Tibial Fracture Patients Research Articles

Staged Minimally Invasive Osteosynthesis with Nonanatomical T-shaped Locked Plates for Intra-articular Tibial Plafond Fractures

Background: Numerous studies have assessed the outcomes of extra-articular tibial plafond fractures following staged minimally invasive osteosynthesis with various locked plates (LCPs). Recently, the Taiwan National Health Insurance has been contemplating the inclusion of nonanatomical LCPs into a benefit package. For tibial plafond fracture patients, nonanatomical T-shaped LCPs may serve as an alternative choice for those unable to afford anatomical anterolateral LCP. Objectives: This retrospective study was designed to assess the outcomes of intra-articular tibial plafond fractures following staged minimally invasive osteosynthesis with nonanatomical T-shaped LCPs. Materials and Methods: From April 2010 to October 2016, 18 consecutive patients with intra-articular fractures of the tibial plafond underwent treatment through staged minimally invasive nonanatomical T-shaped LCP osteosynthesis. The median patient age of the cohort, comprising nine women and nine men, at the time of surgery was 49 (22–71) years. The first-stage treatment consisted of radical debridement, followed by external skeletal fixation, and the second-stage treatment consisted of minimally invasive osteosynthesis with nonanatomical T-shaped LCPs. In addition, we identified factors predictive of poor results, delayed union, or nonunion of the fractures. Factors such as age, sex, open fracture, fracture severity, concomitant injuries, presence of comorbidities, and arthrosis were analyzed. Results: At 6 months of follow-up, 3 (17%) patients had delayed/nonunion according to the radiographic definition of nonunion. At the final follow-up, 17 (94%) of the 18 patients achieved union, whereas 1 (6%) did not. Patients with open fractures and concomitant injuries tend to exhibit poor clinical and radiographic outcomes. Conclusions: We found a high rate of satisfaction and union and few complications with staged minimally invasive osteosynthesis with nonanatomical T-shaped LCPs for the treatment of patients with intra-articular tibial plafond fractures. We postulate that this technique is an effective and safe alternative for the treatment of tibial plafond fractures.

The Nursing Problem for Physical Mobility Impairments in Tibia Fracture Patients Post ORIF Operation with Rom Free Active Exercise (FAE)

The Nursing Problem for Physical Mobility Impairments in Tibia Fracture Patients Post ORIF Operation with Rom Free Active Exercise (FAE)

Fasciotomy and rate of amputation after tibial fracture in adults: a population-based cohort study.

Limb amputation is a possible outcome of acute compartment syndrome. We undertook this study to investigate the occurrence of fasciotomy and amputation in patients with tibial fractures in the Ontario adult population, aiming to evaluate variables that may be associated with each of these outcomes. Retrospective, population-based cohort study (April 1, 2003-March 31, 2016). Canadian province of Ontario. Patients with tibial fracture, aged 14 years and older. Fasciotomy after tibial fracture. The primary outcomes were fasciotomy and amputation within 1 year of fasciotomy. Secondary outcomes included repeat surgery, new-onset renal failure, and mortality, all within 30 days of fasciotomy. We identified 76,299 patients with tibial fracture; the mean (SD) age was 47 (21) years. Fasciotomy was performed in 1303 patients (1.7%); of these, 76% were male and 24% female. Patients who were younger, male, or experienced polytrauma were significantly more likely to undergo fasciotomy. Limb amputation occurred in 4.3% of patients undergoing fasciotomy, as compared with 0.5% in those without fasciotomy; older age, male sex, presence of polytrauma, and fasciotomy were associated with an increased risk of amputation (age odds ratio [OR] of 1.03 [95% CI, 1.02-1.03], P < 0.0001; sex OR of 2.04 [95% CI, 1.63-2.55], P < 0.0001; polytrauma OR of 9.37 [95% CI, 7.64-11.50], P < 0.0001; fasciotomy OR of 4.35 [95% CI, 3.21-5.90], P < 0.0001), as well as repeat surgery within 30 days (sex OR of 1.54 [95% CI, 1.14-2.07], P = 0.0053; polytrauma OR of 4.24 [95% CI, 3.33-5.38], P < 0.0001). Among tibial fracture patients, those who were male and who experienced polytrauma were at significantly higher risk of undergoing fasciotomy and subsequent amputation. Fasciotomy was also significantly associated with risk of amputation, a finding that is likely reflective of the severity of the initial injury.

