Abstract
Sixty-two centres in 16 countries contributed with 2,694 open fractures cases to an international, multi-centric, retrospective cohort study involving different healthcare settings. The INTELLECT study results show that there are significant disparities on the management of open lower limb fractures internationally. A timely, multidisciplinary, guideline-directed care is a protective factor for developing infective complications, non-union and requiring an amputation.
Introduction
Trauma remains a major cause of mortality and disability across the world1, with a higher burden in developing nations2. Open lower extremity injuries are devastating events from a physical3, mental health4, and socioeconomic5 standpoint. The potential sequelae, including risk of chronic infection and amputation, can lead to delayed recovery and major disability6. This international study aimed to describe global disparities, timely intervention, guideline-directed care, and economic aspects of open lower limb injuries.
Methods
The INTELLECT (International Lower Limb Collaborative) study was an international, multicentre, retrospective audit supported by the Reconstructive Surgery Trials Network. Investigators in participating centres were tasked to retrieve demographic and clinical data for patients who had an open lower extremity fracture treated between 1 January 2017 and 31 December 2018. Primary outcomes were soft tissue infection, deep infection, non-union, and amputation. Secondary outcomes were median time to discharge and instances of deep venous thrombosis. Details of the study protocol and inclusion criteria can be found in Appendix S1 and Table S1 respectively. According to National Health Service Health Research Authority guidance, this study was not considered to be research, but an audit. Therefore, no formal ethics approval was required for centres in the UK. For other countries, local policies regarding information governance were adhered to.
Results
Sixty-two centres in 16 countries contributed with 2694 patients, a median of 17 per unit each year. Mean age at presentation was 44.5 (range 2–100) years, and 104 patients (3.9 per cent) were aged less than 16 years. Some 71 per cent of the affected individuals identified as male, and median follow-up was 11 (range 0–47) months (Fig. S1). The most common mechanism of injury was road traffic accidents (52.6 per cent), followed by low-energy (18.7 per cent) and high-energy (11 per cent) falls (Table S2). A descriptive summary, including demographic information, treatment provided and outcomes, can be found in Tables 1 and 2.
Table 1.
Descriptive baseline information uploaded to INTELLECT database
| Total (n = 2694) | Femoral fractures (n = 272) | Tibial/fibular fractures (n = 2131) | Hindfoot fractures (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.
Table 2.
Treatment and outcomes data uploaded to INTELLECT database
| Total (n = 2694) | Femoral fractures (n = 272) | Tibial/fibular fractures (n = 2131) | Hindfoot fractures (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.
A multivariate logistic regression analysis adjusting for age, mechanism of injury, and country income group showed that patients with Gustilo IIIB and IIIC fractures had a higher likelihood of wound infection (odds ratio (OR) 1.44; P = 0.047) or secondary amputation (OR 2.39; P = 0.027). There was no significant statistical association between time to antibiotics, time to debridement, or time to definitive fixation with soft tissue infection, deep infection, non-union, and amputation. However, male gender identity was a risk for developing superficial wound infection (OR 1.5; P = 0.038), deep infection (OR 1.68; P = 0.035), non-union (OR 1.96; P = 0.016), and amputation (OR 8.02; P = 0.004). Delay in achieving soft tissue closure beyond 72 h after injury was associated with a greater likelihood of developing soft tissue infection, deep infection, non-union, and requiring an amputation (Table S3). Joint treatment by orthopaedic or trauma surgeons working with plastic surgeons from the time of the debridement onwards was identified as protective factor for secondary amputation (OR 0.41; P = 0.008).
Two-thirds of injuries that required soft tissue reconstruction were previously classified as Gustilo IIIB and IIIC, 76 per cent in high-income countries with guidelines, 58 per cent in high-income countries with no guidelines, and 63 per cent in low- and middle-income countries. There were differences in surgical-site infections and duration of follow-up (Table 3). Multivariable analysis showed that being treated in a setting with national guidelines7–9 was protective with respect to developing a deep tissue infection (OR 0.66; P = 0.040) or non-union (OR 0.66; P = 0.043), with a 34 per cent lower likelihood of developing either of these.
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 countries with guidelines (n = 1098) | High-income countries with no guidelines (n = 801) | Middle- and low-income countries with no guidelines (n = 232) | P‡ | |
|---|---|---|---|---|
| % 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.
