A retrospective analysis of the definitive management of open talus fractures at a major trauma centre, comparing ORIF to FUSION: cohort study and audit of BOAST 4 guidelines

Purpose Open talus fractures are notoriously difficult to manage, and they are commonly associated with a high level of complications including non-union, avascular necrosis and infection. Currently, the management of such injuries is based upon BOAST 4 guidelines although there is no suggested definitive management, and thus, definitive management is based upon surgeon preference. The key principles of open talus fracture management which do not vary between surgeons are early debridement, orthoplastic wound care, anatomic reduction and definitive fixation whenever possible. However, there is much debate over whether the talus should be preserved or removed after open talus fracture/dislocation and proceeded to tibiocalcaneal fusion. Methods A review of electronic hospital records for open talus fractures from 2014 to 2021 returned fourteen patients with fifteen open talus fractures. Seven cases were initially managed with ORIF, and five cases were definitively managed with FUSION, while the others were managed with alternative methods. We collected patient’s age, gender, surgical complications, surgical risk factors and post-treatment functional ability and pain and compliance with BOAST guidelines. The average follow-up of the cohort was 4 years and one month. EQ-5D-5L and FAAM-ADL/Sports score was used as a patient reported outcome measure. Data were analysed using the software PRISM. Results Comparison between FUSION and ORIF groups showed no statistically significant difference in EQ-5D-5L score (P = 0.13), FAAM-ADL (P = 0.20), FAAM-Sport (P = 0.34), infection rate (P = 0.55), surgical times (P = 0.91) and time to weight bearing (P = 0.39), despite a higher proportion of polytrauma and Hawkins III and IV fractures in the FUSION group. Conclusion FUSION is typically used as second line to ORIF or failed ORIF. However, there is a lack of studies that directly compared outcome in open talus fracture patients definitively managed with FUSION or ORIF. Our results demonstrate for the first time that FUSION may not be inferior to ORIF in terms of patient functional outcome, infection rate and quality of life, in the management of patients with open talus fracture patients. Of note, as open talus fractures have increased risks of complications such as osteonecrosis and non-union, FUSION should be considered as a viable option to mitigate these potential complications in these patients.

Treatment of chronic osteomyelitis with antibiotic-impregnated polymethyl methacrylate (PMMA) – the Cierny approach: is the second stage necessary?

Background Chronic osteomyelitis is a challenge for orthopedic surgeons. Most patients with osteomyelitis receive two-stage management according to Cierny-Mader. The first stage includes radical debridement and insertion of an antibiotic-impregnated cement spacer (ACS) (beads, rods, nails, or blocks) into the bone defect. The second stage is performed 6–8 weeks later, when the spacer is removed and a cancellous autograft is placed within the bone defect. The possibility of ACS as definitive management for osteomyelitis, avoiding the second stage, is presented. Methods Sixteen patients with osteomyelitis received radical debridement and insertion of an ACS in all forms into the bone defect as a definitive management. In 8 patients, the tibia was infected, 4 had femur infection, 2 humerus, 1 fibula, and 1 ankle. The mean age at the time of the first stage of reconstruction was 49 years (range, 13–71 years). According to the Cierny-Mader classification, 1 patient was C-M IA, another was IB, 7 IIIA, 6 IIIB, and 1 was 4A. All B hosts had systemic illnesses. The mean follow-up period was 6 years (1.5–16 years). Results No patient exhibited radiographic evidence of excessive bone loss. Signs of recurrence of osteomyelitis were not noted in any of the patients, and no fractures had occurred by the last follow-up. Conclusion Our study suggests that a proportion of patients with planned retention of ACS appear to function well without requiring further surgical intervention, especially in elderly or vulnerable patients.

Wellens Syndrome: A Review Article

Wellens syndrome is a pre-infarct stage of coronary syndrome and a clinical condition associated with left descending proximal anterior artery stenosis. Diagnostic criteria for Wellens syndrome include clinical history, ECG changes, and laboratory results. The pathognomonic ECG of Wellens syndrome is anterior inverted T-wave in precordial leads, which can be seen during pain-free period, accompanied by isoelectric or minimally elevated ST segment (<1 mm), no precordial Q waves, and normal or slightly elevated cardiac serum markers. Early diagnosis leads to early management and a better prognosis. Early management of Wellens syndrome involves maintaining an airway, breathing, circulation, monitoring vital signs, and medical management. Still, the only definitive management is urgent cardiac angiography to prevent further myocardial ischemia. The combination of early diagnostic and appropriate management will reduce complications and mortality rates. Keywords: Wellens Syndrome, Acute Coronary Syndromes, pre-Infarct MI.

