The development of a novel patient-derived recovery scale for open tibial fractures.

AIMS: The aim of this study was to develop a psychometrically sound measure of recovery for use in patients who have suffered an open tibial fracture. METHODS: An initial pool of 109 items was generated from previous qualitative data relating to recovery following an open tibial fracture. These items were field tested in a cohort of patients recovering from an open tibial fracture. They were asked to comment on the content of the items and structure of the scale. Reduction in the number of items led to a refined scale tested in a larger cohort of patients. Principal components analysis permitted further reduction and the development of a definitive scale. Internal consistency, test-retest reliability, and responsiveness were assessed for the retained items. RESULTS: The initial scale was completed by 35 patients who were recovering from an open tibial fracture. Subjective and objective analysis permitted removal of poorly performing items and the addition of items suggested by patients. The refined scale consisted of 50 Likert scaled items and eight additional items. It was completed on 228 occasions by a different cohort of 204 patients with an open tibial fracture recruited from several UK orthoplastic tertiary referral centres. There were eight underlying components with tangible real-life meaning, which were retained as sub-scales represented by ten Likert scaled and eight non-Likert items. Internal consistency and test-retest reliability were good to excellent. CONCLUSION: The Wales Lower Limb Trauma Recovery (WaLLTR) Scale is the first tool to be developed from patient data with the potential to assess recovery following an open tibial fracture. Cite this article: Bone Joint J 2020;102-B(1):17-25.

Orthopedic treatment for open fracture of lower extremities and soft tissue defects in young children and rapid rehabilitation after operation.

Objective: This study aims to explore the clinical features of open fracture of lower extremities with soft tissue injury in young children, and its surgical and postoperative rehabilitation methods.Methods: A total of 32 children with open fracture of lower extremities and soft tissue injury treated in our department from January 2010 to December 2016 were included into this study. An individualized treatment plan was established according to the characteristics of each patient's condition, and rapid rehabilitation procedures were carried out after the operation to promote the healing of the wound, and shape and function recovery.Results: In the present study, four children developed superficial infection after the operation, and healed after proper management. Furthermore, two children were found to have osteomyelitis during follow-up after discharge, and healed after they returned to the hospital for debridement. All patients were followed up until fracture healing, and the follow-up duration ranged within 6-15 months, with an average duration of 8.5 months. All patients achieved bony union, and none of the patients had bone exposure. In the curative effect assessment, 24 children were classified as excellent, six children were classified as good, one child was classified as moderate, and one child was classified as poor. The excellent and good rate was 93.75%.Conclusions: Open fracture of the lower extremities commonly occur in the middle and lower segment of the tibia and fibula in children, and is usually combined with soft tissue injury. The correct treatment of fractures, and skin and soft tissue injuries, as well as the rapid rehabilitation of children, are the keys to achieving a good clinical effect.

Luxación erecta expuesta de hombro en un niño: reporte de un caso / Erect shoulder dislocation in a child: case report / Erecto luxação do ombro em uma criança: relato de caso

La luxación erecta expuesta de hombro es una asociación lesional de muy baja frecuencia en la edad pediátrica. Son más frecuentes las lesiones fisarias y epifisarias que las luxaciones y lesiones ligamentarias. Esto es debido a la presencia de un tejido óseo con gran poder de deformidad elástica y un periostio grueso. Presentamos un caso clínico de un paciente de 11 años de edad que sufrió una luxación erecta expuesta de hombro derecho, producto de una caída de 1 metro y medio de altura. El tratamiento consistió en una limpieza quirúrgica de urgencia, reducción gleno humeral y antibioticoterapia empírica, penicinila 400.000 UI/kg/día fraccionado cada 6 hs y gentamicina 3mg/Kg/día fraccionada cada 8 h por 10 días, inmovilización por 3 semanas con cabestrillo seguido de rehabilitación, y un follow up de 2 años al final del cual el paciente no presento secuelas funcionales en la articulación glenohumeral derecha.

