Paediatric open fractures presenting to a level 1 trauma centre: a 10 year epidemiological study.

PURPOSE: The epidemiology of paediatric fractures has been previously described, however there is limited data available on open fractures in this population. The purpose of this study was to investigate trends, mechanism of injury (MOI) and severity of paediatric open fractures and undertake an epidemiological study. METHODS: All children ≤ 16.0 years presenting with open fractures were identified between 01/04/2013 and 01/04/2023. Those with craniofacial, thoracic and distal phalangeal fractures were excluded. Incidence was calculated based on those presenting within the local geographical region. Social deprivation was measured using the Index of Multiple Deprivation (IMD). RESULTS: There were 208 open fractures with a median age of 11.0(q1 7.4-q3 13.4) years, and 153(74.6%) were in males. The MOIs were road traffic collisions 73(35.1%), sports/play 45(21.6%), fall > 2m 29(13.9%), simple fall 25(12.0%), crush 16(7.7%), bites 8(3.8%), assault 6(2.9%), and other 6(2.9%). Nineteen children (9.1%) presented with polytrauma. Gustilo-Anderson grade for long bone fractures were I-61(29.3%), II-24(11.5%), IIIa-36(17.3%), IIIb-30(14.4%) and IIIc-7(3.4%). There were 129 children presenting within the local geographical region providing an annual incidence of 8.0/100,000. Radius and ulna were the most frequently injured 49(38.0%) followed by tibia and fibula 44(34.1%). There were 69(53.5%) children presenting from an IMD quintile 1 with open fractures. CONCLUSION: Paediatric open fractures are commonly seen in the adolescent male and affect those who are from a more socially deprived background. These injuries account for 3.2% of fractures admitted to a MTC. Data suggests children principally sustain open fractures through two distinct injury patterns and ten-year trends suggests that there is a gradual decline in the annual incidence.

Neurovascular injury from supracondylar fractures in children: a 10-year experience of 762 cases.

We evaluated the management of supracondylar paediatric fractures at our institution over a 10-year period in this retrospective cohort study. In total, 762 children with a supracondylar fracture were treated. The mean age of injury was 5.2 years. The incidence of documented nerve and/or vascular injury was 8.3%. A total of 26 patients had early plastic surgeon involvement; of these, 25 had an open exploration. Eight patients required vein grafting for brachial artery reconstruction for intimal tears. There was one nerve rupture requiring repair and 12 children underwent neurolysis. There were 17 late referrals to the plastic surgery service, of which three were explored (two neurolysis, one neuroma resection and sural nerve grafting). In all cases of nerve injury, the deficit took 7.9 months to recover, indicating a more significant injury than neurapraxia. Early exploration of supracondylar fractures allows direct visualization of the extent of neurovascular injury and immediate intervention.Level of evidence: IV.

Blunt Vascular Trauma in the Lower Extremity at a Major Trauma Centre: Salvage Rate and Complications.

Introduction: Blunt trauma of the lower limb with vascular injury can cause devastating outcomes, including loss of limb and even loss of life. The primary aim of this study was to determine the limb salvage rate of patients sustaining such injuries when treated at Leeds General Infirmary (LGI) since becoming a Major Trauma Centre (MTC). The secondary aim was to establish patient complications. Methods: A retrospective analysis found that from 2013 to 2018, 30 patients, comprising of 32 injured limbs, were treated for blunt trauma to the lower limb associated with vascular injury. Results: Twenty-four patients were male and six were female. Their mean ages were 32 and 49, respectively. Three limbs were deemed unsalvageable and underwent primary amputation; of the remaining 29 potentially salvageable limbs, 27 (93%) were saved. Median ischaemic times for both amputees and salvaged limbs were under 6 hours. Of the 32 limbs, 27 (84%) were salvaged. All amputees had a MESS score ≥ 7, although not all patients with MESS ≥ 7 required amputation. Eleven limbs had prophylactic fasciotomies, three limbs developed compartment syndrome - all successfully treated and three contracted deep infections - one of which necessitated amputation. All but one patient survived their injuries and were discharged from the hospital. Conclusion: Attempted salvage of 27/29 (93%) limbs was successful and all but one patient survived these injuries when treated at an MTC. MESS scoring and ischaemic time are useful but not sole predictors of limb salvage. Complication rates are low but may be significant for their future implications. How to cite this article: Barnard L, Karimian S, Foster P, et al. Blunt Vascular Trauma in the Lower Extremity at a Major Trauma Centre: Salvage Rate and Complications. Strategies Trauma Limb Reconstr 2023;18(2):87-93.

