Open Tibial Diaphyseal Fractures Research Articles

Management of Open Tibia Shaft Fractures in Ghana: A Prospective Longitudinal Study

Objective To evaluate patient and injury characteristics and functional outcomes of open tibial shaft fractures among patients treated at a tertiary hospital in Ghana. Methods We recruited consenting patients with open tibial shaft fractures over a 3-month period and followed-up each participant for at least 2 years. The functional status of each enrolled patient was assessed at 2 years following injury, using Short Form 36. Results Over the 3-month inclusive period of the study, a total of 55 open fractures of the tibia and fibula diaphysis were recorded in 55 patients. Most (52.7%) had Gustillo-Anderson grade III injury. External fixation was the mode of stabilisation (65.5%) At 2 years, 51.9% (28 of 54) had excellent functional outcome. In total, 52.7% of the participants were able to use the affected limb as before the injury, and 92.6% (50 of 54) had returned to their previous work. Conclusion The outcome of open tibial shaft fractures at the study site is good-to-excellent in most (92.6%) patients, with a return-to-previous occupation rate of 92.6%. Gustillo-Anderson grade III injury was the most predominant (52.7%) and sub-type IIIB, the most common among the grade III injuries. External fixation was the most common mode of stabilization of open tibial diaphyseal fractures.

ROLE OF DYNAMIZATION IN INTRAMEDULLARY NAILING OF TIBIA

Objectives: This study aims to know the functional outcomes of intramedullary nailing (IMN) osteosynthesis in long bone shaft fractures among adult patients with stable internal fixation and union. Additionally, it seeks to assess the specific and general complications experienced by both groups. Methods: The study was conducted at the Department of Orthopedics, Government Medical College, and Rajindra Hospital in Patiala, spanning from March 2021 to December 2022. It was a prospective, manipulative, controlled study involving a total of 40 cases of tibia diaphyseal fractures that were presented to the orthopedics department. Fractures were classified according to the AO fracture classification. Results: The average time for union in the dynamic group was 15.60 weeks (with a standard deviation of 1.27). A significant statistical difference was observed, favoring the dynamization nailing group (p<0.01), indicating a strong trend toward faster union. Out of the 40 patients, 16 (40%) experienced at least one complication. In conclusion, dynamic IMN osteosynthesis permits micromotion between fracture fragments, directly stimulating bone formation and the development of callus. Conclusion: For closed or open tibial diaphyseal fractures with minimal comminution (types A and B based on the AO classification) up to Gustilo 3A, dynamic IMN assembly is considered a safe and effective treatment option.

Circular frame versus reamed intramedullary tibial nail in the treatment of grade III open tibial diaphyseal fractures.

Grade III open tibial diaphyseal fractures are challenging to treat and controversy exists on whether to treat them with an intramedullary nail (IMN) or a circular frame (CF). This study aims to compare outcomes for intramedullary nail and circular frame in the treatment of open tibial diaphyseal fractures. Retrospective study at a major trauma center of all patients admitted with a grade III open tibial diaphyseal fracture between January 2016 and January 2022. The primary outcome measures were major complications: non-union, malunion, refracture, DBI and amputation. Secondary outcome measures were time to union and reoperation rates. Fifty-five patients were included in the study, 32 patients in CF group and 23 patients in IMN group. There were no significant differences in the baseline demographics of patients in both groups. Major complications were recorded in 13 limbs (54%) in IMN group and in 18 limbs (56%) in CF group which were not statistically significant (p = 0.797). Deep bone infection rates were noted in 4 (12.5%) in the CF group, compared to 1 (4%) in IMN group; however, the result was not statistically significant (p = 0.240). Amputation rates as a result of infected non-unions were seen in 1 limb (4%) in IMN group and 2 limbs (6%) in CF group (p = 0.99). Median time to union was significantly shorter in IMN group at 30weeks compared to 30weeks for CF group (p = 0.04). IMN should be the treatment of choice in the treatment of grade III open tibial diaphyseal fracture, but CF should be considered for delayed treatment and in patients with bone loss.

Management of Open Tibial Diaphyseal Fractures by Limb Reconstruction System As Primary and Definitive Treatment: A Prospective Cohort Study.