Discussion
Moderate interobserver reliability has been reported for the Gustilo classification10, but it was unexpected to find that one-third of open tibial fractures requiring soft tissue reconstruction were classified as Gustilo I, II, and IIIA fractures initially. This proportion was higher in countries with no guidelines. Patients treated in high-income countries with established clinical guidelines had better access to healthcare and outcomes. Under-representation of studies conducted in less economically developed settings poses the risk of skewing data towards practices in higher-income nations. Guidelines for the management of open lower limb fractures advocate a multidisciplinary approach and global partnerships may offer quality improvement initiatives11–13. Patients treated in middle- and low-income settings experienced delays in accessing 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 expected14. There are inherent challenges associated with a methodology that relies on patient records in some institutions, including selection, information, detection, and collection biases. A prospective study would provide more reliable data that could include mental health and quality-of-life measures to refine global cooperative plans.
Supplementary Material
Contributor Information
Juan Enrique Berner, Department of Plastic Surgery, Royal London Hospital, London, UK; Kellogg College, University of Oxford, Oxford, UK.
James K K Chan, Department of Plastic Surgery, Stoke Mandeville Hospital, Aylesbury, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
Matthew D Gardiner, Department of Plastic and Reconstructive Surgery, Wexham Park Hospital, Slough, UK; Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
Alfonso Navia, Sección de Cirugía Plástica y Reconstructiva, División de Cirugía. Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
Rodrigo Tejos, Sección de Cirugía Plástica y Reconstructiva, División de Cirugía. Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
Manuel Ortiz-Llorens, Facultad de Ciencias, Universidad Mayor, Santiago, Chile.
Alina Ortega-Briones, Trauma and Orthopaedic Surgery Department, Hospital San José Quirónsalud, Madrid, Spain.
Hinne A Rakhorst, Plastic and Reconstructive Surgery Department, Medisch Spectrum Twente, Enschede, the Netherlands.
Jagdeep Nanchahal, Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
Abhilash Jain, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
INTELLECT Collaborative:
G Nolan, H Samarendra, A Mohan, K Cooper, N Pereira, G Mangelsdorff, J Venegas, A Layseca, J Skillman, A Kennedy, A Qureshi, K Wallis, L Harry, A Hagiga, S Ibrahim, M Albendary, K A Shah, C B Chuo, C Katsura, J R Rodríguez Astudillo, A López Ortega, J P Henríquez Rissios, M Nova Nova, J Hughes, C Wearn, D Peberdy, B Ho, K Gohil, A Abood, N Rabey, M Nizamoglu, G Biosse-Duplan, K To, S R Sabapathy, M Mohan, H Venkatramani, S Rajasekaran, H Hsu, A R Ambriz Plascencia, L E Escalona Ramírez, C A Zepeda Torres, E Santamaria, S Vallejo Toro, C West, W Bhat, C McArdle, S Louette, S Hassan, P W van Egmond, W J J Bekkers, D Capitani, L Troisi, T Talamonti, P Capitani, V Cerbone, G Materazzi, L Ballini, J Tomas-Hernandez, J A Porcel-Vazquez, Y Garcia-Sanchez, J V Andrés-Peiró, J Teixidor-Serra, J Selga-Marsà, H Dafydd, S Ali, R Slade, S Tarassoli, B Olías López, J Boluda Mengod, D González Martín, A Bashir, A Dearden, V Itte, F Smith, W C Lee, V A A Paulus, P Romijn, T N Tromp, T de Jong, S Koide, K Lim, F Raiola, S Ferris, A Rodríguez, E L Jonsson, S Holm, O Wolff, A Abugarja, H Elbahari, H K S Hamid, M Awadelkarim, J Erdocia Pascual, L Bahillo O'Mahoney, M A Quiroga Bilbao, M Felipe Peña, W Eardley, A Egglestone, S Taher, N Wei, J Martínez Ros, G Valero Cifuentes, A Ondoño Navarro, A Escudero Martínez, A Ortega