Management Of Open Fractures Research Articles

Transparency films: intraoperative templating to prevent limb deformity.

Operative management of fractures and malunions can be challenging when restoring native anatomy is not straightforward. Comminuted fractures and managing deformity correction in the setting of osteolysis, callus, and even complete fracture healing must include careful planning. Preoperative planning has been popularized and taught as an integral part of a surgeon's skill set, with critical evaluation and assessment of the implemented plan being the final step in the process. We present a robust, reproducible, and cost-effective technique for intraoperative fracture fixation assessment with case examples, used routinely at our institution.

Outcome of a 2-stage management of open tibia fracture in a low-income country lacking plastic surgeons: A retrospective cohort study

Outcome of a 2-stage management of open tibia fracture in a low-income country lacking plastic surgeons: A retrospective cohort study

1061 Improving the Emergency Management of Unstable Ankle Fractures in a District General Hospital: A Quality Improvement Project

Abstract Aim To assess and improve initial casting techniques in the emergency management of unstable ankle fractures. Method All patients who underwent operative management of ankle fractures over two consecutive 3-month periods were selected, before and after an intervention. Following the first cycle, an intervention included presentation of results and teaching delivery to the Emergency Department, with agreement to advocate for backslab as preferred casting technique. Results A total of fifty-two patients were identified, with an age range of 8 to 96 years. The majority were female (63%). Initial results demonstrated 61% were managed in below ankle backslabs, 33% in full casts and 1 patient in a moonboot. Subsequent loss of reduction was demonstrated in 27% of patients. Rates were higher with full casts (45.4%) compared to backslabs (20%). Following intervention, results demonstrated a 28% increase in use of backslab casting method (89%). Only 5% were managed with a full cast (28% decrease) and 1 inappropriately discharged without immobilisation. There was a 7% decrease in overall loss of reduction (21%). There was no loss of reduction within the full cast group and 22% with backslab management. Conclusions The use of backslab immobilisation in the management of unstable ankle fractures is preferred. Following a brief intervention, rates of backslab immobilisation increased and loss of reduction decreased. Results show an improvement in casting techniques in the management of these patients in an NHS Trust.

998 Distal Radius Fractures – Assessing Time to Surgery

Abstract Background The British Orthopaedic Association Standards for Trauma (BOAST guidelines) recommend that intra-articular distal radius fractures should be operated within 3 days and extra-articular fractures within 7 days of a decision to operate (1). Aim The objectives of this audit were to assess compliance with BOAST guidelines for operative management of distal radius fractures within a local trauma unit. Method Three audit cycles were completed between 2018 and 2021 over 3 -4-month periods. The second and third cycles were completed after elective orthopaedic cases were moved to an elective orthopaedic centre, and commencement of a weekly half day dedicated hand trauma list. All skeletally mature patients with acute distal radius fractures were included. Results Despite the addition of a dedicated hand trauma list and elective services moving to a dedicated site, compliance with BOAST guidelines remained almost unchanged. Compliance was at 100% for extra-articular fractures. However, for intra-articular fractures, compliance only slightly improved from 50 % to 53.3%. The average time to surgery improved from 4.25 days to 3.66 days for intra-articular fractures. Average time to surgery for extra-articular fractures was 3 days. Proposed reasons for delay included lack of trauma theatre time, prioritisation of other urgent cases such as femur fractures and lack of appropriate surgeon. Conclusions No distinction was being made to prioritise intra-articular distal radius fractures over extra-articular fractures for surgery. Trauma and Orthopaedic (T&O) staff have been educated and changes made to the T&O department’s trauma database to resolve this.

Factors and Radiographic Findings Influencing Patient-Reported Outcomes Following Maisonneuve Fractures.

