Norwegian Open Fracture Management System: Outcomes After 10 Years Working in Low-Resource Settings in Cambodian Hospitals

Introduction: The treatment of open lower limb fractures represents a major challenge for any trauma surgeon, and this even more so in resource-limited areas. The aim of the study is to describe the intervention, report the treatment plan, and observe the effectiveness of the Norwegian Open Fracture Management System in saving lower limbs in rural settings. Materials and Methods: A retrospective and prospective interventional study was carried out in the period 2011 through 2017 in six rural hospitals in Cambodia. The fractures were managed with locally produced external fixators and orthosis developed in 2007. Based on skills and living locations, two local surgeons and one paramedic without reconstructive surgery experience were selected to reach the top of the reconstructive ladder and perform limb salvage surgeries. This study evaluated 56 fractures using the Ganga Hospital Open Injury Score (GHOIS) for Gustilo-Anderson Type IIIA and Type IIIB open fracture classification groups. Results: The primary success rate in open tibia fractures was 64.3% (95% CI, 50.3 - 76.3). The average treatment time to complete healing for all of the patients was 39.6 weeks (95% CI, 34.8 - 44.4). A percentage of 23.2% (95% CI, 13.4 - 36.7) experienced a deep infection. Fifteen of the patients had to undergo soft tissue reconstruction and 22 flaps were performed. Due to non-union, a total of 15 bone grafts were performed. All of the 56 patients in the study gained limb salvage and went back to work. Conclusion: The given fracture management program proves that low-resource countries are able to produce essential surgical tools at high quality and low price. Treatment with external fixation and functional bracing, combined with high-level training of local surgeons, demonstrates that a skilled surgical team can perform advanced limb salvage surgery in low-resource settings.

Magnetic Resonance Imaging of the Knee in the Presence of Bridging External Fixation: A Comparative Experimental Evaluation of Four External Fixators, Including Dolphix®

Performing MR investigation on patients instrumented with external fixators is still controversial. The aim of this study is to evaluate the quality of MR imaging of the knee structures in the presence of bridging external fixators. Different cadaveric lower limbs were instrumented with the MR-conditional external fixators Hofmann III (Stryker, Kalamazoo, MI, USA), Large external Fixator (DePuy Synthes, Raynham, MA, USA), XtraFix (Zymmer, Warsaw, IN, USA) and a newer implant of Ketron Peek CA30 and ERGAL 7075 pins, Dolphix®, (Citieffe, Bologna, Italy). The specimens were MR scanned before and after the instrumentation. The images were subjectively judged by a pool of blinded radiologists and then quantitatively evaluated calculating signal intensity, signal to noise and contrast to noise in the five regions of interest. The area of distortion due to the presence of metallic pins was calculated. All the images were considered equally useful for diagnosis with no differences between devices (p > 0.05). Only few differences in the quantification of images have been detected between groups while the presence of metallic components was the main limit of the procedure. The mean length of the radius of the area of distortion of the pins were 53.17 ± 8.19 mm, 45.07 ± 4.33 mm, 17 ± 5.4 mm and 37.12 ± 10.17 mm per pins provided by Zimmer, Synthes, Citieffe and Stryker, respectively (p = 0.041). The implant of Ketron Peek CA30 and ERGAL 7075 pins showed the smallest distortion area.

Treatment of fractures and other orthopedic problems in cats and dogs using versatile external fixator

Many complicated bone fractures can be healed by different techniques including linear external fixation. New generation linear external fixators enhanced the scope of application for bone fractures by mechanical progress. Difficulties include implementing enough pins through fixation clamps to the comminuted fragments or clamp addition and fixing it properly to the rod with the correct pin insertion angle. Effective configurations may not always result. This study sought to reveal the clinical efficiency of modified clamps of a versatile external fixator (VEF) to fix different types of fractures and orthopedic problems according to the radiographic and clinical results. We used this fixator on 17 cats and 17 dogs of different ages and sizes, having different types of antebrachium, humerus, tibia, ulna fractures, and bone-muscle deformities. Clamps had different features to connect fixator pins. Many fixator configurations were created according to the fracture type and body weight of the animals. The most used ones were unilateral and bilateral configurations. The callus formation and visual gait analysis were observed after the operations, until the removal of the fixator. After fixator removal, the visual gait status of the limbs was excellent in 67% of the cases, good in 15%, fair in 12%, and poor in 6%. We found that rods and fixator pins were connected easily by semi-locked clamps. Also, the double pin holding clamps saved space on the fixation rod by the application of two pins through one clamp. We think that clamps of versatile external fixators can easily be constructed to limb fractures and save time during surgery.

Physiotherapy Rehabilitation in Post Operative Tibia- Fibula Fracture with External Fixators

Introduction: A tibia - fibula fracture occurs when a fall or trauma to the lower extremities puts more tension on the bones than they can tolerate. Diaphyseal tibial fractures are the most common long bone fracture. Lower extremity Tibia and fibula fractures are examples of fractures. Tibial shaft fractures are most typically associated with a history of severe trauma. The tibia is the most commonly fractured bone in the lower extremity. The bone's shaft is in the middle Fibula fractures are usually, but not always, accompanied by tibial shaft fractures. Case Presentation: At the previous 15 days, a 49-year-old male patient accounted in a hospital with a road traffic accident. Discussion: The physiotherapy was given to this patient for muscle energy technique resulting in a high degree of range of motion in the lower extremity, reduce pain, and improves flexibility and strength. Conclusion: Physiotherapy has a significant effect on pain, strength, and range of motion. The result of this case report specifies that it may be effective for pain relief, improvement in strength, and functional ability.

