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Complex lower limb trauma and reconstructive surgery: understanding health service resource use

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Complex lower limb trauma is a challenging problem. Achieving optimal long-term outcomes requires multi-disciplinary input, while patients are in hospital, and after discharge. The aim of this study was to evaluate the long-term health services resource use of patients with such injuries, in the context of a publicly funded health system.


This is a population-based retrospective cohort study. Data were obtained from the Information Services Division (ISD) Scotland. We included patients with isolated lower extremity injuries, sustained between 1997 and 2015, with follow-up to 2017. Cases were identified defined by ICD-10 and OPCS-4 procedural codes and divided into two groups, complex and simple injuries and analysed for their subsequent contacts with the health service.


There were 42,601 patients with isolated lower limb injuries. 2976 (7.0%) had suffered complex injuries. The in-hospital mortality of these patients was 1.9%. 538 (18.1%) of the patients who sustained complex injuries underwent reconstructive surgery. Just over half attended an orthopaedic outpatient clinic in the first year, and 31.7% attended a plastic surgery clinic. Very few patients attended pain management clinics, or other clinics that might provide pain services.


Only a small proportion of patients who undergo reconstructive surgery are followed up by specialist services. The reasons for such low follow-up rates are not obvious. Our findings raise the question of whether the health service in Scotland has sufficient resources to optimise functional outcome in this patient group.

Level of evidence: Level III, risk / prognostic study

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  1. Momoh AO, Kumaran S, Lyons D, Venkatramani H, Ramkumar S, Chung K, Sabapathy S (2015) An argument for salvage in severe lower extremity trauma with posterior tibial nerve injury: the Ganga Hospital experience. Plast Reconstr Surg 136:1337–1352

    Article  CAS  Google Scholar 

  2. Boriani F, Haq AU, Baldini T, Urso R, Granchi D, Baldini N, Tigani D, Tarar M, Khan U (2017) Orthoplastic surgical collaboration is required to optimise the treatment of severe limb injuries: a multi-centre, prospective cohort study. J Plast Reconstr Aesthet Surg 70:715–722

    Article  Google Scholar 

  3. Nanchahal J, Nayagam S, Khan U, et al. ((2009)) for British Orthopaedic Association (BOA) and British Association of Plastic, Reconstructive and Aesthetic Surgeons, (BAPRAS). Standards for the management of open fractures of the lower limb

  4. Mathews JA, Ward J, Chapman TW, Khan U, Kelly M (2015) Single-stage orthoplastic reconstruction of Gustilo-Anderson Grade III open tibial fractures greatly reduces infection rates. Injury 46:2263–2266

    Article  CAS  Google Scholar 

  5. Harris AM, Althausen PL, Kellam J, Bosse M, Castillo R (2009) The Lower Extremity Assessment Project Study Group, (LEAP). Complications following limb-threatening lower extremity trauma. J Orthop Trauma 23:1–6

    Article  Google Scholar 

  6. Court-Brown CM, RImmer S, Prakash U, McQueen M (1998) The epidemiology of open long bone fractures. Injury 29:529–534

    Article  CAS  Google Scholar 

  7. Archer KR, Castillo RC, MacKenzie EJ, Bosse MJ, The LEAP Study Group (2010) Perceived need and unmet need for vocational, mental health, and other support services after severe lower-extremity trauma. Arch Phys Med Rehabil 91:774–780

    Article  Google Scholar 

  8. Harries L, Emam A, Khan U (2018) Pain after ortho-plastic reconstruction of lower limb injuries: a snapshot study. Injury 49:414–419

    Article  Google Scholar 

  9. Bhat W, Marlino S, Teoh V, Khan S, Khan U (2014) Lower limb trauma and posttraumatic stress disorder: a single UK trauma unit’s experience. J Plast Reconstr Aesthet Surg 67:555–560

    Article  Google Scholar 

  10. Ladlow P, Phillip R, Coppack R, Etherington J, Bilzon J, McGuigan MP, Bennett A (2016) Influence of immediate and delayed lower-limb amputation compared with lower-limb salvage on functional and mental health outcomes post-rehabilitation in the U.K. Military. J Bone Jt Surg 98:1996–2005

    Article  Google Scholar 

  11. McCarthy ML, MacKenzie EJ, Edwin D, Bosse MJ, Castillo RC, Starr A, LEAP study group (2003) Psychological distress associated with severe lower-limb injury. J Bone Jt Surg Am 85:1689–1697

    Article  Google Scholar 

  12. Doukas WC, Hayda RA, Frisch HM, Andersen RC, Mazurek MT, Ficke JR, Keeling JJ, Pasquina PF, Wain HJ, Carlini AR, Mackenzie E (2013) The Military Extremity Trauma Amputation/Limb Salvage (METALS) study: outcomes of amputation versus limb salvage following major lower-extremity trauma. J Bone Jt Surg Am 95:138–145

    Article  Google Scholar 

  13. Page PRJ, Trickett RW, Rahman SM, Walters A, Pinder LM, Brooks CJ, Hutchings H, Pallister I (2015) The use of secure anonymised data linkage to determine changes in healthcare utilisation following severe open tibial fractures. Injury 46:1287–1292

    Article  Google Scholar 

  14. Information Services Divison (ISD) Scotland. CHI Number, ISD Scotland Data Dictionary. (2019). Available at Accessed 11 July, 2019.

  15. Information Services Divison (ISD) Scotland. Use of the NSS National Safehaven (eDRIS). (2019). Available at Accessed 12 September, 2018.

  16. Egeler SA, de Jong T, Luijsterburg AJM, Mureau M (2018) Long-term patient-reported outcomes following free flap lower extremity reconstruction for traumatic injuries. Plast Reconstr Surg 141:773–783

    Article  CAS  Google Scholar 

  17. Michaels AJ, Michaels CE, Smith JS, Moon C, Peterson C, Long W (2000) Outcome from injury: general health, work status, and satisfaction 12 months after trauma. Trauma 48:841–850

    CAS  Google Scholar 

  18. Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP, Patterson BM, McCarthy ML, Travison TG, Castillo R (2002) An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med 347:1924–1931

    Article  Google Scholar 

  19. Mole RJ, Wong KY, Khan M (2018) Accuracy of clinical coding in plastic surgery trauma. Bull R Coll Surg Engl 100(6):273–276

    Article  Google Scholar 

  20. Townley WA, Urbanska C, Dunn RLR, Khan U (2011) Costs and coding - free - flap reconstruction in lower-limb trauma. Injury. 42:381–384

    Article  CAS  Google Scholar 

  21. National Institute for Health and Care Excellence (NICE) (2017) Fractures (complex): assessment and management.

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The authors thank Dr Neil Scott, a medical statistician at the University of Aberdeen for providing statistical support. We are also grateful to Mr Shehan Hettiaratchy for his advice on clinical plastic surgery and Dr Florence Kyalo at Information Services Division Scotland for her support in obtaining the data.


The study was funded by the NHS Grampian Endowments Emergency Surgery Surgical and Trauma Fund (NER 11480).

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Authors and Affiliations



Eleanor S. Lumley: Concept and design, acquisition of data, data analysis, interpretation of data, drafting and revision of the article, final approval for publication, agreement to be accountable for all aspects of the work

George Ramsay: Acquisition of data, drafting and revision of the article, final approval for publication, agreement to be accountable for all aspects of the work

Helen S. Wohlgemut: drafting and revision of the article, final approval for publication, agreement to be accountable for all aspects of the work

Jan O. Jansen: Concept and design, acquisition of data, drafting and revision of the article, final approval for publication, agreement to be accountable for all aspects of the work

Corresponding author

Correspondence to Jan O. Jansen.

Ethics declarations

Ethical approval

The study was approved by the Public Benefit and Privacy Panel Board (Reference 1718-0264), through which ethics is granted. The study was also registered with the Research Governance Department of the University of Aberdeen. The study was a retrospective cohort analysis of prospectively collected data and did not involve any human subjects.

Informed consent

Data obtained is from National Statistics for Scotland (NSS) and stored by the Information Services Division (ISD) of NHS, which follows the principles of the Data Protection Act 1998 (DPA), UK. This Act governs how personal data is used. Any patient who uses NHS Scotland services has the right to opt out of having their information used in this way. This is an observational study on healthcare usage and does not directly impact on individual patients. However, this work may improve patient flow and council patients for their expected outcome. As such, we have not specifically obtained consent for this project. Importantly, no patient who has expressed their wish to opt out of this process shall have their data used.

Conflict of interest

Eleanor S. Lumley, George Ramsay, Helen S. Wohlgemut and Jan O. Jansen declare no conflict of interest.

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Lumley, E.S., Ramsay, G., Wohlgemut, H.S. et al. Complex lower limb trauma and reconstructive surgery: understanding health service resource use. Eur J Plast Surg 44, 679–686 (2021).

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