Identifying key risk factors for acute compartment syndrome in tibial diaphysis fracture patients

Acute compartment syndrome (ACS) is a severe orthopedic issue that, if left untreated, can result in lasting nerve and muscle damage or even necessitate amputation. The association between admission laboratory blood test indicators and the occurrence of ACS in patients with tibial diaphysis fractures is currently a subject of debate. The objective of this research was to identify the contributing factors for ACS in individuals suffering from tibial diaphysis fractures. In this retrospective study, we collected data on a total of 705 individuals from our hospital, comprising 86 ACS patients and 619 non-ACS patients with tibial diaphysis fractures. These participants were categorized into two distinct groups: the ACS group and the non-ACS group. Despite the inherent limitations associated with retrospective analyses, such as potential biases in data collection and interpretation, we conducted a comprehensive analysis of demographics, comorbidities, and admission lab results. Our analytical approach included univariate analysis, logistic regression, and receiver operating characteristic (ROC) curve analysis techniques, aiming to mitigate these limitations and provide robust findings. The statistical analysis revealed several predictors of ACS, including gender (p = 0.011, OR = 3.200), crush injuries (p = 0.004, OR = 4.622), lactic dehydrogenase (LDH) levels (p < 0.001, OR = 1.003), and white blood cell (WBC) count (p < 0.001, OR = 1.246). Interestingly, the study also found that certain factors, such as falls on the same level (p = 0.007, OR = 0.334) and cholinesterase (CHE) levels (p < 0.001, OR = 0.721), seem to provide a degree of protection against ACS. In order to better predict ACS, the ROC curve analysis was employed, which determined threshold values for LDH and WBC. The established cut-off points were set at 266.26 U/L for LDH and 11.7 × 109 cells per liter for WBC, respectively. Our research has successfully pinpointed gender, crush injuries, LDH levels, and white blood cell (WBC) count as crucial risk factors for the development of ACS in patients experiencing tibial diaphysis fractures. Furthermore, by establishing the cut-off values for LDH and WBC, we have facilitated a more personalized assessment of ACS risk, enabling clinical doctors to implement targeted early interventions and optimize patient outcomes.

Patient-Reported Outcome Measurement Information Systems Physical Function and Pain Interference Scores Are Correlated With Tibial Shaft Fracture Nonunion Following Intramedullary Nailing.

To assess trends in Patient-Reported Outcome Measurement Information Systems (PROMIS) Physical Function (PF) and Pain Interference (PI) in surgically treated tibial shaft fracture patients progressing to union versus nonunion. Retrospective cohort study. Level 1 trauma center. Patients with operatively treated tibial shaft fractures (AO/OTA 42-A, B, C) using an intramedullary nail. PROMIS PF and PI were compared between patients progressing to union and patients requiring nonunion repair. A total of 234 patients (196 union, 38 nonunion) were included consisting 144 men and 90 women. The mean age of included patients was 40.8 years. A significant difference in mean PROMIS PF between union and nonunion patients was observed at 1-3 months ( P = 0.005), 3-6 months ( P < 0.001), 6-9 months ( P = 0.003), and 6-12 months ( P = 0.018). The odds of developing nonunion for every unit decrease in PROMIS PF was significant at 3-6 months (OR 1.07, P = 0.028) and 6-9 months (OR 1.17, P = 0.015). A significant difference in mean PROMIS PI between union and nonunion patients was observed at 1-3 months ( P = 0.001), 3-6 months ( P = 0.005), and 6-9 months ( P = 0.005). The odds of developing nonunion for every unit increase in PROMIS PI was significant at 1-3 months (OR 1.11, P = 0.005), 3-6 months (OR 1.10, P = 0.011), and 6-9 months (OR 1.23, P = 0.011). Poorly trending PROMIS PF and PI in the clinical setting is a factor that can be used to evaluate progression to nonunion following tibial shaft repair where imaging studies may lag behind. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Olink proteomics analysis uncovers the landscape of inflammation-related proteins in patients with acute compartment syndrome.

