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Thomas B, Hackenberg RK, Krasniqi D, Eisa A, Böcker A, Gazyakan E, Bigdeli AK, Kneser U, Harhaus-Wähner L. [Modern concepts of interdisciplinary extremity reconstruction in open fractures]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:469-480. [PMID: 38739196 DOI: 10.1007/s00113-024-01437-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/08/2024] [Indexed: 05/14/2024]
Abstract
The orthoplastic approach involves the collaboration of orthopedic/trauma surgeons, vascular surgeons and reconstructive microsurgeons. In cases of complex limb fractures, the aims are to optimize blood flow, restore bone stability, reconstruct soft tissue defects, and enhance function and sensitivity. The early administration of antibiotics and a timely, high-quality debridement after initial interdisciplinary assessment are carried out. This is followed by fracture stabilization and temporary wound coverage in order to plan the definitive interdisciplinary procedure. This includes definitive osteosynthesis and soft tissue reconstruction, using local tissue transfer if feasible, or free tissue transfer in cases of extensive trauma zones. The orthoplastic approach allows for faster definitive stabilization, fewer operations, shorter hospital stays, lower complication and revision rates, higher cost-effectiveness and improved long-term function.
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Affiliation(s)
- Benjamin Thomas
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland.
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland.
| | - Roslind K Hackenberg
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Demir Krasniqi
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Amr Eisa
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Arne Böcker
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Emre Gazyakan
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Amir K Bigdeli
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Ulrich Kneser
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Leila Harhaus-Wähner
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
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Yim GH, Pikturnaite J, Harry L, Clement R, Pope-Jones S, Emam A, Marsden N. Enhanced recovery for acute open lower limb fracture 'fix and flap'. Injury 2024; 55:111234. [PMID: 38029681 DOI: 10.1016/j.injury.2023.111234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 10/10/2023] [Accepted: 11/20/2023] [Indexed: 12/01/2023]
Abstract
INTRODUCTION Enhanced recovery (ER) aims to achieve earlier recovery, reduced hospital length of stay (LoS) whilst improving outcomes. Our ER protocol for acute lower-limb open fracture (ALLOFs) includes dangling at day 3 and mobilising fully weight-bearing from day 5. Our aims were to evaluate the outcomes of ALLOFs using our ER protocol for limb salvage, LoS following 'fix & flap', return to theatre, rate of successful flap salvage, flap failure and deep infection rates. METHODS An observational study of a prospectively maintained lower limb flap database from September 2020 to January 2023 was undertaken. Search criteria encompassed patients with a Gustilo IIIB/C injury and a free flap reconstruction. Exclusions were for local/perforator flaps, soft tissue injury only, fracture related/prosthetic joint infections, or chronic osteomyelitis cases. RESULTS 161 patients were available for analysis, 126 male (78 %) and 35 female (22 %) with a median age of 40 years (12-79, interquartile range 30.0). 81 % of cases were high-energy injuries. For all patients, the median time to definitive fixation and soft tissue coverage from injury was 4 days (0-30, interquartile range 2). 18 cases (11.2 %) required return to theatre for flap exploration; 11 cases were successfully salvaged (61 %). Nine free flaps failed (5.4 %). The median total LoS from admission was 10 days (6 to 46, interquartile range 5), with a median LoS following definitive fixation and soft tissue coverage of 7 days (4 to 20, interquartile range 3). The median follow-up period was 18 months (12 to 38.2, interquartile range 9), with a deep infection rate of 6.5 %. CONCLUSION In isolated ALLOFs, our ER protocol is safe and effective in shortening the LoS. Our outcomes sit comfortably within acceptable ranges of contemporary literature for return to theatre, flap salvage/failure and deep infection. Our ER protocol actively involves our allied health professional colleagues early to facilitate discharge.
