Management Of Open Fractures Research Articles

Assessing the Change in Operative Treatment Rates for Acute Midshaft Clavicle Fractures: Incorporation of Evidence-Based Surgery Results in Orthopaedic Practice.

This retrospective cohort analysis used population-level administrative health data on the residents of British Columbia, Canada. Cases were identified by International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes and procedure fee codes. Adult patients (≥18 years) with closed middle-third clavicle fractures between 1997 and 2018 were included. Multivariable logistic regression modeling compared the proportion of clavicle fractures treated operatively before and after January 1, 2007, controlling for patient factors. The Pearson chi-square test compared the proportion of fractures treated operatively for malunion or nonunion in the cohorts. A total of 52,916 patients were included (mean age, 47.5 years; 65.6% male). More clavicle fractures were treated operatively from 2007 onward: 6.9% compared with 2.2% prior to 2007 (odds ratio [OR] = 3.35, 95% confidence interval [CI] = 3.03 to 3.70, p < 0.001). Male sex, moderate-to-high income, and younger age were associated with a greater proportion of operative fixation. The rate of surgery for clavicle malunion or nonunion also increased over this time period (to 4.1% from 3.4%, OR = 1.26, 95% CI = 1.15 to 1.38, p < 0.001). We found a significant change in surgeon practice regarding operative management of clavicle fractures following the publication of a Level-I RCT. With limited high-quality trials comparing operative and nonoperative management, it is important that clinicians, health-care institutions, and health-authority administrations determine what steps can be taken to increase responsiveness to new clinical studies and evidence-based guidelines. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Airway management and related respiratory complications in ankylosing spine disorder patients with operative management of acute cervical fractures

Airway management and related respiratory complications in ankylosing spine disorder patients with operative management of acute cervical fractures

A study on the outcome of open tibial fractures managed definitively by external fixator

Introduction: High energy tibial diaphyseal open fractures are a common occurrence in modern times. In a resource strapped country like India, AO unilateral external fixator is a cheap, technically easier method for the definitive management of the same. The aim of the paper is to present the results of the treatment of 33 patients with open tibia fractures, as well as the complications that accompany the treatment of these fractures. Method: An observational prospective study was undertaken including all open diaphyseal tibia fractures with Gustilo Anderson classification Type II, IIIA, IIIB and Ganga hospital open injury severity score of 6-12. Patients underwent debridement, definitive fixation with exfix, and later Patellar Tendon Bearing Cast after removal. Outcome was measured by the Association for the Study and Application of the Method of Ilizarov Group score. Results: In 81.8% cases the mechanism of injury was road traffic accident. Mean time for complete weight bearing was 19.33 weeks, mean time for union was 26.18 months. ASAMI Radiological outcome was Excellent in 45.5%, Good in 30.3%, Fair in 9.1% and Poor in 15.2% cases. ASAMI Functional outcome was Excellent in 33.3%, Good in 51.5%, Poor in 15.2% cases. Pin tract infection was found in 39.4% and malunion in 24.2%. The mean time for union (p=0.0004), incidence of non-union (p=0.014) was found to be statistically significant to the severity of initial injury. Conclusion: Thus by this study it can be expressed that external fixator is a feasible implant in the definitive management of open tibia fractures.

Exclusive Fibula Osteosynthesis for Treating Open Fractures Gustillo I-III B of the Distal Half of the Leg Bones in a Resources-Limited Setting

Introduction: Management of open leg bones fractures is a challenging health issue for the surgeon, particularly true in resource-limited settings. In this study, we evaluate exclusive fibular osteosynthesis in the treatment of open fractures of the distal half of the leg bones as a therapeutic option in our context. Methods: This is a prospective, experimental, multicenter study of 30 open fractures of the distal half of the leg bones treated with exclusive fibula osteosynthesis, conducted in 3 hospitals in the DRC from January 1, 2013 to September 30, 2016. Results: The age range of 20 to 40 years grouped 22 (73.4%) patients, the sex ratio was 1:1 and the unemployed were the most involved with 16 (53.3%) cases. The Gustilo II, I, III B and III A types represented 40%, 33.3%, 20% and 6.7%, respectively. The fractures were located in the distal third in 12 (40%) cases, in the middle third in 11 (36.7%) cases, and in both malleoli in 7 cases (23.3%). Osteosynthesis of the fibula by screw plate was applied in 22 (73.3%) patients and pinning in 8 (26.7%). Satisfactory reduction of the tibial fracture site was achieved in 29 (96.7%) cases and 100% bone healing was achieved within an average of 10 weeks. Four (13.3%) loss of alignment, 1 (3.3%) infection, 1 (3.3%) skin necrosis and 2 (6.7%) ankle stiffness complicated our fractures. Conclusion: Exclusive osteosynthesis of the fibula as a common technique for fractures of the distal half of the leg bones allowed us to reduce, immobilize and consolidate the tibial fracture in the required time and to preserve the mobility of the ankle.

