Microbiological and functional outcomes after open extremity fractures sustained overseas: The experience of a UK level I trauma centre.

BACKGROUND: Open extremity fractures carry a high risk of limb loss and poor functional outcomes. Transfer of extremity trauma patients from developing countries and areas of conflict adds further layers of complexity due to challenges in the delivery of adequate care. The combination of extensive injuries, transfer delays and complex microbiology presents unique challenges. METHODS: A retrospective review was conducted to analyse the surgical and microbiological themes of patients with open extremity fractures transferred from overseas to our institution (Imperial College NHS Trust) between January 2011 and January 2016. RESULTS: Twenty civilian patients with 21 open extremity fractures were referred to our unit from 11 different countries. All patients had poly-microbial wound contamination on initial surveillance cultures. Five patients (25%) underwent amputation depending on the extent of osseous injury; positive surveillance cultures did not preclude limb reconstruction, with seven patients undergoing complex reconstruction and eight undergoing simple reconstruction to achievewound coverage. Hundred percent of patients demonstrated infection-free fracture union on discharge. CONCLUSION: Patients with open extremity fractures transferred from overseas present the unique challenge of poly-microbial infection in addition to extensive traumatic wounds. Favourable outcomes can be achieved despite positive microbiological findings on tissue culture with adequate antimicrobial therapy. The decision to salvage the limb and the complexity of reconstruction used should be based on the chance of achieving meaningful functional recovery, mainly determined by the extent of bony injury. The complexity of reconstruction was based on the predicted long-term functionality of the salvaged limb.

Improving the care of patients with severe open fractures of the tibia: the effect of the introduction of Major Trauma Networks and national guidelines.

AIMS: The management of open lower limb fractures in the United Kingdom has evolved over the last ten years with the introduction of major trauma networks (MTNs), the publication of standards of care and the wide acceptance of a combined orthopaedic and plastic surgical approach to management. The aims of this study were to report recent changes in outcome of open tibial fractures following the implementation of these changes. PATIENTS AND METHODS: Data on all patients with an open tibial fracture presenting to a major trauma centre between 2011 and 2012 were collected prospectively. The treatment and outcomes of the 65 Gustilo Anderson Grade III B tibial fractures were compared with historical data from the same unit. RESULTS: The volume of cases, the proportion of patients directly admitted and undergoing first debridement in a major trauma centre all increased. The rate of limb salvage was maintained at 94% and a successful limb reconstruction rate of 98.5% was achieved. The rate of deep bone infection improved to 1.6% (one patient) in the follow-up period. CONCLUSION: The reasons for these improvements are multifactorial, but the major trauma network facilitating early presentation to the major trauma centre, senior orthopaedic and plastic surgical involvement at every stage and proactive microbiological management, may be important factors. TAKE HOME MESSAGE: This study demonstrates that a systemised trauma network combined with evidence based practice can lead to improvements in patient care.

Segmental neck of femur fractures: A unique case report of an ipsilateral subcapital, greater trochanteric and intertrochanteric fracture and proposed management algorithm.

INTRODUCTION: Neck of femur fractures are now increasingly common in an ageing population. The management is well known and has been described in great detail. Concomitant ipsilateral segmental fractures of the neck of femur (SFNOF) however are rare and their investigation and management is poorly described. PRESENTATION OF CASE: We present the surgical management of a unique and complex case of an ipsilateral subcapital, greater trochanteric and intertrochanteric fracture sustained in an 87-year-old female following a low trauma injury. This fracture configuration has not been described in the literature to date, neither has our method of reconstruction for this fracture, namely hemiarthorplasty, trochanteric stabilising plate and cerclage wires. DISCUSSION: 15 cases from 1989 to 2011 managed by 8 different fixation devices and followed up for an average of 17 months (2-58 months). There was an initial mortality rate of 13% (n=2). All associated with low energy trauma occurred in female (n=8), and most with high energy trauma occurred in males (83%; n=5). The diagnosis was delayed or missed in 20% of cases, and the most common pattern was a concomitant undisplaced subcapital and intertrochanteric fracture (37.5%, n=6). The overall risk of avascular necrosis was 20%, with a greater risk in patients greater than 65 years of age (33%). CONCLUSION: Ipsilateral SFNOF are rare injuries with a bimodal distribution, and carry a greater risk of AVN. We advise that all SFNOF should have pre-operative CT planning and propose an algorithm to treat these patients with a standardised surgical approach.

Atraumatic posterior dislocation of the native hip: an unusual presentation of septic arthritis.

