Treatment Of Open Tibial Fractures Research Articles

Prevalence and Associated Factors of Nonunion in Open Tibial Shaft Fracture among Patients Treated with External Fixation in Tibebe Ghion Specialized Hospital

Background: The definitive treatment of open tibial shaft fractures remains challenging and nonunion after treatment of open tibial shaft fractures with external fixation complicates a significant proportion of cases. There are varying rates of occurrence of nonunion and the prevalence is not well known in Ethiopia. The objective of the study is to assess the prevalence and associated factors of nonunion in open tibial shaft fractures treated with EX FIX in TGSH. Methods: The study was conducted using a cross-sectional study in patients with open tibial shaft fractures who were admitted and treated with external fixation in the Tibebe Ghion Specialized Hospital orthopedics department from January 1, 2019, to January 29, 2021. The study involved 75 patients, which was the total number of cases in the study period and fulfilled the inclusion criteria. Bivariate and multiple variable logistic regression analyses were used to analyze the association between variables. The degree of association between variables was determined at the p-value of <0.05. Results: The overall prevalence of nonunion in open tibial shaft fractures treated with external fixation in TGSH was 21.3%. The severity of the injury, presence of wound infection, and treatment factors affect the occurrence of nonunion. It occurs in 9 of 19 (47.4%) Gustilo-Anderson grade IIIB fractures and 6 of 48 (12.5%) Gustilo-Anderson grade IIIA fractures. A delay in soft tissue covering of Gustilo-Anderson grade IIIB fracture of 15 days or more increases the nonunion rate to 72.7%. Nonunion occurred in 41.7% of cases with SSI and 11.8% of cases without SSI. Gustilo-Anderson grade (AOR=4.85, CI 95%: 1.31-18.01), surgical site infection (AOR=4.12, CI 95%: 1.11-15.26), and time until coverage of bone of Gustilo-Anderson grade IIIB fracture (AOR=18.23, CI 95%: 1.17-284.8) have statistically significant association with nonunion. Conclusion and Recommendation: External fixation use for definitive treatment of open tibial fractures should be disfavored as the prevalence of nonunion in open tibial shaft fractures treated with EX FIX is higher than other previous studies done in European and Asian countries. Gustilo-Anderson grade of injury, surgical site infection, and time from injury to bone coverage of Gustilo-Anderson grade IIIB fractures were found to be statistically significantly associated with the occurrence of nonunion. Therefore, attention should be given to early soft tissue reconstruction of exposed bones to establish a favorable environment for bone healing and to make treatment with internal fixations possible. Better management of wounds to minimize surgical site infections is required for better healing of open tibial shaft fractures. Prospective studies are also recommended on the issue.

A review of 10 patients treated with the masquelet technique and microsurgical technique combined for Gustilo type III open tibial fractures

BackgroundOpen tibial fractures often include severe bone loss and soft tissue defects and requires complex reconstructive operations. However, the optimal treatment is unclear.MethodsThis retrospective study enrolled patients with Gustilo type III open tibial fractures from January 2018 to January 2021 to assess the clinical utility of Masquelet technique together with microsurgical technique as a combined strategy for the treatment of open tibial fractures. The demographics and clinical outcomes including bone union time, infection, nonunion and other complications were recorded for analysis. The bone recovery quality was evaluated by the AOFAS Ankle-Hindfoot Scale score and the Paley criteria.ResultsWe enrolled 10 patients, the mean age of the patients and length of bone defects were 31.7 years (range, 23–45 years) and 7.5 cm (range, 4.5–10 cm) respectively. Bone union was achieved for all patients, with an average healing time of 12.2 months (range, 11–16 months). Seven patients exhibited a bone healing time of less than 12 months, whereas 3 patients exhibited a bone healing time exceeding 12 months. No significant correlation was found between the length of bone loss and healing time. In addition, no deep infection or nonunion was observed, although 2 patients experienced wound fat liquefaction with exudates and 1 patient presented with a bloated skin flap. The average AOFAS Ankle-Hindfoot Scale score was 80.5 (range, 74–85), and all patients were evaluated as good or exellent based on the Paley criteria.ConclusionsOur study indicated that the use of the Masquelet technique and the microsurgical technique as a combined strategy is safe and effective for the treatment of Gustilo type III open tibial fractures.

