The Experts below are selected from a list of 4197 Experts worldwide ranked by ideXlab platform
Jay Wiper - One of the best experts on this subject based on the ideXlab platform.
-
managing soft tissues in severe Lower Limb Trauma in an ageing population
Injury-international Journal of The Care of The Injured, 2018Co-Authors: T M Noblet, Philippa C Jackson, P Foster, D M Taylor, P J Harwood, Jay WiperAbstract:Abstract Purpose With an ageing population, the incidence of Trauma in those aged over 65 years is increasing. Strategies for dealing with these patients must be developed. At present the standard management of open tibial fractures in the UK is described by the BOAST4 guidelines (from the British Orthopaedic Association and British Association of Plastic & Aesthetic Surgeons). It is not clear to what extent these are appropriate for older patients. We describe our experience of managing elderly patients presenting with open tibial fractures. Method Patients were identified via prospectively collected national and departmental databases. These data were supplemented by review of the patient records and radiographs. Data collated included patient demographics, injury details, orthopaedic and plastic surgery operative details, and long-term outcomes. Results Between January 2013 and June 2016, 74 patients aged over 65 years were admitted with open Lower Limb fractures. 54 of these were open tibial fractures and these patients formed the study group. 19 patients required soft-tissue reconstruction for Gustilo and Anderson IIIB tibial fractures (age range, 67–95 years). In these patients, there were 7 midshaft (AO 42), 1 proximal (AO 41), and 11 distal (AO 43) fractures. 13 patients were treated with internal fixation and 6 with circular frames. The median length of hospital stay was 27 days (range, 4–85). 14 patients received loco-regional flaps and 5 underwent free tissue transfer with one requiring preoperative femoral angioplasty. There were no flap losses. Four patients had fasciocutaneous flaps, 3 tibialis anterior transposition, 2 an extensor digitorum brevis flap, 1 a hemisoleus flap, and 4 were skin grafted. All patients went on to unite and return to their premorbid weight-bearing status (4 using walking frames, 3 using sticks, and 12 walking independently). Conclusion Although the literature suggests a significantly higher complication rate in elderly patients with open fractures, we have demonstrated comparable rates of flap survival and bony union to those observed in younger patients. Challenges are presented in terms of patient physiology and these must be carefully managed pre- and postoperatively. These challenges are reflected in prolonged hospital stays.
-
managing soft tissue in severe Lower Limb Trauma in an ageing population
Orthopaedic Proceedings, 2018Co-Authors: T M Noblet, Philippa C Jackson, P Foster, D M Taylor, P J Harwood, Jay WiperAbstract:BackgroundWith an ageing population, the incidence of Traumatic injuries in those aged over 65 years is increasing. As a result, strategies for dealing with these patients must be developed. At present the standard management of open tibial fractures is described by the BOAST4 guidelines. We describe our experience of managing elderly patients presenting with open tibial fractures to our Major Trauma Centre.MethodsPatients were identified via prospectively collected national and departmental databases. Data collated included patient demographics, injury details, orthopaedic and plastic surgery operative details, and long term outcomes.ResultsBetween April 2013 and January 2016, 97 patients aged over 65 were admitted with open fractures, 38 of these were open tibial fractures. 10 patients required soft tissue reconstruction for Gustillo and Anderson IIIB tibial fractures (age range 67–95). In this group there were 4 midshaft (AO 42), 1 proximal (AO 41) and 5 distal (AO 43) fractures. Five patients were tre...
