Management of neglected open extremity fractures in low-resource settings: Experience of the French Army Medical Service in Chad

Tibia fracture management in low-resource settings using the External Fixation and Traction Device of the Guinean Military Health Service

INTRODUCTION

The authors analyzed results over a 7-year period for a locally manufactured external fixation and traction device (EFTD) used in tibial fracture. Three models were used, depending on the medical and technological context of the healthcare structure in question. The aim of the present study was to reports results for tibial fracture treated by EFTD in low-resource settings.

MATERIALS AND METHODS

A multicenter observational study was conducted for the period 2008-2015 in a series of 34 tibial fractures (22 right, 12 left, with 1 bilateral) in 33 young adults (28 male, 5 female; mean age, 42.2 years). Nineteen were closed fractures and 15 open. The 11 recent open fractures comprised 2 Cauchoix-Duparc type I, 3 type II and 6 type III; the 4 older open fractures were infected. Four patients were lost to follow-up.

RESULTS

Seventeen of the patients with closed fracture had very good results, in 75% (6/8) of shaft fractures and 55.55% (5/9) of complex metaphyseal-epiphyseal fractures. In infected fractures older than 48h, there were good results in 25% of cases. In recent open fractures, there were 100% (2/2), 66.6% (2/3) and 20% (1/5) good results for types I, II and III respectively. Five patients showed malunion, well-tolerated functionally. Mean time to bone healing was 16 weeks (range, 12-72 weeks).

CONCLUSION

In developing countries, the pitfall in treating open fractures is delayed surgery due to patients' socioeconomic situation and to underequipment. The EFTD is a promising technique, readily available at low cost, easy to implement and with minimal iatrogenesis.

LEVEL OF EVIDENCE

IV, prospective observational study.

Exposure and Health Effects of Bacteria in Healthcare Units: An Overview

Healthcare units consist of numerous people circulating daily, such as workers, patients, and companions, and these people are vehicles for the transmission of microorganisms, such as bacteria. Bacteria species may have different allergenic, pathogenic, infectious, or toxic properties that can affect humans. Hospital settings foment the proliferation of bacteria due to characteristics present in the indoor hospital environment. This review article aims to identify the potential health effects caused by bacterial contamination in the context of healthcare units, both in patients and in workers. A search was carried out for articles published in PubMed, Web of Science and Scopus, between 1 January 2000 and 31 October 2021, using the descriptor hospital exposure assessment bacteria. This bibliographic research found a total of 13 articles. Bacteria transmission occurs mainly due to the contact between healthcare workers and patients or through the handling of/contact with contaminated instruments or surfaces. The most common bacterial contaminants are Escherichia coli, Pseudomonas aeruginosa, Staphylococcus spp., Staphylococcus aureus and Micrococcus luteus, and the principal health effects of these contaminants are hospital-acquired infections and infections in immunocompromised people. A tight control of the disinfection methods is thus required, and its frequency must be increased to remove the microbial contamination of wards, surfaces and equipment. A better understanding of seasonal variations is important to prevent peaks of contamination.

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.

The Impact of Inadequate Soft-tissue Coverage following Severe Open Tibia Fractures in Tanzania

Managing lower extremity fractures complicated by large soft-tissue defects is challenging for surgeons in low- and middle-income countries, and long-term quality of life (QOL) for these patients is unclear.

METHODS

We examined QOL, surgical complications, and longitudinal outcomes in 10 patients with Gustilo-Anderson Classification Type IIIB open tibia fractures seen at an orthopedic institute in Tanzania, from December 2015 to March 2017. Patients completed follow-up at 2-, 6-, 12-, 26-, and 52-week time points, and returned for qualitative interviews at 2.5 years. The primary outcome was QOL, as measured using EuroQoL-5D scores and qualitative semi-structured interview responses. The secondary outcome was rate of complication, as defined by reoperation for deep infection or nonunion.

