Management Of Open Tibial Fractures Research Articles

Nationwide study on open tibial fractures in the Netherlands: Incidence, demographics and level of hospital care

ObjectivesOpen tibial fractures are relatively common injuries following traffic accidents. The vulnerability of the soft tissues surrounding the tibia increases the susceptibility to complications, including infection and nonunion. To minimize complications, a multidisciplinary, timely approach is crucial. To date, the Dutch incidence and level of hospital treatment remain unknown due to a lack of condition-specific nationwide registries. This study aimed to estimate the incidence and management of open tibial fractures in the Netherlands, providing essential information for public health policymaking and guideline development. MethodsThe 2018 and 2019 Dutch National Hospital Care Basic Registration data, provided by the Dutch Hospital Data Foundation, were utilized to identify all patients admitted to Dutch hospitals with tibial fractures. Incidence rates, patient demographics, primary diagnoses, fracture classification, level of hospital, and length of hospital stays were analyzed using descriptive statistics. Results1,079 ICD-10 codes for closed and open tibial fractures were identified in patients that were admitted to a Dutch hospital. Thirty-four percent were classified as open tibial fractures, accounting for an estimated incidence rate of 1.1 per 100,000 person-years (95 % CI 0.97–1.12). When categorized by age, the calculated incidence rate was higher in males for all age categories up until the age of 70. Notably, the overall highest incidence rate was found for females aged 90 and above (6.6 per 100,000 person-years). Open tibial fractures were predominantly treated in general or top clinical hospitals (comprising 69 % of open all tibia fractures). Notably, the minority (31 %) presented at university medical centers, all Level-1 trauma centers, equipped with orthoplastic teams. ConclusionThis is the first study to report the nationwide incidence rate of open tibial fractures in the Netherlands; 34 % of tibial fractures were registered as open. Notably, a limited proportion of open tibial fractures underwent treatment within Level-1 trauma centers. Consequently, in the majority of cases, the implementation of an orthoplastic team approach was unattainable. This study underscores the need for more comprehensive data collection to assess and improve the current treatment landscape.

Bone union and mobility outcomes for reconstructed open tibial fractures: a plastic surgical experience from a major trauma center.

The goal in open tibial fracture management is to achieve a united tibia in an extremity that allows pain free mobilization. The objective of this study was to assess factors that lead to this functional outcome in lower limb reconstruction, from a plastic surgical perspective. The Plastic and Reconstructive Surgery lower limb database at a tertiary trauma hospital was searched for open tibial injuries from February 2015 to March 2020. The nature and severity of injury, timing and details of all operations including reconstructions were collected prospectively. Mobility including gait aids, pain, and complications were retrospectively collected. Union was assessed in two ways, depending on fracture location. Metaphyseal and diaphyseal tibial fractures were provided mRUST scores (union defined as RUST > 13) and epiphyseal tibial fractures were categorically classified as "united" or "non-union" by two independent radiologists. During the five-year study period there were 148 open leg injuries in the database. Twenty-one patients underwent a primary amputation due to severity of their initial injury. One hundred patients underwent primary limb salvage. Sixty-one patients in the limb salvage group achieved primary tibial union with a mean follow-up time of 19.4 months post injury. Twenty-three additional patients were confirmed to subsequently unite. Patient who achieved union were more likely to mobilise without gait aids. In this study definitive external fixation and soft tissue infection were both associated with higher rates of non-union. Longer times to soft tissue reconstruction was not associated with an increase in acute soft tissue complications. More importantly bone union, pain and mobility did not decline. After undertaking a primary limb salvage pathway for 100 patients, the ultimate tibial fracture union rate was 84% and the confirmed ambulation rate was 96%.

