The burden of chronic elbow dislocations in Cambodia and early results of a cost-effective surgical approach.

Chronic elbow dislocation presents a surgical challenge and there is difficulty in balancing stability with early mobilisation. We present a series of 103 patients treated with open reduction via a posterior approach and provide early results of an alternative combined medial and lateral approach (Soddo technique, Anderson et al.). Of the 103 patients, 81% initially consulted a traditional healer and the mean dislocation period was 11 weeks. There was significant loss to follow-up. Only 12 patients having undergone the posterior approach had complete datasets. The mean preoperative arc of movement was 10° and the postoperative arc was 65° at a mean follow-up of 16 weeks. Five patients treated with the Soddo technique had sufficient follow-up data. The mean preoperative arc was 20° and the mean postoperative arc was 95° (mean follow-up of 20 days). Those having undergone the Soddo technique achieved a 20° greater increase in range of movement and no re-dislocations.

Application of hydrosurgery for burn wound debridement: An 8-year cohort analysis.

INTRODUCTION: During the last decade, the Versajet™ hydrosurgery system has become popular as a tool for tangential excision in burn surgery. Although hydrosurgery is thought to be a more precise and controlled manner for burn debridement prior to skin grafting, burn specialists decide individually whether hydrosurgery should be applied in a specific patient or not. The aim of this study was to gain insight in which patients hydrosurgery is used in specialized burn care in the Netherlands. METHODS: A retrospective study was conducted in all patients admitted to a Dutch burn centre between 2009 and 2016. All patients with burns that underwent surgical debridement were included. Data were collected using the national Dutch Burn Repository R3. RESULTS: Data of 2113 eligible patients were assessed. These patients were treated with hydrosurgical debridement (23.9%), conventional debridement (47.7%) or a combination of these techniques (28.3%). Independent predictors for the use of hydrosurgery were a younger age, scalds, a larger percentage of total body surface area (TBSA) burned, head and neck burns and arm burns. Differences in surgical management and clinical outcome were found between the three groups. CONCLUSION: The use of hydrosurgery for burn wound debridement prior to skin grafting is substantial. Independent predictors for the use of hydrosurgery were mainly burn related and consisted of a younger age, scalds, a larger TBSA burned, and burns on irregularly contoured body areas. Randomized studies addressing scar quality are needed to open new perspectives on the potential benefits of hydrosurgical burn wound debridement.

Field amputation: response planning and legal considerations inspired by three separate amputations.

BACKGROUND: Surgical procedures in the field are occasionally required as life-saving measures. Few centers have a planned infrastructure for field physician support. Focused efforts are needed to create teams that can meet such needs. Additionally, certain legal issues surrounding these efforts should be considered. Three cases of field dismemberment inspired this call for preparation. METHODS: In one case, an earthquake caused the collapse of a bridge, entrapping a child within a car. A through-knee amputation was required to free the patient with local anesthetic only. The second case was the result of a truck bomb causing the collapse of a building whereby a victim was trapped by a pillar. After retrieval of supplies from a local hospital, a through-knee amputation was performed. The third case involved a young man whose arm became entangled in an oil derrick. This patient was sedated and intubated in an erect position and the arm was amputated. RESULTS: Fortunately, each of these victims survived. However, the care these patients received was unplanned and had the potential for failure. The authors feel that disaster teams, including a surgeon, should be identified in advance as responders to a disaster on short notice. Legal issues including statespecific Good Samaritan laws and financial support systems must also be considered. CONCLUSION: As hospitals and trauma systems prepare for disaster situations, they should consider the eventuality of field dismemberment. This involves identifying a team, including a surgeon, and devising an infrastructure allowing rapid response capabilities, including surgical procedures in the field.

Indications and complications of major limb amputations in Kano, Nigeria.

