BJS, 2022, 109, 792–795 https://doi.org/10.1093/bjs/znac105 Advance Access Publication Date: 26 April 2022 Short Report International Lower Limb Collaborative (INTELLECT) study: a multicentre, international retrospective audit of lower extremity open fractures Juan Enrique Berner1,2,* , James K.-K. Chan3,4, Matthew D. Gardiner5,6, Alfonso Navia7 , Rodrigo Tejos7, Manuel Ortiz-Llorens8, Alina Ortega-Briones9, Hinne A. Rakhorst10, Jagdeep Nanchahal6, Abhilash Jain4 and INTELLECT Collaborative 1 Department of Plastic Surgery, Royal London Hospital, London, UK 2 Kellogg College, University of Oxford, Oxford, UK 3 Department of Plastic Surgery, Stoke Mandeville Hospital, Aylesbury, UK 4 Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK 5 Department of Plastic and Reconstructive Surgery, Wexham Park Hospital, Slough, UK 6 Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK 7 Sección de Cirugía Plástica y Reconstructiva, División de Cirugía. Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile 8 Facultad de Ciencias, Universidad Mayor, Santiago, Chile 9 Trauma and Orthopaedic Surgery Department, Hospital San José Quirónsalud, Madrid, Spain 10 Plastic and Reconstructive Surgery Department, Medisch Spectrum Twente, Enschede, the Netherlands *Correspondence to: Juan Enrique Berner, Department of Plastic Surgery, Royal London Hospital, Whitechapel Road, London E1 1FR, UK (e-mail: juan.berner@ kellogg.ox.ac.uk) Members of the INTELLECT Collaborative are co-authors of this study and are listed under the heading Collaborators. Presented virtually at the 92nd Congreso Chileno de Cirugía in December 2020 and at the British Association of Plastic, Reconstructive and Aesthetic Surgeons Winter Meeting in December 2020 Introduction Results Trauma remains a major cause of mortality and disability across Sixty-two centres in 16 countries contributed with 2694 patients, a the world1, with a higher burden in developing nations2. Open median of 17 per unit each year. Mean age at presentation was lower extremity injuries are devastating events from a physical3, 44.5 (range 2–100) years, and 104 patients (3.9 per cent) were mental health4, and socioeconomic5 standpoint. The potential aged less than 16 years. Some 71 per cent of the affected sequelae, including risk of chronic infection and amputation, individuals identified as male, and median follow-up was 11 can lead to delayed recovery and major disability6. This (range 0–47) months (Fig. S1). The most common mechanism of international study aimed to describe global disparities, timely injury was road traffic accidents (52.6 per cent), followed by intervention, guideline-directed care, and economic aspects of low-energy (18.7 per cent) and high-energy (11 per cent) falls open lower limb injuries. (Table S2). A descriptive summary, including demographic information, treatment provided and outcomes, can be found in Tables 1 and 2. Methods A multivariate logistic regression analysis adjusting for age, mechanism of injury, and country income group showed that The INTELLECT (International Lower Limb Collaborative) study patients with Gustilo IIIB and IIIC fractures had a higher was an international, multicentre, retrospective audit supported likelihood of wound infection (odds ratio (OR) 1.44; P = 0.047) or by the Reconstructive Surgery Trials Network. Investigators in participating centres were tasked to retrieve demographic and secondary amputation (OR 2.39; P = 0.027). There was no clinical data for patients who had an open lower extremity significant statistical association between time to antibiotics, fracture treated between 1 January 2017 and 31 