A Linked Population-Based Analysis of Severe Lower Extremity Traumas in Ontario

Background: Successful management of open tibial fractures often requires a multidisciplinary approach. Previous literature has shown that admission to a trauma centre and coordinated management of early bony fixation and soft-tissue reconstruction improve patient outcomes. The objective of this study was to describe patients who had open tibial fractures in Ontario and analyse their outcomes. Method: Linked population-based administrative data pertaining to patients who had open tibia fractures between the years 2009 and 2020 were examined. Demographic information, admission location, timing of soft-tissue reconstruction, and complication rates were collected. Results: 4240 patients were identified. The mean age was 47, and the majority were males. One-third of the patients were admitted to a trauma centre. This group were more likely to have an Injury Severity Score >15, and associated neurovascular injuries of the leg. When outcomes were compared over 1 year, the trauma centre group was more likely to undergo limb amputation, but also more likely to have a soft-tissue reconstruction. The average time to soft-tissue reconstruction was 20 days. Patients receiving care in a trauma centre were more likely to have an external fixation, plastic surgery consults, and longer hospital stay. There were no differences in the odds of infection, malunion or nonunion, and 30-day mortality. Conclusions: These findings provide a comprehensive examination of the clinical course for patients experiencing open tibia fractures in Ontario. Future studies can help facilitate coordinated efforts between different specialties to expedite care and improve overall outcomes.

Predictive factors for fracture-related infection in open tibial fractures in a Sub-Saharan African setting

IntroductionThe management of open tibial fractures (OTF) is challenging in low and middle-income countries (LMICs) where appropriate human resources and infrastructure (including equipment, implants and surgical supplies) are not readily available and medical care is not readily accessible. OTF are not rarely associated with a subsequent fracture-related infection (FRI), which is one of the most devastating and difficult to cure complications in orthopaedic trauma care. The aim of this study was to determine the rate and the predictive factors of FRI in OTF in a limited-resource setting of sub-Saharan Africa. MethodsPatients with OTF who underwent surgery from July 2015 to December 2020 and followed-up for at least 12 months in a tertiary care teaching hospital in Yaoundé (Cameroon) were retrospectively investigated. Diagnosis of FRI was based on the confirmatory criteria of the International FRI Consensus definition. All patients with bone infections, occurring at any time point during follow-up, were included. Logistic regression was used to determine the predictive factors for FRI. ResultsOne hundred and five patients with OTF were studied. With a mean follow-up period of 29.5 ± 16.6 months, 33 patients (31.4%) presented with FRI. Gustilo-Anderson type of OTF, compliance with antibiotics, blood transfusion, time to first washing of the wounds and method of bone fixation were factors associated with the occurrence of FRI. In multivariable logistic regression, 6-hours delay to first washing of the wounds (OR=8.07, 95% CI: 1.43–45.31, p = 0.01), and compliance with antibiotics (OR=11.33, 95%CI: 1.11–115.6, p = 0.04) were the only independent predictors of FRI. ConclusionThe overall rate of FRI in open tibial fracture is still high in the sub-Saharan African context. For similar low-resources settings, this study supports the recommendations (1) to perform a very early washing-dressing-splinting of OTF on admission of the patient, (2) to administer antibiotics early, and (3) to perform surgery as soon as reasonably possible, once appropriate personnel, equipment, implants and surgical supplies are available.

Functional outcome analysis of ilizarov ring fixator as definitive fixation of open tibial fractures

: Ilizarov fixator for open tibia fractures permits axial micro mobility at fracture site to encourage bone regrowth. Literature search revealed dearth of studies from Indian centres which have evaluated its utility in open tibia fractures. : This was an observational prospective study conducted by Department of Orthopaedics at VVPF Medical College, Ahmednagar in Maharashtra, between July 2021 to June 2022. All patients who had open tibia fractures and managed by Ilizarov ring fixator were included. Duration of treatment with fixator was evaluated, along with range of motion at knee and ankle, union status and complications.: 30 patients were enrolled, majority being males (n=22, 73.33%). Most patients suffered from fractures of right side (n=21, 70%) confined to metaphyseal region (n=16, 53.33%). Commonest mode of injury was road traffic accidents (n=26, 86.67%). Based on Gustilo-Anderson classification, majority cases were grade IIIA (n=16, 53.33%). 23 cases (76.67%) were managed initially with external fixators, while 7 cases were directly managed with Ilizarov ring fixator. Most cases (n=15, 50%) received definitive fixation on day-3 of injury. Commonest complication noted was pin site infection (n=11, 36.67%) and delayed union (n=4, 13.33%). Knee stiffness at 30was noted in 3 cases, corrected by physiotherapy. All patients attained fracture union, with the earliest evidence of radiological union observed after 2 months of surgery. : As it allows for early full weight bearing mobilisation, has higher union rates and lesser incidences of malunion, use of Ilizarov external fixator maintains its importance in the management of open tibial fractures.

