Between June 1999 and May 2003 we undertook direct
The Open-Fracture Patient Evaluation Nationwide (OPEN) study was performed to provide clarity in open fracture management previously skewed by small, specialist centre studies and large, unfocused registry investigations. We report the current management metrics of open fractures across the UK. Patients admitted to hospital with an open fracture (excluding phalanges or isolated hand injuries) between 1 June 2021 and 30 September 2021 were included. Institutional information governance approval was obtained at the lead site and all data entered using Research Electronic Data Capture software. All domains of the British Orthopaedic Association Standard for Open Fracture Management were recorded.Aims
Method
The aim of this study was to investigate the relationship between the Orthopaedic Trauma Society (OTS) classification of open fractures and economic costs. Resource use was measured during the six months that followed open fractures of the lower limb in 748 adults recruited as part of two large clinical trials within the UK Major Trauma Research Network. Resource inputs were valued using unit costs drawn from primary and secondary sources. Economic costs (GBP sterling, 2017 to 2018 prices), estimated from both a NHS and Personal Social Services (PSS) perspective, were related to the degree of complexity of the open fracture based on the OTS classification.Aims
Methods
To describe a new objective classification for open fractures of the lower limb and to correlate the classification with patient-centred outcomes. The proposed classification was investigated within a cohort of adults with open fractures of the lower limb who were recruited as part of two large clinical trials within the UK Major Trauma Network. The classification was correlated with patient-reported Disability Rating Index (DRI) and EuroQol five-dimension questionnaire (EQ-5D) health-related quality of life in the year after injury, and with deep infection at 30 days, according to the Centers for Disease Control and Prevention definition of a deep surgical site infection.Aims
Methods
It has been generally accepted that open fractures require early skeletal stabilization and soft-tissue reconstruction. Traditionally, a standard gauze dressing was applied to open wounds. There has been a recent shift in this paradigm towards negative pressure wound therapy (NPWT). The aim of this study was to compare the clinical outcomes in patients with open tibial fractures receiving standard dressing versus NPWT. This multicentre randomized controlled trial was approved by the ethical review board of a public sector tertiary care institute. Wounds were graded using Gustilo-Anderson (GA) classification, and patients with GA-II to III-C were included in the study. To be eligible, the patient had to present within 72 hours of the injury. The primary outcome of the study was patient-reported Disability Rating Index (DRI) at 12 months. Secondary outcomes included quality of life assessment using 12-Item Short-Form Health Survey questionnaire (SF-12), wound infection rates at six weeks and nonunion rates at 12 months. Logistic regression analysis and independent-samples Aims
Methods
Type IIIB open tibial fractures are devastating high-energy injuries. At initial debridement, the surgeon will often be faced with large bone fragments with tenuous, if any, soft-tissue attachments. Conventionally these are discarded to avoid infection. We aimed to determine if orthoplastic reconstruction using mechanically relevant devitalized bone (ORDB) was associated with an increased infection rate in type IIIB open tibial shaft fractures. This was a consecutive cohort study of 113 patients, who had sustained type IIIB fractures of the tibia following blunt trauma, over a four-year period in a level 1 trauma centre. The median age was 44.3 years (interquartile range (IQR) 28.1 to 65.9) with a median follow-up of 1.7 years (IQR 1.2 to 2.1). There were 73 male patients and 40 female patients. The primary outcome measures were deep infection rate and number of operations. The secondary outcomes were nonunion and flap failure.Aims
Patient and Methods
Fractures of the distal femur can be challenging to manage and
are on the increase in the elderly osteoporotic population. Management
with casting or bracing can unacceptably limit a patient’s ability
to bear weight, but historically, operative fixation has been associated
with a high rate of re-operation. In this study, we describe the outcomes
of fixation using modern implants within a strategy of early return
to function. All patients treated at our centre with lateral distal femoral
locking plates (LDFLP) between 2009 and 2014 were identified. Fracture
classification and operative information including weight-bearing
status, rates of union, re-operation, failure of implants and mortality
rate, were recorded.Aims
Patients and Methods
This study describes the use of the Masquelet technique to treat
segmental tibial bone loss in 12 patients. This retrospective case series reviewed 12 patients treated between
2010 and 2015 to determine their clinical outcome. Patients were
mostly male with a mean age of 36 years (16 to 62). The outcomes
recorded included union, infection and amputation. The mean follow-up
was 675 days (403 to 952). Aims
Patients and Methods
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. 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. Aims
Patients and Methods
This is a retrospective study of survivors of
recent conflicts with an open fracture of the femur. We analysed
the records of 48 patients (48 fractures) and assessed the outcome.
The median follow up for 47 patients (98%) was 37 months (interquartile
range 19 to 53); 31 (66%) achieved union; 16 (34%) had a revision
procedure, two of which were transfemoral amputation (4%). The New Injury Severity Score, the method of fixation, infection
and the requirement for soft-tissue cover were not associated with
a poor outcome. The degree of bone loss was strongly associated
with a poor outcome (p = 0.00204). A total of four patients developed
an infection; two with This study shows that, compared with historical experience, outcomes
after open fractures of the femur sustained on the battlefield are
good, with no mortality and low rates of infection and late amputation.