Our primary purpose was to explore the landscape of inflammation-related proteins, and our second goal was to investigate these proteins as potential biomarkers of acute compartment syndrome (ACS), which is a serious complication of tibial fractures. We collected sera from 15 healthy subjects (control group, CG) and 30 patients with tibial fractures on admission day, comprising 15 patients with ACS (ACS group, AG) and 15 patients without ACS (fracture group, FG). Ten samples in each group were analyzed by the inflammation panel of Olink Proteomics Analysis, and all samples were verified by an ELISA. Receiver-operating characteristic (ROC) curve analysis was performed to identify the diagnostic ability and cutoff values of potential biomarkers. Our findings showed that the levels of IL6, CSF-1, and HGF in the FG were significantly higher than those in the CG. Similar results were found between the AG and CG, and their cutoff values for predicting ACS compared with the CG were 9.225 pg/ml, 81.04 pg/ml, and 0.3301 ng/ml, respectively. Furthermore, their combination had the highest diagnostic accuracy. Notably, compared with FG, we only found a higher expression of CCL23 in the AG. Additionally, we identified 35.75 pg/ml as the cutoff value of CCL23 for predicting ACS in patients with tibial fractures. We identified CCL23 as a potential biomarker of ACS in comparison with tibial fracture patients and the significance of the combined diagnosis of IL6, CSF-1, and HGF for predicting ACS compared with healthy individuals. Furthermore, we also found their cutoff values, providing clinicians with a new method for rapidly diagnosing ACS. However, we need larger samples to verify our results.

Diagnostic Performance of a telephone questionnaire for fracture-related infections (FRIs) in open tibia fracture patients in Tanzania

IntroductionFracture-related infections (FRIs) are a major cause of trauma-associated morbidity worldwide. In 2018, an expert group supported by the AO Foundation, European Bone and Joint Infection Society developed a consensus definition of FRI. Still, there is limited knowledge on the applicability of this definition in low- and middle-income countries (LMICs). Given the unique barriers that cause low follow-up rates for orthopaedic trauma patients in LMICs, this study aims to evaluate the diagnostic performance of a telephone questionnaire in identifying patients with FRIs after open tibia fracture fixation in Tanzania. Materials and MethodsPatients from a randomized controlled trial investigating the infection prevention benefit of locally applied gentamycin for open tibial fractures were included. Patients completed FRI based telephone questionnaires 7–10 days prior to scheduled follow-ups at 6 weeks, 3 months, 6 months, 9 months, and 1 year. The questionnaire included two “confirmatory” criteria questions for FRI (i.e., open wound and purulent drainage) and three “suggestive” criteria questions (i.e., wound drainage, fever, and warmth). Contingency tests were performed to identify the sensitivity and specificity between answers and adjudicated FRI diagnoses at the corresponding in-person follow-up. Data was analysed using STATA version 15.0 and MedCalc's online diagnostic test calculator. ResultsThere were a total of 234 complete questionnaires and 85 unique patients included. The sensitivity and specificity of having any positive answer in the questionnaire was highest at 6 months (100 % and 92.5 %, respectively). For all time-points pooled, sensitivity was 71.4 % and specificity was 93.0 %. Drainage had the highest sensitivity (71.4 %) while fever had the highest specificity (99.6 %). For confirmatory criteria, sensitivity was 14.3 % and specificity was 96.0 %. Contrastingly, the sensitivity for suggestive criteria was higher (71.4 %), with a similar specificity (93.8 %). ConclusionOur study indicates that telephone questionnaires have adequate diagnostic performance when assessing FRIs. The presence of drainage identified the majority of patients with FRI, and specificities were high across confirmatory and suggestive criteria. Our study is one of the first to evaluate telephone questionnaires as a diagnostic tool for FRIs in patients with open tibia fractures in a LMIC hospital and validates the FRI consensus definition criteria.

