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Matthew L. Costa - One of the best experts on this subject based on the ideXlab platform.
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the orthopaedic trauma society classification of Open Fractures
Journal of Bone and Joint Surgery-british Volume, 2020Co-Authors: Alex Trompeter, Ruth Knight, Nicholas R Parsons, Matthew L. CostaAbstract:AIMS To describe a new objective classification for Open Fractures of the lower limb and to correlate the classification with patient-centred outcomes. METHODS The proposed classification was investigated within a cohort of adults with Open Fractures of the lower limb who were recruited as part of two large clinical trials within the UK Major Trauma Network. The classification was correlated with patient-reported Disability Rating Index (DRI) and EuroQol five-dimension questionnaire (EQ-5D) health-related quality of life in the year after injury, and with deep infection at 30 days, according to the Centers for Disease Control and Prevention definition of a deep surgical site infection. RESULTS A total of 748 participants were included in the analysis. Of these, 288 (38.5%) had a simple Open Fracture and 460 (61.5%) had a complex Fracture as defined by the new classification system. At 12 months, the mean DRI in the simple Fracture group was 32.5 (SD 26.8) versus 43.9 (SD 26.1) in the complex Fracture group (odds ratio (OR) 8.19; 95% confidence interval (CI) 3.69 to 12.69). At 12 months the mean health-related quality of life (EQ-5D utility) in the simple Fracture group was 0.59 (SD 0.29) versus 0.56 (SD 0.32) in the complex Fracture group (OR -0.03; 95% CI -0.09 to 0.02). The differences in the rate of deep infection at 30 days was not statistically significant. CONCLUSION The Orthopaedic Trauma Society Open Fracture classification is based upon objective descriptors of the injury and correlates with patient-centred outcomes in a large cohort of Open Fractures of the lower limb. Cite this article: Bone Joint J 2020;102-B(11):1469-1474.
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patient experience of long term recovery after Open Fracture of the lower limb a qualitative study using interviews in a community setting
BMJ Open, 2019Co-Authors: Sophie Rees, Julie Bruce, Elizabeth Tutton, Juul Achten, Matthew L. CostaAbstract: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.
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negative pressure wound therapy versus standard dressings for adults with an Open lower limb Fracture the wollf rct
Health Technology Assessment, 2018Co-Authors: Sonia Davis, Susie Hennings, Keith Willett, Julie Bruce, Juul Achten, Matthew L. Costa, Stavros PetrouAbstract:Background Open Fractures of the lower limb occur when a broken bone penetrates the skin and is exposed to the outside environment. These are life-changing injuries. The risk of deep infection may be as high as 27%. The type of dressing applied after surgical debridement could potentially reduce the risk of infection in the Open-Fracture wound. Objectives To assess the disability, rate of deep infection, quality of life and resource use in patients with severe Open Fracture of the lower limb treated with negative-pressure wound therapy (NPWT) versus standard wound management after the first surgical debridement of the wound. Design A pragmatic, multicentre randomised controlled trial. Setting Twenty-four specialist trauma hospitals in the UK Major Trauma Network. Participants A total of 460 patients aged ≥ 16 years with a severe Open Fracture of the lower limb were recruited from July 2012 through to December 2015. Patients were excluded if they presented more than 72 hours after their injury or were unable to complete questionnaires. Interventions Negative-pressure wound therapy (n = 226) where an ‘Open-cell’ solid foam or gauze was placed over the surface of the wound and connected to a suction pump which created a partial vacuum over the dressing versus standard dressings not involving negative pressure (n = 234). Main outcome measures Disability Rating Index (DRI) – a score of 0 (no disability) to 100 (completely disabled) at 12 months was the primary outcome measure, with a minimal clinically important difference of 8 points. The secondary outcomes were deep infection, quality of life and resource use collected at 3, 6, 9 and 12 months post randomisaton. Results There was no evidence of a difference in the patients’ DRI at 12 months. The mean DRI in the NPWT group was 45.5 points [standard deviation (SD) 28.0 points] versus 42.4 points (SD 24.2 points) in the standard dressing group, giving a difference of –3.9 points (95% confidence interval –8.9 to 1.2 points) in favour of standard dressings (p = 0.132). There was no difference in HRQoL and no difference in the number of surgical site infections or other complications at any point in the 12 months after surgery. NPWT did not reduce the cost of treatment and it was associated with a low probability of cost-effectiveness. Limitations Owing to the emergency nature of the interventions, we anticipated that some patients who were randomised into the trial would subsequently be unable or unwilling to take part. Such post-randomisation withdrawal of patients could have posed a risk to the external validity of the trial. However, the great majority of these patients (85%) were found to be ineligible after randomisation. Therefore, we can be confident that the patients who took part were representative of the population with severe Open Fractures of the lower limb. Conclusions Contrary to the existing literature and current clinical guidelines, NPWT dressings do not provide a clinical or an economic benefit for patients with an Open Fracture of the lower limb. Future work Future work should investigate alternative strategies to reduce the incidence of infection and improve outcomes for patients with an Open Fracture of the lower limb. Two specific areas of potentially great benefit are (1) the use of topical antibiotic preparations in the Open-Fracture wound and (2) the role of orthopaedic implants with antimicrobial coatings when fixing the associated Fracture. Trial registration Current Controlled Trials ISRCTN33756652 and UKCRN Portfolio ID 11783.
