International Lower Limb Collaborative (INTELLECT) study: a multicentre, international retrospective audit of lower extremity open fractures

Free tissue transfer for limb salvage following acute diabetes-related foot infections: A multicentre outcome study of success and failure

BACKGROUND

In cases of limb-threatening diabetes-related foot infections (DFIs), the primary goal of treatment is to control the infection while maintaining as much functional limb as possible. Aggressive surgical debridement is one of the cornerstones of treatment. Once the infection is controlled, extensive soft tissue defects with exposed vital structures such as bone or joint may remain, limiting the mobility of the patient and posing a risk for the development of new (deep) infections. One possible treatment option for these soft tissue defects is free tissue transfer (FTT). Although reported FTT success rates in diabetic foot ulcers are over 90%, patient selection and indications for FTT in diabetic foot disease vary widely in the literature, and little has been described about FTT after limb-threatening DFI.

METHODS

This multicentre, retrospective study included patients that underwent FTT after a limb-threatening DFI between 01-01-2017 and 01-03-2024 in four Dutch hospitals. The primary outcome was flap success rate within 30 days. Secondary outcomes included limb salvage within 90 days, incidence of major amputation during follow-up, ulcer recurrence, and ambulation.

RESULTS

Fourteen patients with a limb-threatening DFIs were included. The flap survival rate within 30 days was 78.6% (11/14). Limb salvage within 90 days was 92.9% (13/14). The total incidence of major amputations during follow-up was 28.6% (4/14), performed after flap failure in one and ulcer recurrence in three patients.

CONCLUSION

Our results suggest that FTT following acute limb-threatening DFI is technically feasible and may increase the chance of limb salvage.

Assessment of applicability of Ganga Hospital Score in the management of open tibia fracture

Aims

Open fractures of the tibia encompass a wide spectrum of injuries, posing multiple challenges for treating surgeons. This study evaluates the Ganga Hospital Open Injury Severity Score (GHOISS) in predicting the outcomes of open tibia fractures in Rwanda, focusing on its ability to guide wound management choices and assist in decision-making between preservation and amputation.

Methods

This was a prospective cohort study conducted between March and September 2022 in Kigali, Rwanda, involving patients aged 18 years and older with open tibial fractures. The GHOISS was calculated, and the patients were organized into three groups: Group I: score 1 to 13; Group II: score 14 to 16; and Group III: score ≥ 17. Outcome data were collected at one and six months of follow-up. The predictive validity of the GHOISS was determined through sensitivity, specificity, and predictive values. Correlation and analysis of variance (ANOVA) tests were also conducted to compare groups. Ethical considerations were respected, and institutional review board approval was obtained.

Results

The study involved 111 participants, with a mean age of 34 years (18 to 80) and a male-to-female ratio of 3.44:1. The amputation rate was 10 (9.0%), with a mean hospital stay of 30.55 days (SD 34.09). The infection rate was 54.05%, and the need for soft-tissue reconstruction was 36.9%. The GHOISS in predicting the amputation showed high sensitivity of 100% and sensitivity of 96.03%, with a positive predictive value of 71.4% and negative predictive value of 100%. ANOVA revealed significant differences between the groups (F (2,108) = 21.12; p < 0.001), and a strong positive correlation was found between the covering tissue score and the need for soft-tissue reconstruction.

Conclusion

The GHOISS demonstrated a remarkable ability to predict amputation and salvage in open tibia fractures and the potential for predicting related outcomes. The GHOISS subscore, which assesses skin and covering injuries, has shown a significant ability to predict the need for soft-tissue reconstruction.

Flap coverage within 8 days does not increase fracture-related infection risk: results of a protocol implementation in a developing country

INTRODUCTION

Open tibia fractures that require a soft tissue flap for adequate coverage (Gustilo- Anderson IIIB) are a significant challenge for trauma units. The incidence of fracture-related infection (FRI) has been reported to range between 10% and 52%. Early antibiotic therapy, followed by surgical debridement and early soft tissue coverage, is considered a safe and effective treatment. Typically, the gold standard is the "fix and flap" approach. However, local circumstances can impact the feasibility of early flap coverage. This study aims to determine whether there is a safe window for soft tissue coverage when an immediate ortho-plastic approach is not available.

