Amputation in emergency situations: indications, techniques and Médecins Sans Frontières France's experience in Haiti

PURPOSE: The decision to amputate is always difficult but becomes even harder in emergency situations, which usually present extra complicating factors. MSF EXPERIENCE: These include human factors (related to both the surgeon and the patient); poor or nonexistent medical facilities, especially in war conditions or resource-poor countries; and cultural and religious considerations. Médecins Sans Frontières (MSF) has developed a quick medical and logistical response that relies on surgical protocols adapted to emergency situations, together with complete "kits" of medical equipment, supplies and inflatable facilities. CONCLUSION: Our response to Haiti's 2010 earthquake relied on these tools but also highlighted the need to develop more detailed protocols that will help our teams on the ground

Outcome of the Treatment of Gunshot Open Fractures of the Lower Extremities with ‘SIGN’ Interlocking Nails

Background: Gunshot injuries are gradually on the increase in civilian populations in developing countries due to increasing violence in our society. The treatment of fractures from these injuries is changing with the use of locked intramedullary nailing becoming an acceptable and effective method of fixation. Surgical Implant Generation Network interlocking nails are gaining universal acceptability in these countries due to ease of use without the need for image intensifier. The purpose of this study was to evaluate the outcome of the use ‘SIGN’ interlocking nailing in gunshot open fractures of the lower limbs. Methods: This is a prospective study of all patients in three tertiary centres in developing countries who had gunshot fractures of lower limbs fixed with SIGN nails from 1st January to 31st December 2009 and followed up for a period of 2 years. Results: Twenty eight patients with 31 fractures with average age of 32.5years±12.6SD. All the patients were males except one female. Fractures occurred in femur in 20(71.4%) and tibia in 11(29.6%) SIGN nail was used to fix all fractures and union was achieved in all the patients. The most common complication was wound in infection in 5 (15.2%). Conclusion: SIGN intramedullary locked nail provided an effective method of fixation for gunshot fractures of the lower extremity with minimal complication

Gunshot fractures of tibia and femur - excellent results with reamed bone marrow graft and interlocking nailing

Objective: To document the outcome of treatment of femur and tibia diaphyseal fractures due to gunshot injury grafted with reamed bone marrow and immobilised with Surgical Implant Generation Network (SIGN) interlocking nail.Design: A prospective study.Setting: Three referral centres in two developing countriesSubjects: Thirty-three patients with 36 fractures due to gunshot injury were studied.Interventions: Stabilised patients were commenced on prophylactic parenteral antibiotic; X-rays done to classify fractures by Gustillo-Anderson classification. Documented were entry, exit wounds and neurovascular status of the limb. Bone marrow was reamed manually and collected oozing reamed marrow was used as graft. Drain was used minimally and when used, was placed where the reamed marrow would not be drained.Patients were followed-up between one to three years.Mean outcome measure: Clinical and radiological evidences of healing of the fracture at six weeks.Results: Patients age ranged between 15-70 years with mean of 32.2±12.2 years. M : F 32:1. Thirty-one (86.1 %) were femoral fractures and 15 (41.7%) of studied long bone fractures were around the knees. The fractures were mainly Gustillo- Anderson type I (41.7%) and II (41.7%). At six weeks there was massive callus formation in 86.1 % of the fractures sites. All other fractures healed within three to four months except one fracture.                                                              Conclusion: Fractures of femur and tibia fractures due to gunshot injury fixed with SIGN intramedullary interlocking nails and grafted with reamed bone marrow give excellent result. This may be due to the use of harvested osteogenic and osteoinductive bone marrow

Femoral bifurcation with ipsilateral tibia hemimelia: Early outcome of ablation and prosthetic fitting

Femoral bifurcation and tibia hemimelia are rare anomalies. Hereby, we present a case report of a 2-year-old boy who first presented in our orthopedic clinic as a 12-day-old neonate, with a grossly deformed right lower limb from a combination of complete tibia hemimelia and ipsilateral femoral bifurcation. Excision of femoral exostosis, knee disarticulation and prosthetic fitting gives satisfactory early outcome

Reconstruction of Mandibular Defects Using Nonvascularized Autogenous Bone Graft in Nigerians