-
managing soft tissue in severe Lower Limb Trauma in an ageing population
Journal of Bone and Joint Surgery-british Volume, 2017Co-Authors: T M Noblet, Philippa C Jackson, P Foster, D M Taylor, P J Harwood, Jay WiperAbstract:Background With an ageing population, the incidence of Traumatic injuries in those aged over 65 years is increasing. As a result, strategies for dealing with these patients must be developed. At present the standard management of open tibial fractures is described by the BOAST4 guidelines. We describe our experience of managing elderly patients presenting with open tibial fractures to our Major Trauma Centre. Methods Patients were identified via prospectively collected national and departmental databases. Data collated included patient demographics, injury details, orthopaedic and plastic surgery operative details, and long term outcomes. Results Between April 2013 and January 2016, 97 patients aged over 65 were admitted with open fractures, 38 of these were open tibial fractures. 10 patients required soft tissue reconstruction for Gustillo and Anderson IIIB tibial fractures (age range 67–95). In this group there were 4 midshaft (AO 42), 1 proximal (AO 41) and 5 distal (AO 43) fractures. Five patients were treated with internal fixation and 5 with circular frames. The median length of hospital stay was 33 days (range 16–113 days), 50% longer than comparable patients under 65. Four patients received pedicled local flaps and six underwent free tissue transfer. Of the 6 patients treated with free tissue transfer, one required pre-operative femoral angioplasty. There were no flap losses. Two patients had fasciocutaneous flaps, one an EDB flap and one gastrocnemius flap. All patients went on to unite and return to their pre-morbid weight-bearing status (2 using frames, 3 using sticks, 5 independent). Discussion Although the literature suggests a significantly higher complication rate in elderly patients with open fractures, we have demonstrated comparable rates of flap survival and bony union to those observed in younger patients. Challenges are presented in terms of patient physiology and these must be carefully managed pre- and post-operatively. These challenges are reflected in the significantly longer length of stay in comparably injured patients under the age of 65.
David P Moore - One of the best experts on this subject based on the ideXlab platform.
-
the use of circular external fixators in the management of sterile and infected fracture non unions in the Lower Limb a 20 year experience
Orthopaedic Proceedings, 2018Co-Authors: B J Oneill, O C Breathnach, David P MooreAbstract:The purpose of this study was to review the outcomes and complications of all circular external fixators (frames) used for the management of sterile and infected fracture non-unions in the Lower Limb in our institution over a twenty year period.We retrospectively reviewed a prospectively compiled database of all frames applied in our institution and identified all frames which were applied for acute Lower Limb Trauma. We identified 76 non-unions in 76 patients. There were 22 femoral non-unions and 54 tibial non-unions. Five femoral non-unions and 12 tibial non-unions were confirmed infected. The mean time in frame was 281 days for a sterile non-union and 457 days for an infected non-union. There was a union rate of 87% for sterile non-unions and 71% of infected non-unions at cessation of treatment. Factors associated with persistent non-union included cigarette smoking, soft tissue complications, and excessive pin-site toilet by the patient.Lower-Limb fracture non-unions can be extremely difficult to trea...
-
the use of circular external fixators in the management of Lower Limb Trauma in dublin a 20 year experience
Orthopaedic Proceedings, 2018Co-Authors: B J Oneill, C M Fox, A P Molloy, David P MooreAbstract:The purpose of this study was to review the outcomes and complications of all circular external fixators (frames) used for the management of acute Lower Limb Trauma in our institution over a twenty year period.We retrospectively reviewed a prospectively compiled database of all frames applied in our institution and identified all frames which were applied for acute Lower Limb Trauma. We identified 68 fractures in 63 patients. There were 11 femoral fractures and 57 tibial fractures. All fractures were classified using the AO Classification system, and most fractures were Type C fractures. We used an Ilizarov frame in 53 patients and a Taylor Spatial Frame in 15 patients. The mean time in frame was 365 days for a femoral fracture and 230 days for a tibial fracture. There were five tibial non-unions giving an overall union rate of 93%. Factors associated with non-union included high energy Trauma and cigarette smoking.The vast majority of Lower Limb fractures can be treated using ‘conventional’ methods. Comp...
