Patient reported outcomes after definitive open tibial fracture management.

AIMS: Open tibial fractures are often life-changing injuries and patient outcomes remain poor despite the introduction of national management guidelines. The longer-term impact to the patient can be considerable but this is often overlooked in the literature. This study aims to establish the functional, physical, and psychosocial impact of sustaining an open tibial fracture. METHODS: We reviewed 69 consecutive Gustilo-Anderson grade IIIB and IIIC open tibial fractures that presented to our Major Trauma Centre (MTC) between September 2012 and April 2018. Each participant was interviewed and sent patient-reported outcome questionnaires, a minimum of 12 months following injury. Our primary outcome was the Lower Extremity Functional Scale (LEFS). Secondary outcomes included the Short-Form 36 Healthy Survey (SF-36), Sickness Impact Profile 128 (SIP) and return to occupation. Subgroups were analysed according to age, Injury Severity Score (ISS) and limb amputation. RESULTS: The mean follow up was 43 months. 96% were grade IIIB and 4% grade IIIC. The response rate for our study was 72%. The mean LEFS was 42 (IQR 21.5-58.5). All total and sub-domain scores within both the SF-36 and SIP questionnaires were reduced when compared to normative population data. Only 48% of patients returned to full time employment. Subgroup analysis revealed significantly reduced LEFS, SIP and SF-36 subdomain scores for those with a presenting ISS >14 and those undergoing limb amputation. CONCLUSION: Patients are at significant risk of longer-term functional, physical and psychosocial harm after suffering an open tibial fracture. Those sustaining major polytrauma or amputation demonstrated to have the greatest risk of poor outcome. Early identification of these individuals likely to suffer most from their injury would help direct appropriate resources to those with greatest need at the earliest opportunity.

What Is Important to Patients Who Are Recovering From an Open Tibial Fracture? A Qualitative Study.

BACKGROUND: Open tibial fracture research has traditionally focused on surgical techniques; however, despite technological advances, outcomes from these injuries remain poor, with patients facing a sustained reduced quality of life. Research has rarely asked patients what is important to them after an open tibial fracture, and this question could potentially offer great insight into how to support patients. A qualitative study may assist in our understanding of this subject. QUESTIONS/PURPOSES: We asked: (1) What common themes did patients who have experienced open tibial fractures share? (2) What stresses and coping strategies did those patients articulate? (3) What sources for acquiring coping strategies did patients say they benefited from? METHODS: Semistructured interviews were conducted with patients who had sustained an open tibial fracture between January 1, 2016 and January 1, 2019. All participants were recruited from a Level 1 trauma center in England, and 26 participants were included. The mean age was 44 ± 17 years, and 77% (20 of 26) were men. The patients' injuries ranged in severity, and they had a range of treatments and complications. Transcripts were analyzed using framework analysis, with codes subsequently organized into themes and subthemes. RESULTS: Four themes were identified, which included recouping physical mobility, values around treatment, fears about poor recovery, and coping strategies to reduce psychological burden. Coping strategies were important in mitigating the psychological burden of injury. Task-focused coping strategies were preferred by patients and perceived as taking a proactive approach to recovery. Healthcare practitioners, and others with lived experience were able to educate patients on coping, but such resources were scant and therefore probably less accessible to those with the greatest need. CONCLUSION: Most individuals fail to return to previous activities, and it is unlikely that improvements in surgical techniques will make major improvements in patient outcomes in the near future. Investment in psychosocial support could potentially improve patient experience and outcomes. Digital information platforms and group rehabilitation clinics were identified as potential avenues for development that could offer individuals better psychosocial support with minimal additional burden for surgeons. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Treatment of severely open tibial fractures, non-unions, and fracture-related infections with a gentamicin-coated tibial nail-clinical outcomes including quality of life analysis and psychological ICD-10-based symptom rating.