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.

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.

Risk Factors for Delayed Hospital Admission and Surgical Treatment of Open Tibial Fractures in Tanzania.

Open fractures, especially of the tibia, require prompt intervention to achieve optimal patient outcomes. While open tibial shaft fractures are common injuries in low- and middle-income countries (LMICs), there is a dearth of literature examining delays to surgery for these injuries in low-resource settings. This study investigated risk factors for delayed management of open tibial fractures in Tanzania. We conducted an ad hoc analysis of adult patients enrolled in a prospective observational study at a tertiary referral center in Tanzania from 2015 to 2017. Multivariable models were utilized to analyze risk factors for delayed hospital presentation of ≥2 hours, median time from injury to the treatment hospital, and delayed surgical treatment of ≥12 hours after admission among patients with diaphyseal open tibial fractures. Two hundred and forty-nine patients met the inclusion criteria. Only 12% of patients used an ambulance, 41% were delayed ≥2 hours in presentation to the first hospital, 75% received an interfacility referral, and 10% experienced a delay to surgery of ≥12 hours after admission. After adjusting for injury severity, having insurance (adjusted odds ratio [aOR] = 0.48; 95% confidence interval [CI] = 0.24 to 0.96) and wounds with approximated skin edges (aOR = 0.37; 95% CI = 0.20 to 0.66) were associated with a decreased risk of delayed hospital presentation. Interfacility referrals (2.3 hours greater than no referral; p = 0.015) and rural injury location (10.9 hours greater than urban location; p < 0.001) were associated with greater median times to treatment hospital admission. Older age (aOR = 0.54 per 10 years; 95% CI = 0.31 to 0.95), single-person households (aOR = 0.12 compared with ≥8 people; 95% CI = 0.02 to 0.96), and an education level greater than pre-primary (aOR = 0.16; 95% CI = 0.04 to 0.62) were associated with fewer delays to surgery of ≥12 hours after admission. Prehospital network and socioeconomic characteristics are associated with delays to open tibial fracture care in Tanzania. Reducing interfacility referrals and implementing surgical cost-reduction strategies may help to reduce delays to open fracture care in LMICs. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of open Tibia Fracture using Ilizarov Ring Fixator

Background: Currently, there has been a rise in severe trauma that occurs as a consequence of road accidents. Different treatment modalities are used for open tibia fracture but currently ilizarov ring fixator is used with better outcomes. Objective: To assess the outcomes of open tibia fracture using ilizarov ring fixator Methodology: This prospective study was carried out at the Orthopedic Department of Mercy Teaching Hospital Peshawar for duration of two years from November 2019 to November 2021. The Ilizarov ring fixator was scheduled for all of the participants in our research. Proper radiographs of the affected leg were acquired, comprising antero-posterior and lateral views. Postoperative radiographs were also collected. All the data was analyzed statistically by using SPSS version 24. Results: In this study, totally 40 patients were included. Based on radio-graphical results, 10 (25%), 18 (45%) and 12 (30%) and 00 (00%) patients have excellent, good and fair and poor results respectively while on the basis of functional outcomes, 12 (30%), 22 (55%), 2 (5%) and 4 (10%) patients have excellent, good and fair and poor results respectively. Complications like pin tract infection, superficial skin infection and chronic osteomyelitis were observed in 10 (25%), 6 (15%) and 2 (5%) patients respectively. Conclusion: Our study concludes that ilizarov external fixator can be effectively used for the management of open tibial fractures. Keywords: Open tibia fracture; Ilizarov ring fixator; Radiographs; Complication

LCP as supracutaneous plate vs IMLN tibia for open grade 1 and Ⅱ distal tibial fractures. A comparison study (RCT) on Functional outcome between a conventional method and a Novel technique

