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Rehabilitation After Severe Open Tibial Fractures 

Rehabilitation After Severe Open Tibial Fractures
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Rehabilitation After Severe Open Tibial Fractures
DOI:
10.1093/med/9780198849360.003.0018
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date: 30 November 2020

Summary

  1. 1. Rehabilitation in major trauma centres (MTCs) should be delivered by a multidisciplinary team (MDT) led by a consultant in rehabilitation medicine.

  2. 2. Patients with an isolated open tibial fracture should be assessed by a member of the MDT and provided with a rehabilitation prescription (RP) within two calendar days of admission.

  3. 3. Patients requiring inpatient rehabilitation (usually for injuries other than their open tibial fracture) should be assessed by the inpatient unit within 10 days.

  4. 4. The weight-bearing status of the limb and permissible range of movement of joints (with respect to both bony stability and soft tissue reconstruction) must be recorded in the clinical notes and RP immediately after definitive surgical treatment. Unrestricted rehabilitation should be the goal of surgery and achieved as early as possible.

  5. 5. The patient’s recovery after severe open tibial fracture should be assessed 12 months after injury using the EuroQol-Five Dimensions (EQ-5D) tool.

  6. 6. A member of the rehabilitation MDT should have the ability to screen patients for post-traumatic stress disorder (PTSD); ideally the team should include a clinical psychologist.

  7. 7. Referral to a specialist pain medicine service should be considered if pain symptoms are becoming chronic, are not related to a treatable cause, and are persisting despite treatment by the surgical team and GP.

  8. 8. A patient undergoing delayed amputation should have a peri-operative pain control plan in place prior to surgery.

  9. 9. A patient undergoing delayed amputation should be assessed by a prosthetist or a consultant in rehabilitation medicine prior to surgery.

  10. 10. Surgeons should consider referring patients with poorly functioning but reconstructed lower limbs for dynamic orthotics.

  11. 11. Patients with a high trans-femoral amputation who do not tolerate standard prosthetic sockets could be considered for osseointegration.

Introduction

Sustaining a severe open tibial fracture is a life-changing injury regardless of whether the eventual clinical outcome is amputation or limb reconstruction (1). Surgical treatment is only the first stage of the patient’s recovery. For the patient to achieve their maximum potential for physical, social, and psychological function, greatest participation in society, and quality of living, they require a combination of training and therapy collectively referred to as rehabilitation (2).

After initial surgical treatment there are a finite number of possible clinical outcomes ranging from the surgical objective of infection-free bony union and healed wounds and a useful limb, to primary amputation in an unreconstructable limb. Between these two outcomes is a spectrum of limbs requiring ongoing treatment for infection and/or problems with healing of bones and soft tissues. Those that suffer with persistent complications/consequences of injury may end up with a delayed amputation. The goals for rehabilitation, however, must remain the same, namely to maximise the return of limb functionality and to help integrate the patient back into society by facilitating optimal quality of life. Aside from the limb injury, patients may well have other injuries, e.g. traumatic brain injuries or pre-existing medical co-morbidities, and therefore each patient’s rehabilitation needs will vary considerably.

There is a lack of prospective interventional trial data on rehabilitation following open tibial fracture. However there are sufficient observational studies together with trials from related fields, e.g. neuro-rehabilitation, to allow clinical standards and recommendations to be developed. The standards presented in this chapter are consistent with those proposed by the National Institute for Health and Care Excellence (NICE) (3), the British Society of Rehabilitation Medicine (BSRM) (2), the NHS Clinical Advisory Group Trauma (Trauma-CAG) (4), and those adopted by the National Clinical Audit of Specialist Rehabilitation following Major Injury (NCASARI) (5).

Rehabilitation services

The Trauma-CAG identified rehabilitation services as a central component of the formation of the Major Trauma Network (4). Rehabilitation in major trauma centres (MTCs) should be delivered by a multidisciplinary team (MDT) led by a consultant in rehabilitation medicine (2, 3, 4).