Outcomes of ankle joint distraction in a paediatric and young adult cohort presenting with symptomatic ankle arthritis.

Ankle arthritis in paediatric and young adult patients causes significant morbidity; therefore, joint-preserving procedures are preferable. Ankle joint distraction (AJD) is a technique that preserves the native joint. However, only short-term outcomes are reported in paediatric patients. Therefore, this study reports on intermediate-term outcomes in a paediatric cohort. Demographics for all patients who underwent AJD at two centres were prospectively collected. Case records were reviewed retrospectively for complications and further intervention. Mean joint space at baseline and follow-up radiographs were evaluated by two independent observers. All patients were contacted for completion of a Foot and Ankle Outcome Score (FAOS). Seven patients received AJD between February 2016 and June 2019. Median age at surgery was 15 years (9.0-24.6 years). Complications included one superficial pin-site infection and one patient death due to complications from juvenile idiopathic arthritis 6.2 years post-operatively. Two patients were converted to fusion, at 12.6 months and 26.2 months following frame removal; one patient underwent spontaneous fusion at 9 months following frame removal. The four patients who continued without further intervention achieved 2.59 mm mean joint space at last follow-up (0.65-5.08 mm) and FAOS of 35-79%. Mean follow-up length was 4.3 years (2.9-6.3 years) with final radiographs at mean 2.6 years. While recognising the limitations of this retrospective review, several patients had significant, sustained improvements in joint space with good clinical outcome. Complications for this procedure are minimal, and it is a potential joint-preserving option for managing end-stage ankle arthritis in young patients.

Resource implications of managing paediatric femoral fractures in a major trauma centre: Analysis of 98 cases.

INTRODUCTION: The management of paediatric femoral shaft fractures is expensive and is guided by age and fracture characteristics. The primary aim of this study was to perform a cost evaluation for managing paediatric femoral shaft fractures. The secondary aim of this study was to perform and compare costs of the different techniques of managing paediatric femoral shaft fractures. METHODS: Ninety-eight femoral shaft fractures in children aged ≤16 were identified between 01/06/2014-30/06/2019. Retrospective data of clinical complications were obtained on infection, malunion and non-union. Data on additional intervention, reoperations for complications and routine removal of metal work were obtained. Costing analysis was performed by a bottom-up calculation, and gathering Patient Level Information and Costing System (PLICS) data. RESULTS: There were 41 hip spica casting (HSC), 21 flexible intramedullary nailing (FIN), 14 submuscular plating (SMP), 19 rigid intramedullary nailing (RIN) and 3 external fixation (EF). Complications observed were HSC 3(7%); FIN 8(38%); SMP 2(14%); RIN 1(5%); EF 2(67%). The total costs for managing femoral shaft fractures were £8,955pp the costs for the different managements were; HSC £3,442pp; FIN £7,739pp; SMP £6,953pp; RIN £8,925pp; EF £19,116pp. The additional costs incurred for managing complications and routine removal of metal work for the internal fixation methods were: HSC 0.7%, FIN 23.7%, SMP 16.3%, RIN 10.9%, EF 28.1%. CONCLUSION: The operative management of paediatric femoral shaft fractures is associated with a high cost burden and this study demonstrates how financial data can be used to influence clinical management strategy. RIN carry a high initial implant cost however when considering the additional costs, such as treating complications it remains comparable to other modes of fixation. Our cost analysis did not demonstrate a significant difference between FIN, SMP and RIN. Due to the clinical complications observed and associated additional costs, we have discontinued the routine use of FIN for femoral shaft fractures at our centre. We recognise other centres may have a different complication and cost profile for each technique, but recommend they evaluate their practice given the potential economic benefit it has on the service provider.

Impact of telescopic intramedullary rodding on the growth of tibia: Comparative experimental study in dogs.