OBJECTIVES: To determine the indications and complications of major limb amputations in a Nigerian hospital. DESIGN: A five-year retrospective descriptive study. SETTING: National Orthopaedic Hospital, Dala, Kano, Nigeria. PARTICIPANTS: Patients who had amputations above the wrist or ankle between January 2006 and December 2010. MAIN OUTCOME MEASURES: Indications, complications and mortality. RESULTS: There were 132 unilateral amputations. The patients were mostly males and below the age of 40. Lower limb amputations (74.2%) exceeded upper limb amputations (25.8%). The commonest indication was trauma (42.4%) followed by TBS gangrene (31.8%) and malignant tumours (12.9%). Wound infection, the commonest complication, occurred in patients who had identifiable predisposing factors. The 3 deaths that occurred were in patients who had had traditional bone setter intervention: 2 were due to septicaemia; 1, due to severe tetanus. CONCLUSION: Trauma and traditional bone setter gangrene were the commonest indications. Most of the amputations were avoidable. Institution of preventive measures is imperative. Paying attention to predisposing factors can reduce complications.

Comfort and satisfaction during axillary brachial plexus block in trauma patients: comparison of techniques.

STUDY OBJECTIVE: To investigate the comfort and satisfaction of patients with trauma of the upper limb during two different techniques of axillary brachial plexus block, electrical nerve stimulation and fascial pop. DESIGN: Randomized-prospective, observational study. SETTING: University surgical center. PATIENTS: 100 ASA physical status I and II patients undergoing surgery for trauma of the hand and forearm. INTERVENTIONS: Patients received axillary brachial plexus block with a mixture of 0.5% bupivacaine and 2% lidocaine. They were then allocated to one of two groups to receive either electrical nerve stimulation (Group 1, n = 50), or fascial pop technique (Group 2, n = 50) for nerve location. MEASUREMENTS: Data were collected on patient demographics, surgery, frequency of complications, and sedation required during the block. Discomfort during the block and surgical comfort were quantified by visual analog scale (0-10). Satisfaction was determined by the following scale: very satisfied, satisfied, dissatisfied, and very dissatisfied. Patients also indicated if in the future they would like to receive the same method of anesthesia. MAIN RESULTS: No differences in demographic or surgical data were found. No serious complications were observed. Eighteen Group 1 patients (36%) and none in Group 2 needed sedation during the blocks. Discomfort during the procedures was greater in Group 1 than Group 2 (4.5 +/- 1.2 vs 1.5 +/- 1, P < 0.05), while patients reported good surgical comfort with both techniques (2.4 +/- 2.9 vs 2.2 +/- 2.1, NS). Eighteen patients in Group 1 and 48 patients in Group 2 would accept the same block for future surgery. CONCLUSIONS: In trauma patients, the fascial pop technique is effective, reduces sedation during axillary brachial plexus block, and has a higher patient acceptance rate than the electrical nerve stimulation technique.

Do successful surgical results after operative treatment of long-bone nonunions correlate with outcomes?

UNLABELLED: There has been increased emphasis on validated, patient-reported functional outcomes after orthopaedic interventions for various conditions. The few reports on these types of outcomes after treatment of fracture nonunions are limited to specific anatomic sites, limited by small numbers, and retrospective. To determine whether successful healing of established long-bone nonunions resulted in improved functional outcomes and reduction in patient-reported pain scores, we prospectively followed 80 patients. These patients had a mean of 1.4 surgical procedures before enrollment and a mean of 18 months had elapsed from previous surgery until enrollment. Baseline data and functional scores were obtained before intervention. Seventeen of the 80 patients (21%) had positive intraoperative cultures. At a mean of 18.7 months (range, 12-36 months), 72 (90%) nonunions had healed. Patients with healed nonunions scored better on the Short Musculoskeletal Functional Assessment. Pain scores among all patients improved compared with baseline, but to a greater degree in patients who achieved healing by final followup. Our data suggest improvement in pain scores is seen in all patients after surgery, whereas successful internal fixation leads to improved function. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Misadventure in traditional medicine practice: an unusual indication for limb amputation.

