Open Injuries Research Articles

Microlearning Reduces Unnecessary Antibiotic Provision for Open Hand Injuries.

Background Antimicrobial stewardship approaches are important in managing the growing global challenge of antibiotic resistance. Microlearning describes educational interventions involving small, digestible chunks of information focussed on a single learning objective. Aim This quality improvement project aimed to improve the compliance of antibiotic administration for open hand injury referrals with national and local guidelines using a microlearning educational intervention. Method Antibiotic administration for open hand injury referrals was audited at baseline, following the creation and dissemination of an infographic displaying the indications for antibiotics, and again after the creation and dissemination of a short video providing the same information. Result The proportion of referrals with no indication for antibiotics that were given or recommended antimicrobials fell from 50.0%(22/44) to 14.3%(5/35) after dissemination of the infographic and short video. Conclusion Microlearning educational interventions are effective at improving compliance with clinical guidelines in this context.

Diagnostic evaluation of open knee injuries: a comparison of arthrography and CT scans.

Currently, traumatic arthrotomy of the knee could be diagnosed by saline loading test and computed tomography (CT) which reported excellent sensitivity and specificity. However, there are drawbacks associated with CT, such as cost and radiation hazards. This study aims to evaluate a new diagnostic tool using knee arthrography for individuals with suspected open knee injury and reported sensitivity and specificity using CT scan as the gold standard. A prospective diagnostic study, involving 43 patients who sustained laceration wounds over the knee, was conducted. The physical examination and conventional radiographic imaging were inconclusive in determining the presence of open joint injury. The established protocol involved directing the patients to undergo a CT scan, which is considered the gold standard for detecting open knee injuries. Subsequently, arthrography of the affected knee was performed. The diagnostic value was subsequently determined based on the outcomes derived from these procedures. There were 5/43 cases (11.6%) that diagnosed open knee injuries as determined by CT scans. The calculated diagnostic parameters of arthrography derived from these findings are as follows: The sensitivity was 83.3%, the specificity was 96.5%, the negative predictive value was 96.5%, the positive predictive value was 83.3%, the accuracy is 94.3%, the false positive rate is 16.7%, and the false negative rate was 3.4%. Interobserver reliability was substantial (Kappa 0.617). No complication was observed during the arthrography procedure. Knee arthrography demonstrated high sensitivity, specificity and accuracy for diagnosing open knee injuries, offering a viable alternative to CT scans in certain situations, such as when minimizing radiation exposure is a priority and cost considerations are paramount. Ultimately, careful clinical judgement should guide the choice of diagnostic modality based on individual patient circumstances.

Multidisciplinary standardized protocol decreases time to antibiotic administration for open fractures.

Wound complications after open fracture are common, including superficial and deep infections. Many factors may contribute to outcomes after open fracture, including comorbidities, injury location and characteristics, timing and quality of surgical debridement, and soft tissue coverage. Early prophylactic antibiotic administration is one of the few modifiable factors demonstrated to reduce infection rates. Retrospective comparative study at a single Level 1 Trauma Center evaluated patients age > 18 who presented directly to and were admitted with open long-bone fracture. Primary outcome measure was time from arrival to antibiotic administration pre- and post-implementation of a standardized open fracture protocol. Secondary analysis evaluated percentage of patients receiving antibiotics within one hour for open long-bone fracture, injury characteristics and patient demographics influence on time to antibiotics. Median time to antibiotic administration improved post-protocol (69min vs. 39min, p < 0.001). Patients receiving antibiotics within one hour improved after protocol implementation (42.9% vs. 79.0%, p < 0.001). Antibiotic administration was more often delayed for patients with penetrating injuries compared to blunt injuries (80min vs. 54min, p = 0.003). Patients with penetrating injuries were less likely to receive antibiotics within one hour (46% vs 56%, p < 0.001). The implementation of a standardized protocol reduced the time to antibiotic administration and increased the percentage of patients with open fractures receiving antibiotics within one hour. Penetrating injuries were often not appreciated as open fractures during the initial evaluation, which led to a delay in antibiotic administration. Level III, Therapeutic/Care Management.

