Norwegian Open Fracture Management System: Outcomes After 10 Years Working in Low-Resource Settings in Cambodian Hospitals

Introduction: The treatment of open lower limb fractures represents a major challenge for any trauma surgeon, and this even more so in resource-limited areas. The aim of the study is to describe the intervention, report the treatment plan, and observe the effectiveness of the Norwegian Open Fracture Management System in saving lower limbs in rural settings. Materials and Methods: A retrospective and prospective interventional study was carried out in the period 2011 through 2017 in six rural hospitals in Cambodia. The fractures were managed with locally produced external fixators and orthosis developed in 2007. Based on skills and living locations, two local surgeons and one paramedic without reconstructive surgery experience were selected to reach the top of the reconstructive ladder and perform limb salvage surgeries. This study evaluated 56 fractures using the Ganga Hospital Open Injury Score (GHOIS) for Gustilo-Anderson Type IIIA and Type IIIB open fracture classification groups. Results: The primary success rate in open tibia fractures was 64.3% (95% CI, 50.3 - 76.3). The average treatment time to complete healing for all of the patients was 39.6 weeks (95% CI, 34.8 - 44.4). A percentage of 23.2% (95% CI, 13.4 - 36.7) experienced a deep infection. Fifteen of the patients had to undergo soft tissue reconstruction and 22 flaps were performed. Due to non-union, a total of 15 bone grafts were performed. All of the 56 patients in the study gained limb salvage and went back to work. Conclusion: The given fracture management program proves that low-resource countries are able to produce essential surgical tools at high quality and low price. Treatment with external fixation and functional bracing, combined with high-level training of local surgeons, demonstrates that a skilled surgical team can perform advanced limb salvage surgery in low-resource settings.

Pediatric Clavicle Fractures and Congenital Pseudarthrosis Unraveled

Clavicle fractures are commonly seen in the pediatric and adolescent populations. In contrast, congenital pseudarthrosis of the clavicle is rare. Although both conditions may present with similar signs and symptoms, especially in the very young, clear differences exist. Clavicle fractures are often caused by trauma and are tender on palpation, while pseudarthrosis often presents with a painless protuberance on the clavicle, which becomes more prominent as the child grows. Its presence may only become apparent after trauma, as it is usually asymptomatic. The diagnosis is confirmed on plain radiography, which shows typical features to distinguish both entities. Both clavicle fractures and congenital pseudarthrosis are generally treated conservatively with a high success rate. Operative treatment for a fracture can be indicated in the case of an open fracture, severely displaced fracture, floating shoulder, neurovascular complications or polytrauma. Congenital pseudarthrosis requires operative treatment if the patient experiences progressive pain, functional limitation and late-onset thoracic outlet symptoms, but most operations are performed due to esthetic complaints.

Analysis of Risk Factors for Non-union After Surgery for Limb Fractures: A Case-Control Study of 669 Subjects

Objective: The purpose of this study was to analyze the risk factors for limb fracture non-union in order to improve non-union prevention and early detection.Methods: A total of 223 patients with non-union after surgery for limb fractures performed at our institution from January 2005 to June 2017 were included as the case group, while a computer-generated random list was created to select 446 patients with successful bone healing after surgery for limb fractures who were treated during the same period as the control group, thus achieving a ratio of 1:2. The medical records of these patients were reviewed retrospectively. Age, sex, body mass index, obesity, smoking, alcohol, diabetes, hypertension, osteoporosis, fracture type, multiple fractures, non-steroidal anti-inflammatory drugs (NSAIDs) use, delayed weight bearing, internal fixation failure, and infection data were analyzed and compared between the two groups. A multivariate logistic regression model was constructed to determine relevant factors associated with non-union.Results: After comparison between two groups by univariate analysis and multivariate logistic regression, we found some risk factors associated that osteoporosis (odds ratio [OR] = 3.16, 95% confidence interval [CI]: 2.05–4.89, p < 0.001), open fracture (OR = 2.71, 95%CI: 1.72–4.27, p < 0.001), NSAIDs use (OR = 2.04, 95%CI: 1.24–3.37, p = 0.005), delayed weight bearing (OR = 1.72, 95%CI: 1.08–2.74, p = 0.023), failed internal fixation (OR = 5.93, 95%CI: 2.85–12.36, p < 0.001), and infection (OR = 6.77, 95%CI: 2.92–15.69, p < 0.001) were independent risk factors for non-union after surgery for limb fractures.Conclusions: Osteoporosis, open fracture type, NSAIDs use, delayed weight bearing, failed internal fixation, and infection were found to be the main causes of bone non-union; clinicians should, therefore, take targeted measures to intervene in high-risk groups early.

