Aims

The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of infected segmental bone defects, and to analyze predictive factors associated with unfavourable outcomes.

Aims. Musculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections. Methods. Between January 2019 and December 2022, 106 patients with bone and joint infections were treated by five surgeons in five hospitals. Surgical debridement and calcium sulphate bead insertion was performed for local elution of antibiotics in high concentration. In all, 100 patients were available for follow-up at regular intervals. Choice of antibiotic was tailor made for each patient in consultation with microbiologist based on the organism grown on culture and the sensitivity. In majority of our cases, we used a combination of vancomycin and culture sensitive heat stable antibiotic after a thorough debridement of the site. Primary wound closure was achieved in 99 patients and a split skin graft closure was done in one patient. Mean follow-up was 20 months (12 to 30). Results. Overall, six out of 106 patients (5.6%) presented with sepsis and poorly controlled comorbid conditions, and died in the hospital within few days of index surgery. Out of the remaining 100 patients, control of infection was achieved in 95 patients (95%). Persistence of infection was noted in five (5%) patients. Out of these 95 patients that had good control of infection, four patients (4.2%) with gap nonunion needed Masquelet procedure to achieve union. Conclusion. Our multicentre experience confirmed that surgical debridement along with calcium sulphate bead insertion was effective in treating bone and joint infections without any side effects and complications. Cite this article: Bone Jt Open 2023;4(7):516–522

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The Open-Fracture Patient Evaluation Nationwide (OPEN) study was performed to provide clarity in open fracture management previously skewed by small, specialist centre studies and large, unfocused registry investigations. We report the current management metrics of open fractures across the UK.

Aims

It has been generally accepted that open fractures require early skeletal stabilization and soft-tissue reconstruction. Traditionally, a standard gauze dressing was applied to open wounds. There has been a recent shift in this paradigm towards negative pressure wound therapy (NPWT). The aim of this study was to compare the clinical outcomes in patients with open tibial fractures receiving standard dressing versus NPWT.

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In this randomized study, we aimed to compare quality of regenerate in monolateral versus circular frame fixation in 30 patients with infected nonunion of tibia.

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Type IIIB open tibial fractures are devastating high-energy injuries. At initial debridement, the surgeon will often be faced with large bone fragments with tenuous, if any, soft-tissue attachments. Conventionally these are discarded to avoid infection. We aimed to determine if orthoplastic reconstruction using mechanically relevant devitalized bone (ORDB) was associated with an increased infection rate in type IIIB open tibial shaft fractures.

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The aims of this study were to quantify health state utility values (HSUVs) after a tibial fracture, investigate the effect of complications, to determine the trajectory in HSUVs that result in these differences and to quantify the quality-adjusted life years (QALYs) experienced by patients.

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The aim of this study was to evaluate near-infrared spectroscopy (NIRS) as a continuous, non-invasive monitor for acute compartment syndrome (ACS).

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The aim of this study was to explore the patients’ experience of recovery from open fracture of the lower limb in acute care.

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This study reviews the use of a titanium mesh cage (TMC) as an adjunct to intramedullary nail or plate reconstruction of an extra-articular segmental long bone defect.

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This study describes the use of the Masquelet technique to treat segmental tibial bone loss in 12 patients.

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The aim of this study was to identify risk factors for the failure of exchange nailing in nonunion of tibial diaphyseal fractures.

This is a retrospective study of survivors of recent conflicts with an open fracture of the femur. We analysed the records of 48 patients (48 fractures) and assessed the outcome. The median follow up for 47 patients (98%) was 37 months (interquartile range 19 to 53); 31 (66%) achieved union; 16 (34%) had a revision procedure, two of which were transfemoral amputation (4%).

The New Injury Severity Score, the method of fixation, infection and the requirement for soft-tissue cover were not associated with a poor outcome. The degree of bone loss was strongly associated with a poor outcome (p = 0.00204). A total of four patients developed an infection; two with S. aureus, one with E. coli and one with A. baumannii.

This study shows that, compared with historical experience, outcomes after open fractures of the femur sustained on the battlefield are good, with no mortality and low rates of infection and late amputation. The degree of bone loss is closely associated with a poor outcome.

Cite this article: Bone Joint J 2015;97-B:842–6.