The Applicability of Dynamic External Fixator in a Prospective Evaluation of Open Tibial Fracture Treatment.

This prospective study assessed the clinical and radiological outcomes of open tibia fractures treated with a dynamic external fixator. Twenty-five patients underwent surgical debridement and stabilisation with a dynamic external fixator between November 2016 and April 2022. Regular follow-up evaluated bone healing progression. Favourable outcomes were demonstrated in 20 patients. However, there were three cases of non-union, two of which subsequently deformed, and two cases of pin site-related infection. There were no fracture site infections. This study demonstrates the use of dynamic external fixation in the treatment of open tibia fractures. The low incidence of complications suggests its effectiveness and potential. Bezerra BS, Araujo TA, Cardonia GG, et al. The Applicability of Dynamic External Fixator in a Prospective Evaluation of Open Tibial Fracture Treatment. Strategies Trauma Limb Reconstr 2024;19(1):36-39.

Clinical and radiographic outcomes of negative pressure wound therapy combined with polymethylmethacrylate sealant for wound management of Gustilo type III open tibia fractures.

This study aimed to introduce a new wound management method combining negative pressure wound therapy and polymethylmethacrylate sealant for Gustilo type III open tibia fractures and to evaluate its clinical outcomes. Among 186 patients who visited our institution for the treatment of open tibia fractures between January 2016 and December 2019, 20 male patients who sustained Gustilo type III open tibia fractures and were compelled to undergo delayed flap coverage using negative pressure wound therapy combined with polymethylmethacrylate sealant due to initial critical condition were enrolled in this study. We retrospectively investigated patients' demographics, interval between the injury and flap coverage, number of negative pressure wound therapy changes, flap survival, bone union time, and infection-induced complications. The mean interval from injury until flap coverage was 27.8 (range, 8-63) days. Most soft-tissue defects were reconstructed using free flaps (14/20, 70%); the anterolateral thigh flap was the most frequently used flap (12/20, 60%) in this study. Among 20 flaps trans- ferred, 16 flaps (80%) survived uneventfully, 1 flap (5%) developed partial necrosis, and 3 flaps (15%) failed. The mean follow-up period was 22.7 (range, 12- 43) months. A total of 17 patients (85%) achieved tibia fracture union. The mean bone union time was 31 (range, 12-81) weeks. With regard to infection-induced complications, 3 patients (15%) developed osteomyelitis and no patient showed superficial surgical site infection. Combination therapy using negative pressure wound therapy and polymethylmethacrylate sealant serves as a useful and reliable therapeutic strategy for wound management of Gustilo type III open tibia fractures, especially when delayed soft-tissue recon- struction is unavoidable. Corresponding author: Yoo Joon Sur yoojoon@catholic.ac.kr Content of this journal is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. Level IV, Therapeutic Study.

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

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

A novel primary antibiotic cement-coated locking plate as a temporary fixation for the treatment of open tibial fracture

Complex lower extremity trauma reconstruction remains a challenge. This study used an internal fixation composite structure of antibiotic cement plates as a temporary fixation to treat lower extremity Grade III open fractures; thus, reducing the treatment period and complications of external fixation. We aimed to assess the safety and efficacy of this technique in the initial surgery stage. Between January 2018 and March 2021, 20 patients with Gustilo grade IIIB/C open fractures received an antibiotic cement-coated locking plate as a temporary internal fixator during initial surgery. Thorough debridement and temporary internal fixation were performed with a 3.5-mm system antibiotic cement-coated locking plate. Ten patients required free bone fragment removal, followed by bone cement packing. The final stage involved internal fixation and wound repair with a free anterolateral thigh flap. Clinical and imaging results were retrospectively analysed. The repair time ranged 1–7 days. All flaps survived. Two patients experienced wound infection, and one developed severe bone infection 3 months after three-stage bone graft surgery. Autologous cancellous bone grafting was performed on 10 patients with bone defects 6 weeks after surgery. Bone union was universally achieved after 1 year. This method proved safe and effective, successfully repairing Grade III open fractures of the lower extremity 1–7 days post-treatment.