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negative pressure wound therapy versus standard dressings for adults with an Open lower limb Fracture the wollf rct
Health Technology Assessment, 2018Co-Authors: Sonia Davis, Susie Hennings, Keith Willett, Julie Bruce, Juul Achten, Matthew L. Costa, Stavros PetrouAbstract:Background Open Fractures of the lower limb occur when a broken bone penetrates the skin and is exposed to the outside environment. These are life-changing injuries. The risk of deep infection may be as high as 27%. The type of dressing applied after surgical debridement could potentially reduce the risk of infection in the Open-Fracture wound. Objectives To assess the disability, rate of deep infection, quality of life and resource use in patients with severe Open Fracture of the lower limb treated with negative-pressure wound therapy (NPWT) versus standard wound management after the first surgical debridement of the wound. Design A pragmatic, multicentre randomised controlled trial. Setting Twenty-four specialist trauma hospitals in the UK Major Trauma Network. Participants A total of 460 patients aged ≥ 16 years with a severe Open Fracture of the lower limb were recruited from July 2012 through to December 2015. Patients were excluded if they presented more than 72 hours after their injury or were unable to complete questionnaires. Interventions Negative-pressure wound therapy (n = 226) where an 'Open-cell' solid foam or gauze was placed over the surface of the wound and connected to a suction pump which created a partial vacuum over the dressing versus standard dressings not involving negative pressure (n = 234). Main outcome measures Disability Rating Index (DRI) - a score of 0 (no disability) to 100 (completely disabled) at 12 months was the primary outcome measure, with a minimal clinically important difference of 8 points. The secondary outcomes were deep infection, quality of life and resource use collected at 3, 6, 9 and 12 months post randomisaton. Results There was no evidence of a difference in the patients' DRI at 12 months. The mean DRI in the NPWT group was 45.5 points [standard deviation (SD) 28.0 points] versus 42.4 points (SD 24.2 points) in the standard dressing group, giving a difference of -3.9 points (95% confidence interval -8.9 to 1.2 points) in favour of standard dressings (p = 0.132). There was no difference in HRQoL and no difference in the number of surgical site infections or other complications at any point in the 12 months after surgery. NPWT did not reduce the cost of treatment and it was associated with a low probability of cost-effectiveness. Limitations Owing to the emergency nature of the interventions, we anticipated that some patients who were randomised into the trial would subsequently be unable or unwilling to take part. Such post-randomisation withdrawal of patients could have posed a risk to the external validity of the trial. However, the great majority of these patients (85%) were found to be ineligible after randomisation. Therefore, we can be confident that the patients who took part were representative of the population with severe Open Fractures of the lower limb. Conclusions Contrary to the existing literature and current clinical guidelines, NPWT dressings do not provide a clinical or an economic benefit for patients with an Open Fracture of the lower limb. Future work Future work should investigate alternative strategies to reduce the incidence of infection and improve outcomes for patients with an Open Fracture of the lower limb. Two specific areas of potentially great benefit are (1) the use of topical antibiotic preparations in the Open-Fracture wound and (2) the role of orthopaedic implants with antimicrobial coatings when fixing the associated Fracture. Trial registration Current Controlled Trials ISRCTN33756652 and UKCRN Portfolio ID 11783. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 73. See the NIHR Journals Library website for further project information.
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economic outcomes associated with deep surgical site infection in patients with an Open Fracture of the lower limb
Journal of Bone and Joint Surgery-british Volume, 2018Co-Authors: Benjamin A Parker, Stavros Petrou, James P M Masters, Felix A Achana, Matthew L. CostaAbstract: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 ...
Juul Achten - One of the best experts on this subject based on the ideXlab platform.
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patient experience of long term recovery after Open Fracture of the lower limb a qualitative study using interviews in a community setting
BMJ Open, 2019Co-Authors: Sophie Rees, Julie Bruce, Elizabeth Tutton, Juul Achten, Matthew L. CostaAbstract: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.
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negative pressure wound therapy versus standard dressings for adults with an Open lower limb Fracture the wollf rct
Health Technology Assessment, 2018Co-Authors: Sonia Davis, Susie Hennings, Keith Willett, Julie Bruce, Juul Achten, Matthew L. Costa, Stavros PetrouAbstract:Background Open Fractures of the lower limb occur when a broken bone penetrates the skin and is exposed to the outside environment. These are life-changing injuries. The risk of deep infection may be as high as 27%. The type of dressing applied after surgical debridement could potentially reduce the risk of infection in the Open-Fracture wound. Objectives To assess the disability, rate of deep infection, quality of life and resource use in patients with severe Open Fracture of the lower limb treated with negative-pressure wound therapy (NPWT) versus standard wound management after the first surgical debridement of the wound. Design A pragmatic, multicentre randomised controlled trial. Setting Twenty-four specialist trauma hospitals in the UK Major Trauma Network. Participants A total of 460 patients aged ≥ 16 years with a severe Open Fracture of the lower limb were recruited from July 2012 through to December 2015. Patients were excluded if they presented more than 72 hours after their injury or were unable to complete questionnaires. Interventions Negative-pressure wound therapy (n = 226) where an ‘Open-cell’ solid foam or gauze was placed over the surface of the wound and connected to a suction pump which created a partial vacuum over the dressing versus standard dressings not involving negative pressure (n = 234). Main outcome measures Disability Rating Index (DRI) – a score of 0 (no disability) to 100 (completely disabled) at 12 months was the primary outcome measure, with a minimal clinically important difference of 8 points. The secondary outcomes were deep infection, quality of life and resource use collected at 3, 6, 9 and 12 months post randomisaton. Results There was no evidence of a difference in the patients’ DRI at 12 months. The mean DRI in the NPWT group was 45.5 points [standard deviation (SD) 28.0 points] versus 42.4 points (SD 24.2 points) in the standard dressing group, giving a difference of –3.9 points (95% confidence interval –8.9 to 1.2 points) in favour of standard dressings (p = 0.132). There was no difference in HRQoL and no difference in the number of surgical site infections or other complications at any point in the 12 months after surgery. NPWT did not reduce the cost of treatment and it was associated with a low probability of cost-effectiveness. Limitations Owing to the emergency nature of the interventions, we anticipated that some patients who were randomised into the trial would subsequently be unable or unwilling to take part. Such post-randomisation withdrawal of patients could have posed a risk to the external validity of the trial. However, the great majority of these patients (85%) were found to be ineligible after randomisation. Therefore, we can be confident that the patients who took part were representative of the population with severe Open Fractures of the lower limb. Conclusions Contrary to the existing literature and current clinical guidelines, NPWT dressings do not provide a clinical or an economic benefit for patients with an Open Fracture of the lower limb. Future work Future work should investigate alternative strategies to reduce the incidence of infection and improve outcomes for patients with an Open Fracture of the lower limb. Two specific areas of potentially great benefit are (1) the use of topical antibiotic preparations in the Open-Fracture wound and (2) the role of orthopaedic implants with antimicrobial coatings when fixing the associated Fracture. Trial registration Current Controlled Trials ISRCTN33756652 and UKCRN Portfolio ID 11783.
