Open tibial fractures in Sweden

Abstract

Background: Open tibial fractures are serious injuries, challenging both for patients and doctors. For the patients, personal, psychological and physical costs are enormous. For healthcare and society, open tibial fractures are injuries that require resources at a high cost. The literature on Swedish patients with open tibial fractures is sparse. Fortunately, we have our national patient registers that represent an invaluable source of information. The aim of this thesis was to map the population of Swedish patients with open tibial fractures, with specific attention to serious complications, mortality and opioid consumption. Furthermore, we aimed to identify fields with room for improvement and possibilities of prevention.

Study 1 is a nationwide study on amputation rate and reconstructive surgery after open tibial fractures, based on all 3,777 Swedish patients admitted during 1998-2010. Amputation rate over-all was low, 3.6 % during the study period. Reconstruction surgery was performed in 9 % of the patients. Main risk factors for amputation were age above 70 years and reconstructive surgery, the latter as an indicator of severe soft tissue injury. The amputation rate after attempted limb salvage with either a pedicled or free flap was 9 %. We also evaluated timing of reconstructive surgery and found results consistent with gold standard according to Godina´s earlier work: flap surgery should be performed within 72 hours whenever possible. Study 2 is a study on mortality and causes of death based on the same study population as in study 1. We found an increased standard mortality ratio for all age- and gender groups during 2 years after injury. External causes of death were over-represented in all age-groups, and dominating among the younger patients 15-39 years (accidents, suicide and poisoning). Risk factors for premature death were increasing age, length of hospital stay, limb amputation and cause of injury. Two main populations especially at risk were identified: the elderly population and younger/middle-aged men. Study 3 is based on data from both the Swedish National Patient Register and the Swedish Register of Prescribed Drugs, during the study period 2007-2019. We found that patients with consumption of pharmaceuticals for psychiatric disorders (depression, anxiety and drug dependency) were at risk for prolonged use of opioids after an open tibial fracture. We conclude that patients with prescribed pharmaceuticals at admission should be identified and may need extra support during de-escalation of their opioid consumption. Study 4 is a validation study of the diagnosis open tibial fracture in the Swedish National Patient Register. Positive predictive values (PPV) were calculated through review of a randomized sample of patient records. We found PPV to be high, 87 %. We calculated the PPV for two sub-groups, moderate and severe injury (defined as having procedure codes for amputation and/or reconstructive surgery). Severe injury had a higher PPV (96 %) compared with moderate injury (86 %). In conclusion, the Swedish National Patient Register is well suited for research purposes regarding trauma diagnoses.