The Preferred Management of a Single-Digit Distal Phalanx Amputation

Background: Replantation of a single digit at the distal phalanx level is not routinely performed since it is technically challenging with questionable cost-effectiveness. The purpose of this study was to analyze international microsurgeons’ clinical decisions when faced with this common scenario.

Methods: A survey of a right-middle finger distal phalanx transverse complete amputation case was conducted via online and paper questionnaires. Microsurgeons around the world were invited to provide their treatment recommendations. In total, 383 microsurgeons replied, and their responses were stratified and analyzed by geographical areas, specialties, microsurgery fellowship training, and clinical experiences.

Results: Among 383 microsurgeons, 170 (44.3%) chose replantation as their preferred management option, 137 (35.8%) chose revision amputation, 62 (16.2%) chose local flap coverage, 8 (2.1%) chose composite graft, and 6 (1.6%) favored other choices as their reconstruction method for the case study. Microsurgeons from the Asia-Pacific, Middle East/South Asia, and Central/South America regions tend to perform replantation (70.7, 68.8, and 67.4%, respectively) whereas surgeons from North America and Europe showed a lower preference toward replantation (20.5 and 26.8%, respectively p < 0.001). Having completed a microsurgery fellowship increased the attempt rate of replantation by 15.3% (p = 0.004). Clinical experience and the surgeons' specialties did not show statistical significance in clinical decision making.

Conclusion: From the present study, the geographic preferences and microsurgery fellowship experience influence the method of reconstruction for distal phalanx amputation. Multiple factors are taken into consideration in selecting the most suitable reconstructive method for each case scenario. In addition to the technical challenges of the proposed surgery, the cost of the procedure and the type of facility needed are important variables in the decision making process.

Clinical profile and patterns of extremity fractures among patients visiting orthopedics department in Tikur Anbessa specialized hospital, Ethiopia.

Background: Fracture is a loss in the structural continuity of bone which results from injury, repetitive stress, or abnormal weakening of the bone. Globally, fracture injury continues to be an important cause of morbidity and disability both in the developed and developing countries.

Objective: The aim of this study was to assess the clinical profile and patterns of extremity fracture patients visiting orthopedic department at TASH, Ethiopia.

Materials and Method: Institutional based retrospective cross-sectional study was carried out. The sample size was 354 and study participants were extermity fracture cases. The data were analyzed using SPSS 21. Chi-square (χ2) test was applied to see if there was any association between the different variables.

Results: Most of the fracture victims, 111 (32.6%), were between the ages of 15 and 29 years. Lower extremity fracture (65.6%) was more common compared to upper extremity (34.7%). The femur (23.7 %) was the commonest fractured bone. The common patterns of fractures were transverse type which accounted for (35.5 %). The leading causes of fractures were road traffic injuries (RTIs) (42.2%) followed by falling down accidents (29.6%). The Cause of fracture and number of bone fracture were significantly associated with age (p<0.05).

Conclusion: The most commonly fractured bone in the extremities was the femur followed by tibia and fibula. Transverse factures followed by communited-type of fractures were the commonest patterns of fracture. The leading cause of fracture was road traffic injury followed by falling-down accidents.

Delays in hospital admissions in patients with fractures across 18 low-income and middle-income countries (INORMUS): a prospective observational study

Background: The Lancet Commission on Global Surgery established the Three Delays framework, categorising delays in accessing timely surgical care into delays in seeking care (First Delay), reaching care (Second Delay), and receiving care (Third Delay). Globally, knowledge gaps regarding delays for fracture care, and the lack of large prospective studies informed the rationale for our international observational study. We investigated delays in hospital admission as a surrogate for accessing timely fracture care and explored factors associated with delayed hospital admission.

Methods: In this prospective observational substudy of the ongoing International Orthopaedic Multicenter Study in Fracture Care (INORMUS), we enrolled patients with fracture across 49 hospitals in 18 low-income and middle-income countries, categorised into the regions of China, Africa, India, south and east Asia, and Latin America. Eligible patients were aged 18 years or older and had been admitted to a hospital within 3 months of sustaining an orthopaedic trauma. We collected demographic injury data and time to hospital admission. Our primary outcome was the number of patients with open and closed fractures who were delayed in their admission to a treating hospital. Delays for patients with open fractures were defined as being more than 2 h from the time of injury (in accordance with the Lancet Commission on Global Surgery) and for those with closed fractures as being a delay of more than 24 h. Secondary outcomes were reasons for delay for all patients with either open or closed fractures who were delayed for more than 24 h. We did logistic regression analyses to identify risk factors of delays of more than 2 h in patients with open fractures and delays of more than 24 h in patients with closed fractures. Logistic regressions were adjusted for region, age, employment, urban living, health insurance, interfacility referral, method of transportation, number of fractures, mechanism of injury, and fracture location. We further calculated adjusted relative risk (RR) from adjusted odds ratios, adjusted for the same variables. This study was registered with ClinicalTrials.gov, NCT02150980, and is ongoing.

