Open Fractures Research Articles

Long-Term Treatment Outcome of a Patient with Extensive Circular Soft Tissue Defect of the Distal Third of the Lower Extremity: A Case Report

Background. Open fractures of the lower leg bones associated with extensive soft tissue defects are among the most challenging in trauma surgery.
 Aim of the study is to demonstrate the possibilities of modern reconstructive surgery in the treatment of severe polystructural trauma of the lower limb using a unique clinical example.
 Case description. An 18-year-old patient sustained a polytrauma which included head and extremities injuries as a result of a fall under a moving train. Due to the signs of uncompensated ischemia of the left lower limb at the first stage of treatment the patient underwent emergency left tibial artery thrombectomy, repeated debridement of the left lower leg wound, remounting of the external fixator, and lumbar sympathectomy. The second stage of surgical treatment included free transplantation of a vascularized anterolateral flap of the right thigh. The third stage included staged necrectomies; replacement of the soft tissue defect of the posteromedial surface of the distal lower leg with a sural fasciocutaneous vascularized flap on the distal vascular pedicle from the contralateral tibia; the fourth stage included cutting off the fasciocutaneous cross flap. At the follow-up, 2 years after the end of the treatment the patient complained of persisting swelling of the foot, which occurred during prolonged standing in the upright position and required elastic compression of the ankle joint. The cause of the swelling was impaired lymphatic outflow due to the damage to all venous collaterals in the injury area. She walks with full load on the injured limb without additional support. There is no pain syndrome, foot sensitivity is fully preserved.
 Conclusion. Presented clinical case demonstrates the possibility of successful replacement of an extensive circular defect of the distal lower leg using sequentially free and non-free vascularized tissue complexes.

Characteristics of Femur Fracture Patients at RSUD Sanjiwani from January - August 2023

Background: The causes of femur fractures are diverse and can be influenced by several factors. These bone fractures often occur due to high-impact trauma, such as car accidents, sports injuries, or other traumatic events that result in excessive stress on the bone. Another contributing factor is bone energy or strength reduction, which is frequently observed in the elderly population. Methods: This study is retrospective descriptive research with cross-sectional data collection. Data were obtained from the medical records of patients diagnosed with femur fractures who received treatment at RSUD Sanjiwani Gianyar in 2023. Results: The majority of patients experienced injuries due to falls (68.2%). Based on age, the study noted that 29.5% of patients were between 18 and 40 years old, 25% were between 40 and 65 years old, and 45.5% were over 65 years old. Most patients were female (72.7%), and the majority of patients had closed fractures (93.2%), while only a small percentage had open fractures (6.8%). Based on this data, the majority of fractures occurred in the proximal one-third of the femur bone (56.8%), followed by the medial one-third (20.5%) and the distal one-third (22.7%). Conclusion: There is a variation in patient age, with the majority being over 65 years old. Furthermore, most patients are female, with the majority experiencing closed fractures, and the most common location for fractures is the proximal one-third of the femur bone. These findings provide a general overview of the characteristics of this study's patient population with femur fractures. Keywords: Femur Fracture, Frailty, Pathological Fracture

Monotherapy Antibiotic Prophylaxis of Lower Extremity Long Bone Type III Open Fractures.

Gustilo type III open fractures involve extensive soft tissue damage and wound contamination that pose significant infection risks. The historical standard for antibiotic prophylaxis has been cefazolin and gentamicin. We conducted a retrospective cohort study of lower extremity type III open fractures treated with ceftriaxone alone for prophylaxis. Eighty-six patients were identified. Nearly all (98%) were managed with appropriate antibiotics, but only 55 (64%) received prophylaxis within 1hour. Overall, there were 12 infections. This infection rate was not statistically different than the reported literature (14% vs 19%, P = .20). The infection rate between those who received antibiotics within 1 hour was not statistically different from those who got it beyond 1hour (15% vs 13%, P = .98). In conclusion, the use of ceftriaxone as monotherapy for antibiotic prophylaxis in lower extremity type III open fractures is not statistically different than the use of historic prophylactic regimens.