Limb amputation is a major cause of disability in Nigeria, and inadequate health facilities for limb salvage procedures and rehabilitation have increased the burden of amputation surgery in our environment. The common indication for limb amputation in Nigeria is limb gangrene due to trauma. A road traffic accident is an important cause of the trauma, and the role of the traditional bonesetters in the increasing incidence of limb gangrene has been reported. The complications of the traditional bonesetter's practice in Nigeria account for about 50-60% of the limb gangrene necessitating amputation in our hospitals. Misadventures in traditional medicine practice are not new to us. People have lost their lives in the cause of testing the efficacy of traditional medicine. This paper reports an unusual indication for limb amputation in Nigeria following misadventure in a traditional medicine practice in a rural community.

Host classification predicts infection after open fracture.

UNLABELLED: We propose that the classification commonly used in patients with osteomyelitis, the Gustilo classification, also is applicable to patients with open fractures as a method of identifying increased risk of infection because of comorbid medical illness. The records of 174 adult patients sustaining open fractures of long bones were retrospectively reviewed. Each patient was sorted into Class A, B, or C based on 14 immune system compromising factors. Class A has no compromising factors, Class B has one or two compromising factors, and Class C has more than three compromising factors. The association between class and infection was examined. The incidence of infection was 4%, 15%, and 30% in patients in Classes A, B, and C, respectively. Patients in Class B were 2.86 times more likely to have an infection, and patients in Class C were 5.72 times more likely to have an infection when both groups of patients were compared with patients in Class A. The Gustilo classification, location of fracture, and tobacco use are all factors associated with infection. Patients in Class B or C are at markedly increased risk of infection and may benefit from additional or alternative therapies that decrease the risk of infection. LEVEL OF EVIDENCE: Prognostic study, Level II-1 (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.

[Treatment of MRSA infection in orthopedic surgery]. / Behandlung der MRSA-Infektion in der septischen Extremitätenchirurgie.

INTRODUCTION: Infection with methicillin-resistant Staphylococcus aureus (MRSA) remains a major challenge both therapeutically and hygienically. METHODS: Between January 2000 and January 2002, 27 patients with MRSA infections were treated and evaluated in a prospective clinical study. For effective wound management, operative revisions were performed every 3rd day. Following debridement, the wounds were vacuum sealed and specific i.v. antibiotics were administered. Wound closure was performed if three consecutive wound samples submitted for bacterial culture remained negative. RESULTS: All patients with MRSA infections were treated successfully until signs of infection disappeared and bacterial cultures were negative. An average of 7.3 operations per patient was required to eradicate MRSA infection. Follow-up of patients revealed recurrence of infection in four patients. CONCLUSION: Prevention of further spreading and successful treatment of MRSA infections in reconstructive orthopedic surgery is possible with appropriate surgical and hygienic concepts. In almost every second patient complex revision procedures were required.

[Postoperative rehabilitation in patients with peripheral nerve lesions]. / Postoperativna rehabilitacija bolesnika sa lezijom perifernih nerava.

