Open Tibial Fractures Research Articles

Temporary spacer rod and plate technique: a novel intraoperative technical tip for minimizing the docking site malalignment during bone transport for bone loss in Gustilo IIIb open tibial fractures.

Distraction osteogenesis is a safe and reliable option for managing bone defects of the tibia following major open fractures. Even though the Limb Reconstruction System (LRS) is a popular option, it may result in malalignment, necessitating an additional procedure to correct the alignment. The objective of the study is to assess the efficacy of a novel surgical technique in minimising malalignment. This was a retrospective cohort study conducted at a level 1 tertiary trauma centre consisting of 35 patients with primary bone loss following open tibia fractures. A uniplanar LRS frame was applied using a combined spacer rod with plate technique. Radiological assessment of docking site characteristics (translation, angulation) and functional assessment using ASAMI score was done. The mean distraction regenerate length was 8.4 ± 3.45cm. At the docking site, 18 patients did not have any deformity, 13 had a minor deformity of ≤ 5°, 2 had a moderate deformity of 6°-10° and 2 with a severe deformity > 10°. Circumferential docking was seen in 88.5% (31/35). According to the ASAMI functional scoring, 13 patients had excellent outcomes, 19 had good, one had fair, and two had poor outcomes. Six patients had pin tract infections, three had deep infections, and 17 had a delayed union. Our study had a lower incidence of malalignment compared to similar studies in the literature. The use of this simple and economical intra-operative technique allowed for much higher precision in aligning the fracture ends, thus minimising the docking site malalignment. III. Level I Tertiary trauma centre.

Patient reported outcomes after definitive open tibial fracture management

Aims: Open tibial fractures are often life-changing injuries and patient outcomes remain poor despite the introduction of national management guidelines. The longer-term impact to the patient can be considerable but this is often overlooked in the literature. This study aims to establish the functional, physical, and psychosocial impact of sustaining an open tibial fracture.Methods: We reviewed 69 consecutive Gustilo-Anderson grade IIIB and IIIC open tibial fractures that presented to our Major Trauma Centre (MTC) between September 2012 and April 2018. Each participant was interviewed and sent patient-reported outcome questionnaires, a minimum of 12 months following injury. Our primary outcome was the Lower Extremity Functional Scale (LEFS). Secondary outcomes included the Short-Form 36 Healthy Survey (SF-36), Sickness Impact Profile 128 (SIP) and return to occupation. Subgroups were analysed according to age, Injury Severity Score (ISS) and limb amputation.Results: The mean follow up was 43 months. 96% were grade IIIB and 4% grade IIIC. The response rate for our study was 72%. The mean LEFS was 42 (IQR 21.5–58.5). All total and sub-domain scores within both the SF-36 and SIP questionnaires were reduced when compared to normative population data. Only 48% of patients returned to full time employment. Subgroup analysis revealed significantly reduced LEFS, SIP and SF-36 subdomain scores for those with a presenting ISS >14 and those undergoing limb amputation.Conclusion: Patients are at significant risk of longer-term functional, physical and psychosocial harm after suffering an open tibial fracture. Those sustaining major polytrauma or amputation demonstrated to have the greatest risk of poor outcome. Early identification of these individuals likely to suffer most from their injury would help direct appropriate resources to those with greatest need at the earliest opportunity.

New insights into pathogenesis of congenital pseudarthrosis of tibia in children using periosteum proteomics analysis.

The exact etiology and pathogenesis of congenital pseudarthrosis of tibia (CPT) are not clear. Quantitative proteomics analysis plays a vital role in disease pathology research. Tandem mass tag (TMT)-based proteomics techniques were employed to identify and analyze the differentially expressed proteins (DEP) in the tibia periosteum tissues of CPT patients. The samples were divided into three groups: CPT with NF1 group, CPT without NF1 group (non-NF1-CPT), and control group (patients with open tibial fracture). A fold change ≥1.5 or ≤0.66 and P-value <0.05 were used as the thresholds to screen DEPs. Subsequently, bioinformatics resources such as online tools DAVID and String were used to generate gene ontology (GO) annotation, KEGG pathways enrichment, and protein-protein interaction (PPI) network for these DEPs. The results show that a total of 347 proteins were differentially expressed in NF1-CPT groups, 212 of which were upregulated and 135 were downregulated. There were more DEPs in non-NF1-CPT groups; we identified 467 DEPs, including 281 upregulated and 186 downregulated. Among them, NF1-CPT groups and non-NF1-CPT groups shared 231 DEPs, and the remaining 230 DEPs showed the same expression trend in the two disease groups, with 117 upregulated and 113 downregulated. In particular, 116 proteins were altered only in NF1-CPT groups (94 were upregulated and 22 were downregulated), whereas 236 proteins were altered only in non-NF1-CPT groups (164 were upregulated and 72 were downregulated). Finally, compared with non-NF1-CPT groups, 47 proteins changed 1.5-fold and P-value < 0.05 in NF1-CPT groups. To sum up, we found that common DEPS in periosteum of NF1-CPT and non-NF1-CPT groups are mainly involved in cell matrix assembly, cell adhesion, AKT-PI3K signal pathway activation, and vascular agglutination, which indicate that these are the pathological characteristics of CPT. The osteogenic ability is weak, the osteoclastic ability is strong, the vascular lumen is narrow, the invasive growth and the proliferation of fibroblasts are enhanced in CPT patients.