Objectives: The aim of this study is to evaluate the success rate and complications of mandibular reconstruction with nonvascularized bone graft in Ile‑Ife, Nigeria. Patients and Methods: A total of 25 patients who underwent reconstruction of mandibular discontinuity defects between January 2003 and February 2012, at the Obafemi Awolowo University Teaching Hospitals Complex, Ile‑Ife constituted the study sample. Relevant information was retrieved from the patients’ records. This information include patients’ demographics (age and sex) as well as the type of mandibular defect, cause of the defect, type of mandibular resection done, source of the bone graft used, and the method of graft immobilization. Morbidity associated with the graft procedures were assessed by retrieving information on graft failures, length of hospital stay following surgery, rehabilitation device used and associated graft donor and recipient site complications. Result: There were 12 males and 13 females with a male:female ratio was 1:1.1. The age of the patients ranged from 13 to 73 years with a mean age for males 32.7 ± standard deviation (SD) 12.9 and for females 35.0 ± SD 17.1. Jaw defect was caused by resection for tumours and other jaw pathologies in 92% of cases. Complete symphyseal involvement defect was the most common defect recorded 11 (44%). Reconstruction with nonvascularized rib graft accounted for 68% of cases while iliac crest graft was used in 32% of the patients. Successful take of the grafts was recorded in 22 patients while three cases failed. Wound dehiscence (two patients) and postoperative wound infection (eight patients) were the most common complications recorded. Conclusion: The use of nonvascularized graft is still relevant in the reconstruction of large mandibular defects caused by surgical ablation of benign conditions in Nigerians. Precise surgical planning and execution, extended antibiotic therapy, and meticulous postoperative care contributed to the good outcome.Keywords: Mandibular defect, mandibular reconstruction, nonvascularized bone graf

Cost-effectiveness of replacing skeletal traction by interlocked intramedullary nailing for femoral shaft fractures in a provincial trauma hospital in Cambodia

In this article the costs and effectiveness of introducing the SIGN nailing system for femoral shaft fractures in a provincial trauma hospital in Cambodia are compared to those of Perkin’s traction treatment. At an average cost per patient of $1,107 in the traction group and$888 in the nail group (p < 0.01), and with better clinical outcomes in the nail group, internal fixation is more cost-effective than conservative treatment

Low infection rates after 34,361 intramedullary nail operations in 55 low- and middle-income countries: Validation of the Surgical Implant Generation Network (SIGN) Online Surgical Database

Background: The Surgical Implant Generation Network (SIGN) supplies intramedullary (IM) nails for the treatment of long bone fractures free of charge to hospitals in low- and middle-income countries (LMICs). Most operations are reported to the SIGN Online Surgical Database (SOSD). Follow-up has been reported to be low, however. We wanted to examine the pattern of follow-up and to assess whether infection rates could be trusted. Patients and methods: The SOSD contained 36,454 IM nail surgeries in 55 LMICs. We excluded humerus and hip fractures, and fractures without a registered surgical approach. This left 34,361 IM nails for analysis. A generalized additive regression model (gam) was used to explore the association between follow-up rates and infection rates. Results: The overall follow-up rate in the SOSD was 18.1% (95% CI: 17.7–18.5) and national follow-up rates ranged from 0% to 74.2%. The overall infection rate was 0.7% (CI: 0.6–0.8) for femoral fractures and 1.2% (CI: 1.0–1.4) for tibial fractures. If only nails with a registered follow-up visit were included (n = 6,224), infection rates were 3.5% (CI: 3.0–4.1) for femoral fractures and 7.3% (CI: 6.2–8.4) for tibial fractures. We found an increase in infection rates with increasing follow-up rates up to a level of 5%. Follow-up above 5% did not result in increased infection rates. Interpretation: Reported infection rates after IM nailing in the SOSD appear to be reliable and could be used for further research. The low infection rates suggest that IM nailing is a safe procedure also in low- and middle-income countries.publishedVersio

Assessment of Limited Joint Mobility of the Hand in Black Africans with Diabetes Mellitus and in Non-diabetics

ABSTRACT Objective: This study is designed to further characterize Limited Joint Mobility (LJM) of the hand using quantitative goniometric measurements among Black Africans with Type 2 diabetes mellitus and nondiabetes. Methods: Seventy-six patients with Type 2 diabetes and 63 normal controls matched for age and gender were purposively selected. Visual clinical examination and quantitative goniometric assessment of patients with DM and non-DM controls were done. The LJM was graded using the criteria of Silverstein et al. Glycaemic control and proteinuria were also assessed. Results: Prevalence of LJM among Type 2 DM patients was 26.3% compared with 4.8% in normal controls. Subjects with LJM within the control group were significantly older than those with LJM within the DM group (p < 0.05). Prayer sign was 11.8% in DM patients compared with 4.8% of control. The flattening sign demonstrated by the inability to flatten their hands on a flat surface was more in patients with DM (10.5%) compared with 4.8% in the control group. Stage II LJM with 18.4% prevalence was the commonest followed by Stage III (7.9%) among patients with DM. Poor glycaemic control was found in 85%, using fasting plasma glucose and 70%, using 2-hour postprandial blood glucose (2 hpp). Conclusion: We conclude that Black Africans with Type 2 DM only have moderately severe cases of LJM. Evaluación de la Limitación de la Movilidad Articular de la Mano en Africanos Negros que Padecen de Diabetes Mellitus y en los no Diabéticos RESUMEN Objetivo: Este estudio fue diseñado para caracterizar más a fondo la limitación de la movilidad articular (LMA) de la mano, usando mediciones goniométricas entre africanos. Métodos: Setenta y seis pacientes con diabetes mellitus tipo 2 y 63 controles normales pareados por edad y género fueron seleccionados para este propósito. Se realizó un examen clínico visual y una evaluación goniométrica cuantitativa de los pacientes con DM y controles no DM. La LMA fue graduada usando los criterios de Silverstein et al. También se evaluaron el control glicérico y la proteinuria. Resultados: La prevalencia de LMA entre pacientes con DM tipo 2 fue de 26.3% comparada con 4.8% en los controles normales. Los sujetos con LMA en el grupo de control fueron significativamente mayores en edad que aquellos con LMA en el grupo con DM (p < 0.05). La signo de las manos en oración fue 11.8% en los pacientes con DM comparado con el 4.8% del control. El signo de aplanamiento demostrado por la incapacidad de los pacientes de poner sus manos totalmente planas sobreuna superficie, fue mayor en aquellos con DM (10.5%) en comparación con el 4.8% del grupo control. La LMA de la segunda etapa con una prevalencia de 18.4%, fue la más común seguida por la de etapa III (7.9%) entre pacientes con DM. Un control glicémico pobre fue hallado en 85%, usando glucosa plasmática en ayunas. Conclusión: Concluimos que los africanos negros con DM tipo 2 presentan sólo casos moderadamente severos de LM