Introduction Orthopaedics is an ever evolving branch. Especially for fractures that have controversies in management options, recent advances are being done. Open distal tibial fractures belong to these groups of difficult, yet very common injuries. As the necessity is the mother of invention, for such a common injury a common plate-LCP was used supracutaneously for better biological fixation and shorter duration of surgery. We have compared the results of IMLN nailing vs supracutaneous plating for open distal tibial fractures. Material and methods The patients who had Gustilo and Anderson type 1 and 2 # of distal tibia were enrolled in this study. They were randomized into 2 groups. In one group (IMLN) intramedullary locking nail and in another group Supracutaneous plating was done (SCP). Duration of clicnal and radiological union was calculated. Functional outcome in both groups was measured in AOFSAS score, Knee Society Score (KSS),Lower extremity functional scoring (LEFS) and Ketenjian and Shelton Criteria modified by Yokoyama. Any complications were charted. Results 100 % fracture union was seen in both cases. Intra operative blood loss was 165 ml and was more in IMLN group than SCP group (100) ml. LEFS at 1 year was 90 in SCP group whereas it was 80 in IMLN group. AOFAS score was similar in both groups showing good functional outcome around ankle joint. Knee society score was statistically better in SCP group (82) whereas in IMLN group it was 70. Incidence of infection and surgical duration was similar in both groups.Due to need for removal in some cases duration of stay was more in IMLN. Conclusion Patients in SCP Group had lesser incidence of persistent pain or other chronic symptoms and were happier (better LEFS score, better Yokahama scoring) than their counterparts with interlocking nail. Using locking plate in a supracutaneous mode is a very simple, easy, rapid, reliable and effective method for management of open tibial fractures in adults, especially in terms of patient satisfaction and can be considered as an effective alternative to nailing in selected patients.

Management of Gustilo-Anderson IIIB open tibial fractures in adults-a systematic review.

Open tibial fractures are the most common open long bone fracture, despite this, the management of these complex injuries still remains a topic of discussion amongst orthopaedic surgeons. We searched the EMBASE, MEDLINE and Google Scholar and a systematic review of 7500 articles, leaving 23 after exclusion criteria were applied, in order to analyse the management of open tibial fractures. Infection was noted to be the most significant concern amongst authors, with definitive external fixation having a high rate of superficial pin-site infection and internal fixation having a high deep infection rate. It is essential to have a combined ortho-plastic approach to the management of these fractures as muscle flaps were the most common form of soft tissue coverage. A national pragmatic trial into the management of open tibial fractures is required looking at fixation methods and soft tissue coverage, with at least a 2-year follow-up in order to ascertain the most appropriate management of these fractures and patient-related outcomes.

Open tibial fractures: An overview

Open tibial fractures are complex injuries with multifactorial outcomes and variable prognosis. The close proximity of the tibia to the skin makes it prone to extensive soft tissue damage and subsequent detrimental complications, such as infection and non-union. Thus, they were historically associated with high rates of amputation, sepsis, or even death. The advancement of surgical instruments and techniques, along the emergence of evidence-based guidance, have resulted in a significant reduction in complications. Peculiarly though, modern management strategies have a strong foundation in practices described in the ancient times. Nevertheless, post-operative complications are still a challenge in the management of open tibial fractures. Efforts are actively being made to refine the surgical approaches used, while noteworthy is the emergence of the Orthoplastic approach. The aim of this review is to summarise and discuss the historical perspective of the management of open tibial fractures, their epidemiology and classification, up-to-date principles of surgical management and outcomes following injury.

The Effect of Delayed Surgical Debridement in the Management of Open Tibial Fractures: A Systematic Review and Meta-Analysis.

