title: The impact of the Major Trauma Network: will trauma units continue to treat complex foot and ankle injuries?
abstract: BACKGROUND
  April 1st 2012 saw the introduction of National Trauma Networks in England. The aim to optimise the management of major trauma. Patients with an ISS≥16 would be transferred to the regional Major Trauma Centre (level 1). Our premise was that trauma units (level 2) would no longer manage complex foot and ankle injuries thereby obviating the need for a foot and ankle specialist service.
  
  
  METHODS
  Retrospective analysis of the epidemiology of foot and ankle injuries, using the Gloucestershire trauma database, from a trauma unit with a population of 750,000. Rates of open fractures, complex foot and ankle injuries and requirement for stabilisation with external fixation were reviewed before and after the introduction of the regional Trauma Network. Secondly, using the Trauma Audit & Research Network (TARN) database, all foot and ankle injuries triaged to the regional Major Trauma Centre (MTC) were reviewed.
  
  
  RESULTS
  Incidence of open foot and ankle injuries was 2.9 per 100,000 per year. There were 5.1% open injuries before the network and 3.2% after (p>0.05). Frequency of complex foot and ankle injuries was 4.2% before and 7.5% after the network commenced, showing no significant change. There was no statistically significant change in the numbers of patients with complex foot and ankle injuries treated by application of external fixators. Analysis of TARN data revealed that only 18% of patients with foot and ankle injuries taken to the MTC had an ISS≥16. The majority of these patients were identified as requiring plastic surgical intervention for open fractures (69%) or were polytrauma patients (43%). Only 4.5% of patients had isolated, closed foot and ankle injuries.
  
  
  CONCLUSIONS
  We found that at the trauma unit there was no decrease in the numbers of complex foot and ankle injuries, open fractures, or the applications of external fixators, following the introduction of the Trauma Network. These patients will continue to attend trauma units as they usually have an ISS<16. Our findings suggest that there is still a need for foot and ankle specialists at trauma units, in order to manage patients with complex foot and ankle injuries.
authors.affiliation: Registrar Trauma & Orthopaedics, Department of Trauma & Orthopaedics, Cheltenham General Hospital, United Kingdom. Electronic address: A.Hay-David@nhs.net.
authors.forename: A G C
authors.initials: AG
authors.lastname: Hay-David
authors.affiliation: Consultant Orthopaedic Surgeon, Specialist in Foot & Ankle Surgery, Cheltenham General Hospital, United Kingdom.
authors.forename: S A
authors.initials: SA
authors.lastname: Clint
authors.affiliation: Consultant Orthopaedic Surgeon, Specialist in Foot & Ankle Surgery, Cheltenham General Hospital, United Kingdom.
authors.forename: R R
authors.initials: RR
authors.lastname: Brown
mesh_terms: D000328:Adult; D016512:Ankle Injuries / Q000453:epidemiology* / Q000601:surgery; D004739:England / Q000453:epidemiology; D005260:Female; D018409:Foot Injuries / Q000453:epidemiology* / Q000601:surgery; D005593:Fracture Fixation, Internal / Q000379:methods*; D050723:Fractures, Bone / Q000453:epidemiology* / Q000601:surgery; D005597:Fractures, Open / Q000453:epidemiology* / Q000601:surgery; D006801:Humans; D015601:Injury Severity Score; D004204:Joint Dislocations / Q000453:epidemiology* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D014193:Trauma Centers / Q000706:statistics & numerical data*
keywords: Complex foot and ankle injuries; Major Trauma Centre; Trauma unit