Evaluation of the treatment outcome of tibia shaft fracture by close reduction and internal fixation with interlocking intramedullary nail, Freetown, Sierra Leone, 2023

Introduction: The tibia shaft is a common site for bone fractures and open fractures. Tibia shaft fracture is mostly caused by high-energy trauma such as a fall from a height or a road traffic accident. The objective of this study was to evaluate the treatment outcome of tibia shaft fracture managed by close reduction and internal fixation with interlocking Intramedullary Nails (IMN) and to determine factors that are associated with tibia fracture infection. Methods: This retrospective study was conducted at the Emergency Trauma Hospital, Freetown, Sierra Leone. We analyzed the medical records of a mixed cohort of patients who were treated for, tibia shaft fracture by closed reduction and internal fixation with interlocking intramedullary nails for the period January 2020 to January 2022; with at least 15 months of follow-up. We later used both bivariate and multivariate logistic regressions to determine the factors that are associated with wound infection post-internal fixation. Results: A total of Ninety (n = 90) patients’ medical records were reviewed of which 79 were included for analysis. The median age was 30 years (Inter Quartile Range: 16-67 years). The average hospital stay was 20 days (Inter Quartile Range: 6-156 days). The mean fracture nailing time was 11 days. Infection and non-union rates were at 18.99% and 3.8% respectively. Type of tibia shaft fracture (AOR = 25.51, 95% CI = 2.06-422.75,) and characteristics of wound (AOR = 29.51, 95% CI = 2.06-422.75) were significantly associated with wound infection. The treatment outcome categorization of IMN was successful in 88.61% of the patients. Conclusion: This study concludes that the type of tibia shaft fracture and characteristics of the wound are major predictors of wound infection. The findings of this study suggest that IMN fixation of closed and Gustilo type 1 Tibia shaft fracture led to successful healing in the majority of the cases with a low non-union rate.

Is the Ankle Fusion the Single Salvage Procedure and the Best Result for the Massive Distal Tibial Loss: Surgical Techniques and Clinical Results

Background. Management of high-energy injuries with extensive soft tissue damage and massive distal tibial loss is challenging and often lead to severe dysfunction. In these complex situations ankle fusion procedure is the most commonly performed surgery. Publications devoted to treatment options and outcomes in these surgical challenging conditions are relatively rare. Objective The purpose of this work is to present our clinical experience in using staged external fixation protocol in the treatment of six patients who suffered from complex open fractures of the distal tibial segment with severe bone and soft tissue loss due to high-energy trauma. Methods. The retrospective analysis of six patients (Gustilo-Anderson III B and III C fractures) with massive distal tibial loss and treated using a staged protocol of external fixation between 1998 and 2010, was carried out. Mean bone loss was 11.5 cm (range, 9 – 15 cm). Results. All patients had reconstructive surgery using circular external fixation frames. The outcome in three of them was solid ankle fusion – two patients had acute distal shortening and proximal tibial elongation by distraction osteogenesis and one had acute fibular transfer to replace distal tibial loss with fixation using Ilizarov circular frame. In other three patients, the functional and the radiological outcome was pain-free ankle joint pseudoarthrosis – one had proximal tibial elongation, one had a combination of bone transport with distal fibular transfer and one had acute limb shortening without tibial elongation. All six patients were pain-free and satisfied with functional outcomes, regardless of the final solid bone fusion or pseudoarthrosis. Conclusions. The method of circular external fixation combined with proximal tibial elongation by distraction histogenesis is recommended for limb reconstruction in high-energy injuries with massive distal tibial loss including articular surface. Level of Evidence: Diagnostic Level Ⅳ.

The Continued Impact of Godina's Principles: Outcomes of Flap Coverage as a Function of Time After Definitive Fixation of Open Lower Extremity Fractures.

