Gustilo-Anderson type III tibial fractures have poor functional outcomes in patients over 75 years

Abstract

Background: Previous outcome studies in open tibial fractures have commonly assessed young patients and there is a paucity of data regarding outcomes in the elderly. The aim of this study is to assess functional outcomes for patients over 75 years with Gustilo-Anderson Grade III open tibial fractures, including mobility and residential status. Methods: Outcomes for all patients over 75 years admitted with grade III open tibial fractures to a UK level 1 trauma centre during a 5-year period (January 2010eMay 2015) were analysed. Long-term follow up of surviving patients (median 44 months post injury) was undertaken in February 2016. Results: Twenty-nine patients (24 female, 5 male -median 85 years) were included. Prior to injury 48% (n ¼ 14) patients were independently mobile and 45% (n ¼ 13) were living at home without care. Twothirds of injuries were low energy; all patients sustained a grade III open tibial fracture. The 12-month mortality rate was 28% (n ¼ 8) and mortality at long-term follow-up 48% (n ¼ 14). From pre-injury to long-term 8% (n ¼ 1) patients did not change mobility status, 75% (n ¼ 9) reduced by one grade (e.g. independent to walking aid) and 16% (n ¼ 2) by two grades. Fifty eight percent (n ¼ 7) of patients retained residential status, 17% (n ¼ 2) reduced by one grade and 25% (n ¼ 3) by two grades. Conclusion:Grade III open tibial fractures are a significant injury in the elderly associated with poor outcomes with respect to return to mobility and pre-injury residential status. Our results suggest that a greater emphasis on intensive rehabilitation should be considered in this patient group.

Open tibia/fibula in the elderly: A retrospective cohort study

“…The bimodal age and gender distribution of open tibia/fibula fractures in this study are consistent with previous UK data. 21 , 22 , 23 This study demonstrated a similar soft tissue insult in terms of Gustilo-Anderson classification despite the difference in mechanism. This observation may be explained by skin fragility and systemic frailty, 22 , 24 allowing a greater degree of tissue destruction despite lower forces involved.…”

“… 36 Compared to previous data we report lower rates of amputation overall; this may relate to the lower proportion of Gustilo-Anderson grade 3 injuries in our cohort. 23 , 26 Additionally, despite similar operative interventions across both age groups, elderly patients had a significantly longer time to discharge. Length of stay in both age groups was comparable with previous reports.…”

“…Our data on method of soft tissue coverage and initial skeletal fixation are consistent with previous studies in elderly cohorts with similar injury severities. 23 , 33 Some surgeons may be reluctant to perform free flap reconstruction in the elderly, owing to concerns regarding comorbidities and flap survival. In the extended free flap cohort, microvascular venous thrombosis and partial flap necrosis were only reported in the 18–65 years age group, despite more comorbidities in the elderly, including diabetes mellitus.…”

“…Length of stay in both age groups was comparable with previous reports. 23 , 37 , 38 Longer recovery times in elderly patients are expected due to reduced physiological reserves, 39 and co-morbidities may also lengthen their stay. It seems reasonable to give equal access to limb reconstruction based on the above, and future work into enhanced care pathways that could accelerate the rehabilitation of these patients in a cost-effective manner should be undertaken, as has been the case for elderly neck of femur fractures.…”

Classification of open fractures: the need to modernize

“…The host status, already has classification tools available 31 . Perhaps elderly patients need to be considered differently as it has been shown outcomes are worse in this cohort 32 . However, the risk of doing so is to potentially undermine the whole concept of developing a very simplistic grading system.…”