Typical causes and clinical presentations of traumatic and nontraumatic soft tissue and organ haemorrhage in emergency departments

Acute bleeding often occurs in awide variety of forms in clinical emergency medicine. In traumatic bleeding, soft tissue injuries to the head or extremities are common, while severe bleeding is less common in chest injuries or pelvic trauma. In nontraumatic emergencies, gastrointestinal bleeding is the leading cause, but many other bleeding entities are possible. Structured management helps to detect the critically ill patient, identify the possible source of bleeding and provide appropriate radiological diagnostics and therapy. Clinical examination, blood gas analyses and emergency ultrasound are crucial in the initial phase of diagnosis. Initially, symptomatic therapy is usually indicated to stabilize the patient, and then interventional or surgical care is indicated in the course of the disease, depending on the location of the bleeding. Volume and catecholamine therapy, coagulation management and emergency transfusion are important components of interdisciplinary emergency care, in addition to primary bleeding control, especially in the case of open injuries.

Outcomes of Open Knee Joint Injuries in Trauma Patients at Tibebe-Ghion Specialized Hospital, Bahir-Dar, Ethiopia

Background: Open knee joint injury is a deep traumatic laceration violating the joint capsule. This study aimed to assess outcomes and associated factors of open knee joint injuries in trauma patients at Tibebe-Ghion Specialized Hospital, Bahirdar, Ethiopia, 2021. Methods: An institution-based retrospective cross-sectional study was conducted by reviewing the medical records of 43 patients treated for open knee joint injuries from January 2019 to July 2021, with an 86% response rate. Data were entered and exported using Epidata Manager Version 4.4 and analyzed using SPSS version 25. Results: Fourteen (32.5%) of the study subjects developed either infections or limping during follow-up due to open knee injuries, with the majority of injuries (58.1%) being caused by car accidents. The presence of associated injuries, wound size, time to wound closure, debridement as a management option, sex, and diagnostic methods showed a significant association with complication outcomes. Among the diagnosed infections, 90% were cases of septic arthritis. During the study period, eight patients (18.6%) developed limping during follow-up. The complication rate among open knee injury patients in the study area was significantly high, with one-third of patients experiencing complications. Targeted public awareness campaigns like car accidents should be conducted to educate the population about orthopedic emergencies and strategies to reduce complication risks, aiming for more favorable outcomes.

Time to death and its predictors among traumatic brain injury patients admitted to East Amhara comprehensive specialized hospitals, Ethiopia: retrospective cohort study

BackgroundGlobally, 64–74 million individuals around the world are estimated to sustain traumatic brain injury every year. Moderate and severe traumatic brain injury can lead to a lifetime physical, cognitive, emotional, and behavioral changes. There were limited studies conducted in Ethiopia regarding to traumatic brain injury mortality.MethodsAn institutional based retrospective cohort study was conducted on 429 randomly selected traumatic brain injury patients aged 18 to 64 years who were admitted to East Amhara Comprehensive Specialized Hospitals from January 1, 2016 to December 31, 2021. Kobo toolbox was applied for data collection and exported to Stata version 17 for data processing and analysis. To estimate death free time, a Kaplan Meier failure curve was used. The Cox proportional hazards regression model was used at the 5% level of significance to determine effect of predictor variables on time to death.ResultA total of 429 traumatic brain injury patients aged 18 to 64 years were included with response rate of 91.3% and 145(33.8%) were dead. Open injuries (AHR = 0.25; 95% CI: 0.18–0.36), co-existing injuries (AHR = 0.40; 95% CI: 0.24–0.66), ICU admission (AHR = 0.42; 95% CI: 0.29–0.60), arrival within 4–24 h (AHR = 3.48; 95% CI: 2.01–6.03), arrival after 24 h (AHR = 6.69; 95% CI: 3.49–12.28), subdural hematoma (AHR = 2.72; 95% CI: 1.77–4.19), serum albumin < 3.5 g/dL (AHR = 0.66; 95% CI: 0.49–0.94), moderate (AHR = 0.56; 95% CI: 0.21–0.89), and mild traumatic brain injury (AHR = 0.43; 95% CI: 0.29–0.56) were predictors of traumatic brain injury mortality.ConclusionThe finding of this study showed that the mortality was 1/3rd of the total patients. Open injuries, co-existing injuries, ICU admission, arrival time (4–24 h and > 24 h), subdural hematoma, serum albumin < 3.5 g/dL and severity of traumatic brain injury (mild and moderate) were predictors of traumatic brain mortality. Therefore, working on these factors to reduce the morality of traumatic brain injury patients is very important.