MATERIALS AND METHODS

In this retrospective analysis of a prospective cohort of 803 patients who sustained a tibia fracture and were treated in a level I trauma centre in a developing country, we describe a local protocol of management. Of all the patients, 61 met the inclusion criteria and were followed for at least 12 months after flap coverage. The primary outcome was the development of FRI.

RESULTS

Patients who underwent flap surgery within 8 days of the fracture, following the local protocol, had a 12.5% infection rate.

CONCLUSIONS

Utilizing a standardized management protocol followed by soft tissue flap coverage performed within 8 days is safe and effective in reducing the risk of developing FRI in open tibia fractures GA IIIB.

The benefit of national clinical guidelines for open lower limb fractures in reducing healthcare burden: A length of inpatient stay cost-analysis

INTRODUCTION

Severe open lower limb fractures are complex and costly injuries. Studies reporting the costs associated with these injuries, the economic impact of complications, and the clinical benefit of adherence to national guidelines have been previously reported. However, the economic benefits of national guidelines and their relationship with length of inpatient stay have not been described.

METHODS

An international retrospective cohort study, using length of stay as a proxy for in-hospital economic impact, comparing the duration of inpatient stay in countries with national guidelines and those without.

RESULTS

In a cohort of 2641 patients from 16 countries, length of stay was 17 % lower in countries with national guidelines, equivalent to 2-3 fewer inpatient days per patient. This difference was primarily driven by a lower incidence of deep infection observed in countries with national clinical guidelines.

CONCLUSION

The presence of national guidelines for the management of severe lower limb injuries is associated with both improved clinical outcomes and reduced length of stay and therefore healthcare burden. Whilst application and adoption of national guidelines is not without challenges, their implementation is associated with significant clinical and economic benefits.

Anatomic study of propeller flaps based on perforators of the posterior tibial artery

Lower limb injuries resulting from sports activities, industrial accidents, and traffic incidents represent a significant global healthcare challenge. These injuries often entail a high risk of complications, especially when fractures are associated with substantial soft tissue damage. Open fractures classified as Gustilo type II or III are particularly susceptible to complications such as fistula and osteomyelitis. Globally, millions of lower limb injuries are reported annually, leading to considerable morbidity and escalating healthcare costs. The standard treatment for shin ulcers with bone exposure involves the debridement of necrotic tissue, followed by coverage of the defect with well-vascularized tissue. Classical flaps are employed in certain cases; however, their applicability, along with techniques such as pedicled muscle flaps from the rectus abdominis or tensor fasciae latae muscles, depends on the extent and location of the injury. Classical flaps are employed in certain cases, but their applicability depends on the extent and location of the injury. Given these limitations, propeller flaps have emerged as highly effective alternatives for microsurgical reconstruction in lower limb recovery. The objective of our study was to delineate the anatomy and demonstrate the utility of propeller flaps based on the perforators of the posterior tibial artery. By providing detailed anatomical insights, we aimed to highlight the strategic advantages of propeller flaps in complex lower limb reconstruction cases.

Avoiding "a piece of paper on the wall that everyone ignores": A qualitative study on the barriers for implementing open fracture guidelines

BACKGROUND

Ortho-plastic evidence-based clinical guidelines for open fractures have demonstrated to standardise care and improve outcomes for patients admitted following lower extremity trauma. Despite its benefits, very few countries have introduced such guidance. The aim of this study was to explore the attitudes, barriers and limitations to the development and implementation of guidelines for lower limb open fractures METHODS: Twelve renowned orthopaedic and plastic surgeons, based in countries with no guidelines at present, underwent semi-structured interviews. A qualitative appraisal was conducted using reflexive thematic analysis methodology. Systematic coding led to the development and refinement of themes to address the research question.

