Aims. A core outcome set for adult, open lower limb fracture has been established consisting of ‘Walking, gait and mobility’, ‘Being able to return to life roles’, ‘Pain or discomfort’, and ‘Quality of life’. This study aims to identify which outcome measurement instruments (OMIs) should be recommended to measure each core outcome. Methods. A systematic review and quality assessment were conducted to identify existing instruments with evidence of good measurement properties in the open lower limb fracture population for each core outcome. Additionally, shortlisting criteria were developed to identify suitable instruments not validated in the target population. Candidate instruments were presented, discussed, and voted on at a consensus meeting of key stakeholders. Results. The Wales Lower Limb Trauma Recovery scale was identified, demonstrating validation evidence in the target population. In addition, ten candidate OMIs met the shortlisting criteria. Six patients, eight healthcare professionals, and 11 research methodologists attended the consensus meeting. Consensus was achieved for the EuroQol five-dimension five-level questionnaire (EQ-5D-5L) and the Lower Extremity Functional Scale (LEFS) to measure ‘Quality of life’ and ‘Walking, gait and mobility’ in future research trials, audit, and clinical assessment, respectively. No instrument met consensus criteria to measure ‘Being able to return to life roles’ and ‘Pain or discomfort’. However, the EQ-5D-5L was found to demonstrate good face validity and could also be used pragmatically to measure these two outcomes, accepting limitations in sensitivity. Conclusion. This study recommends the LEFS and EQ-5D-5L to measure the core outcome set for adult open lower limb fracture. Cite this article: Bone Joint Res 2023;12(6):352–361

Aims. Open lower limb fracture is life-changing, resulting in substantial morbidity and resource demand, while inconsistent outcome-reporting hampers systematic review and meta-analysis. A core outcome set establishes consensus among key stakeholders for the recommendation of a minimum set of outcomes. This study aims to define a core outcome set for adult open lower limb fracture. Methods. Candidate outcomes were identified from a previously published systematic review and a secondary thematic analysis of 25 patient interviews exploring the lived experience of recovery from open lower limb fracture. Outcomes were categorized and sequentially refined using healthcare professional and patient structured discussion groups. Consensus methods included a multi-stakeholder two-round online Delphi survey and a consensus meeting attended by a purposive sample of stakeholders, facilitated discussion, and voting using a nominal group technique. Results. Thematic analysis and systematic review identified 121 unique outcomes, reduced to 68 outcomes following structured discussion groups. Outcomes were presented to 136 participants who completed a two-round online Delphi survey. The Delphi survey resulted in 11 outcomes identified as consensus ‘in’ only. All outcomes were discussed at a consensus meeting attended by 15 patients, 14 healthcare professionals, 11 researchers, and one patient-carer. Consensus was achieved for a four-core outcome set: ‘Walking, gait and mobility’, ‘Being able to return to life roles’, ‘Pain or discomfort’, and ‘Quality of life’. Conclusion. This study used robust consensus methods to establish a core outcome set that should be measured in all future research studies and audits of clinical practice without precluding the measurement of additional outcomes. Cite this article: Bone Joint Res 2023;12(4):294–305

Aims. Open lower limb fracture is a life-changing injury affecting 11.5 per 100,000 adults each year, and causes significant morbidity and resource demand on trauma infrastructures. This study aims to identify what, and how, outcomes have been reported for people following open lower limb fracture over ten years. Methods. Systematic literature searches identified all clinical studies reporting outcomes for adults following open lower limb fracture between January 2009 and July 2019. All outcomes and outcome measurement instruments were extracted verbatim. An iterative process was used to group outcome terms under standardized outcome headings categorized using an outcome taxonomy. Results. A total of 532 eligible studies were identified, reporting 1,803 outcomes with 786 unique outcome terms, which collapsed to 82 standardized outcome headings. Overall 479 individual outcome measurement instruments were identified, including 298 outcome definitions, 27 patient- and 18 clinician-reported outcome measures, and six physical performance measures. The most-reported outcome was ‘bone union/healing’ reported in over 50% of included studies, while health-related quality of life was only measured in 6% of included studies. Conclusion. Outcomes reported for people recovering from open lower limb fracture are heterogeneous, liable to outcome reporting bias, and vary widely in the definitions and the measurement tools used to collect them. Outcomes likely to be important to patients, such as quality of life and measures of physical functioning, have been neglected. This systematic review identifies the need to unify outcome measures reported on patients recovering from open lower limb fracture; this may be addressed by creating a core outcome set. Cite this article: Bone Joint Res 2023;12(2):138–146