Contribution of the Association of CT scan and Ocular Trauma Score in Open Globe Ocular Injuries: Mohammed VI University Hospital Experience

Objective: The aim of this study was to assess the association between oculo-orbital CT scan results and Ocular Trauma Score (OTS) in open globe injuries. Methods: In 65 eyes with open globe injuries undergoing oculo-orbital CT, they were classified into 5 major types: intraocular foreign body/air, scleral irregularity with decreased globe volume, lens dislocation, abnormal vitreous density, choroid layer thickening, and choroidal detachment. The association between different types and the number of CT findings with OTS stages was evaluated. Results: The average age of patients was 37 ± 15.8 years. The most common CT findings were the presence of intraocular foreign bodies (63.1%), severe scleral irregularity (18.5%), and abnormal vitreous density (23.1%). The most frequent OTS stages were III (47.7%) and II (21.5%). Univariate analysis showed that severe scleral irregularity (OR = 0.015; p = 0.001), abnormal vitreous density (OR = 0.095; p &lt; 0.004), choroidal layer thickening (OR = 0.211; p = 0.006), and foreign body (OR = 9.50; p = 0.004) were associated with more advanced OTS stages (I and II). The discovery of more anomalies on CT was associated with severe ocular injuries, namely OTS I (p &lt; 0.001) with corresponding low final visual acuity. Conclusion: CT results can aid in predicting OTS stage and visual prognosis in open globe eye injuries.

Lower Limb Comprehensive Reconstructive Surgery: Experiences from an Orthopedic Teaching Unit

Abstract Introduction: The burden of open extremity fractures is well recognized in placing a burgeoning demand on an already exhausted medical facility in low- and middle-income countries. This study aims to evaluate the functional outcome following “orthoplastic management” by orthopedic surgeons trained in limb reconstruction surgery. Methodology: Adult patients with open lower limb injuries treated from January 1, 2022, to December 30, 2022, who underwent single or staged fixation and reconstruction procedures were identified. Patients with Gustilo–Anderson type IIIB fractures requiring skeletal stabilization with soft-tissue cover were included. Polytrauma patients requiring multidisciplinary surgical attention were excluded. A team of orthopedic surgeons trained in limb reconstruction was involved in the management. Inpatient and outpatient department follow-up by the treating team was done to document complications (infections, reoperations, and graft failures) and functional outcomes using the Lower Extremity Function Score. The duration of mean follow-up was 1 year since index surgery. Results: A total of 24 adult patients with open lower limb injuries with preoperative Ganga Hospital Score (GHS) were included. Decision toward fixation with primary closure or further reconstruction was made collectively. The gray zone (GHS score of 15–16) of patients was more aggressively managed with emphasis on salvage. Additional reconstructive procedures were carried out based on the assessment at consequent follow-up. Three patients had a suboptimal joint function (less than functional range of motion for the involved joint) due to the resultant loss of compartment(s) and joint contracture. Five patients were retaken to the theater for further supplementary or corrective procedures following the index, definitive surgical procedure (bone grafting, partial flap loss, and fixator readjustment). Conclusion: Good-to-excellent functional outcome was demonstrated with the “orthoplastic approach” where skeletal stabilization as well as soft-tissue reconstruction was performed by trained orthopedic surgeons. This study demonstrated that orthoplastic surgery is a safe and effective method of limb salvage.

3D Bilayered Hydrogel and Nanofiber Multifunctional Sponge Dressing: An Efficacious Healing Agent for Chronic Wound Healing.

Chronic wound management using biomaterial-based dressings has significantly impacted the standard and efficiency of wound healing. However, various available wound healing aids are ineffective in treating deep open injuries and chronic wounds such as diabetic wounds. Herein, we developed a 3D bilayered multifunctional sponge, which addresses the structural and functional issues faced by biomaterial dressings in treating deep and chronic wounds. The 3D bilayered sponge consists of a hydrogel base functionalized with wound healing peptide (Tylotoin)-carrying nanoparticles and topped with a nanofiber layer functionalized with an antimicrobial peptide (LLKKK18). The 3D bilayered sponge, with its highly porous, elastic, and enhanced fluid absorption ability, makes it a suitable wound treatment aid. The developed multifunctional 3D sponge shows antibacterial action and promotes a microenvironment similar to the extracellular matrix (ECM) in regulating dermal cell survival and migration. Study in a full-thickness skin defect diabetic mouse model has shown that the developed 3D bilayered sponge accelerated wound closure and promoted functional skin regeneration through reduced inflammation, faster granulation tissue formation, re-epithelialization, neovascularization, and skin appendage restoration, which make the developed 3D bilayered multifunctional sponge an efficient and advanced chronic wound management aid with potential for future clinical application.