This research adds to the literature by providing prognostic information for physicians and patients regarding the outcomes of operative management of Maisonneuve fractures (MFs). To date, this is the only cohort study of patient-reported outcomes measurement information systems (PROMIS) scores following surgical fixation of MF. Patient outcomes were compared focusing onthe mean population with an inter-analysis usingbasic demographic information, radiographic findings, and patient comorbidities and their respective impact on PROMIS scores. A total of 24 patients between 2012 and 2020 met the inclusion criteria and completed PROMIS surveys at a minimum of 18 months postoperatively. Patient charts were reviewed through the electronic medical record (EMR) for demographic information and comorbidities as well as operative variables. PROMIS scores for physical function (PF), pain interference (PI), and depression were obtained via follow-up visits and phone calls. The impact of categorical variables on complications was compared using Chi-Squared tests. Variables were analyzed with a type 3 SS test to stratify independent risk factors' effect on PROMIS scores and to account for confounding variables. PROMIS PF averaged 44.84 and was significantly affected by BMI>30 (p=.033), hypertension (HTN) (p=.026), patients with clinical anxiety or depression (p=.047), and subsequent screw removal (p=.041). PROMIS PI averaged a score of 54.57 and was significantly affected by BMI>30 (p=.0046), coronary artery disease (CAD) (p=.0123), patients with clinical anxiety or depression (p=.0206), and subsequent screw removal (p=.0039). PROMIS depression scores averaged 46.03 and were significantly affected by the presence of CAD (p=.049) and subsequent screw removal (p=.023). Patient-reported outcomes following MF surgery demonstrated PROMIS scores within +/- 1 standard deviation of the population-based control, and thus many patients can reasonably expect to return to a level of function comparable to the general population. Nonetheless, the significant effects of patient comorbidities and surgical variables ought to be evaluated and utilized as prognostic indicators when managing patient expectations prior to operative treatment of an MF injury.

Results of Antibiotic-Impregnated Cement/Polymer-Coated Intramedullary Nails in the Management of Infected Nonunion and Open Fractures of Long Bones.

Background Fractures of long bones can sometimes lead to complications such as infection or nonunion, resulting in significant patient morbidity. Surgical intervention and antibiotics are often necessary to treat these complications. Antibiotic-impregnated cement/polymer-coated intramedullary nails have emerged as an effective surgical treatment for infected nonunion and open fractures. These implants elude high concentrations of antibiotics at the infection site while stabilizing the fracture. Extensive research has shown promising results, with success rates ranging from 60% to 100%. Benefits of these implants include stable fracture fixation, early weight-bearing, and reduced need for prolonged antibiotic therapy. However, concerns remain regarding antibiotic resistance and potential toxicity. This study aims to evaluate the efficacy and safety of these implants in managing infected nonunion and open fractures of the femur and tibia. Methods This prospective hospital-based study aimed to assess the efficacy and safety of antibiotic-impregnated cement/polymer-coated intramedullary nails for managing infected nonunion and open fractures of the femur and tibia. The study included patients aged 18 or older who received treatment with these implants between January 1, 2021 and December 31, 2022. Patients allergic to vancomycin or teicoplanin, with gap nonunion >2 cm, or lost to follow-up were excluded. Data on demographics, fracture details, previous treatment, surgery, antibiotics, and outcomes were collected using a structured proforma. Surgeries involved implant removal, debridement, culture testing, reaming, fracture reduction, and stabilization with an antibiotic-impregnated cement/polymer-coated intramedullary nail. Postoperatively, patients received antibiotics, had wound inspections, and were gradually allowed weight-bearing. Follow-up appointments and radiographic/laboratory assessments were conducted at regular intervals. The primary outcome was successful bone union, and secondary outcomes included time to union, infection rate, nonunion rate, and revision surgery. Results The majority of participants were male, with a mean age of 39.76 years. Most fractures were Gustilo-Anderson grade 3 (46.7%) and involved the tibia (73.3%). The mean bone gap after debridement was 1.3 cm. The median follow-up period was 8.21 months. Infection was controlled in 93.3% of patients, with the tibia being the most common site (70.0%). Successful bone union was achieved in 90.0% of patients, with a mean union rate of 22.13 weeks for tibial fractures and 17.21 weeks for femoral fractures. Among patients with bone union, 60.0% did not require additional procedures. Most patients had excellent bony (76.7%) and functional (70.0%) outcomes. The most common complications were the persistence of bone nonunion, impingement of proximal nail, and debonding of nail cement, each occurring in 10.0% of patients. Conclusion The study concluded that antibiotic-impregnated cement/polymer-coated intramedullary nails are effective in managing infected nonunion and open fractures of the femur and tibia. The procedure demonstrated a high success rate in controlling infections (93.3%) and achieving bone union (90.0%). Paley's criteria showed excellent bony and functional outcomes in the majority of patients. These findings support the use of this treatment option for such fractures.

