Treatment of non-union in open tibial fractures Gustilo-Anderson(GA)-3A/3B fractures remains a challenging problem. Most of these can be dealt using treatment methods that requires excision of the non-union followed by bone grafting, masquelet technique, or acute shortening. Circular fixators with closed distraction or bone transport also remains a useful option. However, sometimes due to patient specific factors these cannot be used. Recently antibiotic loaded bone substitutes have been increasingly used for repairing infected non-unions. They provide local antibiotic delivery, fill dead space, and act as a bone conductive implant, which is resorted at the end of a few months. We aimed to assess the outcome of percutaneous injection of bone substitute while treating non-union of complex open tibial fractures. Three cases of clinical and radiological stiff tibial non-union requiring further intervention were identified from our major trauma open fracture database. Two GA-3B cases, treated with a circular frame developed fracture-related-infection(FRI) manifesting as local cellulitis, loosened infected wires/pins with raised blood-markers, and one case of GA-3A treated with an intramedullary nail. At the time of removal of metalwork/frame, informed consent was obtained and Cerament-GTM(bone-substitute with gentamicin) was percutaneously injected through a small cortical window using a bone biopsy(Jamshedi needle). All patients were allowed to weight bear as tolerated in a well-fitting air-cast boot and using crutches. They were followed up at 6 weekly intervals with clinical assessment of their symptoms and radiographs. Fracture union was assessed using serial radiographs with healing defined as filling of fracture gap, bridging callus and clinical assessment including return to full painless weight bearing.Introduction
Materials & Methods
This study aims to assess the impact of re-configuration on provision of trauma care at Hospital A, in particular management of hip fractures. Originally, Hospitals A and B both provided trauma and elective orthopaedic services. These services are undergoing re-configuration such that Hospital A will provide an elective orthopaedic service while Hospital B will provide an orthopaedic trauma service. Two time periods, one prior to reconfiguration (time period 1) and one after reconfiguration (time period 2) were identified. All trauma patients presenting to Hospital A requiring surgery during the defined time periods were included. During time period 1, 197 patients requiring surgery presented to Hospital A, 70 with hip fractures. During time period 2, 149 patients requiring surgery presented to Hospital A, 55 with hip fractures. As part of the reconfiguration process, there was a reduction in dedicated trauma operating capacity at Hospital A with no equivalent increase in operating capacity at Hospital B. During time period 1, 70% of patients with hip fractures were operated on within 36 hours, compared to 44% during time period 2. During the re-configuration process, there was a statistically significant decrease in the percentage of patients with hip fractures meeting the recommended standards of care.