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negative pressure wound therapy versus standard dressings for adults with an Open lower limb Fracture the wollf rct
Health Technology Assessment, 2018Co-Authors: Sonia Davis, Susie Hennings, Keith Willett, Julie Bruce, Juul Achten, Matthew L. Costa, Stavros PetrouAbstract:Background Open Fractures of the lower limb occur when a broken bone penetrates the skin and is exposed to the outside environment. These are life-changing injuries. The risk of deep infection may be as high as 27%. The type of dressing applied after surgical debridement could potentially reduce the risk of infection in the Open-Fracture wound. Objectives To assess the disability, rate of deep infection, quality of life and resource use in patients with severe Open Fracture of the lower limb treated with negative-pressure wound therapy (NPWT) versus standard wound management after the first surgical debridement of the wound. Design A pragmatic, multicentre randomised controlled trial. Setting Twenty-four specialist trauma hospitals in the UK Major Trauma Network. Participants A total of 460 patients aged ≥ 16 years with a severe Open Fracture of the lower limb were recruited from July 2012 through to December 2015. Patients were excluded if they presented more than 72 hours after their injury or were unable to complete questionnaires. Interventions Negative-pressure wound therapy (n = 226) where an 'Open-cell' solid foam or gauze was placed over the surface of the wound and connected to a suction pump which created a partial vacuum over the dressing versus standard dressings not involving negative pressure (n = 234). Main outcome measures Disability Rating Index (DRI) - a score of 0 (no disability) to 100 (completely disabled) at 12 months was the primary outcome measure, with a minimal clinically important difference of 8 points. The secondary outcomes were deep infection, quality of life and resource use collected at 3, 6, 9 and 12 months post randomisaton. Results There was no evidence of a difference in the patients' DRI at 12 months. The mean DRI in the NPWT group was 45.5 points [standard deviation (SD) 28.0 points] versus 42.4 points (SD 24.2 points) in the standard dressing group, giving a difference of -3.9 points (95% confidence interval -8.9 to 1.2 points) in favour of standard dressings (p = 0.132). There was no difference in HRQoL and no difference in the number of surgical site infections or other complications at any point in the 12 months after surgery. NPWT did not reduce the cost of treatment and it was associated with a low probability of cost-effectiveness. Limitations Owing to the emergency nature of the interventions, we anticipated that some patients who were randomised into the trial would subsequently be unable or unwilling to take part. Such post-randomisation withdrawal of patients could have posed a risk to the external validity of the trial. However, the great majority of these patients (85%) were found to be ineligible after randomisation. Therefore, we can be confident that the patients who took part were representative of the population with severe Open Fractures of the lower limb. Conclusions Contrary to the existing literature and current clinical guidelines, NPWT dressings do not provide a clinical or an economic benefit for patients with an Open Fracture of the lower limb. Future work Future work should investigate alternative strategies to reduce the incidence of infection and improve outcomes for patients with an Open Fracture of the lower limb. Two specific areas of potentially great benefit are (1) the use of topical antibiotic preparations in the Open-Fracture wound and (2) the role of orthopaedic implants with antimicrobial coatings when fixing the associated Fracture. Trial registration Current Controlled Trials ISRCTN33756652 and UKCRN Portfolio ID 11783. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 73. See the NIHR Journals Library website for further project information.