Management and Outcomes of Femur Fractures in Patients with Duchenne Muscular Dystrophy

Background: Duchenne muscular dystrophy (DMD) is a severe, progressive X-linked recessive neuromuscular disorder characterized by muscle weakness and atrophy. Additionally, patients with DMD have significant reductions in bone mineral density compared to age-matched controls, which is exacerbated by concomitant steroid use. These findings dramatically increase fracture risk, which may irreparably decrease functional status. The aim of this case series is to examine outcomes of operative versus nonoperative management of femur fractures in this patient population.Methods: An IRB-approved retrospective chart review was completed for patients with DMD treated at a single institution for a femur fracture between 2013-2022. Patients were excluded for incomplete documentation, treatment initiation at an outside hospital, or diagnosis of a different muscular dystrophy. Demographic variables, treatment information, functional status, and adverse events were collected for each patient. Descriptive statistics were used to summarize demographic and outcome variables.Results: A total of 10 patients with 11 femur fractures were included for analysis. All patients were male with an average age of 12.7 years and clinical follow-up of 286 days. Five fractures in five patients underwent operative fixation (Group A), and six fractures in five patients underwent nonoperative management (Group B). In Group A, three patients were short-distance ambulators prior to injury, and all patients regained a similar functional status postoperatively. All three patients were treated with a locked intramedullary nail. One patient in Group B was a short-distance ambulator prior to injury; the remainder were nonambulatory. All patients in Group B were primary wheelchair users at final follow-up. There were no adverse events as a result of treatment in either group.Conclusion: Nonoperative management with cast immobilization remains an acceptable option for nonambulatory patients and those with minimally displaced fractures not amenable to surgical intervention. Surgical intervention is recommended for higher-functioning patients with the goal of restoring ambulatory status. Regardless of treatment modality, patients should receive aggressive physical therapy directed at early weight-bearing, range of motion, and mobilization to preserve strength, muscle mass, and mobility.Level of Evidence: Level IV case series Key Concepts•Management of femur fractures in Duchenne muscular dystrophy should account for fracture morphology as well as patient functional status.•Surgical management is safe and effective in promoting fracture union and preserving functional status.•Nonoperative management is preferred in nonambulatory patients and for minimally displaced fractures.

Ultrasound guided suprascapular and supraclavicular nerve block in combination with continuous perineural brachial plexus block for operative management of upper limb multiple fractures: a case report

We report a case of multiple upper limb fractures resulting from a road traffic accident, wherein the patient declined general anesthesia. Instead, we successfully administered anesthesia using ultrasound-guided supraclavicular and suprascapular nerve blocks, combined with continuous perineural brachial plexus block. The surgical procedure was successfully completed within six hours, and no complications were encountered.

External fixation versus intramedullary nailing for the management of open tibial fracture: meta-analysis of randomized controlled trials.

Tibial shaft fractures are the most common type of long-bone fractures. External fixation (EF) and intramedullary nailing (IMN) are widely used surgical techniques for the definitive fixation of open tibial shaft fractures. The aim of this systematic review and meta-analysis was to compare EF to IMN for the definitive fixation of open tibial fractures. Medline, Embase, and CENTRAL databases were searched for eligible studies. We included randomized controlled trials (RCTs) that compared EF to IMN for skeletally mature adults with open tibial fracture (Gustilo I, II, and III). We evaluated the following outcomes: superficial infection, pin-track infection, deep infection, malunion, nonunion, delayed union, and implant/hardware failure. The risk ratio (RR) was used to represent the desired outcomes. The statistical analysis was performed using the random-effects model. A total of 12 RCTs that enrolled 1090 participants were deemed eligible for the analysis. EF showed a significantly higher rate of superficial infection, pin track infection, and malunion compared to IMN (RR = 2.30, 95% confidence interval (CI): 1.34 to 3.95; RR = 13.52, 95% CI: 6.16 to 29.66; RR = 2.29, 95% CI 1.41 to 3.73, respectively). No substantial difference was found between EF and IMN in terms of deep infection, nonunion, delayed union, or implant/hardware failure (RR = 1.15, 95% CI 0.67 to 1.98; RR = 0.92, 95% CI 0.77 to 1.10; RR = 1.50, 95% CI 0.98 to 3.33; RR = 0.96, 95% CI 0.36 to 2.60, respectively). The findings of our meta-analysis are consistent with the previous systematic reviews excepts for the implant/hardware failure which was found to be significant in favour of IMN by one of the previous reviews. This meta-analysis confirms that IMN is better than EF with respect to clinical outcomes and complication rate for the definitive fixation of open tibial fracture.