BACKGROUND: Implant-associated infections depict a major challenge in orthopedics and trauma surgery putting a high burden on the patients and health care systems, strongly requiring improvement of infection prevention and of clinical outcomes. One strategy includes the usage of antimicrobial-coated implants. We evaluated outcomes after surgical treatment using a gentamicin-coated nail on (i) treatment success in terms of bone consolidation, (ii) absence of infection, and (iii) patient-reported quality of life in a patient cohort with high risk of infection/reinfection and treatment failure. METHODS: Thirteen patients with open tibia fractures (n = 4), non-unions (n = 2), and fracture-related infection (n = 7) treated with a gentamicin-coated intramedullary nail (ETN ProtectTM) were retrospectively reviewed. Quality of life was evaluated with the EQ-5D, SF-36, and with an ICD-10-based symptom rating (ISR). RESULTS: At a mean follow-up of 2.8 years, 11 of the 13 patients (84.6%) achieved bone consolidation without any additional surgical intervention, whereas two patients required a revision surgery due to infection and removal of the implant. No specific implant-related side effects were noted. Quality of life scores were significantly lower compared to a German age-matched reference population. The mean ISR scores revealed mild psychological symptom burden on the scale depression. CONCLUSION: The use of a gentamicin-coated intramedullary nail seems to be reasonable in open fractures and revision surgery for aseptic non-union or established fracture-related infection to avoid infection complications and to achieve bony union. Despite successful treatment of challenging cases with the gentamicin-treated implant, significantly reduced quality of life after treatment underlines the need of further efforts to improve surgical treatment strategies and psychological support.

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.

Patient experience of long-term recovery after open fracture of the lower limb: a qualitative study using interviews in a community setting.

OBJECTIVES: Treatment of open fractures is complex and patients may require muscle and skin grafts. The aim of this study was to gain a greater understanding of patient experience of recovery from open fracture of the lower limb 2-4 years postinjury. DESIGN: A phenomenological approach was used to guide the design of the study. Interviews took place between October 2016 and April 2017 in the participants' own homes or via telephone. SETTING: England, UK. PARTICIPANTS: A purposive sample of 25 patients were interviewed with an age range of 26-80 years (median 51), 19 were male and six female, and time since injury was 24-49 months (median 35 months). RESULTS: The findings identified a focus on struggling to recover as participants created a new way of living, balancing moving forward with accepting how they are, while being uncertain of the future and experiencing cycles of progress and setbacks. This was expressed through three themes: (i) 'being disempowered' with the emotional impact of dependency and uncertainty, (ii) 'being changed' and living with being fragile and being unable to move freely and (iii) 'being myself' with a loss of self, feeling and looking different, alongside recreation of self in which they integrated the past, present and future to find meaningful ways of being themselves. CONCLUSION: This study identified the long-term disruption caused by serious injury, the hidden work of integration that is required in order to move forward and maximise potential for recovery. Supportive strategies that help people to self-manage their everyday emotional and physical experience of recovery from injury are required. Research should focus on developing and testing effective interventions that provide support and self-management within a holistic rehabilitation plan. TRIAL REGISTRATION NUMBER: Current Controlled Trials ISRCTN33756652; Post-results.

Can simulation impact on first year diagnostic radiography students' emotional preparedness to encounter open wounds on their first clinical placement: A pilot study.

INTRODUCTION: This study reports on the use of moulage within a simulation to introduce first year diagnostic radiography students to open wounds in preparation for clinical practice. METHODOLOGY: A mixed-method quasi-experimental design was used. Visual Analogue Scales were used to capture state feelings at the point of seeing open wounds. Interpretative Phenomenological Analysis was used to draw themes from focus groups and an interview following clinical placement. RESULTS: The simulation reduced negative feelings whilst emotional preparedness, distraction and excitement increased. Five major themes were identified including emotional engagement, engagement with wound, building relationships, developing professional self and simulation impact. CONCLUSION: The use of moulage and a simulation provides an opportunity to explore initial reactions. Students actively reflect on this experience during clinical practice changing practice. The impact of open wounds can be long lasting and support from radiographers should allow these new experiences to be processed reducing the risk of burnout.

The utility of adding symptoms and signs to the management of injury-related pain.

