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Barone N, Ziolkowski N, Haykal S. The Role of Negative Pressure Wound Therapy in Temporizing Traumatic Wounds before Lower Limb Soft Tissue Reconstruction: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e6003. [PMID: 39071768 PMCID: PMC11281775 DOI: 10.1097/gox.0000000000006003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 05/31/2024] [Indexed: 07/30/2024]
Abstract
Background In practice, there is often a delay from initial debridement and temporary fixation to definitive soft tissue coverage of traumatic leg wounds. Without clear evidence, conservative negative pressure wound therapy (NPWT) is increasingly used to temporize these wounds. This systematic review summarizes and synthesizes the literature on using NPWT to temporize traumatic leg wounds before surgery in adult surgical patients. Methods A comprehensive search of Medline, Embase, and Cochrane Library was performed from inception until July 2022, inclusively. Two independent reviewers performed screening, data extraction, and risk of bias assessment. Primary English studies, including adult patients (≥16 years old) with a fracture below the knee up to and including the ankle that received NPWT to temporize wounds before definitive soft tissue reconstruction with a flap and/or graft, were included. Results Thirty-four studies, including 804 patients who received NPWT, were included. The partial/total flap loss rate was 6.95% (n = 9 studies), the infection rate was 19.5% (n = 25 studies), the nonunion rate was 18% (n = 15 studies), the delayed union rate was 9.31% (n = 3 studies), and the amputation rate was 15.4% (n = 6 studies). The mean late stay was 43.1 days (n = 9 studies), and the follow-up length was 23.7 months (n = 9 studies). The mean time to wound healing was 5.63 months (n = 2 studies), and the time to soft tissue coverage was 40.8 days (n = 12 studies). The mean time to achieve bone union was 7.26 months (n = 6 studies). Conclusion NPWT can be used to temporize traumatic wounds while awaiting soft tissue reconstruction.
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Affiliation(s)
- Natasha Barone
- From the Division of Plastic, Reconstructive and Aesthetic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Natalia Ziolkowski
- From the Division of Plastic, Reconstructive and Aesthetic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Siba Haykal
- From the Division of Plastic, Reconstructive and Aesthetic Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science and Toronto General Hospital Research Institute, University of Toronto, Toronto, Ontario, Canada
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, Yale New Haven Hospital, New Haven, Conn
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Farhat T, Moussally K, Nahouli H, Hamad SA, Qaraya KA, Abdul-Sater Z, El Sheikh WG, Jawad N, Al Sedawi K, Obaid M, AbuKhoussa H, Nyaruhirira I, Tamim H, Hettiaratchy S, Bull AMJ, Abu-Sittah G. The integration of ortho-plastic limb salvage teams in the humanitarian response to violence-related open tibial fractures: evaluating outcomes in the Gaza Strip. Confl Health 2024; 18:35. [PMID: 38658929 PMCID: PMC11040898 DOI: 10.1186/s13031-024-00596-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 04/09/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Limb salvage by ortho-plastic teams is the standard protocol for treating open tibial fractures in high-income countries, but there's limited research on this in conflict settings like the Gaza Strip. This study assessed the clinical impact of gunshot-related open tibial fractures, compared patient management by orthopedic and ortho-plastic teams, and identified the risk factors for bone non-union in this context. METHODS A retrospective review of medical records was conducted on Gaza Strip patients with gunshot-induced-open tibial fractures from March 2018 to October 2020. Data included patient demographics, treatments, and outcomes, with at least one year of follow-up. Primary outcomes were union, non-union, infection, and amputation. RESULTS The study included 244 injured individuals, predominantly young adult males (99.2%) with nearly half (48.9%) having Gustilo-Anderson type IIIB fractures and more than half (66.8%) with over 1 cm of bone loss. Most patients required surgery, including rotational flaps and bone grafts with a median of 3 admissions and 9 surgeries. Ortho-plastic teams managed more severe muscle and skin injuries, cases with bone loss > 1 cm, and performed less debridement compared to other groups, though these differences were not statistically significant. Non-union occurred in 53% of the cases, with the ortho-plastic team having the highest rate at 63.6%. Infection rates were high (92.5%), but no significant differences in bone or infection outcomes were observed among the different groups. Logistic regression analysis identified bone loss > 1 cm, vascular injury, and the use of a definitive fixator at the first application as predictors of non-union. CONCLUSIONS This study highlights the severity and complexity of such injuries, emphasizing their significant impact on patients and the healthcare system. Ortho-plastic teams appeared to play a crucial role in managing severe cases. However, further research is still needed to enhance our understanding of how to effectively manage these injuries.
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Affiliation(s)
- Theresa Farhat
- Global Health Institute, American University of Beirut, Gefinor Center Block D, 3rd floor, P.O. Box 11-0236, Riad El Solh, Beirut, 1107-2020, Lebanon
| | - Krystel Moussally
- Médecins Sans Frontières, Lebanon Branch Office, Middle East Medical Unit, Beirut, Lebanon
| | - Hasan Nahouli
- Division of Orthopedic Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Shahd Abu Hamad
- Global Health Institute, American University of Beirut, Gefinor Center Block D, 3rd floor, P.O. Box 11-0236, Riad El Solh, Beirut, 1107-2020, Lebanon
| | - Khulood Abul Qaraya
- Global Health Institute, American University of Beirut, Gefinor Center Block D, 3rd floor, P.O. Box 11-0236, Riad El Solh, Beirut, 1107-2020, Lebanon
| | - Zahi Abdul-Sater
- Global Health Institute, American University of Beirut, Gefinor Center Block D, 3rd floor, P.O. Box 11-0236, Riad El Solh, Beirut, 1107-2020, Lebanon
| | - Walaa G El Sheikh
- Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nadine Jawad
- Global Health Institute, American University of Beirut, Gefinor Center Block D, 3rd floor, P.O. Box 11-0236, Riad El Solh, Beirut, 1107-2020, Lebanon
| | - Khouloud Al Sedawi
- Operational Centre Brussels, Gaza mission, Médecins Sans Frontières, Gaza, Palestine
| | - Mohammed Obaid
- Operational Centre Brussels, Gaza mission, Médecins Sans Frontières, Gaza, Palestine
| | - Hafez AbuKhoussa
- Operational Centre Brussels, Gaza mission, Médecins Sans Frontières, Gaza, Palestine
| | - Innocent Nyaruhirira
- Operational Centre Brussels, Medical Department, Médecins Sans Frontières, Brussels, Belgium
| | - Hani Tamim
- Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Shehan Hettiaratchy
- Centre for Blast Injury Studies, Imperial College London, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - Anthony M J Bull
- Centre for Blast Injury Studies, Imperial College London, London, UK
| | - Ghassan Abu-Sittah
- Global Health Institute, American University of Beirut, Gefinor Center Block D, 3rd floor, P.O. Box 11-0236, Riad El Solh, Beirut, 1107-2020, Lebanon.
