key: cord-0731428-rchocum2
authors: Berner, Juan Enrique; Chan, James K.-K.; Gardiner, Matthew D.; Rakhorst, Hinne; Ortega-Briones, Alina; Nanchahal, Jagdeep; Jain, Abhilash
title: Standards for treatment of open lower limb fractures maintained in spite of the COVID-19 pandemic: Results from an international, multi-centric, retrospective cohort study
date: 2020-12-26
journal: J Plast Reconstr Aesthet Surg
DOI: 10.1016/j.bjps.2020.12.052
sha: 24585f8e2233d7c44fc4e391c914610780a649c7
doc_id: 731428
cord_uid: rchocum2

nan

Results from an international, multi-centric, retrospective cohort study Dear sir, The COVID-19 pandemic has severely disrupted provision of healthcare services, impacting both emergency and elective pathways. 1 In March 2020, the British Orthopaedic Association in conjunction with other relevant bodies published guidance for the treatment of limbthreatening injuries during the pandemic. 2 These were designed to minimise the risks of patients contracting COVID-19 from prolonged inpatient stay and reduce the burden on stretched health services. They recommended that multiple and complex procedures should be avoided and the threshold for early amputation reduced.

The aim of this study was to assess the safety of care pathways for patients sustaining open extremity injuries during the first wave of the COVID-19 pandemic. Our primary objective was to investigate the risk of SARS-CoV-2 related complications in this group of patients, including death. As a secondary objective we intended to capture deviations from the standard of care usually provided for these injuries and associated outcomes. Given the burden of trauma in developing countries even before the pandemic, we examined the impact on a global scale.

We conducted an international, multi-centric, retrospective study in patients with open lower limb fractures, of any severity, treated between the 1st January and 31st May 2020. Participating units in the UK and overseas provided anonymised data using a pre-established proforma on a secure REDCap platform. Approval by clinical audit departments and independent board review in each collaborating hospital was sought as per local protocols.

A total of 212 patients from 15 centres in the United Kingdom (36%), Chile (20%), Sudan (14%), Spain (10%), the Netherlands (6%), Taiwan (5%), South Korea (5%), Mexico (2%) and Italy (2%) were included. Demographic data, injury characteristics, treatment received, and inpatient recovery were recorded ( Table 1 ) .

Despite the pandemic, all centres treated patients according to their usual standards with minimal deviation. Seven patients (3.3%) had their follow-up appointments delayed or adapted to telephone consultations. The majority underwent debridement in the first 24 h (73%), Median time to definitive skeletal fixation and soft tissue reconstruction, if required, from time of injury was two and ten days, respectively. Limbs preservation at discharge was achieved in 94.4% of the cases, with 12 patients (5.6%) requiring immediate or early amputation. Serious complications included three total (6%) and five partial flap failures (10%), 10 cases of acute wound infection (5%), two hematomas that required evacuation (1%) and two deep venous thrombosis (1%). Three patients in the flap failure group required further reconstruction: two with a local flap and one with a second free flap. Two patients in this cohort died because of their injuries and two succumbed to hospital acquired non-COVID pneumonias in the context of pre-existing COPD. No patients were diagnosed with SARS-CoV-2 prior to admission and only one tested positive as an inpatient (0.5%) on PCR and CT-scans and eventually made a full recovery.

Even though there have not been any previous international studies of these characteristics, there are large cohort series published. For the UK subgroup, three of 79 patients (3.7%) required amputation which is similar to the recent UK WOLFF trial (2% of 460 cases). 3 Partial and total free flap failure rates (6.8% for both) are also similar to those reported by a recent study of 129 patients treated in the United States, which reported 10.8% partial and 14.7% total flap failure, and 7.8% requiring amputation. 4 Our study is limited by its retrospective nature, geographic variability, different resource settings and limited follow up (1 to 105 days). This design was necessary to achieve a rapid and global response during the ongoing COVID-19 pandemic. The incidence of patients with COVID-19 in this international sample of emergency admissions was very low. Despite guidance advocating the avoidance of staged procedures and limb salvage in borderline situations, almost all patients received standard care.

Our data demonstrate that lower limb trauma services across many countries have managed to adhere to their usual pre-COVID standard of care. 5 The outcomes so far have remained largely within modern acceptable outcomes. Provided standard surgical COVID-19 precautions are maintained, including screening patients with unknown COVID status upon admission, and routine use of personal protective equipment, it would be reasonable to follow pre-COVID guidance and expect similar outcomes during the current second wave of the pandemic.

JID: PRAS [m6+

The impact of the COVID-19 pandemic on cancer care

British Orthopaedic AssociationManagement of Patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic

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

Joshua Thompson The Hull University Teaching Hospitals NHS Trust (UK): Cher Bing Chuo, Chie Katsura Hospital Universitario de Gran Canaria

The authors would like to thank the Reconstructive Surgery Trials Network (RSTN) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) for their support throughout this project. We would also like to thank The Kennedy Institute of Rheumatology, University of Oxford, for providing us access to their REDCap platform.A protocol for this study has been submitted for publication as part of the RSTN -COVID group.

All the authors deny any conflicts of interest.

Not applicable, as this is a service evaluation project.

None