Introduction. Open fractures are complex injuries associated with substantial morbidity. These injuries are associated with harm to both physical and emotional health as well as preclusion of work, social, and leisure activities. Patient reported outcome measures (PROMs) and health related quality of life are critical indicators of successful rehabilitation following open fracture treatment. This study aimed to measure the PROMs for patients with open lower limb fractures and investigate the relationship with injury severity. Materials & Methods. A retrospective cohort study was performed at a single major trauma centre in the UK. All adult patients with an open lower limb fracture were eligible for inclusion. Patients were identified through a search of a local Open Fracture Database. Epidemiological, clinical, and fracture classification data were obtained by reviewing case notes. Lower Extremity Function Scale (LEFS) and EQ5-D were used as PROMs and measured by a postal questionnaire, alongside return to employment data. Results. A total of 73 patients responded to the questionnaire. Median LEFS was 42 (IQR 26.5 – 59.5), and median EQ5-D was 0.69 (IQR 0.48 – 0.89). There was no significant association between open fracture classification and PROMs. Over 40% of patients reported a change in employment due to their injury. Those who changed jobs had a statistically significant reduction in the EQ5-D of 0.12 (p = 0.021); no significant difference existed in LEFS. Conclusions. This study demonstrates the devastating functional impact of open fractures. This cohort of open injuries reported lower functional and quality-of-life measures compared to population norms. Injury classification was not a valuable predictor of PROMs. A substantial proportion of patients were forced to change employment due to their injury, and these patients reported a significantly lower quality of life. Further work is required to understand the factors contributing to open fracture PROMs

Open lower limb fractures are resource-intensive fractures, accounting for a significant proportion of the workload and cost of orthopaedic trauma units. A recent study has evaluated that the median cost of direct inpatient treatment of open lower-limb fractures in the National Health Service (NHS) is steep, at £19189 per patient. Healthcare providers are expected to be aware of the costs of treatments, although there is very limited dissemination of this information, neither on a national or local level. Older adults (>65 years old) are at an increased risk of the types of high-energy injuries that can result in open lower limb fractures. Generally, there remains a significant lack of literature surrounding the cost of open fracture management, especially in specific patient groups that are disproportionately affected by these fractures. This study has calculated the direct inpatient care costs of older adults with open lower limb fractures. Open lower limb fractures in adult patients over 65 years old treated at Addenbrooke's Hospital of Cambridge University Hospitals NHS Trust were identified over the period of March 2014-March 2019. Isolated fractures of the femur, tibia and fibula over this time period were included. Direct inpatient care costs were calculated using information about the sustained fracture, operative time, implant(s) and theatre kit(s) used, the number of patient bed-days on the orthopaedic ward and critical care unit, and the number of hours of inpatient physiotherapy received. Direct inpatient care costs were compared with the income received by our centre for each of these cases, according to Healthcare Resource Group (HRG) cost codes. Our data was also compared with existing literature on Patient Level Costing (PLC) figures for open lower limb fractures. We extracted data from 58 patients over the age of 65 years treated for open isolated lower limb fractures at Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, between March 2014 and March 2019. The median cost of inpatient care calculated in this study was £20,398 per patient, resulting in a financial loss to the hospital of £5113 per patient. When the results were disaggregated by sex, the median cost for an open lower limb fracture in a male patient was £20,886 compared to £19,304 in a female patient. Data were also disaggregated by the site of injury, which produced a median cost for an open femur fracture of £23,949, and £24,549 and £15,362 for open tibia and ankle fractures, respectively. The absence of published primary literature and clinical audits on this topic continues to hinder the inclusion of cost-effectiveness as an important factor in clinical decision-making. This study provides valuable insight into the true cost of open lower limb fractures in a key patient population in a Major Trauma Centre in England and highlights the large losses incurred by hospitals in treating these cases. These results support the revision of the remuneration structures in the NHS for the treatment of elderly patients with these injuries