The exposed erect dislocation of the shoulder is a very low frequency lesion association in the pediatric age. The physical and epiphyseal lesions are more frequent than the dislocations and ligament injuries. This is due to the presence of a bone tissue with great elastic deformity power and a thick periosteum. We present a clinical case of an 11-year-old patient who suffered an exposed erect dislocation of the right shoulder, due to a fall of 1 meter and a half high. The treatment consisted of emergency surgical cleaning, humeral gleno reduction and empirical antibiotic therapy, penicinila 400,000 IU/kg/day divided every 6 hours and gentamicin 3mg/Kg/day divided every 8 hours for 10 days, immobilization for 3 weeks with a sling followed by rehabilitation, and a follow-up of 2 years at the end of which the patient did not present functional sequelae in the right glenohumeral joint.

A luxação ereta exposta do ombro é uma associação de lesão de freqüência muito baixa na idade pediátrica. As lesões físicas e epifisárias são mais freqüentes que as luxações e lesões ligamentares. Isto é devido à presença de um tecido ósseo com grande poder de deformidade elástica e um periósteo espesso. Apresentamos um caso clínico de um paciente de 11 anos de idade que sofreu uma luxação ereta exposta do ombro direito, devido a uma queda de 1 metro e meio de altura. O tratamento consistiu em limpeza cirúrgica de emergência, redução de gleno umeral e antibioticoterapia empírica, penicinila 400.000 UI / kg / dia dividida a cada 6 horas e gentamicina 3mg / Kg / dia dividida a cada 8 horas por 10 dias, imobilização por 3 semanas com tipóia seguida de reabilitação e seguimento de 2 anos no final dos quais o paciente não apresentava sequela funcional na articulação glenoumeral direita.

Patient coping and expectations predict recovery after major orthopaedic trauma.

BACKGROUND: Persistent post-surgical pain and associated disability are common after a traumatic fracture repair. Preliminary evidence suggests that patients' beliefs and perceptions may influence their prognosis. METHODS: We used data from the Fluid Lavage of Open Wounds trial to determine, in 1560 open fracture patients undergoing surgical repair, the association between Somatic PreOccupation and Coping (captured by the SPOC questionnaire) and recovery at 1 yr. RESULTS: Of the 1218 open fracture patients with complete data available for analysis, 813 (66.7%) reported moderate to extreme pain at 1 yr. The addition of SPOC scores to an adjusted regression model to predict persistent pain improved the concordance statistic from 0.66 to 0.74, and found the greatest risk was associated with high (≥74) SPOC scores [odds ratio: 5.63; 99% confidence interval (CI): 3.59-8.84; absolute risk increase 40.6%; 99% CI: 30.8%, 48.6%]. Thirty-eight per cent (484 of 1277) reported moderate to extreme pain interference at 1 yr. The addition of SPOC scores to an adjusted regression model to predict pain interference improved the concordance statistic from 0.66 to 0.75, and the greatest risk was associated with high SPOC scores (odds ratio: 6.06; 99% CI: 3.97-9.25; absolute risk increase: 18.3%; 95% CI: 11.7%, 26.7%). In our adjusted multivariable regression models, SPOC scores at 6 weeks post-surgery accounted for 10% of the variation in short form-12 physical component summary scores and 14% of short form-12 mental component summary scores at 1 yr. CONCLUSIONS: Amongst patients undergoing surgical repair of open extremity fractures, high SPOC questionnaire scores at 6 weeks post-surgery were predictive of persistent pain, reduced quality of life, and pain interference at 1 yr. CLINICAL TRIAL REGISTRATION: NCT00788398.

Economic outcomes associated with deep surgical site infection in patients with an open fracture of the lower limb.