Changing trends in injury patterns of undocumented migrants along the Hungarian–Serbian border from 2018 to 2022

ObjectiveThe Traumatology Clinic of the University of Szeged is a level one Trauma center situated near the Hungarian - Serbian border, where a 4 m tall fence constructed in 2018 serves as a barricade leading to numerous trauma cases. The objective of this study is to characterize the epidemiology of injuries, challenges, and recent trends whilst treating these undocumented migrants in Hungary. Materials and methodsA national retrospective mono-centrical study was performed, examining 982 patients who were admitted to the emergency trauma center in the University of Szeged between January 2018 and December 2022, using data from our electronic administrative system (eMedSol). Factors such as basic epidemiology, country of origin, fractures- according to the AO classification- and its respective treatments, mechanism of injury, duration of stay, and costs were assessed to set as a basis for prediction using a regression model. ResultsA total of 982 patients from 2018 to 2022 were included in the study. Patterns of injury included calcaneal fractures in 2018 and 2019 whereas in 2021 and 2022 along with the exponential increase in patient number, bilateral calcaneal fractures, open and multi-fragmentary tibial fractures were also observed. Additionally, seasonal variations, favoring the months of September through November were observed. Treatment cost ratios, especially surgeries, have also been consistent with the pattern of proximalizing injuries; more proximal surgeries indicate higher surgical costs which is evidently visible in the significantly higher cost ratio dedicated to surgery in 2022. ConclusionWhile migration seems to be a global problem affecting governments and citizens alike, rarely do we understand the direct consequences of illegal migration affecting healthcare services. Hungary in particular created a 4 m tall wall between Serbia in 2019 with means of preventing illegal migration, which in turn led to gradual and later an exponential increase in the number of injured patients particularly in the years 2021 and 2022. Undocumented migrant cases have increased exponentially between 2018 and 2022, with certain patterns seen not only in the injury types but also in seasonal variations and cost expectations. Injuries have been showing a trend of proximalization and have been of more serious quality, including bilateral and/or open injuries. Revisions after surgery were virtually impossible due to the discharging of patients back to border control after their definitive treatment. The need for adequate quality surgical care, manpower and financial aid should be considered.

Epidemiology of orthopedic injuries among inpatients admitted at a tertiary teaching and referral hospital in Kenya: a retrospective cross-sectional study

BackgroundOrthopedic injuries are serious and continue to be a concern for healthcare systems worldwide. Approximately 90% of the estimated traumatic injuries occur in low- and middle-income countries. In Kenya, there is a dearth of information on orthopedic injury patterns that could be used to prioritize injury prevention measures and to help hospital management teams allocate resources appropriately. The purpose of this study was to determine the epidemiology of orthopedic injuries admitted to Kenyatta National Hospital.MethodsThis was a retrospective cross-sectional study. Overall, 720 charts were reviewed. Data were analyzed using frequency distribution, pearson chi-square test and logistic regression.ResultsOverall, 85% were aged 15–64 years. Approximately 80% were male, married or single. Patients with primary or secondary education composed 72%. Road traffic accidents (59.4%) and falls (24.7%) were the most common mechanisms of injury. A total of 99.9% of the inpatients were Kenyans. Open injuries were 40.1%. Lower limb (67.4%) and upper limb (26.9%) injuries were the most common. Inpatients aged 15–24 years were 74% less likely to have upper limb injuries than those aged 0–14 years (p = 0.023). However, those aged 15–24 years were 19.250 times more likely to have spine injuries than those aged 0–14 years (p = 0.008). Males were 68.6% and 51.2% less likely to have pelvic injury and comorbidities, respectively, than females (p < 0.001). Patients with secondary and tertiary education were 2.016 (p = 0.003) and 2.3 (p < 0.001) times more likely to have upper limb injuries, respectively, than those with no or preschool education. Similarly, those with tertiary education were 2.079 times more likely to have comorbidities than those with no or preschool education (p = 0.017).ConclusionMost of the inpatients with orthopedic injuries were young, male involved in Road traffic accidents and therefore Kenya National Transport and Safety Authority needs to enforce road safety measures to reduce road carnage. Those with higher education and children were more likely to have upper limb injuries. Females were more likely to have pelvic injuries and co-morbidities. Lower and upper limb injuries were the most common injuries and this should guide resource allocation in management of orthopedic injuries.