Supercutaneous Plating Technique: A Case Report of Locking Plate Used as an External Fixator

Introduction: Open fracture is one of the most common and challenging healthcare problem in orthopedic practice1.Despite improvements in implant design, management of open fractures remain a challenge for the orthopedic surgeon. Locked compression plates (LCP) have advantages of angular stability from the locking-head mechanism and less irritation when compared with traditional external fixators due to their low profiles. Here is a case report of the same. Case Report: A 50-year-old lady, a municipal worker by occupation, came to casualty with alleged history of road traffic accident and injury to right thigh and knee. Plain radiograph of of right femur with knee revealed a supracondylar fracture of right femur. As a definitive treatment, patient underwent open reduction and supercutaneous plating. Skin grafting was done for the external wound over distal thigh. The External fixation plate for right distal knee was removed after 6 weeks and knee ROM of 0 to 100 degree flexion was achieved by one year. Conclusion: Open fractures can be treated by external fixation using the LCP plates, which are safe, reliable and have acceptable functional outcomes with minimal complication rates. Its advantages also include ease of performing surgery and ease of removing plate after fracture healing. Keywords: Supercutaneous plating, LCP- locking compression plate, External fixator

Clinical effectiveness of the Ganga Hospital Open Injury Severity Score for limb salvage versus amputation in patients with complex limb injuries : a systematic review and meta-analysis.

Clinical management of open fractures is challenging and frequently requires complex reconstruction procedures. The Gustilo-Anderson classification lacks uniform interpretation, has poor interobserver reliability, and fails to account for injuries to musculotendinous units and bone. The Ganga Hospital Open Injury Severity Score (GHOISS) was designed to address these concerns. The major aim of this review was to ascertain the evidence available on accuracy of the GHOISS in predicting successful limb salvage in patients with mangled limbs. We searched electronic data bases including PubMed, CENTRAL, EMBASE, CINAHL, Scopus, and Web of Science to identify studies that employed the GHOISS risk tool in managing complex limb injuries published from April 2006, when the score was introduced, until April 2021. Primary outcome was the measured sensitivity and specificity of the GHOISS risk tool for predicting amputation at a specified threshold score. Secondary outcomes included length of stay, need for plastic surgery, deep infection rate, time to fracture union, and functional outcome measures. Diagnostic test accuracy meta-analysis was performed using a random effects bivariate binomial model. We identified 1,304 records, of which six prospective cohort studies and two retrospective cohort studies evaluating a total of 788 patients were deemed eligible for inclusion. A diagnostic test meta-analysis conducted on five cohort studies, with 474 participants, showed that GHOISS at a threshold score of 14 has a pooled sensitivity of 93.4% (95% confidence interval (CI) 78.4 to 98.2) and a specificity of 95% (95% CI 88.7 to 97.9) for predicting primary or secondary amputations in people with complex lower limb injuries. GHOISS is highly accurate in predicting success of limb salvage, and can inform management and predict secondary outcomes. However, there is a need for high-quality multicentre trials to confirm these findings and investigate the effectiveness of the score in children, and in predicting secondary amputations.Cite this article: Bone Joint J2023;105-B(1):21-28.