AIMS: The aim of this study was to estimate economic outcomes associated with deep surgical site infection (SSI) in patients with an open fracture of the lower limb. PATIENTS AND METHODS: A total of 460 patients were recruited from 24 specialist trauma hospitals in the United Kingdom Major Trauma Network. Preference-based health-related quality-of-life outcomes, assessed using the EuroQol EQ-5D-3L and the 6-Item Short-Form Health Survey questionnaire (SF-6D), and economic costs (£, 2014/2015 prices) were measured using participant-completed questionnaires over the 12 months following injury. Descriptive statistics and multivariate regression analysis were used to explore the relationship between deep SSI and health utility scores, quality-adjusted life-years (QALYs), and health and personal social service (PSS) costs. RESULTS: Deep SSI was associated with lower EQ-5D-3L derived QALYs (adjusted mean difference -0.102, 95% confidence interval (CI) -0.202 to 0.001, p = 0.047) and increased health and social care costs (adjusted mean difference £1950; 95% CI £1383 to £5285, p = 0.250) versus patients without deep SSI over the 12 months following injury. CONCLUSION: Deep SSI may lead to significantly impaired health-related quality of life and increased economic costs. Our economic estimates can be used to inform clinical and budgetary service planning and can act as reference data for future economic evaluations of preventive or treatment interventions. Cite this article: Bone Joint J 2018;100-B:1506-10.

Wound irrigation does not affect health-related quality of life after open fractures: results of a randomized controlled trial.

AIMS: The Fluid Lavage in Open Fracture Wounds (FLOW) trial was a multicentre, blinded, randomized controlled trial that used a 2 × 3 factorial design to evaluate the effect of irrigation solution (soap versus normal saline) and irrigation pressure (very low versus low versus high) on health-related quality of life (HRQL) in patients with open fractures. In this study, we used this dataset to ascertain whether these factors affect whether HRQL returns to pre-injury levels at 12-months post-injury. PATIENTS AND METHODS: Participants completed the Short Form-12 (SF-12) and the EuroQol-5 Dimensions (EQ-5D) at baseline (pre-injury recall), at two and six weeks, and at three, six, nine and 12-months post-fracture. We calculated the Physical Component Score (PCS) and the Mental Component Score (MCS) of the SF-12 and the EQ-5D utility score, conducted an analysis using a multi-level generalized linear model, and compared differences between the baseline and 12-month scores. RESULTS: We found no clinically important differences between irrigating solutions or pressures for the SF-12 PCS, SF-12 MCS and EQ-5D. Irrespective of treatment, participants had not returned to their pre-injury function at 12-months for any of the three outcomes (p < 0.001). CONCLUSION: Neither the composition of the irrigation solution nor irrigation pressure applied had an effect on HRQL. Irrespective of treatment, patients had not returned to their pre-injury HRQL at 12 months post-fracture. Cite this article: Bone Joint J 2018;100-B:88-94.

Combat-related acetabular fractures: Outcomes of open versus closed injuries.

INTRODUCTION: Since the onset of the Global War on Terror close to 50,000 United States service members have been injured in combat, many of these injuries would have previously been fatal. Among these injuries, open acetabular fractures are at an increased number due to the high percentage of penetrating injuries such as high velocity gunshot wounds and blast injuries. These injuries lead to a greater degree of contamination, and more severe associated injuries. There is a significantly smaller proportion of the classic blunt trauma mechanism typically seen in civilian trauma. METHODS: We performed a retrospective review of the Department of Defense Trauma Registry into which all US combat-injured patients are enrolled, as well as reviewed local patient medical records, and radiologic studies from March 2003 to April 2012. Eighty seven (87) acetabular fractures were identified with 32 classified as open fractures. Information regarding mechanism of injury, fracture pattern, transfusion requirements, Injury Severity Score (ISS), and presence of lower extremity amputations was analyzed. RESULTS: The mechanism of injury was an explosive device in 59% (n=19) of patients with an open acetabular fracture; the remaining 40% (n=13) were secondary to ballistic injury. In contrast, in the closed acetabular fracture cohort 38% (21/55) of fractures were due to explosive devices, and all remaining (n=34) were secondary to blunt trauma such as falls, motor vehicle collisions, or aircraft crashes. Patients with open acetabular fractures required a median of 17units of PRBC within the first 24h after injury. The mean ISS was 32 in the open group compared with 22 in the closed group (p=0.003). In the open fracture group nine patients (28%) sustained bilateral lower extremity amputations, and 10 patients (31%) ultimately underwent a hip disarticulation or hemi-pelvectomy as their final amputation level. DISCUSSION: Open acetabular fractures represent a significant challenge in the management of combat-related injuries. High ISS and massive transfusion requirements are common in these injuries. This is one of the largest series reported of open acetabular fractures. Open acetabular fractures require immediate damage control surgery and resuscitation as well as prolonged rehabilitation due to their severity. The dramatic number of open acetabular fractures (37%) in this review highlights the challenge in treatment of combat related acetabular fractures.