RESULTS

Individualistic decision-making, reliance on multidisciplinary interpersonal relationships, and the presence of immobile determinants of open fracture care emerged as three themes that define how patients are currently managed in settings with no guidelines in place. Although guidelines can potentially improve care by presenting evidence-based recommendations, introducing audit practices, establishing pathways for multidisciplinary collaboration, and enhancing effective leadership; if barriers to the implementation are not considered, they may end up as a "piece of paper on the wall that everyone ignores" CONCLUSIONS: This study is the first to explore the challenges of introducing ortho-plastic guidelines for open extremity trauma. The themes presented describe the status quo in settings with no such protocols in place, establishing the foundation for future initiatives aiming to provide a practical strategy to aid the development and introduction of clinical guidelines for open lower limb fractures.

The economic impact of open lower limb fractures in the Netherlands: a cost-of-illness study

PURPOSE

To estimate the one-year sum of direct costs related to open lower limb fracture treatment in an academic setting in the Netherlands. The secondary objective was to estimate the impact of deep infection and nonunion on one-year total direct costs.

METHODS

A multi-center, retrospective cost analysis of open lower limb fractures treated in an academic setting in the Netherlands, between 1 January 2017 and 31 December 2018, was conducted. The costing methodology was based on patient level aggregation using a bottom-up approach. A multiple linear regression model was used to predict the total costs based on Fracture-related-infections, multitrauma, intensive care unit (ICU) admission, Gustilo-Anderson grade and nonunion.

RESULTS

Overall, 70 fractures were included for analysis, the majority Gustilo-Anderson grade III fractures (57%). Median (IQR) one-year hospital costs were €31,258 (20,812-58,217). Costs were primarily attributed to the length of hospital stay (58%) and surgical procedures (30%). The median length of stay was 16 days, with an increase to 50 days in Fracture-related infections. Subsequent costs (46,075 [25,891-74,938] vs. 15,244 [8970-30,173]; p = 0.002), and total hospital costs (90,862 [52,868-125,004] vs. 29,297 [21,784-40,677]; p < 0.001) were significantly higher for infected cases. It was found that Fracture-related infection, multitrauma, and Gustilo-Anderson grade IIIA-C fractures were significant predictors of increased costs.

CONCLUSION

In treatment of open lower limb fractures, deep infection, higher Gustilo-Anderson classification, and multitrauma significantly increase direct hospital costs. Considering the impact of infection on morbidity and total healthcare costs, future research should focus on preventing Fracture-related infections.

An evaluation of the management of severe open tibial fractures in the United Kingdom's major trauma centres

AIM

To evaluate the management of patients with severe open tibial fractures at major trauma centres (MTCs) in the UK with respect to BOAST 4 guidelines.

METHODS

Data collected by the Trauma and Audit Research Network (TARN) for all severe open tibial fractures treated at the 23 adult MTCs were evaluated. Key performance indicators (KPIs) included MTC admission under orthoplastics, administration of antibiotics within three hours of injury, initial debridement within 24 h and definitive fixation and soft tissue coverage within 72 h. Outcomes included 30-day infection rate, amputation rate and mortality rate. A score was calculated according to overall attainment of KPIs, and correlated to outcomes.

RESULTS

From 2014 to 2020, 3359 adults with Gustilo-Anderson (GA) IIIB and/or IIIC fractures were admitted to MTCs. Male to female ratio was 2:1 with a mean age of 43 and 65 years respectively. There was a negative correlation between KPI score and mortality rate (r=-0.4929, p = 0.0169). Direct admission to an MTC was positively correlated with receipt of antibiotics within three hours (r = 0.5452, p = 0.0070). Joint orthoplastic plans were documented in 89 % of patients (MTC range 30-95 %). Soft tissue cover was achieved within 72 h for 48 % (MTC range 5.23-89.39 %). Patients over 65 were significantly more likely to have a delay to MTC admission and prophylactic antibiotic administration. Mortality rate in this group was 6% vs 2 % in those under 65. The older cohort were twice as likely to require an amputation.

