Management Of Open Tibia Fractures Research Articles

Prevention of Equinus Deformity after External Fixation for Open Tibia Fractures: A Comparison between Plaster of Paris Backslab and Passive Ankle Physiotherapy.

Ankle equinus deformity is a common complication of prolonged external fixator use in tibia fractures with an incidence of 15%-16%. It affects gait and may lead to foot, leg, and back problems. Treatment of equinus deformity increases the cost of treatment of open tibia fractures and increases the time spent off work. Several preventive modalities have been suggested in literature with variable success, but no standard protocol exists. The aim of this study was to determine the most appropriate method of preventing equinus deformity of the ankle joint during the management of open tibia fractures with unilateral uniplanar external fixators by comparing plaster of paris (POP) backslab application with passive ankle physiotherapy using strips of car tyre inner tubing. The study was a prospective randomised study involving patients with open tibia fractures who were managed with external fixators at the Korle Bu Teaching Hospital between April 2020 and February 2021. Patients were randomised into two groups; one group had below knee POP backslab and the other group did passive ankle physiotherapy using a strip of car tyre inner tubing. The passive ankle range of motion was measured at the beginning and after 6 weeks using a goniometer. Fifty-six participants were recruited with 29 in the POP backslab group and 27 in the ankle physiotherapy group. The median age was 35.0 years. Male-to-female ratio was 4.6:1. Motor vehicle crash contributed to over 90% with 42.9% being motorbike riders. Initial and final mean ankle measurements for the POP backslab group were 6.79° and 10.14° for dorsiflexion and 29.93° and 34.52° for plantarflexion, respectively. The ankle physiotherapy group had initial and final dorsiflexion of 7.19° and 12.85° and plantarflexion of 30.44° and 34.52°, respectively. The ankle physiotherapy group had a better range of motion (47.37°) than the POP group (40.66°) with a P value of 0.008. One participant (3.7%) from the ankle physiotherapy group had equinus deformity compared with seven (24%) from the POP backslab group, a difference which gives a P value of 0.029. Passive ankle physiotherapy with car tyre inner tube is a better and cheaper modality of preventing ankle equinus deformity and maintaining ankle range of motion.

Comparing outcomes following direct admission and early transfer to specialized trauma centers in open tibial fracture treatment: a systematic review and meta-analysis.

Guidelines on the management of open tibia fractures recommend timely treatment in a limb reconstruction center which offer joint orthopedic-trauma and plastic surgery services. However, patient's transfer between centers remains inevitable. This review aims to evaluate the clinical outcomes and hospital factors for patients directly admitted and transferred patients to a limb-reconstruction center. A research protocol adhering to PRISMA standards was established. The search included databases like MEDLINE, EMBASE, and the Cochrane library up until March 2023. Nine articles met the inclusion criteria, focusing on open tibia fractures. Exclusion criteria were experimental studies, animal studies, and case reports. Outcomes of interest were operation and infection rates, nonunion, limb salvage, and the Enneking limb score. The analysis involved data from 520 patients across nine studies published between 1990 and 2023, with the majority (83.8%) having Gustilo Anderson type III open tibia fractures. Directly admitted patients showed lower overall infection rates (RR 0.30; 95% CI 0.10-0.90; P = 0.03) and fewer deep infections (RR 0.39; 95% CI 0.22-0.68; P = 0.001) compared to transferred patients. Transferred patients experienced an average five-day delay in soft tissue closure and extended hospital stays by eight days. Patients transferred without initial surgical management underwent fewer total surgical procedures. The direct admission group displayed more favorable functional outcomes. Low- to moderate-quality evidence indicates worse clinical outcomes for transferred patients compared to directly admitted patients. Early treatment in specialized limb reconstruction units is essential for improved results in the management of open tibia fractures. Therapeutic level IIa.