Wound photography for evaluation of surgical site infection and wound healing after lower limb trauma

Aims Deep surgical site infection (SSI) is common after lower limb fracture. We compared the diagnosis of deep SSI using alternative methods of data collection and examined the agreement of clinical photography and in-person clinical assessment by the Centers for Disease Control and Prevention (CDC) criteria after lower limb fracture surgery. Methods Data from two large, UK-based multicentre randomized controlled major trauma trials investigating SSI and wound healing after surgical repair of open lower limb fractures that could not be primarily closed (UK WOLLF), and surgical incisions for fractures that were primarily closed (UK WHiST), were examined. Trial interventions were standard wound care management and negative pressure wound therapy after initial surgical debridement. Wound outcomes were collected from 30 days to six weeks. We compared the level of agreement between wound photography and clinical assessment of CDC-defined SSI. We are also assessed the level of agreement between blinded independent assessors of the photographs. Results Rates of CDC-defined deep SSI were 7.6% (35/460) after open fracture and 6.3% (95/1519) after closed incisional repair. Photographs were obtained for 77% and 73% of WOLLF and WHiST cohorts respectively (all participants n = 1,478). Agreement between photographic-SSI and CDC-SSI was fair for open fracture wounds (83%; k = 0.27 (95% confidence interval (CI) 0.14 to 0.42)) and for closed incisional wounds (88%; k = 0.29 (95% CI 0.20 to 0.37)) although the rate of photographically detected deep SSIs was twice as high as CDC-SSI (12% vs 6%). Agreement between different assessors for photographic-SSI (WOLLF 88%, k = 0.63 (95% CI 0.52 to 0.72); WHiST 89%; k = 0.61 (95% CI 0.54 to 0.69)); and wound healing was good (WOLLF 90%; k = 0.80 (95% CI 0.73 to 0.86); WHiST 87%; k = 0.57 (95% CI 0.50 to 0.64)). Conclusion Although wound photography was feasible within the research context and inter-rater assessor agreement substantial, digital photographs used in isolation overestimated deep SSI rates, when compared to CDC criteria. Wound photography should not replace clinical assessment in pragmatic trials but may be useful for screening purposes where surgical infection outcomes are paramount. Cite this article: Bone Joint J 2021;103-B(12):1802–1808.

CLINICAL EVALUATION OF EFFECT OF MADHU ON WOUND HEALING

In the Indian context, the formal description of wound care has been widely elaborated in the three great treaties (Brahatrayi) of Ayurveda i.e., Charak Samhita, Sushruta Samhita, Ashtang Sangrah. Madhu has been described by them as Vrana Ropaka. A 42-year-old patient came to us with Ignored 10 days old open fracture of the Base 2nd Metatarsal with an infected wound right foot. After debridement of the wound and application of Madhu was done for 3 weeks, and B/K POP Slab applied. The treatment plan followed may be adopted in the future for cases.

245. Risk Factors Associated with Open Fracture Complications Following Antibiotic Prophylaxis

Background Surgical site infection is concerning after an open fracture. The Eastern Association for the Surgery of Trauma guidelines provide antibiotic selection and duration recommendations based on open fracture type. Risk factors for open fracture complications (e.g. infection, acute kidney injury [AKI], multi-drug resistant organisms [MDRO], or Clostridioides infection [C. difficile]) and overall guideline adherence are unclear at our institution. Methods This was a single center, retrospective study of adult patients with an open fracture who received antibiotic prophylaxis and were admitted for at least 24 hours between March 2011 and October 2020. Patients were excluded if open fracture was due to gun-shot wound, had a history of renal replacement therapy, MDRO, or C. difficile infection, were an outside hospital transfer, received antibiotics for another indication, or had a delayed presentation. The primary outcome was to identify risk factors for infection and secondary outcomes to identify risk factors for AKI, MDRO, C. difficile infection, and to evaluate guideline adherence. Patient demographics including injury details and management, microbiologic cultures, and antibiotic information were collected. Data were analyzed by univariate analysis, as appropriate, and logistic regression. Results A total of 401 patients met study criteria; median age 46 years, 62% male, and 77% white. Fracture classifications were similar: 30% type I, 39% type II, and 30% type III. Infection occurred in 18% of patients, AKI in 18%, MDRO in 3%, and no patients developed C. difficile. Of those with culture-positive infection, 51% grew gram-positive organisms. In bivariate analysis, fracture classification (p=0.023), medical fracture management (p=0.034), and antibiotic choice (p=0.004) were associated with infection. The only independent risk factor associated with AKI was receiving a nephrotoxic medication (p=0.012). Eighty-one percent received guideline adherent antibiotics and of those that received too narrow antibiotics, 36% developed an infection (p=0.004). Conclusion Appropriate fracture classification and antibiotic choice is crucial to reduce infection following open fracture. Reducing concomitant exposure to nephrotoxic agents may reduce the risk of AKI. Disclosures All Authors: No reported disclosures