Nightingale, Jessica
(2021)
Open fractures of the tibia: a national, regional and individual perspective.
PhD thesis, University of Nottingham.
Abstract
Introduction
Open tibial fractures are complex high energy injuries, associated with soft tissue loss and contamination; they are amongst the most severe injuries seen in orthopaedic practice. Modern practice demonstrates a tendency to reconstruct severely injured limbs; yet despite the use of aggressive protocols, recovery is often incomplete with long-term implications for patients. Robust research in this field is limited; much of the published work is based on single institutional experiences and hampered by poor study design. Ultimately, there will be a role for randomised controlled trials in determining the best interventions for these patients; although research questions in randomised controlled trials must be set on firm foundations with comprehensive work undertaken to understand current perspectives. These perspectives are currently not clearly outlined in the literature where; epidemiological patterns, the limits of established practice and patient views are all poorly represented. The aim of this thesis is to pursue answers to these questions, with an overall purpose of supporting the future development of high quality research in open tibial fractures.
Methods
A mixed-methods study with a sequential explanatory study design. Descriptive statistics, sensitivity analysis and generalised linear models were used to analyse data from two large datasets. The two datasets included data from the Trauma Audit Research Network (TARN); the national registry for trauma which contains comprehensive characterisation of patients and care-pathways; and a detailed local injury register from the East Midlands Trauma Centre which holds linked micro-costings and a cross-sectional patient-reported outcome measures (PROMS) dataset. A qualitative systematic review was performed using Joanna Briggs Institute methodology, and the results of these three studies were triangulated to inform the design of a qualitative study considering patient perspective. The qualitative study used semi-structured interviews with individuals who had sustained an open tibial fracture 12-72 months ago and were analysed using framework and cross-case analysis.
Results
Based on an analysis of 7994 cases from the TARN dataset, crude incidence rate of open tibial fracture was 2.85 per 100,000 persons per year. Injury occurred most frequently in males aged 25-30; however, incidence was 15% higher in patients aged over 65 when compared to the 15-39 age group (IRR: 1.15 (1.09-1.22). A fully adjusted model identified the mortality rate was two times greater in patients with comorbidities (OR: 2.34, CI: 1.60 – 3.42). In a further fully adjusted model including 2157 Gustilo 3B or 3C fractures, time to soft tissue coverage was related to wound complications. The proportion of individuals experiencing early inpatient wound complication increased by 0.3% per hour until definitive soft tissue cover (OR: 1.003, (CI: 1.001 - 1.004); other variables in this model relating to the injury or treatment were mostly not significant. The study highlighted the challenges of applying a research question to a dataset collected with a different aim.
The regional injury dataset included 212 individuals. The complication rate was 24% with mean time to revision surgery at 260 days. One year after injury, individuals reported a 26% (p<0.01) reduction in quality of life, and a 30% increase in disability (p<0.01). The mean cost of treatment was £27312, however, there was significant variation in cost dependant on injuries, treatment (p<0.05) and complications (p<0.05).
The qualitative study included 26 individuals who described recovery with parallel physical and psychological narratives. Regaining mobility was a priority for individuals who perceived this to be the gateway to returning to their former roles and responsibilities; whilst mobility was important, many symptoms were reported. The breakdown of routine and purpose that came after the accident was devastating and challenging to navigate. Hope was difficult to sustain due to unknown outcomes, although coping strategies such as goal setting and seeking personal support were important psychological mediators. Experience of recovery differed dependant on fixation strategy; with ring-fixators appearing more difficult to tolerate with broad social consequences. Age was also relevant; the gravity of these challenges was exacerbated for younger individuals, who did not have the financial stability or social capital to endure this life-changing injury without long-term social ramifications.
Conclusion:
This thesis provides a clear national picture of the epidemiology, care pathways and costs associated with open tibial fracture, and provides insight into the implications of this injury for individuals. The thesis offers a case for improving surgical care for individuals with an open tibial fracture; but recognises that this will only be achieved with carefully planned research that adequately controls for variation in these injuries. In addition, modest restructuring of care-pathways to acknowledge the psychosocial implications of these injuries could dramatically improve patient experience with minimal cost.
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