Locally developed external fixators as definitive treatment of open tibia diaphyseal fractures: a clinical prospective study conducted in Ivory Coast.

BACKGROUND: This study sought to evaluate the effectiveness of locally developed external fixators (LDEF) as definitive treatment for open tibia diaphyseal fractures (OTDF) in Ivory Coast. METHODS: Gustilo I, II, and IIIA OTDFs of patients admitted within 24 hours of injury were prospectively included and treated with LDEF. The rates of union, mal-union, septic complications, as well as the functional results were assessed, in addition to the LDEF construct's integrity. Predictive factors of failure or poor results were assessed. RESULTS: Overall, 40 OTDF patients were admitted within 24 hours of injury. Gustilo I, II, and IIIA fractures were observed in three, 13, and 24 patients, respectively. Uneventful fracture healing was obtained in 29 cases, with an average union time of 8.47 months. Mal-union and non-union were registered in three and four cases, respectively. Pin-track infection (PTI) was observed in 13 cases and deep infection in seven. Infection resolved in all patients except four, who developed chronic osteomyelitis. None of the non-unions were associated with an infection. The overall functional result was satisfactory in 32 patients. PTI was the only predictive factor for chronic infection. Biplanar frames, when compared to monoplanar constructs, were associated with a significantly improved functional outcome. CONCLUSION: LDEF improved significantly the OTDF management, as it provided better stability and superior fracture healing rates than what is observed with the standard of care in the same environment. PTI remains an essential problem but with, hopefully, limited negative consequences.

[The reasons for refusal and abandonment of treatment in the emergency surgery at the University Hospital Center of Bouake, Ivory Coast]. / Les raisons du refus et abandon de soins aux urgences chirurgicales du Centre Hospitalier et Universitaire de Bouaké, Côte d'Ivoire.

The refusal and abandonment of treatment is a behavior frequently observed in our daily practice. The purpose of this study was to describe the epidemiology and to identify the reasons for refusals and abandonment of treatment. We conducted a prospective study in the emergency surgery at the University Hospital Center of Bouake from 1st January 2018 to 31st December 2018. It involved all patients admitted with traumatic lesions who had refused or abandoned treatment. Data from 106 cases (16%) of refusal and abandonment of treatment out of 662 cases admitted with limb traumas were examined over this period. The average age of patients was 37 years. The study enrolled 77 men (72.6%). Tertiary sector workers accounted for 56.6% (n= 60) of cases. Lesions were dominated by closed fractures (82.1%; n= 87) and pelvic limbs were the most achieved (78.3%; n=83). Treatment was based on surgery (n=85; 80.2% ) and orthopaedic treatment (n=21; 19.8%). The cost of orthopedic treatment was estimated at 26 500 CFA francs (40 euros) while at 250 000 FCFA (380 euros) for surgical treatment. These costs varied as a function of implant prescribed and its location. Refusal of tratment was expressed by patients (n=30; 28.3%) and by parents (n=76; 71.7%). Reported reasons were dominated by financial problems (n=62; 58.5%), trust in traditional medicine (n=42; 39.6%), religious belief (n=2; 1.9%). The average time of refusal was 22 hours. Eighty eight point seven percent (n=94) of patients signed discharge while 11.3% (n=12) escaped. Refusal of care is a recurrent theme in our context and is due to inadequate health care management of people with limited financial resources.

Treatment of open tibia fractures in Sub-Saharan African countries : a systematic review.

Open tibia fracture (OTF) treatment is well documented in developed countries. Yet, this fracture pattern remains challenging because it is associated with an increased risk of infection and delayed union, particularly in case of Gustilo III B and C open fractures. Since access to healthcare is limited in Sub- Saharan African countries, this paper explores the results of OTF management in this setting. A systematic review of the literature was conducted using current databases such as MEDLINE, Cochrane, EMBASE, PubMed, ScienceDirect, Scopus, and Google Scholar in order to identify prospective studies with cohorts of patients treated for OTF. Studies were included based on predefined inclusion and exclusion criteria. The quality of studies was analyzed by the Coleman Methodology Score (CMS). Eight papers met the inclusion criteria and had an average CMS of 70 (range 54-73). The most common treatment was non-operative management of the fracture with cast immobilization (67%). Gustilo Type II and III fractures were associated with a higher risk of complications. The infection rate was 30%. Malunion, chronic osteomyelitis and nonunion were observed in 14.5%, 12.3%, and 7% of the cases, respectively. More complications were observed with non-operative treatment (cast immobilization) than with surgical fixation. Although the surgical environment does not allow for internal fixation, poor results of non-operative management of open fractures should lead to the introduction of trainings on the proper use of external fixators. It is also advisable to support the development of locally produced external devices that utilize local source materials, which would make external fixation available at a reasonable cost.

[Fractures of the pelvis causing vaginal wound]. / Fractures du bassin occasionnant une plaie du vagin.