The degree of bone loss is closely associated with a poor outcome. Cite this article:
Controversy continues to surround the management
of patients with an open fracture of the lower limb and an associated
vascular injury (Gustilo type IIIC). This study reports our 15-year
experience with these fractures and their outcome in 18 patients
(15 male and three female). Their mean age was 30.7 years (8 to
54) and mean Mangled Extremity Severity Score (MESS) at presentation
was 6.9 (3 to 10). A total of 15 lower limbs were salvaged and three underwent
amputation (two immediate and one delayed). Four patients underwent
stabilisation of the fracture by external fixation and 12 with an
internal device. A total of 11 patients had damage to multiple arteries
and eight had a vein graft. Wound cover was achieved with a pedicled
flap in three and a free flap in six. Seven patients developed a
wound infection and four developed nonunion requiring further surgery.
At a mean follow-up of five years (4.1 to 6.6) the mean visual analogue
scale for pain was 64 (10 to 90). Depression and anxiety were common.
Activities were limited mainly because of pain, and the MESS was
a valid predictor of the functional outcome. Distal tibial fractures
had an increased rate of nonunion when associated with posterior
tibial artery damage, and seven patients (39%) were not able to
return to their previous occupation.
We describe 261 peripheral nerve injuries sustained
in war by 100 consecutive service men and women injured in Iraq
and Afghanistan. Their mean age was 26.5 years (18.1 to 42.6), the
median interval between injury and first review was 4.2 months (mean
8.4 months (0.36 to 48.49)) and median follow-up was 28.4 months
(mean 20.5 months (1.3 to 64.2)). The nerve lesions were predominantly
focal prolonged conduction block/neurapraxia in 116 (45%), axonotmesis
in 92 (35%) and neurotmesis in 53 (20%) and were evenly distributed
between the upper and the lower limbs. Explosions accounted for
164 (63%): 213 (82%) nerve injuries were associated with open wounds.
Two or more main nerves were injured in 70 patients. The ulnar,
common peroneal and tibial nerves were most commonly injured. In
69 patients there was a vascular injury, fracture, or both at the
level of the nerve lesion. Major tissue loss was present in 50 patients:
amputation of at least one limb was needed in 18. A total of 36 patients
continued in severe neuropathic pain. This paper outlines the methods used in the assessment of these
injuries and provides information about the depth and distribution
of the nerve lesions, their associated injuries and neuropathic
pain syndromes.
This is a case series of prospectively gathered
data characterising the injuries, surgical treatment and outcomes
of consecutive British service personnel who underwent a unilateral
lower limb amputation following combat injury. Patients with primary,
unilateral loss of the lower limb sustained between March 2004 and
March 2010 were identified from the United Kingdom Military Trauma
Registry. Patients were asked to complete a Short-Form (SF)-36 questionnaire.
A total of 48 patients were identified: 21 had a trans-tibial amputation,
nine had a knee disarticulation and 18 had an amputation at the
trans-femoral level. The median New Injury Severity Score was 24 (mean
27.4 (9 to 75)) and the median number of procedures per residual
limb was 4 (mean 5 (2 to 11)). Minimum two-year SF-36 scores were
completed by 39 patients (81%) at a mean follow-up of 40 months
(25 to 75). The physical component of the SF-36 varied significantly
between different levels of amputation (p = 0.01). Mental component
scores did not vary between amputation levels (p = 0.114). Pain
(p = 0.332), use of prosthesis (p = 0.503), rate of re-admission
(p = 0.228) and mobility (p = 0.087) did not vary between amputation
levels. These findings illustrate the significant impact of these injuries
and the considerable surgical burden associated with their treatment.
Quality of life is improved with a longer residual limb, and these
results support surgical attempts to maximise residual limb length. Cite this article:
The aim of this study was to report the pattern
of severe open diaphyseal tibial fractures sustained by military personnel,
and their orthopaedic–plastic surgical management. Cite this article:
In this retrospective study we evaluated the method of acute shortening and distraction osteogenesis for the treatment of tibial nonunion with bone loss in 17 patients with a mean age of 36 years (10 to 58). The mean bone loss was 5.6 cm (3 to 10). In infected cases, we performed the treatment in two stages. The mean follow-up time was 43.5 months (24 to 96). The mean time in external fixation was 8.0 months (4 to 13) and the mean external fixator index was 1.4 months/cm (1.1 to 1.8). There was no recurrence of infection. The bone evaluation results were excellent in 16 patients and good in one, while functional results were excellent in 15 and good in two. The complication rate was 1.2 per patient. We conclude that acute shortening and distraction osteogenesis is a safe, reliable and successful method for the treatment of tibial nonunion with bone loss, with a shorter period of treatment and lower rate of complication.
