Case study: Treatments for broken bones
A broken bone, or fracture, of the lower limb is a common injury which occurs when a force exerted against the bone is stronger than the bone can bear.
If the fracture is ‘open’, where the bone has broken through the skin, the wound is exposed to contamination - leading to an increased risk of infection. In the UK general population, the risk of open long-bone fractures occurring is approximately 11.5 per 100,000 people per year. However this type of injury is much more common for military personnel, who often suffer more severe injuries too. In severe cases, the risk of an open fracture becoming infected can be as high as 27%.
Open fractures require urgent surgery to clean the wound, remove dead tissue and stabilise the broken bone. However, despite the surgery, there is still a risk of wound healing complications such as infection.
As well as affecting the recovery of the patient, infections can also increase healthcare costs due to longer hospital stays or extra treatments.
One of the factors which may improve wound healing after an open fracture is the choice of dressing applied to the wound at the end of surgery. Standard dressings have a non-stick surface which is applied to the wound covered with a waterproof layer.
Negative Pressure Wound Therapy (NPWT) is an alternative dressing for open fractures. The device creates a vacuum using a suction pump which removes blood and fluid that may collect in a wound. However, NPWT dressings and the vacuum machines are considerably more expensive than traditional wound dressings, and whilst popular with surgeons and patients, there was little information about its effectiveness prior to the WOLLF (Wound Management of Open Lower Limb Fractures) study.
As part of the NIHR-funded WOLLF study, 460 patients across 24 major trauma hospitals took part in research comparing NPWT with standard dressings for open fractures of the lower limb.
The £2.18m trial was funded by the NIHR Health Technology Assessment Programme and supported by the NIHR Oxford Biomedical Research Centre, the NIHR Collaboration for Leadership in Applied Health Research and Care Oxford, and the NIHR Clinical Research Network who helped to consent patients to take part in the trial.
The findings of the research showed that there was no evidence that NPWT reduced patients' disability after 12 months, and therefore the research doesn’t support this particular treatment for severe open fractures.
As a direct result of these findings, NICE clinical guidelines for the assessment and management of complex fractures will be updated. This update will focus on the role of NPWT in open fractures.
Given that NPWT dressings and the vacuum machines are considerably more expensive than traditional wound dressings (with NPWT costing on average £84 compared with approximately £4 for standard dressings), the research and subsequent change in guidelines will be expected to lead to considerable cost-savings for the NHS.
Delivery of the research wouldn’t have been possible without the expertise of NIHR research nurses in taking consent under such challenging circumstances and within difficult environments
- Professor Matt Costa, Chief Investigator of the study and NIHR National Specialty Lead for Injuries and Emergencies
Dominic Burton, a demonstration car driver from Banbury, was enrolled onto the study in 2013 after sustaining an injury to his right leg following a forklift truck accident at work. The ambulance crew made the decision to admit him to the John Radcliffe Hospital in Oxford, a major trauma centre serving the Thames Valley region.
Explaining his decision to take part, Dominic said: “Everything was explained in terms of what the trial was aiming to do and what it would focus on.
“I knew I probably wouldn’t be coming home in the next couple of days and was feeling a bit low at that point, and I thought about how the trial might help someone else who found themselves in the same position as me, so I said it was absolutely fine.”
Dominic was given a standard dressing and was in hospital for just over three weeks before he was discharged. He experienced benefits from the trial that he did not initially expect.
Patients taking part in the trial were required to complete questionnaires during the year after sustaining their injuries, to allow the research team to assess their level of disability, rate of infection and quality of life. This aspect of the research supported Dominic’s 18-month recovery in additional ways.
“By asking about my personal wellbeing in addition to my physical injury, the questionnaire made me think a bit differently.
“I don’t think I would have even considered some of the questions had I not been asked them as part of the trial.”
It gave me more of a focus. Being on the trial heightened my interest, so i learned more about the type of injury I had and the long-term effects of it
- Dominic Burton, WOLLF participant
- Read the full research paper in the NIHR Journals Library: A randomised controlled trial of standard-of-care wound management versus negative pressure wound therapy in the treatment of adult patients with an open fracture of the lower limb
- 2018 exceptional surveillance of fractures (complex): assessment and management (NICE guideline NG37)
- NDORMS news article: High-tech treatment of open leg wounds no better than using regular dressings
- JAMA paper: Effect of Negative Pressure Wound Therapy vs Standard Wound Management on 12-Month Disability Among Adults With Severe Open Fracture of the Lower Limb: The WOLLF Randomized Clinical Trial.