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Sabawo M, Jaffry Z, Chokotho L, Schade AT. An Assessment of Open Fracture Management in Hospitals in Malawi Before and Immediately After Implementing Open Fracture Guidelines. JB JS Open Access 2024; 9:e23.00078. [PMID: 38572496 PMCID: PMC10984658 DOI: 10.2106/jbjs.oa.23.00078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2024] Open
Abstract
Background Open fractures, a common consequence of road traffic collisions, are associated with a high risk of complications. The introduction of standard guidelines has been shown to improve patient care and reduce the risk of complications in several countries. In September 2021, the Malawi Orthopaedic Association/Arbeitsgemeinschaft für Osteosynthesefragen Alliance (MOA/AOA) guidelines and standards for open fracture management were introduced in Malawi. This study aimed to assess the management of open fractures in hospitals in Malawi, before and after implementing a training course on the MOA/AOA open fracture guidelines. Methods This was a descriptive and quantitative, before-and-after study that reviewed the medical files of patients with open fractures at Zomba Central Hospital and Mulanje, Salima, and Mangochi district hospitals over two 3-month periods. Variables included initial assessment; antibiotic prophylaxis; place of debridement; type of anesthesia; treatment of the open fracture in the emergency department, operating room, and wards; and short-term complications requiring hospital treatment. Results A total of 88 open-fracture case files were reviewed; 43 were prior and 45 were subsequent to the implementation of the open fracture guidelines. The overall median patient age was 36 years (interquartile range, 27 to 45 years), and 91% (80) were male. Limb neurovascular status assessment and documentation improved from 26% (11) of the patients before the guidelines to 62% (28) afterward (p = 0.0002). The percentage who underwent debridement in the operating room significantly increased from 19% (8) to 69% (31) (p = 0.01). The percentage who underwent debridement under general or spinal anesthesia significantly increased from 5% (2) to 38% (17) and from 12% (5) to 29% (13), respectively (p= 0.001). The wound infection rate decreased from 21% to 11%, but this was not significant, and there was no change in the overall complication rate (p = 0.152). Conclusions This study suggests that training on the MOA/AOA open fracture management guidelines followed by their implementation can lead to at least temporary improvement in the management of open fractures. Nevertheless, additional studies need to be performed to understand the effect on long-term patient outcomes. Levels of Evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Zahra Jaffry
- Barts Health NHS Trust, The Royal London Hospital, London, England
| | - Linda Chokotho
- Malawi University of Science and Technology, Mikolongwe, Malawi
| | - Alexander Thomas Schade
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, England
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Perdomo-Lizarraga JC, Andrade-Orellano DJ, Necchi M, Zavatta M, Ryan-Coker M, Dixon-Cole R. Usefulness of external fixation and reverse Sural fasciocutaneous flap: Treatment of grade III B open tibial fractures in resource-limited settings. Injury 2024; 55:111349. [PMID: 38277877 DOI: 10.1016/j.injury.2024.111349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 01/11/2024] [Accepted: 01/13/2024] [Indexed: 01/28/2024]
Abstract
PURPOSE Sierra Leone is a low-income country located on the west coast of Africa where the majority of the population does not have free access to emergency medical and surgical services, the principal cause of open tibia fractures is motorcycle collision. Open fractures of the middle and distal third of the tibial segments, particularly those classified as type III B, represent a challenge for orthopedic surgeons because of the loss of soft tissue coverage. The Reverse Sural Fasciocutaneous Flap (RSFF) has been shown to be an ideal and reproducible option for the treatment of soft tissue defects. The main aim of this study was to demonstrate the experience in Resource Limited Settings (RLS) by means of a short series of the efficacy of using a combination of external fixation and RSFF in the treatment of grade III B open tibia fractures where plastic surgeons were not available. METHODS This retrospective, descriptive, and non-experimental study included 8 patients who underwent surgical intervention between September 2020 and September 2021. RESULTS The skin defects were of various sizes; the smallest size was 4 × 7 cm, and the biggest size of 12 × 18 cm. We obtained a success rate in seven of the eight cases. CONCLUSIONS External fixation and reverse sural fasciocutaneous sural flap are excellent therapeutic options for the treatment of open grade III B diaphyseal and metaphyseal distal tibial fractures.
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Affiliation(s)
- Juan Carlos Perdomo-Lizarraga
- Emergency Surgery Centre, Goderich, Sierra Leone,Africa; Department of Orthopedics, University Hospital of Jaen, 23009, Jaen city, Spain.
| | - Dennys J Andrade-Orellano
- Emergency Surgery Centre, Goderich, Sierra Leone,Africa; Department of Orthopedics, Galeazzi Orthopedic Institute, 20161, Milan, Italy.
| | - Marco Necchi
- Emergency Surgery Centre, Goderich, Sierra Leone,Africa; Department of Surgery and Orthopedics, Sterzing Hospital, Margarethenstraße 24, 39049 Sterzing, Italy.
| | | | - Marcella Ryan-Coker
- Emergency Surgery Centre, Goderich, Sierra Leone,Africa; Department of Surgery, University of Nairobi, Nairobi, Kenya; College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK.