Updated Meta-Analysis of Randomized Controlled Trials Comparing External Fixation to Intramedullary Nailing in the Treatment of Open Tibial Fractures.

Background: The purpose of this study was to collect all available randomized controlled trials (RCT) on the treatment of open tibial fractures with an external fixator (EF) and intramedullary nailing (IMN) for meta-analysis to provide reliable evidence-based data for clinical decision-making. Material and methods: The systematic review was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and AMSTAR (Assessing the Methodological Quality of Systematic Review). An electronic search of PubMed, Cochrane Library, and Web of Science was performed until 1 March 2023 to identify RCTs which compared either IMN or EF to fix the open tibial fracture. Outcome measures were: postoperative superficial and deep infection, time to union, delayed union, malunion, nonunion and hardware failure. In addition, pain and health-related quality of life were evaluated after 3 and 12 months of follow-up. Results: Sixteen publications comprising 1011 patients were included in the meta-analysis. The pooled results suggested that the IMN technique had a lower postoperative superficial infection and malunion rate (RR = 3.56, 95%CI = 2.56-4.95 and RR = 1.96, 95%CI = 1.12-3.44, respectively), but higher hardware failure occurrence in contrast to EF (RR = 0.30; 95%CI = 0.13-0.69). No significant differences were found in the union time, delayed union or nonunion rate, and postoperative deep infection rate between the treatments. Lower levels of pain were found in the EF group (RR = 0.05, 95%CI = 0.02-0.17, p < 0.001). A difference in quality of life favoring IMN after 3 months was found (RR = -0.04, 95%CI = -0.05-0.03, p < 0.001), however, no statistical difference was found after 12 months (RR = 0.03, 95%CI = -0.05-0.11, p = 0.44). Conclusions: Meta-analysis presented reduced incidence rates of superficial infection, malunion, and health-related quality of life 3 months after treatment in IMN. However, EF led to a significant reduction in pain and incidence rate of hardware failure. Postoperative deep infection, delayed union, nonunion and health-related quality of life 12 months following therapy were similar between groups. More high-quality RCTs should be conducted to provide reliable evidence-based data for clinical decision-making.

Comparative study of open fractures of tibia (Interlocking v/s External fixator)

: Open/Compound fractures of tibia are the most common type of fracture to occur following road traffic accidents; however, sports injury, fall from height can also frequently produce these fractures. Open fractures of tibia (Type 3B) are quite challenging to treat, with respect to associated soft tissue injury and the decision for type of implant to be used by an orthopaedic surgeon. The decision making is based on the wound condition, the amount of muscle and soft tissue damage, type of fractures, and availability of equipments. This study was undertaken to evaluate the most optimal method for the management of compound fractures of tibia vis a vis comparing reamed tibia interlocking nail and external fixator in the management of type 3b compound fractures of tibia.Controversy exists over whether the use of external fixation or tibial intramedullary nailing is optimal for the treatment of open tibial fractures. The aim of this study was to compare clinical outcomes in terms of postoperative infection, malunion, delayed union, nonunion and hardware failure between these two treatment methods. : The study was undertaken in the Department of Orthopedics, Goa Medical College. The study involved both male and female patients with open fractures of tibia, (Gustillo and Anderson, Type 3B). This was a prospective study conducted from month of September 2017 onwards. Hundred patients who had compound fracture of tibia (Type 3B) were evaluated. The patients were followed-up for duration of 6 to 10 months (Average 8 months).Detailed analysis of function of the patient was done on the basis of following criteria by Johner and Wruh.: The study conducted on 100 patients, who suffered from compound fracture tibia (Type 3b), it was reported that patients who were operated with reamed tibia interlocking nail had better outcome and decreased morbidity, as compared to patients treated with external fixator.

Treatment Outcome of Open Tibial Shaft Fractures in A Teaching Hospital in Ghana

Background: Objective of this prospective study is to report results of treatment of open tibia fractures in Korle-Bu Teaching Hospital Accra Ghana.Patients and Methods: In this prospective study 47 patients were considered over a 6-month period from February 2012 to July 2012, and each patient was however followed up for at least 3 months. Treatment of these fractures was guided by the unit protocol.Results: Out of the 47 patients, 35 (74%) had a good outcome and 12 (26%) had complications.Conclusion: The results of treatment of open fracture of tibia in this study are encouraging (with 74% of patients having a good outcome). Considering that three decades ago an open fracture of the tibia in Ghana had the common fate of surgical Amputation, Sepsis and Death. Further improvements in treatment of these fractures with early antibiotics, Debridement and irrigation andmodern stabilization methods are recommended.

