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Complications in Orthopaedics: Open Fractures

Edited by L. Scott Levin pp. 93 Rosemont: American Academy of Orthopaedic Surgeons, 2010 ISBN: 978-0-89203-639-4

This is a relatively short book from the American Academy of Orthopaedic Surgeons, and is essentially a series of invited case based discussions on various pitfalls in the management of open fractures. Each chapter consists of one or more illustrative clinical cases, which is a departure from the didactic teaching methods of many textbooks. This has the distinct advantage of grounding the reader in the real world, and also emphasising that there is scant research in this area on which to base instruction.

The order of events is rather off-putting. The opening chapter jumps straight in with a presentation of several segmental defects in the upper limb that have been treated by free tissue transfer. It is clear that this is a brief description of what can be achieved in centres of excellence, and not a 'do it yourself' aid. It is followed by a chapter on pitfalls in limb salvage, which centres around an attempt to 'fix and flap' a leg with massive soft-tissue trauma in a diabetic. Complications ensue and are dealt with in a manner that will garner the sympathy of anyone who has watched their best efforts suffer sequential complications.

The third chapter may be the weakest. It is specifically dedicated to chronic neuropathic pain following open fractures, and unfortunately has a very 'mechanistic' approach to what is the most difficult of problems. A discussion of the relationship between pain, function and psychological well-being would have made this a more rounded chapter.

It is not until the fourth chapter on the management of the soft tissues that a more recognisable structure in the form of the 'reconstructive ladder' is introduced. This is also well illustrated with case examples, as are subsequent chapters on open fracture with vascular injury, malunions and infections. These latter two chapters are a compact treatise on the Ilizarov principles crammed into 16 and 18 pages respectively. There can only be the broadest of outlines in this limited space, and so it proves.

This book then is a great series of well managed cases. The pioneering work of the Lower Extremity Assessment Project (LEAP) study group  is mentioned throughout the text, but the lack of randomised trials in this area means that at worst the book can be seen as a collection of 'anecdote-based medicine'. This however should not be seen as a criticism; these cases are so rare that a book that combines warnings about how it can go wrong combined with information about treatment modalities that are available in some centres can only be useful. It's also a much less boring read than many dry textbooks!

D. Goodier

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