Early soft tissue coverage of open lower extremity fractures within 72 hours of injury leads to improved outcomes. Little is known about outcomes when definitive fixation is completed first. The purpose of this study is to quantify postoperative outcomes when soft tissue reconstruction is delayed until after definitive open reduction and internal fixation (ORIF) is completed. An insurance claims database was queried for all patients with open lower extremity fractures between 2010 and 2020 who underwent free or axial flap reconstruction after ORIF. This cohort was stratified into three groups: reconstruction performed 0 to 3, 3 to 7, and 7+ days after ORIF. The primary outcome was 90-day complication and reoperation rates. Bivariate and multivariable regression of all-cause complications and reoperations was evaluated for time to flap as a risk factor. A total of 863 patients with open lower extremity fractures underwent ORIF prior to flap soft tissue reconstruction. In total, 145 (16.8%), 162 (18.8%), and 556 (64.4%) patients underwent soft tissue reconstruction 0 to 3 days, 4 to 7 days, and 7+ days after ORIF, respectively. The 90-day complication rate of surgical site infections ( SSI; 16.6%, 16,7%, 28.8%; p = 0.001) and acute osteomyelitis (5.5%, 6.2%, 27.7%; p < 0.001) increased with delayed soft tissue reconstruction. Irrigation and debridement rates were directly related to time from ORIF to flap (33.8%, 51.9%, 61.9%; p < 0.001). Hardware removal rates were significantly higher with delayed treatment (10.3%, 9.3%, 39.3%; p < 0.001). The 0 to 3 day (odds ratio [OR] = 0.22; 95% confidence interval [CI]: 0.15, 0.32) and 4 to 7 day (OR = 0.26; 95% CI: 0.17, 0.40) groups showed protective factors against all-cause complications after bivariate and multivariate regression. Early soft tissue reconstruction of open lower extremity fractures performed within 7 days of ORIF reduces complication rates and reduces the variability of complication rates including SSIs, acute osteomyelitis, and hardware failure.

Efficacy of damage control orthopedics strategy in the management of lower limb trauma

BackgroundLittle is known about the efficacy of damage control (DC) surgery in the management of lower limb trauma. Here we compared the clinical parameters and complication rates of such patients received either DC or emergency comprehensive (EC) surgery treatment. MethodsThis study is a retrospective study on patients with lower limb trauma that received surgical treatment. Data of 120 patients were divided into DC and EC surgery groups. Clinical parameters obtained at hospital admission and complications during follow-up were analyzed. Injury Severity Score (ISS), Gustilo classification and Mangled Extremity Severity Score (MESS) were used to assess trauma severity, open fractures and viability of injured limb, respectively. ResultsAge, sex, ISS, fracture type, injury site, MESS, operation time, blood loss, pulmonary and cranial injuries were compared. We found that patients in the DC group had more severe injury as reflected by the higher injury severity score (ISS) (28.1 ± 10.9 vs 21.3 ± 7.4, P < 0.001). ISS was also identified as a significant influencer for the treatment selection (P < 0.001). In addition, patients treated with DC surgery demonstrated less complications (7 cases vs 27 cases), which was supported by the propensity score logistic regression analysis (Odd ratio 4.667). ConclusionsDC surgery is more often selected to treat patients with more severe lower limb injuries, which leads to lower complication rates.

Primary Radial Nerve Lesions in Humerus Shaft Fractures-Revision or Wait and See.

Background: This study investigates the surgical state-of-the-art procedure for humeral shaft fractures with primary radial nerve palsy based on its own case series in relation to the current and established literature. Methods: Retrospective review of treated cases between January 2018 and December 2022 describing radial nerve palsy after humerus shaft fractures, radiological fracture classification, intraoperative findings, surgical procedure, patient follow-up and functional outcome. Results: A total of 804 patients (463 women and 341 men) with humerus shaft fractures were identified. A total of 33 patients showed symptomatic lesions of the radial nerve (4.1%). The primary lesion was identified in 17 patients (2.1%). A broad and inhomogeneous distribution of fractures according to the AO classification was found. According to the operative reports, the distraction of the radial nerve was found eleven times, bony interposed three times and soft tissue constricted/compressed three times. In every case the radial nerve was surgically explored, there was no case of complete traumatic nerve transection. Four intramedullary nails and thirteen locking plates were used for osteosynthesis. Complete recovery of nerve function was seen in 12 cases within 1 to 36 months. Three patients still showed mild hypesthesia in the thumb area after 18 months. Two patients were lost during follow-up. Conclusions: With this study, we support the strategy of early nerve exploration and plate osteosynthesis in humeral fractures with primary radial nerve palsy when there is a clear indication for surgical fracture stabilisation. In addition, early exploration appears sensible in the case of palsies in open fractures and secondary palsy following surgery without nerve exposure as well as in the case of diagnostically recognisable nerve damage. Late nerve exploration is recommended if there are no definite signs of recovery after 6 months. An initial wait-and-see strategy with clinical observation seems reasonable for primary radial nerve palsies without indication for surgical fracture stabilisation.