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Schade AT, Sabawo M, Nyamulani N, Mpanga CC, Ngoie LB, Metcalfe AJ, Lalloo DG, Madan JJ, Harrison WJ, MacPherson P. Functional outcomes and quality of life at 1-year follow-up after an open tibia fracture in Malawi: a multicentre, prospective cohort study. Lancet Glob Health 2023; 11:e1609-e1618. [PMID: 37666261 PMCID: PMC10509037 DOI: 10.1016/s2214-109x(23)00346-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/04/2023] [Accepted: 07/11/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Injuries are a major cause of disability globally and injury incidence is rapidly increasing, largely due to road traffic injuries in low-income and middle-income countries. Current estimates of the scale and consequences of disability from injury are largely based on modelling studies, with a scarcity of empirical evidence from severe injuries in low-income countries. We aimed to better understand the outcomes for individuals with open tibia fractures in Malawi. METHODS In this multicentre, prospective cohort study, adults (aged ≥18 years) with open tibia fractures were systematically recruited at six hospitals in Malawi (two tertiary hospitals and four district hospitals). Follow-up lasted at least 1 year, during which in-person follow-up reviews were done at 6 weeks, 3 months, 6 months, and 1 year post-injury. The primary outcome was function at 1 year post-injury, measured by the Short Musculoskeletal Functional Assessment (SMFA) score. Secondary outcomes included quality-adjusted life-years (QALYs; as determined via the European Quality of Life 5-Dimensions 3-Levels [EQ-5D-3L] survey) and fracture-related infection at 1 year post-injury. Multilevel regression models investigated associations between SMFA score, EQ-5D-3L, baseline factors, and orthopaedic management. FINDINGS Between Feb 12, 2021, and March 14, 2022, 287 participants were enrolled (median age 34 years [IQR 25-44]; 84% male). The most common mode of injury was road traffic injuries (194 [68%] of 287). Overall, 268 (93%) participants had debridement; of the 63 participants who were debrided in district hospitals, 47 (75%) had the procedure under local or no anaesthesia. Following substantial declines by 6 weeks after injury, function and quality of life had not recovered by 1 year post-injury for participants with Gustilo grade I-II fractures (posterior mean SMFA at 1 year: 10·5, 95% highest density interval [HDI]: 9·5-11·6; QALYs: 0·73, 95% HDI: 0·66-0·80) nor Gustilo grade III fractures (posterior mean SMFA at 1 year: 14·9, 95% HDI: 13·4-16·6; QALYs: 0·67, 95% HDI: 0·59-0·75). For all fracture grades, intramedullary nailing substantially improved function and quality of life at 1 year post-injury. Delayed definitive fixation after 5 days had 5-times greater odds of infection compared with early management within 2 days (adjusted odds ratio: 5·1, 95% CI 1·8-16·1; p=0·02). INTERPRETATION Adults with open tibia fractures in Malawi have poor function and quality of life in the 1 year following injury. Centralised orthopaedic surgical management, including early definitive fixation and intramedullary nailing for more severe injuries, might improve outcomes. FUNDING Wellcome Trust. TRANSLATION For the Chichewa translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Alexander Thomas Schade
- Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, UK; Queen Elizabeth Central Hospital, Blantyre, Malawi.
| | | | | | - Chikumbutso Clara Mpanga
- Queen Elizabeth Central Hospital, Blantyre, Malawi; Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | | | | | | | | | - Peter MacPherson
- Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, UK; University of Glasgow, Glasgow, UK
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Faraji N, Goli R, Shaddeli S, Rahmati A, Amirashayeri M, Yengejeh SY. Surgical management on a rare type of vertical liner fracture of tibia: A case report study. Int J Surg Case Rep 2023; 110:108692. [PMID: 37633194 PMCID: PMC10509799 DOI: 10.1016/j.ijscr.2023.108692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 08/28/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE The vertical liner fracture of the tibia is an infrequent and intricate injury that presents considerable difficulties in terms of its diagnosis, treatment, and long-term consequences. This particular fracture pattern is distinguished by a vertical line of fracture along the length of the tibial shaft, spanning from the proximal to the distal end. CASE PRESENTATION The 31-year-old female patient, who had no prior medical conditions, presented to the emergency department with complaints of intense pain and impaired ambulation in her right lower limb. She reported an accidental fall while descending a staircase, resulting in substantial impact and pressure on her right leg. CLINICAL DISCUSSION While fractures of the tibia are frequently encountered, there exist exceptional instances of vertical liner fractures within this category. A vertical long liner fracture of the tibia denotes a distinct fracture type in the elongated bone of the lower limb, characterized by a vertical fracture line that extends along the length of the bone. CONCLUSION Vertical liner fractures of the tibia, although rare, are distinct from more common tibial fracture patterns. Accurate diagnosis and thorough evaluation using various imaging methods are crucial for assessing the extent of the fracture and any associated injuries.
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Affiliation(s)
- Navid Faraji
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Urmia University of Medical Sciences, Urmia, Iran
| | - Rasoul Goli
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Urmia University of Medical Sciences, Urmia, Iran
| | - Sevda Shaddeli
- School of Medicine, Urmia University of Medical Sciences, Urmia, Iran.
| | - Ata Rahmati
- School of Paramedical, Hamedan University of Medical Sciences, Hamedan, Iran
| | | | - Sepideh Yousefi Yengejeh
- Department of Nursing, School of Nursing and Midwifery, Islamic Azad University of Urmia, Urmia, Iran
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Jiang Y, Zhou J, Tang B, Zhu X. Treating open tibular fracture (Type gustillo IIIA) with medullary nail assisted by cortex screws: A case report. Medicine (Baltimore) 2023; 102:e33747. [PMID: 37171304 PMCID: PMC10174398 DOI: 10.1097/md.0000000000033747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Open fractures of the tibia are mostly caused by high-energy injuries, accompanied by severe soft tissue injuries. Staged operations are reported performing better prognosis in these cases. CASE SUMMARY The author reports a case of open comminuted fracture of the left tibia (GustilloIIIA) and discusses its clinical features and treatment experience with the literature. The patient was admitted to our hospital by an ambulance for half an hour due to pain in her left leg caused by a car collision on an electric bike. During hospitalization, external fixation and an intramedullary nail were sequential used. CONCLUSION The case report suggests that cortex screws are likely benefit the prognosis of severe open tibial fracture.
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Milandri G, Wijesinghe PCI, Munidasa D, Pathmanathan C, Saeidi M, Bull AMJ, Silva P. Clinical trial of a low-cost external fixator for global surgery use. INTERNATIONAL ORTHOPAEDICS 2023:10.1007/s00264-023-05807-9. [PMID: 37074376 PMCID: PMC10267263 DOI: 10.1007/s00264-023-05807-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 03/23/2023] [Indexed: 04/20/2023]
Abstract
PURPOSE A low-cost modular external fixator for the lower limb has been developed for global surgery use. The purpose of this study is to assess outcome measures in the first clinical use of the device. METHODS A prospective cohort study was conducted with patients recruited in two trauma hospitals. Initial clinical procedure data were collected, and patients were followed up every two weeks until 12 weeks or definitive fixation. Follow-up assessed infection, stability, and radiographic outcomes. In addition, patient-reported outcomes and surgeons' feedback on device usability were collected by questionnaires. RESULTS The external fixator was used on 17 patients. Ten were mono-lateral, five were joint spanning, and two were delta configuration. One patient had a pin site infection at 12-week follow-up. All were stable when tested mechanically and using radiographic assessment, and 53% were converted to definitive fixation. CONCLUSION The low-cost external fixator developed is appropriate for use in global surgery trauma centres with good clinical outcomes. PROSPECTIVE TRIAL REGISTRATION NUMBER AND DATE SLCTR/2021/025 (06 Sep 2021).