December 2018. time to debridement, or time to definitive fixation with soft Primary outcomes were soft tissue infection, deep infection, tissue infection, deep infection, non-union, and amputation. non-union, and amputation. Secondary outcomes were median However, male gender identity was a risk for developing time to discharge and instances of deep venous thrombosis. superficial wound infection (OR 1.5; P = 0.038), deep infection (OR Details of the study protocol and inclusion criteria can be found 1.68; P = 0.035), non-union (OR 1.96; P = 0.016), and amputation in Appendix S1 and Table S1 respectively. According to National (OR 8.02; P = 0.004). Delay in achieving soft tissue closure beyond Health Service Health Research Authority guidance, this study was not considered to be research, but an audit. Therefore, no 72 h after injury was associated with a greater likelihood of formal ethics approval was required for centres in the UK. For developing soft tissue infection, deep infection, non-union, and other countries, local policies regarding information governance requiring an amputation (Table S3). Joint treatment by were adhered to. orthopaedic or trauma surgeons working with plastic surgeons Received: December 26, 2021. Revised: February 01, 2022. Accepted: March 15, 2022 © The Author(s) 2022. Published by Oxford University Press on behalf of BJS Society Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Berner et al. | 793 Table 1 Descriptive baseline information uploaded to INTELLECT database Total (n = 2694) Femoral fractures Tibial/fibular fractures Hindfoot fractures (n = 272) (n = 2131) (n = 291) Age (years)* (n = 2670) 44.5(20.4) 37.9(17.9) 45.5(20.8) 43.5(19.1) Gender ratio (M : F) (n = 2690) 71 : 29 79 : 21 69 : 31 72 : 28 Mechanism of injury (%) (n = 2656) Road traffic accident 53 70 52 37 Low-energy fall 19 9 11 13 High-energy fall 11 4 21 17 Sports-related 6 1 4 12 Work-related 4 2 6 8 Interpersonal violence 5 12 5 5 Other 2 2 1 8 Fracture classification (Gustilo–Anderson) (%) (n = 2593) I 16 16 15 21 II 31 38 29 38 IIIA 20 31 19 15 IIIB 28 9 32 21 IIIC 5 6 5 5 No. of patients per country (n = 2694) UK 1045 73 918 54 Spain 396 51 288 57 Chile 322 35 216 71 Netherlands 227 30 180 27 Mexico 113 14 86 13 Italy 98 18 74 6 Austria 78 5 60 13 Australia 70 2 53 15 India 60 6 54 0 Taiwan 59 14 38 7 Argentina 50 2 48 0 Sweden 45 6 24 15 Sudan 43 7 29 7 Czechia 37 9 25 3 South Korea 31 0 23 8 Egypt 20 0 15 5 Co-morbidities (%) (n = 2447) None 65 73 63 70 Hypertension 16 9 17 15 Diabetes 8 7 9 6 Ischaemic heart disease 4 4 4 2 Asthma 4 2 4 5 COPD 3 2 3 3 Peripheral vascular disease 1 1 2 1 Smoker (%) (n = 2666) Yes 24 26 23 25 No 42 32 43 43 Unknown 34 42 34 32 *Values are mean(s.d.). COPD, chronic obstructive pulmonary disease. Reported missing values: 2.7 per cent. from the time of the debridement onwards was identified as one-third of open tibial fractures requiring soft tissue protective factor for secondary amputation (OR 0.41; P = 0.008). reconstruction were classified as Gustilo I, II, and IIIA Two-thirds of injuries that required soft tissue reconstruction fractures initially. This proportion was higher in countries were previously classified as Gustilo IIIB and IIIC, 76 per cent with no guidelines. Patients treated in high-income countries in high-income countries with guidelines, 58 per cent in with established clinical guidelines had better access to high-income countries with no guidelines, and 63 per cent healthcare and outcomes. Under-representation of studies in low- and middle-income countries. There were differences in conducted in less economically developed