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Optimising operating theatre (OT) efficiency while maintaining the standardised patient care in adolescent idiopathic scoliosis (AIS) surgery with the dedicated spine team approach: a specialised spine unit experience

Lee SY, Chan CYW, Chiu CK, Chung WH, Hasan MS, Kwan MK

Eur Spine J, 2024 Oct;33(10):3806-3813.
PMID: 38861024 DOI: 10.1007/s00586-024-08352-0

PURPOSE: To report the efficiency of OT utilisation and perioperative outcomes with a dedicated spine team approach in AIS patients who underwent posterior spinal fusion (PSF) surgeries in a consecutive case operation list.
METHODS: Three AIS patients operated in a day (8:00 AM-8:00 PM) by a dedicated spine team were recruited between 2021 and 2022. The dedicated team comprised of three senior spine consultants who operated using a dual attending surgeon strategy, an anaesthetic consultant, dedicated surgical scrub nurses, anaesthesiology nurses, radiographers, and neuromonitoring technicians. Patients were categorised according to the sequence of operation list of the day (Case 1, Case 2, and Case 3). OT efficiency was represented by OT time in five stages (preoperative time, operative time, postoperative time, total OT time, and turnover time). OT time and perioperative outcomes were compared.
RESULTS: 102 cases were analysed. On average, Case 1 began at 8:38 AM whereas Case 3 ended by 5:54 PM. OT efficiency was consistent throughout the day of operation with comparable OT time in all five stages between groups (p > 0.05). The mean turnover time was 15.1 ± 13.5 min and the mean operative time was 123.0 ± 28.1 min. Intraoperative arterial blood gas (ABG) parameters were maintained in an optimal range. The complication rate was 2.0% (N = 2/102).
CONCLUSION: Consistent OT efficiency was demonstrated with a dedicated spine team approach. Despite performing three AIS cases in a consecutive case operation list, patients' safety was not compromised as perioperative outcomes between groups were comparable.

Matched MeSH terms: Operating Rooms*
Fulltext Early detection, appropriate management - ensure a legacy of good health

Amir, S.K.

JUMMEC, 2009;12(2):44-46.
MyJurnal

The current volume of JUMMEC contains a wide spectrum of health topics highlighting the importance of controlling metabolic factors in diabetes, selection of heart failure patients for innovative treatment, early postoperative analgesia, testing of a translated screener for urinary tract problems, problems when commissioning a new operating theatre and breastfeeding issues.(Copied from article).

Matched MeSH terms: Operating Rooms
Fulltext Radiation exposure to operating theatre personnel during fluoroscopic-assisted orthopaedic surgery

Radhi AM, Masbah O, Shukur MH, Shahril Y, Taiman K

Med J Malaysia, 2006 Feb;61 Suppl A:50-2.
PMID: 17042230

Orthopaedic procedures especially dynamic hip screw (DHS) fixation, interlocking nailing (ILN) of the tibia and femur require fluoroscopic assistance. Frequent exposure to radiation is a major concern to members of the orthopaedic surgical team. This study was undertaken to measure shallow (skin) dose to the operating team personnel and deep (whole body) dose to the surgeon during such procedures in view to provide guidelines to the operating team members regarding the number of procedures allowable for them to perform or assist annually. Skin dose for the operating personnel and whole body dose for the operating surgeon during 25 procedures; ten cases of DHS, seven and six cases of ILN of the tibia and femur respectively, was measured using Thermoluminescent Dosimeter (TLD) chips. The shallow radiation dose for theatre personnel ranged from 0.19 mSy to 0.61 per case while the deep dose for the surgeon was 0.28, 0.55 and 0.81 mSy for seven cases of tibial ILN, ten cases of DHS and six cases of femur ILN respectively. The surgeon has the highest radiation exposure than other theatre personnel and the whole body exposure for DHS was higher than that of for ILN. However, the estimated cumulative dose was still far below the permissible annual dose limit.