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Affiliation(s)
| | | | | | | | - Mehdi Saeidi
- Department of Bioengineering, Imperial College London, London, UK
| | - Anthony M J Bull
- Department of Bioengineering, Imperial College London, London, UK
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Jaffry Z, Sabawo M, Harrison WJ, Schade AT. Using a consensus meeting to enhance fracture care education in low income countries. BMC MEDICAL EDUCATION 2023; 23:111. [PMID: 36793036 PMCID: PMC9930265 DOI: 10.1186/s12909-023-04077-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 02/01/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND A key strategy to building surgical capacity in low income countries involves training care providers, particularly in the interventions highlighted by the Lancet Commission for Global Surgery, including the management of open fractures. This is a common injury, especially in areas with a high incidence of road traffic incidents. The aim of this study was to use a nominal group consensus method to design a course on open fracture management for clinical officers in Malawi. METHODS The nominal group meeting was held over two days, including clinical officers and surgeons from Malawi and the UK with various levels of expertise in the fields of global surgery, orthopaedics and education. The group was posed with questions on course content, delivery and evaluation. Each participant was encouraged to suggest an answer and the advantages and disadvantages of each suggestion were discussed before voting through an anonymous online platform. Voting included use of a Likert scale or ranking available options. Ethical approval for this process was obtained from the College of Medicine Research and Ethics Committee Malawi and the Liverpool School of Tropical Medicine. RESULTS All suggested course topics received an average score of greater than 8 out of 10 on a Likert scale and were included in the final programme. Videos was the highest ranking option as a method for delivering pre-course material. The highest ranking methods for each course topic included lectures, videos and practicals. When asked what practical skill should be tested at the end of the course, the highest ranking option was "initial assessment". CONCLUSION This work outlines how a consensus meeting can be used to design an educational intervention to improve patient care and outcomes. Through combining the perspectives of both the trainer and trainee, the course aligns both agendas so that it is relevant and sustainable.
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Affiliation(s)
| | | | - William J Harrison
- Countess of Chester Hospital NHS Trust, London, UK
- AO Alliance Africa, Davos, Switzerland
| | - Alexander T Schade
- Malawi- Liverpool Wellcome Trust, Blantyre, Malawi.
- Liverpool School of Tropical Medicine, Liverpool, UK.
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Saeidi M, Barnes SC, Berthaume MA, Holthof SR, Milandri GS, Bull AMJ, Jeffers J. Low-cost locally manufacturable unilateral imperial external fixator for low- and middle-income countries. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 4:1004976. [PMID: 36530549 PMCID: PMC9753939 DOI: 10.3389/fmedt.2022.1004976] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/07/2022] [Indexed: 03/19/2024] Open
Abstract
Treating open fractures in long bones can be challenging and if not performed properly can lead to poor outcomes such as mal/non-union, deformity, and amputation. One of the most common methods of treating these fracture types is temporary external fixation followed by definitive fixation. The shortage of high-quality affordable external fixators is a long-recognised need, particularly in Low- and Middle-Income Countries (LMICs). This research aimed to develop a low-cost device that can be manufactured locally to international standards. This can provide surge capacity for conflict zones or in response to unpredictable incidents and situations. The fixator presented here and developed by us, the Imperial external fixator, was tested on femur and tibia specimens under 100 cycles of 100 N compression-tension and the results were compared with those of the Stryker Hoffmann 3 frame. The Imperial device was stiffer than the Stryker Hoffmann 3 with a lower median interfragmentary motion (of 0.94 vs. 1.48 mm). The low-cost, easy to use, relatively lightweight, and easy to manufacture (since minimum skillset and basic workshop equipment and materials are needed) device can address a critical shortage and need in LMICs particularly in conflict-affected regions with unpredictable demand and supply. The device is currently being piloted in three countries for road traffic accidents, gunshot wounds and other conflict trauma-including blast cohorts.
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Affiliation(s)
- Mehdi Saeidi
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Spencer C. Barnes
- Department of Mechanical Engineering, Imperial College London, London, United Kingdom
| | | | - Sander R. Holthof
- Department of Mechanical Engineering, Imperial College London, London, United Kingdom
| | | | - Anthony M. J. Bull
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Jonathan Jeffers
- Department of Mechanical Engineering, Imperial College London, London, United Kingdom
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Belangero WD, Fogagnolo F, Kojima KE, Miguel GCDE, Bidolegui F, Bertune AD, Lombardo E, Dias ADEL, Torres JBM, Coutinho BP, Silva JDS, Leonhardt MDEC, Pereira PS, Mariolani JRL, Giordano V. Isolated open tibial shaft fracture: a seven-hospital, prospective observational study in two Latin America countries. Rev Col Bras Cir 2022; 49:e20223301. [PMID: 36449940 PMCID: PMC10578785 DOI: 10.1590/0100-6991e-20223301-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 06/06/2022] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION open tibial fractures are challenging due to the frequent severe bone injury associated with poor soft tissue conditions. This is relevant in low- and middle-income countries, mainly related to delayed definitive fixation and lack of adequate training in soft tissue coverage procedures. Due to these factors, open tibial fracture is an important source of disability for Latin American countries. Herein we sought to provide an epidemiological overview of isolated open tibial shaft fracture across seven hospitals in southern cone of Latin America. The secondary goal was to assess the impact on quality of life based on return-to-work rate (RWR). METHODS patients with an isolated open tibial shaft fracture treated in seven different hospitals from Brazil and Argentina from November 2017 to March 2020 were included in the study. Clinical and radiographic results were evaluated throughout the 120-day follow-up period. Final evaluation compared RWR with the SF-12 questionnaire, bone healing, and gait status. RESULTS Seventy-two patients were treated, 57 followed for 120 days and 48 completed the SF-12 questionnaire. After 120 days, 70.6% had returned to work, 61.4% had experienced bone healing. Age, antibiotic therapy, type of definitive treatment, and infection significantly influenced the RWR. Gait status exhibited strong correlations with RWR and SF-12 physical component score. CONCLUSIONS Isolated open tibial shaft fractures are potentially harmful to the patient's quality of life after 120 days of the initial management. RWR is significantly higher for younger patients, no history of infection, and those who could run in the gait status assessment.