Introduction: Open tibial fractures are complex injuries with variable outcomes that significantly impact patients’ lives. Surgical debridement is paramount in preventing detrimental complications such as infection and non-union; however, the exact timing of debridement remains a topic of great controversy. The aim of this study is to evaluate the association between timing of surgical debridement and outcomes such as infection and non-union in open tibial fractures. Materials and Methods: We performed a systematic review and meta-analysis of the literature to capture studies evaluating the association between timing of initial surgical debridement and infection or non-union, or other reported outcomes. We searched the MEDLINE, PubMed Central, EMBASE, SCOPUS, Cochrane Central and Web of Science electronic databases. Our methodology was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane handbook for systematic reviews of interventions. Results: The systematic review included 20 studies with 10,032 open tibial fractures. The overall infection rate was 14.3% (314 out of 2193) and the overall non-union rate 14.2% (116 out of 817). We did not find any statistically significant association between delayed debridement and infection rate (OR = 0.87; 95% CI, 0.68 to 1.11; p = 0.23) or non-union rate (OR = 0.70; 95% CI, 0.42 to 1.15; p = 0.13). These findings did not change when we accounted for the effect of different time thresholds used for defining early and late debridement, nor with the Gustilo–Anderson classification or varying study characteristics. Conclusion: The findings of this meta-analysis support that delayed surgical debridement does not increase the infection or non-union rates in open tibial fracture injuries. Consequently, we propose that a reasonable delay in the initial debridement is acceptable to ensure that optimal management conditions are in place, such that the availability of surgical expertise, skilled staff and equipment are prioritised over getting to surgery rapidly. We recommend changing the standard guidance around timing for performing surgical debridement to ‘as soon as reasonably possible, once appropriate personnel and equipment are available; ideally within 24-h’.

Outcomes following the delayed management of open tibial fractures

AimsNational guidelines set standards for the definitive management of open fractures within 72 h. This study aims to investigate our outcomes where this timeline was unachievable for most cases due to a split-site orthoplastic service. Patients & Methods116 consecutive Gustilo-Anderson grade IIIB & IIIC open tibial fractures presenting to our major trauma centre (MTC) between September 2012 and April 2018 were reviewed. The mean follow up was 46 months (17 to 88). 110 (95%) were grade IIIB and 6 (5%) grade IIIC. The most common injury mechanism included road traffic accidents (59%) and falls (28%). Primary outcomes were recorded according to; timing of initial debridement and definitive cover, rates of superficial and deep infection, non-union and amputation. Subgroups were statistically analysed according to time to initial debridement, definitive soft-tissue cover and injury severity score (ISS). ResultsThe mean time to initial debridement was 11.3 h (2.9 to 38.9) and definitive soft-tissue cover 9.9 days (0 to 37). We recorded rates of: superficial infection; 42 cases (36%), deep infection; 14 cases (12%) and non-union requiring revision; 19 cases (16%). There were 20 amputations (17%) with 9 (8.6%) performed early and 11 (9.5%) delayed. Subgroup analysis showed higher rates of superficial infection (50%, p = 0.002) and amputation (26.6%, p = 0.01) for those debrided <12 h. A greater presenting ISS related to a delay to definitive cover >7 days (p = 0.05). Primary outcomes trended worse for those covered >7 days but did not reach significance. ConclusionMajor trauma patients are particularly vulnerable to poor outcomes resulting from the delay in definitive management of open fractures. MTC's need resources and a co-located orthoplastic service to achieve national standards and better outcomes. Current guidelines do not advise for the management of patients where a delay in definitive surgery is anticipated.

Orthoplastic management of open tibial fractures in children : a consecutive five-year series from a paediatric major trauma centre.

Open tibial fractures are limb-threatening injuries. While limb loss is rare in children, deep infection and nonunion rates of up to 15% and 8% are reported, respectively. We manage these injuries in a similar manner to those in adults, with a combined orthoplastic approach, often involving the use of vascularised free flaps. We report the orthopaedic and plastic surgical outcomes of a consecutive series of patients over a five-year period, which includes the largest cohort of free flaps for trauma in children to date. Data were extracted from medical records and databases for patients with an open tibial fracture aged < 16 years who presented between 1 May 2014 and 30 April 2019. Patients who were transferred from elsewhere were excluded, yielding 44 open fractures in 43 patients, with a minimum follow-up of one year. Management was reviewed from the time of injury to discharge. Primary outcome measures were the rate of deep infection, time to union, and the Modified Enneking score. The mean age of the patients was 9.9 years (2.8 to 15.8), and 28 were male (64%). A total of 30 fractures (68%) involved a motor vehicle collision, and 34 (77%) were classified as Gustilo Anderson (GA) grade 3B. There were 17 (50%) GA grade 3B fractures, which were treated with a definitive hexapod fixator, and 33 fractures (75%) were treated with a free flap, of which 30 (91%) were scapular/parascapular or anterolateral thigh (ALT) flaps. All fractures united at a median of 12.3 weeks (interquartile range (IQR) 9.6 to 18.1), with increasing age being significantly associated with a longer time to union (p = 0.005). There were no deep infections, one superficial wound infection, and the use of 20 fixators (20%) was associated with a pin site infection. The median Enneking score was 90% (IQR 87.5% to 95%). Three patients had a bony complication requiring further surgery. There were no flap failures, and eight patients underwent further plastic surgery. The timely and comprehensive orthoplastic care of open tibial fractures in this series of patiemts aged < 16 years resulted in 100% union and 0% deep infection, with excellent patient-reported functional outcomes. Cite this article: Bone Joint J2021;103-B(6):1160-1167.