Matched MeSH terms: Operating Rooms/manpower*; Operating Rooms/standards
Fulltext Ensuring patient safety in the new operating theatre of UMMC Trauma Centre: an anaesthesiologist novice experience

Mamat, M., Chan, L.

JUMMEC, 2009;12(2):83-91.
MyJurnal

Patient safety is a serious global healthcare issue. Harm can be caused by a range of errors or adverse events. Therefore, it is vital that the commissioning of a new operating theatre should comply to the highest standard before it is allowed to function. This paper accounts our experience in the commissioning of the University Malaya Medical Centre (UMMC) trauma centre operating theatre(OT) complex in July 2008. We highlighted the problems we faced in adhering to the international standard guidelines. Unanticipated events were handled professionally and solved. With this experience, we hope that the identified problems would provide suggestions for commissioning an operating theatre in the local setting in the future.

Matched MeSH terms: Operating Rooms
Fulltext Under-body forced-air warming blanket versus resistive heating blanket for prevention of hypothermia during spinal surgery: a randomized prospective study

Shariffuddin, I.I., Hasan, M.S., Chong, T.H., Kwan, M.K., Chan, Y.K.

JUMMEC, 2016;19(1):1-6.
MyJurnal

Background:
Prevention of hypothermia in patients undergoing major posterior approach spinal surgery can be difficult, as a
large body surface is exposed to the cold environment of the operating theatre. We compared the efficacy of a
new under-body forced-air warming blanket with that of a resistive heating blanket in preventing hypothermia.
Methods:
Sixty patients undergoing major posterior approach spinal surgery lasting for more than 2 hours were randomly
assigned to warming with a full under-body forced-air warming blanket or three segments of resistive heating
blankets, both set at 42°C. The ambient temperature was kept near 20°C. Nasopharyngeal, rectal and axillary
temperatures were measured at regular intervals. Changes in core temperature (average of nasopharyngeal
and rectal) over time were compared by the independent t-test.
Results:
The characteristics of the patients were comparable. The baseline core temperature was 36.36 ±0.38°C in the
forced-air group and 36.27 ± 0.46°C in the resistive heating group. During the first hour, the core temperature
decreased similarly from baseline in both groups. From 100 minutes after induction until the end of the surgery,
core temperature rose in both groups. At the end of surgery, the core temperature was increased by 0.08
± 0.09°C from baseline in the forced-air group but decreased by 0.40 ±0.04°C from baseline in the resistive
heating group. The difference in the change of the core temperature, at the end of the surgery, between the
two groups is statistically significant (P

Matched MeSH terms: Operating Rooms
Fulltext Intraoperative glycaemic control in non insulin dependent diabetes mellitus: a comparison between normal saline and ringer’s lactate

Sulaiman, I.M., HS, Lee, Balan, S., Jaafar, M.Z.

Medicine & Health, 2006;1(1):20-24.
MyJurnal

Fifty Non Insulin Dependent Diabetes Mellitus (NIDDM) patients undergoing surgery under epidural anaesthesia were studied. All patients received dextrose 5% infusion at 100 ml/hr from the period of fasting until upon arrival to the operation room. Patients were randomly divided into two groups. Patients in Group 1 (n=25) received normal saline while patients in Group 2 (n=25) were given Ringer’s lactate. Both groups received their infusion throughout the operative period up to four hours postoperatively. Blood glucose level was measured at baseline, 45 minutes intra operatively and postoperatively at 30 minutes and four hours by using a glucometer. Patients in Group 2 has a larger mean increase in blood glucose level of 1.5 mmol/L between 4 hours postoperatively and baseline compared to 0.96 mmol/L in Group 1. However, this was not statistically significant. There was no difference in the increase of mean glucose level at 30 minutes when compared to baseline. There was a significant increase in mean blood glucose level in both groups in the postoperative period when compared to baseline. This study demonstrated that patients with NIDDM receiving Ringer’s lactate has a larger increase in mean blood glucose level compared to those receiving normal saline, but the magnitude is not statistically significant.