1130 Does Fracture Location and Patient Comorbidity Influence Opioid Requirements in Tibial and Ankle Fractures?

Abstract Aim Opioid requirement in post-operative rehabilitation is an important area in orthopaedic surgery, with no large UK-based studies. Guidelines should reflect anticipated patient requirements. Our study explores the characteristics predisposing surgically managed tibial fracture patients to increased opioid requirements. Method All tibial fractures from 2015-2022 at a Major Trauma Centre were evaluated. 1890 patients were included. Post-operative opioid prescriptions in the 1st post-operative year were calculated every month up to 6 months and then from the 7th-12th month. Overall prescribed Morphine Milligram Equivalents (MME) “strength” and days with at least one opioid prescription (“coverage”) were calculated. Demographic, fracture location and various comorbidities were included in the multivariate modelling. Results Compared to the tibial average, plateau and Pilon fractures had x1.51 and x1.20 times the strength in the first year, with significance at every sub-interval (p&amp;lt;0.01) and ankle fractures had x0.756, significance at every individual time-interval (p&amp;lt;0.05). For relative strength and coverage, for all time intervals, obesity, pulmonary disease, and drug abuse were associated with higher opioid requirements (p&amp;lt;0.05). Age, Charleston Comorbidity Index (CCI) and BMI were each positively associated with coverage in each of the first 3 months, with age and CCI associated with strength in 1st month (p&amp;lt;0.05). Conclusions Our study begins to elucidate a range of patient factors that can predispose to increased opioid usage in total strength and overall coverage. This, begins to construct an evidence-based tool for clinicians to base opioid prescriptions, manage patients effectively, and guide opioid stewardship.

Plating fixation or ring fixation compression during a masquelet technique for tibial fracture patients: a systematic review and meta-analysis

Abstract Purpose The purpose of this study is to compare the outcomes of using a ring fixator compression or plating fixation in tibial shaft fracture patients treated with the Masquelet technique. Methods The author conducted a search of the literature for studies that compared the use of a ring fixator or plate for the Masquelet technique in patients with tibial shaft fractures. All full English only articles in the form of randomized and nonrandomized studies were included. Search engines used included PubMed/Medline, Scopus, Cochrane, Web of Science, Embase, Google scholar, Science Direct, and Clinicaltrials.gov. Results The results demonstrate that, patients who underwent the plating fixation with Masquelet technique had greater risks of developing superficial surgical site infections (P &lt; 0.001), stiffness/decreased range of motion (P &lt;0.001), wound and soft tissue disclosure (P = 0.026), postoperative fractures (P &lt; 0.001), and had overall greater risk for postoperative failure (P = 0.003) in comparison to the ring fixation compression with Masquelet technique. In terms of deep surgical site infections, there was no significant difference between the two techniques. The results of this study would therefore suggest that the ring fixation compression with Masquelet technique is a greater alternative to the plating fixation with Masquelet technique for tibial shaft fracture patients. Conclusion Plating fixation with Masquelet technique had significantly higher rates of superficial surgical site infection, operation failure, refracture, stiffness with decreased range of motion, wound and soft tissue disclosure than ring fixation compression. This would suggest that ring fixation compression with Masquelet technique is a better alternative to repairing tibial fractures than plating fixation with Masquelet technique.

WITHDRAWN: Déformation en valgus négligée dans les fractures de la diaphyse tibiale, avec ou sans atteinte fibulaire, chez l’enfant : cause du valgus résiduel à deux ans de recul