Patient Comorbidities Associated With Acute Infection After Open Tibial Fractures.

Introduction:Open tibial shaft fractures are high-risk injuries for developing acute infection. Prior research has focused on injury characteristics and treatment options associated with acute inpatient infection in these injuries without primary analysis of host factors. The purpose of this study was to determine the patient comorbidities associated with increased risk of acute infection after open tibial shaft fractures during initial hospitalization.Methods:A total of 147,535 open tibial shaft fractures in the National Trauma Data Bank from 2007 to 2015 were identified that underwent débridement and stabilization. Infection was defined as a superficial surgical site infection or deep infection that required subsequent treatment. The International Classification of Diseases, ninth revision codes were used to determine patient comorbidities. Comparative statistical analyses including odds ratios (ORs) for patient groups who did develop infection and those who did not were conducted for each comorbidity.Results:The rate of acute inpatient infection was 0.27% with 396 patients developing infection during hospital management of an open tibial shaft fracture. Alcohol use (OR, 2.26, 95% confidence interval [CI], 1.73-2.96, P < 0.0001), bleeding disorders (OR, 4.50, 95% CI, 3.13-6.48, P < 0.0001), congestive heart failure (OR, 3.25, 95% CI, 1.97-5.38, P < 0.0001), diabetes (OR, 1.73, 95% CI, 1.29-2.32, P = 0.0002), psychiatric illness (OR, 2.17, 95% CI, 1.30-3.63, P < 0.0001), hypertension (OR, 1.56, 95% CI, 1.23-1.95, P < 0.0001), obesity (OR, 3.05, 95% CI, 2.33-3.99, P < 0.0001), and chronic obstructive pulmonary disease (OR, 2.09, 95% CI, 1.51-2.91, P < 0.0001) were all associated with increased infection rates. Smoking (OR, 0.957, 95% CI, 0.728-1.26, P = 0.722) and drug use (OR, 1.11, 95% CI, 0.579-2.11, P = 0.7607) were not associated with any difference in infection rates.Discussion:Patients with open tibial shaft fractures who have congestive heart failure, bleeding disorders, or obesity are three to 4.5 times more likely to develop an acute inpatient infection than patients without those comorbidities during their initial hospitalization. Patients with diabetes, psychiatric illness, hypertension, or chronic obstructive pulmonary disease are 1.5 to 2 times more likely to develop subsequent infection compared with patients without those comorbidities. Patients with these comorbidities should be counseled about the increased risks. Furthermore, risk models for the infectious complications after open tibial shaft fractures can be developed to account for this more at-risk patient population to serve as modifiers when evaluating surgeon/hospital performance.Conclusion:Patient comorbidities are associated with increased risk of acute inpatient infection of open tibial shaft fractures during hospitalization.

Unreamed Intramedullary Nailing Versus External Fixation for the Treatment of Open Tibial Shaft Fractures in Uganda: A Randomized Clinical Trial.