Igelströmite, Fe3+(Sb3+Pb2+)O4, and manganoschafarzikite, Mn2+Sb3+2O4, two new members of the newly established minium group, from the Långban Mn–Fe deposit, Värmland, Sweden

Abstract. The two new minerals igelströmite, Fe3+(Sb3+Pb2+)O4, and manganoschafarzikite, Mn2+Sb23+O4, are found in the Långban Fe–Mn deposit, in open fractures in a fine-grained hematite ore, with minor amounts of aegirine, a serpentine-group mineral, fluorcalcioroméite, baryte, nadorite, mimetite and other late-stage minerals. Igelströmite is named after the Swedish geologist–mineralogist Lars Johan Igelström (1822–1897). Mohs hardness = 3–4 and Dcalc= 6.33(1) and 5.37(2) g cm−3 for igelströmite and manganoschafarzikite, respectively. Cleavage is distinct on {110}. Both minerals are brittle, with an uneven to conchoidal fracture. The chemical formulae obtained from microprobe data are (Fe0.593+Mn0.292+As0.063+Fe0.062+)Σ=1.00(Sb1.243+Pb0.652+As0.113+)Σ=2.00O4 and (Mn0.642+Fe0.252+Mg0.08)Σ=0.97(Sb1.973+As0.033+Pb0.012+)Σ=2.01O4. The crystal structures for igelströmite and manganoschafarzikite have been refined in space group P42/mbc from single-crystal X-ray diffraction data to R1 = 3.73 % and 1.51 %, respectively, giving the following sets of unit-cell parameters: a= 8.4856(2), 8.65159(8) Å; c= 6.0450(3), 5.97175(9); and V= 435.27(3), 446.986(11) Å3 for Z = 4. Both minerals are isostructural with minium, Pb4+Pb22+O4, where Pb4+O6 forms distorted octahedra, which connect via trans-edges to form rutile-like ribbons along c. The Pb2+ atoms appear in trigonal, flattened PbO3 pyramids, which are linked via corners to form zigzag (PbO2)n chains. The minium group, of general formula MX2O4(X= As3+, Sb3+, Pb2+), presently consists of the minerals minium, trippkeite, schafarzikite, igelströmite and manganoschafarzikite. For future new members, it is recommended to consider the X cation content for the root name and add prefixes to indicate the dominant metal at the M position.

Consensus on managing open ankle fractures in the frail patient.

Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest. A modified Delphi method was used and a group of experts with a vested interest in best practice were invited from the British Foot and Ankle Society (BOFAS), British Orthopaedic Association (BOA), Orthopaedic Trauma Society (OTS), British Association of Plastic & Reconstructive Surgeons (BAPRAS), British Geriatric Society (BGS), and the British Limb Reconstruction Society (BLRS). In the first stage, there were 36 respondents to the survey, with over 70% stating their unit treats more than 20 such cases per year. There was a 50:50 split regarding if the timing of surgery should be within 36 hours, as per the hip fracture guidelines, or 72 hours, as per the open fracture guidelines. Overall, 75% would attempt primary wound closure and 25% would utilize a local flap. There was no orthopaedic agreement on fixation, and 75% would permit weightbearing immediately. In the second stage, performed at the BLRS meeting, experts discussed the survey results and agreed upon a consensus for the management of open elderly ankle fractures. A mutually agreed consensus from the expert panel was reached to enable the best practice for the management of patients with frailty with an open ankle fracture: 1) all units managing lower limb fragility fractures should do so through a cohorted multidisciplinary pathway. This pathway should follow the standards laid down in the "care of the older or frail orthopaedic trauma patient" British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guideline. These patients have low bone density, and we should recommend full falls and bone health assessment; 2) all open lower limb fragility fractures should be treated in a single stage within 24 hours of injury if possible; 3) all patients with fragility fractures of the lower limb should be considered for mobilisation on the day following surgery; 4) all patients with lower limb open fragility fractures should be considered for tissue sparing, with judicious debridement as a default; 5) all patients with open lower limb fragility fractures should be managed by a consultant plastic surgeon with primary closure wherever possible; and 6) the method of fixation must allow for immediate unrestricted weightbearing.