Functional outcome of management of open fractures both bones of leg with primary intramedullary interlocking nailing

Functional outcome of management of open fractures both bones of leg with primary intramedullary interlocking nailing

Causes, complications, and treatment of open ankle fracture

Open ankle fractures are uncommon (3-6%) among all ankle fractures. Emerging trends show that the incidence of low-energy open ankle fractures is prevalent in older women. The mechanism of open fracture management continues to pose difficulties for orthopaedic surgeons. A simple fall is responsible for just under half of all fractures caused by motor vehicle collisions (MVCs). Despite technological advancements and surgical methods, infectious and non-infectious rates remain problematic. The mainstay of care is to combine antibiotic therapy with thorough irrigation and debridement. To prevent additional soft tissue and vascular damage, these fractures must be stabilized immediately, preferably with an external fixator. When the residual infection has cleared and the soft tissue envelope is adequate, do a definitive open reduction and internal fixation, adapting the procedure to the patient and type of fracture. Functional outcomes could be enhanced by taking safeguards against preventable comorbidities to reduce postoperative complications.

A Simple Scoring Model for Evaluation of Concomitant Vascular Injuries in Patients with Lower Extremity Open Fractures.

Timely diagnosis and management of concomitant vascular injuries is usually needed for the management of lower extremity open fractures. In the current study, a prediction model and simplified scoring system of vascular injuries were developed for the primary evaluation of patients with lower extremity open fractures. Patients with lower extremity open fractures were retrospectively reviewed from 2017 to 2020. Multivariate logistic regression analysis was used to evaluate independent risk factors for concomitant vascular injuries in these patients using data collected from 2017 through 2019 and a prediction scoring model was created accordingly. Model performance was validated with data from 2020. In total, 949 patients with lower extremity open fractures (development cohort, 705 patients, 2017 through 2019; validation cohort, 244 patients, 2020) were enrolled. Concomitant vascular injuries occurred in 44 patients in the development cohort (6.2%). Three clinical variables were identified for a prediction scoring model with weighted points, including hard or soft vascular signs (3 points), segmental fractures (2 points), and degloving soft-tissue injury (1 point). The model showed good discrimination (area under the receiver operating characteristic curve, 0.928), calibration (Hosmer-Lemeshow test, P = 0.661), and precision (Brier score, 0.041). Subsequent management regarding different aspects (observation only, further imaging study, or direct surgical exploration) can thus be decided. The model also demonstrated good discrimination (area under the receiver operating characteristic curve, 0.949), good calibration (Hosmer-Lemeshow test, P = 0.174), and good precision (Brier score, 0.042) in the validation cohort. This model may guide the subsequent management of vascular injuries associated with lower extremity open fractures. Risk, III.

Barriers to and Outcomes of Initiating Clinical Research at Two Trauma Centers in Mexico

IntroductionDespite efforts to advance clinical research through collaboration between Latin and North American partners, there remains persistent barriers to performing investigative work. To overcome these obstacles, a team of over 100 surgeon-leaders from 18 Latin American countries founded the Asociación de Cirujanos Traumatólogos de las Américas (ACTUAR). One of ACTUAR’s first major collaborative projects, initiated in 2018, was a prospective, observational, multicenter study evaluating quality of life after open tibia fracture management. The current study identified common barriers experienced during the initiation of this study, as exemplified through two sites in Mexico. The study aims to identify obstacles to proactively overcome these in future collaborative work. MethodsTwo research assistants from University of California, San Francisco and two research coordinators from Mexico were recruited to share their experiences, identify common barriers experienced during site enrollment and on-boarding for the ACTUAR open tibia study, and discuss possible solutions. ResultsBarriers were organized into three categories: structural, logistical, and intrapersonal. Structural barriers included differences in patient populations and resources between private and public hospitals. Logistical barriers included ambiguous ethical review processes, internet availability, and low patient follow-up. Primary enrollment as a resident responsibility led to some intrapersonal barriers. Potential solutions were identified for each barrier and agreed upon by all collaborators. ConclusionsMultiple barriers were identified by research personnel who initiated a prospective surgical clinical research study in Mexico. Through collaborative approaches, many potential solutions may help overcome these barriers and build locally led research capacity in Latin America.