OBJECTIVE: Improved pain assessment and management in the emergency department (ED) is warranted. We aimed to determine the impact on pain management, of adding symptoms and signs to pain assessment. PATIENTS AND METHODS: A single center before-and-after study was conducted, supplemented by an interrupted time series analysis. The intervention included the addition of clinical presentation (CP) of the injury and facial expression (FE) of the patient to pain assessment scales of patients with soft tissue injures. Pain intensity was categorized as: mild, moderate, and severe. We compared types of pain relief medications, use of strong opioids, and pain relief efficacy between pre and post intervention phases. RESULTS: Before-and-after analysis revealed a significant reduction in the use of strong opioids. The adjusted relative ratio for the use of strong opioids in the post intervention phase was 0.63 (95% CI: 0.48-0.82). This reduction was mostly driven by less use of strong opioids in patients reporting severe pain (from 17.3%-7.9%) (P < 0.0001). A larger proportion of patients in the post intervention phase than in the pre intervention phase received weak opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) (27.4% vs 19.1%, P = 0.002), and a larger proportion did not receive any pain relief medication (19.8% vs 10.5%, p < 0.0001). The use of strong opioids increased with higher levels of FE and CP. Among patients with mild injury and reporting severe pain, the odds of receiving a strong opioid was nearly 9 times (OR = 8.9, 95% CI: 4.0-19.6) higher among those who were with an unrelaxed FE and showed pain behavior than those with relaxed FE. Interrupted time-series analysis showed that the mean ΔVAS (VAS score at entry minus VAS score at discharge) in the post intervention phase compared with the pre intervention phase was not statistically significant (P = 0.073). The use of strong opioids in the post intervention phase was significantly reduced (P = 0.017). CONCLUSION: Adding symptoms and signs to pain assessment of patients admitted with soft tissue injuries decreased the use of strong opioids, without affecting pain relief efficacy.

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.

Participation in a trial in the emergency situation: a qualitative study of patient experience in the UK WOLLF trial.

BACKGROUND: Patients can struggle to make sense of trials in emergency situations. This study examines patient experience of participating in the United Kingdom, Wound management of Open Lower Limb Fractures (UK WOLLF) study, a trial of standard wound management versus Negative Pressure Wound Therapy (NPWT). METHODS: The aim of the study was to understand the patient's lived experience of taking part in a trial of wound dressings. Interviews drawing on Phenomenology were undertaken with a purposive sample of 20 patients, on average 12 days into their hospital stay from July 2012-July 2013. RESULTS: The participants were vulnerable due to the emotional and physical impact of injury. They expressed their trial experience through the theme of being compromised identified in categories of being dependent, being trusting, being grateful and being without experience. Participants felt dependent on and trusted the team to make the right decisions for them and not cause them harm. Their hopes for future recovery were also invested within the expertise of the team. Despite often not being well enough to consent to the study prior to surgery, they wished to be involved as much as possible. In agreeing to take part they expressed gratitude for their care, wanted to be helpful to others and considered the trial interventions to be a small component in relation to the enormity of their injury and broader treatment. In making sense of the trial they felt they could not understand the interventions without experience of them but if they received NPWT they developed a strong technological preference for this intervention. CONCLUSIONS: Patients prefer to be involved in studies within the limits of their capacity, despite not being able to provide informed consent. A variety of sources of knowledge may enable participants to feel that they have a better understanding of the interventions. Professional staff need to be aware of the situated nature of decision making where participants invest their hopes for recovery in the team. TRIAL REGISTRATION: Current Controlled Trials, ID: ISRCTN33756652 . Registered on 24 February 2012.

A qualitative study of patient experience of an open fracture of the lower limb during acute care.

Aims: The aim of this study was to explore the patients' experience of recovery from open fracture of the lower limb in acute care. Patients and Methods: A purposeful sample of 20 participants with a mean age of 40 years (20 to 82) (16 males, four females) were interviewed a mean of 12 days (five to 35) after their first surgical intervention took place between July 2012 and July 2013 in two National Health Service (NHS) trusts in England, United Kingdom. The qualitative interviews drew on phenomenology and analysis identified codes, which were drawn together into categories and themes. Results: The findings identify the vulnerability of the patients expressed through three themes; being emotionally fragile, being injured and living with injury. The participants felt a closeness to death and continued uncertainty regarding loss of their limb. They experienced strong emotions while also trying to contain their emotions for the benefit of others. Their sense of self changed as they became a person with visible wounds, needed intimate help, and endured pain. When ready, they imagined what it would be like to live with injury. Conclusion: Recovery activities require an increased focus on emotional wellbeing. Surgeons are aware of the need for clinical expertise and for adequate pain relief but may not be as aware that their patients require support regarding their body image and help to imagine their future life. Cite this article: Bone Joint J 2018;100-B:522-6.