A Comprehensive Investigation of the Relationship between Fractures and Oil Production in a Giant Fractured Carbonate Field

This study examines the connections between various fracture indicators and production data with an example from one of the giant fields in the Middle East producing complex fractured carbonate lithologies. The field under study hosts two reservoirs with a long development and production history, including carbonates from the Asmari and Bangestan Formations. A fracture intensity map was generated based on the interpretation of image logs from 28 wells drilled within the field. Mud loss data were collected and mapped based on the geostatistical Gaussian Random Function Simulation (GRFS) algorithm. Maximum curvature maps were generated based on Asmari structural surface maps. Comparing the results shows a good agreement between the curvature map, fault distribution model, mud loss map, fracture intensity map, and productivity index. The results of image log interpretations led to the identification of four classes of open fractures, including major open fractures, medium open fractures, minor open fractures, and hairline fractures. Using the azimuth and dip data of the four fracture sets mentioned above, the fracture intensity log was generated as a continuous log for each well with available image log data. For this purpose, the fracture intensity log and a continuous fracture network (CFN) model were generated. The continuous fracture network model was used to generate a 3D discrete fracture network (DFN) for the Asmari Formation. Finally, a 3D upscaled model of fracture dip and azimuth, fracture porosity, fracture permeability, fracture length, fracture aperture, and the sigma parameter (the connectivity index between matrix and fracture) were obtained. The results of this study can illuminate the modeling of intricate reservoirs and the associated production challenges, providing insights not only during the initial production phase but also in the application of advanced oil recovery methods, such as thermal recovery.

Complications of Open Reduction and Internal Fixation of Mandibular Condyle Fractures in Oman.

This study aimed to report the complication rate associated with open reduction and internal fixation (ORIF) of mandibular condyle fractures in Oman. This retrospective cohort study was conducted among patients who underwent ORIF of mandibular condyle fractures at Al-Nahdha Hospital and the Sultan Qaboos University Hospital in Muscat, Oman, from January 2008 to December 2020. Data collected included patient demographics, fracture aetiology, fracture side and type, surgical approach and recorded complications and outcomes. A total of 68 patients (59 males and 9 females; mean age of 30.1 years) with 83 mandibular condyle fractures underwent ORIF during the study period. Subcondylar fractures were the most common type, occurring in 62.7% of patients, while bilateral fractures were observed in 21 (30.8%) patients. The most common surgical approach was retromandibular, used in 42.2% of patients. The overall complication rate was 42.6%, with the most frequently reported complications being transient facial nerve palsy (18.1%), malocclusion (14.7%) and restricted mouth opening (10.3%). Subsequent surgical interventions to correct malocclusion were performed in 6 cases. There was no statistically significant association between the overall complication rate and the patients' clinical characteristics. Although ORIF of mandibular condyle fractures generally offers favourable outcomes, it carries a risk of complications.

The impact of elective surgery postponement during COVID-19 on emergency bellwether procedures in a large tertiary centre in Singapore.

The coronavirus disease 2019 (COVID-19) pandemic drove many healthcare systems worldwide to postpone elective surgery to increase healthcare capacity, manpower, and reduce infection risk to staff. The aim of this study was to assess the impact of an elective surgery postponement policy in response to the COVID-19 pandemic on surgical volumes and patient outcomes for three emergency bellwether procedures. A retrospective cohort study of patients who underwent any of the three emergency procedures [Caesarean section (CS), emergency laparotomy (EL), and open fracture (OF) fixation] between 1 January 2018 and 31 December 2021 was conducted using clinical and surgical data from electronic medical records. The volumes and outcomes of each surgery were compared across four time periods: pre-COVID (January 2018-January 2020), elective postponement (February-May 2020), recovery (June-November 2020), and postrecovery (December 2020-December 2021) using Kruskal-Wallis test and segmented negative binomial regression. There was a total of 3886, 1396, and 299 EL, CS, and OF, respectively. There was no change in weekly volumes of CS and OF fixations across the four time periods. However, the volume of EL increased by 47% [95% confidence interval: 26-71%, P = 9.13 × 10-7) and 52% (95% confidence interval: 25-85%, P = 3.80 × 10-5) in the recovery and postrecovery period, respectively. Outcomes did not worsen throughout the four time periods for all three procedures and some actually improved for EL from elective postponement onwards. Elective surgery postponement in the early COVID-19 pandemic did not affect volumes of emergency CS and OF fixations but led to an increase in volume for EL after the postponement without any worsening of outcomes.