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Affiliation(s)
- Guang Hua Yim
- The Welsh Centre for Burns & Plastics, Morriston Hospital, Heol Maes Eglwys, Morriston SA6 6NL, Swansea, United Kingdom; Major Trauma Centre, University Hospital of Wales, Cardiff CF14 4XW, United Kingdom
| | - Jurga Pikturnaite
- The Welsh Centre for Burns & Plastics, Morriston Hospital, Heol Maes Eglwys, Morriston SA6 6NL, Swansea, United Kingdom; Major Trauma Centre, University Hospital of Wales, Cardiff CF14 4XW, United Kingdom
| | - Lorraine Harry
- The Welsh Centre for Burns & Plastics, Morriston Hospital, Heol Maes Eglwys, Morriston SA6 6NL, Swansea, United Kingdom; Major Trauma Centre, University Hospital of Wales, Cardiff CF14 4XW, United Kingdom
| | - Rhys Clement
- The Welsh Centre for Burns & Plastics, Morriston Hospital, Heol Maes Eglwys, Morriston SA6 6NL, Swansea, United Kingdom; Orthopaedic department, Morriston Hospital, Heol Maes Eglwys, Morriston SA6 6NL, Swansea, United Kingdom
| | - Sophie Pope-Jones
- The Welsh Centre for Burns & Plastics, Morriston Hospital, Heol Maes Eglwys, Morriston SA6 6NL, Swansea, United Kingdom; Major Trauma Centre, University Hospital of Wales, Cardiff CF14 4XW, United Kingdom
| | - Ahmed Emam
- The Welsh Centre for Burns & Plastics, Morriston Hospital, Heol Maes Eglwys, Morriston SA6 6NL, Swansea, United Kingdom; Major Trauma Centre, University Hospital of Wales, Cardiff CF14 4XW, United Kingdom
| | - Nicholas Marsden
- The Welsh Centre for Burns & Plastics, Morriston Hospital, Heol Maes Eglwys, Morriston SA6 6NL, Swansea, United Kingdom; Major Trauma Centre, University Hospital of Wales, Cardiff CF14 4XW, United Kingdom.
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Levin SR, Burke PA, Brahmbhatt TS, Siracuse JJ, Slama J, Roh DS. Assessment of Risk Factors Correlated with Outcomes of Traumatic Lower Extremity Soft Tissue Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4961. [PMID: 37124392 PMCID: PMC10132714 DOI: 10.1097/gox.0000000000004961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/06/2023] [Indexed: 05/02/2023]
Abstract
Identifying risk factors for traumatic lower extremity reconstruction outcomes has been limited by sample size. We evaluated patient and procedural characteristics associated with reconstruction outcomes using data from almost four million patients. Methods The National Trauma Data Bank (2015-2018) was queried for lower extremity reconstructions. Univariable and multivariable analyses determined associations with inpatient outcomes. Results There were 4675 patients with lower extremity reconstructions: local flaps (77%), free flaps (19.2%), or both (3.8%). Flaps were most commonly local fasciocutaneous (55.1%). Major injuries in reconstructed extremities were fractures (56.2%), vascular injuries (11.8%), and mangled limbs (2.9%). Ipsilateral procedures prereconstruction included vascular interventions (6%), amputations (5.6%), and fasciotomies (4.3%). Postoperative surgical site infection and amputation occurred in 2% and 2.6%, respectively. Among survivors (99%), mean total length of stay (LOS) was 23.2 ± 21.1 days and 46.8% were discharged to rehab. On multivariable analysis, vascular interventions prereconstruction were associated with increased infection [odds ratio (OR) 1.99, 95% confidence interval (CI) 1.05-3.79, P = 0.04], amputation (OR 4.38, 95% CI 2.56-7.47, P < 0.001), prolonged LOS (OR 1.59, 95% CI 1.14-2.22, P = 0.01), and discharge to rehab (OR 1.49, 95% CI 1.07-2.07, P = 0.02). Free flaps were associated with prolonged LOS (OR 2.08, 95% CI 1.74-2.49, P < 0.001). Conclusions Prereconstruction vascular interventions were associated with higher incidences of adverse outcomes. Free flaps correlated with longer LOS, but otherwise similar outcomes. Investigating reasons for increased complication and healthcare utilization likelihood among these subgroups is warranted.
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Affiliation(s)
- Scott R. Levin
- From the Division of Plastic and Reconstructive Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Peter A. Burke
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Tejal S. Brahmbhatt
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Jeffrey J. Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Jaromir Slama
- From the Division of Plastic and Reconstructive Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Daniel S. Roh
- From the Division of Plastic and Reconstructive Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
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Grigor EJM, Bitoiu B, Zeitouni C, Zhang J. Patient-reported outcomes following free flap lower extremity reconstruction: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2023; 76:251-267. [PMID: 36566631 DOI: 10.1016/j.bjps.2022.08.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 07/12/2022] [Accepted: 08/18/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Free flap reconstruction in the lower extremity has shown success for the management of large and complex defects, restoration of function, and favorable aesthetic outcomes. Patient-reported outcomes (PROs) have not been well explored in previous literature. This meta-analysis aimed to provide a comprehensive summary of PROs after free flap reconstruction in the lower extremity. METHODS We searched MEDLINE and Embase from 1946 to 2021 for studies reporting on PROs following free flap reconstruction in the lower extremity. RESULTS Overall, 53 studies were included, and 11 studies reported validated PRO measures for meta-analysis. A total of 1953 patients underwent reconstruction with 1958 free flaps for lower limb defects with a mean follow-up of 3.26 (0.25-7.83) months. The mean postoperative Lower Extremity Functional Scale (LEFS) scores were 60.3 (±12) out of 80 points (4 studies, 85 patients). The mean postoperative AOFAS scores were 75.1 (±15) out of 100 points (4 studies, 68 patients). The mean postoperative SF-36 scores were 88.1 (±8.0) out of 100 points; mental health component was 48.7 (±8.9), and physical component was 38.4 (±8.2), out of 50 points (4 studies, 88 patients). CONCLUSION Our findings demonstrated that patients report improved physical health, mental health, and function following lower extremity reconstruction with free flaps. Patients reported similar improvements in functional scores following lower extremity reconstruction regardless of their free flap type. Furthermore, patients with myocutaneous flaps may have improved mental health and worse physical health scores when compared to perforator flaps. The evidence profiles presented in this review indicate that additional research is needed to help guide future decision-making.