Background One of the most frequent long bone fractures that most orthopaedic surgeons see is a tibial diaphyseal fracture. The tibia has more open fractures than any other major long bone because it is covered by skin for the majority of its length. The best course of therapy is still up for debate due to the high occurrence of comorbidities linked to these fractures. Materials and methods In this prospective study, 30patients who met the inclusion criteria were admitted to the Department of Orthopaedics of Shri B. M. Patil Medical College Hospital and Research Centre, Vijayapura, Karnataka, India. The period of study was from January 2021to May 2022. The patients were followed up for a period of six months. Longer follow-up was required for some patients. Results In our study, there were 26 (86.7%)male and four (13.3%)female patients. The mode of injury was road traffic accidents in all cases. The functional outcomes obtained using the modified Anderson and Hutchinson's criteria were goodresults in22 (73.3%), moderateresults in five (16.7%), and poor results in three (10%)of the study population. Pin tract infections (six cases; 20%) and shortening (eight cases; 26.7%) were the most frequent complications Conclusion Because of the ease of use, good fracture stability, adjustable geometry, light weight, reasonable price, and patient friendliness, the limb reconstruction system (LRS) provides an excellent alternative treatment option for treating compound fractures of the tibia.

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.

Orthoplastic Reconstruction of Type IIIB Open Tibial Shaft Fractures Using Debrided, Devitalized Cortical Segments: Health-Related Quality-of-Life Outcomes.

To determine health-related quality of life (HRQoL) in patients who sustained type IIIB open tibial diaphyseal (OTA/AO-42) fractures and underwent orthoplastic reconstruction using mechanically relevant devitalized bone (ORDB) versus those who did not require the use of devitalized bone as part of their orthoplastic reconstruction. Consecutive cohort study. The study included 74 patients who sustained a type IIIB open tibial diaphyseal fracture requiring orthoplastic reconstruction over a 4-year period in a major trauma center. All patients underwent a two-stage orthoplastic reconstruction protocol, with the second stage consisting of definitive fixation and flap coverage (free fascial anterolateral thigh flap) in a single sitting. Patients were contacted at a minimum of 30 months to measure HRQoL. Patients requiring ORDB versus those who did not require the use of devitalized bone as part of their orthoplastic reconstruction. The primary outcome measure was HRQoL ascertained using Euro-Qol (EQ)-5D and Short-Form (SF)-36 scores. Thirty (n = 30) patients underwent ORDB with the remaining 44 not requiring devitalized bone as part of their reconstruction. The median age was 46.5 years [interquartile range (IQR) 29.0], with a median follow-up of 3.8 years (IQR 1.5). The median cohort EQ-5D was 0.743 (IQR 0.222), ORDB 0.743 (IQR 0.195) versus non-ORDB 0.748 (IQR 0.285), P = 0.71. The median physical component SF-36 score was 80 (IQR 50), ORDB 80 (IQR 34.5) versus non-ORDB 77.5 (IQR 58.75), P = 0.72. The median mental component SF-36 score was 80 (IQR 28), ORDB 80 (IQR 21) versus non-ORDB 80 (IQR 36), P = 0.29. In patients who sustained a type IIIB open tibial shaft fracture and who underwent a 2-stage orthoplastic reconstruction, ORDB does not seem to be associated with inferior health-related quality of life based on EQ-5D or SF-36 scores. The results of this approach should be considered within the strict combined orthoplastic approach in the study unit. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Prospective Study on Clinical Outcome of Primary Nailing in Open Type I to Type IIIA Tibial Diaphyseal Fractures

Background and Objectives: Tibia is a superficial long bone, with one third of its surface being subcutaneous. An increasing incidence of road traffic accidents, farm accidents, gunshot wound predisposes it for open fracture. Open fractures of the tibia are the most common open long bone fractures. High-energy trauma is the primary mechanism of injury, with over 50% of cases being attributed to road traffic accidents are frequently contaminated. The treatment of open tibia fractures is still controversial. This prospective study was conducted at a tertiary care trauma center to evaluate the functional outcome and complications following primary debridement and nailing in type I to type IIIA open tibia fractures. Materials and Methods: A total of 30 patients diagnosed with open tibial diaphyseal fractures, who underwent primary debridement and fixation with intramedullary interlocking nail were included in the study and type III B, type III C open fractures were excluded. Patients were followed for a period of 12 months and assessed using Modified Ketenjian criteria and Johner − Wruhs' criteria. Results: Out of 30 patients who underwent primary nailing for open tibia fractures, 66.67% had excellent, 26, 67% good, and 6.66% of patients had fair results. 93.33% of the patients had union within 9 months and 6.66% of the cases had delayed union. Conclusion: Primary intramedullary interlocking nailing in open tibia fractures is a good treatment option, it aids early patient mobilization and early resume to work. It avoids multiple surgical procedures and promotes early fracture union.