Rising incidence of acute total hip arthroplasty for primary and adjunctive treatment of acetabular fracture in older and middle-aged adults

BackgroundAcute total hip arthroplasty (THA) may be an alternative or an adjuvant to internal fixation for surgical treatment of acetabular fractures. We investigate recent trends in the operative management of acetabular fractures. We hypothesize that the incidence of acute THA for acetabular fractures has increased over time.Methods4569 middle-aged (45–64 years) and older adults (≥ 65 years) who received acute operative management of an acetabular fracture within 3 weeks of admission between 2010 and 2020 were identified from the United States Nationwide Inpatient Sample database. Treatment was classified as open reduction internal fixation (ORIF), THA, or combined ORIF and THA (ORIF + THA). Patients were stratified by age ≥ 65 years old. Associations between demographic factors and the incidence of each procedure over the study period were modeled using linear regression.ResultsThe relative incidence of treatments was 80.9% ORIF, 12.1% THA, and 7.0% ORIF + THA. Among patients aged 45–64 years old, THA increased 4.8% [R2 = 0.62; β1 = 0.6% (95% Confidence Interval (CI) 0.2–0.9%)] and ORIF + THA increased 2.6% [R2 = 0.73; β1 = 0.3% (95% CI 0.2–0.4%)], while the use of ORIF decreased 7.4% [R2 = 0.75; β1 = −0.9% (95% CI −1.2 to −0.5%)]. Among patients ≥ 65 years old, THA increased 16.5% [R2 = 0.87; β1 = 1.7% (95% CI 1.2–2.2%)] and ORIF + THA increased 5.0% [R2 = 0.38, β1 = 0.6% (95% CI 0.0–1.3%)], while ORIF decreased 21.5% [R2 = 0.75; β1 = −2.4% (95% CI −3.45 to −1.3%)].ConclusionThe treatment of acetabular fractures with acute THA has increased in the last decade, particularly among older adults.

Clinical outcome of open ankle fractures in patients above 70 years of age.

Open fractures of the ankle are complex injuries requiring multidisciplinary input and are associated with significant morbidity and mortality. However, data on the clinical outcomes of open ankle fracture management in patients older than 70 is minimal. To evaluate the clinical outcomes following open ankle fracture management in patients older than 70. Our secondary aim is to look at predictors of poor outcomes. Following local research and audit department registration, 22 years of prospectively collated data from an electronic database in a district general hospital were assessed. All patients older than 70 years of age with an open ankle fracture requiring surgical intervention were identified. Demographic information, the nature, and the number of surgical interventions were collated. Complications, including surgical site infection (SSI), venous thromboembolic events (VTEs) during hospital stay, and mortality rate, were reviewed. A total of 37 patients were identified (median age: 84 years, range: 70-98); n = 30 females median age: 84 years, range: 70-97); n = 7 males median age: 74 years, range: 71-98)) who underwent surgical intervention after an open ankle fracture. Sixteen patients developed SSIs (43%). Superficial SSIs (n = 8) were managed without surgical intervention and treated with antibiotics and regular dressing changes. Deep SSIs (n = 8; 20%) required a median of 3 (range: 2-9) surgical interventions, with four patients requiring multiple washouts and one patient having metalwork removed. VTE incidence was 5% during the hospital stay. Eight patients died within 30 d, and mortality at one year was 19%. The 10-year mortality rate was 57%. The presence of a history of stroke, cancer, or prolonged inpatient stay was found to be predictive of lower survivorship in this population (log-rank test: cancer P = 0.008, stroke P = 0.001, length of stay > 33 d P = 0.015). The presence of a cardiac history was predictive of wound complications (logistic regression, P = 0.045). Age, number of operations, and diabetic history were found to be predictive of an increase in the length of stay (general linear model; age P < 0.001, number of operations P < 0.001, diabetes P = 0.041). An open ankle fracture in a patient older than 70 years has at least a 20% chance of requiring repeated surgical intervention due to deep SSIs. The presence of a cardiac history appears to be the main predictor for wound complications.