A study on the outcome of open tibial fractures managed definitively by external fixator

Introduction: High energy tibial diaphyseal open fractures are a common occurrence in modern times. In a resource strapped country like India, AO unilateral external fixator is a cheap, technically easier method for the definitive management of the same. The aim of the paper is to present the results of the treatment of 33 patients with open tibia fractures, as well as the complications that accompany the treatment of these fractures. Method: An observational prospective study was undertaken including all open diaphyseal tibia fractures with Gustilo Anderson classification Type II, IIIA, IIIB and Ganga hospital open injury severity score of 6-12. Patients underwent debridement, definitive fixation with exfix, and later Patellar Tendon Bearing Cast after removal. Outcome was measured by the Association for the Study and Application of the Method of Ilizarov Group score. Results: In 81.8% cases the mechanism of injury was road traffic accident. Mean time for complete weight bearing was 19.33 weeks, mean time for union was 26.18 months. ASAMI Radiological outcome was Excellent in 45.5%, Good in 30.3%, Fair in 9.1% and Poor in 15.2% cases. ASAMI Functional outcome was Excellent in 33.3%, Good in 51.5%, Poor in 15.2% cases. Pin tract infection was found in 39.4% and malunion in 24.2%. The mean time for union (p=0.0004), incidence of non-union (p=0.014) was found to be statistically significant to the severity of initial injury. Conclusion: Thus by this study it can be expressed that external fixator is a feasible implant in the definitive management of open tibia fractures.

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.

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.

592 Surgical Management of Open Tibia Fractures at A Major Trauma Centre: A Review of Cases Over A One-Year Period

Abstract Introduction The BOAST/BAPRAS updated the open fracture guidelines in December 2017 to replace BOAST 4 Open fracture guidelines; the changes gave clearer recommendations for timing of surgery and recommendations for reducing infection rates. Method Our work retrospectively evaluates the surgical management of open tibia fractures at a Major Trauma Centre (MTC), over a one-year period in light of key standards (13,14 and 15 of the standards for open fractures). Results The vast majority of cases (93%) had definitive internal stabilization only when immediate soft tissue coverage was achievable. 90% of cases were not managed as ‘clean cases’ following the initial debridement. 50% of cases underwent definitive closure within 72 hours. The reasons for definitive closure beyond 72hours were: patients medically unwell (20%), multiple wound debridement’s (33%) and no medical or surgical reason was clearly stated (47%). Conclusions The implementation of a ‘clean surgery’ protocol following surgical debridement is essential in diminishing risk of recontamination and infection. Hence, this must be the gold standard and should be clearly documented in operation notes. The extent of availability of a joint Orthoplastic theatre list provides a key limiting step in definitive bony fixation and soft tissue coverage of open tibia fractures.

P93 Pre-operative assessment and management of open tibia fractures at a Major Trauma Centre (MTC): a review of cases over a one-year period

IntroductionDespite perianal abscess being a common presentation, certain aspects of its management remain controversial, especially the routine use of intra-operative swab cultures.MethodsA retrospective review of patients that underwent incision and drainage procedures for a perianal abscess over a six-month period was undertaken.ResultsOver 6 months, 50 patients were identified. The male to female ratio was 3:1 and median ASA score was 1. Only 6/50 patients presented with recurrent abscess and 1 patient had history of inflammatory bowel disease. On the basis of operative findings, 39 patients (78%) had uncomplicated abscess (not associated with cellulitis, sinus or fistula); swab cultures were performed in 26 (67%) of these patients. All patients were discharged on the same day; microbiology reports did not impact the treatment and no patients were followed up in clinic post-operatively or presented with recurrence. The number of unnecessary microbiology swabs undertaken in this cohort equates to approximately 52 unnecessary swabs a year. The cost of one swab is £10.10p, which means £520 could potentially be saved annually.ConclusionRoutine intra-operative swab cultures do not impact management decisions, add to unnecessary costs and therefore should not be undertaken in uncomplicated or first presentation of peri-anal abscesses.

Amputation Rates in More Than 175,000 Open Tibia Fractures in the United States.