Bone union with an in situ spacer after the first stage of the induced membrane technique.

INTRODUCTION: We report a case of an infected bone defect in the tibia in which the treatment was stopped in the first stage of the induced membrane technique. The polymethylmethacrylate (PMMA) spacer, retained in the bone defect, was encapsulated by the bone regeneration. CASE REPORT: A 37-year-old male patient with a 7-cm infected bone defect in the tibia was submitted to the first stage of the induced membrane technique with debridement and implantation of a PMMA spacer with antibiotics. The patient refused the second stage of the procedure and achieved bone union with the spacer in situ. There was no recurrence of infection at the 6-year follow-up. CONCLUSION: his is the first report of a case in which bone union was achieved with the spacer in situ after the first stage of the induced membrane technique. Keeping the spacer in the bone defect could be an option in some exceptional situations.

The "Road to Union" protocol for the reconstruction of isolated complex high-energy tibial trauma.

INTRODUCTION: The purpose of this study was to describe a standardized staged approach, "The Road to Union", for the reconstruction of isolated complex tibial trauma, both acute and chronic in nature. METHODS: This retrospective study included all patients treated for complex tibial trauma at a specialized limb reconstruction centre, including acute open fracture as well as infected and aseptic non-unions. This standardized approach includes eight specific steps, employed in sequence. The time in external fixation (EFT), the external fixation index (EFI), and the distraction consolidation index (DCI) were the primary outcome measures. The relationship between EFI and DCI was assessed using Pearson's moment correlations. RESULTS: Thirty-two patients with a mean age of 34.7±14.2years were included; 12 were treated for complex open tibial fractures with bone loss, 13 for infected non-unions, and 6 for aseptic non-union. The mean bone defect was 66±32mm. The total EFT was 42.5±14.8 weeks; the EFI measured 51.9±25.3 days/cm, and the DCI measured 48.3±21.4 days/cm. Union was achieved in 29 out of 32 patients (91%), and there was a strong and significant relationship between EFI and DCI (r=0.92, p=0.0001) measurements. Pin site infections were observed in 11 patients, and 3 patients had persistent non-union. Three patients underwent delayed amputations when reconstructive procedures were unable to achieve union. CONCLUSION: The findings of this study demonstrate that a standardized staged treatment protocol of debridement, circular external fixation, soft-tissue management, distraction osteogenesis, and functional rehabilitation can result in a high rate of union in cases of complex tibial trauma, both acute and chronic in nature. LEVEL OF EVIDENCE: Level IV; case series.

Open lower limb fractures in Major Trauma Centers - A loss leader?