We describe the outcome of tibial diaphyseal fractures in the elderly (≥ 65 years of age). We prospectively followed 233 fractures in 225 elderly patients over a minimum ten-year period. Demographic and descriptive data were acquired from a prospective trauma database. Mortality status was obtained from the General Register Office database for Scotland. Diaphyseal fractures of the tibia in the elderly occurred predominantly in women (73%) and after a fall (61%). During the study period the incidence of these fractures decreased, nearly halving in number. The 120-day and one-year unadjusted mortality rates were 17% and 27%, respectively, and were significantly greater in patients with an open fracture (p < 0.001). The overall standardised mortality ratio (SMR) was significantly increased (SMR 4.4, p < 0.001) relative to the population at risk, and was greatest for elderly women (SMR 8.1, p < 0.001). These frailer patients had more severe injuries, with an increased rate of open fractures (30%), and suffered a greater rate of nonunion (10%).

Tibial diaphyseal fractures in the elderly are most common in women after a fall, are more likely to be open than in the rest of the population, and are associated with a high incidence of nonunion and mortality.

Cite this article: Bone Joint J 2013;95-B:1255–62.

The aim of this study was to report the pattern of severe open diaphyseal tibial fractures sustained by military personnel, and their orthopaedic–plastic surgical management.The United Kingdom Military Trauma Registry was searched for all such fractures sustained between 2006 and 2010. Data were gathered on demographics, injury, management and preliminary outcome, with 49 patients with 57 severe open tibial fractures identified for in-depth study. The median total number of orthopaedic and plastic surgical procedures per limb was three (2 to 8). Follow-up for 12 months was complete in 52 tibiae (91%), and half the fractures (n = 26) either had united or in the opinion of the treating surgeon were progressing towards union. The relationship between healing without further intervention was examined for multiple variables. Neither the New Injury Severity Score, the method of internal fixation, the requirement for vascularised soft-tissue cover nor the degree of bone loss was associated with poor bony healing. Infection occurred in 12 of 52 tibiae (23%) and was associated with poor bony healing (p = 0.008). This series characterises the complex orthopaedic–plastic surgical management of severe open tibial fractures sustained in combat and defines the importance of aggressive prevention of infection.

Cite this article: Bone Joint J 2013;95-B:101–5.

Heterotopic ossification (HO) is perhaps the single most significant obstacle to independence, functional mobility, and return to duty for combat-injured veterans of Operation Enduring Freedom and Operation Iraqi Freedom. Recent research into the cause(s) of HO has been driven by a markedly higher prevalence seen in these wounded warriors than encountered in previous wars or following civilian trauma. To that end, research in both civilian and military laboratories continues to shed light onto the complex mechanisms behind HO formation, including systemic and wound specific factors, cell lineage, and neurogenic inflammation. Of particular interest, non-invasive in vivo testing using Raman spectroscopy may become a feasible modality for early detection, and a wound-specific model designed to detect the early gene transcript signatures associated with HO is being tested. Through a combined effort, the goals of early detection, risk stratification, and development of novel systemic and local prophylaxis may soon be attainable.

The open blast fracture of the pelvis is considered to be the most severe injury within the spectrum of battlefield trauma. We report our experience of 29 consecutive patients who had sustained this injury in Afghanistan between 2008 and 2010. Their median new injury severity score (NISS) was 41 (8 to 75), and mean blood requirement in the first 24 hours was 60.3 units (0 to 224). In addition to their orthopaedic injury, six had an associated vascular injury, seven had a bowel injury, 11 had a genital injury and seven had a bladder injury. In all, eight fractures were managed definitively with external fixation and seven required internal fixation. Of those patients who underwent internal fixation, four required removal of metalwork for infection. Faecal diversion was performed in nine cases. The median length of hospital stay following emergency repatriation to the United Kingdom was 70.5 days (5 to 357) and the mean total operating time was 29.6 hours (5 to 187). At a mean follow-up of 20.3 months (13.2 to 29.9), 24 patients (82.8%) were able to walk and 26 (89.7%) had clinical and radiological evidence of stability of the pelvic ring.