-
the use of circular external fixators in the management of Lower Limb Trauma in dublin a single surgeon s 20 year experience
Irish Journal of Medical Science, 2016Co-Authors: B J Oneill, C M Fox, A P Molloy, S Oheireamhoin, David P MooreAbstract:Introduction It has been estimated that approximately 520,000 injury presentations are made to Irish accident and emergency departments each year. Fractures account for 20 % of these injuries. Circular external fixators (frames) have been shown to be a safe and effective method of treatment for long bone fractures where internal fixation is impossible or in-advisable. We present the outcomes of all frames applied at our institution for stabilisation of acute fractures over a 20-year period.
-
the use of circular external fixators in the management of sterile and infected fracture non unions in the Lower Limb a 20 year experience
Journal of Bone and Joint Surgery-british Volume, 2014Co-Authors: B J Oneill, O C Breathnach, David P MooreAbstract:The purpose of this study was to review the outcomes and complications of all circular external fixators (frames) used for the management of sterile and infected fracture non-unions in the Lower Limb in our institution over a twenty year period. We retrospectively reviewed a prospectively compiled database of all frames applied in our institution and identified all frames which were applied for acute Lower Limb Trauma. We identified 76 non-unions in 76 patients. There were 22 femoral non-unions and 54 tibial non-unions. Five femoral non-unions and 12 tibial non-unions were confirmed infected. The mean time in frame was 281 days for a sterile non-union and 457 days for an infected non-union. There was a union rate of 87% for sterile non-unions and 71% of infected non-unions at cessation of treatment. Factors associated with persistent non-union included cigarette smoking, soft tissue complications, and excessive pin-site toilet by the patient. Lower-Limb fracture non-unions can be extremely difficult to treat. The patients included in our study had previously undergone more traditional treatments in an attempt to establish union. The results presented demonstrate that circular frames are an excellent treatment modality in non-unions resistant to other forms of treatment. We would recommend this as a first line treatment for patients at higher risk of developing fracture non-union.
-
the use of circular external fixators in the management of Lower Limb Trauma in dublin a 20 year experience
Journal of Bone and Joint Surgery-british Volume, 2014Co-Authors: B J Oneill, C M Fox, A P Molloy, David P MooreAbstract:The purpose of this study was to review the outcomes and complications of all circular external fixators (frames) used for the management of acute Lower Limb Trauma in our institution over a twenty year period. We retrospectively reviewed a prospectively compiled database of all frames applied in our institution and identified all frames which were applied for acute Lower Limb Trauma. We identified 68 fractures in 63 patients. There were 11 femoral fractures and 57 tibial fractures. All fractures were classified using the AO Classification system, and most fractures were Type C fractures. We used an Ilizarov frame in 53 patients and a Taylor Spatial Frame in 15 patients. The mean time in frame was 365 days for a femoral fracture and 230 days for a tibial fracture. There were five tibial non-unions giving an overall union rate of 93%. Factors associated with non-union included high energy Trauma and cigarette smoking. The vast majority of Lower Limb fractures can be treated using ‘conventional’ methods. Complex fractures which are not amenable to open reduction and internal fixation or cast immobilisation can be treated in a frame with excellent results. The paucity of published reports regarding the use of frames for complex Trauma reflects the under-utilisation of the technique.
Ellen J Mackenzie - One of the best experts on this subject based on the ideXlab platform.