The BSRM standards for major trauma recommend that all trauma casualties with an Injury Severity Score (ISS) ≥9 (i.e. an isolated open tibia fracture) be assessed by a member of the MDT and provided with an initial rehabilitation prescription (RP) within two calendar days of admission (2), which can be finalised after definitive skeletal fixation and soft tissue reconstruction. The minimum surgical input to the RP should include clear direction regarding the weight-bearing status of the limb and the permissible range of movement of the adjacent joints. This should be agreed jointly by orthopaedic and plastic surgeons, and clearly documented at each stage of surgical treatment. To facilitate rehabilitation, the default position after definitive surgery should be no restrictions on either joint movement or weight-bearing, i.e. ‘weight-bearing as tolerated’. The reason for and time limits of any restrictions should be clearly documented.

It is anticipated that most patients with isolated open tibial fractures will require a basic RP, which will be delivered on an outpatient basis. However, those with more complex treatment needs, concurrent injuries, or significant medical co-morbidities will require a specialist RP and may well need inpatient rehabilitation (5). Patients requiring inpatient rehabilitation should be assessed by the inpatient unit within 10 days.

Measuring outcomes

This is covered in greater detail in Chapter 16. Units treating open tibial fractures should measure their results alongside submission of data to the Trauma Audit Research Network (TARN) (6). Measuring outcomes offers a surrogate of the performance of a unit and drives quality improvement efforts.

Outcome measures should be valid, i.e. actually measure the outcome of interest, and standardised to not only allow a unit to determine trends in their own performance over time, but also permit comparisons between units (7).

Infection

Infection following open tibial fracture is associated with amputation and fixation failure (8), and the rate of infection is cited as a surrogate marker of unit performance (9). For this measure to be meaningful a clear definition of infection must be employed and the time period over which infection surveillance occurs specified.

There remains no accepted definition of ‘infection’, with studies employing various definitions, including positive microbiological specimens (10), clinical diagnosis (9), a requirement for surgical treatment (8), or the use of diagnostic criteria. The most commonly used diagnostic criteria is the US Centers for Disease Control (CDC) surgical site infection tool (11), though the recently proposed fracture-specific tool from Metsemakers et al. (12) should be considered for future use.

Amputation rate

The rate of amputation following severe open tibial fracture, often regarded as synonymous with ‘failed reconstruction’, has also been cited as an outcome measure (9). However, this is problematic as it assumes reconstruction is always the superior outcome, a position not supported by multiple studies that have found either similar or superior patient-reported outcomes following amputation (1, 13, 14, 15). The use of amputation rates as an outcome measure in isolation should be avoided and surgeons should continue to base complicated discussions with patients regarding amputation and reconstruction on the likely best outcome for the individual patient.

Patient-reported outcome measures

It is now accepted practice to measure the success of medical treatment at least in part on the patient’s perception of the results of the intervention. Following open tibial fracture, the main choice is between using an anatomic-specific measure, i.e. looking at knee or ankle function, or a general health-related quality-of-life (HRQOL) measure (15). There is currently no specific outcome measure for measuring recovery after tibia fracture.

The main HRQOL measures used following orthopaedic trauma are the Short Form-36 (SF-36) (15), the Sickness Impact Profile (SIP) (16), and the EQ-5D (17). The main disadvantage of these tools is that concurrent injuries, e.g. traumatic brain injury, will be reflected in the overall outcome measure, and not just the effect of the lower limb injuries. An advantage over anatomic-specific patient-reported outcome measures (PROMs) is that general HRQOL measures are applicable both to patients who retain their limbs and those who undergo amputation.

SF-36 has been the most widely used measure in studies of orthopaedic trauma, but its use normally incurs a cost, whereas SIP and EQ-5D are available on an open-use basis for non-commercial purposes.

EQ-5D is the HRQOL outcome measure used by NHS England in the PROMs programme (18), and is therefore recommended as the generic PROM for assessing recovery following open tibial fracture. It is known that PROMs will change for years after injury (1), and so an arbitrary 12-month point is recommended for recording EQ-5D scores.