The prevalence of hand pathology in regional orthopaedic hospitals in KwaZulu-Natal: A cross-sectional study.

Pathology of the hand causes functional impairment, with downstream effects for patient occupation, and consequently presents a socioeconomic burden. Investigation of the epidemiology of hand pathology in KwaZulu-Natal (KZN) can help reduce the burden of disease. Identifying where the greatest need is can direct patient awareness initiatives, medical training and appropriate allocation of resources. To establish the prevalence of hand pathology at regional hospitals that offer orthopaedic services in KZN, to describe the patients most commonly affected by these pathologies and to identify the most common pathologies. A cross-sectional investigation of hospital records and charts of patients presenting for orthopaedic care across all 10 regional hospitals in KZN that offer orthopaedic services was undertaken for 1 week's duration (June 2022). Patients were categorised into hand pathology (HP) and general orthopaedic pathology (OP) groups, which were each subdivided into trauma and non-trauma subgroups. Demographic details were collected for all patients. For HP patients, additional detail was collected regarding diagnosis, mechanism, admission and management. The prevalence of HP was calculated as a factor of all orthopaedic presentations. During the investigation, 2 335 patients presented to orthopaedic services. HP represented 21% of these cases. The majority (17%, 406/2 335) were related to trauma and represented 23% of all the traumatic orthopaedic presentations. Distal radius (DR) fractures were the most common hand injury (46%, 188/406) and a large proportion of trauma to the bony elements of the hand were open injuries (23%, 93/406). The remainder of HP cases comprised the non-traumatic group (4%, 91/2 335) and were predominantly infections (68%, 62/91), and many patients with non-traumatic hand pathology required surgery (60%, 55/91) and admission (56%, 52/91). HP represents approximately one-fifth of all orthopaedic presentations to regional health facilities in KZN offering orthopaedic care, and close to a quarter of orthopaedic trauma occurs in the hand. Based on these findings, targeted efforts to improve community awareness of precautions against trauma to the hand, osteopaenia and hand hygiene are suggested as preventive measures. Medical training should emphasise the appropriate management of DR fractures and hand infections, and resources should be differentially allocated to the management of these debilitating HPs to decrease the burden of disease.

Elective Surgical Repair of Popliteal Artery Aneurysms with Posterior Approach vs. Endovascular Exclusion: Early and Long Term Outcomes of Multicentre PARADE Study

The aim of this study was compare elective surgical repair of popliteal artery aneurysms (PAAs) via a posterior approach vs. endovascular exclusion, analysing early and five year outcomes in a multicentre retrospective study. Between January 2010 and December 2023, a retrospectively maintained dataset of all consecutive asymptomatic PAAs that underwent open repair with posterior approach or endovascular repair in 37 centres was investigated. An aneurysm length of ≤ 60 mm was considered the only inclusion criterion. A total of 605 patients were included; 440 PAAs (72.7%) were treated via a posterior approach (open group) and the remaining 165 PAAs (27.3%) were treated using covered stents (Endo group). Continuous data were expressed as median with interquartile range. Thirty day outcomes were assessed and compared. At follow up, primary outcomes were freedom from re-intervention, secondary patency, and amputation free survival. Secondary outcomes were survival and primary patency. Estimated five year outcomes were compared using log rank test. At 30 days, no differences were found in major morbidity, mortality, graft occlusion, or re-interventions. Three patients (0.7%) in the open group experienced nerve injury. The overall median duration of follow up was 32.1 months. At five year follow up, freedom from re-intervention was higher in the open group (82.2% vs. 68.4%; p = .021). No differences were observed in secondary patency (open group 90.7% vs. endo group 85.2%; p = .25) or amputation free survival (open group 99.0% vs. endo group 98.4%; p = .73). A posterior approach was associated with better survival outcomes (84.4% vs. 79.4%; p = .050), and primary patency (79.8% vs. 63.8%; p = .012). Early and long term outcomes following elective repair of PAAs measuring ≤ 60 mm via a posterior approach or endovascular exclusion seem comparable. Nerve injury might be a rare but potential complication for those undergoing open surgery. Endovascular repair is associated with more re-interventions.