-
the impact of Trauma center care on functional outcomes following major Lower Limb Trauma
Journal of Bone and Joint Surgery American Volume, 2008Co-Authors: Ellen J Mackenzie, Frederick P Rivara, Gregory J Jurkovich, Avery B Nathens, Brian L Egleston, David S Salkever, Katherine Frey, Daniel O ScharfsteinAbstract:Background: Although studies have shown that treatment at a Trauma center reduces a patient's risk of dying following major Trauma, important questions remain as to the effect of Trauma centers on functional outcomes, especially among patients who have sustained major Lower-Limb Trauma. Methods: Domain-specific scores on the Medical Outcomes Study Short Form Health Survey (SF-36) supplemented by scores on the mobility subscale of the Musculoskeletal Function Assessment (MFA) and the Revised Center for Epidemiologic Studies Depression Scale (CESD-R) were compared among patients treated in eighteen hospitals with a level-I Trauma center and fifty-one hospitals without a Trauma center. Included in the study were 1389 adults, eighteen to eighty-four years of age, with at least one Lower-Limb injury with a score of ≥3 points according to the Abbreviated Injury Scale (AIS). To account for the competing risk of death, we estimated the survivors' average causal effect. Estimates were derived for all patients with a Lower-Limb injury and separately for a subset of patients without associated injuries of the head or spinal cord. Results: For patients with a Lower-Limb injury resulting from a high-energy force, care at a Trauma center yielded modest but clinically meaningful improvements in physical functioning and overall vitality at one year after the injury. After adjustment for differences in case mix and the competing risk of death, the average differences in the SF-36 physical functioning and vitality scores and the MFA mobility score were 7.82 points (95% confidence interval: 2.65, 12.98), 6.80 points (95% confidence interval: 2.53, 11.07), and 6.31 points (95% confidence interval: 0.25, 12.36), respectively. These results were similar when the analysis was restricted to patients without associated injuries to the head or spine. Treatment at a Trauma center resulted in negligible differences in outcome for the subset of patients with injuries resulting from low-energy forces. Conclusions: This study provides evidence that patients who sustain high-energy Lower-Limb Trauma benefit from treatment at a level-I Trauma center. Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.
-
factors influencing outcome following Limb threatening Lower Limb Trauma lessons learned from the Lower extremity assessment project leap
Journal of The American Academy of Orthopaedic Surgeons, 2006Co-Authors: Ellen J Mackenzie, Michael J BosseAbstract:The Lower Extremity Assessment Project (LEAP) is a multicenter study of severe Lower extremity Trauma in the US civilian population. At 2- and 7-year follow-ups, the LEAP study found no difference in functional outcome between patients who underwent either Limb salvage surgery or amputation. However, outcomes on average were poor for both groups. This study and others provide evidence of wide-ranging variations in outcome following major Limb Trauma, with a substantial proportion of patients experiencing long-term disability. In addition, outcomes often are more affected by the patient's economic, social, and personal resources than by the initial treatment of the injury--specifically, amputation or reconstruction and level of amputation. A conceptual framework for examining outcomes after injury may be used to identify opportunities for interventions that would improve outcomes. Because of essential differences between the civilian and military populations, the findings of the LEAP study may correlate only roughly with combat casualty outcomes.
-
long term persistence of disability following severe Lower Limb Trauma results of a seven year follow up
Journal of Bone and Joint Surgery American Volume, 2005Co-Authors: Ellen J Mackenzie, Marc F Swiontkowski, Michael J Bosse, Andrew N Pollak, Lawrence X Webb, James F Kellam, Douglas G Smith, Roy Sanders, Alan L Jones, Adam J StarrAbstract:Background: A recent study demonstrated that patients treated with amputation and those treated with reconstruction had comparable functional outcomes at two years following Limb-threatening Trauma. The present study was designed to determine whether those outcomes improved after two years, and whether differences according to the type of treatment emerged. Methods: Three hundred and ninety-seven patients who had undergone amputation or reconstruction of the Lower extremity were interviewed by telephone at an average of eighty-four months after the injury. Functional outcomes were assessed with use of the physical and psychosocial subscores of the Sickness Impact Profile (SIP) and were compared with similar scores obtained at twenty-four months. Results: On the average, physical and psychosocial functioning deteriorated between twenty-four and eighty-four months after the injury. At eighty-four months, one-half of the patients had a physical SIP subscore of ≥10 points, which is indicative of substantial disability, and only 34.5% had a score typical of a general population of similar age and gender. There were few significant differences in the outcomes according to the type of treatment, with two exceptions. Compared with patients treated with reconstruction for a tibial shaft fracture, those with only a severe soft-tissue injury of the leg were 3.1 times more likely to have a physical SIP subscore of 5 points (p < 0.05) and those treated with a through-the-knee amputation were 11.5 times more likely to have a physical subscore of 5 points (p < 0.05). There were no significant differences in the psychosocial outcomes according to treatment group. Patient characteristics that were significantly associated with poorer outcomes included older age, female gender, nonwhite race, Lower education level, living in a poor household, current or previous smoking, low self-efficacy, poor self-reported health status before the injury, and involvement with the legal system in an effort to obtain disability payments. Except for age, predictors of poor outcome were similar at twenty-four and eighty-four months after the injury. Conclusions: The results confirm previous conclusions that reconstruction for the treatment of injuries below the distal part of the femur typically results in functional outcomes equivalent to those of amputation. Regardless of the treatment option, however, long-term functional outcomes are poor. Priority should be given to efforts to improve post-acute-care services that address secondary conditions that compromise optimal recovery. Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.