Aims. The aim of this study was to report the outcomes of patients with severe open fractures of the lower limb in the five years after they took part in the Wound management for Open Lower Limb Fracture (WOLLF) trial. Methods. The WOLLF trial compared standard dressings to negative pressure wound therapy (NPWT) applied at the end of the first surgical wound debridement, and patients were followed-up for 12 months. At 12 months, 170 of the original 460 participants agreed to take part in this medium-term follow-up study. Patients reported their Disability Rating Index (DRI) (0 to 100, where 100 is total disability) and health-related quality of life (HRQoL) using the EuroQol five-dimension three-level health questionnaire (EQ-5D-3L) annually by self-reported questionnaire. Further surgical interventions related to the open fracture were also recorded. Results. There was no evidence of a difference in patient-reported disability, HRQoL, or the need for further surgery between patients treated with NPWT versus standard dressings at five years. Considering the combined results for all participants, there was a small but statistically significant change in DRI scores over time (1.6 units per year; p = 0.005), but no evidence that EQ-5D-3L scores changed significantly during years two to five (p = 0.551). Conclusion. This study shows that the high levels of disability and reduced HRQoL reported by patients 12 months after severe open fractures of the lower limb persist in the medium term, with little evidence of improvement between years two and five. Cite this article: Bone Joint J 2022;104-B(5):633–639

Aims. Deep surgical site infection (SSI) is common after lower limb fracture. We compared the diagnosis of deep SSI using alternative methods of data collection and examined the agreement of clinical photography and in-person clinical assessment by the Centers for Disease Control and Prevention (CDC) criteria after lower limb fracture surgery. Methods. Data from two large, UK-based multicentre randomized controlled major trauma trials investigating SSI and wound healing after surgical repair of open lower limb fractures that could not be primarily closed (UK WOLLF), and surgical incisions for fractures that were primarily closed (UK WHiST), were examined. Trial interventions were standard wound care management and negative pressure wound therapy after initial surgical debridement. Wound outcomes were collected from 30 days to six weeks. We compared the level of agreement between wound photography and clinical assessment of CDC-defined SSI. We are also assessed the level of agreement between blinded independent assessors of the photographs. Results. Rates of CDC-defined deep SSI were 7.6% (35/460) after open fracture and 6.3% (95/1519) after closed incisional repair. Photographs were obtained for 77% and 73% of WOLLF and WHiST cohorts respectively (all participants n = 1,478). Agreement between photographic-SSI and CDC-SSI was fair for open fracture wounds (83%; k = 0.27 (95% confidence interval (CI) 0.14 to 0.42)) and for closed incisional wounds (88%; k = 0.29 (95% CI 0.20 to 0.37)) although the rate of photographically detected deep SSIs was twice as high as CDC-SSI (12% vs 6%). Agreement between different assessors for photographic-SSI (WOLLF 88%, k = 0.63 (95% CI 0.52 to 0.72); WHiST 89%; k = 0.61 (95% CI 0.54 to 0.69)); and wound healing was good (WOLLF 90%; k = 0.80 (95% CI 0.73 to 0.86); WHiST 87%; k = 0.57 (95% CI 0.50 to 0.64)). Conclusion. Although wound photography was feasible within the research context and inter-rater assessor agreement substantial, digital photographs used in isolation overestimated deep SSI rates, when compared to CDC criteria. Wound photography should not replace clinical assessment in pragmatic trials but may be useful for screening purposes where surgical infection outcomes are paramount. Cite this article: Bone Joint J 2021;103-B(12):1802–1808

We sought to evaluate the impact of a dedicated weekly ortho-plastics operating list on our ability to provide definitive soft tissue cover of open lower limb fractures within 72 hours. We reviewed all open lower limb fractures at our centre before and after the introduction of an ortho-plastics list to determine whether definitive soft tissue coverage was achieved within 72 hours. There were 23 open lower limb fractures at our centre in 2012 before the introduction of the ortho-plastics operating list of which only 7 (30%) had definitive soft tissue coverage within 72 hours. We hypothesised that the main reason for this was not patient or injury related factors but rather the logistical difficulties of coordinating theatre time on a routine trauma list with senior orthopaedic and plastic surgeon availability. To test this hypothesis we re-audited our time to soft tissue cover six months after the introduction of the ortho-plastics list and 70% of cases achieved coverage within 72 hours. Achieving definitive soft tissue coverage of open lower limb fractures within 72 hours of injury is a challenge. A dedicated weekly ortho-plastics operating list significantly improves our ability to deliver this service