Outcomes and Incidence of Deep Bone Infection in Grade III Diaphyseal Open Tibial Fractures: Circular Fixator vs Intramedullary Nail.

IntroductionHigh-energy grade III open fractures of tibia are associated with significant complications and generate debate over the ideal fixation method. This study compares the clinical outcomes for circular frame fixation (CFF) vs intramedullary nail fixation (IMF) in grade III open tibial fractures.Materials and methodsSingle-centre retrospective study of patients admitted from January 2008 to December 2016. All patients with grade III open diaphyseal tibial fractures (AO 42 A, B, C), treated with either CFF or IMF, were included. The primary outcome was deep bone infection (DBI). Secondary outcomes were delayed or non-union, secondary intervention, and amputation.ResultsA total of 48 limbs in 47 patients had CFF, and 25 limbs in 23 patients had IMF. Median time to definitive fixation was significantly longer for CFF at 9 days (IQR 3–13) compared to IMF at 1 day (IQR 0–3.5) (p <0.001). The DBI rate was significantly lower (2 vs 16%) in the CFF group (p = 0.04). There were 14 limbs (29%) with delayed or non-union in the CFF group vs 5 limbs (20%) in the IMF group. In the CFF group, significantly more limbs required bone grafting for delayed or non-union (p = 0.03). However, there was a greater proportion of limbs in the CFF group with segmental fractures or bone loss (46 vs 4%) and these high-energy fracture patterns were associated with secondary bone grafting (p = 0.005), and with delayed or non-union (p = 0.03). A subgroup analysis of patients without segmental fractures or bone loss treated with either CFF or IMF showed no significant difference in secondary bone grafting (p >0.99) and delayed or non-union rates (p = 0.72). Overall, one patient in each group went on to have an amputation.ConclusionOur study found that CFF had a lower rate of DBI compared to IMF. Injuries with high-energy fracture patterns (segmental fractures or bone loss) were more likely to have delayed or non-union and require secondary bone grafting. These factors should be considered when selecting the appropriate method of definitive fixation.How to cite this articleNatalwala I, Chuo CB, Shariatmadari I, et al. Outcomes and Incidence of Deep Bone Infection in Grade III Diaphyseal Open Tibial Fractures: Circular Fixator vs Intramedullary Nail. Strategies Trauma Limb Reconstr 2021;16(3):161–167.

COMPARISON OF EFFECTS OF DIFFERENT NAIL TIP POSITIONS ON ANTERIOR KNEE PAIN AFTER INTRAMEDULLARY INTERLOCKING NAILING FOR TIBIAL SHAFT FRACTURES

Objective: To determine the frequency of anterior knee pain after intramedullary interlocking nailing in tibial shaft fractures and to compare the intensity of anterior knee pain between positive and negative anterior cortex nail groups.Study Design: Quasi-experimental study.&#x0D; Place and Duration of Study: Department of Orthopaedic Surgery, Combined Military Hospital Rawalpindi, from Oct 2018 to Apr 2019.&#x0D; Methodology: 100 cases of tibial shaft fracture were divided into two groups according to anterior cortex nail distance. Patients 18-40 years of age of both genders, closed fractures, Gustilo Andersen I open tibial diaphyseal fractures and nail tip more than 5mm from tibial tuberosity were included. Patients with osteoarthritis, pathological fractures, renal disease, open fracture GA-II &amp; GA-III and knee instability were excluded from the study. Both groups with positive and negative anterior cortex nail distance were compared for pain using the chi-square test.&#x0D; Results: Frequency of anterior knee pain after intramedullary interlocking nailing in tibial shaft fractures was found in 24% of patients. 8 (16%) out of 50 patients in the group with nail tip deep to anterior cortex had anterior knee pain while 16 (32%) out of 50 patients in the group with nail tip protruding from anterior cortex suffered anterior knee pain (p-value = 0.061).&#x0D; Conclusion: Intramedullary interlocking nailing in tibial shaft fractures with nail tip deep to anterior cortex showed less pain as compared to nail tip protruding from anterior cortex although it was not statistically significant.