PURPOSE: Open lower limb fractures are resource intensive injuries. Regardless of the financing model, the cost of treatment is an important consideration for any healthcare provider. METHODS: Open lower limb fractures treated at our centre were identified over a six-month period. Isolated open femur or tibia fractures were included as well as cases with multiple fractures. Direct inpatient care costs were calculated and income was reviewed for each case according to 'Healthcare Resource Group' (HRG) cost codes. RESULTS: A total of 41 open lower limb fractures (32 patients) were identified. There were isolated open fractures in twenty-five and multiple lower limb open fractures in seven patients. Twenty-three patients (72%) were male and nine were female (28%) with an average age of 40 years (range 10-89 years). The fractures were classified according to Gustilo and Anderson (GA) and divided into two main groups; there were 13 mild and 28 severe open fractures. The median direct cost of inpatient treatment for open lower limb fractures was £19,189 per patient. There was a net gain of £6,288 per fracture in the mild group and a loss of £7,582 in the severe group. The total deficit was £149,545 over the six-month period for this cohort of 41 fractures. CONCLUSION: Open lower limb fractures are expensive to treat at a cost of approximately £19,200 per patient and associated with a significant loss of income in our MTC. Cost codes should reflect the complex and more expensive treatment of these patients to avoid the inadvertent financial 'penalties' of treating such patients. This study is the first to calculate the direct inpatient treatment costs of open lower limb fractures in a major trauma centre. It highlights the need for cost saving strategies and for appropriate remuneration in MTCs.

Knee megaprosthesis: a salvage solution for severe open and complex distal femoral fracture associated with an ipsilateral brachial plexus injury (a case report with literature review).

Complex distal femoral fractures in the young patient often occur as a result of high velocity trauma. Timely recognition and treatment is everything in such a situation, and it needs a robust staged management pathway to optimize the chance of limb preservation. We report a case of a motorcyclist admitted to the department of orthopedics at Chambery hospital, France, with a complex comminuted and open distal femoral fracture of the left leg, associated with a brachial plexus injury to the ipsilateral upper limb. On arrival to the emergency department, damage control stabilization and surgery was commenced, debridement of contaminated non-viable tissue, abundant antiseptic lavage and application of external fixation coupled with the use of antibiotic spacer. Following normalization of inflammatory markers and ensuring no clinical signs of infection, subsequent management consisted of joint reconstruction to achieve a functional knee. The external fixator and femoral spacer was removed and a modular megaprosthesis was implanted with a lateral gastrocnemius flap to cover the exposed knee joint and reinforce the extensor apparatus. Nerve graft to the left brachial plexus injury was performed at University Hospital of Grenoble. Our patient entered an intensive rehabilitation program and at 1 year follow-up achieved good knee function and sensation to the left upper limb.

Assessing functional mobility after lower limb reconstruction: a psychometric evaluation of a sensor-based mobility score.

OBJECTIVE: To develop and validate a robust, objective mobility assessment tool, Hamlyn Mobility Score (HMS), using a wearable motion sensor. BACKGROUND: Advances in reconstructive techniques allow more limbs to be salvaged. However, evidence demonstrating superior long-term outcomes compared with amputation is unavailable. Lack of access to quality regular functional mobility status may be preventing patients and health care staff from optimizing rehabilitation programs and evaluating the reconstructive services. METHODS: In this prospective cohort study, 20 patients undergoing lower limb reconstruction and 10 age-matched controls were recruited. All subjects completed the HMS activity protocol twice under different instructors at 3 months postoperatively, and again at 6 months, while wearing an ear-worn accelerometer. Demographic and clinical data were also collected including a short-form health survey (SF-36). HMS parameters included standard test metrics and additional kinematic features extracted from accelerometer data. A psychometric evaluation was conducted to ascertain reliability and validity. RESULTS: The HMS demonstrated excellent reliability (intraclass correlation coefficient >0.90, P < 0.001) and internal consistency (Cronbach α = 0.897). Concurrent validity was demonstrated by correlation between HMS and SF-36 scores (Spearman ρ = 0.666, P = 0.005). Significant HMS differences between healthy subjects and patients, stratified according to fracture severity, were shown (Kruskal-Wallis nonparametric 1-way analysis of variance, χ = 21.5, P < 0.001). The HMS was 50% more responsive to change than SF-36 (effect size: 1.49 vs 0.99). CONCLUSIONS: The HMS shows satisfactory reliability and validity and may provide a platform to support adaptable, personalized rehabilitation and enhanced service evaluation to facilitate optimal patient outcomes.

Treatment of seawater immersion-complicated open-knee joint fracture.