Matched MeSH terms: Operating Rooms
Fulltext Systematic study on the relationship between particulate matter and microbial counts in hospital operating rooms

Tan H, Wong KY, Nyakuma BB, Kamar HM, Chong WT, Wong SL, et al.

Environ Sci Pollut Res Int, 2022 Jan;29(5):6710-6721.
PMID: 34458973 DOI: 10.1007/s11356-021-16171-9

In this study, a systematic procedure for establishing the relationship between particulate matter (PM) and microbial counts in four operating rooms (ORs) was developed. The ORs are located in a private hospital on the western coast of Peninsular Malaysia. The objective of developing the systematic procedure is to ensure that the correlation between the PMs and microbial counts are valid. Each of the procedures is conducted based on the ISO, IEST, and NEBB standards. The procedures involved verifying the operating parameters are air change rate, room differential pressure, relative humidity, and air temperature. Upon verifying that the OR parameters are in the recommended operating range, the measurements of the PMs and sampling of the microbes were conducted. The TSI 9510-02 particle counter was used to measure three different sizes of PMs: PM 0.5, PM 5, and PM 10. The MAS-100ECO air sampler was used to quantify the microbial counts. The present study confirms that PM 0.5 does not have an apparent positive correlation with the microbial count. However, the evident correlation of 7% and 15% were identified for both PM 5 and PM 10, respectively. Therefore, it is suggested that frequent monitoring of both PM 5 and PM 10 should be practised in an OR before each surgical procedure. This correlation approach could provide an instantaneous estimation of the microbial counts present in the OR.

Matched MeSH terms: Operating Rooms
Fulltext Robotic neurosurgery: a preliminary study using an active vision-guided robotic arm for bone drilling and endoscopic manoeuvres

Awang MS, Abdullah MZ

Malays J Med Sci, 2011 Apr;18(2):53-7.
PMID: 22135587 MyJurnal

Surgical robots have been appearing in operating rooms over the past decade, and neurosurgery has been one of the pioneers in this area. In neurosurgery, the clinical use of robots has been limited to stereotactic procedures and endoscopic manoeuvres, although the brain is a unique organ and well-suited for robotic application. The aim of this study was to assess the ability of our vision-guided robotic system to perform basic neurosurgical procedures.

Matched MeSH terms: Operating Rooms
Fulltext Nitrous oxide pollution in the operating room. A comparison of two modes of ventilation

Noorddin Y, Raha AR, Jaafar MZ, Rozaidi SH, Muraly S, Marlizan MY

Med J Malaysia, 2007 Jun;62(2):127-9.
PMID: 18705444 MyJurnal

The use of laryngeal mask airway (LMA) as an alternative to the endotracheal tube (ETT) is becoming more popular in the practice of anesthesia. It is undeniable that this device has numerous advantages over endotracheal tube, however it does not provide an airtight seal between the airway and atmospheric gases. This may lead to pollution of the operating room environment with nitrous oxide. One hundreds adult patients undergoing general anaesthesia were divided into two groups. The airway in Group I was maintained with LMA with spontaneous ventilation and ETT with intermittent positive pressure ventilation (IPPV) was used for Group II. The result demonstrated that the ETT group recorded concentrations of nitrous oxide that were well above the NIOSH recommended eight hour time weighted average of 25ppm throughout the duration of surgery when compared to patients using LMA.