BackgroundChildren with a tibial shaft fracture often present with valgus malalignment, even when anatomical reduction had been achieved at the fracture site. Pediatric bony structure has more elastic bones than that of adults, it can cause bowing deformity. Therefore, we evaluated pediatric tibial shaft fracture for the presence of bowing deformity, associated risk factors, and its clinical significance. HypothesisThere is an overlooked bowing deformity in pediatric tibial shaft fracture. Patients and methodsIn total, 57 tibial shaft fracture patients aged 2 to 15 years with Risser stage 0 were retrospectively reviewed. Clinicoradiologic factors and radiographs taken within 3 post-traumatic months and at 2-year follow-up were assessed. To evaluate the tibial bowing deformity, the tibial interphyseal angle and tibial shaft angle were measured, and their differences were calculated as a tibial bowing angle. ResultsMultivariate analysis revealed the tibial shaft fracture with fibular involvement is significantly associated with a higher initial tibial bowing angle (valgus deformity). The tibial bowing angle did not change over 2-year follow-up. A high initial tibial bowing angle (≥ 5°) was a significant risk factor for the persistence of valgus malalignment. DiscussionPediatric tibial shaft fractures with/without fibular involvement carry the risk of valgus bowing deformity, which may not develop during post-traumatic growth but may be present at the time of injury. The risk is high if the tibial fracture is accompanied by a fibular fracture. This tibial deformity presents limited remodeling potential at 2-year follow-up. Level of evidenceIV, retrospective study.

Early postoperative step count and walking time have greater impact on lower limb fracture outcomes than load-bearing metrics

IntroductionWeight-bearing protocols for rehabilitation of lower extremity fractures are the gold standard despite not being data-driven. Additionally, current protocols are focused on the amount of weight placed on the limb, negating other patient rehabilitation behaviors that may contribute to outcomes. Wearable sensors can provide insight into multiple aspects of patient behavior through longitudinal monitoring. This study aimed to understand the relationship between patient behavior and rehabilitation outcomes using wearable sensors to identify the metrics of patient rehabilitation behavior that have a positive effect on 1-year rehabilitation outcomes. MethodsProspective observational study on 42 closed ankle and tibial fracture patients. Rehabilitation behavior was monitored continuously between 2 and 6 weeks post-operative using a gait monitoring insole. Metrics describing patient rehabilitation behavior, including step count, walking time, cadence, and body weight per step, were compared between patient groups of excellent and average rehabilitation outcomes, as defined by the 1-year Patient Reported Outcome Measure Physical Function t-score (PROMIS PF). A Fuzzy Inference System (FIS) was used to rank metrics based on their impact on patient outcomes. Additionally, correlation coefficients were calculated between patient characteristics and principal components of the behavior metrics. ResultsTwenty-two patients had complete insole data sets, and 17 of which had 1-year PROMIS PF scores (33.7 ± 14.5 years of age, 13 female, 9 in Excellent group, 8 in Average group). Step count had the highest impact ranking (0.817), while body weight per step had a low impact ranking (0.309). No significant correlation coefficients were found between patient or injury characteristics and behavior principal components. General patient rehabilitation behavior was described through cadence (mean of 71.0 steps/min) and step count (logarithmic distribution with only ten days exceeding 5,000 steps/day). ConclusionStep count and walking time had a greater impact on 1-year outcomes than body weight per step or cadence. The results suggest that increased activity may improve 1-year outcomes for patients with lower extremity fractures. The use of more accessible devices, such as smart watches with step counters combined with patient reported outcome measures may provide more valuable insights into patient rehabilitation behaviors and their effect on rehabilitation outcomes.

Comparison of Free-hand and K-wires Technique in Distal Locking of Expert Tibia Nail.

The purpose of this study was to analyse the application value of K-wires technique for distal locking of expert tibia nail (ETN). It was a retrospective study carried out from September 2019 to July 2020 at the First Affiliated Hospital of Jinzhou Medical University. All the patients of distal tibial fracture, treated with the ETN and free-hand or K-wires technique for distal locking, were included in this study. A total of 98 patients were evaluated, which included 47 with free-hand and 51 with K-wires technique. The operation time of the K-wires technique was shorter than that of free-hand (p <0.001). The number of distal shots, distal locking time, and the total number of shots with K-wires technique were lower than those with free-hand (p=0.015, p=0.025, and p=0.030, respectively). The adjustment time for the K-wires was less than that by free-hand (p=0.001). The K-wires can be better used for the distal locking of the ETN. Key Words: Distal locking, Tibia fractures, Intramedullary nail.