INTRODUCTION: The most commonly accepted method of long bone deformity correction in children with osteogenesis imperfecta is surgical realignment with transphyseal telescopic intramedullary rodding. This approach ensures reinforcement of the bone throughout the growth period. Although longitudinal growth does occur with these implants there has been very little work carried out to calculate the effect of such factors as rod position or implant material on growth. We carried out a prospective comparative study on 12 puppies using titanium alloy telescopic tibial rods with and without hydroxyl-apatite coating. The aim of this non-randomized controlled experimental study was to assess the impact of telescopic intramedullary rodding on spontaneous growth of the tibia. MATERIAL AND METHODS: Twelve mongrel puppies aged of 5 months underwent intramedullary transphyseal rodding of the right tibia. In group I (6 dogs) a titanium telescopic rod was used, in group II (6 dogs) a titanium rod with hydroxyapatite (HA)-coated threaded end was used. The following radiological criteria were assessed before surgery and every month until age of 12 months (natural fusion of physes in dogs): length of tibia, amount of superposition of inner (male) rod into external (female) rod; alteration of anatomy in terms of joint angles (mMPTA, mLDTA, mPPTA, mADTA); positioning of threaded ends in proximal and distal epiphyses and evidence of premature growth arrest. Parameters were compared with left tibia serving as control segment. The null hypothesis was that neither rod position nor implant material altered growth. RESULTS: The transphyseal rods did not lead to irreversible epiphysiodesis in either group. In group II (HA-coated) some loss of residual length was found in all six dogs, over 7mm (5.9%) in comparison to left intact tibia. In contrast to that, in group I (titanium nail) only one animal (16.7%) demonstrated a tibia length discrepancy of 8mm (4.8%). Eccentric ( posterior) positioning of the rod in the distal epiphysis resulted in a procurvatum deformity (increased anterior distal tibial angle) in both groups. We found no failure of telescoping and no loss of fixation of threaded parts in either epiphyses. DISCUSSION: The presence of telescopic rods with HA-coated threads parts clearly contributes to inhibition of spontaneous longitudinal growth. We hypothesize that HA stimulates maturation of chondrocytes of growth plate. Our findings regarding the potential adverse effect of thread position in the distal physis demonstrate the importance of attempting to place the rod as central as possible. CONCLUSION: Titanium alloy telescopic rods did not reveal significant effect on physeal growth in puppies in comparison to HA-coated implants. Transphyseal HA-coated implants did however inhibit growth plate function with mean loss of length of 5.2% compared to the other side. Eccentric positioning of rods relative to center of physis resulted in angular deformity due to irregular growth. There were no cases of mechanical failure or loss of telescopic function with either group of titanium implant. LEVEL OF EVIDENCE: II; prospective comparative experimental study.

Distal tibial osteotomy compared to proximal osteotomy for limb lengthening in children.

AIMS: The aim of this retrospective cohort study was to assess and investigate the safety and efficacy of using a distal tibial osteotomy compared to proximal osteotomy for limb lengthening in children. METHODS: In this study, there were 59 consecutive tibial lengthening and deformity corrections in 57 children using a circular frame. All were performed or supervised by the senior author between January 2013 and June 2019. A total of 25 who underwent a distal tibial osteotomy were analyzed and compared to a group of 34 who had a standard proximal tibial osteotomy. For each patient, the primary diagnosis, time in frame, complications, and lengthening achieved were recorded. From these data, the frame index was calculated (days/cm) and analyzed. RESULTS: All patients ended their treatment with successful lengthening and deformity correction. The frame index for proximal versus distal osteotomies showed no significant difference, with a mean 48.5 days/cm (30 to 85) and 48.9 days/cm (28 to 81), respectively (p = 0.896). In the proximal osteotomy group, two patients suffered complications (one refracture after frame removal and one failure of regenerate maturation with subsequent valgus deformity) compared to zero in the distal osteotomy group. Two patients in each group sustained obstacles that required intervention (one necessitated guided growth, one fibula lengthening, and two required change of wires). There was a similar number of problems (pin-site infections) in each group. CONCLUSION: Our data show that distal tibial osteotomies can be safely employed in limb lengthening for children using a circular frame, which has implications in planning a surgical strategy; for example, when treating a tibia with shortening and distal deformity, a second osteotomy for proximal lengthening is not required.Cite this article: Bone Joint J 2022;104-B(11):1273-1278.