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effect of negative pressure wound therapy vs standard wound management on 12 month disability among adults with severe Open Fracture of the lower limb the wollf randomized clinical trial
JAMA, 2018Co-Authors: Julie Bruce, Elizabeth Tutton, Stavros Petrou, Juul Achten, Sarah E Lamb, Matthew L. CostaAbstract:Importance Open Fractures of the lower limb occur when a broken bone penetrates the skin. There can be major complications from these Fractures, which can be life-changing. Objectives To assess the disability, rate of deep infection, and quality of life in patients with severe Open Fracture of the lower limb treated with negative pressure wound therapy (NPWT) vs standard wound management after the first surgical debridement of the wound. Design, Setting, and Participants Multicenter randomized trial performed in the UK Major Trauma Network, recruiting 460 patients aged 16 years or older with a severe Open Fracture of the lower limb from July 2012 through December 2015. Final outcome data were collected through November 2016. Exclusions were presentation more than 72 hours after injury and inability to complete questionnaires. Interventions NPWT (n = 226) in which an Open-cell solid foam or gauze was placed over the surface of the wound and connected to a suction pump, creating a partial vacuum over the dressing, vs standard dressings not involving application of negative pressure (n = 234). Main Outcomes and Measures Disability Rating Index score (range, 0 [no disability] to 100 [completely disabled]) at 12 months was the primary outcome measure, with a minimal clinically important difference of 8 points. Secondary outcomes were complications including deep infection and quality of life (score ranged from 1 [best possible] to −0.59 [worst possible]; minimal clinically important difference, 0.08) collected at 3, 6, 9, and 12 months. Results Among 460 patients who were randomized (mean age, 45.3 years; 74% men), 88% (374/427) of available study participants completed the trial. There were no statistically significant differences in the patients’ Disability Rating Index score at 12 months (mean score, 45.5 in the NPWT group vs 42.4 in the standard dressing group; mean difference, −3.9 [95% CI, −8.9 to 1.2];P = .13), in the number of deep surgical site infections (16 [7.1%] in the NPWT group vs 19 [8.1%] in the standard dressing group; difference, 1.0% [95% CI, −4.2% to 6.3%];P = .64), or in quality of life between groups (difference in EuroQol 5-dimensions questionnaire, 0.02 [95% CI, −0.05 to 0.08]; Short Form–12 Physical Component Score, 0.5 [95% CI, −3.1 to 4.1] and Mental Health Component Score, −0.4 [95% CI, −2.2 to 1.4]). Conclusions and Relevance Among patients with severe Open Fracture of the lower limb, use of NPWT compared with standard wound dressing did not improve self-rated disability at 12 months. The findings do not support this treatment for severe Open Fractures. Trial Registration isrctn.org Identifier:ISRCTN33756652
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a qualitative study of patient experience of an Open Fracture of the lower limb during acute care
Journal of Bone and Joint Surgery-british Volume, 2018Co-Authors: Elizabeth Tutton, Keith Willett, Juul Achten, Sarah E Lamb, Matthew L. CostaAbstract: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...
Stavros Petrou - One of the best experts on this subject based on the ideXlab platform.
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negative pressure wound therapy versus standard dressings for adults with an Open lower limb Fracture the wollf rct
Health Technology Assessment, 2018Co-Authors: Sonia Davis, Susie Hennings, Keith Willett, Julie Bruce, Juul Achten, Matthew L. Costa, Stavros PetrouAbstract:Background Open Fractures of the lower limb occur when a broken bone penetrates the skin and is exposed to the outside environment. These are life-changing injuries. The risk of deep infection may be as high as 27%. The type of dressing applied after surgical debridement could potentially reduce the risk of infection in the Open-Fracture wound. Objectives To assess the disability, rate of deep infection, quality of life and resource use in patients with severe Open Fracture of the lower limb treated with negative-pressure wound therapy (NPWT) versus standard wound management after the first surgical debridement of the wound. Design A pragmatic, multicentre randomised controlled trial. Setting Twenty-four specialist trauma hospitals in the UK Major Trauma Network. Participants A total of 460 patients aged ≥ 16 years with a severe Open Fracture of the lower limb were recruited from July 2012 through to December 2015. Patients were excluded if they presented more than 72 hours after their injury or were unable to complete questionnaires. Interventions Negative-pressure wound therapy (n = 226) where an ‘Open-cell’ solid foam or gauze was placed over the surface of the wound and connected to a suction pump which created a partial vacuum over the dressing versus standard dressings not involving negative pressure (n = 234). Main outcome measures Disability Rating Index (DRI) – a score of 0 (no disability) to 100 (completely disabled) at 12 months was the primary outcome measure, with a minimal clinically important difference of 8 points. The secondary outcomes were deep infection, quality of life and resource use collected at 3, 6, 9 and 12 months post randomisaton. Results There was no evidence of a difference in the patients’ DRI at 12 months. The mean DRI in the NPWT group was 45.5 points [standard deviation (SD) 28.0 points] versus 42.4 points (SD 24.2 points) in the standard dressing group, giving a difference of –3.9 points (95% confidence interval –8.9 to 1.2 points) in favour of standard dressings (p = 0.132). There was no difference in HRQoL and no difference in the number of surgical site infections or other complications at any point in the 12 months after surgery. NPWT did not reduce the cost of treatment and it was associated with a low probability of cost-effectiveness. Limitations Owing to the emergency nature of the interventions, we anticipated that some patients who were randomised into the trial would subsequently be unable or unwilling to take part. Such post-randomisation withdrawal of patients could have posed a risk to the external validity of the trial. However, the great majority of these patients (85%) were found to be ineligible after randomisation. Therefore, we can be confident that the patients who took part were representative of the population with severe Open Fractures of the lower limb. Conclusions Contrary to the existing literature and current clinical guidelines, NPWT dressings do not provide a clinical or an economic benefit for patients with an Open Fracture of the lower limb. Future work Future work should investigate alternative strategies to reduce the incidence of infection and improve outcomes for patients with an Open Fracture of the lower limb. Two specific areas of potentially great benefit are (1) the use of topical antibiotic preparations in the Open-Fracture wound and (2) the role of orthopaedic implants with antimicrobial coatings when fixing the associated Fracture. Trial registration Current Controlled Trials ISRCTN33756652 and UKCRN Portfolio ID 11783.
