The role of plastic surgery in major trauma in the United Kingdom and workforce recommendations.

INTRODUCTION: The 22 major trauma centres (MTCs) in England were appointed in 2012 to provide care to severely injured patients despite variation in existing infrastructure, resources, culture and skillset. Six MTCs remain unsupported by a co-located plastic surgery department. We describe the plastic surgical major trauma workload in England, the plastic surgical workforce and skillset available in each centre, and suggest what plastic surgical skills are required in an MTC. METHODS: A multi-centre, prospective cohort study was performed to collect operative workload data. Eleven MTCs in England submitted complete datasets. Workforce data were provided by the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS). RESULTS: Fifty-three percent (n = 1582) of Trauma and Audit Research Network (TARN)-eligible patients admitted during the study period underwent at least one operation during their index admission. Of these, 14% (n = 227) required plastic surgery. The majority of plastic surgical operative work involved the extremities: 62% of index procedures involved the lower limb and 38% involved the upper limb. The number of full-time plastic surgical consultants per MTC ranged from 1 to 22. Only 10 MTCs had at least one plastic surgeon with a primary interest in lower limb trauma. CONCLUSION: Plastic surgery contributes substantially to major trauma care and the majority of this workload relates to extremity trauma. However, there is significant variability in the size, accessibility and skillset of the workforce available. On the basis of these data, we suggest a plastic surgical skillset which should be represented in plastic surgical departments supporting an MTC.

Time to intravenous antibiotic administration (TIbiA) in severe open tibial fractures: Impact of change to national guidance.

INTRODUCTION: Severe open tibial fractures are limb-threatening injuries. Outcomes depend on a complex interplay of patient, injury and treatment factors. 2009 guidelines from the British Orthopaedic Association (BOA) and British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) recommend prophylactic intravenous antibiotic administration within three hours of injury. More recent National Institute for Health and Care Excellence (NICE) 2016 guidelines recommend pre-hospital antibiotic administration where possible. This study aimed to analyse the impact of time to antibiotics on development of deep infection. METHODS: Adult acute Gustilo-Anderson 3B open tibial fractures managed at a single UK Major Trauma Centre were reviewed retrospectively over a three-year period, including a period before and after the regional ambulance service introduced a policy of administering pre-hospital intravenous antibiotics to open fractures in 2016. Development of deep infection was recorded as the primary outcome measure. Complete case regression analysis was performed. Time was assessed as a continuous variable and as thresholds with antibiotics received within one or three hours of injury. RESULTS: 156 patients with 159 fractures were included. Following introduction of new guidance in 2016, median time to antibiotics decreased from 180 to 160 min and more patients received pre-hospital antibiotics (2% vs. 33%). Overall, 7.5% developed deep infection (n = 12) within a median follow-up of 26 months. Logistic regression found no relationship between any independent variable, including time to antibiotic administration, and development of deep infection. CONCLUSIONS: There are a variety of factors identified in the literature and in national policies and treatment guidelines as potentially modifiable to reduce the risk of deep infection following open fractures. In this study, time to antibiotic administration was not associated with the risk of developing deep infection. The results of this study demonstrate a low infection rate, which may be due to expedient expert care delivered by a dedicated orthoplastic service in line with national guidance where achievable.

Solitary neurofibroma of the face masquerading as a low-flow vascular malformation - case report and experience of management.

This case report presents a 34-year-old woman who was referred to our regional plastic surgery unit following a 32-year history of a progressively enlarging mass overlying the left maxilla. The mass was initially diagnosed and treated as a low-flow vascular malformation. However, subsequent histopathological assessment confirmed the diagnosis of a cutaneous neurofibroma. To the best of our knowledge, there are only two other reported cases of a solitary neurofibroma arising from the soft tissue of the face, and this is the first reported case in the United Kingdom (UK). This article highlights difficulties in pre-operative diagnosis of solitary facial neurofibromas. We present our experience in managing this unusual case, discuss radiological clues to aid diagnosis and provide a review of the literature.

Time to Initial Debridement and wound Excision (TIDE) in severe open tibial fractures and related clinical outcome: A multi-centre study.

BACKGROUND: Recent national (NICE) guidelines in England recommend that initial debridement and wound excision of open tibial fractures take place within 12 h of the time of injury, a change from the previous target of 24 h. This study aims to assess the effect of timing of the initial debridement and wound excision on major infective complications, the impact of the new guidance, and the feasibility of adhering to the 12 h target within the infrastructure currently existing in four major trauma centres in England. METHODS: A retrospective review was performed of Gustilo-Anderson grade 3B open tibial fractures presenting acutely to four Major Trauma Centres (MTCs) in England with co-located plastic surgery services over a ten-month period. The incidence of deep infective complications was compared between patients who underwent initial surgery according to the new NICE guidance and those who did not. Patients warranting emergency surgery for severely contaminated injury, concomitant life-threatening injury and neurovascular compromise were excluded. Multi-variable logistic regression analysis was performed to assess the effect of timing of surgical debridement on development of deep infective complications. RESULTS: 112 patients with 116 fractures were included. Six fractures (5.2%) developed deep infective complications. 38% (n = 44) underwent primary debridement within 12 h and 90% within 24 h. There was no significant difference in the incidence of major infective complications if debrided in less than or greater than 12 h (4.5% vs 5.6%, p = 1.00). Logistic regression found no significant relationship between timing of wound excision and development of deep infection. There was no significant decrease in mean time to debridement following introduction of new national guidance (13.6 vs 16.1 h) in these four MTCs. CONCLUSION: Overall, the rate of deep infection in high energy open tibial fractures managed within the four major trauma centes is low. Achieving surgical debridement within 12 h is challenging within the current infrastructure, and it is unclear whether adhering to this target will significantly affect the incidence of severe infective complications. Debridement within 24 h appears achievable. If a 12-h target is to be met, it is vital to ensure dedicated orthoplastic capacity is adequately resourced.