Open tibia fractures are often associated with considerable soft tissue injuries. Management of open tibia fractures can be challenging, and some patients require amputation. The patient and treatment factors have not been described on a population level in the United States. A retrospective analysis was completed using the 2000 to 2011 Nationwide Inpatient Sample. Amputation rates during the index hospitalization after open tibia fracture were computed based on injury, patient, and hospital characteristics in patients 18 years or older. The overall amputation rate in open tibia fractures during the index hospitalization was 2.2% (n=3769). Patients with midshaft tibia fractures comprised the largest portion of patients undergoing amputation (46.8% of total amputations) compared with distal tibia (34.0%) and proximal tibia (19.3%) fractures. Patients with no neurovascular injury comprised the largest portion of patients undergoing amputation (85.9%), followed by isolated arterial injury (11.1%), combined neurovascular injury (1.9%), and isolated nerve injury (1.1%). Amputation rates were significantly increased for midshaft tibia fractures with neurovascular injury (odds ratio, 12.39; 95% CI, 5.52-27.83) and distal tibia fractures with neurovascular injury (odds ratio, 5.45; 95% CI, 1.73-17.19) compared with tibia fractures with no neurovascular injury while controlling for confounders. On the basis of a review of the Nationwide In-patient Sample during the past decade, the authors have shown that the early amputation rate in open tibia fractures for all-comers is 2.2%. Rates of amputation varied based on fracture site, associated neurovascular injury, medical comorbidities, and hospital location. [Orthopedics. 2021;44(1):48-53.].

Current concepts in the management of open tibia fractures

Open tibia fractures are associated with an increased risk of infection, delayed union, non-union and wound complications. Management is aimed at mitigating the risk of infection while optimising the biological and biomechanical environment to encourage soft tissue and bone healing. With ongoing clinical trials and research, our knowledge around best clinical practice continues to evolve. Multiple consensus documents and protocols have been formulated, yet some controversy exists around the ideal management for high risk grade III injuries. Early antibiotic therapy has become a cornerstone in the management of these injuries. However, some controversy remains around the type and duration of antibiotic therapy. Emergent debridement and lavage is a critical factor in treatment success. Intramedullary nailing is a viable fixation option for most open tibia fractures while circular external fixation has gained prominence in the management of high energy grade III injuries, especially in the presence of bone and soft tissue loss. The timing of the various treatment interventions continues to provoke debate and controversy. Considering the available literature, the local context needs to be considered. Inadequate access to theatre, shortage of staff, resources and expertise are frequently encountered. We aim to elucidate current literature with regard to the management of open tibia fractures guided in part by various consensus documents and protocols. Level of evidence: Level 5

The management of open tibial fractures in children: a retrospective case series of eight years' experience of 61 cases at a paediatric specialist centre.

Following the introduction of national standards in 2009, most major paediatric trauma is now triaged to specialist units offering combined orthopaedic and plastic surgical expertise. We investigated the management of open tibia fractures at a paediatric trauma centre, primarily reporting the risk of infection and rate of union. A retrospective review was performed on 61 children who between 2007 and 2015 presented with an open tibia fracture. Their mean age was nine years (2 to 16) and the median follow-up was ten months (interquartile range 5 to 18). Management involved IVantibiotics, early debridement and combined treatment of the skeletal and soft-tissue injuries in line with standards proposed by the British Orthopaedic Association. There were 36 diaphyseal fractures and 25 distal tibial fractures. Of the distal fractures, eight involved the physis. Motor vehicle collisions accounted for two thirds of the injuries and 38 patients (62%) arrived outside of normal working hours. The initial method of stabilisation comprised: casting in nine cases (15%); elastic nailing in 19 (31%); Kirschner (K)-wiring in 13 (21%); intramedullary nailing in one (2%); open reduction and plate fixation in four (7%); and external fixation in 15 (25%). Wound management comprised: primary wound closure in 24 (39%), delayed primary closure in 11 (18%), split skin graft (SSG) in eight (13%), local flap with SSG in 17 (28%) and a free flap in one. A total of 43 fractures (70%) were Gustilo-Anderson grade III. There were four superficial (6.6%) and three (4.9%) deep infections. Two deep infections occurred following open reduction and plate fixation and the third after K-wire fixation of a distal fracture. No patient who underwent primary wound closure developed an infection. All the fractures united, although nine patients required revision of a mono-lateral to circular frame for delayed union (two) or for altered alignment or length (seven). The mean time to union was two weeks longer in diaphyseal fractures than in distal fractures (13 weeks versus 10.8 weeks, p = 0.016). Children aged > 12 years had a significantly longer time to union than those aged < 12 years (16.3 weeks versus 11.4 weeks, p = 0.045). The length of stay in hospital for patients with a Gustilo-Anderson grade IIIB fracture was twice as long as for less severe injuries. Fractures in children heal better than those in adults. Based on our experience of deep infection we discourage the use of internal fixation with a plate for open tibial fractures in children. We advocate aggressive initial wound debridement in theatre with early definitive combined orthopaedic and plastic surgery in order to obtain skeletal stabilisation and soft-tissue cover. Cite this article: Bone Joint J 2017;99-B:544-53.