An FPGA-based system for generalised electron devices testing.

Electronic systems are becoming more and more ubiquitous as our world digitises. Simultaneously, even basic components are experiencing a wave of improvements with new transistors, memristors, voltage/current references, data converters, etc, being designed every year by hundreds of R &D groups world-wide. To date, the workhorse for testing all these designs has been a suite of lab instruments including oscilloscopes and signal generators, to mention the most popular. However, as components become more complex and pin numbers soar, the need for more parallel and versatile testing tools also becomes more pressing. In this work, we describe and benchmark an FPGA system developed that addresses this need. This general purpose testing system features a 64-channel source-meter unit, and [Formula: see text] banks of 32 digital pins for digital I/O. We demonstrate that this bench-top system can obtain [Formula: see text] current noise floor, [Formula: see text] pulse delivery at [Formula: see text] and [Formula: see text] maximum current drive/channel. We then showcase the instrument's use in performing a selection of three characteristic measurement tasks: (a) current-voltage characterisation of a diode and a transistor, (b) fully parallel read-out of a memristor crossbar array and (c) an integral non-linearity test on a DAC. This work introduces a down-scaled electronics laboratory packaged in a single instrument which provides a shift towards more affordable, reliable, compact and multi-functional instrumentation for emerging electronic technologies.

Analysis of COVID-19 infection amongst healthcare workers in Rivers State, Nigeria

Background/aimsHealthcare workers (HCWs) are at an increased risk of infection and mortality associated with the COVID-19 pandemic. This study determined the illness severity and mortality amongst COVID-19 infected healthcare workers. MethodsThe current study was a retrospective cohort study using population-level data. Secondary analysis was conducted on collated data from the Public Health Emergency Operations Centre (PHEOC) at the State Ministry of Health. The cohort included all documented healthcare workers with confirmed COVID-19 infection (diagnosed by Polymerase Chain Reaction). Data were gathered from the COVID-19 patient database of the PHEOC, on demographics, place of work, illness severity and outcome. Descriptive statistics were reported on the cohort characteristics. Adjusted odds ratio was used to report the measure of association between illness severity and risk factors. ResultsThe mean age was 43 years and 50.5% of the cohort were female. Of the 301 healthcare workers, 187 patients were symptomatic with 32 requiring hospitalisation. From the available data, seven infected HCWs died of their COVID-19 infection, resulting in a case fatality ratio of 2.3%. A subgroup analysis was conducted on the health professionals infected -doctors (71.7%), nurses (27.3%), others (1%). Symptomatic cases were more inclined to progress to severe illness. Predictors of mortality assessed included age, sex, case class and illness severity. The logistic regression model was statistically significant,{chi} 2(9) = 16.965, = 0.049. ConclusionFrontline healthcare workers are at an increased risk of exposure to COVID-19 infections. In Nigeria, there is a higher risk of experiencing a severe disease if symptomatic while infected with COVID-19. It is imperative that preventive strategies, proper education, and awareness are put in place to protect healthcare workers. Summary BoxHealthcare workers as first responders, are vulnerable to workplace infections. It is manifest in the COVID-19 pandemic where deaths of healthcare workers resulted in further shortage of the already compromised human resource; consequently compromising effective healthcare delivery. As the pandemic progresses, studies have been conducted globally on this topic and scientific evidence continues to show higher mortality and disease severity of COVID-19. Nevertheless, it is important to understand the effect of COVID-19 on healthcare workers in Nigeria-a developing country. This study highlights the illness severity and mortality associated with COVID-19 among the study population; its results presented a higher case fatality rate than both national and subnational rates. The results also further emphasises the need to protect healthcare workers; ensure they are knowledgable in both infection prevention and control, and that the healthcare space is safe against nosocomial infections The study adds to the scientific evidence on the severity and mortality associated with COVID-19 in Nigeria. A national research is needed to extrapolate the findings from this study to the nation. Hence, expatiate on the global fight against coronaviruses such as COVID-19.