Antibiotic Sensitivity Against Klebsiella spp. in the Post Debridement Culture an Open Fracture in Emergency Department of dr. Soebandi Hospital Jember

Surgical site infection (SSI) in open fracture is often caused by bacterial contamination in the management of open fracture. Because of that, one of the most important thing in handling open fracture is debridement. Prophylactic antibiotics given are Cephalosporin and Aminoglycosides. Post-debridement culture is important in predicting the incidence of infection. One of the bacteria that is often found in post-debridement culture is Klebsiella spp. which can produce ESBL to fight β-lactam class of antibiotics. The purpose of this study was to determine antibiotic sensitivity against Klebsiella spp. in the post-debridement culture of cases of open fractures in the emergency department of dr. Soebandi hospital Jember. This study uses a laboratory exploratory research design. The sample of this study was the isolate of Klebsiella spp. which amounts to 5 from post debridement culture of open fracture patients in the emergency department of dr. Soebandi hospital Jember from March to May 2019.The method used is diffusion (Kirby Baurer) by matching using the CLSI standard table to determine sensitive, intermediate, or resistant. The results of this study showed that most antibiotics had resistance to Klebsiella spp., including β-lactam antibiotics, such as Amoxicillin, Ceftriaxone, Cefixime, Penicilin, Meropenem, and Cefadroxil. Vancomycin antibiotics are still sensitive to Klebsiella spp. in all patients. Gentamicin, Ciprofloxacin, Tetracycline, and Chloramphenicol antibiotics were sensitive in 1 patient. Erythromycin intermediates antibiotics against Klebsiella spp.. The conclusion of this study is that all β-lactam group antibiotics are resistant to Klebsiella spp while the most sensitive antibiotic is Vancomycin.

Orthoplastic Treatment of Open Lower-Limb Fractures Improves Outcomes: A 12-Year Review.

The British Orthopaedic Association Standards for Orthopaedics and Trauma 4 (BOAST 4) inform the management of open lower-limb fractures. The authors conducted repeated reviews of performance against these standards over a 12-year period. This latest iteration has shown further improvements in outcomes concomitant with changes in service delivery. Data on Gustilo-Anderson grade IIIB or IIIC open lower-limb fractures were collected from a prospectively constructed departmental database and analyzed using Excel. Outcomes assessed included time to stabilization, time to definitive soft-tissue coverage, and deep infection rates. A total of 69% of patients in our cohort received care that aligned with BOAST 4 guidelines. Median time to stabilization was 14.2 hours and to soft-tissue coverage was 47 hours, with 71% of cases compliant with BOAST 4 guidelines. The overall deep infection rate was 6.5% in our cohort. There was a significantly lower deep infection rate in BOAST 4-compliant cases (2%) versus noncompliant cases (16%), respectively (P = 0.05). A total of 41 of 61 patients had fixation and soft-tissue coverage in a single operation (fix and flap), eight had staged operations, and 12 required local flap closure. There was no significant difference in deep infection rates among these approaches. Compliance with the BOAST 4 guidelines and time to definitive soft-tissue coverage have improved at our center since the last review. Deep infection rates were significantly lower in BOAST 4-compliant cases, further validating this approach. The fix and flap technique was introduced during the study period and reduces operative burden for patients. These results support a joint orthoplastic approach as the optimal management for these complex injuries. Therapeutic, IV.

Are outcomes after fixation of distal humerus coronal shear fractures affected by surgical approach? A systematic review and meta-analysis.