Functional and radiological outcome of primary fixation of compound tibial fractures with LRS and antibiotic beads: A prospective case series

Open fractures are more common in tibia than in any other long bones due to its distal location and less soft tissue envelope. The conventional goals for treatment of open tibial fractures include prevention of infection, soft tissue coverage, and fracture stabilization leading to union. LRS (limb reconstruction system) considered as a definitive treatment option, as it offers rigid fixation of fracture fragments and allows early weight bearing and reduces economic burden for patients. In this study, we are using antibiotic beads (as the local prophylactic device to prevent future infection) along with Limb Reconstruction System (LRS) to allow for the aseptic union of fracture while the patient is mobile throughout the period of treatment and without the requirement of another surgery.

TO EVALUATE THE OUTCOME OF ELASTIC NAILING ALONG WITH EXTERNAL FIXATOR IN OPEN TIBIA FRACTURES

Background: Open tibial fractures account for over 40% of all open fractures and are frequently accompanied by significant damage to soft tissues, including skin, muscle, and neurovascular structures . This article presents a intramedullary(TENS)- and external fixator technique. The purpose of this study is TO EVALUATE THE OUTCOME OF ELASTIC NAILING ALONG WITH EXTERNAL FIXATOR IN OPEN TIBIA FRACTURES . Materials and Methods: Following ethical approval, thirty patients with tibial fractures were treated by the EF-TENs system between NOVEMBER 2019 and SEPTEMBER 2021. The follow-up studies included clinical and radiographic examinations. All relevant outcomes were recorded during follow-up. Results: All 30 patients were assessed by follow-ups. According to the Anderson-Gustilo classification, there were 19 Type Grade II, 6 Type Grade IIIA and 5 Type Grade IIIB. All thirty patients were achieved follow-ups. All follow-up fractures united at last, but delayed union was observed in 5/30 patients. The average union time is 23.83+_4.47 weeks (range, 18–32 weeks). The main complication mentioned in this study was pin track infection, which occupied 6/30 cases. According to Johner–Wruhscriteriaof tibial shaft fractures, 19 fractures had excellent, 5 had good, 5 had fair and 1 had poor results. Conclusion: This study indicated that the outcome of elastic nailing along with external fixator , as a definitive intra- and extramedullary fixation technique, which was effective in treatment of open tibial fractures.

Clinical characteristics and cost-effectiveness of intramedullary nail and plate for the treatment of open tibial fractures