RESULTS

Ten patients enrolled in the study and 7 completed 1-year follow-up. All fractures were caused by road traffic accidents and treated by external fixation. No patients received initial soft-tissue (flap) coverage of the wound. All patients developed an infected nonunion. No patients returned to work at 6 weeks, 3 months, or 6 months. EQ-5D index scores at 1 year were poor (0.71 ± 0.09). Interview themes included ongoing medical complications, loss of employment, reduced income, and difficulty with activities of daily living.

CONCLUSIONS

Patients in low- and middle-income countries with IIIB open tibia fractures not treated with appropriate soft-tissue coverage experience poor QOL, high complication rates, and severe socioeconomic effects as a result of their injuries. These findings illustrate the need for resources and training to build capacity for extremity soft-tissue reconstruction in LMICs.

Soft tissue reconstruction in the leg by orthopedic surgeons: Practices at an African trauma center

INTRODUCTION

Soft-tissue coverage is a crucial step when treating open tibial fractures, which is often performed by orthopedic surgeons in a low resource setting. The objective of this study was to analyze the use of non-microsurgical flaps to treat such injuries in a West African trauma center.

HYPOTHESIS

Pedicled flaps are reliable procedures that can be used by any orthopedic surgeon for soft-tissue coverage in the leg.

METHODS

A retrospective study was conducted including patients treated between 2007 and 2011 for open tibial fractures or posttraumatic sequelae requiring flap coverage. Early flap necrosis and skin viability at the last follow-up were evaluated.

RESULTS

Fifty-five patients with mean age 34 years were included. They had 57 soft-tissue defects requiring flap reconstruction, 36 of which were infected. In total, 62 pedicled flaps were performed: 12 muscular flaps and 50 fasciocutaneous flaps, including 40 rotational flaps and 10 island flaps. The short-term result was successful in 55 flaps (89%). Seven flaps had partial or complete necrosis, including three soleus flaps and three lateral supramalleolar rotational flaps. At the average follow-up of 9 months, skin viability was inferior in the posttraumatic sequelae group and seemed to be altered by primary bone infection.

CONCLUSION

Soft-tissue coverage in the leg can be reliably achieved by orthopedic surgeons using simple and robust flaps that do not require pedicle dissection. Surgeon training in basic flap surgery is essential and still inadequate in emerging countries.

LEVEL OF EVIDENCE

IV, Retrospective study.

Bone reconstruction by the induced membrane technique. What differences between conventional and ballistic trauma?

BACKGROUND

The induced membrane technique (IMT) has been widely evaluated for reconstruction of post-traumatic bone defects. However, no specific evaluation was conducted in ballistic injuries. The objective of the present study was to compare IMT in conventional trauma (CT) versus ballistic trauma (BT) managed in a military trauma center.

METHODS

A retrospective study was conducted between 2009 and 2018 in patients treated by IMT for post-traumatic bone defects, whatever the defect location. Endpoints comprised bone union, residual infection, additional bone grafting and lower-limb amputation.

RESULTS

Thirty-six patients were included: 24 in the CT and 12 in the BT group. Demographics and injury pattern were similar in both groups, with open fracture and infected lesions predominating. The only significant difference was that tibial bone defects were larger in the BT group. Operative parameters and results were also similar. At a mean 24 months' follow-up, bone union rate was 83% in both groups, without significant differences in residual infection, complementary grafting or late amputation.

CONCLUSION

IMT is appropriate to bone reconstruction in the aftermath of ballistic trauma, with similar results to those obtained in conventional trauma.

LEVEL OF EVIDENCE

IV, retrospective study.

Application of the Masquelet technique in austere environments: experience from a French forward surgical unit deployed in Chad

PURPOSE

We sought to evaluate the results of the Masquelet-induced membrane technique (IMT) for long bone defect reconstruction within the limited-resource setting of a French forward surgical unit deployed in Chad.