Delay in Initial Debridement for Open Tibial Fractures and Its Possible Impact on Patient Outcomes: A Single-Center Prospective Cohort Study.

Background:The current consensus regarding the management of open fracture indicates that the initial debridement should be performed within the first 6 hours after injury. Unfortunately, in Pakistan, the emergency medical services are not well-established and patient arrival at the hospital is delayed the majority of the time. In this study, we present our experience with delayed surgical management of open tibial fractures.Methods:A prospective study of patients who presented to the accident and emergency department of the authors’ institution was performed. The duration of the study was 4 years. All patients ≥18 years of age with an isolated open fracture of the tibia were included in the study. Open fractures were graded using the Gustilo-Anderson (GA) classification. The study participants were divided into 3 groups based on the timing of the surgery. Infection and nonunion rates were compared using chi-square analysis. P < 0.05 was considered significant.Results:A total of 1,896 patients were included in the study. There was no significant difference between the results of surgery performed before 48 hours and those of surgery performed after 48 hours with regard to the infection rates associated with GA type-I (p = 0.48), type-II (p = 0.70), or type-III (p = 0.87) fractures or the nonunion rates associated with type-I (p = 0.6338), type-II (p = 0.4030), or type-III (p = 0.4808) fractures. A higher GA classification was associated with higher rates of infection and nonunion independent of the timing of the surgery (95% confidence interval [CI] = 1.24 to 1.89, p < 0.01).Conclusions:Our study indicates that the risks of infection and nonunion remain acceptable despite delays in the management of open tibial fractures within a 24 to 96-hour window. A delay in the initial time to debridement is acceptable only when early care cannot be provided. Prompt initial debridement remains the best possible treatment for open tibial fractures.Level of Evidence:Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

A comparative study of functional and radiological outcome in management of type IIIB tibial fractures by AO and ilizarov external fixator

Background a nd Objectives: Tibia fractures are relatively common & Annual incidence of open tibial fracture is 11.5 /1,00,000 persons. Majority of these fractures are open diaphyseal fractures, of which 60% are Gustillo type III. Open fractures of tibia are more commonly seen than any other long bones because of the subcutaneous location of the bone. External fixators offer several advantages in management of open tibial fractures. AO and Ilizarov are types of external fixators. Ilizarov technique is cost effective, primary and definitive treatment and offer acceptable stability for the fracture, minimal operative trauma and good access to soft tissues and offers high union rates. AO is simple and safe to apply can be used in management of open tibial fractures. This study was conducted to determine the comparison of Radiological & Functional outcome & complications of the acute Open tibial fractures treated with primary Ilizarov external fixator and AO external fixator. Materials and Methods: Randomized comparative Study period was from November 2017 to May 2019. Age group between 18– 60 years was considered. The follow up would be for one year. Initially for every 3 weeks in first 6 weeks for wound care, every 6weeks for one year and assessed by Radiological evidence of union of fracture and Functional assessment by Patient’s Functional and Bone results are assessed based on ASAMI and functional assessment done by knee and ankle joint Range of motion & complications. Results: This is a prospective study population consists of 40 patients with IIIB open Tibia fractures of mean age in AO group is 44.3 +/- 10.6 years with male preponderance. In AO group majority of fractures were 42B3 (40%) & 43A3 (35%). Ilizarov group majority are 43A3 (25%), 15% fractures of each 41A3, 42A1, 42A3 & 42C3. Mean Radiological union time was 22.84 +/- 2.3 weeks in AO group, 24.95 +/- 4.6 weeks in Ilizarov group & Non union rate is 1 (5%) case in both the group. ASAMI bone results &