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Affiliation(s)
- William Dias Belangero
- - Universidade Estadual de Campinas, Faculdade de Ciências Médicas - Campinas - SP - Brasil
| | - Fabricio Fogagnolo
- - Universidade de São Paulo, Faculdade de Medicina - Ribeirão Preto - SP - Brasil
| | - Kodi Edson Kojima
- - Universidade de São Paulo, Instituto de Ortopedia e Traumatologia - São Paulo - SP - Brasil
| | | | | | | | - Ernesto Lombardo
- - Hospital de Emergencias Clemente Alvarez - Rosario - Santa Fé - Argentina
| | - Adélio DE Lima Dias
- - Universidade Estadual de Campinas, Faculdade de Ciências Médicas - Campinas - SP - Brasil
| | | | - Bruno Parilha Coutinho
- - Hospital Municipal Miguel Couto, Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro - Rio de Janeiro - RJ - Brasil
| | - Jorge Dos Santos Silva
- - Universidade de São Paulo, Instituto de Ortopedia e Traumatologia - São Paulo - SP - Brasil
| | | | | | | | - Vincenzo Giordano
- - Hospital Municipal Miguel Couto, Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro - Rio de Janeiro - RJ - Brasil
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Cortez A, Urva M, Haonga B, Donnelley CA, von Kaeppler EP, Roberts HJ, Shearer DW, Morshed S. Outcomes of Intramedullary Nailing and External Fixation of Open Tibial Fractures: Three to Five-Year Follow-up of a Randomized Clinical Trial. J Bone Joint Surg Am 2022; 104:1877-1885. [PMID: 35980080 DOI: 10.2106/jbjs.22.00016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND While surgeons in low and middle-income countries have increasing experience with intramedullary nailing (IMN), external fixation (EF) continues to be commonly used for the management of open tibial fractures. We examined outcomes with extended follow-up of the participants enrolled in a clinical trial comparing these treatments. METHODS Adults who were ≥18 years old with acute AO/OTA type-42 open tibial shaft fractures were randomly assigned to statically locked, hand-reamed IMN or uniplanar EF. These participants were reevaluated 3 to 5 years after treatment. The primary outcome was death or reoperation for the treatment of deep infection, nonunion, or malalignment. Unresolved complications such as persistent fracture-related infection, nonunion, or malalignment were collected and analyzed. Secondary outcomes included the EuroQol-5 Dimension-3 Level (EQ-5D-3L) questionnaire, the Function IndeX for Trauma (FIX-IT) score, radiographic alignment, and the modified Radiographic Union Scale for Tibial fractures (mRUST). RESULTS Of the originally enrolled 240 participants,126 (67 managed with IMN and 59 managed with EF) died or returned for follow-up at a mean of 4.0 years (range, 2.9 to 5.2 years). Thirty-two composite primary events occurred, with rates of 23.9% and 27.1% in the IMN and EF groups, respectively. Six of these events (3 in the IMN group and 3 in the EF group) were newly detected after the original 1-year follow-up. Unresolved complications in the form of chronic fracture-related infection or nonunion were present at long-term follow-up in 25% of the participants who sustained a primary event. The EQ-5D-3L index scores were similar between the 2 groups and only returned to preinjury levels after 1 year among patients without complications or those whose complications resolved. CONCLUSIONS This observational study extended follow-up for a clinical trial assessing IMN versus EF for the treatment of open tibial fractures in sub-Saharan Africa. At a mean of 4 years after injury, fracture-related infection and nonunion became chronic conditions in nearly a quarter of the participants who experienced these complications, regardless of reintervention. LEVEL OF EVIDENCE Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Abigail Cortez
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California.,Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Mayur Urva
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Billy Haonga
- Muhimbili Orthopaedic Institute, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Claire A Donnelley
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Ericka P von Kaeppler
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Heather J Roberts
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - David W Shearer
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Saam Morshed
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California.,Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California
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13
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Schade AT, Sibande W, Kumwenda M, Desmond N, Chokotho L, Karasouli E, Metcalfe A, Harrison WJ. "Don't rush into thinking of walking again": Patient views of treatment and disability following an open tibia fracture in Malawi. Wellcome Open Res 2022; 7:204. [PMID: 36110835 PMCID: PMC9453110 DOI: 10.12688/wellcomeopenres.18063.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 12/05/2022] Open
Abstract
Background: Open tibia fractures are a common injury following road traffic accidents in Malawi and can lead to long term disability. Very little is known about patients' experiences of the healthcare system and the disability in low-income countries following this injury. The aim of the study was to explore patient experiences of treatment and disability following an open tibia fracture in Malawi. Methods: A qualitative study was conducted using semi-structured interviews with ten patients with open tibia fractures at a central hospital in Blantyre, Malawi. A mixed deductive-inductive thematic analysis was used to identify broad themes of treatment and disability. Written informed consent was obtained from all participants. Results: Patient characteristics included an average age of 39.1 years old (22-63) and 80% were male. Broad themes found were delays in receiving treatment, change in individuals' societal role and delayed recovery associated with pain and immobility. Conclusions: Open tibia fractures in Malawi have a devastating impact on patients and their families. Further studies are required to explore the reasons for the delays in open fracture emergency treatment.
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Affiliation(s)
- Alexander Thomas Schade
- Public Health, Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi
- Clinical Trials Unit, University of Warwick, Coventry, UK
- Trauma and Orthopaedics, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Wakumanya Sibande
- Public Health, Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Moses Kumwenda
- Public Health, Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Nicola Desmond
- Public Health, Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Linda Chokotho
- Trauma and Orthopaedics, Queen Elizabeth Central Hospital, Blantyre, Malawi
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14
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Houwen T, de Munter L, Lansink KWW, de Jongh MAC. There are more things in physical function and pain: a systematic review on physical, mental and social health within the orthopedic fracture population using PROMIS. J Patient Rep Outcomes 2022; 6:34. [PMID: 35384568 PMCID: PMC8986932 DOI: 10.1186/s41687-022-00440-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background The Patient-Reported Outcomes Information System (PROMIS®) is more and more extensively being used in medical literature in patients with an orthopedic fracture. Yet, many articles studied heterogeneous groups with chronic orthopedic disorders in which fracture patients were included as well. At this moment, there is no systematic overview of the exact use of PROMIS measures in the orthopedic fracture population. Therefore this review aimed to provide an overview of the PROMIS health domains physical health, mental health and social health in patients suffering an orthopedic fracture.