Surgical management of coronal shear fractures of the distal humerus is associated with a high rate of complications. Several surgical approaches have been described to address these fractures. The complication profiles associated with each approach have not previously been compared, and that is the aim of the present study. A systematic review of the literature was performed to identify all studies addressing coronal shear fractures of the distal humerus published between 2001 and January 2022. Of the 189 articles identified, 45 met the criteria for inclusion. Summaries of continuous data were calculated using the inverse variance method for pooling with random effects models. Fixed effects model estimates were reported unless significant heterogeneity was observed between studies. A subset of 6 studies reported the surgical approach and complications associated with the operative management of capitellar shear fractures without posterior comminution. The complication profiles of the extended lateral and anterolateral approaches were compared. The 45 studies included yielded 899 patients. The average age was 44.9 years (95% confidence interval [CI]: 39.7 to 50.2). The fracture type was Dubberley A in 38% (n=342), Dubberley B in 33% (n=300), and not reported in the remainder. The reoperation rate was 13.8% (95% CI: 9.6% to 19.5%). Pooled complication rates included post-traumatic arthritis in 21.2% (95% CI: 18.0% to 24.9%), heterotopic ossification in 12.0% (95% CI: 9.2% to 15.6%), nerve injury in 7.8% (95% CI: 5.6% to 10.9%), and avascular necrosis in 7.4% (95% CI: 5.3% to 10.2%). The complication rate in noncomparative studies was 25.8% following the lateral approach and 16.7% following the anterolateral approach. Reported complications following the anterolateral approach were pain (9.5%) and nerve injury (7.1%). Reported complications following the lateral approach included arthritis (9.1%), heterotopic ossification (6.1%), avascular necrosis (4.5%), instability (3.0%), nerve injury (1.5%), and wound issues (1.5%). Complications are common following operative management of capitellar shear fractures. In noncomparative studies, the complication rate was higher following the extended lateral compared to the anterolateral approach for Dubberley A fractures. Additionally, the reported complications following the extended lateral approach may impact long-term outcomes. Insufficient comparative evidence currently exists to recommend one approach over the other. High-quality comparative studies are needed.

Computer-Generated Radiographic Measurements of Distal Radius Fractures: Does It Help With Decision Making?

Operative management of distal radius fractures (DRFs) has become increasingly common. Age, activity levels, and comorbid conditions are major factors influencing the treatment decision, although operative indications are still controversial. Radiographic parameters (RPs), such as radial inclination, dorsal tilt, and articular step-off, can provide objective support for effective decision making. However, manual measurement of RPs may be imprecise and subject to inconsistency. To address this problem, we developed custom software of an algorithm to automatically detect and compute 6 common RPs associated with DRF in anteroposterior and lateral radiographs. The aim in this study was to assess the effect of this software on radiographic interobserver variability among orthopedic surgeons. Our hypothesis was that precise and consistent measurement of RPs will improve radiographic interpretation variability among surgeons and, consequently, may aid in clinical decision making. Thirty-five radiograph series of DRFs were presented to 9 fellowship-trained hand and orthopedic trauma surgeons. Each case was presented with basic clinical information, together with plain anteroposterior and lateral radiographs. One of the 2 possible treatment options was selected: casting or open reduction with a locking plate. The survey was repeated 3 weeks later, this time with computer-generated RP measurements. Data were analyzed for interobserver and intraobserver variability for both surveys, and the interclass coefficient, kappa value, was calculated. The interobserver reliability (interclass coefficient value) improved from poor to moderate, 0.35 to 0.50, with the provided RP. The average intraobserver interclass coefficient was 0.68. When participants were assessed separately according to their subspecialties (trauma and hand), improved interobserver variability was found as well. Providing computed RPs to orthopedic surgeons may improve the consistency of the radiographic judgment and influence their clinical decision for the treatment of DRFs. Orthopedic surgeons' consistency in the radiographic judgment of DRFs slightly improved by providing automatically calculated radiographic measurements to them.

Management of Displaced Midshaft Clavicle Fractures in Pediatrics and Adolescents: Operative vs Nonoperative Treatment.

The purpose of the current review is to describe the management of displaced midshaft clavicle fractures in pediatric and adolescent patients. Midshaft clavicle fractures are relatively common in pediatric and adolescent patients. They most commonly occur from direct trauma and are often related to sports participation in adolescents. Recent literature in the management of adult midshaft clavicle fractures has supported operative management due to improved functional outcomes, decreased time to union, leading to early return to activity. A similar trend of increasing frequency in operative management has been seen in pediatric and adolescent patients with no consensus in the literature on optimal management. Nonoperative treatment consists of with a brief period of sling immobilization followed by range of motion. Operative management may be considered for open fractures, fractures with significant neurovascular compromise and soft tissue complications. Studies have shown comparable mid- to long-term functional and patient-reported outcomes after operative and nonoperative management of midshaft clavicle fractures in pediatric patients.

The Incidence of Fracture-Related Infection in Open Tibia Fracture with Different Time Interval of Initial Debridement.