Matched MeSH terms: Operating Rooms*
The impact on patients' time-to-theatre following colour coding classification in emergency operation theatre, Sarawak General Hospital

Khaw SK, Teo SC, Bujang MA

Med J Malaysia, 2020 07;75(4):379-384.
PMID: 32723998

INTRODUCTION: A proper prioritisation system of emergency cases allows appropriate timing of surgery and efficient allocation of resources and staff expertise. The aim of this study was to determine the impact of colour coding classification on Time-to- theatre (TTT) of patients in comparison with the normal practice.
METHOD: Categorisation was a surgical judgment call after thorough clinical assessment. There were 4 levels of urgency with their respective TTT; Red (2 hours), Yellow (8 hours), Green (24 hours), Blue (72 hours). Caesarean cases were excluded in colour coding due to pre - existing classification. The data for mean TTT was collected 4 weeks before the implementation (Stage 1), and another 4 weeks after implementation (Stage II). As there was a violation in the assumption for parametric test, Mann Whitney U test was used to compare the means between these two groups. Using logarithmic (Ln) transformation for TTT, Analysis of Covariance (ANCOVA) was conducted for multivariate analysis to adjust the effect of various departments. The mean TTT for each colour coding classification was also calculated.
RESULTS: The mean TTT was reduced from 13 hours 48 min to 10 hours, although more cases were completed in Stage II (428 vs 481 cases). Based on Mann-Whitney U test, the difference in TTT for Stage I (Median=6.0, /IQR=18.9) and Stage II (Median=4.2, IQR=11.5) was significantly different (p=0.023). The result remained significant (p=0.039) even after controlled for various department in the analysis. The mean/median TTT after colour coding was Red- 2h 24min/1h, Yellow- 8h 26min/3h 45 min, Green- 15h 8min/8h 15min, and Blue- 13h 46min/13h 5min.
CONCLUSION: Colour coding classification in emergency Operation (OT) was effective in reducing TTT of patients for non-caesarean section cases.

Matched MeSH terms: Operating Rooms*
Evaluation of door to operation theatre time following activation of trauma team

Nik Azlan NM, Ong SF

Med J Malaysia, 2019 04;74(2):116-120.
PMID: 31079121

INTRODUCTION: This study evaluates factors that influence door to operation theatre (OT) time in a tertiary referral centre following activation of trauma team. Specific factors observed in this study were association of the injury severity score (ISS), activation of trauma team and the number of referred specialty to door to operation theatre time.
METHODS: Retrospective chart review that evaluates all trauma patients which required immediate operative intervention from January 2011 to December 2015. Trauma patients were selected from the resuscitation log book and data were collected by chart review of selected patients.
RESULTS: Only 5 out of 279 patients (1.8%) achieved optimal door to OT time. (<60 minutes) Mean door to OT time was 299.27 minutes (95% CI: 280.52, 318.52). Trauma team activation has shown significant improvement in door to OT time (p=0.047). Time of multiple team referrals (p=0.023) and time of operative decision (p<0.001) both had significant impact on door to OT time. Other factors included were demographics, ISS score, Glasgow Coma Scale (GCS), mechanism of injury and systolic blood pressure on arrival all which showed no significance.
CONCLUSION: Trauma team activation in a tertiary centre improved trauma care by reducing door to OT time to less than 60 minutes. Implementation of an effective trauma team activation system in all hospitals throughout Malaysia is recommended.

Matched MeSH terms: Operating Rooms/statistics & numerical data*
Fulltext Public health preparedness and response to flood disaster in Johore, Malaysia : challenges and lessons learned

Arbaiah, O., Daud, A.R., Surinah, A., Noorhaida, U., Shaharom, N.A.M.C.D., Rahim, A.