Acute shortening and angulation for complex open fractures: an updated perspective

Summary: Reestablishing an intact, healthy soft tissue envelope is a critical step in managing lower extremity injuries, particularly high-grade open tibia fractures. Acute shortening and angulation can be used independently or together to address complex soft tissue injuries, particularly when bone loss is present. These techniques facilitate management of difficult wounds and can be combined with local soft tissue rearrangement or pedicled flaps as needed, avoiding the need for free tissue transfer. After angular deformity correction, adjacent bone loss can be addressed with bone grafting or distraction histogenesis. This article discusses the indications for, surgical technique for, and limitations of acute shortening and angulation for management of open lower extremity fractures.

Resource implications of managing paediatric femoral fractures in a major trauma centre: Analysis of 98 cases

IntroductionThe management of paediatric femoral shaft fractures is expensive and is guided by age and fracture characteristics. The primary aim of this study was to perform a cost evaluation for managing paediatric femoral shaft fractures. The secondary aim of this study was to perform and compare costs of the different techniques of managing paediatric femoral shaft fractures. MethodsNinety-eight femoral shaft fractures in children aged ≤16 were identified between 01/06/2014–30/06/2019. Retrospective data of clinical complications were obtained on infection, malunion and non-union. Data on additional intervention, reoperations for complications and routine removal of metal work were obtained. Costing analysis was performed by a bottom-up calculation, and gathering Patient Level Information and Costing System (PLICS) data. ResultsThere were 41 hip spica casting (HSC), 21 flexible intramedullary nailing (FIN), 14 submuscular plating (SMP), 19 rigid intramedullary nailing (RIN) and 3 external fixation (EF). Complications observed were HSC 3(7%); FIN 8(38%); SMP 2(14%); RIN 1(5%); EF 2(67%). The total costs for managing femoral shaft fractures were £8,955pp the costs for the different managements were; HSC £3,442pp; FIN £7,739pp; SMP £6,953pp; RIN £8,925pp; EF £19,116pp. The additional costs incurred for managing complications and routine removal of metal work for the internal fixation methods were: HSC 0.7%, FIN 23.7%, SMP 16.3%, RIN 10.9%, EF 28.1%. ConclusionThe operative management of paediatric femoral shaft fractures is associated with a high cost burden and this study demonstrates how financial data can be used to influence clinical management strategy. RIN carry a high initial implant cost however when considering the additional costs, such as treating complications it remains comparable to other modes of fixation. Our cost analysis did not demonstrate a significant difference between FIN, SMP and RIN. Due to the clinical complications observed and associated additional costs, we have discontinued the routine use of FIN for femoral shaft fractures at our centre. We recognise other centres may have a different complication and cost profile for each technique, but recommend they evaluate their practice given the potential economic benefit it has on the service provider.

PROPHYLACTIC USE OF LOCAL ANTIBIOTICS IN OPEN FRACTURES: A SYSTEMATIC REVIEW AND META-ANALYSIS

IntroductionThe management of open long bone fractures is well described and has been standardised through a number of well-established guidelines. However, there is no consensus regarding the application of local antibiotics into the open fracture site as a means of reducing infection rates.Materials &amp; MethodsA systematic review and meta-analysis were undertaken as per PRISMA guidelines. PROSPERO Registration CRD42022323545. PubMed, EMBASE, Scopus and CENTRAL were the databases assessed. The Newcastle Ottawa Scale and the Rob 2 Tool were used to assess bias. A qualitative synthesis of all included studies and meta-analysis of suitable subgroups was undertaken.ResultsIn total, 12 studies (11 observational, 1 RCT) assessing 2431 open fractures were included for analysis. All compared the addition of a local antibiotic therapy to a standard treatment versus the standard treatment alone. The methods of delivery were vancomycin powder (4 papers), tobramycin polymethylmethacrylate beads (4 papers), gentamicin coated intramedullary (IM) nails (2 papers), gentamicin injections (1 paper) and antibiotic released IM core cement (1 paper). The addition of vancomycin powder did not decrease infection rates in comparison to intravenous antibiotics alone (OR 1.3, 95% CI (0.75 – 2.26)). Antibiotic coated IM Nails appear to have an association with lower infection rates than standard IM Nails. PMMA antibiotics have shown varied results in reducing infection rates depending on the individual studies.ConclusionsThere are numerous methods available to deliver antibiotics locally to an open fracture site. Further high-quality research is required to provide a definitive conclusion on their efficacy irrespective of delivery method.