FACTORS CONTRIBUTING TO OPEN GLOBE INJURIES AMONG PATIENTS ATTENDING EYE CARE SERVICES AT MBALE REGIONAL REFERRAL HOSPITAL FROM AUGUST 2022 TO MARCH 2023. A CROSS-SECTIONAL STUDY.

Background Cases of open globe injuries are on the increase in various countries mainly as a result of occupation, accidents, and sharp instruments in children. Thus, this study determined the factors contributing to open globe eye injuries among patients attending the eye care services at Mbale Regional Referral Hospital. Methodology Used a cross-sectional design employing quantitative methods of data collection. 100 respondents who participated in the study were selected, where only patients with open globe injuries as well as caretakers were chosen among patients attending eye care services at MRRH. Results Regarding socio-demographic factors, the majority of the respondents (43%) who drank alcohol, (79%) agreed that open globe injuries are more common in children than adults, (52%) mentioned the cornea as the most affected part of the eye. According to individual-related factors, (70%) of the respondents agreed that social-economic status is associated with open globe injuries, (58%) said playing with sharp instruments/objects. Regarding environmental-related factors contributing to open globe injuries, the majority (47%) got injuries at home, (35%) said industry/construction jobs have high risks of open globe injuries. Conclusions Open globe injuries are more common at young age than the adults. Sharp objects like sticks are the most common cause of global injuries among individuals. The socioeconomic status of an individual is associated with global injuries Recommendations Health workers especially ophthalmologists, and ophthalmic clinical officers should sensitize the community and the whole public on risk factors, causes, and how to prevent global injuries. Parents should strictly monitor their children to prevent open globe injuries. Finally, industrial managers, construction engineers, and army commanding officers should procure protective gear and ensure that their workers take precautions like wearing protective gear while at work

Prospective validation of a preoperative scoring system for difficult laparoscopy cholecystectomy.

Difficult laparoscopic cholecystectomy (LC) is defined by its surgical outcomes, including operative time, conversion to open surgery, bile duct and/or vascular injury. Difficult LC can be graded based on intraoperative findings. The main objective of this study is to apply and validate the reliability of their proposed risk score to predict the operative difficulty of an LC, based on their own validated intraoperative scale. Single-center prospective cohort study from 01/2020-12-2023. 367 patients > 18years who underwent LC were included. The preoperative risk scale and intraoperative grading system were registered. Surgical outcomes were determined. Predictive accuracy was evaluated by the Receiver Operator Characteristic curve, sensitivity, specificity, positive, and negative predictive values, and Youden's Index (J). Patients' mean age was 44.1 ± 15.3years. According to the risk score, 39.5% LC were "low" risk difficulty, 49.3% were "medium" risk, and 11.2% were "high" risk difficult LC. Based on the intraoperative grading system, 31.9% were difficult LC (Nassar grades 3-4) and 68.1% were easy LC (Nassar grades 1-2). There was a statistically significant correlation (0.428, p < 0.05) between the preoperative risk score and the intraoperative grading system. The AUC for the preoperative risk score scale and intraoperative difficult LC was 0.735 (95% CI 0.687-0.779) (J: 0.34). A preoperative risk score > 1.5 had an 83.7% sensitivity and a 50.8% specificity for intraoperative difficult LC. A predictive preoperative score for difficult LC and a routine collection of the intraoperative difficulty should be implemented to improve surgical outcomes and surgical planning.

Nontubercular Primary Spinal Epidural Abscess – A Retrospective Study of 11 Culture-Positive Cases