CONCLUSION

This is the largest cohort of open tibial injuries managed in the UK with wide variation in practice between centres demonstrated and better adherence to BOAST guidelines linked to reduced mortality in those aged 65 and over. The older cohort of patients also had higher rates of infection and amputation. It is unclear whether these poor outcomes are due to the pre-morbid physiological status of the patient or non-compliance to Standards. We present these data to highlight the need for improved adherence to Standards - the adoption of a scoring system provides a simple way to evidence this.

Comparing outcomes following direct admission and early transfer to specialized trauma centers in open tibial fracture treatment: a systematic review and meta-analysis

INTRODUCTION

Guidelines on the management of open tibia fractures recommend timely treatment in a limb reconstruction center which offer joint orthopedic-trauma and plastic surgery services. However, patient's transfer between centers remains inevitable. This review aims to evaluate the clinical outcomes and hospital factors for patients directly admitted and transferred patients to a limb-reconstruction center.

METHODS

A research protocol adhering to PRISMA standards was established. The search included databases like MEDLINE, EMBASE, and the Cochrane library up until March 2023. Nine articles met the inclusion criteria, focusing on open tibia fractures. Exclusion criteria were experimental studies, animal studies, and case reports. Outcomes of interest were operation and infection rates, nonunion, limb salvage, and the Enneking limb score.

RESULTS

The analysis involved data from 520 patients across nine studies published between 1990 and 2023, with the majority (83.8%) having Gustilo Anderson type III open tibia fractures. Directly admitted patients showed lower overall infection rates (RR 0.30; 95% CI 0.10-0.90; P = 0.03) and fewer deep infections (RR 0.39; 95% CI 0.22-0.68; P = 0.001) compared to transferred patients. Transferred patients experienced an average five-day delay in soft tissue closure and extended hospital stays by eight days. Patients transferred without initial surgical management underwent fewer total surgical procedures. The direct admission group displayed more favorable functional outcomes.

CONCLUSION

Low- to moderate-quality evidence indicates worse clinical outcomes for transferred patients compared to directly admitted patients. Early treatment in specialized limb reconstruction units is essential for improved results in the management of open tibia fractures.

LEVEL OF EVIDENCE

Therapeutic level IIa.

How Porcine Acellular Dermal Matrix Influences the Development of the Breast Capsule 1 Year after Implantation: A Histopathological Analysis

Background

In prepectoral breast reconstruction (PPBR) the acellular dermal matrix (ADM)'s integration capacity into the tissue is known. The aim of this study was to analyze the effect of the ADM on development and composition of the peri-implant breast capsule in a dynamic setting of breast tissue expansion during two-stage prepectoral breast reconstruction.

Methods

This is a prospective single-center study in which 50 patients who underwent mastectomy and breast reconstruction with prepectoral tissue expander and Braxon ADM (group A) and submuscular tissue expander (group B) were enrolled. One-year post implantation hematoxylin & eosin (H&E) staining and immunohistochemistry analyses were done on capsule tissue samples.

Results

The analysis conducted on H&E-stained samples showed a significant reduction of cellular density and a decrease of the cellular infiltration in capsules of ADM-covered expanders compared with naked expander capsules (P < 0.05). The immunohistochemical analyses showed that group A capsules presented significantly less M1 CD68+ macrophages (P < 0.05), lower alfa-SMA expression levels, and a lower number of myofibroblasts (P < 0.05) compared with group B capsules. Presence of lymphatic vessels was minimally detected in both groups.

Conclusions

The ADM presence around the prepectoral tissue expander influences the development of the peri-implant capsule, causing a significant reduction of the number of cells and inflammatory infiltrate, especially M1 macrophages and myofibroblasts. The ADM Braxon is therefore effective in creating a noninflamed capsule around the implant and in dynamic tissue conditions, and such an environment is maintained in time.