1. Rehabilitation in major trauma centres (MTCs) should be delivered by a multidisciplinary team (MDT) led by a consultant in rehabilitation medicine.
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. Patients requiring inpatient rehabilitation (usually for injuries other than their open tibial fracture) should be assessed by the inpatient unit within 10 days.
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. 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. 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. 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. A patient undergoing delayed amputation should have a peri-operative pain control plan in place prior to surgery.
9. A patient undergoing delayed amputation should be assessed by a prosthetist or a consultant in rehabilitation medicine prior to surgery.
10. Surgeons should consider referring patients with poorly functioning but reconstructed lower limbs for dynamic orthotics.
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).
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.
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 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.
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.
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.
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. Patients with persistent or recurrent pain not adequately managed by surgical team in conjunction with the patient’s GP.
3. Patients whose pain is causing significant distress or functional impairment.
4. Patients with analgesic misuse problems or who are taking recreational drugs/alcohol for pain relief.
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.
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).
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