To analyze clinical characteristics and cost-effectiveness of different final surgical options for treating patients with open tibial fractures. A retrospective analysis was conducted by enrolling 55 surgically treated patients with open tibial fractures from January 2018 to June 2019. All the patients were categorized in intramedullary nailing (IMN) group and locking compression plate(LCP) group according to the final fixation option. There were 35 cases in group IMN including 27 males and 8 females, aged from 25 to 69 years old with an average of (49.0±10.6) years old. Based on Gustilo-Anderson classification, there were 1 case of typeⅠ, 19 cases of typeⅡand 15 cases of type Ⅲ. There were 20 cases in group LCP including 15 males and 5 females, aged from 46 to 72 years old with an average age of (53.4±14.7) years old. Based on Gustilo-Anderson classification, there were 2 cases of typeⅠ, 11 cases of typeⅡand 7 cases of type Ⅲ. Preoperative waiting time, surgical debridement times, intraoperative bleeding loss, blood and albumin transfusion, operation time, bacterial cultures and complications, bone union time, Johner-Wruhs criteria at 1 year after operation and total cost within 1 year after surgery between two groups were compared. The variables recorded between two groups were statistically analyzed and compared respectively, then the factors affecting hospital costs were evaluated by univariate and multiple linear regression analysis respectively, finally the cost-effectiveness analysis was performed. Total 55 patients were enrolled with an average follow-up time of(16.4±7.1) months ranged from 14 to 27 months postoperatively. There were no significantly statistical differences of the demographic materials between the two groups. The intraoperative bleeding loss were(243.18±118.82) ml and (467.86±490.53) ml respectively in group IMN and LCP, the significantly statistical difference was discovered(P<0.05). The surgical duration were(247.50±57.94) min and(350.00±178.77) min respectively in group IMN and LCP, the significantly statistical difference was discovered(P<0.05). There were no significantly statistical differences of the average days before operation, surgical debridement times, received blood and albumin transfusion, wound cultures, complications and bone union time between the two groups(P>0.05). The univariate analysis of the factors affecting the hospital costs indicated that patients with smoke or alcohol (P=0.042), high energy damage (P=0.012), patients with comorbidity diseases(P=0.045), surgical debridement over 2 times (P=0.001), intraoperative bleeding loss over 400 ml (P<0.001), blood and albumin transfusion (P=0.027), wound cultures (P=0.000) and complications (P=0.035) were the factors. The multiple linear regression analysis demonstrated the smoke or alcohol using[β=-0.256, t=-2.628, 95%CI(-29 667.09, -4 997.47), P=0.014] was the only factor affecting the total cost. The excellent and good rate were 80% and 85% respectively based on the Johner-Wruhs criteria. The average total cost within 1 year after surgery was (136 435.90±39 093.98) CNY in group IMN and (140 034.62±56 821.12) CNY in group LCP. The total surgical duration and total intraoperative bleeding loss were significant lower in group IMN than in group LCP. The average total costs of was significantly higher. The average cost for every 1% of excellent and good rate was 1 705.45 CNY in group IMN and 1 647.46 CNY in group LCP. Each 1% increasing of excellent and good rate cost 719.74 CNY more in group LCP compared with group IMN. Both IMN and LCP could provide a satisfactory outcome for open tibial fractures. Meanwhile considering the total cost, patients with smoke or alcohol history, traffic accident, comorbidity diseases, surgical debridement over 2 times, intraoperative bleeding loss over 400 ml, and complications should not be ignored.

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.

Efficacy of Staged Surgery in the Treatment of Open Tibial Fractures with Severe Soft Tissue Injury and Bone Defect.

PurposeWe aimed to report the clinical and radiological outcomes of staged surgery using the acute induced membrane technique with an antibiotic-impregnated cement spacer (ACS) and soft-tissue reconstructive surgery and to identify factors affecting clinical outcomes.Materials and MethodsThirty-two patients with severe open tibia fractures were treated via staged surgery from January 2014 to December 2019 and followed up for ≥1 year. In the first surgery, an ACS was inserted into the bone defect site along with debridement and irrigation and was temporarily fixed in place with an external fixator. The internal fixator was placed, and flap surgery and cement spacer changes were performed during the next surgery. In the third surgery, an autogenous bone graft was performed. Radiologic and functional results were investigated according to the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria, and factors affecting the ASAMI score were analyzed.ResultsThe average bone defect width was 43.9 mm, and the size of soft-tissue defect was 79.3 cm2 . Bone union was achieved in all cases except one and required 9.4 months on average. Complications occurred in 10 cases (31.2%). Good or better clinical effects, in terms of ASAMI radiologic and functional scores, were observed in 29 and 24 cases, respectively. Complications and additional surgery were common factors affecting the two scores.ConclusionStaged surgery using the acute induced membrane technique and soft-tissue reconstructive surgery is an efficacious treatment for open tibial fractures with bone defects.

Antibiotic-Coated Nail in Open Tibial Fracture: A Retrospective Case Series.

Implant-associated infections still represent one of the main problems in treatment of open fracture. The role of systemic antibiotic prophylaxis is now agreed and accepted; however, recent literature seems to underline the importance of local antibiotic therapy at the fracture site, and antibiotic nails have been shown to play a role in the treatment of open fractures in terms of fracture healing and lower risk of infection. We retrospectively analyzed our results, from January 2016 to March 2020, with the use of coated nails in the treatment of open tibial fractures, evaluating the rates of infection and fracture healing as primary outcomes and the rate of reoperations, time from trauma to nailing and hospital stay as secondary outcomes. Thirty-eight patients treated with coated nail (ETN ProtectTM, Synthes) were included in the study. Minimum follow-up was of 18 months. Thirty-four of 38 patients achieved bone union and 2 patients underwent septic non-union. In our series, no systemic toxicity or local hypersensitivity to antibiotics were recorded. From this study, use of antibiotic-coated nails appears to be a valid and safe option for treatment of open tibial fractures and prevention of implant-related infections, particularly in tibial fractures with severe soft tissue exposure and impairment.

