Outcomes from open lower limb fractures in elderly patients undergoing orthoplastic surgery - an observational cohort study from the South Wales Orthoplastic Service

Abstract

Background: Patient-reported outcomes following treatment of open lower limb fractures in the elderly are poorly reported. This study aimed to report clinical outcomes from the South Wales orthoplastic service using the Lower Extremity Functional Scale (LEFS).

Materials and methods: A retrospective observational cohort study was performed using LEFS scores for patients aged 65 years and over with open lower limb fractures undergoing either local or free flap reconstruction from June 2020 - June 2023. LEFS scores were collected from paper questionnaires of patients returning to the orthoplastic clinic for follow up. Deep infection, secondary amputation and time to union were recorded. Patients undergoing primary closure alone or reconstruction due to infection were excluded.

Result: Fifty-one patients were included, 15 (29 %) male and 36 (71 %) female. The median age was 72. There were 26 (51 %) ankle, 24 (47 %) tibial and 1 (2 %) mid-foot open fractures. Of the 24 open tibial fractures, 17 (71 %) were fixed with nails, 5 (21 %) with plates and screws or a combination of both (2, 8 %). Sixteen (67 %) received local flaps and 9 (38 %) required free flaps. Ankle fractures were fixed with screws, plates or fibula nails. Seven (27 %) required free flaps and 19 (73 %) pedicled flaps. The mid foot fracture received a bridging plate, screws and a free flap. Of these 51, 3 (6 %) died during admission, 3 (6 %) were lost to follow and 1 (2 %) died before the first follow up appointment. Of the remaining 44 patients, the median LEFS score was 35 at a median follow up of 51 weeks indicating moderate functional limitation. The median time to union was 26 weeks. One (2 %) patient developed a deep infection requiring metalwork removal and there were 6 (14 %) non-unions. There were no secondary amputations.

Conclusions: Open lower limb fractures in the elderly population can present challenges for orthoplastic reconstruction. We have shown successful fix and flap procedures are possible in a cohort traditionally considered to be high risk for surgery. Patients had reasonable functional outcomes at 12 months post-operatively. LEFS scores can provide objective data to evaluate recovery following orthoplastic reconstruction in this cohort.

Keywords: Elderly; Fragility; Free tissue transfer; Functional outcome; Lower limb; Open fracture; Reconstruction.