Umraz Khan - One of the best experts on this subject based on the ideXlab platform.
-
The Use of a Tetraminos Chimeric Free Flap in Lower Limb Trauma
Cureus, 2021Co-Authors: Timothy Schrire, Asmat H. Din, Umraz KhanAbstract:Major Trauma care has improved in the UK since the evolution and acceptance of specialist centers . A mission statement for major Trauma care is "reduction in mortality and disability following Trauma." The care for extremity Trauma has benefited from this specialization. Traumatic loss of skin integument in the extremities, especially over mobile joints, may lead to a compromised functional outcome. Modern reconstructive plastic surgery aims to provide flaps with minimal donor site morbidity. In this case report, we present the use of two chimeric flaps undertaken sequentially (one acutely and the second delayed) around the knee joint to allow a greater range of motion and function after a severe Traumatic event. In this clinical case, the original tissue defects had meant that a free flap was used to reconstruct an open fractured bone, and split skin grafting was undertaken on the anterior aspect of the knee. The latter was then replaced after some months of recovery.
-
Lower Limb Trauma and postTraumatic stress disorder a single uk Trauma unit s experience
Journal of Plastic Reconstructive and Aesthetic Surgery, 2014Co-Authors: Waseem Bhat, Sergio Marlino, Victoria Teoh, Salman Khan, Umraz KhanAbstract:Summary Introduction The incidence and factors influencing postTraumatic stress disorder (PTSD) in victims of severe Lower extremity injuries are largely unknown. We studied a cohort of patients treated in a specialist centre to try and elucidate these unknowns. Materials and methods The PostTraumatic Stress Disorder Checklist Scale (PCL-S) was used as a reliable and reproducible patient-reported outcome measure (PROM) assessing all patients for PTSD. Sixty patients were included in the study. This was a prospective analysis of the progression of the PCL-S scores. The data were analysed using a non-parametric Wilcoxon test. Results Sixty patients were recruited into the study cohort. We found that the incidence in this cohort of PTSD was 30%. We found that age had an influence on outcome. Those who were 50 years old or over had a significantly Lower incidence of PTSD according to the PCL-S scores and appeared to recover from it significantly more effectively. Conclusions Up to a third of patients suffering from a severe Lower extremity injury will develop PTSD. Patients of the younger age group are more severely affected and will need psychological support to overcome their distress.
-
is the injury severity score relevant in complex Lower Limb Trauma
Bulletin of The Royal College of Surgeons of England, 2013Co-Authors: George Filobbos, F Salim, Umraz KhanAbstract:First described by Baker et al in 1974, the injury severity score (ISS) is an anatomical scoring system that provides an overall score for patients with multiple injuries. It was developed initially to evaluate motor vehicle victims with multiple injuries, with an original study group of 2,128 patients. The ISS is an established score to assess Trauma severity and its application has extended beyond motor vehicle injuries to cover all aspects of Trauma.
