A retrospective analysis of the definitive management of open talus fractures at a major trauma centre, comparing ORIF to FUSION: cohort study and audit of BOAST 4 guidelines

Purpose Open talus fractures are notoriously difficult to manage, and they are commonly associated with a high level of complications including non-union, avascular necrosis and infection. Currently, the management of such injuries is based upon BOAST 4 guidelines although there is no suggested definitive management, and thus, definitive management is based upon surgeon preference. The key principles of open talus fracture management which do not vary between surgeons are early debridement, orthoplastic wound care, anatomic reduction and definitive fixation whenever possible. However, there is much debate over whether the talus should be preserved or removed after open talus fracture/dislocation and proceeded to tibiocalcaneal fusion. Methods A review of electronic hospital records for open talus fractures from 2014 to 2021 returned fourteen patients with fifteen open talus fractures. Seven cases were initially managed with ORIF, and five cases were definitively managed with FUSION, while the others were managed with alternative methods. We collected patient’s age, gender, surgical complications, surgical risk factors and post-treatment functional ability and pain and compliance with BOAST guidelines. The average follow-up of the cohort was 4 years and one month. EQ-5D-5L and FAAM-ADL/Sports score was used as a patient reported outcome measure. Data were analysed using the software PRISM. Results Comparison between FUSION and ORIF groups showed no statistically significant difference in EQ-5D-5L score (P = 0.13), FAAM-ADL (P = 0.20), FAAM-Sport (P = 0.34), infection rate (P = 0.55), surgical times (P = 0.91) and time to weight bearing (P = 0.39), despite a higher proportion of polytrauma and Hawkins III and IV fractures in the FUSION group. Conclusion FUSION is typically used as second line to ORIF or failed ORIF. However, there is a lack of studies that directly compared outcome in open talus fracture patients definitively managed with FUSION or ORIF. Our results demonstrate for the first time that FUSION may not be inferior to ORIF in terms of patient functional outcome, infection rate and quality of life, in the management of patients with open talus fracture patients. Of note, as open talus fractures have increased risks of complications such as osteonecrosis and non-union, FUSION should be considered as a viable option to mitigate these potential complications in these patients.

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.

Management of Frontal Bone Fracture in a Tertiary Neurosurgical Care Center—A Retrospective Study

Aim We present our experience in the management of frontal bone fractures using the previously described radiologic classification of frontal bone fractures. Methodology A retrospective study was conducted, which reviewed the medical records and computed tomographic (CT) scan images of patients with frontal bone fracture from January 2016 to February 2019. Patients with complete medical records and a follow-up of minimum 1 year were included in the study. Demographic details, mechanism of injury, associated intracranial injuries, maxillofacial fractures, management, and complications were analyzed. CT scan images were used to classify the frontal bone fractures using the novel classification given by Garg et al (2014). The indications for surgical treatment were inner table frontal sinus fracture with cerebrospinal fluid (CSF) leak, intracranial hematoma with significant mass effect requiring surgical evacuation, and outer table comminuted fracture that is either causing nasofrontal duct obstruction or for cosmetic purpose. Results A total of 55 patients were included in the study. Road traffic accidents as the commonest cause of frontal bone fractures. The most common fracture pattern was type 1 followed by type 5 and depth B followed by depth A. Four patients presented with CSF rhinorrhea. CSF rhinorrhea was more frequent with fracture extension to the skull base (depth B, C, D), which was statistically significant (p < 0.001). Conclusion Frontal bone fracture management has to be tailor-made for each patient based on the extent of the fracture, presence of CSF leak, and associated intracranial and maxillofacial injuries.

Associated Injuries Related to Patients With Facial Fractures

Purpose To find out the incidence, type, and severity of injuries in other parts of the body in patients diagnosed with facial fractures. The study also analyzed any correlation between these injuries and facial fractures. Material & Methods A retrospective study of 991 patients with facial fractures during the period of 2006-2016. Results 111 patients reported associated injuries (11.1%). The most common type of injury was limb injury (33.33%), followed by head injury (22.5%), clavicle fracture (14.7%), rib fracture (10.9%), cervical spine injury (5.4%), and other injuries constituted (13.2%). Multiple associated injuries were observed in 14% of patients. Conclusion The findings show that facial fracture management is a multidisciplinary approach. Prompt diagnosis and proper management are important to reduce the mortality rate and improve the prognosis of the patient.