Findings: Between April 3, 2014, and May 10, 2019, we enrolled 31 255 patients with fractures, with a median age of 45 years (IQR 31-62), of whom 19 937 (63·8%) were men, and 14 524 (46·5%) had lower limb fractures, making them the most common fractures. Of 5256 patients with open fractures, 3778 (71·9%) were not admitted to hospital within 2 h. Of 25 999 patients with closed fractures, 7141 (27·5%) were delayed by more than 24 h. Of all regions, Latin America had the greatest proportions of patients with delays (173 [88·7%] of 195 patients with open fractures; 426 [44·7%] of 952 with closed fractures). Among patients delayed by more than 24 h, the most common reason for delays were interfacility referrals (3755 [47·7%] of 7875) and Third Delays (cumulatively interfacility referral and delay in emergency department: 3974 [50·5%]), while Second Delays (delays in reaching care) were the least common (423 [5·4%]). Compared with other methods of transportation (eg, walking, rickshaw), ambulances led to delay in transporting patients with open fractures to a treating hospital (adjusted RR 0·66, 99% CI 0·46-0·93). Compared with patients with closed lower limb fractures, patients with closed spine (adjusted RR 2·47, 99% CI 2·17-2·81) and pelvic (1·35, 1·10-1·66) fractures were most likely to have delays of more than 24 h before admission to hospital.

Interpretation: In low-income and middle-income countries, timely hospital admission remains largely inaccessible, especially among patients with open fractures. Reducing hospital-based delays in receiving care, and, in particular, improving interfacility referral systems are the most substantial tools for reducing delays in admissions to hospital.

Travel barriers, unemployment, and external fixation predict loss to follow-up after surgical management of lower extremity fractures in Dar es Salaam, Tanzania

Objective:
Predict loss to follow-up in prospective clinical investigations of lower extremity fracture surgery.

Design:
Secondary analysis of 2 prospective clinical trials.

Setting:
National public orthopaedic and neurologic trauma tertiary referral hospital in Dar es Salaam, Tanzania, a low-income country in sub-Saharan Africa.

Patients/Participants:
Three hundred twenty-nine femoral shaft and 240 open tibial shaft fracture patients prospectively enrolled in prospective controlled trials of surgical fracture management by external fixation, plating, or intramedullary nailing between June 2015 and March 2017.

Intervention:
Telephone contact for failure to attend scheduled 1-year clinic visit.

Main Outcome Measurements:
Ascertainment of primary trial outcome at 1-year from surgery; post-hoc telephone questionnaire for reasons patient did not attend the 1-year clinic visit.

Results:
One hundred twenty-seven femur fracture (39%) and 68 open tibia fracture (28%) patients did not attend the 1-year clinic visit. Telephone contact significantly improved ascertainment of the primary study outcome by 20% between 6-month and 1-year clinic visits to 82% and 92% respectively at study completion. Multivariable analysis associated unemployment (OR = 2.5 [1.7–3.9], P < .001), treatment with an external fixator (OR = 1.7 [1.0–2.8], P = .033), and each additional 20 km between residence and clinic (OR = 1.03 [1.00–1.06], P = .047] with clinic nonattendance. One hundred eight (55%) nonattending patients completed the telephone questionnaire, reporting travel distance to the hospital (49%), and travel costs to the hospital (46%) as the most prevalent reasons for nonattendance. Sixty-five percent of patients with open tibia fractures cited relocation after surgery as a contributing factor.

Conclusions:
Relocation during recovery, travel distance, travel cost, unemployment, and use of an external fixator are associated with loss to clinical follow-up in prospective investigations of femur and open tibia fracture surgery in this population. Telephone contact is an effective means to assess outcome.