The current study aimed to select suitable remedies for seawater immersion-complicated open-knee joint fracture by exploring the effects of different treatment methods. Forty adult rabbits weighing 2.20 ± 0.25 kg were divided equally into internal fracture fixation group (A), seawater-immersed group with primary internal fixation (B), seawater-immersed group with secondary internal fixation (C), and seawater-immersed group with external fixation (D), using the random-digit table method. Open-femoral internal condylar fracture models were established. Group A was left untreated for 2 h, whereas the other three groups were subjected to seawater immersion for 2 h. Afterwards, groups A and B underwent debridement and steel plate and screw internal fixation. Group C underwent debridement and external fixation, which was followed by secondary steel plate and screw internal fixation after the wound healed. Group D underwent transarticular arthrodesis. Wound infection, joint functional rehabilitation, and radiological and histopathological changes in fracture healing in each group were assessed. The results showed that delayed internal fixation effectively reduces the infection rate of seawater immersion-complicated open fracture and benefits joint function rehabilitation.

Clinical evaluation of patients with osteomyelitis after open fractures treated at the Hospital de Urgências de Goiânia, Goiás / Avaliação clínica de pacientes com osteomielite crônica após fraturas expostas tratados no Hospital de Urgências de Goiânia, Goiás

OBJECTIVE: To evaluate clinically patients with chronic osteomyelitis after open fractures, treated in the Hospital of urgencies in Goiania. METHODS: A cross-sectional study, with data collection through questionnaire, from a review of medical records. We collected data on the type of trauma and the clinical characteristics of the patient. The hour of attendance and the injuries on the patients were collected, and then classified according to Gustilo and Anderson (1976). Samples of the lesion during the surgical procedure were collected for culture of pathogenic microorganisms. The analyzes were performed using STATA/SE version 8.0. Descriptive analysis was performed (absolute and relative frequencies) and to verify existence of association between variables was performed using thur-square or Fisher's Exact Test. This study was approved by the Research Ethics Committee of the Hospital and Emergency in Goiania. RESULTS: There was predominance of male adult, presenting open fractures with increased involvement of the leg bones or in two or more bones (polytrauma). The majority of patients presented with a lesion type III (high-energy trauma). There was loss of excessive time since the time of the accident until the initial surgical care. We detected the presence of gram-positive cultures of material obtained after the diagnosis of osteomyelitis. CONCLUSIONS: The control of factors such as antibiotics, exposure time, bacterial resistance to the antimicrobial used, extensive tissue damage and location of the fracture are extremely important to the predictive effect of infection in open fractures.

OBJETIVO: Avaliar clinicamente pacientes com osteomielite crônica após fraturas expostas, tratados no Hospital de Urgências de Goiânia. MÉTODOS: Estudo do tipo transversal, com coleta de dados mediante questionário, a partir de uma revisão de prontuário. Coletaram-se dados relativos ao tipo de trauma e às características clínicas do paciente. Foram descritas a hora do atendimento e as lesões encontradas no paciente e depois classificadas de acordo com Gustilo e Anderson (1976). Amostras da lesão durante o ato cirúrgico foram coletadas para cultura de microorganismos patogênicos. As análises foram feitas no programa STATA/SE versão 8.0. Fez-se análise descritiva (frequências absolutas e relativas) e para verificar existência de associação entre variáveis foi usado o teste qui-quadrado de Pearson ou exato de Fisher. Este estudo foi aprovado pelo Comitê de Ética em Pesquisa do Hospital de Urgências de Goiânia. RESULTADOS: Houve predomínio de adultos do sexo masculino, que apresentaram fraturas expostas com maior acometimento de ossos da perna ou em dois ou mais ossos (politrauma). A maioria dos pacientes apresentou lesão tipo III (trauma de alta energia). Observou-se perda de tempo excessiva desde o momento do acidente até o atendimento cirúrgico inicial. Detectou-se presença de germes gram positivos nas culturas de material obtido após diagnóstico de osteomielite. CONCLUSÕES: O controle de fatores como antibioticoterapia, tempo de exposição, resistência bacteriana ao antimicrobiano usado, grande dano tecidual e localização da fratura é importantíssimo para anular o efeito preditivo de infecção em fraturas expostas.