Introduction. Lower limb open fractures are severe injuries, with a joint orthoplastic approach for management recommended by BOAST. An initial audit highlighted a discrepancy in time to definitive wound coverage between the Queen Elizabeth University Hospital (QEUH), which at the time was not an orthoplastic centre, and the Glasgow Royal Infirmary (GRI) which was. Our aim was to perform a secondary audit to identify if the introduction of an orthoplastic service at the QEUH led to a reduction in time to definitive wound coverage. Materials and Methods. Forty-six patients with open lower limb fractures treated at the QEUH in 2019 following introduction of the orthoplastic service were identified. Management including time to antibiotics and wound coverage, and rates of complication were compared with previous audit data. Results. Days to washout was similar between the second cohort of QEUH patients and the first (p=0.522), as was days to definitive management without plastics input (p=0.143). When plastics input was required, there was a reduction in days to wound coverage in the second cohort of QEUH patients compared to the first (3 days vs 8.5 days; p=0.002), and a similar time if compared to the GRI cohort (p=0.778). Conclusions. Time to definitive wound coverage was reduced in those that required plastics input in the second cohort of QEUH patients, with a similar time to that of the original GRI cohort. The QEUH now displays improved concordance with the BOAST guidelines, with definite wound coverage on average occurring within 72 hours

Aims. The management of open lower limb fractures in the United Kingdom has evolved over the last ten years with the introduction of major trauma networks (MTNs), the publication of standards of care and the wide acceptance of a combined orthopaedic and plastic surgical approach to management. The aims of this study were to report recent changes in outcome of open tibial fractures following the implementation of these changes. Patients and Methods. Data on all patients with an open tibial fracture presenting to a major trauma centre between 2011 and 2012 were collected prospectively. The treatment and outcomes of the 65 Gustilo Anderson Grade III B tibial fractures were compared with historical data from the same unit. . Results. The volume of cases, the proportion of patients directly admitted and undergoing first debridement in a major trauma centre all increased. The rate of limb salvage was maintained at 94% and a successful limb reconstruction rate of 98.5% was achieved. The rate of deep bone infection improved to 1.6% (one patient) in the follow-up period. . Conclusion. The reasons for these improvements are multifactorial, but the major trauma network facilitating early presentation to the major trauma centre, senior orthopaedic and plastic surgical involvement at every stage and proactive microbiological management, may be important factors. . Take home message: This study demonstrates that a systemised trauma network combined with evidence based practice can lead to improvements in patient care. Cite this article: Bone Joint J 2016;98-B:420–4

Introduction. The BOAST (British Orthopaedic Association Standards for Trauma) guidelines do advise that open pilon fractures amongst other open lower limb fractures need to be treated at a specialist centre with Orthoplastic care. The purpose of this study was to determine clinical outcomes in patients with open pilon fractures treated as per BOAST guidelines including relatively aggressive bone debridement. Methods. A retrospective analysis of a single surgeon series of open pilon fractures treated between 2014 and 2019 was conducted. Injuries were graded according to the Gustillo-Anderson classification and all patients were included for the assessment of the rate of infection and fracture healing. Functional outcome assessment was performed in all patients according to the American Orthopedic Foot and Ankle Score (AOFAS) at 6 months after definitive surgery. Initial wound with bone debridement and application of a spanning external fixator was performed within an average of 13.5 (Range: 3–24) hours. Fixation with FWF (Fine Wire Frame) was performed when the wound was healed, with the mean time from primary surgery to application of FWF being 24.5 (Range: 7–60) days. Results. There was a total of 20 patients including 16 males and 4 females. The mean age was 50.45 (Range: 16–88) years. Follow-up was for an average of 23.2 (Range: 5–51) months. There were 3 patients with Gustilo Type I injuries, 6 with Type II, 4 Type with type IIIa and 7 with Type IIIb injuries. Average time to bone union was 9.3 (Range: 2–18) months. The mean AOFAS score was 66 (Range: 15–97) points. TSF was used on 18 patients, while 2 patients had an Ilizarov frame. A corticotomy was performed on 4 patients with critical bone defect post debridement, while 2 patients had Stimulan beads with antibiotics. There was 1 case (5%) of deep infection and 9 cases (45%) of superficial infection. There were also 2 cases (10%) of non-union which required bone grafting from their femur using a RIA (Reamer Irrigation Aspirator). Other complications included 1 case of acute compartment syndrome, 1 case of pulmonary embolism, 1 case of necrotic skin and 1 case of amputation. Conclusion. Results of our study suggests that the use of staged wound debridement including relatively aggressive bone debridement in conjunction with antibiotics, external fixators and patient tailored conversion from spanning external fixator to fine wire frame achieves low rates of wound infection and complications for patients with open pilon fractures

