Clinical effectiveness of the Ganga Hospital Open Injury Severity Score for limb salvage versus amputation in patients with complex limb injuries : a systematic review and meta-analysis.

AIMS: Clinical management of open fractures is challenging and frequently requires complex reconstruction procedures. The Gustilo-Anderson classification lacks uniform interpretation, has poor interobserver reliability, and fails to account for injuries to musculotendinous units and bone. The Ganga Hospital Open Injury Severity Score (GHOISS) was designed to address these concerns. The major aim of this review was to ascertain the evidence available on accuracy of the GHOISS in predicting successful limb salvage in patients with mangled limbs. METHODS: We searched electronic data bases including PubMed, CENTRAL, EMBASE, CINAHL, Scopus, and Web of Science to identify studies that employed the GHOISS risk tool in managing complex limb injuries published from April 2006, when the score was introduced, until April 2021. Primary outcome was the measured sensitivity and specificity of the GHOISS risk tool for predicting amputation at a specified threshold score. Secondary outcomes included length of stay, need for plastic surgery, deep infection rate, time to fracture union, and functional outcome measures. Diagnostic test accuracy meta-analysis was performed using a random effects bivariate binomial model. RESULTS: We identified 1,304 records, of which six prospective cohort studies and two retrospective cohort studies evaluating a total of 788 patients were deemed eligible for inclusion. A diagnostic test meta-analysis conducted on five cohort studies, with 474 participants, showed that GHOISS at a threshold score of 14 has a pooled sensitivity of 93.4% (95% confidence interval (CI) 78.4 to 98.2) and a specificity of 95% (95% CI 88.7 to 97.9) for predicting primary or secondary amputations in people with complex lower limb injuries. CONCLUSION: GHOISS is highly accurate in predicting success of limb salvage, and can inform management and predict secondary outcomes. However, there is a need for high-quality multicentre trials to confirm these findings and investigate the effectiveness of the score in children, and in predicting secondary amputations.Cite this article: Bone Joint J 2023;105-B(1):21-28.

Preconsultation Questionnaires for Patients Attending Elective Foot and Ankle Clinics: Is This the Way Forward in Outpatient Clinics?

Orthopaedic clinics can often be overbooked' busy and delayed appointments are a common sight in the National Health Service. We recognize this is becoming a growing problem that needs to be addressed; therefore, we have carried out a quality improvement project (QIP) that can save clinicians time. We have developed the "Stockport Foot and Ankle Questionnaire," a novel preconsultation questionnaire to gather information about patient history and symptoms. We found that the average time required for consultation reduced from a mean of 22 minutes, without questionnaires, to a mean of 15 minutes with the questionnaire, effectively saving 7 minutes per consultation. The preconsultation questionnaire in foot and ankle clinics is a novel technique to improve efficiency, productivity, and standardization in outpatient clinics. It is a patient-centered approach that identifies where effective changes can be implemented in how outpatient services are run. We recommend routine use of these questionnaires to save valuable clinician time.Levels of Evidence: Level II.

The CT gap sign, a case of failure to seat the polythene component in total ankle replacement (infinity).

We present a case of incorrect seating of the polyethylene liner in an INFINITY total ankle replacement causing discomfort and eventually leading to a revision ankle replacement. This malposition of the implant was observed on a computed tomography (CT) scan as a 'gap' between the liner and the body of the replacement. The patient complained of discomfort on walking postoperatively, which limited activity. All investigations were normal including X-Ray, inflammatory markers, ultrasound, and it was only the subtle CT changes along with history that confirmed the diagnosis. This case demonstrates a complication of the design of the INFINITY prosthesis and the approach taken to the ankle when inserting. The patient fortunately made a full recovery after revision surgery, returning to normal activities with minimal pain.

Erratum: A novel technique for fabricating antibiotic-coated intramedullary nails using an antibiotic-loaded calcium sulphate hydroxyapatite bio-composite, Cerament-V.

[This corrects the article DOI: 10.1093/jscr/rjz327.].

Acute Compartment Syndrome of the Leg Following Injury to Perforating Branch of Peroneal Artery After a Severe Ankle Sprain in a Pediatric Patient - A Case and a Review of Literature.

INTRODUCTION: Acute compartment syndrome (ACS) of the leg is seen most often following severe fractures, crush injuries, burns, tight casts, or dressings but rarely after ankle sprains. Very few cases have been found in the literature of compartment syndrome developing after ankle ligament disruptions. We report a case of ACS secondary to an ankle sprain in a 10-year-old child. CASE REPORT: A 10-year-old girl presents to the emergency department after jumping on an in-ground trampoline and slipping onto the surrounding grass and twisting her right ankle. This was followed by immediate swelling of her ankle. In the emergency department, her examination was notable for compartment syndrome. Although there was significant swelling around the ankle, she had good pulses in dorsalis pedis and posterior tibial vessels and normal sensations in her foot. A radiograph demonstrated an undisplaced fracture of medial malleolus with possible disruption of lateral ligament complex of the ankle. The patient was admitted, and the leg became more swollen the following morning with significant increase in pain levels and foot turned cold and purple with weak pulses. She had a delayed capillary refill time and reduced sensation in common peroneal nerve distribution over lateral aspect of foot and tense anterior and lateral compartments of the leg. Therefore, she was taken to theater and a standard open fasciotomy of the leg was performed through a longitudinal incision on the lateral side of leg and compartments decompressed. Fasciotomy revealed a large hematoma in the leg extending into the ankle joint and an avulsed perforating branch of peroneal artery. Postoperatively pain improved, passive toe stretching was no longer painful and she was immobilized in a below-knee plaster cast. CONCLUSION: ACS of leg is often associated with high-energy trauma and rarely seen after ankle injuries. To the best of our knowledge, this is the first reported case of compartment syndrome developing in a pediatric patient following inversion sprain of ankle, leading to rupture of perforating peroneal vessel in the leg.

End-capping of amputation stumps with a local antibiotic containing hydroxyapatite bio-composite - A report of 13 cases with chronic lower limb osteomyelitis.

We present our novel technique of end capping of amputation stumps with absorbable antibiotic containing hydroxyapatite bone cement as a marrow plug controlling bleeding and achieving high local concentration of antibiotics in cases complicated by chronic osteomyelitis.Our case series consisted of 13 patients who underwent lower limb amputations for chronic medullary osteomyelitis.Of 13 patients 12 had below knee and 1 had above knee amputation. All wounds healed uneventfully without any surgical site infection. There were no stump hematomas/seromas or instances of recurrent stump osteomyelitis or need for revision surgery.

A novel technique for fabricating antibiotic-coated intramedullary nails using an antibiotic-loaded calcium sulphate hydroxyapatite bio-composite, Cerament-V.

Deformity correction in the setting of osteomyelitis is a challenge for any orthopaedic surgeon. Principles of management are well described and include staged debridement, stable fixation and a combination of local and systemic antibiotic therapy. An antibiotic-coated nail (ACN) can prove a useful tool-stabilizing bone, whilst allowing for local antibiotic elution. Typically, the surgeon will prepare these implants in the operating room using materials that are routinely at hand. Most frequently, this will involve the use of antibiotic-loaded poly-methyl methacrylate (PMMA). This method of ACN fabrication has several disadvantages. PMMA is non-degradable and can be difficult to remove surgically. There are limitations with regard to antibiotic suitability, antibiotic release as well as toxicity effects. In this case report, we present a novel technique for the preparation of ACNs for use in hindfoot surgery, using a calcium sulphate/hydroxyapatite-based bio-composite-Cerament-V.