To compare unreamed intramedullary nailing versus external fixation for the treatment of Gustilo-Anderson type II and IIIA open tibial fractures admitted to a hospital in rural Uganda. Randomized clinical trial. Regional referral hospital in Uganda. Fifty-five skeletally mature patients with a Gustilo-Anderson type II or IIIA open tibia shaft fracture treated within 24 hours of injury between May 2016 and December 2019. Unreamed intramedullary nailing (n = 31) versus external fixation (n = 24). The primary outcome was function within 12 months of injury, measured using the Function IndeX for Trauma (FIX-IT) score. Secondary outcomes included health-related quality of life (HRQoL) using the 3-level version of the 5-dimension EuroQol instrument (EQ-5D-3L), radiographic healing using the Radiographic Union Scale for Tibia (RUST) fractures score, and clinical complications. Treatment with an intramedullary nail resulted in a 1.0-point higher [95% credible intervals (CrI), 0.1 to 1.9] FIX-IT score compared with external fixation. Results were similar for the secondary patient-reported outcomes, EQ-5D-3L and the visual analog scale component of the EuroQol instrument (EQ-VAS). RUST scores were not different between groups at any time point. Treatment with an intramedullary nail was associated with a 22.1% (95% CrI, -42.6% to 1.7%) lower rate of malunion and a 20.8% (95% CrI, -44.0% to 2.9%) lower rate of superficial infection. In rural Uganda, treatment of open tibial shaft fractures with an unreamed intramedullary nail results in marginal clinically important improvements in functional outcomes, although there is likely an important reduction in malunion and superficial infection. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

The lateral supramalleolar flap for the treatment of open foot and ankle fractures

The purpose of this study is to describe the efficacy of lateral supramalleolar flap as an option for soft tissue repair in open fractures of foot and ankle and to present the experience in 2 trauma units: Hospital Susana López de Valencia, Popayán Colombia, and Hospital Universitario de Santander, Bucaramanga Colombia. This is an observational, case series study including all patients with open fractures of foot and ankle who were treated from January 2016 to June 2021 and who required soft tissue coverage. Patients whose soft tissue injury was located on the anatomical area of the perforating peroneal artery, those with less than 6 months of follow-up and those who refused the proposed treatment were excluded. On the other hand, although literature reports flaps of up to 100 cm 2 [1], in our hands, this flap unsuitable for skin defects larger than 60 cm 2 , and other procedures such as free flaps should be considered in these cases. Thirteen patients were selected, 9 men and 4 women, with a mean age of 30 years (12–62 years) and mean follow-up duration of 10.3 months [ [6] , [7] , [8] , [9] , [10] , [11] , [12] , [13] , [14] ]. In 11 patients, the mechanism of trauma involved a motorcycle accident. Mean flap size was 40 cm 2 (30–48 cm 2 ). Ten flaps survived with no acute problems, 2 presented with venous congestion and epidermolysis, which were treated conservatively, and 1 developed complete necrosis requiring reintervention. All interventions were performed by the authors belonging to the orthopedic trauma units from the involved hospitals. The lateral supramalleolar flap is an excellent alternative for the treatment of coverage defects caused by open foot and ankle fractures, producing satisfactory and predictable results in the hands of orthopedic surgeons with no specific training in microsurgical techniques. Level of clinical evidence: 4. • The treatment of open distal tibial, ankle, and foot fractures, represents a significant challenge, and it needs early coverage. • Microvascular techniques and free flaps are demanding procedures not always available in trauma centers. • The supramalleolar flap is a reproducible option for soft tissue coverage in distal tibial, ankle, and open foot fractures.

Complex limb salvage with an orthoplastic approach: a case report

Lower extremity trauma is an important cause of patient morbidity and disability-adjusted life years (DALYs). It also presents a significant reconstructive challenge for surgeons. Mangled extremity injuries can result in an amputation when limb salvage procedures are unsuccessful. Identifying strategies to optimize limb salvage attempts is necessary to improve postoperative outcomes. Establishing a constructive relationship between orthopaedic and plastic surgeons has been shown to be beneficial and subject to a growing interest in the trauma literature. We present the case of a 42-year-old male referred to our institution for limb salvage after sustaining severe bilateral lower extremity injuries. These included a right open Gustilo 3B tibia shaft fracture with a critical bone defect combined with a left floating knee (closed femur fracture and open Gustilo 3C tibia fracture). Bilateral tibia fracture-related infections were treated in conjunction with successful flap coverage. Following eradication of the infections, adequate soft tissue coverage and stable bony fixation, the tibia critical bone defect of close to 8 cm was treated with bone transport. Limb salvage was successful; amputation was avoided, and good function of both limbs was achieved. This manuscript shares a great clinical success in the extensive collaboration between two surgical subspecialties. • Successful complex lower limb salvage. • Orthopedic and plastic surgery collaboration can avoid the need for amputation. • Tertiary care centres are best equipped to manage Orthoplastic trauma. • Tertiary care centres are best equipped to manage Orthoplastic trauma.