Overlooked valgus bowing deformity in pediatric tibial shaft fractures with/without fibular involvement: Cause residual valgus alignment in 2-year follow-up

BackgroundChildren with a tibial shaft fracture often present with valgus malalignment, even when anatomical reduction had been achieved at the fracture site. Pediatric bony structure has more elastic bones than that of adults, it can cause bowing deformity. Therefore, we evaluated pediatric tibial shaft fracture for the presence of bowing deformity, associated risk factors, and its clinical significance. HypothesisThere is an overlooked bowing deformity in pediatric tibial shaft fracture. Patients and methodsFifty-seven tibial shaft fracture patients aged 2 to 15 years with Risser stage 0 were retrospectively reviewed. Clinicoradiologic factors and radiographs taken within 3 post-traumatic months and at 2 years were assessed. To evaluate the tibial bowing deformity, the tibial interphyseal angle and tibial shaft angle were measured, and their differences were calculated as a tibial bowing angle. ResultsMultivariate analysis revealed the tibial shaft fracture with fibular involvement is significantly associated with a higher initial tibial bowing angle (valgus deformity). The tibial bowing angle did not change over 2-year follow-up. A high initial tibial bowing angle (≥ 5°) was a significant risk factor for the persistence of valgus malalignment. DiscussionPediatric tibial shaft fractures with/without fibular involvement carry the risk of valgus bowing deformity, which may not develop during post-traumatic growth but may be present at the time of injury. The risk is high if the tibial fracture is accompanied by a fibular fracture. This tibial deformity presents limited remodeling potential at 2-year follow-up. Level of evidenceIV; retrospective study.

Predictors of Length of Care in Tibial Fracture Patients: Analysis of Secondary Data

Introduction: Predicting the length of care becomes important for intervention in the care system. However, it still seems that the ability to predict the length of treatment is not optimal, so that the length of treatment is prolonged. If the ability to predict the length of treatment can be done optimally, it will improve the patient's return time.&#x0D; Methods: This study uses a retrospective study approach.&#x0D; Result: There was no relationship between the predictor of length of stay with a length of treatment.&#x0D; Conclusion: The predictor of length of stay in this study were patients with tibia fractures at RSD dr. Soebandi. Most of the patients with tibial fractures were in the early elderly, with the gender of patients with tibia fractures being mostly male. Most of the patients with tibial fractures have no complications and the type of fracture in patients with tibia fractures is mostly in the fracture of the shaft of the tibia. There was no correlation between the predictors of length of stay and length of stay in patients with tibia fractures.

EE260 An Early Cost-Effectiveness Analysis of a New Continuous Compartment Pressure Monitoring Device in Tibial Fracture Patients Who Are at Risk of Developing Acute Compartment Syndrome (ACS)

EE260 An Early Cost-Effectiveness Analysis of a New Continuous Compartment Pressure Monitoring Device in Tibial Fracture Patients Who Are at Risk of Developing Acute Compartment Syndrome (ACS)

Predictors of acute compartment syndrome in patients with tibial fractures: a meta-analysis.

This is the first meta-analysis focusing on the risk factors related to ACS after tibial fractures. Acute compartment syndrome (ACS) is a serious complication that affects 2-9% of tibial fracture patients. It is importance of identifying the predictors of ACS in patients with tibial fractures. We performed a meta-analysis to identify the risk factors of ACS after tibial fracture. We searched articles in the English databases, such as PubMed, Embase, and the Cochrane Library and the Chinese databases including CNKI and WAN FANG. We collected data related to ACS from included studies and analyzed data by RevMan 5.3 and STATA 12.0. The rate of ACS was 2.7% (10,708 of 398,414 patients) from 16 included articles. Our data showed that younger age (p < 0.00001, OR = - 7.93, 95% CI [- 9.34, - 6.25]), male patients (p < 0.00001, OR = 2.17, 95% CI [2.07, 2.28]), patients without a history of hypertension (p < 0.00001, OR = 0.69, 95% CI [0.64, 0.74]), with a history of smoking (p < 0.00001, OR = 1.38, 95% CI [1.30, 1.46]), and patients with fibular fractures (p = 0.001, OR = 2.68, 95% CI [1.47, 4.87]), closed fracture (p = 0.02, OR = 0.86, 95% CI [0.75, 0.98]), high-energy injury (p = 0.003, OR = 0.37, 95% CI [0.19, 0.71]), motorized accident (p = 0.0009, OR = 0.41, 95% CI [0.24, 0.69]), proximal fracture, AO-C-type fracture, comminuted fracture, and Schatzker grade IV-VI fracture were associated with the development of ACS. Additionally, femoral displacement ratio and tibial widening ratio in the ACS groups were significantly higher than in the non-ACS group. Many factors were found to be associated with the development of ACS following tibial fractures. We provide references when we met the above characteristics of patients to rapidly identify and highly concern ACS.

