients had open limb injuries from motor vehicle accidents and a further patient had a diabetic foot ulcer. The mean time to healing was 8.5 ± 2.4 days. Following RLF-NPWT, fresh granulation tissue was observed in all wound beds, with no evidence of macroscopical necrosis. All 16 patients in the study achieved secondary healing. The environmentally friendly RLF-NPWT apparatus is easy to use and able to provide continual negative pressure for optimal preparation of the wound bed. The cost-effectiveness of RLF-NPWT compared to standard NPWT requires further investigation. There were no external sources of funding for this study. The authors have no conflicts of interest to declare.

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.

Necrotizing Fasciitis of the Lower Extremity Caused byShewanella algae

Surgical InfectionsVol. 14, No. 1 Letters to Surgical InfectionsNecrotizing Fasciitis of the Lower Extremity Caused by Shewanella algaeNasim Ahmed, Kathleen Casey, Edward Liu, and Lito FuneNasim AhmedDepartment of Surgery, Jersey Shore University Medical Center, Neptune, New Jersey.Search for more papers by this author, Kathleen CaseyDepartment of Infectious Diseases, Jersey Shore University Medical Center, Neptune, New Jersey.Search for more papers by this author, Edward LiuDepartment of Infectious Diseases, Jersey Shore University Medical Center, Neptune, New Jersey.Search for more papers by this author, and Lito FuneDepartment of Infectious Diseases, Jersey Shore University Medical Center, Neptune, New Jersey.Search for more papers by this authorPublished Online:14 Mar 2013https://doi.org/10.1089/sur.2012.068AboutSectionsView articleView Full TextPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"Necrotizing Fasciitis of the Lower Extremity Caused by Shewanella algae." , 14(1), pp. 165–166FiguresReferencesRelatedDetailsCited byShewanella infection in humans: Epidemiology, clinical features and pathogenicity5 September 2022 | Virulence, Vol. 13, No. 1First reported case of non-coastal Shewanella algae in the United States: A case report and literature reviewFoot & Ankle Surgery: Techniques, Reports & Cases, Vol. 2, No. 1Assessment of seawater bacterial infection in rabbit tibia by Illumina MiSeq sequencing and bacterial culture21 July 2021 | Journal of Orthopaedic Surgery and Research, Vol. 16, No. 1Swimming with the Pigs: A Case of Severe Soft Tissue Infection during a Caribbean VacationCase Reports in Infectious Diseases, Vol. 2018Shewanella spp. infections in Gran Canaria, Spain: retrospective analysis of 31 cases and a literature reviewJMM Case Reports, Vol. 4, No. 12Genetic analysis of a PER-2-producing Shewanella sp. strain harbouring a variety of mobile genetic elements and antibiotic resistance determinantsJournal of Global Antimicrobial Resistance, Vol. 11Shewanella-Related Bacteremia and Fournier's Gangrene: A Case Report13 July 2016 | Open Forum Infectious Diseases, Vol. 3, No. 3Shewanella algae infection complicating an open lower limb fractureJournal of Plastic, Reconstructive & Aesthetic Surgery, Vol. 67, No. 3 Volume 14Issue 1Feb 2013 InformationCopyright 2013, Mary Ann Liebert, Inc.To cite this article:Nasim Ahmed, Kathleen Casey, Edward Liu, and Lito Fune.Necrotizing Fasciitis of the Lower Extremity Caused by Shewanella algae.Surgical Infections.Feb 2013.165-166.http://doi.org/10.1089/sur.2012.068Published in Volume: 14 Issue 1: March 14, 2013Online Ahead of Print:March 1, 2013PDF download

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.

Haemodynamic optimisation in lower limb arterial surgery: room for improvement?

Goal-directed therapy has been proposed to improve outcome in high-risk surgery patients. The aim of this study was to investigate whether individualised goal-directed therapy targeting stroke volume and oxygen delivery could reduce the number of patients with post-operative complications and shorten hospital length of stay after open elective lower limb arterial surgery. Forty patients scheduled for open elective lower limb arterial surgery were prospectively randomised. The LiDCO™plus system was used for haemodynamic monitoring. In the intervention group, stroke volume index was optimised by administering 250 ml aliquots of colloid intraoperatively and during the first 6 h post-operatively. Following surgery, fluid optimisation was supplemented with dobutamine, if necessary, targeting an oxygen delivery index level ≥ 600 ml/min(/) m(2) in the intervention group. Central haemodynamic data were blinded in control patients. Patients were followed up after 30 days. In the intervention group, stroke volume index, and cardiac index were higher throughout the treatment period (45 ± 10 vs. 41 ± 10 ml/m(2), P < 0.001, and 3.19 ± 0.73 vs. 2.77 ± 0.76 l/min(/) m(2), P < 0.001, respectively) as well as post-operative oxygen delivery index (527 ± 120 vs. 431 ± 130 ml/min(/) m(2), P < 0.001). In the same group, 5/20 patients had one or more complications vs. 11/20 in the control group (P = 0.05). After adjusting for pre-operative and intraoperative differences, the odds ratio for ≥ 1 complications was 0.18 (0.04-0.85) in the intervention group (P = 0.03). The median length of hospital stay did not differ between groups. Perioperative individualised goal-directed therapy may reduce post-operative complications in open elective lower limb arterial surgery.