The open blast fracture of the pelvis is considered
to be the most severe injury within the spectrum of battlefield trauma.
We report our experience of 29 consecutive patients who had sustained
this injury in Afghanistan between 2008 and 2010. Their median new
injury severity score (NISS) was 41 (8 to 75), and mean blood requirement
in the first 24 hours was 60.3 units (0 to 224). In addition to
their orthopaedic injury, six had an associated vascular injury, seven
had a bowel injury, 11 had a genital injury and seven had a bladder
injury. In all, eight fractures were managed definitively with external
fixation and seven required internal fixation. Of those patients
who underwent internal fixation, four required removal of metalwork
for infection. Faecal diversion was performed in nine cases. The
median length of hospital stay following emergency repatriation
to the United Kingdom was 70.5 days (5 to 357) and the mean total
operating time was 29.6 hours (5 to 187). At a mean follow-up of
20.3 months (13.2 to 29.9), 24 patients (82.8%) were able to walk
and 26 (89.7%) had clinical and radiological evidence of stability
of the pelvic ring. As a result of the increase in terrorism, injuries that were
previously confined exclusively to warfare can now occur anywhere,
with civilian surgeons who are involved in trauma care potentially
required to manage similar injuries. Our study demonstrates that
the management of this injury pattern demands huge resources and significant
multidisciplinary input. Given the nature of the soft-tissue injury,
we would advocate external fixation as the preferred management
of these fractures. With the advent of emerging wound and faecal
management techniques, we do not believe that faecal diversion is
necessary in all cases.
The types of explosive devices used in warfare
and the pattern of war wounds have changed in recent years. There has,
for instance, been a considerable increase in high amputation of
the lower limb and unsalvageable leg injuries combined with pelvic
trauma. The conflicts in Iraq and Afghanistan prompted the Department
of Military Surgery and Trauma in the United Kingdom to establish
working groups to promote the development of best practice and act
as a focus for research. In this review, we present lessons learnt in the initial care
of military personnel sustaining major orthopaedic trauma in the
Middle East.
We carried out a retrospective review of 47 intra-articular fractures of the calcaneum treated by open reduction and internal fixation in 45 patients by a single surgeon between 1993 and 2001. The fractures were evaluated before operation by plain radiographs and a CT scan using Sanders’ classification. Osteosynthesis involved a lateral approach and the use of the AO calcaneal plate. The mean follow-up was for ten years (7 to 15). Clinical assessment included the American Orthopaedic Foot and Ankle Society Score (AOFAS), the Creighton-Nebraska Score, the Kerr, Prothero, Atkins Score and the SF-36 Health Questionnaire. The radiological evaluation consisted of lateral and axial views of the os calcis. Arthritic changes in the subtalar joint were assessed with an internal oblique view and were graded using the Morrey and Wiedeman scale. There were 18 excellent (38.3%), 17 good (36.2%), three fair (6.3%) and nine poor (19.2%) results. Five patients had a superficial wound infection and five others eventually had a subtalar arthrodesis because of continuing pain. Restoration of Böhler’s angle was associated with a better outcome. The degree of arthritic change in the subtalar joint did not correlate with the outcome scores or Sanders’ classification. Prompt osteosynthesis should be considered for intra-articular fractures of the calcaneum in order to restore the shape of the hindfoot and Böhler’s angle.
Heterotopic ossification occurring after the use of commercially available bone morphogenetic proteins has not been widely reported. We describe four cases of heterotopic ossification in patients treated with either recombinant bone morphogenetic protein 2 or recombinant bone morphogenetic protein 7. We found that while some patients were asymptomatic, heterotopic ossification which had occurred around a joint often required operative excision with good results.
Limb-injury severity scores are designed to assess orthopaedic and vascular injuries. In Gustilo type-IIIA and type-IIIB injuries they have poor sensitivity and specificity to predict salvage or outcome. We have designed a trauma score to grade the severity of injury to the covering tissues, the bones and the functional tissues, grading the three components from one to five. Seven comorbid conditions known to influence the management and prognosis have been given a score of two each. The score was validated in 109 consecutive open injuries of the tibia, 42 type-IIIA and 67 type-IIIB. The total score was used to assess the possibilities of salvage and the outcome was measured by dividing the injuries into four groups according to their scores as follows: group I scored less than 5, group II 6 to 10, group III 11 to 15 and group IV 16 or more. A score of 14 to indicate amputation had the highest sensitivity and specificity. Our trauma score compared favourably with the Mangled Extremity Severity score in sensitivity (98% and 99%), specificity (100% and 17%), positive predictive value (100% and 97.5%) and negative predictive value (70% and 50%), respectively. A receiver-operating characteristic curve constructed for 67 type-IIIB injuries to assess the efficiency of the scores to predict salvage, showed that the area under the curve for this score was better (0.988 (± 0.013 The scoring system was found to be simple in application and reliable in prognosis for both limb-salvage and outcome measures in type-IIIA and type-IIIB open injuries of the tibia.