Open diaphyseal fracture of the tibia in Pakistani adults: A comparative study of Plaster of Paris cast vs. Naseer Awais external fixator.

Background: The management of open tibial diaphyseal fractures is the most challenging glitch faced by orthopedic surgeons. For open or comminuted fractures, external fixation remains the gold standard. This study aimed to assess the treatment response of fixators by comparing the results of open diaphyseal tibial fracture stabilization in adults by Plaster of Paris (POP) cast versus Naseer Awais External Fixator (NAEF).&#x0D; Methodology: A single-center, prospective study was conducted at the leading teaching institute and tertiary care hospital of Jamshoro and Hyderabad, Pakistan. A total of 30 patients having an open diaphyseal fracture of the tibia were randomly assigned to two groups (Group A-POP cast and Group B to NAEF; n=15 each). Duration of hospital stay and postoperative complications (like wound infection, union rate, and functional outcome) were compared between groups.&#x0D; Results: On average, group A patients stayed in the hospital for 3.65 weeks, while group B patients stayed for 2.49 weeks (p=0.004). Wound infections were observed in 26.7% and 53.3% of the patients in group A and B, respectively. No significant difference in the adequate callus formation (i.e. union) and good functional outcome was observed among patients of group A and B (p&gt;0.05). &#x0D; Conclusion: The use of NAEF for open diaphyseal fractures of the tibia has a significant advantage over POP cast in reducing the duration of hospital stay. However, no significant differences were observed in wound infection, union rate and time, and functional outcome.

Free tissue versus local tissue: A comparison of outcomes when managing open tibial diaphyseal fractures.

Open lower extremity fractures pose a challenge for treating surgeons. All surgical strategies have the common aim to facilitate fracture healing. Fracture union, however, should be critically considered in the context of functional recovery and not in isolation. Both local and free tissue transfer have benefits and drawbacks. This study aims to compare the functional outcomes of open tibial diaphyseal fractures managed with internal fixation, comparing outcomes of those receiving free tissue transfer as opposed to local flaps METHODS: This study follows the STrengthening the Reporting of Observational studies in Epidemiology (STROBE) criteria. Data were collected retrospectively from a prospectively maintained database at our institution. Inclusion criteria included a non-comminuted Gustilo type-IIIB open tibial diaphyseal fracture requiring intramedullary nailing. Forty three patients with local flaps and 180 patients with free flaps were included RESULTS AND CONCLUSION: 233 patient underwent reconstruction for open fracture using local flaps (n=43) or free flaps (n=180). In the context of Gustilo type-IIIB non-comminuted, mid-tibial diaphyseal fractures treated with intramedullary nailing, free fasciocutaneous flap reconstructions leads to significantly improved functional outcomes in patients of all ages when compared to local fasciocutaenous flaps. (77 ± 19 v 50 ± 22 % for local flaps; P < 0.001).

Management of gustilo and anderson type i and ii open tibial fracture using delayed primary nailing: An assessment of clinical and radiological outcome

Background: Open tibial fracture is one of the most common trauma emergencies. Marked delay in presentation is noticed in developing countries, especially sub-Saharan Africa due to poor pre-hospital care, presentation to traditional bone setters and out-of-pocket payment of services. Primary nailing at the time of initial debridement was noticed to have a high prevalence of infection in some series. Delayed primary nailing after a period of debridement and wound care was found to be safe with less complication rate in this study. Objective: The objective of this study is to determine the clinical and radiological outcome of management of Gustilo and Anderson (GA) Type I and II open tibial fracture using delayed primary nailing, especially in patient with delayed presentation. Methodology: Twenty-one (21) patients with open (GA I and II) tibial diaphyseal fracture were recruited into this study. They had initial debridement and a period of wound care before subsequent nailing. All patients had tibial interlocking nailing 5–9 days post-injury using open technique with aid of the external jig system. The patients were followed up for 9 months. Clinical outcome was assessed using Johner and Wruh's criteria at 6 months. The radiologic outcome was assessed using Radiologic union scale for tibia fracture (RUST). Results: The M: F was 4:1 with a mean age of 37.24 ± 13.8 years. Road traffic accident accounted for 85.7% (n = 18). Marked delayed presentation was noted, only four patients (19.1%) presented within 6 h from injury. GA Type II open fracture was the most prevalent fracture type accounting for 81.9% (n = 17). The clinical outcome using Johner and Wuh's criteria at 6 months post-nailing showed 18 patients (86%) had excellent and good outcome. Only one patient (4.8%) had poor outcome. RUST was used to assess the rate of union following the tibial nailing. Fractures were scored at 6 weeks, 12 weeks, 6 months and 9 months. Ten patients (47.6%) were united at 6 weeks, whereas 21 (100%) had achieved union at 9 months. The average time to radiologic union was 17.3 weeks. Seven patients (33.3% n = 7) had complications. Anterior knee pain, superficial surgical site infection (SSI) and delayed union were the complication recorded. Conclusion: Delayed primary nailing of open tibial fracture produces good to excellent outcome with acceptable complication rate, especially SSI.