Definitive fixation of open tibia fractures: Does reopening the traumatic wound increase complication rates?

BackgroundIt is unknown if surgical approach or use of previous traumatic wounds for open fracture instrumentation has an impact on patient complications or outcomes. This study sought to compare infection and nonunion rates in the staged treatment of open tibia fractures where the traumatic wound was reopened during definitive fixation versus when they were not. MethodsA retrospective review was performed on all patients at a single institution level 1 trauma center. All patients who had a minimum of 1 year clinical and radiographic outcomes were included. Primary outcome measures were incidence of infection and nonunion. Groups of patients were compared based on surgical approach for definitive fixation. ResultsA total of 96 patients were included – 48 patients received definitive treatment and wound closure during initial management of the open fracture (group 1), 22 patients had staged fixation through new incisions (group 2), and 26 patients had their traumatic wound reopened during definitive fixation (group 3). Rates of infection were 10.4%, 31.8% and 11.5% respectively (p = 0.15). Rates of nonunion were 20.8%, 27.3% and 30.8% (p = 1.0). No statistically significant differences in regards to primary outcomes were found between the staged fixation groups. Multiple logistic regression also showed no difference in infection or nonunion when controlling for known risk factors. ConclusionFor open tibia fractures that underwent staged fixation, no significant differences in infection or nonunion were observed between procedures that involved reopening the traumatic wound versus procedures performed through new incisions. The presence of a distal tibia periarticular fracture was found to be independently associated with infection risk.

Prophylactic use of antibiotic coated intramedullary nail in open tibia fractures

Background and Aim: Open fracture of tibia is one of the most common injuries seen in ortho pedic practice. The appropriate treatment of open tibial fractures is one of the priority problems in modern era of traumatology. Present study was done with an aim to assess functional and clinical outcome after intramedullary locking nail fixation of open fracture shaft of tibia. Material and Methods: This prospective study was conducted in the Department of Orthopaedics, Gujarat Adani Institute of Medical Science, Bhuj, Kutch, Gujarat, India. 40 patients were treated over a period of 16 months with gentamicin coated tibia interlocking nail after taking written and informed consent. Antibiotic coated tibia interlocking nail with property of sustained release of gentamicin was used. The coating contains combination of gentamicin and biodegradable polymeric carrier Poly. An average size nail carries 100 mg (1 mg/cm2) gentamicin drug. Radiological Union was assessed using RUST Score and clinical assessment results were graded as excellent, good, fair and poor. Results: The most common cause of injury was found to be due to road traffic accident. Fibula fracture was associated with 92.5% of patients. Time taken in wound healing in majority of patients was less than 5 weeks (45%). Majority of patents (47.5%) had RUST score 8 at six months of duration. Two cases got infected in this study and in one case there was non-union. Average duration of hospital stay was 15 days. Large numbers of patients had fair outcome 45%. Conclusion: In this study we showed that use of antibiotic coated nail to treat open tibial fracture was associated with an absence of deep wound infections. Antibiotic coated tibia interlocking nail is a good treatment option for open tibial fractures, yields good functional outcome with less complications in these fractures and should be used whenever indicated.

Delayed debridement of open tibia fractures beyond 24 and 48h does not appear to increase infection and reoperation risk.