Temporary Cast Application in Dislocated Ankle Fractures Leads to High Rates of Secondary Loss of Reduction: Does the Lauge-Hansen Injury Type Matter?

For the temporary treatment of ankle fracture dislocations (AFDs), previous studies indicate higher rates of secondary loss of reduction (LOR) with splint immobilization, prompting consideration for expanding indications for external fixation (ExFix). However, these studies did not investigate the influence of fracture morphology to further improve patient selection. The aim of this study was to investigate the influence of Lauge-Hansen injury type on the LOR rate in bimalleolar or trimalleolar AFDs for temporary cast vs ExFix immobilization. In this retrospective cohort study, patients with isolated AFD cases treated at our institution from 2011 to 2020 were reviewed. Inclusion criteria required radiographs depicting initial dislocation and appropriate reduction after Cast or ExFix immobilization. Exclusion criteria encompassed concomitant injuries, open fractures, conservative management as well as surgery performed within 48 hours or at a different facility. Patients were grouped by temporary treatment (Cast or ExFix). The primary endpoint was LOR prior to definitive surgery across various Lauge-Hansen types. The LOR rate was significantly higher in the cast group (40/152, 26.3%) compared to the ExFix group (5/191, 2.6%; P < .0001). In the cast group, LOR was associated with an increase in time to definitive surgery by a mean of 3 days (P < .002). During cast treatment, LOR was significantly more likely for pronation abduction (P = .001) and supination external rotation injuries (P < .0001), whereas no significant differences were observed for pronation external rotation (P = .006), supination adduction (P > .99), and fractures not classifiable (P > .99). In cases of AFDs resulting from supination external rotation or pronation abduction trauma according to the Lauge-Hansen classification, especially in the setting of an additional posterior malleolar fracture, primary application of external fixation should be considered to reduce the risk for secondary loss of reduction. Level III, retrospective cohort study.

THE ANATOMY OF BONE HEALING: BONE REGENERATION IN ORTHOPEDIC MEDICINE

Bone regeneration is a physiological bone formation process involved in routine fracture healing and continuous remodeling throughout adult life. The study's main objective is to determine the role of orthopedic medicines in bone regeneration and healing process. This retrospective study was conducted in a public hospital in Karachi, Pakistan, from February 2023 to June 2023. The study aimed to collect data from 120 bone fracture patients and evaluate the progression of bone healing to identify critical determinants of successful regeneration. Clinical assessments, radiological imaging, and histopathological analyses were conducted to achieve the study's objectives. The study collected data from 120 patients, with a mean age of 45.21±12.3 years. Of these, 70 were male and 50 were female. Upper extremities accounted for 40% of fractures, lower extremities 30%, and axial skeleton 30%. Simple fractures accounted for 50% of cases, while comminuted fractures represented 30% and open fractures 20%. There was a strong positive correlation between fracture severity and the time required for radiographic union, with a correlation coefficient (r) of 0.65 (p &lt; 0.001). Additionally, biomarkers of bone turnover exhibited a moderate positive correlation with radiological healing, with a correlation coefficient (r) of 0.45 (p = 0.003). The study concludes that orthopedic interventions have a high success rate in achieving satisfactory outcomes, with the majority of patients experiencing successful bone healing and restoration of function.

A comparison of screw and suture button fixation in the management of adolescent ankle syndesmotic injuries.