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negative pressure wound therapy versus standard dressings for adults with an Open lower limb Fracture the wollf rct
Health Technology Assessment, 2018Co-Authors: Sonia Davis, Susie Hennings, Keith Willett, Julie Bruce, Juul Achten, Matthew L. Costa, Stavros PetrouAbstract:Background Open Fractures of the lower limb occur when a broken bone penetrates the skin and is exposed to the outside environment. These are life-changing injuries. The risk of deep infection may be as high as 27%. The type of dressing applied after surgical debridement could potentially reduce the risk of infection in the Open-Fracture wound. Objectives To assess the disability, rate of deep infection, quality of life and resource use in patients with severe Open Fracture of the lower limb treated with negative-pressure wound therapy (NPWT) versus standard wound management after the first surgical debridement of the wound. Design A pragmatic, multicentre randomised controlled trial. Setting Twenty-four specialist trauma hospitals in the UK Major Trauma Network. Participants A total of 460 patients aged ≥ 16 years with a severe Open Fracture of the lower limb were recruited from July 2012 through to December 2015. Patients were excluded if they presented more than 72 hours after their injury or were unable to complete questionnaires. Interventions Negative-pressure wound therapy (n = 226) where an 'Open-cell' solid foam or gauze was placed over the surface of the wound and connected to a suction pump which created a partial vacuum over the dressing versus standard dressings not involving negative pressure (n = 234). Main outcome measures Disability Rating Index (DRI) - a score of 0 (no disability) to 100 (completely disabled) at 12 months was the primary outcome measure, with a minimal clinically important difference of 8 points. The secondary outcomes were deep infection, quality of life and resource use collected at 3, 6, 9 and 12 months post randomisaton. Results There was no evidence of a difference in the patients' DRI at 12 months. The mean DRI in the NPWT group was 45.5 points [standard deviation (SD) 28.0 points] versus 42.4 points (SD 24.2 points) in the standard dressing group, giving a difference of -3.9 points (95% confidence interval -8.9 to 1.2 points) in favour of standard dressings (p = 0.132). There was no difference in HRQoL and no difference in the number of surgical site infections or other complications at any point in the 12 months after surgery. NPWT did not reduce the cost of treatment and it was associated with a low probability of cost-effectiveness. Limitations Owing to the emergency nature of the interventions, we anticipated that some patients who were randomised into the trial would subsequently be unable or unwilling to take part. Such post-randomisation withdrawal of patients could have posed a risk to the external validity of the trial. However, the great majority of these patients (85%) were found to be ineligible after randomisation. Therefore, we can be confident that the patients who took part were representative of the population with severe Open Fractures of the lower limb. Conclusions Contrary to the existing literature and current clinical guidelines, NPWT dressings do not provide a clinical or an economic benefit for patients with an Open Fracture of the lower limb. Future work Future work should investigate alternative strategies to reduce the incidence of infection and improve outcomes for patients with an Open Fracture of the lower limb. Two specific areas of potentially great benefit are (1) the use of topical antibiotic preparations in the Open-Fracture wound and (2) the role of orthopaedic implants with antimicrobial coatings when fixing the associated Fracture. Trial registration Current Controlled Trials ISRCTN33756652 and UKCRN Portfolio ID 11783. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 73. See the NIHR Journals Library website for further project information.
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economic outcomes associated with deep surgical site infection in patients with an Open Fracture of the lower limb
Journal of Bone and Joint Surgery-british Volume, 2018Co-Authors: Benjamin A Parker, Stavros Petrou, James P M Masters, Felix A Achana, Matthew L. CostaAbstract: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 ...
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effect of negative pressure wound therapy vs standard wound management on 12 month disability among adults with severe Open Fracture of the lower limb the wollf randomized clinical trial
JAMA, 2018Co-Authors: Julie Bruce, Elizabeth Tutton, Stavros Petrou, Juul Achten, Sarah E Lamb, Matthew L. CostaAbstract:Importance Open Fractures of the lower limb occur when a broken bone penetrates the skin. There can be major complications from these Fractures, which can be life-changing. Objectives To assess the disability, rate of deep infection, and quality of life in patients with severe Open Fracture of the lower limb treated with negative pressure wound therapy (NPWT) vs standard wound management after the first surgical debridement of the wound. Design, Setting, and Participants Multicenter randomized trial performed in the UK Major Trauma Network, recruiting 460 patients aged 16 years or older with a severe Open Fracture of the lower limb from July 2012 through December 2015. Final outcome data were collected through November 2016. Exclusions were presentation more than 72 hours after injury and inability to complete questionnaires. Interventions NPWT (n = 226) in which an Open-cell solid foam or gauze was placed over the surface of the wound and connected to a suction pump, creating a partial vacuum over the dressing, vs standard dressings not involving application of negative pressure (n = 234). Main Outcomes and Measures Disability Rating Index score (range, 0 [no disability] to 100 [completely disabled]) at 12 months was the primary outcome measure, with a minimal clinically important difference of 8 points. Secondary outcomes were complications including deep infection and quality of life (score ranged from 1 [best possible] to −0.59 [worst possible]; minimal clinically important difference, 0.08) collected at 3, 6, 9, and 12 months. Results Among 460 patients who were randomized (mean age, 45.3 years; 74% men), 88% (374/427) of available study participants completed the trial. There were no statistically significant differences in the patients’ Disability Rating Index score at 12 months (mean score, 45.5 in the NPWT group vs 42.4 in the standard dressing group; mean difference, −3.9 [95% CI, −8.9 to 1.2];P = .13), in the number of deep surgical site infections (16 [7.1%] in the NPWT group vs 19 [8.1%] in the standard dressing group; difference, 1.0% [95% CI, −4.2% to 6.3%];P = .64), or in quality of life between groups (difference in EuroQol 5-dimensions questionnaire, 0.02 [95% CI, −0.05 to 0.08]; Short Form–12 Physical Component Score, 0.5 [95% CI, −3.1 to 4.1] and Mental Health Component Score, −0.4 [95% CI, −2.2 to 1.4]). Conclusions and Relevance Among patients with severe Open Fracture of the lower limb, use of NPWT compared with standard wound dressing did not improve self-rated disability at 12 months. The findings do not support this treatment for severe Open Fractures. Trial Registration isrctn.org Identifier:ISRCTN33756652
Julie Bruce - One of the best experts on this subject based on the ideXlab platform.