METHODS

A prospective and observational study was conducted in all patients with a traumatic segmental bone defect in any anatomical location treated by IMT from November 2015 to December 2019. Although IMT was applied by various orthopedic surgeons with variable expertise, all followed the same surgical protocol. Endpoint assessment was performed 12 months after IMT application.

RESULTS

Sixteen patients with a mean age of 32.7 years were included in the study. Bone defects were located on the tibia (n = 8), the femur (n = 6) or the radius (n = 2). Thirteen bone defects were infected. After debridement, the mean bone defect length was 4.3 cm. External fixation of the tibia and femur was predominant in both stages. Bone union was achieved in only 8 of the 16 cases at a mean time of 7.6 months. All failures were related to persistent infection or insufficient fixation stability in the second stage.

CONCLUSIONS

This series is the first to report IMT use in a forward surgical unit. Despite frequent complications, local patients can benefit from this procedure, which is the only available method for bone reconstruction in areas with limited medical resources. A rigorous technical completion at both stages is crucial to limit septic or mechanical failures.

Multidisciplinary management of the bone and joint infection complicating treatment of an open fracture of the lower limb

Bone and joint infections (BJI) of the lower limb can cause functional sequelae and in some cases have an impact on patient's life prognostic. One of the main objectives of multidisciplinary consultation team meetings (MTM) in the treatment of bone and joint infections is to provide an appropriate medical-surgical care, pooling skills of different organ specialists: infectious disease physicians, microbiologists, orthopedic surgeons and plastic surgeons. Treatment is based on aggressive debridement, bone stabilization, adequate antibiotic therapy, long-term coverage of the loss of skin substance and close clinical monitoring. The authors present their multidisciplinary diagnostic and therapeutic approaches to BJI complicating an open fracture at a referent center in the management of complex bone and joint infections.

Knowledge deficits and barriers to performing soft-tissue coverage procedures: An analysis of participants in an orthopaedic surgical skills training course in Mexico

Background:

An increasing number of traumatic injuries in low- and low-middle-income countries (LICs/LMICs) have coexisting injuries requiring soft-tissue coverage (flaps). Yet, there is a lack of subspecialty care and flap training in Latin America. This study assesses the effectiveness of a surgical skills training course in improving rotational and free flap knowledge and identifies barriers to performing these types of flaps.

Methods:

Participants attending a surgical skills training course in Guadalajara, Mexico completed a pre/postcourse flaps knowledge survey consisting of 15 questions from the plastic surgery in-training examination and also completed a 7-point Likert survey regarding perceived barriers to performing flaps at their institution.

Results:

Of the course participants, 17 (44.7%) completed the precourse knowledge survey, 24 (63.2%) completed the postcourse survey, and 37 (97.4%) completed the barriers survey. Scores improved from pre- to postcourse knowledge surveys (39.6% to 53.6%, P = .005). Plastic surgery subsection scores also improved (39.0% to 60.4%, P = .003). Twenty-five percent of attendees received prior flap training and had plastic surgeons available to perform flaps. Few participants (38.9%) reported flap procedures being commonly completed at their hospitals. Participants stating that flaps were uncommon in their hospital reported more institutional barriers and less access to dermatomes. These participants also reported lack of operating room and surgical personnel availability.

Conclusion:

A surgical skills training course may be useful in improving knowledge of soft-tissue coverage procedures. There are also modifiable physician and institutional barriers that can improve the ability to perform rotational and free flaps as identified by the course participants.

Management of Gustilo type IIIB open tibial shaft fractures with limited resources: experience from an African trauma center

PURPOSE

We sought to evaluate the management of Gustilo type IIIB open tibia diaphyseal fractures in an African trauma center with respect to soft tissue defect management and bone union achievement. Functional outcome assessment was the secondary objective.

METHODS

A retrospective review was conducted including patients treated for open tibia fractures requiring flap coverage between 2007 and 2011. As plastic surgeons were lacking in availability, all procedures were performed by orthopedic surgeons trained in completing nonmicrosurgical flap transfers.