Methods This systematic review was documented according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. We searched Embase, Medline, Web of Science Core Collection, and Cochrane Central Register of controlled Trials, CINAHL and Google Scholar in December 2020 using a combination of MeSH terms and specific index terms related to orthopedic fractures and PROMIS questionnaires. Inclusion criteria were available full text articles that were describing the use of any PROMIS questionnaires in both the adult and pediatric extremity fracture population. Results We included 51 relevant articles of which most were observational studies (n = 47, 92.2%). A single fracture population was included in 47 studies of which 9 involved ankle fractures (9/51; 17.6%), followed by humeral fractures (8/51; 15.7%), tibia fractures (6/51; 11.8%) and radial -or ulnar fractures (5/51; 9.8%). PROMIS Physical Function (n = 32, 32/51 = 62.7%) and PROMIS Pain Interference (n = 21, 21/51 = 41.2%) were most frequently used questionnaires. PROMIS measures concerning social (n = 5/51 = 9.8%) and mental health (10/51 = 19.6%) were much less often used as outcome measures in the fracture population. A gradually increasing use of PROMIS questionnaires in the orthopedic fracture population was seen since 2017. Conclusion Many different PROMIS measures on multiple domains are available and used in previous articles with orthopedic fracture patients. With physical function and pain interference as most popular PROMIS measures, it is important to emphasize that other health-domains such as mental and social health can also be essential to fracture patients. Supplementary Information The online version contains supplementary material available at 10.1186/s41687-022-00440-3.
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Affiliation(s)
- Thymen Houwen
- Network Emergency Care Brabant, ETZ Hospital (Elisabeth-TweeSteden Ziekenhuis), Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands. .,Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Leonie de Munter
- Department of Traumatology, ETZ Hospital (Elisabeth-TweeSteden Ziekenhuis), Hilvarenbeekseweg 60, 5022 GC, Tilburg, the Netherlands
| | - Koen W W Lansink
- Department of Surgery, ETZ Hospital (Elisabeth-TweeSteden Ziekenhuis), Hilvarenbeekseweg 60, 5022 GC, Tilburg, the Netherlands
| | - Mariska A C de Jongh
- Network Emergency Care Brabant, ETZ Hospital (Elisabeth-TweeSteden Ziekenhuis), Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
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15
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BELANGERO WILLIAMDIAS, FOGAGNOLO FABRICIO, KOJIMA KODIEDSON, MIGUEL GUILHERMECHOHFIDE, BIDOLEGUI FERNANDO, BERTUNE ALEJANDRODANIEL, LOMBARDO ERNESTO, DIAS ADÉLIODELIMA, TORRES JOÃOBATISTAMANZOLI, COUTINHO BRUNOPARILHA, SILVA JORGEDOSSANTOS, LEONHARDT MARCOSDECAMARGO, PEREIRA PABLOSEBASTIÁN, MARIOLANI JOSÉRICARDOLENZI, GIORDANO VINCENZO. Fraturas expostas isoladas da diáfise da tíbia: estudo prospectivo observacional em sete hospitais de dois países da América Latina. Rev Col Bras Cir 2022. [DOI: 10.1590/0100-6991e-20223301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
RESUMO Introdução: o tratamento de fraturas expostas isoladas da diáfise da tíbia (FEIDT) apresenta desafios por frequentemente associar severa lesão óssea com condições ruins de tecido mole, fatores relevantes em países de média e baixa renda, especialmente devido a atrasos na implementação da fixação definitiva e falta de treinamento adequado no manejo de tecidos moles. Consequentemente, FEIDTs representam importante fonte de incapacitação na América Latina. Este estudo objetivou apresentar uma visão geral das FEIDTs em sete hospitais do cone sul da América Latina. O objetivo secundário foi avaliar o seu impacto na qualidade de vida baseado na taxa de retorno ao trabalho (TRT). Métodos: foram incluídos no estudo pacientes com FEIDT tratados em sete hospitais de Brasil e Argentina entre novembro de 2017 e março de 2020. Resultados clínicos e radiográficos foram analisados num período de 120 dias. Avaliação final comparou TRT com o questionário SF-12, consolidação óssea e condições de marcha. Resultados: setenta e dois pacientes foram tratados, 57 seguidos por 120 dias e 48 completaram o questionário SF-12. Após 120 dias, 70,6% havia retornado ao trabalho, 61,4% tinha fratura consolidada. Idade, antibioticoterapia, tipo de tratamento definitivo e infecção influenciaram significativamente na TRT. A condição de marcha apresentou forte correlação com TRT e o componente físico do SF-12. Conclusão: FEIDTs são potencialmente deletérias à qualidade de vida dos pacientes 120 dias após o tratamento inicial. TRT é significativamente maior para pacientes mais jovens, sem história de infecção e que conseguem correr na avaliação da condição de marcha..
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Lee A, Geoghegan L, Nolan G, Cooper K, Super J, Pearse M, Naique S, Hettiaratchy S, Jain A. Open tibia/fibula in the elderly: A retrospective cohort study. JPRAS Open 2021; 31:1-9. [PMID: 34805472 PMCID: PMC8585579 DOI: 10.1016/j.jpra.2021.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/07/2021] [Indexed: 12/17/2022] Open
Abstract
The incidence of open tibia/fibula fractures in the elderly is increasing, but current national guidelines focus on the aggressive treatment of high-energy injuries in younger patients. There is conflicting evidence regarding whether older age affects treatment provision and outcomes in open fractures. The aim of this study was to determine if elderly patients are sustaining a different injury to younger patients and how their treatment and outcomes differ. This may have implications for future guidelines and verify their application in the elderly. In this retrospective single centre cohort study (December 2015-July 2018), we compared the injury characteristics, operative management and outcomes of elderly (≥65 years) and younger (18-65 years) patients with open tibia/fibula fractures. An extended cohort examined free flap reconstruction. In total, 157 patients were included. High-energy injuries were commoner in younger patients (88% vs 37%; p<0.001). Most were Gustilo-Anderson IIIb in both age groups. Elderly patients waited longer until debridement (21:19 vs 19:00 h) and had longer inpatient stays (23 vs 15 days). There was no difference in time to antibiotics, operative approach or post-operative complications. Despite the low-energy nature of elderly patients' injuries, the severity of soft tissue insult was equivalent to younger patients with high-energy injuries. Our data suggest that age and co-morbidities should not prohibit lower limb reconstruction. The current application of generic guidelines appears suitable in the elderly, particularly in the acute management. We suggest current management pathways and targets be reviewed to reflect the greater need for peri-operative optimisation and rehabilitation in elderly patients.
