Orthoplastic Treatment of Open Lower-Limb Fractures Improves Outcomes: A 12-Year Review.

BACKGROUND: The British Orthopaedic Association Standards for Orthopaedics and Trauma 4 (BOAST 4) inform the management of open lower-limb fractures. The authors conducted repeated reviews of performance against these standards over a 12-year period. This latest iteration has shown further improvements in outcomes concomitant with changes in service delivery. METHODS: Data on Gustilo-Anderson grade IIIB or IIIC open lower-limb fractures were collected from a prospectively constructed departmental database and analyzed using Excel. Outcomes assessed included time to stabilization, time to definitive soft-tissue coverage, and deep infection rates. RESULTS: A total of 69% of patients in our cohort received care that aligned with BOAST 4 guidelines. Median time to stabilization was 14.2 hours and to soft-tissue coverage was 47 hours, with 71% of cases compliant with BOAST 4 guidelines. The overall deep infection rate was 6.5% in our cohort. There was a significantly lower deep infection rate in BOAST 4-compliant cases (2%) versus noncompliant cases (16%), respectively (P = 0.05). A total of 41 of 61 patients had fixation and soft-tissue coverage in a single operation (fix and flap), eight had staged operations, and 12 required local flap closure. There was no significant difference in deep infection rates among these approaches. CONCLUSIONS: Compliance with the BOAST 4 guidelines and time to definitive soft-tissue coverage have improved at our center since the last review. Deep infection rates were significantly lower in BOAST 4-compliant cases, further validating this approach. The fix and flap technique was introduced during the study period and reduces operative burden for patients. These results support a joint orthoplastic approach as the optimal management for these complex injuries. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Vascularised composite allotransplantation in solid organ transplant recipients: A systematic review.

INTRODUCTION: A solid organ transplant (SOT) recipient, already taking immunosuppression, may represent the ideal candidate for vascularised composite allograft transplantation (VCA). However, concerns have been raised about the potential risk of SOT loss or the need for increased immunosuppression to sustain the VCA. This systematic review examines all published cases of SOT recipients who have received a VCA to establish associated morbidity and immunosuppression requirements. METHODS: A systematic review was performed in accordance with the PRISMA guidelines. The PubMed, MEDLINE and EMBASE databases were searched for original articles published between January 1997 and May 2019. Only articles relating to patients who had received both a VCA and SOT with a reported follow up of greater than six months were included. RESULTS: Fifteen articles were identified, including data from 39 VCAs in 37 patients. There was no increase in the number of SOT rejection episodes, complications such as post-transplant lymphoproliferative disorder or graft versus host disease, de novo donor specific HLA antibodies or short-term risks to the recipient when compared with SOT in isolation. One child required a sustained increase in their baseline immunosuppression following bilateral hand transplantation. CONCLUSIONS: In this small heterogeneous cohort, the addition of a VCA to a SOT does not appear to increase the short-term risks to the SOT or the patient with comparable results to SOT in isolation. However, data are often poorly reported and longer-term follow up and uniform reporting of outcomes would be beneficial to more accurately assess the safety profile of combining VCA with SOT.

Trends in Decubitus Ulcer Disease Burden in European Union 15+ Countries, from 1990 to 2017.

Decubitus ulcers (DU) are a common pathology with significant morbidity and financial implications for health services globally. This study aimed to compare the burden of DU across European Union (EU) 15+ countries between 1990 and 2017. METHODS: Age-standardized incidence, mortality, and disability-adjusted life-years (DALYs) rates per 100,000 were extracted from the Global Burden of Disease Study online data repository for EU15+ countries (a group of 19 countries with comparable health expenditure, including the United States, Canada, the United Kingdom, and Australia). A joinpoint regression analysis was used to describe trends. RESULTS: The incidence of DU increased between 1990 and 2017 in 15 of 19 EU15+ countries for both men and women. Mortality from DU decreased over the time period analyzed in the majority of EU15+ countries: only in Denmark, Finland, and Germany were increasing mortality rates observed. Decreasing DALY rates were generally observed, with the largest decreases observed in Ireland for men and women. Denmark and Germany were the only countries to demonstrate unfavorable trends in mortality, incidence, and DALYs between 1990 and 2017 for men and women. The United States, the Netherlands, and France were the only EU15+ countries in which improving disease burden was identified between 1990 and 2017 for all parameters assessed. CONCLUSIONS: Incidence of DU is increasing in EU15+ countries, whereas mortality rates and DALYs are improving. The trends in disease burden in Denmark and Germany have followed contrasting and unfavorable trends. Investigation into these trends is called for.

The injury burden of recent combat operations: mortality, morbidity, and return to service of U.K. naval service personnel following combat trauma.

OBJECTIVES: The study establishes the functional outcomes of service personnel injured in current conflicts by correlating data on initial injury to the findings of medical boards after trauma and reconstructive treatment. Data comprehensively include all casualties of the Royal Navy and Royal Marines and all functional outcomes. METHODS: Details of all casualties from 2003 to 2010 taken from the Joint Theatre Trauma Registry and records of all medical boards relating to these personnel were analysed. Population at risk and probability of survival data were calculated. RESULTS: There were 221 casualties: 54 (24%) were fatalities; of 167 survivors, 21 (9% of total) were medically discharged; 26 (12%) were placed in reduced fitness category and 120 (55%) returned to full duty. Casualty risk per year of operational service for Naval Service personnel was 4.6%. New injury severity score and functional outcome were closely correlated, with specific exceptions. There were 3 unexpected survivors and no unexpected fatalities. Extremity injuries predominate in survivors. CONCLUSIONS: The Defence Medical Service (DMS) provides excellent trauma and rehabilitative care. The authors contend that this is a valid proxy for other larger coalition formations. Specific injury patterns have higher impact on functional outcomes; future research efforts should focus on these areas.