Outcome of limb reconstruction system in tibial infected non-union and open tibial diaphysial fracture with bone loss

IntroductionIncidence of open fractures of the long bones is increasing due to the increase in road traffic accidents (RTA) which leads to an increased incidence of complex non-unions of long bones. Patients are usually operated many times for fracture fixation (and healing) or to eradicate infection, which causes soft tissue scarring and devitalization of any surviving bone. ObjectiveIn this study, we assess the outcome of the Limb reconstruction system in tibial infected non-union and open tibial diaphyseal fracture with bone loss. MethodIt is a prospective study conducted on 15 patients and patients included in this study having compound fractures of shaft tibia with bone loss classified by Gustilo-Anderson open fracture classification. With the defect in the distal tibia, proximal corticotomy 1.5 cm distal to the last screw in the proximal clamp and proximal to distal transports were done and vice versa. All patients were evaluated with the ASAMI scoring system into bone results and functional results. ResultsIn the majority of patients, the injury was caused by road traffic accidents 80% of cases. Out of 15 cases, 2 belong to the upper 3rd, 9 cases belong to the middle 3rd and 4 cases belong to the lower 3rd of shaft tibia. The union time ranges from 4 to 11 months but the maximum union was achieved in 7–9 months in 8 (53.33%). Pin tract infection was reported in two (13.33%) patients who became better with regular dressing. Ankle stiffness was present in one case (6.67%), most probably due to improper physiotherapy.According to ASAMI Criteria excellent radiological results were present in 11 (73.33%) cases, good results were found in 4 (26.67) cases and excellent functional results were observed in 7 cases (46.67%) and good results were found in 8 (53.33%) cases. Infection was cured in all patients and did not recur till the last follow-up. ConclusionsAdvantages of rail fixator include less invasive surgery, early weight-bearing, less infection, less blood loss, prevention of diffuse osteoporosis and atrophy, preservation of limb function, no need for bone grafting, correction of deformity during the process of healing, thus no need for a second surgery. Non-union, bone defect, and deformity can be corrected simultaneously. Hence, we recommend the use of this system (rail fixator) especially for infected non-union of long bones and compound fractures with bone loss.

Management of open diaphyseal fracture of tibia in adults: A comparative study between plaster of paris cast versus external fixator.

Objectives: To determine the management of open diaphyseal fracture of tibia with plaster of Paris (pop) cast vs external fixator in orthopedic ward PUMHSW Hospital Nawabshah. Study Design: Cross-Sectional Comparative study. Setting: Orthopedic Department, Peoples University of Medical And Health Science Shaheed Benazirabad. Period: 18 months from January 2017 to June 2018. Material &amp; Methods: The data was analyzed in SPSS Version 22.0. Results: Out of 50 patients with tibial diaphyseal fractures, there were 34 males compared to females 16 (2.1:1) (68% vs 32%) with an average age of 41 years. Patients with external fixator applied yielded decreased rates of infection; shorter duration of hospital stay and early union compared to patients with plaster of Paris (pop) cast application. However, the difference reached statistical significant value. Conclusion: Open Tibial diaphyseal fractures should be managed with external fixation that yields better results. A plaster cast is the initial treatment of modality in patients with open tibial diaphyseal fractures.