Clinical and Functional Outcomes in Patients with Distal Tibial Fracture Treated by Circular External Fixation: A Retrospective Cohort Study.

AIMS AND OBJECTIVES: To examine clinical and functional outcomes in patients with intra- and extra-articular distal tibial fractures treated definitively by Ilizarov fixation. MATERIALS AND METHODS: Patients with tibial fractures extending within 1 Müller square of the ankle joint were identified from our Ilizarov database over a 5-year period. Data on treatment and outcome were assembled from this database and supplemented by a review of patient records. General measures of health-related quality of life and limb-specific functional outcome scores were recorded. Adverse events were documented according to Paley's classification. RESULTS: One hundred and sixty-eight patients with 169 fractures were identified, 28% were open and 63% intra-articular. One hundred and sixty-five (98%) of the fractures united, two following bone grafting in their original frames, at a median of 166.5 days (range 104-537). Three patients with nonunions united with further treatment. One patient (an end-stage diabetic) elected to undergo amputation following multiple early complications during treatment. Closed fractures united more rapidly than open (median 157 vs 183 days; p = 0.005) and true Pilon (43C3) fractures took longer to unite than other fractures (median 157 vs 177 days; p = 0.01).Sixty-seven percent of patients completed functional outcome scores. Sixty-two percent reported good or excellent ankle scores at more than 6 months post frame removal, 38% fair and 10% poor. Patients with intra-articular fractures reported significantly worse ankle scores than those with extra-articular injuries. General measures of health-related quality of life (EuroQol-5D) revealed significant ongoing effects despite good clinical outcomes. CONCLUSION: This study demonstrates a high union and low serious complication rate, suggesting that external ring fixation is a safe and effective treatment for these injuries. HOW TO CITE THIS ARTICLE: Giannoudis VP, Ewins E, Taylor DM, et al. Clinical and Functional Outcomes in Patients with Distal Tibial Fracture Treated by Circular External Fixation: A Retrospective Cohort Study. Strategies Trauma Limb Reconstr 2021;16(2):86-95.

Ilizarov Method for Acute Paediatric Tibial Fractures.

AIM AND BACKGROUND: A systemic method for the application of Ilizarov fixators and on-table fracture reduction is described in this instructional article. This technique has been developed from the unit's practice in adult patients. The indications, underlying principles and rationale for the method are also discussed. TECHNIQUE: The basic concept involves the construction of a series of concentric, colinear rings aligned with the mechanical axis of the limb. An orthogonal ring block is initially placed on the proximal segment and extended distally. Wire to ring reduction techniques are used resulting in the contact, alignment and stability required for early full weight-bearing, free movement of knee and ankle, and subsequent healing. CONCLUSION AND CLINICAL SIGNIFICANCE: Our step-by-step guide takes the reader through a systematic approach to surgery along with tips and tricks on how to achieve reduction and avoid the common pitfalls. With this method, it is possible to achieve an on-table reduction and correction of a multiplanar deformity without the use of expensive hexapod technology. This may allow less experienced users reproduce the technique with a shorter learning curve. HOW TO CITE THIS ARTICLE: Messner J, Prior CP, Pincher B et al. Ilizarov Method for Acute Paediatric Tibial Fractures. Strategies Trauma Limb Reconstr 2021;16(1):46-52.

The PINS Trial: a prospective randomized clinical trial comparing a traditional versus an emollient skincare regimen for the care of pin-sites in patients with circular frames.