Open tibial pilon fracture with an extensive osteochondral defect: Staged reconstruction

The surgical treatment of large post-traumatic osteochondral defects related to open tibial pilon fractures is challenging. Staged treatment with soft tissue damage control and bone reconstruction in the second half is often the best therapeutic option. We present a technical tip using osteochondral allograft to reconstruct an area with extensive bone loss in the distal tibial epiphysis after a gunshot wound, describing the treatment stages and good clinical results. Level of Evidence V; Therapeutic Studies; Expert Opinion.

Short term results with the use of PLA antibiotic coated nail in open tibia fractures: A prospective study

BackgroundAntibiotic impregnated cement coated nails have been described in literature with promising success rates. However, they need removal at a later stage. This study focuses on use of a PLA-precoated antibiotic nail that stops eluting antibiotic after a while and can be retained later as it behaves as a standard interlocking nail in the long run. PurposeTo study if PLA (polylactic acid) -antibiotic coated nails reduces infection and non-union rates and improve the functional outcome in open tibial shaft fracture cases. Materials and methodsIn this prospective cohort study, we included 54 patients with open tibia shaft fractures treated with wound debridement and internal fixation using a reamed PLA (polylactic acid)-antibiotic coated nail (CE-certified, OSSIPRO, MatrixTM). ResultsForty patients with a Grade 2 and ten with grade 3A open tibial fracture, according to the Gustilo-Anderson classification, completed a minimum of six months of follow-up and were included in the analysis. At the final follow-up, four patients (all with grade 3A fracture) had an active infection, 10 (four of grade 2 and six of grade 3A) had non-union, the mean physical component score (SF-36 score) was 55.2 ± 20.10 (grade 2; 58.95 ± 9.99, grade 3A; 40.19 ± 16.37, P value 0.002), and the mean mental component score (SF-36 score) was 54.96 ± 23.5 (grade 2; 57.96 ± 16.63, grade 3A; 42.94 ± 23.75, P value 0.04). Furthermore, Multivariate analysis showed age and grade of fracture to be independently related to the development of infection and non-union. ConclusionAlthough the use PLA-antibiotic coated nail looks promising, short-term results have revealed no additional benefit in terms of reduced infection rates, improved union rates or functional outcomes. Large multicentric randomized controlled trials and a long term follow up are advised to further explore the role of PLA coated antibiotic nails in open tibial fractures.

“Don’t rush into thinking of walking again”: Patient views of treatment and disability following an open tibia fracture in Malawi

Background: Open tibia fractures are a common injury following road traffic accidents in Malawi and can lead to long term disability. Very little is known about patients’ experiences of the healthcare system and the disability in low-income countries following this injury. The aim of the study was to explore patient experiences of treatment and disability following an open tibia fracture in Malawi. Methods: A qualitative study was conducted using semi-structured interviews with ten patients with open tibia fractures at a central hospital in Blantyre, Malawi. A mixed deductive-inductive thematic analysis was used to identify broad themes of treatment and disability. Written informed consent was obtained from all participants. Results: Patient characteristics included an average age of 39.1 years old (22-63) and 80% were male. Broad themes found were delays in receiving treatment, change in individuals’ societal role and delayed recovery associated with pain and immobility. Conclusions: Open tibia fractures in Malawi have a devastating impact on patients and their families. Further studies are required to explore the reasons for the delays in open fracture emergency treatment.

Synchronous circular frame stabilisation and microsurgical soft tissue reconstruction for open lower limb fractures–A cost analysis and description of the surgical technique

IntroductionCurrent surgical paradigms for ortho-plastic management of IIIB open tibial fractures make compromises. Often, definitive circular frame stabilisation is delayed until the soft tissue envelope is secure to allow access for further soft tissue reconstruction if required. This delay has potential clinical and cost implications. A previous study showed acute circular frame stabilisation performed concurrently or before soft tissue reconstruction was feasible without additional soft tissue reconstruction problems. This study examines potential resource savings using this approach. MethodsAll open tibial fractures managed by circular fixator and microsurgical soft tissue reconstruction between April 2015 and June 2019 were identified from a prospectively maintained database. Those receiving circular frame stabilisation with synchronous microsurgical soft tissue reconstruction were considered cases; those in whom the frame stabilisation was delayed were controls. Cost data were derived from the Patient Level Information and Costing System. Salvage cases and those with incomplete treatment were excluded. ResultsNine cases and 25 controls were evaluated. No statistically significant difference was observed between groups in terms of age, sex, injury severity score, time to debridement, time to coverage, length of follow up, or time to union. Median length of stay was 13.3 and 19.7 days for cases and controls respectively (p<0.01). Cases required fewer procedures (2.3) compared to controls (4.5) (p<0.001). The cost of care was less for cases (£25,527) than controls (£32,952) (p <0.05). No cases returned to theatre with flap failure or flap compromise. Complications were similar between groups. ConclusionIn suitable patients, synchronous circular frame stabilisation and microsurgical soft tissue reconstruction is a safe, clinically effective, and cost-saving option.