Abstract Background: An epidural abscess that occurs in the absence of contiguous spread from vertebral osteomyelitis or following spinal surgery, spinal anesthesia, or open spinal injuries is considered to be a primary spinal epidural abscess (SEA). The triad of back pain, fever, and progressive neurological dysfunction has long been considered to be the hallmark of primary SEA. Objective: The vast majority of epidural abscesses in our country are either tubercular or associated with pyogenic spondylitis. Primary non tubercular spinal epidural abscesses are rare and also need a different paradigm of management in terms of need for stabilization and duration of antibiotic treatment that we wish to highlight. Material and Methods: Eleven consecutive cases of nontubercular primary SEA were operated by the corresponding author between 2010 and 2019. Their clinical presentation, magnetic resonance imaging (MRI) findings, blood investigations, bacteriological profile, and outcomes were extracted from the patient files and follow-up visits to the outpatient clinic and analyzed 5 years after the last case. Results: All patients had spinal pain at presentation. Seven patients had fever and ten had neurological deficits at presentation. Diabetes and renal failure were the most common comorbidities. All patients had elevated erythrocyte sedimentation rate and C-reactive protein at presentation. The total leukocyte count was not uniformly elevated. One patient who was human immunodeficiency virus positive with a low cell count could not be operated. Diagnosis in his case was established by computed tomography-guided aspirate of the pus. Of the remainder, one patient had no recovery following surgery and two patients had residual deficits. Gram-positive coverage was started empirically in all patients who were operated and based on cultures changed and later extended orally for 4 weeks after discharge till repeat MRI and blood cultures were satisfactory. Conclusions: SEA is a surgical emergency. The majority of cases are caused by Gram-positive bacteria, and many of the patients have comorbidities that need to be addressed. Patients with better preoperative neurological status and those with lumbar location of abscess tend to have a better recovery. Antibiotic treatment must be continued till postoperative radiological and hematological parameters are satisfactory.

The Role of Computed Tomography in Ophthalmic Surgeon Tactics in Shrapnel Wounds to the Eyeball. Clinical Case

There is a clinical case of eyeball metallosis in the background of a foreign body of the posterior segment of the eye in the article. Patient N, 41, complained of a gradual decrease in vision of the right eye. A duration of open injury to the right eye about eight years ago. At the primary ophthalmic examination, the most corrected visual acuity of the right eye was 0.3. The visual acuity of the left eye was 1.0. Intraocular pressure according to pneumotonometry: OD — 13 mm Hg, OS — 14 mm Hg. According to biomicroscopy of the right eye, it was found: the skin of the eyelids is unchanged, the conjunctiva is hyperemic, the mixed reaction of the vessels, the cornea is transparent, spherical, shiny, the anterior chamber is transparent, uneven, the iris is changed in color, foci of stroma hyperpigmentation are observed, the pupil is deformed, narrowed, displaced along the meridian for 1 hour, artificial. Examination of the central and peripheral parts of the fundus is difficult due to deformation and narrowing of the pupil diameter. Due to difficulty performing ophthalmoscopy, the patient underwent the following studies: static perimetry, ultrasound biomicroscopy (UBM) of the anterior segment of the eyeball, electrophysiological examination, B-­scan, computed tomography of the eyeball and orbit. The static perimetry revealed a concentric narrowing of the OD field of view. According to the ultrasound biomicroscopy, the IOL dislocation was revealed anteriorly. В­-Scanning visualizes the blistering cystic edema of the retina, inside which the induration is determined, giving an acoustic shadow. The electrophysiological examination showed changes in the electrical sensitivity and lability of the retina. According to the results of CT in the vitreous cavity, a foreign body was detected in the lower segment along the meridian 6 hours. In accordance with this, the diagnosis was made: OD — metallosis of the eye. Foreign body of the eye.

Markers and Predictors of Proliferative Vitreoretinopathy in Open Eye Injury in an Experiment

The objective of the study: to analyze characteristics of a standardized model of type B gunshot open global injury (open injury without intraocular foreign body).Methods: The experiment was carried out on 36 rabbits (71 eyes). Simulation of type B gunshot open global injury (GOEI) was accomplished using pump equipment. The complex of modern standard and high­technology diagnostic methods to study characteristics of type B GOEI in the control period was performed. Biomicroscopy, ophthalmoscopy, optical coherence tomography, electroretinography, ultrasound examination, MRI, enzyme multiplied immunoassay to determine vitreous fibronectin, and pathomorphological study of the eye globe were carried out. Non­parametric statistical methods of data analysis were used.Results: The above diagnostic methods being used, the GOEI experimental model characteristics were determined, including proliferative vitreoretinopathy (PVR) i.e.incidence rate and dynamics.Conclusion. High reproducibility (77–100 %) of microlevel signs of type B GOEI experimental model was demonstrated, that evidenced standardization of the developed model. The viability of the use of hyphema and hemophthalmia as the PVR and GOEI predictors was justified on the basis of correlation analysis in experiment. The analysis of proliferative signs being made when using different study methods (pathomorphological, indirect ophthalmoscopy, optical coherence tomography, ultrasound examination and MRI) proved their application as PVR markers possible. The interchangeability of the study methods used for PVR diagnosis was also justified.