Pelvic fractures occur most often in people experiencing a traumatic event. Although they are due to high-velocity injuries, these lesions are rarely associated with vaginal wounds, and data on patients' evolution are scarce. The purpose of our study was to describe anatomoclinic lesions, treatment and progression of these lesions. The study involved five female patients who had had vaginal wounds due to pelvic fracture over the past decade. The patients had a mean age of 23,6 years. Vaginal wounds were mainly due to road accidents. Two patients had linear wounds and three had lacerated wounds. Vaginal suture was performed in all patients. After a mean follow-up period of 2 years, patients' evolution was favorable with healing of vaginal wound and bone. Genital and obstetric functions were not compromised. Although vaginal wounds most often go unnoticed, they should be suspected in female patients with pelvic fracture.

Biomechanical study of a low-cost external fixator for diaphyseal fractures of long bones.

BACKGROUND: External fixation improves open fracture management in emerging countries. However, sophisticated models are often expensive and unavailable. We assessed the biomechanical properties of a low-cost external fixation system in comparison with the Hoffmann® 3 system, as a reference. METHODS: Transversal, oblique, and comminuted fractures were created in the diaphysis of tibia sawbones. Six external fixators were tested in three modes of loading-axial compression, medio-lateral (ML) bending, and torsion-in order to determine construction stiffness. The fixator construct implies two uniplanar (UUEF1, UUEF2) depending the pin-rods fixation system and two biplanar (UBEF1, UBEF2) designs based on different bar to bar connections. The designed low-cost fixators were compared to a Hoffmann® 3 fixator single rod (H3-SR) and double rod (H3-DR). Twenty-seven constructs were stabilized with UUEF1, UUEF2, and H3-SR (nine constructs each). Nine constructs were stabilized with UBEF1, UBEF2, and H3-DR (three constructs each). RESULTS: UUEF2 was significantly stiffer than H3-SR (p < 0.001) in axial compression for oblique fractures and UUEF1 was significantly stiffer than H3-SR (p = 0.009) in ML bending for transversal fractures. Both UUEFs were significantly stiffer than H3-SR in axial compression and torsion (p < 0.05), and inferior to H3-SR in ML bending, for comminuted fractures. In the same fracture pattern, UBEFs were significantly stiffer than H3-DR (p = 0.001) in axial compression and torsion, while only UBEF1 was significantly stiffer than H3-DR in ML bending (p = 0.013). CONCLUSIONS: The results demonstrated that the stiffness of the UUEF and UBEF device compares to the reference fixator and may be helpful in maintaining fracture reduction. Fatigue testing and clinical assessment must be conducted to ensure that the objective of bone healing is achievable with such low-cost devices.

[Secondary amputation of the limb after primary surgery of open fractures of the lower limb]. / Amputations secondaires du membre après une chirurgie primaire des fractures ouvertes du membre inferieur.

This study reports the complications occurred during the management of open fractures of the lower limbs, resulting in secondary amputations, observed in clinicians' practice in recent years as well as different risk factors and possible deficiencies in management at the origin of these complications. We conducted a retrospective study over a period of 06 years (January 2006 - January 2012). It included patients with open fracture of the lower limb initially treated in our institution and whose complications resulted in amputation. All patient undergoing emergency amputation after examination at the Emergency Department were excluded. All patient treated in another hospital before being referred to us were excluded by the study, even if secondary amputation had been performed in our institution. We collected data by analyzing the records of patients (clinical and complementary examinations, surgical reports). We evaluated our management of open fractures of the lower limb according to the guidelines and recommendations found in the literature. These complications were observed in 9 out of 306 open fractures of the lower limb treated in the same period (January 2006 - January 2012), reflecting a rate of 2.9%. The average age was 42.6(26-57) years, all patients were male. We recorded 1 case of fracture of the femur, 7 cases of fracture of 2 leg bones and 1 case of foot crushing. These were open fractures including 1 case of type 1 fracture, 3 cases of type II fracture and 5 cases of type III fracture, according to Gustilo and Anderson classification. We performed 5 amputations of the thigh and 4 amputation of the upper third of the leg. Various complications motivated these amputations, including bone infections or soft-tissue gangrenes of ischemic or infectious origin. The patients had no morbidities such as diabete and were not chronic smokers. No patient died. Open fractures deserve special attention of the surgeon on immediade complications both from a diagnostic and therapeutic point of view in order to reduce the amputation rates after primary surgery giving patients the impression that they had an incorrect procedure performed on them. Particular attention should be paid to the degree of initial contamination and to the presence of a virulent germ at the site of trauma which may motivate particular attitudes during primary management.

[Dorsolumbar cold abscess revealing Pott's disease]. / Abcès froid dorsolombaire révélant un mal de Pott.

Tuberculous cold abscesses are a rare and unusual form of extrapulmonary tuberculosis. We here report the case of a 27-year old patient with a 5-month history of left dorsolumbar swelling presenting with dorsolumbar cold abscess revealing Pott's disease without neurological complications. Examination of pus sample collected at the time the abscess was incised and drained helped to confirm the diagnosis of cold abscesses of TB origin. The patient underwent 12 months of anti-tuberculosis treatment which lead to a faster recovery; the sequelae was slight gibbosity.