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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Alt V, Rupp M, Kerschbaum M, Prantl L, Geis S. [Treatment strategies for fracture-related infections with concurrent soft tissue damage]. Unfallchirurgie (Heidelb) 2024; 127:103-109. [PMID: 38167783 DOI: 10.1007/s00113-023-01403-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/07/2023] [Indexed: 01/05/2024]
Abstract
Fracture-related infections are the predominant complication following surgical fracture treatment. The distal lower leg, e.g., in pilon tibial fractures, is at a high risk of infection due to poor soft tissue coverage, particularly in cases of open fractures in this area. Fracture-related infections with significant soft tissue damage require special attention alongside treatment of the infection itself. In general, the principle is that healing of fracture-related infection is not possible without sufficient soft tissue coverage. Therefore, it is crucial to integrate both soft tissue damage and fracture-related infection into a comprehensive treatment plan from the beginning. An interdiscpilinary treatment approach between trauma and plastic surgery is often necessary and beneficial. In cases, where fracture fixation devices or bone is exposed, mid- or long-term use of vacuum-assisted wound therapy is not advisable due to a higher risk of reinfection. Hence, an interdisciplinary treatment strategy involving trauma and plastic surgery should prioritize early soft tissue closure, referred to as the "orthoplastic approach". If this cannot be done in the own hospital, early patient transfer is indicated to ensure optimal interdisciplinary therapy with early soft tissue closure and simultaneous trauma surgical treatment to control the infection and enable bone healing. Free fasciocutaneous or muscle flap techniques in combination with adequate trauma surgical and antibiotic therapy lead to good reliable results in these situations.
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Affiliation(s)
- Volker Alt
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg (UKR), Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
| | - Markus Rupp
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg (UKR), Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Maximilian Kerschbaum
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg (UKR), Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Lukas Prantl
- Abteilung für Plastische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg (UKR), Regensburg, Deutschland
| | - Sebastian Geis
- Abteilung für Plastische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg (UKR), Regensburg, Deutschland
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Aljawadi A, Islam A, Jahangir N, Niazi N, Elmajee M, Reid A, Wong J, Pillai A. One-stage combined "fix and flap" approach for complex open Gustilo-Anderson IIIB lower limbs fractures: a prospective review of 102 cases. Arch Orthop Trauma Surg 2022; 142:425-434. [PMID: 33389021 DOI: 10.1007/s00402-020-03705-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 12/05/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Management of open fractures is challenging and requires a multidisciplinary team approach. This study aims to evaluate outcomes of open Gustilo-Anderson IIIB fractures managed at a single Ortho-Plastic centre following One-stage "Fix and Flap" approach. METHODS Prospective data review for patients presenting with Gustilo-Anderson IIIB Fractures to our centre and managed with one-stage "Fix and Flap" approach. Postoperative outcomes are presented only for the patients who had a minimum of 12 months postoperative follow-up. RESULTS 120 patients were included (83 males and 37 females). Mean age was 43 years (10-96). Tibia diaphysis was the most common site of injury (60%). 55.9% of injuries were road traffic accidents (RTA). 102 out of 120 patients had a minimum of 12 months follow-up (mean follow-up duration 25 months). Meantime from injury until definitive surgery was 7.71 days. Primary union achieved in 86.73%. Delayed union was encountered in 10.20%. 3.06% of patients had non-union. Limb salvage rate was 97.05% and Deep infection rate was only 0.98%. CONCLUSION Our results showed that low infection rate, high limb salvage rate, and high union rate can be achieved in these complex injuries with meticulous technique, combined Ortho-Plastic (Fix and Flap) approach, and MDT input.
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Affiliation(s)
- Ahmed Aljawadi
- Trauma and Orthopaedics, Manchester University NHS Foundation Trust, Southmoor Rd, Wythenshawe, Manchester, M23 9LT, UK.
| | - Amirul Islam
- Trauma and Orthopaedics, Manchester University NHS Foundation Trust, Southmoor Rd, Wythenshawe, Manchester, M23 9LT, UK
| | - Noman Jahangir
- Trauma and Orthopaedics, Manchester University NHS Foundation Trust, Southmoor Rd, Wythenshawe, Manchester, M23 9LT, UK
| | - Noman Niazi
- Trauma and Orthopaedics, Manchester University NHS Foundation Trust, Southmoor Rd, Wythenshawe, Manchester, M23 9LT, UK
| | - Mohammed Elmajee
- ST5 Spine Department, Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, B31 2AP, UK
| | - Adam Reid
- Consultant Plastic Surgery, Manchester University NHS Foundation Trust, Southmoor Rd, Wythenshawe, Manchester, M23 9LT, UK
| | - Jason Wong
- Consultant Plastic Surgery, Manchester University NHS Foundation Trust, Southmoor Rd, Wythenshawe, Manchester, M23 9LT, UK
| | - Anand Pillai
- Consultant Trauma and Orthopaedics, Manchester University NHS Foundation Trust, Southmoor Rd, Wythenshawe, Manchester, M23 9LT, UK
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