Pain after ortho-plastic reconstruction of lower limb injuries: A snapshot study.

INTRODUCTION: The incidence of pain after flap reconstruction of complex lower limb injury is poorly reported in the literature, and yet represents a significant source of morbidity in these patients. In our centre (Southmead Hospital, Bristol, England) patients who have had flap reconstruction for complex lower limb injury are followed up at a joint ortho-plastics lower limb clinic run weekly. The aim of this study was to report the incidence of pain in such patients at follow-up in the specialist clinic. The impact of the experience of pain upon the quality of life, and the efficacy of analgesia was assessed these cases. PATIENTS AND METHODS: This was a cross sectional snapshot study of a cohort of complex lower limb patients attending our lower limb ortho-plastics outpatient clinic between the dates of: 17/5/16 and 28/6/16. Any patient attending clinic with previous flap reconstruction for lower limb injury was asked to complete the BPI (Brief Pain Index) questionnaire, and details regarding their injury and surgery were collected. RESULTS: There was a 100% response rate, with 33 patients completing the questionnaire. 28 out of the 33 patients (85%) reported ongoing pain. There was no significant relationship between time post operatively and average pain scores (Spearman's Rank R = 0.077), nor was there significant difference by age or gender. Over 25% of the patients with pain were not taking analgesia, however those using simple analgesia (paracetamol, NSAIDS) derived on average over 70% pain relief. CONCLUSIONS: Pain in a common complication following flap reconstruction for complex lower limb injury reported in 85% of our cohort. This pain does not seem to be correlated with time, gender or age, and responds well to simple analgesia in most cases. This emphasises the importance of asking about pain at follow up, and taking simple measures to improve pain outcomes.

Pedaling Toward Revelation: My Summer with Flannery O'Connor.

This section features original work on pathographies-i.e., (auto)biographical accounts of disease, illness, and disability-that provide narrative inquiry relating to the personal, existential, psychological, social, cultural, spiritual, political, and moral meanings of individual experience. Editors are: Nathan Carlin and Therese Jones. For submissions, contact Nathan Carlin at: Nathan.Carlin@uth.tmc.edu.

Is amputation a viable treatment option in lower extremity trauma?

INTRODUCTION: There is currently no consensus on how to treat patients with lower extremity trauma. Should amputation be performed early on to avoid complications or should the limb be saved at any price? The goal of this study was to show that early amputation is a viable treatment option in lower extremity trauma cases. MATERIAL AND METHODS: Twenty patients who underwent early amputation and 16 patients who underwent limb-salvage were included with a minimum follow-up of 1year. The main endpoints were the Mangled Extremity Severity Score (MESS) used to predict amputation, complications, sequelae, bone union and functional outcomes. RESULTS: The amputees had a higher MESS score than those treated conservatively (7.8 vs. 4.9, P<0.00001), had a shorter hospital stay (P<0.022) and had fewer postoperative complications (P<0.003), especially infection-related (P<0.001). The prevalence of infection in limb-salvage patients was 61%. There was no significant difference between the two groups in terms of quality of life. DISCUSSION: In cases of lower extremity trauma, early amputation and limb-sparing treatment each have their advantages and disadvantages. Early amputation seems to be better in cases of complications, despite similar quality of life in the two groups in the long-term. It is a viable treatment option in cases of lower extremity trauma. Amputation must not be considered as a failure, but a deliberate choice due to the functional impact of complications that occur after limb-salvage. LEVEL OF EVIDENCE: Level IV study.

Open Finger Fractures: Incidence, Patterns of Injury and the Influence of Social Deprivation.

BACKGROUND: This study investigates the patterns and epidemiology of open finger fractures. There is little good data about these injuries. METHODS: Data were collected prospectively in a single trauma unit serving a well-defined population. RESULTS: Over a 15 year period 1090 open finger fractures were treated in 1014 patients. These made up the vast majority of open fractures treated in the trauma unit during this period. The incidence of open finger fractures was 14.0 per 100,000 patients per year. Deprivation did not influence the incidence of open finger fractures but did affect treatment choices for women. Most open finger fractures resulted from crush injuries or falls and required only simple operative treatments: debridement, lavage and early mobilization. CONCLUSIONS: Open finger fractures formed the majority of the workload of open fractures at our trauma centre but usually required simple treatments only. Social deprivation was not shown to influence the patterns or epidemiology of these injuries but did affect treatment choices for women.