The primary aim of open fracture management is to prevent fracture-related infection by early antibiotic administration, debridement and wound coverage. However, the timing of the initial debridement is still controversial, and 6 to 24 hours is commonly advocated. Studies have yet to provide substantial evidence regarding the best time for surgical debridement. Thus, this study was conducted to compare the incidence of fracture-related infection at different time intervals of initial debridement of the open tibia fracture. A total of 91 patients with grade I, II and IIIa open tibia fractures were recruited from 2016 to 2018, and their data were obtained from the consensus book and medical records. Participants were divided into four groups based on the time of initial debridement: (1) less than 6 hours, (2) 6 to less than 12 hours, (3) 12 to less than 24 hours, and (4) 24 hours and more. Fracture-related infection was determined by using Metsemakers confirmative criteria. Association between time and infection were determine by Binary Logistic Regression analysis by remerged the group into three; (1) less than 12 hours, (2) 12 to less than 24 hours and (3) 24 hours and more. The collected information was analysed using SPSS version 24 and Microsoft Excel 2010. The mean age of the participants was 31.9 years old, with male predominant (n=80, 87.0%). Most participants had delayed initial debridement of more than 24 hours and predominantly Gustilo-Anderson type IIIa (n=47). A total of 8 fractures complicated with infection (8.7%), majority in grade IIIa and debridement performed within 12 to less than 24 hours. Binary logistic regression showed increased odds of infection with a delayed wound debridement both in clinical presentation and positive culture, but the association was not statistically significant. The commonest organism isolated was Pseudomonas aeruginosa. Comparing to different time interval, initial wound debridement of more than 24 hours did not have strong association with increasing infection rate. However, even though statistically not significant, the odds of infection was increase with increasing time of initial wound debridement of an open tibia fracture, thus it should be performed early.

Definitive Management of Open Fractures in pediatric patients by External Fixators

In the last several decades, vehicle accidents have been the leading cause of long-shaft lower-limb fractures in children. These fractures often involve the tibia and fibula and are accompanied by skin and soft-tissue injuries of varying severity. This research aims to assess the efficacy of external fixators in the final treatment of open fractures in children. Methods: Fifteen patients with open long bone fractures were treated with external fixation at Benha University Hospital, with a median follow-up of 12 weeks. The present study validates previous research showing satisfactory functional and radiological outcomes utilising the external fixation approach. Patients' ages varied from 6-16 years old, with a mean of 9.603.07. Almost four out of five (73.3%) were males. Road traffic accidents accounted for 73.3% of all injury mechanisms, followed by the direct fall of a large item (6.6%) and localised trauma (1.3%). Gustilo grades 2 (53.3% of cases), 3a (33.3%), and 3b (6.7%) were the most common. The tibia was the most often broken bone (80%). A total of 87 minutes and 37 seconds were spent in surgery on average. Eighty percent of patients began ROM right away, whereas the remaining 20% did so within 2 weeks, and the other 7% did so within 5 months. Three patients began bearing weight immediately, two patients waited two weeks, and ten patients waited one month. The mean duration of a radiological union was 4.27 1.22 months. It took 4.63 1.14 months on average to get the fixator out. The most common complications were skin infections (60%) and stiffness (26.7%), followed by NV issues (13.3%), a pin fracture (6.7%), and a refracture of bone (6.7%).

Use of a trauma registry to drive improvement in the regional trauma network systems in Hawassa, Ethiopia

AimOur aim is to establish and analyse the first year of trauma registry data from Hawassa University Comprehensive Specialised Hospital (HUCSH)—an Ethiopian tertiary referral centre. We plan to identify possible trends in injury patterns, access to health care and referral pathways and establish if our observations are in keeping with data published from other sub-Saharan LMIC’s.MethodsProspective data collection using the WHO trauma registry dataset. All trauma patients presenting to HUCSH between November 2019 and November 2020 were included. Military patients were excluded. Dataset: Age, sex, region of residence, mode of transport to hospital, referral centre, time from injury to arrival in HUCSH, arrival triage category, Kampala Trauma Score (KTS), mechanism of injury, injury type, closed/open fracture and 24 h outcomes. Data statistical analysis was performed to calculate frequencies of the above variables.ResultsThere were a total of 1919 cases. Fifty-three per cent were caused by road traffic collision and 49% were fracture/dislocations. Public transport was the most common mode to hospital—40%. Seventy-seven per cent of all trauma admissions were referred from other centres, 69% had a mild KTS. A total of 376 patients presented with an open fracture—76% had a low KTS and 67% remained in ED for > 24 h. Sixty-five per cent of ambulances were utilised for mild KTS patients, only 25% of ambulances transported moderate and severe injuries.ConclusionWe have shown that a ‘one size fits all approach’ should not be adopted for LMIC’s as trends vary between regions and countries. Improvements are needed in ambulance utilisation, the use of appropriate triaging tools to facilitate initial basic trauma care and appropriate, timely referrals and the management of open fractures.