Open fractures: Current treatment perspective.

Severe open fractures present challenges to orthopaedic surgeons worldwide, with increased risks of significant complications. Although different global regions have different resources and systems, there continue to be many consistent approaches to open fracture care. Management of these complex injures continues to evolve in areas ranging from timing of initial operative debridement to the management of critical-sized bone defects. This review, compiled by representative members of the International Orthopaedic Trauma Association, focuses on several critical areas of open fracture management, including antibiotic administration, timing of debridement, bone loss, soft tissue management, and areas of need for future investigation.

Six-Week Radiographic Follow-up Does Not Change Management for Nonoperatively Treated Extraarticular Metacarpal Shaft Fractures.

Metacarpal fractures are common and account for over 30% of all hand fractures. Previous literature has shown similar outcomes between operative and nonoperative management of metacarpal shaft fractures. There is little information regarding the natural history of conservatively managed metacarpal shaft fractures and changes in management based on follow-up radiographs. A retrospective chart review was performed on all patients who presented to a single institution with an extraarticular metacarpal shaft or base fracture between 2015 and 2019. Thirty-one patients with 37 metacarpal fractures were included for review: average age 41 years, male 48%, right hand dominant 91%, and average follow-up duration 7.3 weeks. At follow-up, a change of 2.4° in angulation (P = .0005) and a change in shortening of 0.1 mm (P = .0386) were noted over the 6-week time interval. No fractures had malrotation at presentation, and none developed malrotation during the follow-up period. Recent systematic reviews and meta-analysis have suggested that metacarpal fractures treated nonoperatively had similar outcomes to surgical fixation at 12 months of follow-up. We found that extraarticular metacarpal shaft fractures that do not meet operative indications at the initial visit should be expected to heal reliably with minimal change in angulation and shortening over time. The transition to removable brace or no brace at the 2-week follow-up is likely sufficient, and additional follow-up is not necessary and will reduce cost. Level III.

Long-Term Follow-Up of Open Gustilo-Anderson IIIB Fractures Treated With an Adjuvant Local Antibiotic Hydroxyapatite Bio-Composite.

Background Open fractures associated with significant tissue loss are complex and present challenges in management; they are associated with poor outcomes such as infection, non-union or amputation. This study aimed to evaluate outcomes of using an adjuvant local antibiotic hydroxyapatite bio-composite in the management of open Gustilo-Anderson IIIB fractures with up to eight years of follow-up. Methods This was a retrospective study.A total of 81 patients with Gustilo-Anderson IIIB fractures treated with "fix and flap" limb reconstruction with adjuvant local antibiotic therapy using a bio-composite carrier were reviewed. Results The mean follow-up time for all the patients, at the time of data collection, was 55.8 months. Union was achieved in 96% with a limb salvage rate of 96.3% and a deep infection rate of 3.7%. Conclusion The use of local antibiotic therapy, together with a combined orthoplastic "fix and flap" approach for Gustilo-Anderson IIIB open fractures, was found to be associated with a very low rate of metalwork infection and high union and limb salvage rates. Future studies shouldinclude some functional and quality of life outcome measures to see the efficacy of this method.

Open hand fractures: a prospective analysis of functional outcomes and risk factors for infection after initial management in the emergency department.