Biological Therapy on Infected Traumatic Wounds: A Case-Control Study

Background:Traumatic wound is a great challenging issue to surgeons, because of large in size, heavily contaminated, infected and unscenic. Infection proceeded to progressive tissue necrosis, septicemia, organ failure or even death. Majority has polymicrobial infections. Bacteriohage therapy will have revolutionized in the treatment of wound. The present study was planned to evaluate the efficacy of topical bacteriophage therapy on large traumatic wounds in comparison with conventional therapy. Methods:The Study conducted from Sept. 2018 to July 2020. Samples between 12- 60 years was taken into study. Customized bacteriophage applied over the wound after serial debridement in case and conventional dressing in control. Fifty four wounded person met the clinical inclusion criteria; 27 in each group. Wound swab and tissue biopsy was taken for bacterial isolation. Isolated specific phage was applied over the wound on alternate day till the wound become sterile and fit for further definitive management. Results: A significant and rapid improvement was observed in wound healing in cases then control group. Average number of day required for complete granulation of wound and attaining sterility was half in cases then control. The hospital stay of the patients on BT was half (20days) than those on CT (40 days). The financial analysis also favours the BT over CT as only 1/third expenditure incurred in BT group as compared to CT Conclusion:Topical Bacteriophage therapy is efficient, effective to clearing the infection in shorter length of time and cost effective for infected traumatic wounds as compared to conventional dressing.

Cutting out Cholecystectomy on Index Hospitalization Leads to Increased Readmission Rates, Morbidity, Mortality and Cost

Biliary tract diseases that are not adequately treated on index hospitalization are linked to worse outcomes, including high readmission rates. Delays in care for conditions such as choledocholithiasis, gallstone pancreatitis, and cholecystitis often occur due to multiple reasons, and this delay is under-appreciated as a source of morbidity and mortality. Our study is based on the latest Nationwide Readmissions Database review and evaluated the effects of postponing definitive management to a subsequent visit. The study shows a higher 30-day readmission rate in addition to increased mortality rate, intubation rate, vasopressor use in this patient population and significantly added financial burden.

O-EGS09 Effect of introducing an ambulatory care service on management of patients requiring acute cholecystectomy

Background Biliary pathology is a large tranche of the emergency surgical take, taking up many bed days, with many patients not receiving definitive management on their primary admission. An Emergency Surgical Ambulatory Care (ESAC) service was established at our hospital in 2019, aiming to provide a streamlined platform for diagnosis and surgical management of patients. Most notably this included patients with symptomatic gallstones which could be managed on a semi-urgent basis without hospital admission. We aim to analyse the efficiency of this novel service in hopes of identifying room for improvement so that we may enhance our patient outcomes. Methods Two time periods were retrospectively assessed; September-December 2018 (pre- ESAC) and September-December 2019 (six months after ESAC started). Patients with Cholelithiasis (ICD-K80) and Cholecystitis (ICD-K81) were identified, and those with either an incidental diagnosis of gallstones without symptoms, with gallstone pancreatitis, severe inflammation (empyema, gangrene, perforation), requiring ERCP or if they were unfit for surgery were excluded. Data was collected on number of admissions, length of stay and rate of cholecystectomy. Patients were divided into 2018 SAU, 2019 SAU and 2019 ESAC to compare the difference in their outcomes. Data are presented as median (range). Results Some 57 patients presented acutely in 2018 compared to 82 in 2019. The median wait to operation of 43.5 days in 2018 was significantly reduced to 7 days in 2019. Conclusions The introduction of an ESAC service in 2019 has allowed a reduction in number of admissions, total length of stay of patients and significantly reduced waiting time for surgery. Use of ESAC has shown to be more efficient in terms of hospital bed occupation and indirectly, utilization of resources. The high surgical success rate also ensures fewer patients re-presenting with the same pathology to the acute take and hence contributes to reducing strain on the on-call team. Further work is being done to reduce the number of patients presenting through the SAU pathway, and preferentially attending through ESAC.

Hoarseness in an older adult: Ortner syndrome

A detailed examination in an older adult presenting with chronic hoarseness is mandatory to exclude an upper aerodigestive tract malignancy. We describe a 71-year-old chronic smoker with essential hypertension who presented with hoarseness and vocal fatigue for 5 months. Laryngoscopic examination showed left vocal fold paralysis with phonation gap. No growth was seen at all laryngeal and hypopharyngeal subsites. The rest of the head and neck, chest, upper limbs and neurovascular examination were unremarkable. A plain chest radiograph demonstrated a cause for the left recurrent laryngeal nerve palsy. The diagnosis, complications and definitive management of the underlying cause and resultant voice problem will be discussed.