We present a case of chronic posterior hip dislocation after severe joint destruction following septic arthritis. In the absence of trauma, infection must be considered in the differential diagnosis of a dislocated joint particularly in patients with risk factors such as intravenous drug abuse and immune compromise. Excision arthroplasty of the hip was performed with good pain relief and functional outcomes. This is an excellent temporary or permanent solution in managing such complex cases although alternative management options are discussed.

Management of severe open tibial fractures: the need for combined orthopaedic and plastic surgical treatment in specialist centres.

Although it is widely accepted that grade IIIB open tibial fractures require combined specialised orthopaedic and plastic surgery, the majority of patients in the UK initially present to local hospitals without access to specialised trauma facilities. The aim of this study was to compare the outcome of patients presenting directly to a specialist centre (primary group) with that of patients initially managed at local centres (tertiary group). We reviewed 73 consecutive grade IIIB open tibial shaft fractures with a mean follow-up of 14 months (8 to 48). There were 26 fractures in the primary and 47 in the tertiary group. The initial skeletal fixation required revision in 22 (47%) of the tertiary patients. Although there was no statistically-significant relationship between flap timing and flap failure, all the failures (6 of 63; 9.5%) occurred in the tertiary group. The overall mean time to union of 28 weeks was not influenced by the type of skeletal fixation. Deep infection occurred in 8.5% of patients, but there were no persistently infected fractures. The infection rate was not increased in those patients debrided more than six hours after injury. The limb salvage rate was 93%. The mean limb functional score was 74% of that of the normal limb. At review, 67% of patients had returned to employment, with a further 10% considering a return after rehabilitation. The times to union, infection rates and Enneking limb reconstruction scores were not statistically different between the primary and tertiary groups. The increased complications and revision surgery encountered in the tertiary group suggest that severe open tibial fractures should be referred directly to specialist centres for simultaneous combined management by orthopaedic and plastic surgeons.

5 degrees to 6 degrees of distal femoral cut for uncomplicated primary total knee arthroplasty: is it safe?

The angle formed between the anatomical axis and mechanical axis of the femur determines the angle of resection of distal femur in total knee arthroplasty. The objective of this study was to analyse the safety of the routine practice of selecting 5-6 degrees of valgus for distal femoral cut during uncomplicated primary total knee arthroplasty. A retrospective study was undertaken involving a review of pre-operative CT scout films of osteoarthritic knees in 83 consecutive patients (44 males and 39 females; mean age 70 years) who presented for total knee arthroplasty. The anatomical and mechanical axis of femur were plotted on CT scout films and the angle between the two femoral axes were measured. Mean femoral axes angle was 5.4 degrees (range 3.3-7.6 degrees, SD 0.9 degrees). Estimated 95% confidence interval of the mean for the population was 5.2-5.6 degrees. There were no significant differences for age, gender or laterality of the limb. The routine practice of selecting 5 degrees to 6 degrees of the distal femoral cut for an uncomplicated primary total knee arthroplasty is safe.

Prospective randomized trial comparing absorbable and non-absorbable sutures in open carpal tunnel release.

A prospective randomized trial was undertaken to compare the influence of absorbable and non-absorbable sutures on pillar pain, scar tenderness, extent of wound inflammation and overall outcome of the surgery following open carpal tunnel release. Forty hands in 33 patients (mean age, 51 years; range, 31-74 years) were randomized into group A (absorbable sutures) or group B (non-absorbable sutures). Clinical assessment was done at 2, 6 and 12 weeks follow-up. The outcome of surgery in terms of improvement of severity of symptoms and functional status of patients was assessed using a self-administered Boston Questionnaire. There was no significant difference between the two groups for any of our outcome measures at the final follow-up.

Stenosis of the cervical canal in craniodiaphyseal dysplasia.

Craniodiaphyseal dysplasia (CDD) is a rare sclerosing bone disorder, the severity of which depends on its phenotypic expression. Hyperostosis can cause progressive foraminal stenosis leading to palsy of cranial nerves, epilepsy and mental retardation. We report the only case of CDD in an adult, with stenosis of the cervical canal leading to quadriparesis as a late complication of hyperostosis, and describe the problems associated with its treatment. Although the syndrome is rare, its pathophysiological and therapeutic considerations may be applicable to the management of stenosis of the spinal canal in other hyperostotic bone disorders.

Stiff man's syndrome.

Myositis ossificans progressiva is an autosomal dominant disease resulting in progressive ossification and skeletal deformities, mainly in the connective tissue of muscle. The diagnosis is based on clinical and radiological findings and demonstration of skeletal malformations. We report a singular case of advanced myositis ossificans progressiva in a fourteen year old male and analyse the natural history, etiopathology, treatment alternatives and prognosis of this crippling disorder.