settings poses the surgical-site infections and duration of follow-up (Table 3). risk of skewing data towards practices in higher-income nations. Multivariable analysis showed that being treated in a setting Guidelines for the management of open lower limb fractures with national guidelines7–9 was protective with respect to advocate a multidisciplinary approach and global partnerships developing a deep tissue infection (OR 0.66; P = 0.040) or may offer quality improvement initiatives11–13. Patients treated in non-union (OR 0.66; P = 0.043), with a 34 per cent lower middle- and low-income settings experienced delays in accessing likelihood of developing either of these. treatment, which was rarely delivered by multidisciplinary teams. Considering that lifelong limb prosthesis is costly, a tendency towards limb preservation in resource-constrained settings is Discussion expected14. There are inherent challenges associated with a Moderate interobserver reliability has been reported for the methodology that relies on patient records in some institutions, Gustilo classification10, but it was unexpected to find that including selection, information, detection, and collection 794 | BJS, 2022, Vol. 109, No. 9 Table 2 Treatment and outcomes data uploaded to INTELLECT database Total (n = 2694) Femoral fractures Tibial/fibular fractures Hindfoot fractures (n = 272) (n = 2131) (n = 291) Time to antibiotics (h)* (n = 2303) 2 (1–5) 2 (1–4) 2 (1–5) 2 (1–5) Direct transfer to specialist centre (%) (n = 2670) 75 83 73 78 Wound debridement within 24 h (%) (n = 2580) 80.2 86.3 79.6 79 Time to debridement (h)* 10 (4–20) 6.5 (3–15) 10 (5–21) 8 (4–20) Specialties involved in primary debridement (%) (n = 2694) Orthopaedic surgeons 68 80 65 79 Plastic surgeons 11 4 12 6 Orthopaedic and plastic surgeons 14 5 16 11 Trauma surgeons 7 10 7 4 Seniority of surgeon leading debridement (%) (n = 2619) Consultant level 80 84 80 81 Non-consultant level 20 16 20 19 Median time to definitive skeletal fixation (days)* (n = 2670) 2 (1–9) 4 (1–9.5) 2 (1–9) 1 (0–5) Primary mode of definitive skeletal fixation (%) (n = 2670) Casting 4 1 3 14 Uni/biplanar external fixator 7 2 7 6 Frame external fixator 12 5 14 4 Plate and screws 33 29 33 38 Intramedullary nail 36 58 38 2 Kirschner wires 4 1 2 27 Other 4 4 3 9 Soft tissue reconstruction required (%) (n = 2672) 41 18 44 41 Modality of soft tissue closure (%) (n = 1109) Conventional dressings 6 8 6 9 Negative pressure wound therapy 5 6 4 11 Skin grafting only 21 56 20 19 Local flaps 9 4 10 3 Perforator flaps 16 11 17 3 Free flaps 43 15 43 55 Time to soft tissue closure (days)* (n = 1061) 7 (3–19) 12 (4–22) 6 (3–17) 16 (4–28) Flap survival rate (%) (n = 748) Local and regional flaps (n = 268) (n = 7) (n = 255) (n = 6) Total flap failure 3 14 3 0 Partial flap failure 9 0 9 0 Total flap survival 88 86 88 100 Free flaps (n = 480) (n = 7) (n = 408) (n = 65) Total flap failure 6 0 7 2 Partial flap failure 6 29 5 9 Total flap survival 87 71 88 89 Deep venous thrombosis (n = 2694) 35 (1.3) 4 (1.5) 27 (1.3) 4 (1.4) Wound infection (%) (n = 2649) 16.3 12.5 16.7 16.9 Time to wound infection (days)* 34 (13–80) 15 (7–41) 39 (16–90) 17 (8–37) Deep wound infection (%) (n = 2655) 10.3 9.4 10.7 8.6 Time to deep infection (days)* 63 (23–180) 52 (19–162) 69 (27–184) 32 (14–63) Non-union (%) (n = 2594) 10.9 14.7 11.7 2.1 Amputation (%) (n = 2624) Immediate 2.1 1.9 1.4 7 Early 2.7 0.8 2.3 7.4 Late 1 0.8 1.1 0 Time to discharge (days)* (n = 2641) 15 (7–30) 16 (8–33) 15 (7–29) 14 (4–30) Median follow-up (months)* (n = 2448) 11 (4–20) 13 (5–22) 11 (4–20) 10 (2–19) Values in parentheses are percentages unless indicated otherwise; *values are median (i.q.r.). Reported missing values: 2.7 per cent. Table 3 Comparison of management and outcomes following open tibial/fibular fractures in high-income countries with and without national guidelines and middle- and low-income countries High-income High-income Middle- and low-income P‡ countries with countries with countries with no guidelines (n = 1098) no guidelines (n = 801) guidelines (n = 232) % Gustilo IIIB–IIIC (n = 2113) 45.3 26.2 35.5 , 0.001 Age (years)* (n = 2113) 48.1.