This study aimed to show the course of treatment in a highly selective patient cohort with lower leg fractures treated with reconstruction and flap coverage. Furthermore, we aimed to detect postoperative complications and outcomes. For all 22 patients, complications such as SSI, necrosis, implant failure, the presence of an open fracture or other factors led to subsequent flap coverage. The bacterial spectrum described in this study is almost identical to that reported in national surveillance data [9].
The results of FAOS and EQ-5D index and VAS instruments in our study detected very poor function and QoL in patients who experienced lower leg fractures requiring flap coverage. Furthermore, patients with flap ischemia have shown the poorest outcomes in our cohort, as measured by FAOS, FAOS subscores, EQ-5D index and VAS.
Van Bergen et al. stated that the minimal detectable changes of each FAOS subscore were 17.1–20.8 at the individual level and 2.0–2.4 at group level in the validation of the German version of the FAOS [10]. In a recent review, the FAOS were shown to be reliable tools for the re-evaluation of ankle injuries and the assessment of their recovery [11]. Considering these data, it is possible to compare our FAOS scores with results from other studies. Duckworth et al. reported a mean FAOS score of 76 (mean follow-up 6 years) in complex tibial pilon fractures, compared with the score of 60.7 in our study (mean follow-up 41 months) [12]. Unfortunately, no subscores were reported. Kent et al. evaluated unstable syndesmotic injuries with different treatment options [13]. Among three subgroups, the group with the worst outcome had the following results in the subscores: pain (89), symptoms (75), ADL (97), sport/rec (75) and QoL (44). In their study with 1,670 patients with different ankle pathologies, despite comparable data, Golightly et al. have found a significantly better QoL (83 points) [14]. In comparison to these studies, it can be confirmed that our patients had a particularly poor outcome.
Two previous studies with different type of ankle fractures found that the EQ-5D VAS score and EQ-5D index were significantly higher than those we observed in our current study with a mean EQ-5D VAS of 57.6 (30–100) and a mean EQ-5D index of 0.621 (-0.205–1.000) [15, 16]. In our study, patients who required many revision surgeries were hospitalized for long periods because of limb salvage with a subsequent limited mobility, which may explain their measured QoL was poor. In a randomized study by Andersen et al. involving 97 patients with ankle injuries and follow-up at two years, much better EQ-5D VAS scores were reported, with a mean of 90 (75–95); however, none of these cases had any large soft tissue defects, so they didn’t need a flap coverage [15]. In our study, instead, each patient needed at least one flap coverage because of large soft tissue defects, which could explain why the scores of our cohort are lower than the scores of the cohort of Andersen et al. [15]. Coherently with previous findings, our study shows that severe injuries and complications determining multiple revisions and flap coverage have a negative impact on factors such as quality of life.
The Lower Extremity Assessment Project (LEAP) study examined patients up to 7 years postoperatively and indicated poor physical and psychosocial results after lower limb trauma regardless of the initial treatment options (amputation or reconstruction). Both patient groups were severely disabled compared to the overall population [1]. Return to work was possible for 37.5% of our patients at the mean follow-up period of 41.2 months (22 to 84); however, according to the LEAP study, the return to work rate was 58% at 7-year follow-up [17]. Therefore, it may be expected that the return to work rate could be higher in our patient group after 7 years. Patients who underwent limb salvaging required many surgeries, experienced complications such as bone and soft tissue infections, experienced disabilities, and required long hospitalizations. A meta-analysis revealed that limb reconstruction was at least as effective as amputation in terms of physical criteria such as the ability to perform ADL and of recovery time required before being able to return to work [18].
Despite having undergone similar surgeries for comparable complications and conditions, the scores of the two amputees in our study showed great discrepancies relative to the other participants. These results may reflect the subjective perception of postoperative daily routines and patient status. These two patients were not able to go back to their professional life. EQ-5D VAS scores of these two patients were reported as 50 vs 80.
By focusing on a specific cohort, our study highlighted the peculiarities that differentiate these patients from those that undergo surgeries with lower rates of complications. However, focusing on a restricted sample was also a source of limitations for our work, as more detailed subgroup analyses could not be carried out. Another limitation consisted in our study having a retrospective single-center design.