Determinants of management outcome in open tibia fractures in ile-ife

Background:Fracture of a normal tibia shaft constitutes a major trauma mostly sustained by young adults during high-energy injuries. Its superficial location and the subcutaneous characteristics of its anteromedial aspect easily causes open fracture. The objectives of this study were to determine the pattern of presentation, and determinants of management outcome in open fractures of the tibia.Methods: This is a prospective hospital based study. A total of 89 patients aged 4 to 80 years with open fractures of the tibia with or without fibula involvement were studied. All the patients received anti tetanus prophylaxis and intravenous antibiotics as well as wound irrigation, debridement and skeletal stabilisation.Results: Students and traders accounted for the majority of the cases (57.3%). Most of the open tibia fractures 69 (77.5%) had above knee Plaster of Paris cast. The majority of the cases were Gustilo and Anderson type II 32 (36.0%) cases and type I 22(24.7%) cases. There was Correlation between the presence of wound infection and (i) Gustilo and Anderson grading (F -.352, P .001); (ii) Injury to Debridement time in hours (F -.304, P .004); (iii) Osteomyelitis (F .397, P .001); (iv) Delayed union (F .253, P .017); and (v) Union time in weeks (F -.350, P .001). There was also correlation between the following: (i) Injury to Debridement time in hours and the distance from the accident scene to the hospital (F .464, P .001); (ii) The fracture pattern and the union time in weeks (F .353, P .001); and (iii) The presence of osteomyelities and delayed union (F .382, P .001). The commonest complications observed were wound infection 35(39.3%) patients and delayed union 30(33.7%) patients.Conclusion:This study shows that the higher the Gustilo and Anderson grading of the open fractures of the tibia, the more severe the wound and bone infection that occurred. The interval between injury time and wound débridement time affected the treatment outcome

External jig in the placement of distal interlocking screws

Background: Placement of distal locking screws is a challenge to many surgeons involved in interlocking nails. Objectives: The aim of this study is to evaluate the accuracy of external jig as a target arm for distal locking screw insertion. Methods: 85 consecutive patients with 90 fractures treated with SIGN interlocking nails were prospectively studied. We report the assessment of the accuracy of insertion of distal locking screws with the use of SIGN external jigs. The patient's demographic data and fracture characteristics were documented. Two distal screws are usually inserted. However, in very difficult cases, one distal screw may be inserted. In all cases there was no access to intra operative radiograph. Results: There were 85 patients and 90 fractures. There were 57 males and 28 females giving a ratio of M:F 2:1. The mean&plusmn;SD age of the patients was 41.19&plusmn;16.28 years and the range was 18-85 years. The two bones studied were femur 62.3% and tibia 37.8%. Retrograde (52.2%) was the commonest surgical approach used for femur. The main indication for SIGN interlocking surgery was recent fracture 77.8%. Open reduction 97.8% was the commonest method of reduction used. The mean&plusmn;SD bone union time was 3.58&plusmn;0.56 months and range 3-5 months. Distal screw insertion was successful (2 screws) in 93.3% and partial success (1 screw) in 6.7%. At first attempt 96.7% of distal screws were inserted while 3.3% distal screws were inserted at 2nd attempt (2nd visit to theatre). The main complication was screw loosing seen in 3.3%. Conclusion: External jig as a target arm is effective for the placement of distal locking screw.Keywords: External jig; Target arm; Distal screws; Interlocking nails