Ankle injuries involving the tibiofibular syndesmosis often necessitate operative fixation to restore stability to the ankle. Recent literature in the adult population has suggested that suture button fixation may be superior to screw fixation. There is little evidence as to which construct is preferable in the pediatric and adolescent population. This study investigates outcomes of suture button and screw fixation in adolescent ankle syndesmotic injuries. A retrospective matched cohort study over 10 years of pediatric patients who underwent ankle syndesmotic fixation at a large Level 1 Trauma Center was conducted. Both isolated syndesmotic injuries and ankle fractures with syndesmotic disruption were included. Preoperative variables collected include basic patient demographics, body mass index, and fracture type. Suture button and screw cohorts were matched based on age, race, sex, and open fracture utilizing propensity scores. Outcomes assessed include reoperation and implant failure. A total of 44 cases of operative fixation of the ankle syndesmosis were identified with a mean age of 16 years. After matching cohorts based on age, sex, race, and open fracture status, there were 17 patients in the suture button and screw cohorts, respectively. Patients undergoing screw fixation had a six times greater risk of reoperation (p = 0.043) and 13 times greater risk of implant failure (p < 0.001). Out of six cases of reoperation in the screw cohort, five were unplanned. Our findings favor suture button fixation in operative management of adolescent tibiofibular syndesmotic injuries. Compared with screws, suture buttons are associated with lower risk of both reoperation and implant failure. level III therapeutic.

Preliminary assessment of the Cambro-Ordovician reservoir potential from the Shushan basin, north Western Desert, Egypt

This study presents the first-ever preliminary assessment of the potential reservoir intervals from the Cambro-Ordovician Shifah Formation of the Shushan Basin, Western Desert. Seismic data, thin sections, XRD, XRF, and wireline logs were integrated to characterize the potential intervals. The study area is characterized by E-W and ENE-WSW trending steeply dipping normal faults creating a series of horsts, grabens, and half-graben structures. Based on the wireline logs-based petrophysical assessment, three potential reservoir intervals are identified with the Shifah Formation below 15000 ft depth. All the promising intervals show little shale volume (10–20 %) and 70–80 % hydrocarbon saturation, but the porosity is dominantly below 10%. The two potential sandstone intervals are composed of quartz arenites affected by silica cementation and mechanical compaction. These glauconite-bearing sandstones exhibit low-angle cross-lamination and planar lamination, likely deposited in a fluvial to shallow marine depositional environment. Both the tight sandstone intervals exhibit E-W, and NW-SE striking, closed, and partially open fractures which can contribute to the reservoir flow capacity. The third potential reservoir interval is an igneous intrusive body, composed of alkali syenite and exhibits secondary intraparticle porosity due to partial feldspar dissolution and minor fractures. The preliminary assessment presented in this work shed critical insights into the reservoir potential of the Shifah Formation.

The Bioburden Associated with Severe Open Tibial Fracture Wounds at the Time of Definitive Closure or Coverage: The BIOBURDEN Study.

Infection is common following high-energy open tibial fractures. Understanding the wound bioburden may be critical to infection risk reduction strategies. This study was designed to identify the bioburden profile of high-energy open tibial fractures at the time of definitive wound closure or coverage and determine the relationship to subsequent deep infection. This multicenter prospective study enrolled 646 patients with high-energy open tibial fractures requiring a second debridement surgery and delayed wound closure or coverage. Wound samples were obtained at the time of definitive closure or coverage and were cultured in a central laboratory. Cultures were also subsequently obtained from patients who underwent a fracture-site reoperation. Two hundred and six (32%) of the wounds had a positive culture at the time of closure or coverage. A single genus was identified in 154 (75%) of these positive cultures and multiple genera, in 52 (25%). Gram-positive cocci (GPCs) were identified in 98 (47%) of the positive cultures. Staphylococci were identified in 64 (31%) of the cultures, and 53 (83%) of these were coagulase-negative (CONS). Enterococci were identified in 26 (13%) of the cultures. Gram-negative rods (GNRs) were identified in 100 (49%) of the cultures; the most frequent GNR genera identified were Enterobacter (39, 19%) and Pseudomonas (21, 10%). Positive cultures were subsequently obtained from 154 (50%) of 310 revision surgeries. A single genus was identified in 85 (55%) of the 154 and multiple genera, in 69. GPCs were identified in 134 (87%) of the 154 positive cultures, staphylococci were identified in 94 (61%), and GNRs were identified in 100 (65%). The bioburden in high-energy open tibial fractures at delayed closure or coverage was often characterized by pathogens of multiple genera and of genera that are nonresponsive to typically employed antibiotic prophylaxis. Awareness of the final wound bioburden might inform strategies to lower the infection rate. Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Ten year outcomes after non-fixation of the smaller posterior malleolar fragment: A retrospective cohort study