RESULTS

Twenty-seven patients with a mean age of 36 years were included. Although the mean time to debridement was 11 h, early infection occurred in 16 (59%) patients. The mean time to flap coverage was 27 days. Among the 29 primary local flap transfers performed, only 4 failed. Secondary amputation was required in one patient after flap failure. Bone reconstruction procedures were required in nine patients and were performed after a mean period of 97 days. At the mean follow-up time of 13 months, 23 (88%) of the 26 remaining fractures had united. There were three septic nonunions and two cases of chronic osteomyelitis. Functional result was negatively influenced by the soft tissue defect area and low-quality flap coverage.

CONCLUSIONS

To our knowledge, this is the first series reporting flap reconstructions performed by orthopedic surgeons for Gustilo type IIIB tibia fractures in an African hospital. Local pedicled flap transfers permitted the achievement of soft tissue coverage and bone union in most cases. Subsequent bone grafting was required in one-third of the cases.

Use of intramedullary nailing in poor sanitary conditions: French Military Medical Service experience

INTRODUCTION

Intramedullary (IM) nailing is the gold standard for treating long bone fractures in developed countries because of its minimally-invasive application and good biomechanical properties. In precarious conditions, external fixation or open plate fixation are often performed because surgeons do not have the means to carry out IM nailing. However, these procedures can lead to infection-related complications and mechanical failures. The aim of our study was to describe the outcomes and postoperative complications of IM nailing of closed, long bone fractures in patients operated in a French front-line combat surgical unit (role 2+). Our hypothesis was that IM nailing is a reliable technique with low morbidity for the initial treatment of long bone fractures, even in precarious situations.

MATERIAL AND METHODS

This was a prospective, single-center, descriptive study of patients operated on between April 2016 and November 2017. All the patients with a closed femur or tibia fracture who were treated by IM nailing were eligible, no matter their time to surgery. The minimum follow-up was 6 months. The primary endpoint was the absence of infection-related complications and the secondary endpoint was fracture union.

RESULTS

Fifty-eight patients were reviewed after an average follow-up of 4.7 months (range, 3-15 months). The mean patient age was 35.2 years (15-85 years) and the majority of patients were men (52 of 58). The fracture was in the femur in 74.1% (n=43) of cases and in the tibia in 25.9% (n=15) of cases. The time to surgery averaged 122.3 days (7-720 days) with a median of 60 days. In 74% of cases (n=43), fracture realignment required an open surgical approach. The postoperative course was considered normal in 96.6% of cases (n=51). No infections were reported as of the last follow-up visit. Union occurred in an average of 4 months in 70.7% of cases (n=41). There were three cases of nonunion after 6 months.

DISCUSSION

Even in precarious situations, IM nailing is an effective, reliable method with a low complication risk and high union rate for the treatment of neglected long bone fractures. This surgical treatment is well suited to the poor sanitary conditions on the African continent.

LEVEL OF EVIDENCE

II, low-powered prospective study.

Osteoarticular Infections Following Open or Penetrating Trauma in Children in the Post-Community-Acquired Methicillin-resistant Staphylococcus aureus Era: The Impact of Enterobacter cloacae

BACKGROUND

Most cases of pediatric osteoarticular infections (OAIs) are hematogenous in nature and caused by Staphylococcus aureus. OAI in children can also occur through direct inoculation of microorganisms secondary to penetrating or open trauma. No studies in the United States have evaluated the microbiology or outcomes of trauma-related OAI (TROAI) in children in the era of community-acquired methicillin-resistant S. aureus (CA-MRSA).

METHODS

Cases were identified from the inpatient infectious diseases consultation database at Texas Children's Hospital from January 2011 to December 2016. TROAI cases were those in which OAI developed following a clear history of penetrating trauma, open fracture, crush injury or traumatic amputation. Only cases with radiographic evidence of bone abscess, gross appearance of infection at the time of surgery and/or positive cultures from bone or joint were included. Complications included recurrence of infection, pathologic fracture or chronic osteomyelitis.