Functional and radiological outcomes of primary ring fixator versus antibiotic nail in open tibial diaphyseal fractures: A prospective study

Management of open fractures of tibia is still a matter of debate due to high incidence of infections. Traditionally external fixators have been advocated in managing open tibial fractures. Due to limited efficacy of systemic antibiotics, recently antibiotic coated intramedullary interlocking nails have been developed for the management of open tibia fractures. Therefore, we conducted this prospective randomized study to compare the functional and radiological outcomes of primary ring fixator versus antibiotic coated nail in open diaphyseal tibial fractures. The study included 32 patients with Gustilo-Anderson type II and type IIIA fractures of tibial diaphysis. Out of them 16 patients were managed with Ring External Fixator (Group I) and 16 were managed with OssiproÒ gentamicin intramedullary interlocking tibial nail (Group II). The radiological and functional outcomes were assessed at final follow-up according to and SMFA criteria. Statistical analysis of the data was performed using IBM SPSS statistics 2.0 software. Chi square test and independent student t-test were used and a P value <0.05 was considered statistically significant RESULTS: Union was achieved in 15 patients (93.8%) in group I and 13 patients (81.2%) in group II. Pin tract infection was seen in 6 patients (37.5%) in group I, whereas infection was present in 2 patients (12.5%) in group II. Bone results were excellent in 13 patients (81.3%), good in 2 patients (12.5%), poor in one patient (6.3%). In group II, bone results were excellent in 12 patients (75%), good in one patient (6.2%), poor in 3 patients (18.8%). At 1 year of final follow up, mean SMFA score was 24.41±5.87 in group I, whereas mean SMFA score was 23.703±8.02 in group II. Ring fixator as well as antibiotic coated tibial interlocking nail achieved comparable rates of union in the present study. Complication rates were similar in both the groups and the functional and radiological outcomes were comparable in both groups. Results of this study indicate that although ring fixation is an established option for management of open tibial fractures, antibiotic-coated intramedullary nail is also a reliable option in open Grade II and grade IIIA injuries. Level II.

"Don't rush into thinking of walking again": Patient views of treatment and disability following an open tibia fracture in Malawi.

Background: Open tibia fractures are a common injury following road traffic accidents in Malawi and can lead to long term disability. Very little is known about patients' experiences of the healthcare system and the disability in low-income countries following this injury. The aim of the study was to explore patient experiences of treatment and disability following an open tibia fracture in Malawi. Methods: A qualitative study was conducted using semi-structured interviews with ten patients with open tibia fractures at a central hospital in Blantyre, Malawi. A mixed deductive-inductive thematic analysis was used to identify broad themes of treatment and disability. Written informed consent was obtained from all participants. Results: Patient characteristics included an average age of 39.1 years old (22-63) and 80% were male. Broad themes found were delays in receiving treatment, change in individuals' societal role and delayed recovery associated with pain and immobility. Conclusions: Open tibia fractures in Malawi have a devastating impact on patients and their families. Further studies are required to explore the reasons for the delays in open fracture emergency treatment.