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Affiliation(s)
- Alice Lee
- Department of Plastic and Reconstructive Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Luke Geoghegan
- Department of Plastic and Reconstructive Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Grant Nolan
- Department of Plastic and Reconstructive Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Kerri Cooper
- Department of Plastic and Reconstructive Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Jonathan Super
- Department of Plastic and Reconstructive Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Michael Pearse
- Department of Orthopaedic Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Satyajit Naique
- Department of Orthopaedic Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Shehan Hettiaratchy
- Department of Plastic and Reconstructive Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Abhilash Jain
- Department of Plastic and Reconstructive Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
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17
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Schade AT, Nyamulani N, Banza LN, Metcalfe AJ, Leather A, Madan JJ, Lallloo DG, Harrison WJ, MacPherson P. Protocol for a prospective cohort study of open tibia fractures in Malawi with a nested implementation of open fracture guidelines. Wellcome Open Res 2021; 6:228. [PMID: 35505977 PMCID: PMC9034175 DOI: 10.12688/wellcomeopenres.17145.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Road traffic injury (RTI) is the largest cause of death amongst 15–39-year-old people worldwide, and the burden of injuries such as open tibia fractures are rapidly increasing in Malawi. This study aims to investigate disability and economic outcomes of people with open tibia fractures in Malawi and improve these with locally delivered implementation of open fracture guidelines. Methods: This is a prospective cohort study describing function, quality of life and economic burden of open tibia fractures in Malawi. In total, 160 participants will be recruited across six centres and will be followed-up with face-to-face interviews at six weeks, three months, six months and one year following injury. The primary outcome will be function at one year measured by the short musculoskeletal functional assessment (SMFA) score. Secondary outcomes will include quality of life measured by EuroQol EQ-5D-3L, catastrophic loss of income and implementation outcomes (acceptability, adoption, appropriateness, costs, feasibility, fidelity, penetration, and sustainability) at one year. A nested pilot pre-post implementation study of an interventional bundle for all open fractures will be developed based on other implementation studies from low- and middle-income countries (LMICs). Regression analysis will be used to model and investigate associations between SMFA score and fracture severity, infection and the pre- and post-training course period. Outcome: This prospective cohort study will report patient reported outcomes from open tibia fractures in low-resource settings. Subsequent detailed evaluation of both the clinical and implementation components of the study will promote sustainability of improved open fractures management in the study sites and further scale-up of open fracture management guidelines. Ethics: Ethics approval has been obtained from the Liverpool School of Tropical Medicine and College of Medicine Research and Ethics committee.
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Affiliation(s)
- Alexander Thomas Schade
- Public Health, Malawi-Liverpool Wellcome Trust, Blantyre, P.O.Box 30096, Malawi
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Nohakhelha Nyamulani
- Trauma and Orthopaedics surgery, Queen Elizabeth Central Hospital, Blantyre, BOX 95, Malawi
| | - Leonard Ngoe Banza
- Trauma and Orthopaedic surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | | | - Andrew Leather
- King’s College Centre for Global Health and Health Partnerships, King's College Hospital, London, London, WC2R 2LS, UK
| | - Jason J. Madan
- Warwick medical school, University of Warwick, Coventry, W Midlands, UK
| | | | | | - Peter MacPherson
- Public Health, Malawi-Liverpool Wellcome Trust, Blantyre, P.O.Box 30096, Malawi
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
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Nicolaides M, Pafitanis G, Vris A. Open tibial fractures: An overview. J Clin Orthop Trauma 2021; 20:101483. [PMID: 34262849 PMCID: PMC8254044 DOI: 10.1016/j.jcot.2021.101483] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/06/2021] [Accepted: 06/19/2021] [Indexed: 12/31/2022] Open
Abstract
Open tibial fractures are complex injuries with multifactorial outcomes and variable prognosis. The close proximity of the tibia to the skin makes it prone to extensive soft tissue damage and subsequent detrimental complications, such as infection and non-union. Thus, they were historically associated with high rates of amputation, sepsis, or even death. The advancement of surgical instruments and techniques, along the emergence of evidence-based guidance, have resulted in a significant reduction in complications. Peculiarly though, modern management strategies have a strong foundation in practices described in the ancient times. Nevertheless, post-operative complications are still a challenge in the management of open tibial fractures. Efforts are actively being made to refine the surgical approaches used, while noteworthy is the emergence of the Orthoplastic approach. The aim of this review is to summarise and discuss the historical perspective of the management of open tibial fractures, their epidemiology and classification, up-to-date principles of surgical management and outcomes following injury.
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Affiliation(s)
- Marios Nicolaides
- Division of Orthopaedics, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Group for Academic Plastic Surgery, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Georgios Pafitanis
- Group for Academic Plastic Surgery, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Plastic and Reconstructive Surgery, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Alexandros Vris
- Division of Orthopaedics, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Trauma and Orthopaedic Surgery, The Royal London Hospital, Barts Health NHS Trust, London, UK
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The Effect of Delayed Surgical Debridement in the Management of Open Tibial Fractures: A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2021; 11:diagnostics11061017. [PMID: 34199379 PMCID: PMC8228778 DOI: 10.3390/diagnostics11061017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 05/24/2021] [Accepted: 05/29/2021] [Indexed: 02/06/2023] Open
Abstract
Introduction: Open tibial fractures are complex injuries with variable outcomes that significantly impact patients’ lives. Surgical debridement is paramount in preventing detrimental complications such as infection and non-union; however, the exact timing of debridement remains a topic of great controversy. The aim of this study is to evaluate the association between timing of surgical debridement and outcomes such as infection and non-union in open tibial fractures. Materials and Methods: We performed a systematic review and meta-analysis of the literature to capture studies evaluating the association between timing of initial surgical debridement and infection or non-union, or other reported outcomes. We searched the MEDLINE, PubMed Central, EMBASE, SCOPUS, Cochrane Central and Web of Science electronic databases. Our methodology was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane handbook for systematic reviews of interventions. Results: The systematic review included 20 studies with 10,032 open tibial fractures. The overall infection rate was 14.3% (314 out of 2193) and the overall non-union rate 14.2% (116 out of 817). We did not find any statistically significant association between delayed debridement and infection rate (OR = 0.87; 95% CI, 0.68 to 1.11; p = 0.23) or non-union rate (OR = 0.70; 95% CI, 0.42 to 1.15; p = 0.13). These findings did not change when we accounted for the effect of different time thresholds used for defining early and late debridement, nor with the Gustilo–Anderson classification or varying study characteristics. Conclusion: The findings of this meta-analysis support that delayed surgical debridement does not increase the infection or non-union rates in open tibial fracture injuries. Consequently, we propose that a reasonable delay in the initial debridement is acceptable to ensure that optimal management conditions are in place, such that the availability of surgical expertise, skilled staff and equipment are prioritised over getting to surgery rapidly. We recommend changing the standard guidance around timing for performing surgical debridement to ‘as soon as reasonably possible, once appropriate personnel and equipment are available; ideally within 24-h’.
