Timing and Outcome Comparison in Lower Limb Open Fractures: The Patient Perspective and Impact on Hospital Management

INTRODUCTION. The treatment of Lower Limb Open Fractures (LLOF) represents a critical challenge, as their management is related to a high incidence of complications. The aim of the study was to compare two groups that underwent LLOF reconstruction: one treated in the acute phase and one in the sub-acute period. The primary outcomes compared flap and limb complications, time to bone union, time to full weight bearing, number of secondary procedures, while the secondary outcome assessed the quality of life.

MATERIALS AND METHODS. A single-center retrospective study at the Plastic and Reconstructive Surgery Department of Trieste, from January 2008 to May 2017 was conducted; all patients suffering from LLOF that needed a debridement, bone fixation and reconstruction with a free flap were included. Two groups were identified: group 1 (within seven days from injury) and group 2 (beyond seven days). The compared outcomes were: free-flap survival, complication rate, number of secondary procedures, time to bony union and time until full-weight bearing [tab1-2]. In addition, one year after surgery all patients were given the Lower Extremity Functional Scale (LEFS) and the 36- Item Short Form Survey (SF-36) for evaluation of the post-trauma/post-surgery.

RESULTS. 25 consecutive patients from January 2007 and May 2017 were analyzed. The mean follow-up was 3 years. There were 4 GAIIIC, 15 GA IIIB, 6 GA IIIA injuries and 11 type 2, 5 type 1, 4 type 3 and 2 type 4 degloving injuries. In Group 1, 12 open fractures were reconstructed by a free-flap transfer while 13 patients had free-flap coverage in group 2. Free flap success rate was 100%. We recorded 41.7% complications in group 1 and 15.4% in group 2 with no statistically significant difference (p=0,20). In group 1, 3/12 patients (25%) needed a secondary surgical procedure while 3/13 (23%) in group 2 with no statistically significant difference (p=0,9). The mean flap dimensions were 187cm2 in group 1, vs 89 cm2 in group 2. In the LEFS score a statistically significant difference was found: group 1 LEFS=56.0, group 2 LEFS=74.5, (p=0,02). The results of the SF-36 showed that patients were more satisfied with their functional results in the Group 2 score= 0.98 vs. group 1 score=0.70 (p=0,007). The physical limitations weremore frequently present in group 1 (score=0.63) vs. group 2 (score=1.00) (p=0,01).

CONCLUSIONS. Despite the advantages of early reconstruction are related to the concept of coverage before bacterial proliferation, modern advancements in wound management with negative pressure therapy have reassessed the concept of urgency in treatment of LLOF, as it allows a sterile sealing of the soft tissue defect after debridement, it enhances the granulation tissue formation and can lead to a coverage with a flap of smaller dimension; it gives the surgeon the possibility of a better hospital management with the dedicated surgical team in a dedicated Operating Room during the working hours. Moreover, the LEFS and SF-36 questionnaires showed an increased satisfaction regarding functional results, suggesting that a better consciousness of what is happeningmight influence the patients' perspective and recovery.