Flaps in the management of open tibial fractures

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The prognosis in open fractures is primarily determined by the amount of soft tissue loss and the level of contamination. Severe open tibial fractures usually require combined orthoplastic approach in the management. Our aim is to study the effectiveness of soft tissue flaps in the management of type III B open tibial fractures.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; The study material consists of 20 cases of grade III B open tibial fractures admitted in our institution. Under anaesthesia, wound debridement was done and fracture stabilised with external fixator or IM nail depending upon the wound status. Patient underwent flap cover once the wound was fit. Periodic follow up was done.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Nonunion occurred in one patient (5%). Chronic osteomyelitis developed in two patients (10%). Deep infection occurred in three cases (15%). There was no secondary amputation in our series. The average union time of fracture was 30.1 weeks. Lower third fractures and those patients with extensive soft tissue injury, delayed flap cover and flap failure had longer union time.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Fasciocutaneous flap has definitive role in the management of type III B open tibial fractures with soft tissue loss.&lt;/p&gt;&lt;p class="abstract"&gt; &lt;/p&gt;

Management of open tibial fractures type IIIB by segment transfer using limb reconstruction system fixator

Purpose To evaluate the effectiveness of bone transport using limb reconstruction system (LRS) fixator and early coverage in open-type IIIB tibial fractures with massive bone and soft tissue loss. Patients and methods In this study, eight patients with type IIIB open tibial fractures were managed by initial debridement and fixation by LRS uniplanar external fixator. A second-stage rotational myocutaneous flap coverage and osteotomy for segment transfer was done within 14 days. All patients were followed up till full union. Results Full union was achieved in all patients. A total of five patients needed iliac bone graft at the docking site. Union occurred in an average external fixator index of 45.3 days/cm. No flap coverage infection occurred, and there was no significant limb malalignment. Significant limb shortening occurred only in one patient. Conclusion LRS fixator is an effective definitive method for management of open tibial fractures with massive bone loss and soft tissue defects. It is easy to apply, allows early intervention by plastic surgeons to obtain soft tissue coverage, and also allows early patient rehabilitation and joint mobilization.

Transverse debridement and acute shortening followed by distraction histogenesis in the treatment of open tibial fractures with bone and soft tissue loss

This retrospective case series evaluates the technique of transverse debridement, acute shortening and subsequent distraction histogenesis in the management of open tibial fractures with bone and soft tissue loss, thereby avoiding the need for a soft tissue flap to cover the wound. Thirty-one patients with Gustilo grade III open tibial fractures between 2001 and 2011 were initially managed with transverse wound extensions, debridement and shortening to provide bony apposition and allowing primary wound closure without tension, or coverage with mobilization of soft tissue and split skin graft. Temporary monolateral external fixation was used to allow soft tissues resuscitation, followed by Ilizarov frame for definitive fracture stabilization. Leg length discrepancy was corrected by corticotomy and distraction histogenesis. Union was evaluated radiologically and clinically. Patients’ mean age was 37.3 years (18.3–59.3). Mean bone defect was 3.2 cm (1–8 cm). Mean time to union was 40.1 weeks (12.6–80.7 weeks), and median frame index was 75 days/cm. Median lengthening index (time in frame after corticotomy for lengthening) was 63 days/cm. Mean clinic follow-up was 79 weeks (23–174). Six patients had a total of seven complications. Four patients re-fractured after frame removal, one of whom required a second frame. Two patients required a second frame for correction of residual deformity, and one patient developed a stiff non-union which united following a second frame. There were no cases of deep infection. Acute shortening followed by distraction histogenesis is a safe method for the acute treatment of open tibial fractures with bone and soft tissue loss. This method also avoids the cost, logistical issues and morbidity associated with the use of local or free-tissue transfer flaps and has a low rate of serious complications despite the injury severity.