Open hand fractures are common orthopaedic injuries, historically managed with early debridement in the operating room. Recent studies suggest immediate operative treatment may not be necessary but have been limited by poor follow-up and lack of functional outcomes. This study sought to prospectively evaluate these injuries treated initially in the emergency department (ED), without immediate operative intervention, to determine long-term infectious and functional outcomes using the Michigan Hand Outcomes Questionnaire (MHQ). Adult patients with open hand fractures managed initially in the ED at a Level-I trauma center were considered for inclusion (2012-2016). Follow-up and MHQ administration occurred at 6weeks, 12weeks, 6months, and 1year. Logistic regression and Kruskal-Wallis testing were used for analysis. Eighty-one patients (110 fractures) were included. Most had Gustilo Type III injuries (65%). Injury mechanisms most commonly included saw/cut (40%) and crush (28%). Nearly half of all patients (46%) had additional injuries involving a nailbed or tendon. Fifteen percent of patients had surgery within 30days. The average follow-up was 8.9months, with 68% of patients completing at least 12months. Eleven patients (14%) developed an infection, of which 4 (5%) required surgery. Subsequent surgery and laceration size were associated with increased odds of infection, and at one-year, functional outcomes were not significantly different regardless of fracture classification, injury mechanism, or surgery. Initial ED management of open hand fractures results in reasonable infection rates compared to similar literature and functional recovery demonstrated by MHQ score improvements over time.

3-D Printed Fracture Models Improve Resident Performance and Clinical Outcomes in Operative Fracture Management

To determine if preoperative examination of patient additive manufactured (AM) fracture models can be used to improve resident operative competency and patient outcomes. Prospective cohort study. Seventeen matched pairs of fracture fixation surgeries (for a total of 34 surgeries) were performed. Residents first performed a set of baseline surgeries (n = 17) without AM fracture models. The residents then performed a second set of surgeries randomly assigned to include an AM model (n = 11) or to omit it (n = 6). Following each surgery, the attending surgeon evaluated the resident using an Ottawa Surgical Competency Operating Room Evaluation (O-Score). The authors also recorded clinical outcomes including operative time, blood loss, fluoroscopy duration, and patient reported outcome measurement information system (PROMIS) scores of pain and function at 6 months. Single-center academic level one trauma center. Twelve orthopaedic residents, between postgraduate year (PGY) 2 and 5, participated in this study. Residents significantly improved their O-Scores between the first and second surgery when they trained with AM models for the second surgery (p = 0.004, 2.43 ± 0.79 versus 3.73 ± 0.64). Similar improvements were not observed in the control group (p = 0.916, 2.69 ± 0.69 versus 2.77 ± 0.36). AM model training also significantly improved clinical outcomes, including surgery time (p = 0.006), fluoroscopy exposure time (p = 0.002), and patient reported functional outcomes (p = 0.0006). Conclusions: Training with AM fracture models improves the performance of orthopaedic surgery residents during fracture surgery.

Predictive factors for fracture-related infection in open tibial fractures in a Sub-Saharan African setting

IntroductionThe management of open tibial fractures (OTF) is challenging in low and middle-income countries (LMICs) where appropriate human resources and infrastructure (including equipment, implants and surgical supplies) are not readily available and medical care is not readily accessible. OTF are not rarely associated with a subsequent fracture-related infection (FRI), which is one of the most devastating and difficult to cure complications in orthopaedic trauma care. The aim of this study was to determine the rate and the predictive factors of FRI in OTF in a limited-resource setting of sub-Saharan Africa. MethodsPatients with OTF who underwent surgery from July 2015 to December 2020 and followed-up for at least 12 months in a tertiary care teaching hospital in Yaoundé (Cameroon) were retrospectively investigated. Diagnosis of FRI was based on the confirmatory criteria of the International FRI Consensus definition. All patients with bone infections, occurring at any time point during follow-up, were included. Logistic regression was used to determine the predictive factors for FRI. ResultsOne hundred and five patients with OTF were studied. With a mean follow-up period of 29.5 ± 16.6 months, 33 patients (31.4%) presented with FRI. Gustilo-Anderson type of OTF, compliance with antibiotics, blood transfusion, time to first washing of the wounds and method of bone fixation were factors associated with the occurrence of FRI. In multivariable logistic regression, 6-hours delay to first washing of the wounds (OR=8.07, 95% CI: 1.43–45.31, p = 0.01), and compliance with antibiotics (OR=11.33, 95%CI: 1.11–115.6, p = 0.04) were the only independent predictors of FRI. ConclusionThe overall rate of FRI in open tibial fracture is still high in the sub-Saharan African context. For similar low-resources settings, this study supports the recommendations (1) to perform a very early washing-dressing-splinting of OTF on admission of the patient, (2) to administer antibiotics early, and (3) to perform surgery as soon as reasonably possible, once appropriate personnel, equipment, implants and surgical supplies are available.