Psychological impact

The physical effects of a severe extremity injury are obvious, however the damage to mental health can also be profound. This is examined in greater detail in Chapter 17. The events surrounding a life-changing injury such as an open tibial fracture are frequently so outside normal experience as to result in psychological injury.

The Lower Extremity Assessment Project (LEAP) group detailed the prolonged psychological impact of a lower limb-threatening injury persisting 7 years after injury (1, 19). The psychological effect for children with severe lower limb injuries was documented by Levy et al., who interviewed 40 paediatric patients with open tibial fractures. A quarter of these patients continued to suffer from flashbacks and nightmares involving the events of the accident.

A study by Bhat et al. (20) looked specifically at post-traumatic stress disorder (PTSD) following open tibial fracture. This study used the Post-Traumatic Stress Disorder Checklist Scale (PCL), a validated scoring system based on the Diagnostic and Statistical Manual IV definition of PTSD. The study showed that in a cohort of 60 patients who had sustained an open tibial fracture and who had undergone successful limb reconstruction, 30% of patients suffered from PTSD. The other significant finding in this study was that patients younger than 50 years of age were at greater risk of PTSD. The authors speculated that the events producing the higher energies required to fracture younger bone might be more traumatic than those resulting in lower-energy injuries in older patients.

Whilst the majority of patients do not suffer long-term psychological consequences following their injury, there should be provision within rehabilitation MDTs for screening for PTSD using simple tools like the PCL. Ideally a clinical psychologist should be a (usually part-time) member of the rehabilitation MDT (21). If this is not possible, then the rehabilitation MDT’s occupational therapist should be trained to screen for PTSD and a referral pathway to local clinical psychology services established.

Chronic pain

Limb-threatening injuries and the surgical treatments required to manage them are potent pain stimuli. The management of acute pain is a core skill of a surgeon treating these injuries, but it is recognised that for some patients painful symptoms can become more complex and persist beyond the point where the surgical goals of fracture union and wound closure have been achieved.

Identifying chronic pain is challenging. The Royal College of Anaesthetists (RCA) defines complex pain as ‘Any pain associated with, or with the potential to cause, significant disability and/or distress’ (22). The point at which acute pain evolves into more complex chronic pain is poorly understood (23) and there is no defined time point at which pain symptoms can be regarded as becoming ‘chronic’.

The persistence of painful symptoms after treatment for an open tibial fracture occurs after both amputation (24) and reconstruction (25), and is closely associated with, and regarded as a driver of, poor functional recovery (26). The LEAP study reported approximately 20% patients with severe chronic pain 7 years after open tibia fracture (27). In a US study of opioid prescription it was found that 20% of patients who received surgery for a lower limb injury were still using controlled opiate analgesia 3 months after injury (28). In the European Chronic Pain Survey 18% of patients in the UK with chronic pain cited a traumatic injury as the cause of their symptoms (29).

The causes of pain symptoms are as heterogeneous as the limb injuries themselves. Pain following reconstruction is associated with fracture non-union (30), prominent metal work (31), post-traumatic arthritis (32), intra-medullary nail entry point (33), free tissue transfer, nerve damage (34), or often a combination of these factors. Conversely, pain following amputation is usually associated with nerve transection, neuroma (35), or prosthetic fitting issues, such as bony prominence, heterotopic ossification, or soft tissue mobility (36).

Surgeons managing patients with limb-threatening injuries should recognise that the effective control of acute pain is probably the most effective way to prevent the development of chronic and complex pain (23).

Surgeons treating patients with ongoing pain symptoms after severe lower limb fractures should first identify and treat any potentially amenable anatomic cause of pain symptoms (22). Second, they should recognise the development of chronic and complex pain symptoms and identify the need for onward referral to specialist pain services.

The RCA Core Standards on Pain Medicine Service (22) recommend that referral of patients to specialist pain services following severe lower limb injury should be considered in the following circumstances:

  1. 1. Patients with persistent or recurrent pain not adequately managed by surgical team in conjunction with the patient’s GP.

  2. 3. Patients whose pain is causing significant distress or functional impairment.