Open Tibia Fractures: Timely Debridement Leaves Injury Severity as the Only Determinant of Poor Outcome

Recent retrospective studies suggest that the time to debridement of open tibia fractures is not a major determinant of outcome. The aim of this prospective study was to determine the modifiable independent predictors of poor outcomes. A 36-month prospective observational study ending in December 2009 was performed on consecutive open tibia shaft fracture patients (age >18 years) admitted to a Level 1 trauma center. Demographics, mechanism, Injury Severity Score, fracture type/grade, local contamination, time to debridement, time to antibiotics, and interventions were prospectively recorded. Outcome measures were as follows: length of stay, deep infection, secondary procedures, and presence of union at 6 months and 12 months. Univariate, multivariate, and logistic regression analyses were performed. Eighty-nine consecutive patients (74% male, age 41 years±17 years, Injury Severity Score 15±3, and 37% multiple injured) met inclusion criteria. The mean time to surgical debridement and operative stabilization was 8 hours±4 hours (48% within 6 hours). The average length of stay was 21 days±13 days. Fifteen patients (17%) had deep infection and 5 (6%) required amputation (1 acute and 4 late because of the infection). The 6-month and 12-month union rates were 39% and 67%, respectively. Fifty-six patients (63%) required further procedures (a total of 312). The multivariate regression model (18 variables) showed no independent significant predictors for deep infection or nonunion at 6 months and 12 months (multiple injuries and smoking were closest to reach significance, p=0.08). Timely management of open tibia fractures (mean, 8 hours) eliminates time to debridement and contamination as predictors of poor outcome. Patient factors and local and general injury severity determine the outcomes. Aiming for the earliest safe time to debridement minimizes the negative effects of modifiable factors on the outcome.

The orthopedic and social outcome of open tibia fractures in children.

To determine whether the accepted principles of management of open tibia fractures apply to children, 40 consecutive open fractures of the tibial shaft in skeletally immature patients were retrospectively reviewed. Attempts were made to evaluate the functional and social impact of open tibia fractures in children. All open fractures were initially treated by rapid irrigation and debridement which was repeated every 48 hours until soft tissues stabilized. The average age was 10.1 years and average follow up was 26 months (range: 18 to 84). There were 16 grade I, 10 grade II, and 14 grade III open fractures. The grade III fractures were further subdivided into 6 grade IIIA, 7 grade IIIB, and 1 grade IIIC. The average time to union was 7.5 and 11.0 weeks in the grade I and II fractures respectively, with no infections and no delayed unions. In grade III fractures, the average time to union was 15 weeks, with 1 infection and 3 delayed unions. Bone grafting using autogenous iliac crest was performed on 2 patients. The children surveyed missed an average of 4.1 months of school and 33% had to repeat a year. Twenty-five percent of the children complained of nightmares involving the events of the accident. Chronic pain despite solid union was found in 30% of patients. Forty percent of those surveyed (7 grade III fractures) complained of a limp. The low incidence of soft tissue complications and infections in the study population supports applying in children the same basic soft tissue management principles of open fracture treatment as used in adults. While bone stabilization options are limited in children, the rate of successful union without adjunctive bone grafting is much higher than that of adults treated under similar protocols. Routine early iliac crest bone grafting is unnecessary. The prevalence of gait abnormality despite fracture union should be taken into account during the patient's rehabilitation. The extensive time missed from school and resulting scholastic setback should not be underestimated.