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patient experience of long term recovery after Open Fracture of the lower limb a qualitative study using interviews in a community setting
BMJ Open, 2019Co-Authors: Sophie Rees, Julie Bruce, Elizabeth Tutton, Juul Achten, Matthew L. CostaAbstract: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.
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negative pressure wound therapy versus standard dressings for adults with an Open lower limb Fracture the wollf rct
Health Technology Assessment, 2018Co-Authors: Sonia Davis, Susie Hennings, Keith Willett, Julie Bruce, Juul Achten, Matthew L. Costa, Stavros PetrouAbstract:Background Open Fractures of the lower limb occur when a broken bone penetrates the skin and is exposed to the outside environment. These are life-changing injuries. The risk of deep infection may be as high as 27%. The type of dressing applied after surgical debridement could potentially reduce the risk of infection in the Open-Fracture wound. Objectives To assess the disability, rate of deep infection, quality of life and resource use in patients with severe Open Fracture of the lower limb treated with negative-pressure wound therapy (NPWT) versus standard wound management after the first surgical debridement of the wound. Design A pragmatic, multicentre randomised controlled trial. Setting Twenty-four specialist trauma hospitals in the UK Major Trauma Network. Participants A total of 460 patients aged ≥ 16 years with a severe Open Fracture of the lower limb were recruited from July 2012 through to December 2015. Patients were excluded if they presented more than 72 hours after their injury or were unable to complete questionnaires. Interventions Negative-pressure wound therapy (n = 226) where an ‘Open-cell’ solid foam or gauze was placed over the surface of the wound and connected to a suction pump which created a partial vacuum over the dressing versus standard dressings not involving negative pressure (n = 234). Main outcome measures Disability Rating Index (DRI) – a score of 0 (no disability) to 100 (completely disabled) at 12 months was the primary outcome measure, with a minimal clinically important difference of 8 points. The secondary outcomes were deep infection, quality of life and resource use collected at 3, 6, 9 and 12 months post randomisaton. Results There was no evidence of a difference in the patients’ DRI at 12 months. The mean DRI in the NPWT group was 45.5 points [standard deviation (SD) 28.0 points] versus 42.4 points (SD 24.2 points) in the standard dressing group, giving a difference of –3.9 points (95% confidence interval –8.9 to 1.2 points) in favour of standard dressings (p = 0.132). There was no difference in HRQoL and no difference in the number of surgical site infections or other complications at any point in the 12 months after surgery. NPWT did not reduce the cost of treatment and it was associated with a low probability of cost-effectiveness. Limitations Owing to the emergency nature of the interventions, we anticipated that some patients who were randomised into the trial would subsequently be unable or unwilling to take part. Such post-randomisation withdrawal of patients could have posed a risk to the external validity of the trial. However, the great majority of these patients (85%) were found to be ineligible after randomisation. Therefore, we can be confident that the patients who took part were representative of the population with severe Open Fractures of the lower limb. Conclusions Contrary to the existing literature and current clinical guidelines, NPWT dressings do not provide a clinical or an economic benefit for patients with an Open Fracture of the lower limb. Future work Future work should investigate alternative strategies to reduce the incidence of infection and improve outcomes for patients with an Open Fracture of the lower limb. Two specific areas of potentially great benefit are (1) the use of topical antibiotic preparations in the Open-Fracture wound and (2) the role of orthopaedic implants with antimicrobial coatings when fixing the associated Fracture. Trial registration Current Controlled Trials ISRCTN33756652 and UKCRN Portfolio ID 11783.
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negative pressure wound therapy versus standard dressings for adults with an Open lower limb Fracture the wollf rct
Health Technology Assessment, 2018Co-Authors: Sonia Davis, Susie Hennings, Keith Willett, Julie Bruce, Juul Achten, Matthew L. Costa, Stavros PetrouAbstract:Background Open Fractures of the lower limb occur when a broken bone penetrates the skin and is exposed to the outside environment. These are life-changing injuries. The risk of deep infection may be as high as 27%. The type of dressing applied after surgical debridement could potentially reduce the risk of infection in the Open-Fracture wound. Objectives To assess the disability, rate of deep infection, quality of life and resource use in patients with severe Open Fracture of the lower limb treated with negative-pressure wound therapy (NPWT) versus standard wound management after the first surgical debridement of the wound. Design A pragmatic, multicentre randomised controlled trial. Setting Twenty-four specialist trauma hospitals in the UK Major Trauma Network. Participants A total of 460 patients aged ≥ 16 years with a severe Open Fracture of the lower limb were recruited from July 2012 through to December 2015. Patients were excluded if they presented more than 72 hours after their injury or were unable to complete questionnaires. Interventions Negative-pressure wound therapy (n = 226) where an 'Open-cell' solid foam or gauze was placed over the surface of the wound and connected to a suction pump which created a partial vacuum over the dressing versus standard dressings not involving negative pressure (n = 234). Main outcome measures Disability Rating Index (DRI) - a score of 0 (no disability) to 100 (completely disabled) at 12 months was the primary outcome measure, with a minimal clinically important difference of 8 points. The secondary outcomes were deep infection, quality of life and resource use collected at 3, 6, 9 and 12 months post randomisaton. Results There was no evidence of a difference in the patients' DRI at 12 months. The mean DRI in the NPWT group was 45.5 points [standard deviation (SD) 28.0 points] versus 42.4 points (SD 24.2 points) in the standard dressing group, giving a difference of -3.9 points (95% confidence interval -8.9 to 1.2 points) in favour of standard dressings (p = 0.132). There was no difference in HRQoL and no difference in the number of surgical site infections or other complications at any point in the 12 months after surgery. NPWT did not reduce the cost of treatment and it was associated with a low probability of cost-effectiveness. Limitations Owing to the emergency nature of the interventions, we anticipated that some patients who were randomised into the trial would subsequently be unable or unwilling to take part. Such post-randomisation withdrawal of patients could have posed a risk to the external validity of the trial. However, the great majority of these patients (85%) were found to be ineligible after randomisation. Therefore, we can be confident that the patients who took part were representative of the population with severe Open Fractures of the lower limb. Conclusions Contrary to the existing literature and current clinical guidelines, NPWT dressings do not provide a clinical or an economic benefit for patients with an Open Fracture of the lower limb. Future work Future work should investigate alternative strategies to reduce the incidence of infection and improve outcomes for patients with an Open Fracture of the lower limb. Two specific areas of potentially great benefit are (1) the use of topical antibiotic preparations in the Open-Fracture wound and (2) the role of orthopaedic implants with antimicrobial coatings when fixing the associated Fracture. Trial registration Current Controlled Trials ISRCTN33756652 and UKCRN Portfolio ID 11783. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 73. See the NIHR Journals Library website for further project information.
