Hypoalbuminaemia in orthopaedic trauma patients in a rural hospital in South Africa.

BACKGROUND: The deleterious effects of hypoalbuminaemia in the peri-operative period are well documented. We aimed to review serum albumin levels in a cohort of orthopaedic trauma patients to determine the prevalence of hypoalbuminaemia. Secondarily, we aimed to identify factors associated with an increased risk of hypoalbuminaemia. METHODS: A retrospective cross-sectional study was performed of data collected prospectively at a regional hospital serving primarily a rural population in South Africa. RESULTS: Two hundred ninety-five patients were included in the study. Twenty-nine per cent of the cohort was found to have hypoalbuminaemia. Femur neck fractures (p < 0.001), intertrochanteric fractures (p = 0.004), tibial plateau fractures (p = 0.034) and polytrauma (p = 0.013) were associated with hypoalbuminaemia. The mean albumin level was lower in HIV-positive patients when compared to HIV-negative patients (35.7 g/L vs 37.5 g/L, p = 0.007). The presence of comorbidities other than HIV, like diabetes mellitus (p = 0.001), previous pulmonary tuberculosis (p = 0.034) and chronic renal failure (p = 0.007) was associated with hypoalbuminaemia. CONCLUSION: In this cohort of orthopaedic trauma patients from rural South Africa, we found a 29% prevalence of hypoalbuminaemia at the time of presentation. High-risk subgroups include patients with pre-existing comorbidities and increased age, as well as patients presenting with polytrauma, femoral neck, intertrochanteric femur or tibial plateau fractures.

Management of critical-sized bone defects in the treatment of fracture-related infection: a systematic review and pooled analysis.

PURPOSE: This systematic review determined the reported treatment strategies, their individual success rates, and other outcome parameters in the management of critical-sized bone defects in fracture-related infection (FRI) patients between 1990 and 2018. METHODS: A systematic literature search on treatment and outcome of critical-sized bone defects in FRI was performed. Treatment strategies identified were, autologous cancellous grafts, autologous cancellous grafts combined with local antibiotics, the induced membrane technique, vascularized grafts, Ilizarov bone transport, and bone transport combined with local antibiotics. Outcomes were bone healing and infection eradication after primary surgical protocol and recurrence of FRI and amputations at the end of study period. RESULTS: Fifty studies were included, describing 1530 patients, the tibia was affected in 82%. Mean age was 40 years (range 6-80), with predominantly male subjects (79%). Mean duration of infection was 17 months (range 1-624) and mean follow-up 51 months (range 6-126). After initial protocolized treatment, FRI was cured in 83% (95% CI 79-87) of all cases, increasing to 94% (95% CI 92-96) at the end of each individual study. Recurrence of infection was seen in 8% (95% CI 6-11) and amputation in 3% (95% CI 2-3). Final outcomes overlapped across treatment strategies. CONCLUSION: Results should be interpreted with caution due to the retrospective and observational design of most studies, the lack of clear classification systems, incomplete data reports, potential underreporting of adverse outcomes, and heterogeneity in patient series. A consensus on classification, treatment protocols, and outcome is needed to improve reliability of future studies.

Optimising perioperative care for hip and knee arthroplasty in South Africa: a Delphi consensus study.

BACKGROUND: A structured approach to perioperative patient management based on an enhanced recovery pathway protocol facilitates early recovery and reduces morbidity in high income countries. However, in low- and middle-income countries (LMICs), the feasibility of implementing enhanced recovery pathways and its influence on patient outcomes is scarcely investigated. To inform similar practice in LMICs for total hip and knee arthroplasty, it is necessary to identify potential factors for inclusion in such a programme, appropriate for LMICs. METHODS: Applying a Delphi method, 33 stakeholders (13 arthroplasty surgeons, 12 anaesthetists and 8 physiotherapists) from 10 state hospitals representing 4 South African provinces identified and prioritised i) risk factors associated with poor outcomes, ii) perioperative interventions to improve outcomes and iii) patient and clinical outcomes necessary to benchmark practice for patients scheduled for primary elective unilateral total hip and knee arthroplasty. RESULTS: Thirty of the thirty-three stakeholders completed the 3 months Delphi study. The first round yielded i) 36 suggestions to preoperative risk factors, ii) 14 (preoperative), 18 (intraoperative) and 23 (postoperative) suggestions to best practices for perioperative interventions to improve outcomes and iii) 25 suggestions to important postsurgical outcomes. These items were prioritised by the group in the consecutive rounds and consensus was reached for the top ten priorities for each category. CONCLUSION: The consensus derived risk factors, perioperative interventions and important outcomes will inform the development of a structured, perioperative multidisciplinary enhanced patient care protocol for total hip and knee arthroplasty. It is anticipated that this study will provide the construct necessary for developing pragmatic enhanced care pathways aimed at improving patient outcomes after arthroplasty in LMICs.

Femoral locking plate failure salvaged with hexapod circular external fixation: a report of two cases.

Femoral non-unions are difficult to treat even for the experienced orthopaedic trauma surgeon. If the non-union follows failure of modern stable internal fixation, the complexity of the management is further increased. We report two cases of stiff hypertrophic femoral non-unions after failed locking plate fixation that were successfully treated with a new hexapod circular external fixator. In addition to providing the necessary stability for functional rehabilitation and union, the hexapod circular fixator software allows gradual correction of deformities in order to restore the normal mechanical alignment of the limb.

Hexapod external fixator closed distraction in the management of stiff hypertrophic tibial nonunions.

Tibial nonunion represents a spectrum of conditions which are challenging to treat, and optimal management remains unclear despite its high rate of incidence. We present 44 consecutive patients with 46 stiff tibial nonunions, treated with hexapod external fixators and distraction to achieve union and gradual deformity correction. There were 31 men and 13 women with a mean age of 35 years (18 to 68) and a mean follow-up of 12 months (6 to 40). No tibial osteotomies or bone graft procedures were performed. Bony union was achieved after the initial surgery in 41 (89.1%) tibias. Four persistent nonunions united after repeat treatment with closed hexapod distraction, resulting in bony union in 45 (97.8%) patients. The mean time to union was 23 weeks (11 to 49). Leg-length was restored to within 1 cm of the contralateral side in all tibias. Mechanical alignment was restored to within 5° of normal in 42 (91.3%) tibias. Closed distraction of stiff tibial nonunions can predictably lead to union without further surgery or bone graft. In addition to generating the required distraction to achieve union, hexapod circular external fixators can accurately correct concurrent deformities and limb-length discrepancies.

Bicondylar tibial plateau fractures treated with fine-wire circular external fixation.

Bicondylar tibial plateau fractures are serious injuries to a major weight-bearing joint. These injuries are often associated with severe soft tissue injuries that complicate surgical management. We reviewed 54 consecutive patients who sustained bicondylar tibial plateau fractures that were treated with limited open reduction and cannulated screw fixation combined with fine-wire circular external fixation. Forty-six patients met the inclusion criteria of this retrospective review. Eight patients were excluded because they did not complete a minimum of 1-year follow-up. Thirty-six patients had Schatzker type-VI, and ten patients had Schatzker type-V fractures. All fractures were united without loss of reduction; there were no incidences of wound complications, osteomyelitis or septic arthritis. The average Knee Society Clinical Rating Score was 81.6, translating to good clinical results. Minor pin track infection was the most common complication encountered. This review concludes that fine-wire circular external fixation, combined with limited open reduction and cannulated screw fixation, consistently produces good functional results without serious complications.