Antibiotic administration within 1 hour for open lower extremity fractures is not associated with decreased risk of infection.

Open fractures have a high risk of infection with limited data correlating timing of prophylactic antibiotic administration and rate of subsequent infection. The Trauma Quality Improvement Program has established a standard of antibiotic administration within 1 hour of arrival, but there is a lack of adequately powered studies validating this quality metric. We hypothesize that open femur and/or tibia fracture patients undergoing orthopedic surgery have a decreased risk of infectious complications (osteomyelitis, deep and superficial surgical site infection) if antibiotics are administered within 1 hour of presentation compared with administration after 1 hour. The 2019 Trauma Quality Improvement Program was queried for adults with isolated (Abbreviated Injury Scale <1 for the head/face/spine/chest/abdomen/upper extremity) open femur and/or tibia fractures undergoing orthopedic surgery. Transfer patients were excluded. Patients receiving early antibiotics (EA) within 1 hour were compared with patients receiving delayed antibiotics (DA) greater than 1 hour from arrival. Of 3,367 patients identified, 2,400 (70.4%) received EA. Patients receiving EA had a higher rate of infections compared with DA (1.1% vs. 0.2%, p = 0.011). After adjusting for age, comorbidities, injury severity, nerve/vascular trauma to the lower extremity, washout of the femur/tibia performed in <6 hours, blood transfusion, and admission vitals, patients in the EA group had a similar associated risk of surgical site infection/osteomyelitis compared with the DA cohort ( p = 0.087). These results remained in subset analyses of patients with only femur, only tibia, and combined femur/tibia open fractures (all p > 0.05). In this large national analysis, approximately 70% of isolated open femur or tibia fracture patients undergoing surgery received antibiotics within 1 hour. After adjusting for known risk factors of infection, there was no association between timing of antibiotic administration and infection. Reconsideration of the quality metric of antibiotic administration within 1 hour for open fractures appears warranted. Therapeutic/Care Management; Level IV.

Ballistic Tibial Plafond Fractures Compared with Blunt Open Tibial Pilon Fractures: A Control-Matched Study

INTRODUCTION: It is well documented that blunt, open tibial plafond fractures are severe injuries with high complication rates; however, there is a paucity of literature on ballistic intraarticular tibial plafond fractures. The purpose of this study is to determine the differences in outcomes between ballistic tibial plafond fractures and open pilon fractures. METHODS: We report on a consecutive series of patients over a 10-year period that presented to a single level I trauma center with an OTA 43C ballistic tibial plafond fracture. A control group consisting of patients with open pilon fractures matched for OTA classification, Gustilo-Anderson classification, and fixation method was used for comparison. Pearson’s chi-square and Fischer’s exact tests were utilized to determine differences between groups. RESULTS: A total of 27 ballistic tibial plafond fracture patients treated surgically were identified. The control matched group consisted of 21 patients. Fixation was achieved using the following methods: primary open reduction internal fixation (ORIF) (n = 8), primary external fixation (n = 21), staged external fixation and delayed ORIF (n = 18), and staged external fixation and delayed intramedullary nail (n = 1). There was no difference in rates of deep infection (19% vs 38%, p = 0.13) and superficial infection (41% vs 33%, p = 0.60) between the ballistic and control group. CONCLUSION: Our study demonstrates that ballistic intraarticular tibial plafond fractures are severe injuries that have similar outcomes to blunt, open pilon fractures that occur with high-energy axial loading. Although ballistic tibial plafond fractures are rare, our data reveal similarly high complication rates to blunt, open pilon fractures.