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effect of negative pressure wound therapy vs standard wound management on 12 month disability among adults with severe Open Fracture of the lower limb the wollf randomized clinical trial
JAMA, 2018Co-Authors: Julie Bruce, Elizabeth Tutton, Stavros Petrou, Juul Achten, Sarah E Lamb, Matthew L. CostaAbstract:Importance Open Fractures of the lower limb occur when a broken bone penetrates the skin. There can be major complications from these Fractures, which can be life-changing. Objectives To assess the disability, rate of deep infection, and quality of life in patients with severe Open Fracture of the lower limb treated with negative pressure wound therapy (NPWT) vs standard wound management after the first surgical debridement of the wound. Design, Setting, and Participants Multicenter randomized trial performed in the UK Major Trauma Network, recruiting 460 patients aged 16 years or older with a severe Open Fracture of the lower limb from July 2012 through December 2015. Final outcome data were collected through November 2016. Exclusions were presentation more than 72 hours after injury and inability to complete questionnaires. Interventions NPWT (n = 226) in which an Open-cell solid foam or gauze was placed over the surface of the wound and connected to a suction pump, creating a partial vacuum over the dressing, vs standard dressings not involving application of negative pressure (n = 234). Main Outcomes and Measures Disability Rating Index score (range, 0 [no disability] to 100 [completely disabled]) at 12 months was the primary outcome measure, with a minimal clinically important difference of 8 points. Secondary outcomes were complications including deep infection and quality of life (score ranged from 1 [best possible] to −0.59 [worst possible]; minimal clinically important difference, 0.08) collected at 3, 6, 9, and 12 months. Results Among 460 patients who were randomized (mean age, 45.3 years; 74% men), 88% (374/427) of available study participants completed the trial. There were no statistically significant differences in the patients’ Disability Rating Index score at 12 months (mean score, 45.5 in the NPWT group vs 42.4 in the standard dressing group; mean difference, −3.9 [95% CI, −8.9 to 1.2];P = .13), in the number of deep surgical site infections (16 [7.1%] in the NPWT group vs 19 [8.1%] in the standard dressing group; difference, 1.0% [95% CI, −4.2% to 6.3%];P = .64), or in quality of life between groups (difference in EuroQol 5-dimensions questionnaire, 0.02 [95% CI, −0.05 to 0.08]; Short Form–12 Physical Component Score, 0.5 [95% CI, −3.1 to 4.1] and Mental Health Component Score, −0.4 [95% CI, −2.2 to 1.4]). Conclusions and Relevance Among patients with severe Open Fracture of the lower limb, use of NPWT compared with standard wound dressing did not improve self-rated disability at 12 months. The findings do not support this treatment for severe Open Fractures. Trial Registration isrctn.org Identifier:ISRCTN33756652
Keith Willett - One of the best experts on this subject based on the ideXlab platform.