AIMS: Pin-site infection remains a significant problem for patients treated by external fixation. A randomized trial was undertaken to compare the weekly use of alcoholic chlorhexidine (CHX) for pin-site care with an emollient skin preparation in patients with a tibial fracture treated with a circular frame. METHODS: Patients were randomized to use either 0.5% CHX or Dermol (DML) 500 emollient pin-site care. A skin biopsy was taken from the tibia during surgery to measure the dermal and epidermal thickness and capillary, macrophage, and T-cell counts per high-powered field. The pH and hydration of the skin were measured preoperatively, at follow-up, and if pin-site infection occurred. Pin-site infection was defined using a validated clinical system. RESULTS: Out of 116 patients who were enrolled in the study, 23 patients (40%) in the CHX group and 26 (44%) in the DML group had at least one bad or ugly pin-site infection. This difference was not statistically significant (p = 0.71). There was no significant relationship between pH or hydration of the skin and pin-site infection. The epidermal thickness was found to be significantly greater in patients who had a pin-site infection compared with those who did not (p = 0.01). Skin irritation requiring a change of treatment occurred in four patients (7%) using CHX, and none using DML. CONCLUSION: We found no significant difference in the incidence of pin-site infection between the CHX and DML treatment groups. Dermol appeared to offer a small but significant advantage in terms of tolerability. We did not find a significant association between patient or treatment related factors and pin-site infection. It is therefore difficult to make specific recommendations based upon these results. The use of either cleaning agent appears to be appropriate. Cite this article: Bone Joint J 2021;103-B(2):279-285.

Complex Tibial Shaft Fractures in Children Involving the Distal Physis Managed with the Ilizarov Method.

INTRODUCTION: Segmental fractures in the juvenile distal tibia with physeal involvement present specific challenges. Injury to the growth plate may be overlooked, potentially resulting in late sequelae. Fracture stabilization can be complex. Previous reports of management of such an injury are by open reduction and internal fixation. This study reviews the management and outcome of a group of such patients treated with Ilizarov external fixators. MATERIALS AND METHODS: Patients aged 16 or younger treated in our unit between March 2013 and November 2014 by Ilizarov circular fine wire fixation for tibial fractures with ipsilateral physeal injuries were identified. Retrospective collection of patient demographics, fracture classification, treatment pathways, fixation methods, postoperative follow-up, outcomes, and complications was undertaken. RESULTS: Eight patients were identified; two had Gustilo and Anderson grade IIIA open injuries. All were managed definitively using an Ilizarov external fixator in combination with percutaneous screw fixation of the physeal component as required. All patients were ambulant during treatment and were allowed unrestricted weight-bearing immediately postoperative. All but one attended school. All fractures united. In follow-up, one patient had a distal tibial physeal growth arrest, but there were no other complications. CONCLUSION: Pediatric patients with complex distal tibial fractures should be scrutinized for concomitant physeal injury. Where identified treatment, using a combination of internal fixation and an Ilizarov fixator can be considered. HOW TO CITE THIS ARTICLE: Rogers GP, Tan HB, Foster P, et al. Complex Tibial Shaft Fractures in Children Involving the Distal Physis Managed with the Ilizarov Method. Strategies Trauma Limb Reconstr 2019;14(1):20-24.

Managing complex trauma injuries in the elderly: a case report of a free flap and circular frame in a 95-year old patient with an open IIIB tibial fracture.

In an ageing population, increasing numbers of patients over the age of 70 are sustaining severe trauma. These patients require careful multidisciplinary team (MDT) management with careful consideration of existing co-morbidities, as such their treatment should be individually tailored. We present the case of a patient believed to be the oldest documented patient treated in a trauma setting with free flap and circular frame fixation to an open tibial fracture. A 95-year-old male presented to the Level 1 Major Trauma Centre (MTC) with multiple injuries after a pedestrian vs car incident. His injury severity score (ISS) was 22. For treatment of his open tibial fracture, he required soft tissue coverage with a free anterolateral thigh (ALT) flap, and circular frame application. Microsurgery was performed after consultation with the MDT and was uneventful. The circular frame was removed after 10 months and the patient went on to regain pre-injury mobility. Use of free tissue transfer in elderly patients is well documented in the elective setting, but less so in trauma. This case demonstrates that careful patient selection, attention to detail and MDT working can result in an excellent outcome for the patient. The challenges faced in treating this patient will be described in detail. LEVEL OF EVIDENCE: Level V, therapeutic study.

Managing soft tissues in severe lower limb trauma in an ageing population.