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Kouassi KJE, Manon J, Fonkoue L, Detrembleur C, Cornu O. Treatment of open tibia fractures in Sub-Saharan African countries : a systematic review. Acta Orthop Belg 2021. [DOI: 10.52628/87.1.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Open tibia fracture (OTF) treatment is well documented in developed countries. Yet, this fracture pattern remains challenging because it is associated with an increased risk of infection and delayed union, particularly in case of Gustilo III B and C open fractures. Since access to healthcare is limited in Sub- Saharan African countries, this paper explores the results of OTF management in this setting.
A systematic review of the literature was conducted using current databases such as MEDLINE, Cochrane, EMBASE, PubMed, ScienceDirect, Scopus, and Google Scholar in order to identify prospective studies with cohorts of patients treated for OTF. Studies were included based on predefined inclusion and exclusion criteria. The quality of studies was analyzed by the Coleman Methodology Score (CMS).
Eight papers met the inclusion criteria and had an average CMS of 70 (range 54-73). The most common treatment was non-operative management of the fracture with cast immobilization (67%). Gustilo Type II and III fractures were associated with a higher risk of complications. The infection rate was 30%. Malunion, chronic osteomyelitis and nonunion were observed in 14.5%, 12.3%, and 7% of the cases, respectively. More complications were observed with non-operative treatment (cast immobilization) than with surgical fixation.
Although the surgical environment does not allow for internal fixation, poor results of non-operative management of open fractures should lead to the introduction of trainings on the proper use of external fixators. It is also advisable to support the development of locally produced external devices that utilize local source materials, which would make external fixation available at a reasonable cost.
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The economic burden of open tibia fractures: A systematic review. Injury 2021; 52:1251-1259. [PMID: 33691946 DOI: 10.1016/j.injury.2021.02.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/14/2021] [Accepted: 02/12/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Open tibia fractures are a common injury following road traffic collisions and place a large economic burden on patients and healthcare systems. Summarising their economic burden is key to inform policy and help prioritise treatment. METHODS All studies were identified from a systematic search of Medline, Embase and the Cochrane Central Register of Controlled Trials. We included any human with a diagnosed open tibia fracture, following any intervention. The primary outcome was any costs reported or patient return to work status. Secondary outcomes included average length of stay, wage loss, absenteeism and complications such as infection, amputation and nonunion. Data was extracted and we performed a descriptive narrative summary. RESULTS We reviewed 1,204 studies from our searches. A total of 34 studies were included from 14 different countries. The average age was 37.7 years old and 76% of the patients were male. 6.5% were Gustilo I, 12% Gustilo II and 82% Gustilo III. Initial direct hospitalisation costs were reported to be between £356 to £126,479 with an average length of stay of 56 days (3.1-244). 89% of participants were working pre-injury, 60% fully returned to work, 17% returned to work part time or changed profession and 22% did not return to work at one-year. The most common complications reported were 22% infection, 11% nonunion and 16% amputation. Mean follow-up duration for the studies was 25 months. CONCLUSION The economic burden of open tibia fractures varies greatly, but it is costly for both hospitals and patients. The current evidence is predominantly from high-income countries (HICs), especially the USA. Further research is required to investigate the costs of open tibia fractures using validated costing tools, especially in low-income countries (LICs), to help inform and direct policy.
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Watters DA, Wilson L. The Comparability and Utility of Perioperative Mortality Rates in Global Health. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-020-00432-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
Open fractures of the lower limb remain a potentially devastating group of injuries that are challenging to manage. The primary aims of treatment are to optimise limb function and avoid serious complications such as infection and non-union, which are costly for both the patient and healthcare system. The management of these fractures has evolved significantly, and this is evident following the creation of national open fracture guidelines and a formal trauma system. These have served to standardise care for these injuries in the United Kingdom. The aim of this review is to update our colleagues on the current standard of lower limb open fracture care in the United Kingdom, and the impact this has had on patient outcomes.
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Affiliation(s)
- Khalid Al-Hourani
- Edinburgh Orthopaedics, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Oliver Pearce
- Department of Orthopaedic Surgery, Southmead Hospital, Bristol, United Kingdom.
| | - Michael Kelly
- Department of Orthopaedic Surgery, Southmead Hospital, Bristol, United Kingdom
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Schade AT, Yesaya M, Bates J, Martin C, Harrison WJ. The Malawi Orthopaedic Association/AO Alliance guidelines and standards for open fracture management in Malawi: a national consensus statement. Malawi Med J 2021; 32:112-118. [PMID: 33488981 PMCID: PMC7812144 DOI: 10.4314/mmj.v32i3.2] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Background Open fractures are common injuries in Malawi that pose a large burden on the healthcare system and result in long-term disability. Aim Establishing a multiprofessional agreement on the management of open fractures in Malawi from a consensus meeting. Methods AO Alliance convened a consensus meeting to build an agreement on the management of open fractures in Malawi. Eighteen members from different professions and various regions of Malawi participated in a 1-day consensus meeting on 7 September 2019. Prior to the meeting the British Orthopaedic Audit Standards for Trauma (BOAST) for open fractures, as well as relevant systematic reviews and seminal literature were circulated. Panel members gave presentations on open fracture management, followed by an open discussion meeting. At the 1-day consensus meeting panel members developed statements for each standard and guideline. Panel members then voted to accept or reject the statements. Results Substantial agreement (no rejections) was reached for all 17 guidelines and the associated terminology was agreed on. These guidelines were then presented to the members of the Malawi Orthopaedic Association (MOA) at their annual general meeting on 28 September 2019 and all participants agreed to adopt them. Conclusions These MOA/AO Alliance guidelines aim to set a standard for open fracture management that can be regularly measured and audited in Malawi to improve care for these patients.
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Affiliation(s)
| | | | - Jeremy Bates
- Queen Elizabeth Central Hospital, Blantyre, Malawi
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