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 Fisher's 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

Aims. The BOA/BAPRAS guidelines for the management of open tibial fractures (2009) recommend early senior combined orthoplastics input and appropriate facilities to manage a high caseload. St Georges Hospital is one of four London Trauma Centres fulfilling these criteria. Our aim is to determine whether becoming a trauma centre has affected the management of patients with open tibial fractures. Methods. Data were obtained prospectively on consecutive open tibial fractures during two 8 month periods: before and after becoming a Major Trauma Centre (May 2009–Dec 2009 and April 2010–Oct 2010 respectively). Data on patient pathway including, admitting hospital, length of stay, timing and number of operations were recorded. Results. 29 open tibial fractures were admitted during the 8 months after designation as a major trauma centre compared to 15 before. 72% of patients came directly, or as A&E hot transfers (previously 60%). Of the eight tertiary transfers, six were from hospitals outside the South West Trauma Network. The time to transfer patients initially admitted to local orthopaedic departments has fallen from 8.6 to 1.6 days. Despite this improvement as a trauma centre, these patients remained in hospital longer (16.3 vs 14.9) and had more operations (3.7 vs 2.6) than direct admissions. As a trauma centre there were improvements in time to definitive skeletal stabilisation (4.7 to 2.2), skin coverage (8.3 to 3.7 days), average number of operations (4.2 to 2.3) and average length of hospital admission fell from 23 to 16 days. Conclusions. The volume and management of open tibial fractures has been directly affected by introduction of a trauma centre within the London Trauma Network. Implementation of BOAST guidelines has resulted in improved management of open lower limb fractures independent of fracture grade. Our data strongly support the continuing development of trauma networks

The February 2024 Trauma Roundup³⁶⁰ looks at: Posterior malleolus fractures: what about medium-sized fragments?; Acute or delayed total hip arthroplasty after acetabular fracture fixation?; Intrawound antibiotics reduce the risk of deep infections in fracture fixation; Does the VANCO trial represent real world patients?; Can a restrictive transfusion protocol be effective beyond initial resuscitation?; What risk factors result in avascular necrosis of the talus?; Pre-existing anxiety and mood disorders have a role to play in complex regional pain syndrome; Three- and four-part proximal humeral fractures at ten years.

Aims

Clinical management of open fractures is challenging and frequently requires complex reconstruction procedures. The Gustilo-Anderson classification lacks uniform interpretation, has poor interobserver reliability, and fails to account for injuries to musculotendinous units and bone. The Ganga Hospital Open Injury Severity Score (GHOISS) was designed to address these concerns. The major aim of this review was to ascertain the evidence available on accuracy of the GHOISS in predicting successful limb salvage in patients with mangled limbs.

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To describe outcome reporting variation and trends in non-pharmacological randomized clinical trials (RCTs) of distal tibia and/or ankle fractures.

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This is a multicentre, prospective assessment of a proportion of the overall orthopaedic trauma caseload of the UK. It investigates theatre capacity, cancellations, and time to surgery in a group of hospitals that is representative of the wider population. It identifies barriers to effective practice and will inform system improvements.

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The aim of this study was to investigate the relationship between the Orthopaedic Trauma Society (OTS) classification of open fractures and economic costs.

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Periprosthetic joint infections (PJIs) and fracture-related infections (FRIs) are associated with a significant risk of adverse events. However, there is a paucity of data on cardiac complications following revision surgery for PJI and FRI and how they impact overall mortality. Therefore, this study aimed to investigate the risk of perioperative myocardial injury (PMI) and mortality in this patient cohort.

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Despite long-standing dogma, a clear relationship between the timing of surgical irrigation and debridement (I&D) and the development of subsequent deep infection has not been established in the literature. Traditionally, I&D of an open fracture has been recommended within six hours of injury based on animal studies from the 1970s, however the clinical basis for this remains unclear. Using data from a multicentre randomized controlled trial of 2,447 open fracture patients, the primary objective of this secondary analysis is to determine if a relationship exists between timing of wound I&D (within six hours of injury vs beyond six hours) and subsequent reoperation rate for infection or healing complications within one year for patients with open limb fractures requiring surgical treatment.