IntroductionTreatment of posterior malleolar (PM) ankle fractures remains controversial. Despite increasing recommendation for small PM fragment fixation, high quality evidence demonstrating improved clinical outcomes over the unfixated PM is limited. We describe the long term clinical and radiographical outcomes in younger adult patients with PM ankle fractures managed without PM fragment fixation. Material and methodsA retrospective cohort study was performed on PM ankle fracture patients aged 18–55 years old admitted under our orthopaedic unit between 1st of April 2009 and 31st of October 2013. Inclusion criteria were ASA 1 and 2, independent mobility pre-trauma, no pre-existing ankle pathologies, with satisfactory bimalleolar and syndesmotic stabilisation. Open fractures, talar fractures, calcaneal fractures, pilon fractures, subsequent re-injury and major complications were excluded. All PM fragments were unfixated. Clinical outcomes were evaluated using visual analogue scale (VAS) for pain, Foot and Ankle Ability Measure (FAAM) with activities of daily living (ADL) and sports subscale for function, and patient satisfaction ratings. Osteoarthritis was assessed using modified Kellgren-Lawrence scale on follow-up weightbearing ankle radiographs. ResultsSixty-one participants were included. Mean follow-up was 10.26 years. Average PM size was 16.2 ± 7.39%. All participants were evaluated for clinical outcomes. Mean score of FAAM-ADL was 95.5 ± 7.13, FAAM-Sports 86.4 ± 15.5, patient satisfaction 86.2 ± 14.4% and pain score 1.13 ± 1.65. Radiographical outcomes were evaluated in 52 participants, showing no-to-minimal osteoarthritis in 36/52 (69%), mild osteoarthritis in 14/52 (27%) and moderate osteoarthritis in 2/52 (4%). Pain and functional scores were independent of PM fragment size, post-reduction step-off, dislocation, malleoli fractured or syndesmotic injury. PM step-off more than 1 mm and traumatic dislocation/subluxation were associated with worse radiographical osteoarthritis. ConclusionAfter controlling for confounders, the unfixated smaller posterior malleolus fragment at 10-year follow-up demonstrated largely satisfactory clinical outcomes with some radiographical progression of osteoarthritis. Level of evidenceLevel III – Retrospective cohort study

Characteristics, Controlling Factors and Reservoir Quality Implications of Inner Fracture Zones in Buried Hills of Archean Covered Metamorphic Rock in Block 13-2, Bozhong Depression

Inner fracture zones play a decisive role in the formation of high-quality reservoirs in buried hill reservoirs in covered metamorphic rock. Based on core, sidewall core, thin section, seismic, logging and reservoir physical property data, the fracture development characteristics of the Bozhong 13-2 block buried hill reservoir are described in detail and the controlling factors and the influence on reservoir quality are discussed. The results showed: (1) three groups of tectonic fractures developed in the study area—near-EW-striking, ENE-striking and nearly N‒S-striking fractures—were controlled by the early Indosinian thrusting, the late Indosinian to early Yanshanian sinistral strike-slipping and the late Yanshanian late dextral strike-slipping in the Bohai Bay Basin, respectively. The ENE- and nearly-E-W-striking fractures are the most common, and the dip angles of the fractures are mostly between 35° and 75° and thus oblique. (2) The Indosinian-early Yanshanian was the main fracture-forming period, and the dextral strike-slip action in the late Yanshanian was the key to maintaining effective fractures. Imaging logging shows that 97.87% of the fractures are effective fractures. Based on thin section observation, 14.47% of the fractures are unmodified open fractures and 80.37% of the fractures are effective fractures due to reactivation. (3) The late Yanshanian strike-slip fault transformed the deformation adjustment zone formed by the early Indosinian thrust faulting and the core of the fold structure was more conducive to fracture development. The fracture density of a single well located within the deformation adjustment zone and at the core of the fold is between 0.93–1.49 m−1, the fracture density of a single well located only at the core of the fold is between 0.67–0.75 m−1 and that of a single well located at the wing of the fold is between 0.35–0.59 m−1. Diabase dike intrusions promoted the development of local fractures. (4) Fractures promote the migration and accumulation of oil and gas, and the fracture density in the oil layer is between 0.81–2.19 m−1. That in the nonoil layer is between 0.25–1.12 m−1. In addition, fractures not only provide storage space but also effectively improve the reservoir capacity of the inner fracture zones of buried hill reservoirs by concentrating dissolution.