MEDIAL MALLEOLUS: OPERATIVE OR NONOPERATIVE (MOON). A RANDOMIZED CLINICAL TRIAL OF OPERATIVE VERSUS NONOPERATIVE MANAGEMENT OF ASSOCIATED MEDIAL MALLEOLUS FRACTURES IN UNSTABLE ANKLE FRACTURE DISLOCATIONS

IntroductionUnstable ankle fractures are routinely managed operatively. Due to soft-tissue and implant related complications, there has been recent literature reporting on the non-operative management of well-reduced medial malleolus fractures following fibular stabilisation, but with limited evidence supporting routine application. This trial assessed the superiority of internal fixation of well-reduced (displacement ≤2mm) medial malleolus fractures compared with non-fixation following fibular stabilisation.Methods and participantsSuperiority, pragmatic, parallel, prospective randomised clinical trial conducted over a four year period. A total of 154 adult patients with a bi- or trimalleolar fractures were recruited from a single centre. Open injuries and vertical medial malleolar fractures were excluded. Following fibular stabilisation, patients were randomised intra-operatively on a 1:1 basis to fixation or non-fixation after satisfactory fluoroscopic fracture reduction was confirmed. The primary outcome was the Olerud Molander Ankle Score (OMAS) at one-year post-randomisation. Complications and radiographic outcomes were documented over the follow-up period.ResultsAmong 154 participants (mean age, 56.5 years; 119 women [77%]), 144 [94%] completed the trial. At one-year the median OMAS was 80 (IQR, 60–90) in the fixation group compared with 72.5 (IQR, 55–90) in the non-fixation group (p=0.17). Complication rates were comparable. Significantly more patients in the non-fixation group developed a radiographic non-union (20% vs 0%; p&lt;0.001), with the majority (n=8/13) clinically asymptomatic and one patient required surgical re-intervention for this. Fracture type and reduction quality appeared to influence fracture union and patient outcome.ConclusionsIn this randomised clinical trial comparing internal fixation of well-reduced medial malleolus fractures with non-fixation, following fibular stabilisation, fixation was not superior according to the primary outcome. However, 1 in 5 patients following non-fixation developed a radiographic non-union and whilst the re-intervention rate to manage this was low, the future implications require surveillance. These results may support selective non-fixation of anatomically reduced medial malleolus fractures.

Factors affecting early antibiotic delivery in open tibial shaft fractures

IntroductionThe incidence of infection in open tibial shaft injuries varies with the severity of the injury with rates ranging from roughly 2% for Gustilo-Anderson type I to nearly 43% for type IIIB fractures. As with all fractures, timely antibiotics administration in the emergency department (ED) is an essential component of fracture management and infection prevention. This study identifies factors associated with the expedient administration of antibiotics for open tibial shaft fractures. MethodsThis retrospective study identified patients treated for open tibial shaft fractures at an academic level 1 trauma center between 2015 and 2021. Open fractures were identified by reviewing patient charts. We used chart reviews to gather demographics, fracture characteristics, postoperative outcomes, trauma activation, and time to antibiotic order, delivery, and operating room. Univariate analysis was used to compare patients who received antibiotics within 1 h of ED presentation to those who did not. Multivariate analysis was performed to investigate factors associated with faster delivery of antibiotics. ResultsAmong 70 ED patients with open tibial shaft fractures, 39 (56%) received early administration of antibiotics. Arrival at the ED via emergency medical service (EMS) as opposed to walking in (98% vs. 74%, p = 0.01) and trauma activation (90% vs. 52%, p < 0.001) were significantly more common in the early administration group than the late group. The early group had shorter intervals between antibiotic order and delivery (0.02 h vs. 0.35 h, p = 0.007). Multivariate analysis suggested that trauma activation, EMS arrival, and arrival during non-overnight shifts were independent predictors of a shorter time to antibiotic administration (odds ratios 11.9, 30.7, and 5.4, p = 0.001, 0.016, and 0.013, respectively). DiscussionEarlier antibiotic delivery is associated with non-overnight arrival at the ED, arrival via EMS, and a coordinated trauma activation. Our findings indicate that in cases where administering antibiotics is critical to achieving positive outcomes, it is advisable to initiate a coordinated trauma response. Furthermore, hospital personnel should be attentive to the need for rapid administration of antibiotics to patients with open fractures who arrive via walk-in or during late-night hours.