Lagos state ambulance service: a performance evaluation

Objectives: The mortality rate from road traffic accidents (RTAs) in Nigeria is almost double that of the USA. In Nigeria, the first emergency medical services (EMS) system was established in March 2001, The Lagos State Ambulance Service (LASAMBUS). The objectives of this study are to (1) determine the burden of RTAs in Lagos, (2) assess RTA call outcomes, and (3) analyze LASAMBUS’s response time and causes for delay.

Methodology: We reviewed completed LASAMBUS intervention forms spanning December 2017 to May 2018. We categorized the call outcomes into five groups: I. Addressed Crash, II. No Crash (False Call), III. Crash Already Addressed, IV. Did Not Respond, and V. Other. We further explored associations between the (1) causes for delay and outcomes and (2) response times and the outcomes.

Results: Overall, we analyzed 1352 intervention forms. We found that LASAMBUS did not address 53% of the RTA calls that they received. Of this, Outcome II. No Crash (False Call) accounted for 26% and Outcome III. Crash Already Addressed accounted for 22%. Self-reported causes for delay were recorded in 180 forms, representing 13.7% of the RTA burden. Traffic congestion accounted for 60% of this distribution.

Conclusion: LASAMBUS response rates are significantly lower than response rates in high-income countries such as the USA and lead to increased RTA mortality rates. Eliminating causes for delay will improve both LASAMBUS effectiveness and RTA victims’ health outcomes. Changing the public perception of LASAMBUS and standardizing LASAMBUS’ contact information will aid this as well.

Trauma burden, patient demographics and care-process in major hospitals in Tanzania: A needs assessment for improving healthcare resource management

Background
Appropriate referrals of injured patients could improve clinical outcomes and management of healthcare resources. To gain insights for system development, we interrogated the current situation by assessing burden, patient demography, causes of injury, trauma mortality and the care-process.

Methods
We used an observational, cross-sectional study design and convenience sampling to review patient charts from 3 major hospitals and the death registry in Tanzania.

Results
Injury constitutes 9–13% of the Emergency Centre census. Inpatient trauma-deaths were 8%; however, the trauma death registry figures exceeded the ‘inpatient deaths’ and recorded up to 16%. Most patients arrive through a hospital referral system (82%) and use a hospital transport network (76%). Only 8% of the trauma admissions possessed National Health Insurance. Road traffic collision (RTC) (69%), assault (20%) and falls (9%) were the leading causes of injury. The care process revealed a normal primary-survey rate of 73–90%. Deficiencies in recording were in the assessment of: Airway and breathing (67%), circulation (40%) and disability (80%). Most patients had non-operative management (42–57%) or surgery for wound care or skeletal injuries (43%). Laparotomies were performed in 26%, while craniotomy and chest drain-insertion were each performed in 10%.

Conclusion
The burden of trauma is high, and the leading causes are: RTC, assault, and falls. Deaths recorded in the death registries outweigh in-hospital deaths for up to twofold. There are challenges in the care process, funding and recording. We found a functional hospital referral-network, transport system, and death registry.

Designing and implementing a practical prehospital emergency trauma care curriculum for lay first responders in Guatemala

Background Injury disproportionately affects low-income and middle-income countries, yet robust emergency medical services are often lacking to effectively address the prehospital injury burden. A half-day prehospital emergency trauma care curriculum was designed for first responders and piloted in the Sacatepéquez, Chimaltenango, and Escuintla departments in Guatemala.

Methods Three hundred and fifty-four law enforcement personnel, firefighters, and civilians volunteered to participate in a 5-hour emergency care course teaching scene safety, triage, airway management, cardiopulmonary resuscitation, fracture management, and victim transport. A validated 26-question pretest/post-test study instrument was contextually adapted and used to measure overall test performance, the primary study outcome, as well as test performance stratified by occupation, the secondary study outcome. Pretest/post-test score distributions were compared using a Wilcoxon signed-rank test. For test evaluation, knowledge acquisition on a by-question and by-category basis was examined using McNemar’s χ² test, whereas item difficulty indices used frequency-of-distribution tests and item discrimination indices used point biserial correlation.

Results Two hundred and eighty-seven participants qualified for inclusion. Participant mean pretest versus post-test scores improved 24 percentage points after course completion (43% vs 68%, p<0.001). Cronbach’s alpha yielded values of 0.86 (pretest) and 0.94 (post-test), suggesting testing instrument reliability. Between-group analyses demonstrated law enforcement and civilian participants improved more than firefighters (p<0.001). Performance on 23 of 26 questions improved significantly. All test questions except one showed an increase in their PPDI.