(22.1) 45.2.(18.5) 34.1.(17.3) , 0.001 Gender ratio (M : F) (n = 2127) 63 : 37 74 : 26 80 : 20 , 0.001 Time to antibiotics (h)† (n = 1823) 2 (3) 2 (3) 5 (8) , 0.001 Time to debridement (h)† (n = 2044) 14 (16) 6 (11) 11 (17) , 0.001 Time to fixation (days)† (n = 2044) 2 (6) 3 (12) 5 (12) , 0.001 Time to soft tissue cover (when required) (days)† (n = 2044) 4 (7) 12 (23) 8 (35) , 0.001 Multidisciplinary debridement (%) (n = 2131) 24.4 7.0 6.9 , 0.001 Consultant-led debridement (%) (n = 2073) 77.4 90.7 56.9 , 0.001 Wound infection (%) (n = 2095) 17.7 14.2 20.3 0.040 Deep infection (%) (n = 2100) 8.8 11.6 15.9 0.003 Non-union (%) (n = 2051) 11.3 12.5 11.0 0.688 Amputation (%) (n = 2079) 5.2 5.1 1.7 0.374 Follow-up (months)† (n = 1931) 10 (14) 14 (18) 9 (14) , 0.001 Values are *mean(s.d.) and †median (range). A total of 2131 tibial open fractures are included in the analysis. ‡Pearson’s Chi-square test was used for comparing categorical variables and Kruskal-Wallis test for comparing continuous variables. Berner et al. | 795 biases. A prospective study would provide more reliable data that Hospital, Ústí nad Labem, Czechia); A. Crick, C. Mitchell, T. could include mental health and quality-of-life measures to Curran, R. Kuo, S. Eltoum Elamin (Salisbury NHS Foundation refine global cooperative plans. Trust, Salisbury, UK); P. Caba Doussoux, D. Alonso Tejero, J. Gómez Alcaraz, J. M. Pardo García (Hospital 12 de Octubre, Madrid, Spain); K. Kooi, R. Poelstra (Medisch Centrum Leeuwarden, Collaborators Leeuwarden, Netherlands); J. P. Hong, M. Jang, D. W. Hong, J. G. Other members of the INTELLECT Collaborative: G. Nolan, H. Kwon (Asan Medical Center, Seoul, South Korea); M. Francés Samarendra, A. Mohan, K. Cooper (Imperial College Healthcare NHS Monasterio, J. Fernández-Palacios Martínez, A. Suarez Cabañas, M. Trust, London, UK); N. Pereira, G. Mangelsdorff, J. Venegas, A. Marrero Martínez-Carlón (Hospital Universitario de Gran Canaria Layseca (Hospital del Trabajador de Santiago, Santiago, Chile); J. ‘Doctor Negrín’, Las Palmas de Gran Canaria, Spain); W. ten Cate, Skillman, A. Kennedy, A. Qureshi, K. Wallis (University Hospitals J. E. D. Jacobs (Ziekenhuisgroep Twente, Hengelo, Netherlands); J. Coventry and Warwickshire NHS Trust, Coventry, UK); L. Harry, A. Rawlins, J. Haley (Royal Perth Hospital, Perth, Australia); J. Palma, Hagiga, S. Ibrahim, M. Albendary, K. A. Shah (Brighton and Sussex A. Cuadra, H. Demandes, S. Canahuate, D. Moreno (Hospital University Hospitals NHS Trust, Brighton, UK); C. B. Chuo, C. Clínico Pontificia Universidad Católica de Chile, Santiago, Chile); S. Katsura (Hull University Teaching Hospital NHS Trust, Hull, UK); J. Norton, J. Thompson, G. Lafford (Norfolk and Norwich University R. Rodríguez Astudillo, A. López Ortega, J. P. Henríquez Rissios, M. Hospitals NHS Foundation Trust, Norwich, UK); D. Noriego Muñoz, Nova Nova (Hospital Sótero del Río, Santiago, Chile); J. Hughes, C. A. Teixido de la Cruz, M. Vázquez Gómez (Hospital Universitari Wearn, D. Peberdy, B. Ho, K. Gohil (University Hospitals Plymouth Josep Trueta, Girona, Spain); A. Mingoli, D. Ribuffo, G. Marruzzo, P. NHS