Secondary intramedullary nailing for open tibial shaft fractures. Comparison of a one-stage versus two-stage surgical procedure

IntroductionThe objective of this study was to compare the rates of radiological and clinical complications after sequential treatment of a tibial shaft fracture by external fixation followed by secondary nailing with an early-stage conversion (C1S) versus a two-stage late conversion (C2S). The hypothesis of this work was that treatment with C1S does not increase the risk of surgical site infections compared to C2S, and allows faster healing with a lower malunion rate. Material and methodsWe carried out a retrospective and comparative study based on the files of the traumatology department of the Édouard Herriot University Hospital in Lyon. We reviewed the records of patients who presented with a Gustilo grade 1, 2 or 3a open tibial fracture treated with external fixation with conversion by intramedullary nailing within 6 months from January 2010 to December 2020. We assessed the occurrence of Surgical Site Infections (SSI), consolidation time, time until resumption of weight bearing and the malunion rate. ResultsOf the 55 patients included, a C1S procedure was performed in 25 cases (45.5%) versus 30 cases (54.5%) for C2S. No significant difference was found concerning the occurrence of SSI after intramedullary nailing between the two groups (p=0.81). A significant difference was observed in terms of bone healing (p=0.036) and the malunion rate (0.0013) in favor of nailing in one stage. DiscussionThe strategy of converting an open leg fracture early, in one stage (C1S), after initial external fixator placement allows for faster healing and weight bearing, while ensuring a lower malunion rate compared to that of a late two-stage conversion. In the absence of a scar at the time of intramedullary nailing, C1S does not increase the risk of surgical site infections. While the choice of a late and sequential two-stage operation is likely related to the surgeon's apprehension around conversion of an open leg fracture by intramedullary nailing, this study could promote the use of C1S in a greater number of situations. Level of evidenceIV.

Antibiotic cement-coated intramedullary nail is cost-effective for the initial treatment of GAⅢ open tibia fractures

ObjectiveTo evaluate the cost-effectiveness of antibiotic cement-coated intramedullary nails (IMN) in the initial management of Gustilo-Anderson type Ⅲ (GAIII) open tibia fractures. MethodsA break-even equation was used to analyze the costs associated with antibiotic cement-coated IMN and postoperative infection following GAⅢ open tibia fractures. This equation produced a new infection rate, which defines what percentage the antibiotic coated IMN needs to decrease the initial infection rate for its prophylactic use to be cost-effective. The postoperative infection rate used for calculations was 30%, a value established in current literature for these fracture types (6–33%). The institutional costs associated with a single operative debridement and resultant inpatient stay and treatment were determined. A sensitivity analysis was conducted to demonstrate how various total costs of infection and different infection rates affected the break-even rate, the absolute risk reduction (ARR), and the number needed to treat (NNT). ResultsFinancial review yielded an average institutional cost of treating a postoperative infection to be $13,282.85. This number was inclusive of all procedures during an inpatient stay. The added cost of the antibiotic coated implant to the hospital is $743.42. Utilizing the break-even formula with these costs and a 30% initial infection rate, antibiotic coated IMN was economically viable if it decreased infection rate by 0.056% (NNT = 1,785.714). ConclusionThis break-even analysis model suggests the initial use of an antibiotic coated IMN in the setting of GAⅢ open tibia fractures is cost-effective.

Open tibial shaft fracture management in Argentina: an evaluation of treatment standards in diverse resource settings.

Argentina is a country with varying access to orthopedic surgical care. The Argentine Association of Trauma and Orthopedics (AATO) "Interior Committee" was developed to address potential regional differences and promote standardization of orthopedic trauma care. The paper assesses the level of national standardization of the management of open tibia fractures across 9 provinces in Argentina. Utilizing a matched-comparison group design, management of these injuries were assessed and compared between 3 groups: an "AATO Exterior Committee" consisting of surgeons that practice in Buenos Aires, and 2 "Interior Committees," comprising surgeons that practice in outlying provinces, 1 of which is affiliated with the AATO, and 1 that is not affiliated with the AATO. The study was conducted in 2 phases: phase 1 assessed open tibia fracture management characteristics, and phase 2 evaluated the management of soft-tissue wound coverage following open fractures. Soft-tissue coverage procedures for Gustilo Anderson Type IIIB fractures were more commonly performed by orthopedic surgeons in Interior Committees than the AATO Exterior Committee. Greater rates of definitive wound coverage within 7 days post-injury were reported in both Interior Committees compared to the Exterior Committee. Plastic surgeons were reported as more available to those in the AATO Exterior Committee group than in the AATO Interior Committees. While treatment patterns were evident among groups, differences were identified in the management and timing of soft-tissue coverage in Gustilo Anderson Type IIIB fractures between the Exterior Committee and both Interior Committees. Future targeted educational and surgical hands-on training opportunities that emphasize challenges faced in resource-limited settings may improve the management of open tibia fractures in Argentina.

Current Perspectives on the Management of Bone Fragments in Open Tibial Fractures: New Developments and Future Directions.