Surgical debridement is critical to the treatment of open tibia fractures, although the effects of delayed debridement have not been well-established. Other factors such as Gustilo-Anderson type, prompt initiation of antibiotics, and time to definitive closure may be more predictive of infection than time to surgery. We sought to determine the effect of a prolonged delay to surgical debridement with respect to infection and reoperation rates for open tibia fractures. All open diaphyseal tibia fractures with > 12-week follow-up were evaluated. Patient demographics, Gustilo-Anderson type, and rates of deep infection and all-cause reoperation were recorded. Patients were divided into 3 groups based on time to surgery: early (< 24h), delayed (24-48h), and late (> 48h). Univariate and multivariate analyses were performed to evaluate the relationship between time to surgery, fracture type, infection, and reoperation. In total, 96 open tibia fractures with average follow-up of 59.3weeks and infection rate of 13.5% were included. Infection rates for the early, delayed, and late groups were 13.3%, 17.2%, and 9.1%, respectively (p = 0.70). Reoperation rates for the early, delayed, and late groups were 29.8%, 31.0%, and 22.7%, respectively (p = 0.80). The groups did not vary in proportion of Gustilo-Anderson fracture types; infection rates between Gustilo-Anderson types were similar (p = 0.57). Type IIIA-C fractures required more reoperations than other fracture types (p = 0.01). Delayed surgical debridement of open tibia fractures did not result in greater rates of infection or reoperation. Gustilo-Anderson classification was more predictive of reoperation, with Type IIIA-C injuries having a significantly higher reoperation rate.

A novel low-profile external skeletal fixator for type IIIB open tibial fractures: A biomechanical and clinical pilot study.

Although external fixator is standard for managing staged treatment of open tibial fracture, the main disadvantage of this device is too bulky to be tolerated by most patients for longtime use. The purposes of this pilot study were to compare the biomechanical properties of a novel low-profile external fixator (LP-ESF) with a traditional ESF and also to evaluate its performance in patients with Gustilo type IIIb tibial open fractures. A prospective clinical pilot study started from January 2015 to December 2017, and 18 patients with Gustilo type IIIb open tibial fractures underwent the fixation with a novel LP-ESF system. The biomechanical properties of the LP-ESF were compared with the Synthes External Fixation System according to the standard ASTM F1541-02. These patients were divided into two groups according to the size of bony defect. The postoperative clinical outcomes were subsequently collected. The biomechanical properties of the LP-ESF were comparable with those of Synthes External Fixation System and had an improved the axial/torsional stiffness and ultimate strength. In the clinical study, all patients with LP-ESF had fracture union. The duration of application of LP-ESF was 3.5 to 18 months until fracture union. In 10 of 18 patients, their fractures were immobilized with the LP-ESF until bone union, and no pin tract infection and no chronic osteomyelitis were recorded. The 36-Item Short Form Health Survey life quality and health survey were good to excellent in these patients. Notably, the LP-ESF allowed a patient with severe bone and soft-tissue defects to preserve the leg and joints function. In this study, we found that the novel LP-ESFs had improved clinical outcomes. The long-term LP-ESF application seems to be tolerable in our patients. This novel approach permits better controls in deep infection and faster healing of fractures, and thus may provide a viable alternative treatment for Gustilo type IIIb open tibial fractures.

Treatment of open tibia fractures in Sub-Saharan African countries : a systematic review

Open tibia fracture (OTF) treatment is well documented in developed countries. Yet, this fracture pattern remains challenging because it is associated with an increased risk of infection and delayed union, particularly in case of Gustilo III B and C open fractures. Since access to healthcare is limited in Sub- Saharan African countries, this paper explores the results of OTF management in this setting. A systematic review of the literature was conducted using current databases such as MEDLINE, Cochrane, EMBASE, PubMed, ScienceDirect, Scopus, and Google Scholar in order to identify prospective studies with cohorts of patients treated for OTF. Studies were included based on predefined inclusion and exclusion criteria. The quality of studies was analyzed by the Coleman Methodology Score (CMS). Eight papers met the inclusion criteria and had an average CMS of 70 (range 54-73). The most common treatment was non-operative management of the fracture with cast immobilization (67%). Gustilo Type II and III fractures were associated with a higher risk of complications. The infection rate was 30%. Malunion, chronic osteomyelitis and nonunion were observed in 14.5%, 12.3%, and 7% of the cases, respectively. More complications were observed with non-operative treatment (cast immobilization) than with surgical fixation. Although the surgical environment does not allow for internal fixation, poor results of non-operative management of open fractures should lead to the introduction of trainings on the proper use of external fixators. It is also advisable to support the development of locally produced external devices that utilize local source materials, which would make external fixation available at a reasonable cost.