Reamed Versus Unreamed Intramedullary Interlocking Nailing for Open Tibial Fractures – An Observational Study

Background and objectives: With increase in population, industrialization and traffic density there is high incidence of road traffic accidents. The incidence of high energy trauma are increasing in the same proportion. Tibial diaphyseal fractures are the commonest long bone fractures encountered by most orthopedic surgeons. One third of the length of tibial surface is subcutaneous, Open fractures are more common in tibia than in any other major long bone. This led us to design study of reamed versus unreamed intramedullary interlocking nailing for open tibial diaphyseal fractures. Materials and methods: 60 consecutive patients who had open fractures of tibial shaft were treated with wound debridement and interlocking intramedullary nailing with or without reaming during the period from October 2009 to September 2011. The patients have been followed up for 6-8 months during this study. Results: open tibial diaphyseal fractures surgically managed both reamed and unreamed gave good functional results. In our study according to Johner and Wruh’s criteria there is no significant difference in reamed and unreamed intramedullary interlocking nailing for open tibial diaphyseal fractures. Interpretation and Conclusion: Thorough and early wound debridement and early wound coverage along with intramedullary interlocking nailing for open tibial diaphyseal fractures is the key to minimize deep infection. No

Commentary on: “Two-Stage Combined Ortho-plastic Management of Type IIIB Open Diaphyseal Tibial Fractures Requiring Flap Coverage: Is the Timing of Debridement and Coverage Associated With Outcomes?”

Commentary on: “Two-Stage Combined Ortho-plastic Management of Type IIIB Open Diaphyseal Tibial Fractures Requiring Flap Coverage: Is the Timing of Debridement and Coverage Associated With Outcomes?”

Two-Stage Combined Ortho-Plastic Management of Type IIIB Open Diaphyseal Tibial Fractures Requiring Flap Coverage: Is the Timing of Debridement and Coverage Associated With Outcomes?

To delineate whether timing to initial debridement and definitive treatment had an effect on patient outcomes in those undergoing 2-stage ortho-plastic management of Gustilo-Anderson type IIIB open tibial diaphyseal fractures. Retrospective comparative cohort study over a 2-year period. Level 1 trauma center. A total of 148 patients were identified. After exclusion of ankle fractures, nondiaphyseal fractures and those who did not undergo 2-stage ortho-plastic management, 45 patients were eligible for final analysis. Time to initial debridement and definitive management. Deep infection. Secondary outcomes being nonunion and flap failure. Multiple linear regression was used for outcomes. We assumed a priori that P values of less than 0.05 were significant. Mean age was 54 years (SD 23.0), with 28 men and 17 women. Over a mean 2-year follow-up, there were 4 (4/45) deep infections, 2 infection-associated flap failures, and 1 vascular flap failure. All patients progressed to union. The mean time to initial debridement for the whole cohort was 19 hours (SD 12.3), and the mean time to definitive reconstruction was 65 hours (SD 51.7). Longer time to both initial debridement and definitive reconstruction was not found to be significantly associated with deep infection, infected flap failure, or nonunion. Using a 2-stage ortho-plastic operative algorithm, timing to initial debridement and definitive fixation with soft-tissue coverage was not associated with negative outcomes. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Treatment of Open Comminuted Diaphyseal Fracture of the Tibia by Ilizarov

Background: Management of open diaphyseal tibial shaft fractures can be comminuted due to lack of soft tissue coverage and blood supply of the tibial shaft. Open reduction and internal fixation [ORIF] with plates and screws achieves stability, allows joint mobilization but does not allow early weight bearing which as a stimulus is a must for early union. Closed reduction and intramedullary fixation compromise the intramedullary blood supply and increases the risk of infection in open fractures. Ilizarov is considered safe in treating these open injuries, at the same time it has the advantages of easy application, minimal invasive, and convenient subsequent soft tissue repair. Objective: The aim of current study was to evaluate treatment of open comminuted diaphyseal tibial fracture by ilizarov external fixator; its effective, availability, outcomes and complications. Patients and Methods: This prospective study included a total of 10 patients with comminuted tibial diaphyseal fractures managed with early Ilizarov external fixator, attending at Alharam Hospital. This study was conducted between Feb 2018 and July 2019. General assessment indicators included pain, complete union, deformity in comparison to healthy limb, infection, leg limb discrepancy, stiffness and activity of the patients were analysed. Results: Follow-up of all participants for analysis was done. The follow-up time was 17 months. Three cases developed ankle stiffness. The average total range of knee motion in our cases was 130.5 (range 125-140). A significant limp occurred only in 3 cases. NO persistent limp persisted in our cases. Fifteen patients had minimal pain at the site of fracture. Signicant pain occurred in three cases. Pin site infection occurred in 7 patients. All the patients achieved full union and activity. Excellent results were obtained in 4 cases (40%). Good results were obtained in 3 cases (30%) with overall good to excellent results were about (70%). Fair results were obtained in 3 cases (30%). Conclusion: It could be concluded that the Ilizarov external fixator is a golden horse for orthopedic surgeons. It holds wonderful promise in the management of open diaphyseal tibial shaft fractures.