Basic Biomechanics for Craniofacial Surgeons: The Responses of Alloplastic Materials and Living Tissues to Mechanical Forces

Many terms such as twist, compress, bend, and stretch, describe how materials behave when subjected to mechanical stresses. Subjective adjectives to describe the property of materials such as hard or brittle are imprecise and impedes proper understanding of important principles needed in planning and performing surgical treatments. The viability of tissue and time dependent variables effect healing and compound the issue. Some parameters are time dependent (strain rate), while others are nearly independent of time (Young’s modulus). The craniofacial skeleton and enveloping soft tissues are viscoelastic composite materials which undergo time-dependent changes upon loading. The ability to remodel and respond to environmental changes makes them “smart,” reenforcing where needed and removing where not required based on a set of predetermined upper and lower thresholds. This mini review has 7 sections on engineering principles that underpin craniofacial surgery: (1) The general concept of mechanics: load, force, stress, strain, compression, tension, shear, stress-strain curves and values derived from them such as Young’s modulus, fatigue damage, and load- shearing. (2) Material properties of bone and suture and structural engineering of the craniofacial skeleton in normal and pathological conditions. (3) Fixation using wires, screws, and plates: anatomy and function of screws and plates, locking plates, lag screws, internal and external fixators. (4) Biomechanics of distraction osteogenesis and the effects of radiation. (5) Finite element analysis and other computational biomechanical tools. (6) Virtual surgical planning, cutting guides, and intra-operative navigation. (7) Tissue engineering: design goals, criteria, and constraints. An appreciation and understanding of these biomechanical principles will help craniofacial surgeons to facilitate intrinsic optimization and better treat complex morphological problems, helping one achieve the most favorable and durable results. The biological responses to mechanical stress are extremely important as well, but due to space constraints, they will be the subject of a separate dedicated review.

Study on the relationship between the timing of conversion from external fixation to internal fixation and infection in the treatment of open fractures of extremities

Objective To investigate the relationship between the infection rate and the timing of replacement of temporary external fixators with internal fixation, and the timing of immediate or delayed internal fixation after removal of temporary external fixation in the staging treatment modality of open fractures of extremities. Methods A retrospective analysis was performed on 122 cases of open fractures of extremities. External fixators were applied at the early stage and replaced with internal fixation when the condition of soft tissues improved and inflammatory indexes dropped to the normal range or showed a steady downward trend. Depending on the carrying time of external fixators after wound closure or healing, the patients were divided into three groups; the carrying time of groups A, B, and C was ≤ 14 days, 15–28 days, and > 28 days, respectively. Depending on the immediate or delayed internal fixation after removal of external fixator, patients were divided into group a (immediate internal fixation after removal of external fixator) and group b (delayed internal fixation after removal of external fixator, 5–7 days later). Results The infection rates of groups A, B, and C were 6.5%, 5.9%, and 23.3%, respectively. The differences among the three groups were statistically significant (P < 0.05). The infection rates of different Gustilo–Anderson fractures were as follows: no cases of infection out of 10 cases with type I fracture (0%); two cases of infection out of 35 cases with type II fracture (5.7%); three cases of infection out of 36 cases with IIIa fracture (8.3%); five cases of infection out of 28 cases with IIIB fracture (17.9%); and five cases of infection out of 13 cases with IIIC fracture (38.5%). The differences among the five groups were statistically significant. Conclusions The occurrence of infection of open fractures of extremities is associated with the fracture severity (Gustilo classification). For open fractures of Gustilo types I and II, the final internal fixation should be placed as soon as possible when the recovery of general and local conditions is good and the infection is controlled.

Preparation of hospitals for mass casualty incidents in Bavaria, Germany: care capacities for penetrating injuries and explosions in TerrorMASCALs

Background In a terror attack mass casualty incident (TerrorMASCAL), compared to a “normal” MASCAL, there is a dynamic course that can extend over several hours. The injury patterns are penetrating and perforating injuries. This article addresses the provision of material and personnel for the care of special injuries of severely injured persons that may occur in the context of a TerrorMASCAL. Methods To answer the research question about the preparation of hospitals for the care of severely injured persons in a TerrorMASCAL, a survey of trauma surgery departments in Bavaria (Germany) was conducted using a questionnaire, which was prepared in three defined steps based on an expert consensus. The survey is divided into a general, neurosurgical, thoracic, vascular and trauma surgery section. In the specialized sections, the questions relate to the implementation of and material and personnel requirements for special interventions that are required, particularly for injury patterns following gunshot and explosion injuries, such as trepanation, thoracotomy and balloon occlusion of the aorta. Results In the general section, it was noted that only a few clinics have an automated system to notify off-duty staff. When evaluating the data from the neurosurgical section, the following could be established with regard to the performance of trepanation: the regional trauma centers do not perform trepanation but nevertheless have the required material and personnel available. A similar result was recorded for local trauma centers. In the thoracic surgery section, it could be determined that almost all trauma centers that do not perform thoracotomy have the required material available. This group of trauma centers also stated that they have staff who can perform thoracotomy independently. The retrograde endovascular aortic occlusion procedure is possible in 88% of supraregional, 64% of regional and 10% of local trauma centers. Pelvic clamps and external fixators are available at all trauma centers. Conclusion The results of the survey show potential for optimization both in the area of framework conditions and in the care of patients. Consistent and specific training measures, for example, could improve the nationwide performance of these special interventions. Likewise, it must be discussed whether the abovementioned special procedures should be reserved for higher-level trauma centers.