  3. 4. Patients with analgesic misuse problems or who are taking recreational drugs/alcohol for pain relief.

  4. 5. Patients with pain-related psychological and psychosocial problems (e.g. pain-related fear, anxiety, reactive depression, functional impairment) that complicate their pain symptoms or rehabilitation.

In the specific case of limb amputation performed following unsuccessful reconstruction, patients should have preoperative anaesthetic assessment and a pain control plan written for the peri-operative period. Consideration should be given to the use of peri-neural catheterisation (37) or epidural infiltration (38) of analgesic and anaesthetic agents.

Prosthesis and orthotics

The use of a prosthetic to replace function or an orthotic to augment it is commonly required after severe lower limb trauma.

In the case of amputation, the prosthetist’s role in the patient’s rehabilitation is fundamental. When limb amputation is not being performed as an urgent procedure, the patient should be assessed by the rehabilitation consultant or prosthetist prior to surgery (39). This allows the patient to be informed about the likely timing and sequential manner of prosthetic fitting, along with the expected rehabilitation process.

Whilst the role of prosthetics following amputation is obvious, there is increasing evidence that orthotics may significantly improve function after limb reconstruction and retention. It is recognised that in patients with limb-threatening injuries, particularly those involving the foot and ankle, outcomes after limb reconstruction can be inferior to amputation (14).

The development of energy-storing and returning orthotics occurred as part of the effort to improve rehabilitation in US service personnel with severely injured but reconstructed limbs (40), and has been shown to significantly improve outcomes after reconstruction (41). Surgeons should consider referring patients with poorly functioning reconstructed lower limbs for dynamic orthotics.

Osseointegration

The transfer of forces between the skeleton and the prosthesis occurs at the interface between the prosthesis socket and the residual limb. This can frequently be a reason for pain and difficulty with prosthetic use as a result of poor soft tissues, heterotopic ossification, and bony prominence (42). Osseointegration allows for the direct transfer of forces from the skeleton to the prosthesis, bypassing the soft tissue envelope of the residual limb.

In 1990 Brånemark et al. implanted the first osseointegrated mount for a prosthetic coupling in a trans-femoral amputee (43). Since then techniques and implants have improved and osseointegration has developed from an experimental technique to a valid, albeit specialist, treatment modality (44).

It is recommended that patients with a high trans-femoral amputation who do not tolerate standard prosthetic sockets be referred to a specialist centre with experience in osseointegration.

References

1. MacKenzie EJ, Bosse MJ, Pollak AN, Webb LX, Swiontkowski MF, Kellam JF, et al. Long-term persistence of disability following severe lower-limb trauma. Results of a seven-year follow-up. J Bone Joint Surg Am. 2005;87(8):1801–9.Find this resource:

2. British Society of Rehabilitation Medicine. Specialist Rehabilitation in the Trauma Pathway: BSRM Core Standards. London: Royal College of Physicians; 2013.Find this resource:

3. NICE. Trauma—Quality Standards (QS166). London: NICE; 2018.Find this resource:

4. Report NCAG. Regional Networks for Major Trauma. London: NHS; 2010.Find this resource:

5. National Clinical Audit of Specialist Rehabilitation following Major Injury. Specialist rehabilitation for patients with complex needs following major trauma. London: National Clinical Audit of Specialist Rehabilitation following Major Injury; 2016.Find this resource:

6. TARN. Trauma Audit and Research Network Manchester 2018. : https://www.tarn.ac.uk/Content.aspx?ca=4

7. Bryant D, Fernandes N. Measuring patient outcomes: a primer. Injury. 2011;42(3):232–5.Find this resource:

8. Penn-Barwell JG, Bennett PM, Fries CA, Kendrew JM, Midwinter MJ, Rickard RF. Severe open tibial fractures in combat trauma: management and preliminary outcomes. Bone Joint J. 2013;95-B(1):101–5.Find this resource:

9. Wordsworth M, Lawton G, Nathwani D, Pearse M, Naique S, Dodds A, et al. Improving the care of patients with severe open fractures of the tibia: the effect of the introduction of Major Trauma Networks and national guidelines. Bone Joint J. 2016;98-B(3):420–4.Find this resource:

10. Johnson EN, Burns TC, Hayda RA, Hospenthal DR, Murray CK. Infectious complications of open type III tibial fractures among combat casualties. Clin Infect Dis. 2007;45(4):409–15.Find this resource:

11. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control. 1999;27(2):97–132; quiz 3–4; discussion 96.Find this resource:

12. Metsemakers WJ, Morgenstern M, McNally MA, Moriarty TF, McFadyen I, Scarborough M, et al. Fracture-related infection: a consensus on definition from an international expert group. Injury. 2018;49(3):505–10.Find this resource:

13. Doukas WC, Hayda RA, Frisch HM, Andersen RC, Mazurek MT, Ficke JR, et al. The Military Extremity Trauma Amputation/Limb Salvage (METALS) study: outcomes of amputation versus limb salvage following major lower-extremity trauma. J Bone Joint Surg Am. 2013;95(2):138–45.Find this resource:

14. Bennett PM, Stevenson T, Sargeant ID, Mountain A, Penn-Barwell JG. Outcomes following limb salvage after combat hindfoot injury are inferior to delayed amputation at five years. Bone Joint Res. 2018;7(2):131–8.Find this resource:

15. Busse JW, Jacobs CL, Swiontkowski MF, Bosse MJ, Bhandari M. Complex limb salvage or early amputation for severe lower-limb injury: a meta-analysis of observational studies. J Orthop Trauma. 2007;21(1):70–6.Find this resource:

16. Bergner M, Bobbitt RA, Kressel S, Pollard WE, Gilson BS, Morris JR. The sickness impact profile: conceptual formulation and methodology for the development of a health status measure. Int J Health Serv. 1976;6(3):393–415.Find this resource:

17. EuroQol. EuroQol—a new facility for the measurement of health-related quality of life. Health Policy. 1990;16(3):199–208.Find this resource:

18. NHS England. National PROMS Programme Guidance. Leeds: NHS; 2017.Find this resource:

19. McCarthy ML, MacKenzie EJ, Edwin D, Bosse MJ, Castillo RC, Starr A, et al. Psychological distress associated with severe lower-limb injury. J Bone Joint Surg Am. 2003;85-A(9):1689–97.Find this resource:

20. Bhat W, Marlino S, Teoh V, Khan S, Khan U. Lower limb trauma and posttraumatic stress disorder: a single UK trauma unit’s experience. J Plast Reconstr Aesthet Surg. 2014;67(4):555–60.Find this resource:

21. Centre for Work Force Intelligence. NHS Clinical Advisory Group on Major Trauma Workforce. London: NHS; 2011.Find this resource:

22. Faculty of Pain Medicine. Core Standards for Pain Management Services in the UK. London: Royal College of Anaesthetists; 2015.Find this resource:

23. Lavand’homme P. The progression from acute to chronic pain. Curr Opin Anaesthesiol. 2011;24(5):545–50.Find this resource:

24. Penn-Barwell JG. Outcomes in lower limb amputation following trauma: a systematic review and meta-analysis. Injury. 2011;42(12):1474–9.Find this resource:

25. Harries L, Emam A, Khan U. Pain after ortho-plastic reconstruction of lower limb injuries: a snapshot study. Injury. 2018;49(2):414–19.Find this resource:

26. Vallier HA, Cureton BA, Patterson BM. Factors influencing functional outcomes after distal tibia shaft fractures. J Orthop Trauma. 2012;26(3):178–83.Find this resource:

27. Castillo RC, MacKenzie EJ, Wegener ST, Bosse MJ, Group LS. Prevalence of chronic pain seven years following limb threatening lower extremity trauma. Pain. 2006;124(3):321–9.Find this resource:

28. Holman JE, Stoddard GJ, Higgins TF. Rates of prescription opiate use before and after injury in patients with orthopaedic trauma and the risk factors for prolonged opiate use. J Bone Joint Surg Am. 2013;95(12):1075–80.Find this resource:

29. Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain. 2006;10(4): 287–333.Find this resource:

30. Antonova E, Le TK, Burge R, Mershon J. Tibia shaft fractures: costly burden of nonunions. BMC Musculoskelet Disord. 2013;14:42.Find this resource:

31. Brown OL, Dirschl DR, Obremskey WT. Incidence of hardware-related pain and its effect on functional outcomes after open reduction and internal fixation of ankle fractures. J Orthop Trauma. 2001;15(4):271–4.Find this resource:

32. Buckwalter JA, Brown TD. Joint injury, repair, and remodeling: roles in post-traumatic osteoarthritis. Clin Orthop Relat Res. 2004(423):7–16.Find this resource:

33. Toivanen JA, Vaisto O, Kannus P, Latvala K, Honkonen SE, Jarvinen MJ. Anterior knee pain after intramedullary nailing of fractures of the tibial shaft. A prospective, randomized study comparing two different nail-insertion techniques. J Bone Joint Surg Am. 2002;84-A(4):580–5.Find this resource:

34. Harris AM, Althausen PL, Kellam JF, Bosse MJ, Castillo R. Complications following limb-threatening lower extremity trauma. J Orthop Trauma. 2009;23(1):1–6.Find this resource:

35. Ehde DM, Czerniecki JM, Smith DG, Campbell KM, Edwards WT, Jensen MP, et al. Chronic phantom sensations, phantom pain, residual limb pain, and other regional pain after lower limb amputation. Arch Phys Med Rehabil. 2000;81(8):1039–44.Find this resource:

36. Dillingham TR, Pezzin LE, MacKenzie EJ, Burgess AR. Use and satisfaction with prosthetic devices among persons with trauma-related amputations: a long-term outcome study. Am J Phys Med Rehabil. 2001;80(8):563–71.Find this resource:

37. Borghi B, D’Addabbo M, White PF, Gallerani P, Toccaceli L, Raffaeli W, et al. The use of prolonged peripheral neural blockade after lower extremity amputation: the effect on symptoms associated with phantom limb syndrome. Anesth Analg. 2010;111(5):1308–15.Find this resource:

38. Lambert A, Dashfield A, Cosgrove C, Wilkins D, Walker A, Ashley S. Randomized prospective study comparing preoperative epidural and intraoperative perineural analgesia for the prevention of postoperative stump and phantom limb pain following major amputation. Reg Anesth Pain Med. 2001;26(4):316–21.Find this resource:

39. British Society of Rehabilitation Medicine. Amputee and Prosthetic Rehabilitation—Standards and Guidelines. London: British Society of Rehabilitation Medicine; 2003.Find this resource:

40. Patzkowski JC, Blanck RV, Owens JG, Wilken JM, Blair JA, Hsu JR. Can an ankle-foot orthosis change hearts and minds? J Surg Orthop Adv. 2011;20(1):8–18.Find this resource:

41. Highsmith MJ, Nelson LM, Carbone NT, Klenow TD, Kahle JT, Hill OT, et al. Outcomes associated with the intrepid dynamic exoskeletal orthosis (IDEO): a systematic review of the literature. Mil Med. 2016;181(S4):69–76.Find this resource:

42. Webster JB, Hakimi KN, Williams RM, Turner AP, Norvell DC, Czerniecki JM. Prosthetic fitting, use, and satisfaction following lower-limb amputation: a prospective study. J Rehabil Res Dev. 2012;49(10):1493–504.Find this resource:

43. Brånemark R, Brånemark PI, Rydevik B, Myers RR. Osseointegration in skeletal reconstruction and rehabilitation: a review. J Rehabil Res Dev. 2001;38(2):175–81.Find this resource:

44. Al Muderis M, Khemka A, Lord SJ, Van de Meent H, Frolke JP. Safety of osseointegrated implants for transfemoral amputees: a two-center prospective cohort study. J Bone Joint Surg Am. 2016;98(11):900–9.Find this resource: