In Korea, social interest in trauma treatment was increased due to a specific event in which a civilian suffered a gunshot injury after being kidnapped by Somali pirates. This highlighted the importance of a trauma management system in Korea. With this increased social demand, the government supported the establishment of Level-1 trauma centers in tertiary hospitals across the country. A Level-1 trauma center is a comprehensive regional resource, comprising a tertiary care facility central to the trauma system. Such centers is capable of providing total care for every aspect of traumatic injury, from prevention through rehabilitation. Following several years of development of a trauma center at our institution, a Level-1 trauma center was established in 2016.
Prior to the establishment of level-1 trauma center, trauma patients were treated through the emergency room. In Trauma-bay, which is part of the emergency room, after the initial treatment by the emergency medicine doctor, the trauma team's activation led to the trauma surgeon's intervention. After the level-1 trauma center was established, Trauma-bay, an independent initial response space like an independent institution, was equipped with independent CT, angiography facility, etc., and also 3 Trauma intensive care units, 3 Trauma operation rooms, and an independent wards and treated patients under a standardized and independent system. Staffing was also added, with orthopedic surgeons, neurosurgeons, radiologists, anesthesiologists, and specialized nursing personnel and coordinators being placed around the trauma surgeon to perform organic and prompt roles. These changes appear to have been the driving force behind the positive changes seen in this study.
Management of lower extremity trauma patients in our institution focuses on the emergency department, but the cooperation of specialists from supporting departments is also essential in open lower extremity trauma. The time to the intervention from the time of the patient’s arrival at the trauma bay is crucial. Early radical debridement, skeletal fixation, and soft tissue coverage has long been known to reduce complications, such as osteomyelitis and nonunion . There are reports that early reconstruction, within 72 h of injury, may lead to lower flap failure rates, lower infection rates, shorter bone healing times, shorter hospital stays, and fewer overall operative procedures [15, 16]. In actual clinical practice, establishing a consensus on the reconstructive intervention timing between physicians from different departments is problematic. However, in our newly established trauma center system, achieving this consensus is easy, and this is directly linked to our higher lower extremity salvage rates. In our study, in patients requiring amputation, only 30% of cases required plastic surgery services in the injury evaluation. Moreover, our system facilitated active inter-departmental transfer of patients according to intensive care team decision. Most of the cases are initially treated by physicians from the trauma surgery department, usually with the patient in the ICU. Then, physicians in the orthopedic department perform surgery for bone fixation, and concurrently soft tissue defects are managed by the plastic surgery department. Regular wound follow-up is performed by the plastic surgeon, and regular wound meetings are held with all involved departments. In this way, physicians can share the burdens of a long treatment period.
In respect to reconstruction of lower extremity trauma, we have observed a marked paradigm shift occurring with the establishment of your trauma center. Advances in microsurgery have made it possible to reconstruct a fairly large soft tissue defect by using the vascularized free tissue transfer technique [17, 18]. For instance, vascularized free tissue transfer has become indispensable Gustilo‒Anderson type IIIB/IIIC open fractures in the trauma setting. Thus, limbs with traumatic injury involving extensive soft tissue loss that in the past would have required amputation can now be preserved because of the developments in microsurgery. These advances have improved the limb salvage rate markedly, and have highlighted the role of plastic surgeons in treating lower extremity trauma at trauma centers. Nevertheless, amputation remains a valid option for severe open fractures with soft tissue defects.
Limb salvage does not necessarily improve the patient's quality of life, but the existence of amputation was evaluated as benefiting because it has an important value in Korea's cultural and spiritual aspects. Approaching and analyzing the quality of life of major trauma patients through long-term follow-up through level-1 trauma center operation is also considered to be an important topic for further research.
Our experience has highlighted three marked changes that occurred with the establishment of a Level-1 trauma center in terms of management of lower extremity traumatic injuries. First, proportion of patients open lower extremity traumatic injuries who have existing infection at their initial visit to our institution was increased after establishment of the trauma center. In contrast the proportion of patients with initial application of an external fixator was decreased. The application of an external fixator usually leads to delayed reduction/fixation and soft tissue coverage. The increased proportion of cases with infected wounds indicated that the severity of the open wound injuries had increased due to regional trauma center system, although use of an external fixator, linked to early reduction, had decreased. Reduced use of an external fixator facilitates early soft tissue coverage, which is key to our successful outcome. Second, we observed a marked reduction in the interval to emergency surgery (on average 2.24 h), which is directly due to establishment of an outstanding trauma center. To ensure early operation, it is necessary that all staff required, including internal medicine specialists, anesthesiologists, and radiologists, are available as like as independent institute. Integration of these services department makes early bone reduction and other essential vascular intervention possible. Third, active plastic surgeon intervention allows reconstruction that directly contributes to limb salvage. The main trauma surgeons cooperate with the reconstructive surgeon in the wound management, and both are actively involved in the overall patient treatment.
In this study, the primary amputation rate significantly decreased and the lower limb salvage rate significantly increased. Among other factors, our analysis showed that establishment of the center contributed significantly to these outcomes. Rapid emergency surgery contributes to limb salvage. However, other clinical factors, such as age, the need for ICU care, and requirement for intubation, which reflect patients’ severity, should also be considered. Additionally, we have demonstrated that the proportion of patients with severe lower extremity trauma patients, such as those classified as Gustilo‒Anderson type IIIB/IIIC, has increased, and the salvage rate has decreased. This finding correlated with those of recent reports that the rate of secondary amputation after revascularization of open tibial fractures was in the range of 10.2‒19.4% [19, 20]. By comparing data from before and after the opening of our trauma center, it was clear that establishment of the trauma center had increased the limb salvage rate; however, severe open fracture cases inevitably suffered limb loss. The increase in our limb salvage rate is encouraging. Thus, orthoplastic surgery needs to be developed further, procedures must continue to improve, and further prospective studies should be performed to assess the outcomes of reconstruction programs.