PURPOSE: With an ageing population, the incidence of trauma in those aged over 65 years is increasing. Strategies for dealing with these patients must be developed. At present the standard management of open tibial fractures in the UK is described by the BOAST4 guidelines (from the British Orthopaedic Association and British Association of Plastic & Aesthetic Surgeons). It is not clear to what extent these are appropriate for older patients. We describe our experience of managing elderly patients presenting with open tibial fractures. METHOD: Patients were identified via prospectively collected national and departmental databases. These data were supplemented by review of the patient records and radiographs. Data collated included patient demographics, injury details, orthopaedic and plastic surgery operative details, and long-term outcomes. RESULTS: Between January 2013 and June 2016, 74 patients aged over 65 years were admitted with open lower limb fractures. 54 of these were open tibial fractures and these patients formed the study group. 19 patients required soft-tissue reconstruction for Gustilo and Anderson IIIB tibial fractures (age range, 67-95 years). In these patients, there were 7 midshaft (AO 42), 1 proximal (AO 41), and 11 distal (AO 43) fractures. 13 patients were treated with internal fixation and 6 with circular frames. The median length of hospital stay was 27 days (range, 4-85). 14 patients received loco-regional flaps and 5 underwent free tissue transfer with one requiring preoperative femoral angioplasty. There were no flap losses. Four patients had fasciocutaneous flaps, 3 tibialis anterior transposition, 2 an extensor digitorum brevis flap, 1 a hemisoleus flap, and 4 were skin grafted. All patients went on to unite and return to their premorbid weight-bearing status (4 using walking frames, 3 using sticks, and 12 walking independently). CONCLUSION: Although the literature suggests a significantly higher complication rate in elderly patients with open fractures, we have demonstrated comparable rates of flap survival and bony union to those observed in younger patients. Challenges are presented in terms of patient physiology and these must be carefully managed pre- and postoperatively. These challenges are reflected in prolonged hospital stays.

Development and evaluation of an overseas clinical rotation program for undergraduate pharmacy students in Japan.

BACKGROUND AND PURPOSE: Internationalization of pharmacists, as well as pharmacy students, in terms of both the knowledge to care for international patients and to have medical information literacy, is a current concern in Japan. EDUCATIONAL ACTIVITY AND SETTING: Keio University Faculty of Pharmacy has developed an elective course for pharmacy students, based on written agreements with the United States and Thailand that establish a student clinical rotation exchange program. The exchange program lasts for four to six weeks and involves clinical rotations in hospitals abroad during the students' sixth year. Rotations follow a four-week didactic preparatory course. The course objectives are to acquire the knowledge, skills, and attitude needed to function as leading pharmacists with an international perspective. METHODS: We asked students to complete a feedback survey inquiring about the usefulness of preparatory courses, self-evaluation pre- and post-rotation satisfaction with the program, and overall self-assessment. FINDINGS: Twenty-four out of 41, i.e., 58.5% of the students replied with feedback. All respondents replied that the preparatory course was useful. They also replied that, based on their self-evaluation, they were satisfied with their level of English language skill improvement after the rotation. Pharmaceutical knowledge satisfaction, however, was slightly decreased. All respondents replied that this program was of a satisfactory nature, with 71%, 63%, and 92% of the respondents replying that they could acquire the knowledge, skills, and attitude program objectives respectively. SUMMARY: It is possible to successfully develop an overseas clinical rotation program. Students were quite satisfied upon completion and achieved the expected objectives.

Integration of Laser Scanning and Three-dimensional Models in the Legal Process Following an Industrial Accident.

BACKGROUND: In order to obtain a deeper understanding of an incident, it needs to be investigated to "peel back the layers" and examine both immediate and underlying failures that contributed to the event itself. One of the key elements of an effective accident investigation is recording the scene for future reference. In recent years, however, there have been major advances in survey technology, which have provided the ability to capture scenes in three dimension to an unprecedented level of detail, using laser scanners. METHODS: A case study involving a fatal incident was surveyed using three-dimensional laser scanning, and subsequently recreated through virtual and physical models. The created models were then utilized in both accident investigation and legal process, to explore the technologies used in this setting. RESULTS: Benefits include explanation of the event and environment, incident reconstruction, preservation of evidence, reducing the need for site visits, and testing of theories. Drawbacks include limited technology within courtrooms, confusion caused by models, cost, and personal interpretation and acceptance in the data. CONCLUSION: Laser scanning surveys can be of considerable use in jury trials, for example, in case the location supports the use of a high-definition survey, or an object has to be altered after the accident and it has a specific influence on the case and needs to be recorded. However, consideration has to be made in its application and to ensure a fair trial, with emphasis being placed on the facts of the case and personal interpretation controlled.