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negative pressure wound therapy versus standard dressings for adults with an Open lower limb Fracture the wollf rct
Health Technology Assessment, 2018Co-Authors: Sonia Davis, Susie Hennings, Keith Willett, Julie Bruce, Juul Achten, Matthew L. Costa, Stavros PetrouAbstract:Background Open Fractures of the lower limb occur when a broken bone penetrates the skin and is exposed to the outside environment. These are life-changing injuries. The risk of deep infection may be as high as 27%. The type of dressing applied after surgical debridement could potentially reduce the risk of infection in the Open-Fracture wound. Objectives To assess the disability, rate of deep infection, quality of life and resource use in patients with severe Open Fracture of the lower limb treated with negative-pressure wound therapy (NPWT) versus standard wound management after the first surgical debridement of the wound. Design A pragmatic, multicentre randomised controlled trial. Setting Twenty-four specialist trauma hospitals in the UK Major Trauma Network. Participants A total of 460 patients aged ≥ 16 years with a severe Open Fracture of the lower limb were recruited from July 2012 through to December 2015. Patients were excluded if they presented more than 72 hours after their injury or were unable to complete questionnaires. Interventions Negative-pressure wound therapy (n = 226) where an ‘Open-cell’ solid foam or gauze was placed over the surface of the wound and connected to a suction pump which created a partial vacuum over the dressing versus standard dressings not involving negative pressure (n = 234). Main outcome measures Disability Rating Index (DRI) – a score of 0 (no disability) to 100 (completely disabled) at 12 months was the primary outcome measure, with a minimal clinically important difference of 8 points. The secondary outcomes were deep infection, quality of life and resource use collected at 3, 6, 9 and 12 months post randomisaton. Results There was no evidence of a difference in the patients’ DRI at 12 months. The mean DRI in the NPWT group was 45.5 points [standard deviation (SD) 28.0 points] versus 42.4 points (SD 24.2 points) in the standard dressing group, giving a difference of –3.9 points (95% confidence interval –8.9 to 1.2 points) in favour of standard dressings (p = 0.132). There was no difference in HRQoL and no difference in the number of surgical site infections or other complications at any point in the 12 months after surgery. NPWT did not reduce the cost of treatment and it was associated with a low probability of cost-effectiveness. Limitations Owing to the emergency nature of the interventions, we anticipated that some patients who were randomised into the trial would subsequently be unable or unwilling to take part. Such post-randomisation withdrawal of patients could have posed a risk to the external validity of the trial. However, the great majority of these patients (85%) were found to be ineligible after randomisation. Therefore, we can be confident that the patients who took part were representative of the population with severe Open Fractures of the lower limb. Conclusions Contrary to the existing literature and current clinical guidelines, NPWT dressings do not provide a clinical or an economic benefit for patients with an Open Fracture of the lower limb. Future work Future work should investigate alternative strategies to reduce the incidence of infection and improve outcomes for patients with an Open Fracture of the lower limb. Two specific areas of potentially great benefit are (1) the use of topical antibiotic preparations in the Open-Fracture wound and (2) the role of orthopaedic implants with antimicrobial coatings when fixing the associated Fracture. Trial registration Current Controlled Trials ISRCTN33756652 and UKCRN Portfolio ID 11783.
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negative pressure wound therapy versus standard dressings for adults with an Open lower limb Fracture the wollf rct
Health Technology Assessment, 2018Co-Authors: Sonia Davis, Susie Hennings, Keith Willett, Julie Bruce, Juul Achten, Matthew L. Costa, Stavros PetrouAbstract:Background Open Fractures of the lower limb occur when a broken bone penetrates the skin and is exposed to the outside environment. These are life-changing injuries. The risk of deep infection may be as high as 27%. The type of dressing applied after surgical debridement could potentially reduce the risk of infection in the Open-Fracture wound. Objectives To assess the disability, rate of deep infection, quality of life and resource use in patients with severe Open Fracture of the lower limb treated with negative-pressure wound therapy (NPWT) versus standard wound management after the first surgical debridement of the wound. Design A pragmatic, multicentre randomised controlled trial. Setting Twenty-four specialist trauma hospitals in the UK Major Trauma Network. Participants A total of 460 patients aged ≥ 16 years with a severe Open Fracture of the lower limb were recruited from July 2012 through to December 2015. Patients were excluded if they presented more than 72 hours after their injury or were unable to complete questionnaires. Interventions Negative-pressure wound therapy (n = 226) where an 'Open-cell' solid foam or gauze was placed over the surface of the wound and connected to a suction pump which created a partial vacuum over the dressing versus standard dressings not involving negative pressure (n = 234). Main outcome measures Disability Rating Index (DRI) - a score of 0 (no disability) to 100 (completely disabled) at 12 months was the primary outcome measure, with a minimal clinically important difference of 8 points. The secondary outcomes were deep infection, quality of life and resource use collected at 3, 6, 9 and 12 months post randomisaton. Results There was no evidence of a difference in the patients' DRI at 12 months. The mean DRI in the NPWT group was 45.5 points [standard deviation (SD) 28.0 points] versus 42.4 points (SD 24.2 points) in the standard dressing group, giving a difference of -3.9 points (95% confidence interval -8.9 to 1.2 points) in favour of standard dressings (p = 0.132). There was no difference in HRQoL and no difference in the number of surgical site infections or other complications at any point in the 12 months after surgery. NPWT did not reduce the cost of treatment and it was associated with a low probability of cost-effectiveness. Limitations Owing to the emergency nature of the interventions, we anticipated that some patients who were randomised into the trial would subsequently be unable or unwilling to take part. Such post-randomisation withdrawal of patients could have posed a risk to the external validity of the trial. However, the great majority of these patients (85%) were found to be ineligible after randomisation. Therefore, we can be confident that the patients who took part were representative of the population with severe Open Fractures of the lower limb. Conclusions Contrary to the existing literature and current clinical guidelines, NPWT dressings do not provide a clinical or an economic benefit for patients with an Open Fracture of the lower limb. Future work Future work should investigate alternative strategies to reduce the incidence of infection and improve outcomes for patients with an Open Fracture of the lower limb. Two specific areas of potentially great benefit are (1) the use of topical antibiotic preparations in the Open-Fracture wound and (2) the role of orthopaedic implants with antimicrobial coatings when fixing the associated Fracture. Trial registration Current Controlled Trials ISRCTN33756652 and UKCRN Portfolio ID 11783. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 73. See the NIHR Journals Library website for further project information.
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a qualitative study of patient experience of an Open Fracture of the lower limb during acute care
Journal of Bone and Joint Surgery-british Volume, 2018Co-Authors: Elizabeth Tutton, Keith Willett, Juul Achten, Sarah E Lamb, Matthew L. CostaAbstract: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...