Treatment of Open Comminuted Diaphyseal Fracture of the Tibia by Ilizarov

Background: Management of open diaphyseal tibial shaft fractures can be comminuted due to lack of soft tissue coverage and blood supply of the tibial shaft. Open reduction and internal fixation [ORIF] with plates and screws achieves stability, allows joint mobilization but does not allow early weight bearing which as a stimulus is a must for early union. Closed reduction and intramedullary fixation compromise the intramedullary blood supply and increases the risk of infection in open fractures. Ilizarov is considered safe in treating these open injuries, at the same time it has the advantages of easy application, minimal invasive, and convenient subsequent soft tissue repair. Objective: The aim of current study was to evaluate treatment of open comminuted diaphyseal tibial fracture by ilizarov external fixator; its effective, availability, outcomes and complications. Patients and Methods: This prospective study included a total of 10 patients with comminuted tibial diaphyseal fractures managed with early Ilizarov external fixator, attending at Alharam Hospital. This study was conducted between Feb 2018 and July 2019. General assessment indicators included pain, complete union, deformity in comparison to healthy limb, infection, leg limb discrepancy, stiffness and activity of the patients were analysed. Results: Follow-up of all participants for analysis was done. The follow-up time was 17 months. Three cases developed ankle stiffness. The average total range of knee motion in our cases was 130.5 (range 125-140). A significant limp occurred only in 3 cases. NO persistent limp persisted in our cases. Fifteen patients had minimal pain at the site of fracture. Signicant pain occurred in three cases. Pin site infection occurred in 7 patients. All the patients achieved full union and activity. Excellent results were obtained in 4 cases (40%). Good results were obtained in 3 cases (30%) with overall good to excellent results were about (70%). Fair results were obtained in 3 cases (30%). Conclusion: It could be concluded that the Ilizarov external fixator is a golden horse for orthopedic surgeons. It holds wonderful promise in the management of open diaphyseal tibial shaft fractures.

Orthoplastic reconstruction of type IIIB open tibial fractures retaining debrided devitalized cortical segments

Type IIIB open tibial fractures are devastating high-energy injuries. At initial debridement, the surgeon will often be faced with large bone fragments with tenuous, if any, soft-tissue attachments. Conventionally these are discarded to avoid infection. We aimed to determine if orthoplastic reconstruction using mechanically relevant devitalized bone (ORDB) was associated with an increased infection rate in type IIIB open tibial shaft fractures. This was a consecutive cohort study of 113 patients, who had sustained type IIIB fractures of the tibia following blunt trauma, over a four-year period in a level 1 trauma centre. The median age was 44.3 years (interquartile range (IQR) 28.1 to 65.9) with a median follow-up of 1.7 years (IQR 1.2 to 2.1). There were 73 male patients and 40 female patients. The primary outcome measures were deep infection rate and number of operations. The secondary outcomes were nonunion and flap failure. In all, 44 patients had ORDB as part of their reconstruction, with the remaining 69 not requiring it. Eight out of 113 patients (7.1%) developed a deep infection (ORDB 1/44, non-ORDB 7/69). The median number of operations was two. A total of 16/242 complication-related reoperations were undertaken (6.6%), with 2/16 (12.5%) occurring in the ORDB group. In the setting of an effective orthoplastic approach to type IIIB open diaphyseal tibial fractures, using mechanically relevant debrided devitalized bone fragments in the definitive reconstruction appears to be safe. Cite this article: Bone Joint J 2019;101-B:1002-1008.