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Affiliation(s)
- Emma J M Grigor
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ontario, Ottawa, Canada; MD Program, Faculty of Medicine, University of Ottawa, Ontario, Ottawa, Canada
| | - Brendon Bitoiu
- Department of Surgery, Division of Plastics and Reconstructive Surgery, The Ottawa Hospital, Ontario, Ottawa, Canada
| | - Camille Zeitouni
- MD Program, Faculty of Medicine, University of Ottawa, Ontario, Ottawa, Canada
| | - Jing Zhang
- Department of Surgery, Division of Plastics and Reconstructive Surgery, The Ottawa Hospital, Ontario, Ottawa, Canada.
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Hadfield JN, Omogbehin TS, Brookes C, Walker R, Trompeter A, Bretherton CP, Gray A, Eardley WGP. The Open-Fracture Patient Evaluation Nationwide (OPEN) study : epidemiology of open fracture care in the UK. Bone Jt Open 2022; 3:746-752. [PMID: 36181319 PMCID: PMC9626856 DOI: 10.1302/2633-1462.310.bjo-2022-0079.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
AIMS Understanding of open fracture management is skewed due to reliance on small-number lower limb, specialist unit reports and large, unfocused registry data collections. To address this, we carried out the Open Fracture Patient Evaluation Nationwide (OPEN) study, and report the demographic details and the initial steps of care for patients admitted with open fractures in the UK. METHODS Any patient admitted to hospital with an open fracture between 1 June 2021 and 30 September 2021 was included, excluding phalanges and isolated hand injuries. Institutional information governance approval was obtained at the lead site and all data entered using Research Electronic Data Capture. Demographic details, injury, fracture classification, and patient dispersal were detailed. RESULTS In total, 1,175 patients (median age 47 years (interquartile range (IQR) 29 to 65), 61.0% male (n = 717)) were admitted across 51 sites. A total of 546 patients (47.1%) were employed, 5.4% (n = 63) were diabetic, and 28.8% (n = 335) were smokers. In total, 29.0% of patients (n = 341) had more than one injury and 4.8% (n = 56) had two or more open fractures, while 51.3% of fractures (n = 637) occurred in the lower leg. Fractures sustained in vehicle incidents and collisions are common (38.8%; n = 455) and typically seen in younger patients. A simple fall (35.0%; n = 410) is common in older people. Overall, 69.8% (n = 786) of patients were admitted directly to an orthoplastic centre, 23.0% (n = 259) were transferred to an orthoplastic centre after initial management elsewhere, and 7.2% were managed outwith specialist units (n = 81). CONCLUSION This study describes the epidemiology of open fractures in the UK. For a decade, orthopaedic surgeons have been practicing in a guideline-driven, network system without understanding the patient features, injury characteristics, or dispersal processes of the wider population. This work will inform care pathways as the UK looks to the future of trauma networks and guidelines, and how to optimize care for patients with open fractures.Cite this article: Bone Jt Open 2022;3(10):746-752.
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Affiliation(s)
- James N. Hadfield
- Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough, UK,Correspondence should be sent to James N. Hadfield. E-mail:
| | | | - Charlotte Brookes
- Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough, UK
| | - Reece Walker
- Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough, UK
| | | | | | - Andrew Gray
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - William G. P. Eardley
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK,Clinical Trials Unit, University of York, York, UK,Teesside University, Middlesbrough, UK
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Ferry AM, Gimenez AR, Abu-Ghname A, Xue EY, Pederson WC, Lazo DÁA, Maricevich M. Reconstruction of Complex Lower Extremity Defects. CURRENT SURGERY REPORTS 2022. [DOI: 10.1007/s40137-022-00315-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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