The use of flexible intramedullary nails in limb lengthening.

INTRODUCTION: Lower and upper limb length discrepancy and deformity, congenital or acquired, are amongst the most common conditions in children for orthopaedic referral. Over the last twenty years, surgical techniques have evolved in an attempt to decrease Healing Index and minimise these complications. Areas covered: The flexible intramedullary nailing (FIN) is a minimally invasive intramedullary osteosynthesis. In combination with an external fixator, it is appropriated for pediatric bone lengthenings and lengthening of bones of small diameter in adults. In the study the Scopus and/or PubMed indexed publications about this combined technique were analyzed. Expert commentary: The use of titanium or stainless steel or hydroxyapatite-coated bent elastic nails is appropriate in limb lengthening for congenital and acquired limb length discrepancy. Hydroxyapatite-coated FIN should be applied for long-term reinforcement of lengthened bone in patients with metabolic bone disorders, skeletal dysplasias with compromised bone formation. Osteoinductive surface of nails is favorable for bone formation and as well as for stable position of nails without risks of migration in long-term follow-up. The FIN is an unique intramedullary fixation which respects the bone biology which is mandatory for a good bone consolidation.

Historical and Hygienic Aspects on Roles of Quality Requirements for Antibiotic Products in Japan : Part 3-Introduction of Technology and Knowledge in the Production Process and Quality Control of Penicillin from the United States of America.

In order to investigate the roles of quality requirements for antibiotic products in Japan, from historical and hygienic aspects, we examined and analyzed how technology and knowledge in the production and quality control of penicillin were introduced from the United States of America, applied, and further developed. Owing to the strong support of Colonel Crawford Sams, the chief of the Public Health and Welfare Section of the Supreme Commander for Allied Power/General Headquarters, via the Ministry of Welfare in Japan, the technology and knowledge were acquired from an experienced leader, Dr. Jackson W. Foster, and as a result, domestic production of penicillin was successfully achieved in amounts required to meet national demands sufficiently within three years in a devastated post-war-torn Japan. Based on the consensus that penicillin should be dealt with as "biological products" similar to vaccines and antisera, the quality standards for penicillin were enacted as the "Minimum Requirements for Penicillin (MRP)" on the 1st of May 1947. Due to the development of penicillin production technology, the quality standards of penicillin provided by the MRP were revised often to higher levels ; content of the active element from no less than 60 units/mg (purity 3.8%) to no less than 1,430 units/mg (purity 89.7%). Regarding the penicillin preparations, the content of the active ingredient per vial was changed from 30,000 units at the beginning, to 100,000 units in January 1948, to 3,000,000 units in December 1950, and two preparations containing 200,000 units and 1,000,000 units per vial are currently available, according to clinical convenience.

Historical and hygienic aspects on roles of quality requirements for antibiotic products in Japan: Part 4 - Enactment of requirements for individual antibiotic products.

Supplies of high quality antibiotic products to clinics contributed greatly to the health maintenance of the citizens of Japan. In this report, we describe the results of our investigation and analyses on the establishment and amendments of 'he quality standards for individual antibiotic products, which were regarded as the guidelines for quality control in the production processes. "The minimum requirements of penicillin" enacted in May of 1947 was at a relatively moderate standard level, due to considerations for domestic technical levels. However, after several amendments, in response to the rapid development of manufacturing technologies and new penicillin preparations, standards became increasingly stricter. "The minimum requirements of streptomycin" enacted in December of 1949 was prepared by the use of streptomycin preparations imported from the USA. The 3rd and 4th standards, "the minimum requirements of dihydrostreptomycin" and "the minimum requirements of chloramphenicol", were prepared by applying provisions described in the rules for certification of the U.S. Food and Drug Administration. In accordance with an increase in the varieties of antibiotic products, "the minimum requirements of antibacterial products" was enacted by the integration of previously existing standards and newly enacted ones. Thereafter, in response to the innovation of scientific technologies and the globalization of antibiotic products, "the minimum requirements for antibiotic products in Japan" was further developed and became the basis for supplying high quality antibiotic preparations.