Reaming Does Not Affect Functional Outcomes After Open and Closed Tibial Shaft Fractures: The Results of a Randomized Controlled Trial.

OBJECTIVES: We sought to determine the effect of reaming on 1-year 36-item short-form general health survey (SF-36) and short musculoskeletal function assessment (SMFA) scores from the Study to Prospectively Evaluate Reamed Intramedullary Nails in patients with Tibial Fractures. DESIGN: Prospective randomized controlled trial.1319 patients were randomized to reamed or unreamed nails. Fractures were categorized as open or closed. SETTING: Twenty-nine academic and community health centers across the US, Canada, and the Netherlands. PATIENTS/PARTICIPANTS: One thousand three hundred and nineteen skeletally mature patients with closed and open diaphyseal tibia fractures. INTERVENTION: Reamed versus unreamed tibial nails. MAIN OUTCOME MEASUREMENTS: SF-36 and the SMFA. Outcomes were obtained during the initial hospitalization to reflect preinjury status, and again at the 2-week, 3-month, 6-month, and 1-year follow-up. Repeated measures analyses were performed with P < 0.05 considered significant. RESULTS: There were no differences between the reamed and unreamed groups at 12 months for either the SF-36 physical component score [42.9 vs. 43.4, P = 0.54, 95% Confidence Interval for the difference (CI) -2.1 to 1.1] or the SMFA dysfunction index (18.0 vs. 17.6, P = 0.79. 95% CI, -2.2 to 2.9). At one year, functional outcomes were significantly below baseline for the SF-36 physical componentf score, SMFA dysfunction index, and SMFA bothersome index (P < 0.001). Time and fracture type were significantly associated with functional outcome. CONCLUSIONS: Reaming does not affect functional outcomes after intramedullary nailing for tibial shaft fractures. Patients with open fractures have worse functional outcomes than those with a closed injury. Patients do not reach their baseline function by 1 year after surgery. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Grade 3 open tibial shaft fractures treated with a circular frame, functional outcome and systematic review of literature.

We report on the surgical and functional outcome of 22 patients with Grade 3 open tibial fractures treated with circular frame. All cases united and there were no re-fractures or amputations. All patients were assessed at a minimum of 1-year post frame removal. Assessment included clinical examination, IOWA ankle and knee scores, Olerud and Molander ankle score and EuroQol EQ-5D. Clinical scores were either good or excellent in over half of the patients in all knee and ankle scores. There was a significant positive correlation between functional outcomes and the EQ-5D score. The EQ-5D mean health state visual analogue score was comparable to the general UK population despite patients scoring less than the average UK population in three of the five domains. 36% reported some difficulties in walking and 41% had problems with pain. 14% had difficulties with self-care and 46% had difficulties with their usual activities. 14% had problems with anxiety or depression. Systematic review of the literature suggests, in the management of open tibial fractures, circular frames provide equivalent or superior surgical outcomes in comparison with other techniques. Our study finds the application of a circular frame also results in a good functional outcome in the majority of cases.

Medium-term outcomes following limb salvage for severe open tibia fracture are similar to trans-tibial amputation.

Extremity injuries define the surgical burden of recent conflicts. Current literature is inconclusive when assessing the merits of limb salvage over amputation. The aim of this study was to determine medium term functional outcomes in military casualties undergoing limb salvage for severe open tibia fractures, and compare them to equivalent outcomes for unilateral trans-tibial amputees. Cases of severe open diaphyseal tibia fractures sustained in combat between 2006 and 2010, as described in a previously published series, were contacted. Consenting individuals conducted a brief telephone interview and were asked to complete a SF-36 questionnaire. These results were compared to a similar cohort of 18 military patients who sustained a unilateral trans-tibial amputation between 2004 and 2010. Forty-nine patients with 57 severe open tibia fractures met the inclusion criteria. Telephone follow-up and SF-36 questionnaire data was available for 30 patients (61%). The median follow-up was 4 years (49 months, IQR 39-63). Ten of the 30 patients required revision surgery, three of which involved conversion from initial fixation to a circular frame for non- or mal-union. Twenty-two of the 30 patients (73%) recovered sufficiently to complete an age-standardised basic military fitness test. The median physical component score of SF-36 in the limb salvage group was 46 (IQR 35-54) which was similar to the trans-tibial amputation cohort (p=0.3057, Mann-Whitney). Similarly there was no difference in mental component scores between the limb salvage and amputation groups (p=0.1595, Mann-Whitney). There was no significant difference in the proportion of patients in either the amputation or limb salvage group reporting pain (p=0.1157, Fisher's exact test) or with respect to SF-36 physical pain scores (p=0.5258, Mann-Whitney). This study demonstrates that medium term outcomes for military patients are similar following trans-tibial amputation or limb salvage following combat trauma.