-
costs and coding free flap reconstruction in Lower Limb Trauma
Injury-international Journal of The Care of The Injured, 2011Co-Authors: W A Townley, C Urbanska, R L R Dunn, Umraz KhanAbstract:Abstract Introduction The provision of a complex Lower-Limb Trauma service has significant resource implications. This financial burden is not recognised by the current fixed price tariff system (Payment by Results). The aim of this study was to compare the actual costs of treatment with reimbursement. Methods We conducted a prospective study in two large regional plastic surgery centres in the UK, Salisbury Foundation Trust (SFT) and the Frenchay Hospital, Bristol (FH). The total cost of treatment for consecutive patients with complex Lower Limb Trauma requiring free tissue transfer was calculated and compared with the Health Resource Group (HRG) tariff. Results A cost analysis was performed on 20 patients (10 Salisbury, 10 Frenchay) with open tibial fractures (all grade IIIb Gustillo & Anderson) requiring free-flap reconstruction (15 anterolateral thigh (ALT) flaps, one serratus, one latissimus dorsi (LD), one scapular and two gracilis). The mean treatment cost of performing a free flap was £12 792 ± £970 SEM (SFT) and £10 953 ± £650 (FH). In both centres, the cost was more than double the HRG tariff (£4220 SFT, £4892 FH, p Conclusions Our study highlights the considerable disparity between the cost of managing patients with severe Lower-Limb Trauma and the remuneration by Primary Care Trusts (PCTs). Accurate cost analysis of these cases will allow hospital trusts to negotiate appropriate tariffs with PCTs and develop services, which are cost neutral.
Peter Wall - One of the best experts on this subject based on the ideXlab platform.
-
tourniquet use in Lower Limb Trauma and fracture surgery
Journal of Bone and Joint Surgery-british Volume, 2021Co-Authors: Muhamed M Farhanalanie, Alex Trompeter, Peter Wall, Matthew L CostaAbstract:The use of tourniquets in Lower Limb Trauma surgery to control bleeding and improve the surgical field is a long established practice. In this article, we review the evidence relating to harms and benefits of tourniquet use in Lower Limb fracture fixation surgery and report the results of a survey on current tourniquet practice among Trauma surgeons in the UK.
-
the risks associated with tourniquet use in Lower Limb Trauma surgery a systematic review and meta analysis
European Journal of Orthopaedic Surgery and Traumatology, 2021Co-Authors: Muhamed M Farhanalanie, Alex Trompeter, Fatema Dhaif, Martin Underwood, Joyce Yeung, Nicholas R Parsons, Andrew Metcalfe, Peter WallAbstract:Tourniquet use in Lower Limb fracture surgery may reduce intra-operative bleeding, improve surgical field of view and reduce length of procedure. However, tourniquets may result in pain and the production of harmful metabolites cause complications or affect functional outcomes. This systematic review aimed to compare outcomes following Lower Limb fracture surgery performed with or without tourniquet. We searched databases for RCTs comparing Lower Limb fracture surgery performed with versus without tourniquet reporting on outcomes pain, physical function, health-related quality of life, complications, cognitive function, blood loss, length of stay, length of procedure, swelling, time to union, surgical field of view, volume of anaesthetic agent, biochemical markers of inflammation and injury, and electrolyte and acid–base balance. Random-effects meta-analysis was performed. PROSPERO ID CRD42020209310. Six RCTs enabled inclusion of 552 procedures. Pooled analysis demonstrated that tourniquet use reduced length of procedure by 6 minutes (95% CI −10.12 to −1.87; p < 0.010). We were unable to exclude increased harms from tourniquet use. Pooled analysis showed post-operative pain score was higher in tourniquet group by 12.88 on 100-point scale (95% CI −1.25–27.02; p = 0.070). Risk differences for wound infection, deep venous thrombosis and re-operation were 0.06 (95% CI −0.00–0.12; p = 0.070), 0.05 (95% CI −0.02–0.11; p = 0.150) and 0.03 (95% CI -0.03–0.09; p = 0.340). Tourniquet use was associated with a reduced length of procedure. It is possible that tourniquets also increase incidence of important complications, but the data are too sparse to draw firm conclusions. Methodological weaknesses of the included RCTs prevent any solid conclusions being drawn for outcomes investigated. Further studies are required to address these limitations.