Malaysian Journal of Community Health, 2009;15(3):126-131.
MyJurnal

Introduction : The 2006 -2007 flood in Johore which displaced more than 312,386 residents of the state was an extraordinary event and tested everyone preparedness. The disaster caused massive material, economic and environmental losses exceeded the state and local community capacity, forcing them seeks help from other states. Needs assessment, effectiveness of health services as well as leadership and nongovernment organization involvement were evaluated and constitute lessons learnt from the experiences.
Methodology : This is a descriptive review of the Johore flood. The review was based on literature search using established data and published reports of previous disasters. Discussion will focus on the 4 S’s of the surge capacity that is Structure, Staffing, Supplies and System (policies & procedures). Result : Structure- although 49 or 14% of health facilities in the state were affected by the flood, health services continued to be given. Majority of the relief centers were schools with better facilities. Funding for repairs obtained early approval as estimation of damages was timely applied. Temporary isolation centers for the conjunctivitis outbreak was appropriate implemented. Staffing- Leadership was assumed by the Johore State Health Department, the strongest and most prepared health sector. Needs assessment resulted in additional staff being deployed from other states allowing local staff to have their break from work as well as personal stress. Local staff became multi-skilled players. Training in disaster preparedness has to be of utmost priority to support such needs. Supplies- Personnel protective and pest control equipment, and medical supplies were adequately supplied. The laboratory services were well prepared. Pamphlets, posters, buntings and banners were distributed including five new health promotion materials. System- Flood disaster plan of action was well in place resulting in efficient management of the operating rooms, data management, coordination of services and disease surveillance through early warning system.
Conclusion : Public health preparedness is a matter of good governance and management based on evidence and experience. There is a need for a permanent and stable program for the Ministry of Health to prepare and coordinate the response to all disasters.

Matched MeSH terms: Operating Rooms
Fulltext A Limb-Threatening Long Arterial Dissection Caused by Humerus Neck Fracture: A Case Report

Kurnaz R, Ikizler M, Ozbayburtlu M, Gunes T

Malays Orthop J, 2018 Mar;12(1):51-53.
PMID: 29725515 DOI: 10.5704/MOJ.1803.012

Proximal humerus fracture is a common arm trauma and rarely occurs with vascular injury which however is a serious complication. In this case report, we present a long segment dissection of the axillary and brachial arteries as a rare complication due to fragmented proximal humerus fracture and shoulder dislocation. An 80-year old female patient was seen at the emergency department. Radiograph examination has revealed a fragmented proximal humerus fracture besides dislocation of the head of humerus towards the axillary area. On vascular examination, acute arterial occlusion such as absence of radial and ulnar pulses were observed in her left hand. The patient was immediately taken to the operating room. The dissection included the entire segment approximately 20cm between the distal subclavian artery and the distal brachial artery. This injured segment was removed and a 6mm Polytetrafluroethylene (PTFE) graft with rings was interpositoned between subclavian and brachial arteries. This case is a rarity because of such a significant complication after a small injury. Axillary artery injuries caused by humeral neck fractures are rare but should not be missed by the physician.

Matched MeSH terms: Operating Rooms
Fulltext Restructuring burns management during the COVID-19 pandemic: A Malaysian experience

Ilenghoven D, Hisham A, Ibrahim S, Mohd Yussof SJ

Burns, 2020 08;46(5):1236-1239.
PMID: 32471558 DOI: 10.1016/j.burns.2020.05.008
Matched MeSH terms: Operating Rooms/organization & administration
Operating Rooms Scheduling for Elective Surgeries in a Hospital Affected by War-Related Incidents

Ali HH, Lamsali H, Othman SN

J Med Syst, 2019 Apr 10;43(5):139.
PMID: 30972511 DOI: 10.1007/s10916-019-1263-z

Hospital scheduling presents huge challenges for the healthcare industry. Various studies have been conducted in many different countries with focus on both elective and non-elective surgeries. There are important variables and factors that need to be taken into considerations. Different methods and approaches have also been used to examine hospital scheduling. Notwithstanding the continuous changes in modern healthcare services and, in particular, hospital operations, consistent reviews and further studies are still required. The importance of hospital scheduling, particularly, has become more critical as the trade-off between limited resources and overwhelming demand is becoming more evident. This situation is even more pressing in a volatile country where shootings and bombings in public areas happened. Hospital scheduling for elective surgeries in volatile country such as Iraq is therefore often interrupted by non-elective surgeries due to war-related incidents. Hence, this paper intends to address this issue by proposing a hospital scheduling model with focus on neuro-surgery department. The aim of the model is to maximize utilization of operating room while concurrently minimizing idle time of surgery. The study focused on neurosurgery department in Al-Shahid Ghazi Al-Hariri hospital in Baghdad, Iraq. In doing so, a Mixed-integer linear programming (MILP) model is formulated where interruptions of non-elective surgery are incorporated into the main elective surgery based model. Computational experiment is then carried out to test the model. The result indicates that the model is feasible and can be solved in reasonable times. Nonetheless, its feasibility is further tested as the problems size and the computation times is getting bigger and longer. Application of heuristic methods is the way forward to ensure better practicality of the proposed model. In the end, the potential benefit of this study and the proposed model is discussed.