UNLABELLED: Injuries of extremities can be followed by various neuromuscular complications. Injury of peripheral nerves directly depended on the topographic localization of injury (fractures, cuts, contusions). The neuromuscular complications were diagnosed and under follow-up, based on clinical, x-ray, neurologic and neurophysiological findings. The timing of physical treatment and assessment of the necessary neurosurgical intervention depended on the obtained findings. After surgeries, we continued to apply physical treatment and rehabilitation. The aim of the paper was to assess the significance of proper timing for surgery and adequate postoperative rehabilitation, as well as treatment results, depending on the extent of peripheral nerve injury. MATERIAL AND METHODS: Based on the study condocted in the period from 2000-2002, most surgeries were done on the ulnar nerve (4 pts), median nerve (4 pts), radial nerve (3 pts), peroneal nerve (2 pts) and plexus brachialis (3 pts). Paresis and peripheral nerve paralysis, associated with sensibility disorders, predominated in clinical features. In most patients surgery was done during the first 3-6 months after injury. In early postoperative Postoperative rehabilitation in patients with peripherial treatment positioning of extremities with electrotherapy were most often used in early postoperative treatment, Bioptron and dosed kinesitherapy. Depending on the neurophysiological findings, in later treatment stage we included electrostimulation, thermotherapy, kinesitherapy and working therapy, with the necessary application of static and dynamic orthroses. Study results showed that the success of treatment depended on the extent of injury, i.e. whether suture of liberalization of the nerve had been done, on the adequate timing of surgery, as well as on the adequate timing and application of physical therapy and rehabilitation. More rapid and complete functional recovery was achieved if the interval between injury and surgery was shorter, as well as physical therapy was applied early. Based on the analysis of the achieved results, we concluded that peripheral nerve lesions after fractures and contusions had better prognosis in relation to isolated sections of peripheral nerves, having in mind that these were mostly conductive block transfer and nerve stretching lesion, which do not leave sequelae after completed treatment After neurorrhaphies and applied therapy, motor and sensitive deficit mostly depended on good timing of surgery and continual psychiatric treatment. It is also important to point out the significance of team-work among neurosurgeon, neurologist and psychiatrist necessary in early detection and successful treatment of numerous sequelae and invalidity in patients with peripheral nerve lesions.

[Treatment approaches in gunshot injuries of the extremities]. / Behandlung von Schussverletzungen des Bewegungsapparates.

In the view of efficiency and cost effectiveness the increasing incidence of gunshot wounds in Europe demands a modification of treatment protocols. The general basis are debridement of soft tissue injuries, antibiotics and fracture stabilization. The pathology of gunshot wounds and established treatment algorhithms, however have to be adjusted to the ongoing development of gun technology and the thereby caused specific lesions. The treatment of injuries caused by high velocity projectiles necessitates a proactive surgical strategy. Small caliber gunshot wounds can be treated more conservatively. The following review presents an overview on the ballistic and surgical basis for the treatment of gunshot wounds of the musculoskeletal system.

El fijador externo en la extremidad superior catastrófica / The external fixator in the mangled upper extremity

Presentamos la experiencia del uso de la fijación externa en lesiones complejas de la extremidad superior, en un reimplante y cuatro revascularizaciones. Hemos realizado procedimientos de cirugía conservadora primaria y diferida, y en todos ellos el fijador externo ha sido el dispositivo de osteosíntesis utilizado. Pensamos que el fijador externo es capaz de estabilizar la fractura y de facilitar la compleja cirugía del reimplante o de revascularización. Asimismos,es a la vez capaz de asegurar la estabilidad y facilitar los procesos reconstructivos en la cirugía secundaria. Concluimos que la fijación externa puede ser útil en casos seleccionados de cirugía de la extremidad catastrófica. (AU)

[Effects of combined therapy of traditional Chinese and Western medicine on C-reactive protein in post-debridement patients].

Closely monitoring whether the secondary infection in the patients of post-debridement occurred or not and appropriately treating these patients were the important ways to reduce the incidence of infection. Through estimating the level of the serum C-reactive protein (CRP) as the monitoring index of infection, dynamically observed the effect of the combined traditional Chinese and Western medicine therapy (TCM-WM) on CRP after debridement, as was compared with the effect of the Western medicine therapy (WM) group in which only the WM was administrated. The result showed that the levels of CRP decreased in both TCM-WM and WM group on 4th day after the operation, but the level of CRP in former group was lower than that in latter one, the difference was very significant (P < 0.001). So that, it was assumed that TCM-WM significantly excelled the WM on affecting the level of CRP and reducing the incidence of infection. It was suggested that CRP could be used as an effective and objective index to determine whether the secondary infection has happened and to assess the efficacy of some drugs.