Columbrans, P Zamora, J Masiá, A Ibarra, M Fernández, V Giblin, A Kilshaw, B Wood, M Wyman, I E Tinhofer, E Seidl, C J Tzou, S Quadlbauer, J Reichetseder, H Bürger, T Hausner, S van Miltenburg, I Beijk, W Verra, R de Groot, V Kunc, L Kopp, A Crick, C Mitchell, T Curran, R Kuo, S Eltoum Elamin, P Caba Doussoux, D Alonso Tejero, J Gómez Alcaraz, J M Pardo García, K Kooi, R Poelstra, J P Hong, M Jang, D W Hong, J G Kwon, M Francés Monasterio, J Fernández-Palacios Martínez, A Suarez Cabañas, M Marrero Martínez-Carlón, W ten Cate, J E D Jacobs, J Rawlins, J Haley, J Palma, A Cuadra, H Demandes, S Canahuate, D Moreno, S Norton, J Thompson, G Lafford, D Noriego Muñoz, A Teixido de la Cruz, M Vázquez Gómez, A Mingoli, D Ribuffo, G Marruzzo, P Lapolla, W Ayad, A Elbatawy, M Ouf, P Castillón, C García, M Surroca, J Garcia-Coiradas, F Marco, M Cherubino, L Garutti, G Molina Olivella, A Endemaño Lucio, K Oflazoglu, F Lutgendorff, M Botman, G Giannakopoulos, R Dams, P van der Zwaal, R Moral-Nestares, F Requena, N Fernández-Poch, J Cámara-Cabrera, F Macán, M Standen, F Flaherty, M Vizcay, D Yerson, E Sperone, F Bidolegui, S Pereyra, E Chouhy, M Jaureguialzo, Z Arnez, V Cazzato, M A Giraldez, R Moreno Domínguez, B Martínez Sañudo, L Lancerotto, S Sandhu, A Robinson, and C Digney
Collaborators
Other members of the INTELLECT Collaborative: G. Nolan, H. Samarendra, A. Mohan, K. Cooper (Imperial College Healthcare NHS Trust, London, UK); N. Pereira, G. Mangelsdorff, J. Venegas, A. Layseca (Hospital del Trabajador de Santiago, Santiago, Chile); J. Skillman, A. Kennedy, A. Qureshi, K. Wallis (University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK); L. Harry, A. Hagiga, S. Ibrahim, M. Albendary, K. A. Shah (Brighton and Sussex University Hospitals NHS Trust, Brighton, UK); C. B. Chuo, C. Katsura (Hull University Teaching Hospital NHS Trust, Hull, UK); J. R. Rodríguez Astudillo, A. López Ortega, J. P. Henríquez Rissios, M. Nova Nova (Hospital Sótero del Río, Santiago, Chile); J. Hughes, C. Wearn, D. Peberdy, B. Ho, K. Gohil (University Hospitals Plymouth NHS Trust, Plymouth, UK); A. Abood, N. Rabey, M. Nizamoglu, G. Biosse-Duplan, K. To (Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK); S. R. Sabapathy, M. Mohan, H. Venkatramani, S. Rajasekaran (Ganga Hospital, Coimbatore, India); H. Hsu (Dalin Tzu Chi Hospital - Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan); A. R. Ambriz Plascencia, L. E. Escalona Ramírez, C. A. Zepeda Torres (Hospital Civil de Guadalajara, Guadalajara, Mexico); E. Santamaria, S. Vallejo Toro (Hospital General ‘Dr. Manuel Gea González’, Mexico City, Mexico); C. West, W. Bhat, C. McArdle, S. Louette, S. Hassan (Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK); P. W. van Egmond, W. J. J. Bekkers (Elisabeth-TweeSteden Ziekenhuis, Tilburg, Netherlands); D. Capitani, L. Troisi, T. Talamonti, P. Capitani, V. Cerbone, G. Materazzi, L. Ballini (ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy); J. Tomas-Hernandez, J. A. Porcel-Vazquez, Y. Garcia-Sanchez, J. V. Andrés-Peiró, J. Teixidor-Serra, J. Selga-Marsà (Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain); H. Dafydd, S. Ali, R. Slade, S. Tarassoli (Morriston Hospital - Swansea Bay University Health Board, Swansea, UK); B. Olías López, J. Boluda Mengod, D. González Martín (Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain); A. Bashir, A. Dearden, V. Itte, F. Smith, C. W. Lee (The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK); V. A. A. Paulus, P. Romijn, T. N. Tromp, T. de Jong (Radboud UMC, Nijmegen, Netherlands); S. Koide, K. Lim, F. Raiola, S. Ferris (The Alfred Hospital, Melbourne, Australia); A. Rodríguez, E. L. Jonsson, S. Holm, O. Wolff (Uppsala University Hospital, Uppsala, Sweden); A. Abugarja, H. Elbahari, H. K. S. Hamid, M. Awadelkarim (Ribat University Hospital and Ibrahim Malik Teaching Hospital, Khartoum, Sudan); J. Erdocia Pascual, L. Bahillo O'Mahoney, M. A. Quiroga Bilbao, M. Felipe Peña (Complejo Hospitalario Universitario Insular Materno Infantil, Las Palmas de Gran Canaria, Spain); W. Eardley, A. Egglestone, S. Taher, N. Wei (South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK); J. Martínez Ros, G. Valero Cifuentes, A. Ondoño Navarro, A. Escudero Martínez, A. Ortega Columbrans (Hospital Clínico Universitario ‘Virgen de la Arrixaca’, Murcia, Spain); P. Zamora, J. Masiá, A. Ibarra, M. Fernández (Hospital de la Santa Creu i Sant Pau, Barcelona, Spain); V. Giblin, A. Kilshaw, B. Wood, M. Wyman (Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK), I. E. Tinhofer, E. Seidl, C. J. Tzou (Hospital of Divine Savior, Vienna, Austria); S. Quadlbauer, J. Reichetseder, H. Bürger, T. Hausner (AUVA Traumazentrum, Vienna, Austria); S. van Miltenburg, I. Beijk, W. Verra, R. de Groot (Medisch Spectrum Twente, Enschede, Netherlands); V. Kunc, L. Kopp (Masaryk's Hospital, Ústí nad Labem, Czechia); A. Crick, C. Mitchell, T. Curran, R. Kuo, S. Eltoum Elamin (Salisbury NHS Foundation 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, Leeuwarden, Netherlands); J. P. Hong, M. Jang, D. W. Hong, J. G. Kwon (Asan Medical Center, Seoul, South Korea); M. Francés Monasterio, J. Fernández-Palacios Martínez, A. Suarez Cabañas, M. Marrero Martínez-Carlón (Hospital Universitario de Gran Canaria ‘Doctor Negrín’, Las Palmas de Gran Canaria, Spain); W. ten Cate, J. E. D. Jacobs (Ziekenhuisgroep Twente, Hengelo, Netherlands); J. Rawlins, J. Haley (Royal Perth Hospital, Perth, Australia); J. Palma, A. Cuadra, H. Demandes, S. Canahuate, D. Moreno (Hospital Clínico Pontificia Universidad Católica de Chile, Santiago, Chile); S. Norton, J. Thompson, G. Lafford (Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK); D. Noriego Muñoz, A. Teixido de la Cruz, M. Vázquez Gómez (Hospital Universitari Josep Trueta, Girona, Spain); A. Mingoli, D. Ribuffo, G. Marruzzo, P. Lapolla (Policlinico Umberto I - Sapienza University of Rome, Rome, Italy); W. Ayad, A. Elbatawy, M. Ouf (Al Azhar Hospital, Cairo, Egypt); P. Castillón, C. García, M. Surroca (Hospital Universitari Mútua de Terrassa, Barcelona, Spain); J. Garcia-Coiradas, F. Marco (Hospital Clínico San Carlos, Madrid, Spain); M. Cherubino, L. Garutti (Universita degli studi dell'Insubria, Varese, Italy); G. Molina Olivella, A. Endemaño Lucio (Hospital Consorci Sanitari Moises Broggi, Barcelona, Spain); K. Oflazoglu, F. Lutgendorff, M. Botman, G. Giannakopoulos (Amsterdam UMC, Amsterdam, Netherlands); R. Dams, P. van der Zwaal (Haaglanden Medisch Centrum, The Hague, Netherlands); R. Moral-Nestares, F. Requena (Hospital Universitario San Cecilio, Granada, Spain); N. Fernández-Poch, J. Cámara-Cabrera (Hospital Parc Tauli, Barcelona, Spain); F. Macán, M. Standen (Mutual de Seguridad, Santiago, Chile); F. Flaherty, M Vizcay (Sanatorio Otamendi, Buenos Aires, Argentina); D. Yerson (Sanatorio de la Trinidad, Buenos Aires, Argentina); E. Sperone (Sanatorio Finochietto, Buenos Aires, Argentina); F. Bidolegui, S. Pereyra (Sanatorio Sirio Libanés, Buenos Aires, Argentina); E. Chouhy, M. Jaureguialzo (Sanatorio Dupuytren, Buenos Aires, Argentina); Z. Arnez, V. Cazzato (Ospedale di Cattinara, Trieste, Italy); M. A. Giraldez, R. Moreno Domínguez, B. Martínez Sañudo (Hospital Universitario Vírgen del Rocío, Sevilla, Spain); L. Lancerotto, S. Sandhu (NHS Lothian, Edinburgh, UK); A. Robinson, C. Digney (Ulster Hospital - South Eastern Health and Social Care Trust, Dundonald, UK)
Disclosure. The authors declare no conflict of interest.
Supplementary material
Supplementary material is available at BJS online.
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