Matched MeSH terms: Operating Rooms/organization & administration*
Fulltext Peri-operative blood pressure changes in normotensive and hypertensive patients

Poh KS, Lim TA, Airini IN

Med J Malaysia, 2007 Jun;62(2):97-103.
PMID: 18705438

Controversy surrounds the acceptance of hypertension as an independent risk factor for anaesthesia. In an attempt to identify variables that are associated with increased haemodynamic instability during surgery, the blood pressure profiles of 128 patients were analysed. The two variables that contributed most to the instability were pre-operative control of blood pressure and anaesthetic technique. To reduce the fluctuation in blood pressure, it is advisable for patients to be given a regional anaesthetic. Current therapy for hypertension appears to exaggerate the depressant effects of anaesthetic drugs. Care must be taken not only to prevent hypertensive episodes during surgery, but also hypotension.

Matched MeSH terms: Operating Rooms
Waste production from phacoemulsification surgery

Khor HG, Cho I, Lee KRCK, Chieng LL

J Cataract Refract Surg, 2020 02;46(2):215-221.
PMID: 32126034 DOI: 10.1097/j.jcrs.0000000000000009

PURPOSE: To determine the amount of waste produced from phacoemulsification surgeries and ways to curtail the problem.
SETTING: Miri Hospital, Sarawak, Malaysia.
DESIGN: Prospective study.
METHODS: Phacoemulsification surgery cases were included in this study; nonphacoemulsification surgeries were excluded. The waste was subdivided into 3 main categories, general waste, clinical waste, and sharps. The waste produced by ophthalmologists and trainees was accounted for separately. The mean weight of waste per case was obtained by dividing the total weight of waste produced with the total number of cases.
RESULTS: The total waste produced from a total of 203 cases of phacoemulsification surgeries was 167.965 kg, of which, 95.063 kg (56.6%) were clinical waste, 63.197 kg (37.6%) were general waste, and 9.705 kg (5.8%) were sharps; 32.193 kg (50.9%) out of the general waste pool were recyclable waste products. The mean waste production per case of phacoemulsification surgery for an ophthalmologist was 0.814 kg, 1.086 kg per case for a trainee. A case of phacoemulsification surgery would produce 0.282 kg of carbon dioxide equivalents in the setup based on the recyclable general waste.
CONCLUSIONS: The average waste produced per case of phacoemulsification surgery in Miri Hospital was 0.827 kg. After excluding the recyclable material, the average waste produced per case was 0.669 kg. Following the 3 R's principles (reduce, reuse, and recycle) in the handling of waste production might reduce environmental impact.

Matched MeSH terms: Operating Rooms
Fulltext Reconstruction with Composite Cement-Autoclaved Autograft after a Near-Total Excision of the Humerus for Osteosarcoma: A Case Report

Pan, K.L., Zolqarnain A., Ong, G.B.