Eighteen-year follow-up after rotationplasty for a grade IIIC open fracture of the distal femur.

We report the 18-year follow-up of a patient who underwent rotationplasty for severe bone loss and infection after an grade IIIC open fracture of the distal femur. The patient is now 49 years old and fully satisfied with his life. During the follow-up period, he has never had significant physical or psychological problems directly concerning the rotationplasty. The analysis of quality of life using the SF36 questionnaire revealed even higher scores than the normal healthy population in seven out of eight sub-categories. Clinical examination revealed bland soft tissues without hyperkeratosis or other signs of maladaptation. Articular and cutaneous proprioception was intact all over the left leg. The active extension/flexion of the prosthetic knee was 0°-0°-100° and 10°-0°-70° of the ankle joint. Manual testing of motor strength revealed grade five of five for dorsiflexion and plantar flexion of the ankle. Gait patterns including climbing slopes and stairs were close to normal. Examination in sports physiology showed lower maximum power of hip and knee muscles compared to the healthy side, but better muscular endurance. These findings emphasize that rotationplasty can be a good alternative to arthrodesis or amputation in trauma patients providing high satisfaction and activity levels in the long-term follow-up.

Use of free ipsilateral gastrocnemius flap for coverage of distal third tibial defect after Gustilo type III open fracture.

The traditional pedicled gastrocnemius muscle flap has often been used to repair soft-tissue defects caused by trauma. However, it is difficult to cover skin defects in the distal third of the lower extremity because of its range of excursion. We have attempted use of a free ipsilateral gastrocnemius muscle flap for coverage of skin defects in the distal third of the lower extremity. In three patients with skin defects due to Gustilo type III open fractures, a free gastrocnemius flap was used for coverage of the same leg. The follow-up period ranged from 12 months to 2 years. Microsurgical anastomosis of the vascular pedicle to the tibialis posterior vessels was performed by end-to-side anastomosis proximally to the ankle. The postoperative course was uneventful and showed stable coverage of the wound. All free flaps were successfully transferred, and the defects healed primarily. Bone fusion in all of the patients in this series progressed satisfactorily. This free muscle flap is useful for reconstruction of defects in the distal third of the lower extremity in Gustilo III open fractures.

Gustilo IIIC fractures in the lower limb: our 15-year experience.

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.

A qualitative approach to recovery after open tibial fracture: the road to a novel, patient-derived recovery scale.

AIM: The aim of this study was to describe how patients perceive their recovery following open tibial fractures using a qualitative approach. PATIENTS AND METHODS: Following the appropriate ethical approval, adult patients with a diagnosis of open tibial fracture were recruited after completion of their surgical treatment and discharge from Morriston Hospital, a centre with orthoplastic surgical care. A purposive sampling method was employed to ensure that a range of injuries as well as clinical outcomes were included. All patients took part in an in-depth semi-structured interview, exploring aspects of their injury, treatment, rehabilitation and psychosocial and financial situations. Interviews were completed with two interviewers present and were recorded for verbatim transcription. Interview transcripts were analysed to identify items important to patients during their recovery. RESULTS: Nine patients with a mean injury to interview interval of 2.3 years were interviewed. A total of 538 items were identified and subsequently mapped onto 18 categories: pain; mobility; flexibility; temperature (effects on symptoms); fear; appearance; sleep; diet/weight; employment; social; finance; impact on others; self-care; recovery (patient perceptions of recovery); frustration; goal setting (by patients and health-care providers); and adaptation (both physical and mental). CONCLUSION: There is a wide range of factors that our cohort found important during their recovery from open tibial fracture. Despite being considered as 'healed' by the medical staff, patients did not report a corresponding full recovery and return to pre-injury normality. The categories identified will enable the development of a patient-reported recovery scale to be used in lower-limb trauma.