As a result of the increase in terrorism, injuries that were previously confined exclusively to warfare can now occur anywhere, with civilian surgeons who are involved in trauma care potentially required to manage similar injuries. Our study demonstrates that the management of this injury pattern demands huge resources and significant multidisciplinary input. Given the nature of the soft-tissue injury, we would advocate external fixation as the preferred management of these fractures. With the advent of emerging wound and faecal management techniques, we do not believe that faecal diversion is necessary in all cases.

The outcomes of 261 nerve injuries in 100 patients were graded good in 173 cases (66%), fair in 70 (26.8%) and poor in 18 (6.9%) at the final review (median 28.4 months (1.3 to 64.2)). The initial grades for the 42 sutures and graft were 11 good, 14 fair and 17 poor. After subsequent revision repairs in seven, neurolyses in 11 and free vascularised fasciocutaneous flaps in 11, the final grades were 15 good, 18 fair and nine poor. Pain was relieved in 30 of 36 patients by nerve repair, revision of repair or neurolysis, and flaps when indicated. The difference in outcome between penetrating missile wounds and those caused by explosions was not statistically significant; in the latter group the onset of recovery from focal conduction block was delayed (mean 4.7 months (2.5 to 10.2) vs 3.8 months (0.6 to 6); p = 0.0001). A total of 42 patients (47 lower limbs) presented with an insensate foot. By final review (mean 27.4 months (20 to 36)) plantar sensation was good in 26 limbs (55%), fair in 16 (34%) and poor in five (11%). Nine patients returned to full military duties, 18 to restricted duties, 30 to sedentary work, and 43 were discharged from military service. Effective rehabilitation must be early, integrated and vigorous. The responsible surgeons must be firmly embedded in the process, at times exerting leadership.

We describe 261 peripheral nerve injuries sustained in war by 100 consecutive service men and women injured in Iraq and Afghanistan. Their mean age was 26.5 years (18.1 to 42.6), the median interval between injury and first review was 4.2 months (mean 8.4 months (0.36 to 48.49)) and median follow-up was 28.4 months (mean 20.5 months (1.3 to 64.2)). The nerve lesions were predominantly focal prolonged conduction block/neurapraxia in 116 (45%), axonotmesis in 92 (35%) and neurotmesis in 53 (20%) and were evenly distributed between the upper and the lower limbs. Explosions accounted for 164 (63%): 213 (82%) nerve injuries were associated with open wounds. Two or more main nerves were injured in 70 patients. The ulnar, common peroneal and tibial nerves were most commonly injured. In 69 patients there was a vascular injury, fracture, or both at the level of the nerve lesion. Major tissue loss was present in 50 patients: amputation of at least one limb was needed in 18. A total of 36 patients continued in severe neuropathic pain.

This paper outlines the methods used in the assessment of these injuries and provides information about the depth and distribution of the nerve lesions, their associated injuries and neuropathic pain syndromes.

Introduction. Negative pressure wound therapy (NPWT) and vessel loop assisted closure are two common methods used to assist with the closure of fasciotomy wounds. This retrospective review compares these two methods using a primary outcome measurement of skin graft requirement. Methods. A retrospective search was performed to identify patients who underwent fasciotomy at our institution. Patient demographics, location of the fasciotomy, type of assisted closure, injury characteristics, need for skin graft, length of stay and evidence of infection within 90 days were recorded. Results. A total of 56 patients met the inclusion criteria. Of these, 49 underwent vessel loop closure and seven underwent NPWT assisted closure. Patients who underwent NPWT assisted closure were at higher risk for requiring skin grafting than patients who underwent vessel loop closure, with an odds ratio of 5.9 (95% confidence interval 1.11 to 31.24). There was no difference in the rate of infection or length of stay between the two groups. Demographic factors such as age, gender, fracture mechanism, location of fasciotomy and presence of open fracture were not predictive of the need for skin grafting. Conclusion. This retrospective descriptive case series demonstrates an increased risk of skin grafting in patients who underwent fasciotomy and were treated with NPWT assisted wound closure. In our series, vessel loop closure was protective against the need for skin grafting. Due to the small sample size in the NPWT group, caution should be taken when generalising these results. Further research is needed to determine if NPWT assisted closure of fasciotomy wounds truly leads to an increased requirement for skin grafting, or if the vascular injury is the main risk factor