Trust, Plymouth, UK); A. Abood, N. Rabey, M. Nizamoglu, G. Lapolla (Policlinico Umberto I - Sapienza University of Rome, Biosse-Duplan, K. To (Cambridge University Hospitals NHS Rome, Italy); W. Ayad, A. Elbatawy, M. Ouf (Al Azhar Hospital, Foundation Trust, Cambridge, UK); S. R. Sabapathy, M. Mohan, H. Cairo, Egypt); P. Castillón, C. García, M. Surroca (Hospital Venkatramani, S. Rajasekaran (Ganga Hospital, Coimbatore, India); H. Universitari Mútua de Terrassa, Barcelona, Spain); J. Hsu (Dalin Tzu Chi Hospital - Buddhist Tzu Chi Medical Foundation, Garcia-Coiradas, F. Marco (Hospital Clínico San Carlos, Dalin, Taiwan); A. R. Ambriz Plascencia, L. E. Escalona Ramírez, C. Madrid, Spain); M. Cherubino, L. Garutti (Universita degli studi A. Zepeda Torres (Hospital Civil de Guadalajara, dell’Insubria, Varese, Italy); G. Molina Olivella, A. Endemaño Lucio Guadalajara, Mexico); E. Santamaria, S. Vallejo Toro (Hospital (Hospital Consorci Sanitari Moises Broggi, Barcelona, Spain); K. General ‘Dr. Manuel Gea González’, Mexico City, Mexico); C. West, Oflazoglu, F. Lutgendorff, M. Botman, G. Giannakopoulos W. Bhat, C. McArdle, S. Louette, S. Hassan (Leeds Teaching (Amsterdam UMC, Amsterdam, Netherlands); R. Dams, P. van der Hospitals NHS Foundation Trust, Leeds, UK); P. W. van Egmond, W. Zwaal (Haaglanden Medisch Centrum, The Hague, Netherlands); J. J. Bekkers (Elisabeth-TweeSteden Ziekenhuis, R. Moral-Nestares, F. Requena (Hospital Universitario San Cecilio, Tilburg, Netherlands); D. Capitani, L. Troisi, T. Talamonti, Granada, Spain); N. Fernández-Poch, J. Cámara-Cabrera (Hospital P. Capitani, V. Cerbone, G. Materazzi, L. Ballini (ASST Grande Parc Tauli, Barcelona, Spain); F. Macán, M. Standen (Mutual de Ospedale Metropolitano Niguarda, Milan, Italy); J. Seguridad, Santiago, Chile); F. Flaherty, M Vizcay (Sanatorio Tomas-Hernandez, J. A. Porcel-Vazquez, Y. Garcia-Sanchez, J. V. Otamendi, Buenos Aires, Argentina); D. Yerson (Sanatorio de la Andrés-Peiró, J. Teixidor-Serra, J. Selga-Marsà (Vall d’Hebron Trinidad, Buenos Aires, Argentina); E. Sperone (Sanatorio Barcelona Hospital Campus, Barcelona, Spain); H. Dafydd, S. Ali, R. Finochietto, Buenos Aires, Argentina); F. Bidolegui, S. Pereyra Slade, S. Tarassoli (Morriston Hospital - Swansea Bay University (Sanatorio Sirio Libanés, Buenos Aires, Argentina); E. Chouhy, M. Health Board, Swansea, UK); B. Olías López, J. Boluda Mengod, D. Jaureguialzo (Sanatorio Dupuytren, Buenos Aires, Argentina); Z. González Martín (Hospital Universitario de Canarias, Santa Cruz de Arnez, V. Cazzato (Ospedale di Cattinara, Trieste, Italy); M. A. Tenerife, Spain); A. Bashir, A. Dearden, V. Itte, F. Smith, C. W. Lee Giraldez, R. Moreno Domínguez, B. Martínez Sañudo (Hospital (The Newcastle upon Tyne Hospitals NHS Foundation Trust, Universitario Vírgen del Rocío, Sevilla, Spain); L. Lancerotto, S. Newcastle, UK); V. A. A. Paulus, P. Romijn, T. N. Tromp, T. de Jong Sandhu (NHS Lothian, Edinburgh, UK); A. Robinson, C. Digney (Radboud UMC, Nijmegen, Netherlands); S. Koide, K. Lim, F. Raiola, (Ulster Hospital - South Eastern Health and Social Care Trust, S. Ferris (The Alfred Hospital, Melbourne, Australia); A. Rodríguez, E. Dundonald, UK) L. Jonsson, S. Holm, O. Wolff (Uppsala University Hospital, Uppsala, Sweden); A. Abugarja, H. Elbahari, H. K. S. Hamid, M. Disclosure. The authors declare no conflict of interest. Awadelkarim (Ribat University Hospital and Ibrahim Malik Teaching Hospital, Khartoum, Sudan); J. Erdocia Pascual, L. Bahillo Supplementary material O’Mahoney, M. A. Quiroga Bilbao, M. 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