G E Glass1, A Jain2. 1. Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Roosevelt Drive, Oxford, OX3 7FY, UK. 2. Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Roosevelt Drive, Oxford, OX3 7FY, UK; Department of Plastic and Reconstructive Surgery, Imperial College NHS Foundation Trust, Charing Cross Hospital, Fulham Palace Road, Hammersmith, London, W6 8RF, UK. Electronic address: ajainuk@aol.com.
Abstract
BACKGROUND: Pretibial lacerations are an important and neglected problem among the elderly. Poor management leads to prolonged hospitalisation and terminal decline. This study summarises our experience and evidence from the literature to ascertain an evidence-based rationale for referral and management. METHODS: Our data were obtained from review of a prospectively gathered database. Additionally, Pubmed, Embase, Medline, and the Cochrane Database of Systematic Reviews were searched through July 2013, with eligible studies evaluated using standard methodology. RESULTS: Seventy-three pretibial lacerations in 73 patients (63 females) were identified. Mean age was 78 ± 14, 1SD. Sixty patients were managed operatively with a mean length of stay of 11 ± 7 days, 1SD when uncomplicated by medical co-morbidity. Seven deaths occurred (4 in-hospital; 2 treated surgically and 2 treated conservatively) and 3 deaths occurred within 3 months of discharge; a death rate more than twice that of matched controls. Donor site "over-grafting" was performed in 19 cases and resulted in accelerated donor site healing (11 ± 9 days, 1SD vs. 29 ± 42 days, 1SD; P < 0.001). Negative pressure wound therapy delayed discharge (21 ± 23 days, 1SD vs. 15 ± 14 days, 1SD; P = 0.028). Microbiological sampling is unhelpful. Bed rest is unnecessary. "De-fatting" the flap is unproven. CONCLUSION: Admissions expose the elderly to physical/functional decline and death. Our findings support a change of practice, minimising admissions for minor (Dunkin type I/II) injuries and rapid, protocol-driven surgical intervention and discharge for Dunkin type III/IV injuries with avoidance of negative pressure wound therapy in all but selected cases.
BACKGROUND: Pretibial lacerations are an important and neglected problem among the elderly. Poor management leads to prolonged hospitalisation and terminal decline. This study summarises our experience and evidence from the literature to ascertain an evidence-based rationale for referral and management. METHODS: Our data were obtained from review of a prospectively gathered database. Additionally, Pubmed, Embase, Medline, and the Cochrane Database of Systematic Reviews were searched through July 2013, with eligible studies evaluated using standard methodology. RESULTS: Seventy-three pretibial lacerations in 73 patients (63 females) were identified. Mean age was 78 ± 14, 1SD. Sixty patients were managed operatively with a mean length of stay of 11 ± 7 days, 1SD when uncomplicated by medical co-morbidity. Seven deaths occurred (4 in-hospital; 2 treated surgically and 2 treated conservatively) and 3 deaths occurred within 3 months of discharge; a death rate more than twice that of matched controls. Donor site "over-grafting" was performed in 19 cases and resulted in accelerated donor site healing (11 ± 9 days, 1SD vs. 29 ± 42 days, 1SD; P < 0.001). Negative pressure wound therapy delayed discharge (21 ± 23 days, 1SD vs. 15 ± 14 days, 1SD; P = 0.028). Microbiological sampling is unhelpful. Bed rest is unnecessary. "De-fatting" the flap is unproven. CONCLUSION: Admissions expose the elderly to physical/functional decline and death. Our findings support a change of practice, minimising admissions for minor (Dunkin type I/II) injuries and rapid, protocol-driven surgical intervention and discharge for Dunkin type III/IV injuries with avoidance of negative pressure wound therapy in all but selected cases.
Authors: Roy J Powell; Christopher J Hayward; Caroline L Snelgrove; Kathleen Polverino; Linda Park; Rohan Chauhan; Philip H Evans; Rachel Byford; Carolyn Charman; Christopher J W Foy; Colin Pritchard; Andrew Kingsley Journal: Pilot Feasibility Stud Date: 2017-10-17