RESULTS

During the study period, 692 consultations for OAI were performed, with 34 meeting inclusion criteria. In 68%, at least 1 organism was isolated, and the most commonly isolated organisms were S. aureus (32% overall, 21% MRSA) and Enterobacter cloacae (24%). Polymicrobial infections occurred in 38% of patients. Eighty-five percentage of patients had at least 1 surgical procedure, and 38% underwent ≥ 2 procedures. Eighty-two percentage of patients were discharged on oral therapy. Complications developed in 15% of patients and were more commonly associated with E. cloacae (80% vs. 14%, P = 0.007) and fungi (P = 0.03).

CONCLUSION

TROAI are relatively uncommon in children but cause significant morbidity. While MRSA contributes substantially to TROAI, the highly diverse microbiology emphasizes the importance of obtaining cultures for microbiologic diagnosis and management. Clinicians should be aware of the frequency of E. cloacae in TROAI and its high risk for sequelae.

The 7th French Airborne Forward Surgical Team experience of surgical support to the population of a low-income country: a prospective study on 341 patients with short-term follow-up

BACKGROUND

The 7th Airborne Forward Surgical Team (FST) has deployed to Chad in 2015 and 2016, in support of French military forces. Humanitarian surgical care is known to represent a significant part of the surgical activity in such missions, but to date limited data have been published on the subject.

METHODS

All surgical patients from a civilian host population treated by the FST during these missions have been prospectively included. Indications, operative outcomes and postoperative outcomes were evaluated.

RESULTS

During this period, the FST operated on 358 patients. Humanitarian surgical care represented 95% of the activity. Most patients (92.7%) were operated for elective surgery. Emergencies and infectious diseases represented, respectively, 7.3% and 9.1% of cases. The mean length of stay (LOS) was three days (2-4), and the median follow-up was 30 days (22-34). Mortality rate was 0.6% and morbidity was 5.6%. Parietal surgery had no significant complication and had shorter LOS (p<0.001). Emergent surgeries were more complicated (p<0.01) and required more reoperations (p<0.05). Surgical infectious cases had longer LOS (p<0.01).

CONCLUSIONS

Humanitarian surgical care can be provided without compromising the primary mission of the medical forces. Close surveillance and follow-up allowed favourable outcomes with low morbidity and mortality rates. Humanitarian care is responsible for a considerable portion of the workload in such deployed surgical teams. Accounting for humanitarian care is essential in the planning and training for such future medical operations.

Modern teaching of military surgery: why and how to prepare the orthopaedic surgeons before deployment? The French experience

PURPOSE

Improved survival of combat casualties in modern conflicts is especially due to early access to damage control resuscitation and surgery in forward surgical facilities. In the French Army, these small mobile units are staffed with one general surgeon and one orthopaedic surgeon who must be able to perform any kind of trauma or non trauma emergency surgery.

METHODS

This concept of forward surgery requires a solid foundation in general surgery which is no longer provided by the current surgical programs due to an early specialization of the residents. Obviously a specific training is needed in war trauma due to the special pathology and practice, but also in humanitarian care which is often provided in military field facilities.

RESULTS

To meet that demand the French Military Health Service Academy created an Advanced Course for Deployment Surgery (ACDS), also called CACHIRMEX (Cours Avancé de CHIRurgie en Mission EXtérieure). Since 2007 this course is mandatory for young military surgeons before their first deployment. Orthopaedic trainees are particularly interested in learning war damage control orthopaedic tactics, general surgery life-saving procedures and humanitarian orthopaedic surgery principles in austere environments.

CONCLUSION

Additional pre-deployment training was recently developed to improve the preparation of mobile surgical teams, as well as a continuing medical education for any active-duty or reserve surgeon to be deployed.