Malays Orthop J, 2009;3(2):55-57.
MyJurnal

Osteosarcoma occurring in the humerus is often confined to the proximal part, in which case, reconstruction after excision is less daunting. When the tumour spreads down the medullary cavity distally, a total humeral replacement is often required. This is costly and beyond the means of the average patient in a developing country. An amputation is often the procedure of first resort. We report a 13-year-old boy with osteosarcoma originating from the left proximal humerus, with involvement of the marrow reaching down to the distal diaphyseal-metaphyseal junction, leaving only 6 cm of the distal humerus intact after wide resection. Reconstruction of the defect was done with a composite cement-autoclaved autograft fixed to the remaining humerus with a plate. At 40 months of follow-up, the patient is well with normal function of the elbow, wrist and hand. Salvaging the limb despite near total involvement of the humerus by high grade osteosarcoma is possible using material available in the average orthopaedic operating room.

Matched MeSH terms: Operating Rooms
Fulltext A diagnostic workup of perioperative anaphylaxis reveals a selective type 1 hypersensitivity to cefazolin

Meera Thalayasingam, Shek, Lynette Pei-Chi

International e-Journal of Science, Medicine & Education, 2015;9(2):37-39.
MyJurnal

Anaphylaxis in the operating room although infrequent can be potentially fatal. The diagnosis of perioperative anaphylaxis is complex due to a multitude of factors. Firstly, patients under anesthesia cannot verbalize their complaints, the anesthetic agents themselves can alter vital parameters (e.g. heart rate and blood pressure) and cutaneous signs in a completely draped patient may be missed. Secondly, the differential diagnosis of intraoperative anaphylaxis is wide. Conditions such as asthma exacerbation, arrhythmia, hemorrhage, angioedema, mastocytosis, acute myocardial infarction, drug overdose, pericardial tamponade, pulmonary edema, pulmonary embolus, sepsis, tension pneumothorax, vasovagal reaction, venous air embolism, laryngospasm, blood transfusion reaction and malignant hyperthermia need to be considered. Thirdly, the diagnostic workup is challenging due to the multiple medications administered and other exposures encountered such as latex and chlorhexidene. However, through a timely allergy consultation and a systematic approach, identification of the culprit agent and safe alternatives can be established to prevent future occurrences as illustrated in the case below.

Matched MeSH terms: Operating Rooms
Fulltext Single-stage "Fix and Flap" gives Good Outcomes in Grade 3B/C Open Tibial Fractures: A Prospective Study

Singh J, Dhillon MS, Dhatt SS

Malays Orthop J, 2020 Mar;14(1):61-73.
PMID: 32296484 DOI: 10.5704/MOJ.2003.010

Introduction: Grade 3B/C open tibial fractures with grossly contaminated degloving injuries have poor outcomes, with or without vascular injuries. Treatment decision oscillates between limb salvage and amputation. The standard protocol of repeated debridement and delayed wound cover is a challenge in developing countries due to overcrowded emergencies and limited operating room availability. We present results of our modified protocol involving primary stabilisation with external fixation and immediate wound cover as an aggressive modality of treatment.
Material and Methods: Thirty-three patients with severe open tibial shaft fractures were managed using a standardised protocol of emergent debridement, external fixation and immediate wound cover with free distant/local rotational muscle flaps and fasciocutaneous flaps, and with vascular repair in Grade 3C fractures. Intra-articular fractures were excluded. Patients were followed for a minimum of three years, with an assessment of clinical, radiological and functional outcomes.
Results: Wound cover was achieved with 24 distant free muscle flaps, four local rotational muscle flaps and five fasciocutaneous flaps. All fractures united with an average time to union of 40.3 weeks (16-88). Fifteen patients (45.4%) underwent only a single major surgery using primary definitive external fixation. Deep infection was seen in four patients (12.1%). Nineteen patients had excellent to good outcomes, six were fair, and eight were poor.
Conclusion: "Fix and Flap" in the same sitting, using immediate wound cover and external fixation, has given good results in our hands despite the delayed presentation, the neurovascular deficit and the degloving injury. This may be a better management strategy in overcrowded tertiary care centres of developing countries, with a single surgical procedure in almost half the cases.

Matched MeSH terms: Operating Rooms

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