[Meaning of living with external fixation for grade III open fracture of lower limbs: patient view]. / Significado de conviver com fixação externa por fratura exposta grau III em membros inferiores: o olhar do paciente.

The present study is aimed to understand the meaning of living with an external fixation device for grade III open fractures of the lower limbs from the perspective of the patient. The data were collected with six young adults who were undergoing outpatient orthopedic treatment in a public hospital in the city of São Paulo, through semi-structured interviews with open questions, between June and August 2010. Seeking to understand the meaning of this experience, we have maintained a phenomenological attitude during the analysis, which made it possible to reveal the phenomenon "try to live in spite of feeling trapped in a cage." Patients said that their personal desire and support from others helped them reorganize their lives, despite the several challenges they had to overcome to adapt to the fastener attached to their body and the fear of the future and doubts about the success of treatment.

Significado de conviver com fixação externa por fratura exposta grau III em membros inferiores: o olhar do paciente / Meaning of living with external fixation for grade III open fracture of lower limbs: patient view / Significado de la vida con fijación externa por fractura expuesta grado III en miembros inferiores: la mirada del paciente

O objetivo deste estudo foi compreender o significado de conviver com fixação externa por fratura exposta grau III em membros inferiores, sob o olhar do paciente. Os dados foram coletados com seis adultos jovens que faziam tratamento ambulatorial ortopédico, em um hospital público da cidade de São Paulo, por meio de entrevista semiestruturada com questões abertas, entre junho e agosto de 2010. Na busca do significado desta vivência, mantivemos uma atitude fenomenológica na análise, o que propiciou desvelar o fenômeno "buscar viver apesar de se sentir preso em uma gaiola". Os pacientes apontam que é o desejo pessoal e apoio de outras pessoas que propiciam a reorganização de suas vidas, apesar dos inúmeros desafios que precisam superar para adaptarem-se ao fixador acoplado ao seu corpo, do medo que sentem em relação ao futuro e das dúvidas quanto ao tratamento.

The present study is aimed to understand the meaning of living with an external fixation device forgrade III open fractures of the lower limbs from the perspective of the patient.The data were collected with six young adults who were under going out patient orthopedic treatment in a public hospital in the city of SãoPaulo, through semi-structured interviews with open questions, between Juneand August 2010. Seeking to understand the meaning of this experience,we have maintained a phenomenological attitude during the analysis, which made it possible to reveal the phenomenon"try to live in spiteof feeling trapped in a cage." Patients said that their personal desire and support from others helped them reorganize their lives, despite the several challenges they had to overcome to adapt to the fastener attached to their body and the fear of the future and doubts about the success of treatment.

El objetivo de este estudio fue comprender el significado de vivir con fijación externa para las fracturas abiertas de grado III de los miembros inferiores bajo la mirada del paciente. Los datos fueron recogidos con seis jóvenes adultos que no habían recibido tratamiento ortopédico de ambulatorio en un hospital público en la ciudad de SãoPaulo, a través de entrevistas semi estructuradas con preguntas abiertas,entre junio y agosto de 2010. En búsqueda del significado de esta experiencia que hemos mantenido una actitud de análisis fenomenológico, lo que llevó a revelar el fenómeno"tratan de vivir a pesarde sentirse atrapado en una jaula." Los pacientes indican que es el deseo y el apoyo de otros que están a favor de la reorganización de la vida personal, apesar de los numerosos desafíos que se deben superar para adaptarse a la sujeción acoplada a su cuerpo,el miedo que sienten sobre el futuro y las dudas en el tratamiento.