Conversion of External Fixator to Intramedullary Nail in Tibial fractures.

Conversion of provisional external fixation to intramedullary nail (IMN) in femur fractures has been reported to be safe within 14 days of initial surgery. However, there is no current literature guiding this practice in tibial fractures. The purpose of this study was to identify the time period when conversion of external fixation to nail in tibial fractures is safe. After obtaining IRB approval, tibial fractures (OTA 41A, 42, 43A) that received provisional ex-fix and were converted to IMN from 2009 to 2019 were retrospectively reviewed. Skeletally mature patients with minimum 6 months of follow-up were included. The primary outcome was deep infection. External fixation days were categorized as less than 7, 8 to 14, and 15+ days. Risk ratios of infection were estimated using generalized linear regression with a Poisson distribution. A separate regression model evaluated risk factors for infection using both the external fixation and non-external fixation tibial cohorts. Twenty-eight patients (32%) were treated for deep infection. The infection rate for closed fractures was 28% (11 of 39 patients) and for open fractures was 35% (17 of 49 patients) ( P = 0.56). Examining both tibial cohorts, external fixation (odds ratio [OR] = 2.39, P = 0.017), open fracture (OR = 3.13, P = 0.002), and compartment syndrome (OR = 2.58, P = 0.01) were all associated with infection in regression modeling. Median external fixation days for patients with deep infection was 8 days (Inter-quartile range, 3 to 18 days) as compared with 4 days (IQR, 2 to 9 days) in patients without infection ( P = 0.06). While controlling for open fractures, the 8- to 14-day group had RR = 1.81 ( P = 0.2), and the 15+-day group had RR = 2.67 ( P = 0.003) as compared with the <7-day group. Infection rates of tibial fracture patients treated with external fixation and converted to IMN were high. Surgeons should strongly consider the necessity of external fixation for these fractures. Earlier conversion of external fixation to definitive fixation reduced infection rates. Level IV-case series.

Significant Factors of High Performance Outcomes for Tibial Plafond Fractures.

Limited research exists about high performance postsurgical tibial plafond fractures. This study aimed to identify aspects of the plafond fracture injury and care associated with "high performance" based on Patient Reported Outcome Measurement Information System (PROMIS) Physical Function (PF) scores. Tibial plafond fracture patients with minimum 12-month follow-up treated at a level 1 trauma center from 2006 to 2019 were categorized into high (top 25%) vs average-low (AL) (bottom 75%) performers based on PROMIS PF scores. Demographics and fracture characteristics of high and AL performers were compared. Variables with a P value less than .1 were used in stepwise logistic regressions. The final cohort of 198 patients was divided into high (n=51) and AL (n=147) performers based on PF scores. The mean PF scores for the high and AL groups were 58 (SD=5.3) and 41.9 (SD=6.5), respectively. The mean PROMIS Pain Interference scores for the high performers and AL were 43.3 (SD=4.9) and 56.8 (SD=8.6) (P < .001), respectively. FAAM activities of daily living (high 95.4 [SD=5.5] vs AL 70.4 [SD=19.8], P < .001) and FAAM sports (high 76.8 [SD=21.3] vs AL 27.3 [SD=28.9], P < .001) subscale scores were significantly greater in the high-performing group. Sex, age, marital status, and diabetes were nonsignificant factors in univariate analysis. Significant demographic factors associated with high performance from univariate analysis were Caucasian race, private insurance, no tobacco use, lower body mass index (BMI), and mechanism of injury. Patients with fracture characteristics of OTA 43C (complete articular) fractures, bone loss, open fractures, or nonexcellent reduction were significantly less likely to be high performers. Additionally, less than excellent reductions were more common in more complex fracture patterns. Multivariable regression modeling showed that higher BMI, OTA/AO 43-C (complete articular) fracture classification, and open fracture were significant independent risk factors for reducing likelihood of high performance. Significant independent factors associated with high performance after tibial plafond fracture are lower BMI, closed fracture, and OTA/AO 43-B (partial articular) fracture.