Open tibial fractures may be associated with bone loss at the time of the injury or following surgical debridement of the fracture. This article discusses the various treatment options available and the latest developments surrounding the management of free bone fragments in open tibial fractures.

Outcomes of Patients With Large Versus Small Bone Defects in Open Tibia Fractures Treated With an Intramedullary Nail: A Descriptive Analysis of a Multicenter Retrospective Study.

To compare outcomes in patients with open tibia shaft fractures based on defect size. Retrospective review. Eighteen trauma centers. The study included 132 patients with diaphyseal tibia bone defects >1 cm and ≥50% cortical loss treated with intramedullary nail. The primary outcome was number of secondary surgeries to promote healing (bone graft, revision fixation, or bone transport). Additional outcomes included occurrence of secondary surgeries (bone graft, infection, amputation, and flap failure) and proportion healed at one year. Results are compared by "radiographic apparent bone gap" of <2.5 or ≥2.5 cm. The estimated conditional probability of bone grafting within one year given graft-free at 90 days was 44% and 47% in the <2.5 cm and ≥2.5 cm groups, respectively. An estimated infection risk of 14% was observed in both groups [adjusted hazard ratio (HR) 0.98, 95% confidence interval (CI): 0.33-2.92], estimated amputation risk was 9% (<2.5 cm) and 4% (≥2.5 cm) (unadjusted HR 0.66, 95% CI: 0.13-3.29), and estimated flap failure risk (among those with flaps) was 10% and 13%, respectively (unadjusted HR 1.71, 95% CI: 0.24-12.25). There was no appreciable difference in the proportion healed at one year between defect sizes [adjusted HR: 1.07 (95% CI, 0.63-1.82)]. Larger size bone defects were not associated with higher number of secondary procedures to promote healing or a lower overall one-year healing rate. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Tibial Fracture-Pin Model: A Clinically Relevant Mouse Model of Orthopedic Injury.

The tibial fracture-pin model is a mouse model of orthopedic trauma and surgery that recapitulates the complex muscle, bone, nerve, and connective tissue damage that manifests with this type of injury in humans. This model was developed because previous models of orthopedic trauma did not include simultaneous injury to multiple tissue types (bone, muscle, nerves) and were not truly representative of human complex orthopedic trauma. The authors therefore modified previous models of orthopedic trauma and developed the tibial fracture-pin model. This modified fracture model consists of a unilateral open tibial fracture with intramedullary nail (IMN) internal fixation and simultaneous tibialis anterior (TA) muscle injury, resulting in mechanical allodynia that lasts up to 5 weeks post injury. This series of protocols outlines the detailed steps to perform the clinically relevant orthopedic trauma tibial fracture-pin model, followed by a modified hot plate assay to examine nociceptive changes after orthopedic injury. Taken together, these detailed, reproducible protocols will allow pain researchers to expand their toolkit for studying orthopedic trauma-induced pain.

Modeling anabolic and antiresorptive therapies for fracture healing in a mouse model of osteogenesis imperfecta.

Osteogenesis imperfecta (OI) is a genetic bone fragility disorder that features frequent fractures. Bone healing outcomes are contingent on a proper balance between bone formation and resorption, and drugs such as bone morphogenetic proteins (BMPs) and bisphosphonates (BPs) have shown to have utility in modulating fracture repair. While BPs are used for OI to increase BMD and reduce pain and fracture rates, there is little evidence for using BMPs as local agents for fracture healing (alone or with BPs). In this study, we examined wild-type and OI mice (Col1a2+/G610C ) in a murine tibial open fracture model with (i) surgery only/no treatment, (ii) local BMP-2 (10 µg), or (iii) local BMP-2 and postoperative zoledronic acid (ZA; 0.1 mg/kg total dose). Microcomputed tomography reconstructions of healing fractures indicated BMP-2 was less effective in an OI setting, however,BMP-2 +ZA led to considerable increases in bone volume (+193% WT, p < 0.001; +154% OI, p < 0.001) and polar moment of inertia (+125% WT, p < 0.01; +248% OI, p < 0.05). Tissue histology revealed a thinning of the neocortex of the callus in BMP-2 treated OI bone, but considerable retention of woven bone in the healing callus with BMP + ZA specimens. These data suggest a cautious approach may be warranted with the sole application of BMP-2 in an OI surgical setting as a bone graft substitute. However, this may be overcome by off-label BPadministration.