Operative management of acetabular fractures in the elderly: a case series

BackgroundOur objective was to identify acetabular fractures in the elderly population (over 60 years of age), treated with open reduction and internal fixation (ORIF), and to examine their outcomes, primarily the risk for need for further surgery in the form of a total hip arthroplasty (THA), and factors associated with it. Additional outcomes such as infection, avascular necrosis (AVN) of the femoral head, and heterotopic ossification (HO) were also investigated.MethodsFollowing institutional review board (IRB) approval, a retrospective analysis of all consecutive patients presenting to a Level I Trauma Centre over a 13-years period (January 2003–February 2016) was conducted. Patients were excluded if their initial treatment was conservative or simultaneous ORIF with THA.ResultsA total of 62 patients with an age of 71.5 ± 8.04 years were included (14 female; follow-up 54.2 months, range 1–195 months). Sixteen patients required a THA as a secondary procedure due to symptomatic post-traumatic arthritis (25.8%), five (8.1%) of whom having a THA within a year from the original trauma (three patients presenting with loss of reduction and two patients with early AVN). No associations with progression to THA were identified. Surgical approach (ilioinguinal) was the only factor associated with increased risk of development of HO (p = 0.010). The median post-operative survival following an acetabular fracture treated with ORIF was calculated at 90.1 months (95% CI 72.9–107.2).ConclusionAcetabular fractures ORIF in the elderly, is a safe and reliable option. The relatively incidence of development of severe post-operative arthritis was 45.2%. Conversion to THA was 25.8%, with 8.1% having the arthroplasty procedure within a year of the original trauma surgery.Level of evidenceIII.

Effectiveness of melatonin treatment for sleep disturbance in orthopaedic trauma patients: A prospective, randomized control trial

ObjectivesExplore sleep disturbance in postoperative orthopedic trauma patients and determine the impact of melatonin supplementation on postoperative sleep, pain, and quality of life. Materials and MethodsIn this prospective, randomized controlled trial at a Level I trauma center, 84 adult orthopedic trauma patients with operative fracture management were randomized 2-weeks postoperatively to either the melatonin or placebo group. Patients randomized to the melatonin group (42 subjects, mean age 41.8 ± 15.5 years) received 5 mg melatonin supplements. Patients in the placebo group (42 subjects, mean age 41.3 ± 14.0 years) received identical glucose tablets. Both groups were instructed to take the tablets 30 minutes before bed for 4 weeks and received sleep hygiene education and access to the Cognitive Behavioral Therapy for Insomnia (CBT-I) Coach app. Main Outcome MeasuresOur primary outcome was sleep quality as measured by the Pittsburgh Sleep Quality Index (PSQI). Secondary outcomes were pain measured by the Visual Analog Scale (VAS), quality of life measured by the 36-Item Short Form Survey (SF-36), and opioid use. ResultsPatients in both groups had significant sleep disturbance (PSQI ≥ 5) at 2-weeks (83%) and 6-weeks (67%) postoperatively. PSQI improved by 3.3 points (p<0.001) at follow-up, but there was no significant difference between groups (melatonin PSQI = 5.6, placebo PSQI = 6.1, P = 0.615). Compared to placebo, melatonin did not affect VAS, SF-36, or opioid use significantly. ConclusionSleep disturbance is prevalent in orthopedic trauma patients. Melatonin treatment did not significantly improve subjective sleep quality, pain, quality of life or opioid use. Level of evidenceTherapeutic Level I.