Discussion A 1-day, contextually adapted, 5-hour course targeting laypeople demonstrates significant improvements in emergency care knowledge. Future investigations of similar curricula should be trialed in alternate low-resource settings with increased civilian participation to evaluate efficacy and replicability as adequate substitutes for longer courses. This study suggests future courses teaching emergency care for lay first responders may be reduced to 5 hours duration.

Level of evidence Level II.

Can traditional bonesetters become trained technicians? Feasibility study among a cohort of Nigerian traditional bonesetters

Background
Traditional bonesetters (TBS) provide the majority of primary fracture care in Nigeria and other low- and middle-income countries (LMICs). They are widely patronized and their services are commonly associated with complications. The aim of the study was to establish the feasibility of formal training of TBS and subsequent integration into the healthcare system.

Methods
Two focus group discussions were conducted involving five TBS and eight orthopaedic surgeons in Enugu Nigeria. Audio-recordings made during the focus groups were transcribed verbatim and analysed using a thematic analysis method.

Results
Four themes were identified: Training of TBS, their experiences and challenges; perception of traditional bonesetting by orthopaedic surgeons; need for formal training TBS and willingness to offer and accept formal training to improve TBS practice. Participants (TBS group) acquired their skills through informal training by apprenticeship from relatives and family members. They recognized the need to formalize their training and were willing to accept training support from orthopaedists. The orthopaedists recognized that the TBS play a vital role in filling the gap created by shortage of orthopaedic surgeons and are willing to provide training support to them.

Conclusion
This study demonstrates the feasibility of providing formal training to TBS by orthopaedic surgeons to improve the quality of services and outcomes of TBS treatment. This is critical for integration of TBS into the primary healthcare system as orthopaedic technicians. Undoubtedly, this will transform the trauma system in Nigeria and other LMICs where TBS are widely patronized.

Comparison of intraarticular distal humerus fracture outcomes treated with or without olecranon osteotomy – A case series

A case series was extracted from the trauma registry at Aga Khan University Hospital from the period June 2015 to June 2019. Included were 16 adult patients who presented with intra-articular distal humerus fracture type C2. The functional, clinical and radiological outcomes of fractures treated with or without olecranon osteotomy up to 12 months follow-up were compared. Outcomes were assessed at 6 weeks, 3, 6 and 12 months re-visits. Among the 16 studied patients, 9 (56%) were males and 7 (44%) were females. In the group without osteotomy, there was a good functional and clinical outcome with a mean Quick Disability of the Arm, Shoulder and Hand score of 32±30 at 3 months post-procedure. Bone healing was noticed at 6 months after surgery. In the osteotomy group, 50%-70% bone union was seen at 3 months post-surgery while fair functional and clinical outcome was achieved at 6 months after surgery

Managing the soft tissue defects over the dorsum of hand: Our experience with Posterior Interosseous Artery (PIA) flap

Objective: To determine the outcome of posterior interosseous artery (PIA) flap in terms of coverage of the defects and survival of the flap in patients with complex defects over the dorsum of hand and distal forearm.

Methods: This descriptive study was conducted in Hand and Upper Limb Surgery (HULS) CMH Lahore Medical College, Lahore, Pakistan from 15th July 2017 to 15th August 2019.All patients with complex defects of the dorsum of the hand and distal forearm were treated with posterior interosseous artery (PIA) flap. Post operatively the grafts were observed for coverage of the defects and graft survival.

Results: The total number of patients were 24 with 19(79.1%) males and 05(20.8%) females. The mean age was 37±7SD(range 21 to 56 years). Right hand was involved in 17(70.8%) patients and left in 7(29.1%) patients. Complete coverage of the defects were achieved in all cases. Successful graft survival and uptake was seen in 20(83.3%) flaps. Partial loss was seen in 03 (12.5%) flaps which required debridement and subsequent Split Thickness Skin Grafting. Complete graft loss was seen in 01 (4.1%) flap

Conclusion: Posterior interosseous artery flap (PIA) had higher survival rates and larger area of the dorsum of the hand and distal forearm were entirely covered with this graft. We recommend posterior interosseous artery flap as first line surgical technique to treat complex tissue defects of the dorsum of the hand and distal forearm