The impact of stem fixation method on Vancouver Type B1 periprosthetic femoral fracture management

Introduction: Our understanding of the impact of the stem fixation method in total hip arthroplasty (THA) on the subsequent management of periprosthetic femoral fractures (PFF) is still limited. This study aimed to investigate and quantify the effect of the stem fixation method, i.e., cemented vs. uncemented THA, on the management of Vancouver Type B1 periprosthetic femoral fractures with the same plate. Methods: Eight laboratory models of synthetic femora were divided into two groups and implanted with either a cemented or uncemented hip prosthesis. The overall stiffness and strain distribution were measured under an anatomical one-legged stance. All eight specimens underwent an osteotomy to simulate Vancouver type B1 PFF’s. Fractures were then fixed using the same extramedullary plate and screws. The same measurements and fracture movement were taken under the same loading conditions. Results: Highlighted that the uncemented THA and PFF fixation constructs had a lower overall stiffness. Subsequently, the mechanical strain on the fracture plate for the uncemented construct was higher compared to the cemented constructs. Conclusion: PFF fixation of a Vancouver type B1 fracture using a plate may have a higher risk of failure in uncemented THAs.

Hip Fracture Management in an Orthogeriatric Clinical Care Center during the Covid-19 Pandemic in Bogotá, Colombia1

This paper aims to compare treatment results on patients 65 years or older with hip fracture during the COVID-19 pandemic with previous treatment results in an Orthogeriatric Clinical Care Center.

Pelvic Binders in Trauma Patients - Are We Doing it Right?

Introduction: Pelvic fractures from high-energy trauma require immediate stabilisation to avoid significant morbidity and mortality. When applied correctly over the level of the greater trochanters (GT) pelvic binders provide adequate stabilisation of unstable pelvic fractures. The aim of this study was to identify the accuracy of placement of pelvic binders in patients presenting to the local Major Trauma Centre (MTC). Methods: A retrospective study was carried out to assess the level of the pelvic binders in relation to the greater trochanters of the patient-classified as optimal or sub-optimal. Results: An initial review of the computed tomography (CT) trauma series in 28 consecutive patients with pelvic binders revealed that more than 50% of the pelvic binders were placed above the level of the GT, reducing the efficacy of the pelvic binders. A regional educational and training day was held with a focus on pelvic fracture management. Following this, a review was conducted on the placement of the pelvic binder in 100 consecutive patients. This confirmed a significant improvement in the position of the pelvic binder by over 70%. Conclusion: Inaccurately positioned pelvic binders provided suboptimal stabilisation of pelvic fractures. With education and awareness, there has been an improvement in the accuracy of pelvic binder placement in trauma patients. This study has highlighted the need for regular audit of current practice, in combination with regular education and training.

Advanced Physiotherapy of Supracondylar Femur Fracture with Implant In situ: A Case Report

Patient main concerns were restriction of movements of right knee and pus discharge from wound over right knee. In this case, the main clinical findings were a substantial loss in range of motion at right knee joints. There was also fixed flexion deformity seen over right knee. Diagnosis of the case was non united operated infected case of supracondylar femur fracture right side with implant in situ. In these types of circumstances, therapeutic approaches have been demonstrated to be useful. A 35-year-old male visited the orthopaedics who referred department of physiotherapy with complaints of restriction of movement of right knee and pus discharge from wound over right knee. Patient was examine in standing and supine position .On inspection, patient keeps right hip in flexion, knee in flexion patella pointing upwards and foot in equinus. According to the research, starting weight-bearing too soon can lead to failure of implant and mal-union. Supracondylar femoral fracture is a challenging condition to deal with and is associated with many secondary complications. An important role is played by physiotherapist in rehabilitation and supracondylar femur fracture management.

How relevant is lumbar bone mineral density for the stability of symphyseal implants? A biomechanical cadaver study

Purpose Osteoporotic bone tissue appears to be an important risk factor for implant loosening, compromising the stability of surgical implants. However, it is unclear whether lumbar measured bone mineral density (BMD) is of any predictive value for stability of surgical implants at the pubic symphysis. This study examines the fixation strength of cortical screws in human cadaver specimens with different BMDs. Methods The lumbar BMD of ten human specimens was measured using quantitative computed tomography (qCT). A cut-off BMD was set at 120 mg Ca-Ha/mL, dividing the specimens into two groups. One cortical screw was drilled into each superior pubic ramus. The screw was withdrawn in an axial direction with a steady speed and considered failed when a force decrease was detected. Required force (N) and pull-out distance (mm) were constantly tracked. Results The median peak force of group 1 was 231.88 N and 228.08 N in group 2. While BMD values differed significantly (p < 0.01), a comparison of peak forces between both groups showed no significant difference (p = 0.481). Conclusion Higher lumbar BMD did not result in significantly higher pull-out forces at the symphysis. The high proportion of cortical bone near the symphyseal joint allows an increased contact of pubic screws and could explain sufficient fixation. This condition is not reflected by a compromised lumbar BMD in a qCT scan. Therefore, site-specific BMD measurement could improve individual fracture management.