Type IIIC Fractures Research Articles

Evaluation of The Treatment of Open Intercondylar Fracture Distal Femur by Transosseous Osteosynthesis Technique with Ilizarov External Fixator

Objectives: Treatment of Distal femoral fractures cannot be done following simple set of rules and when it is an open fracture the treatment is more difficult. Several methods were studied by different authors both at home and abroad, but none were conclusive. Methods: This prospective study was done between January 2011 to December 2012, 15 patients of the open intercondylar fractures of Distal femur were treated by transosseous osteosynthesis technique by Ilizarov External Fixator in NITOR (National Institute of Traumatology and Orthopaedic rehabilitation), Dhaka. 2 of the patients were not available for final follow up after removal of the fixator frame. So ultimately the final result based on the results of 13 Cases. Minimum 6 months follow up was done from the date of injury. No patient below age 16, no type IIIB or IIIC fractures and no patients having less than 6 months follow up were included in the study. Patients with severe injuries (Head injury, Abdomen and chest injury) were excluded from the study. Patients with medical illness such as Diabetes Mellitus, Peripheral Vascular diseases were not included in the study. Results: 12 male and 01 female patient between 16 and 56 years were studied. Most common age group in this series were 16-30 year age group (53.85%) and average age of the patients was 31.15 years. Most of the patients were male and road traffic accident was the leading cause of injury (92.31%). Right side involved in (69.23%) most of the cases. All patients were C3 type of fractures and G-II and G-IIIA types were same (38.46%). Most of the patients (53.85%) were operated within 1-2 weeks of admission. Average duration of hospital stay was 22 days ranging from 10 day to 45 days. Most of the patient had soft tissue healing by granulation tissue formation. Others were treated by primary closure, Delayed primary closure or secondary closure. Various complications were observed among them pintract infection, wire breakage, wire loosening, stiffness of joints, angulations and rotations, deep infection of the tissue, leg length discrepancy was observed in this study. According to the criteria of Neer et al, 1967 final results of the treatment were analyzed. Acceptable result was found in 61.54% of cases (Excellent 7.69% and good 53.85%). Results of the rest of 38.46% cases were not acceptable (Fair 23.08% and poor 15.38%). The result is similar with others done for open fractures of distal femur by Ilizarov External Fixator or other methods of fixation. Conclusion: So it can be concluded that transosseous osteosynthesis technique is a satisfactory method for treating open intercondylar fracture of distal femur as a primary and definite mode of treatment.

Does the OTA Open Fracture Classification Align With the Gustilo-Anderson Classification? A Study of 2215 Open Fractures.

To characterize the Orthopaedic Trauma Association Open Fracture Classification (OTA-OFC) and Gustilo-Anderson classification of open extremity fractures and determine if there is meaningful alignment between these grading systems. Retrospective case series. Level I academic trauma center. Adult patients with at least 1 operatively treated open extremity fracture and surgeon-assigned OTA-OFC and Gustilo-Anderson classification. Frequency, distribution, and association measures of OTA-OFC category scores and Gustilo-Anderson classification types. Two thousand twenty-seven patients (mean age, 43.1 ± 17.5 years) with 2215 fractures were included. Gustilo-Anderson type I or II fractures (n = 961; 43%) most frequently had the least severe scores for all OTA-OFC categories. Type IIIA fractures (n = 978; 44%) were most often assigned intermediate scores for OTA-OFC Bone Loss (n = 564; 58%). Type IIIB fractures (n = 204, 9%) were most often assigned intermediate OTA-OFC Skin scores (n = 120; 59%). Type IIIC fractures (n = 72; 3%) were most often assigned the most severe OTA-OFC Arterial score (n = 60; 83%). In the multivariable model, OTA-OFC Contamination scores showed little association (β = 0.05; 95% confidence interval [CI], 0.01-0.09) with Gustilo-Anderson classification severity. Conversely, higher OTA-OFC Arterial (β = 0.50; 95% CI 0.44-0.56) and Skin (β = 0.46; 95% CI, 0.40-0.51) scores were strongly associated with more severe Gustilo-Anderson classifications. OTA-OFC Contamination scores were weakly associated with Gustilo-Anderson classification severity for open fractures. The study findings suggest that the current Gustilo-Anderson classification does not adequately account for injury contamination, a known predictor of infection. Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of surgical treatment of the tibial tuberosity fractures in skeletally immature patients: an update.

Tibial tubercle fractures in adolescents are uncommon injuries which typically occur in 12-16year-old males involved in athletic activities. We hereby present our experience in the surgical treatment of such lesion. By reviewing all the tibial tuberosity fractures treated surgically at our institution between January 2012 and January 2016, we were able to identify 12 patients (14 fractures), of which 11 males and 1 female, whose average age at the time of the trauma was of 14.05. According to the Ogden classification, we identified two Type IIA fractures, one Type IIB fracture, one Type IIIB fracture, four Type IIIC fractures, four Type IVA fractures, one Type IVB fracture and one Type IVC fracture. All patients underwent surgical treatment-9 fractures ORIF (64.3%), 5 CRIF (35.7%)-and postsurgical immobilization in plaster cast for 15days, with a non-weight bearing period of approximately 4.7weeks. They all had a complete ROM recovery and returned to preinjury activities within 4.1months on average. The successful union of the fracture was observed in all patients, and no cases of meniscal lesions, compartment syndrome, infections, lower limb length discrepancy or axial deviations emerged at the minimum follow-up of 24months. After an average period of 11months and 2weeks (range 6.1-16.3), all patients underwent surgical implant removal. Our experience matches the outcomes described in the literature, therefore confirming the safety and effectiveness of this treatment.

Clinical efficacy of free flap in repairing Gustilo IIIB and IIIC fractures of tibia and fibula combined with soft tissue defects

Objective To investigate the clinical efficacy of free flap transplantation in repairing the Gustilo type IIIB and IIIC fractures of tibia and fibula combined with soft tissue defects. Methods A retrospective case series study was conducted on the clinical data of 46 patients who had Gustilo type IIIB and IIIC fractures of tibia and fibula with soft tissue defects admitted from June 2013 to January 2017. There were 34 males and 12 females, aged 1-67 years (mean, 39 years). The wound defect areas ranged from 6 cm×20 cm to 7 cm×38 cm. According to the Gustilo fracture classification, there were 31 cases of type IIIB and 15 cases of type IIIC. According to the AO fracture typing, there were five cases of type A, 23 type B, and 18 type C. All patients were repaired with free flap transplantation, among which 40 patients were treated with anterolateral thigh flap and six with latissimus dorsi flap. The areas of anterolateral thigh flap ranged from 6 cm×13 cm to 14 cm×32 cm, and those of the latissimus dorsi flap from 6 cm×22 cm to 7 cm×40 cm. Efficacy was evaluated by flap survival rate, complications, fracture healing time, lower limb function scoring system (LEFS), and skin flap function. Results All limbs were salvaged successfully. One case of total flap necrosis and eight cases of postoperative crisis occurred. After active exploration and treatment, three cases were seen distal local necrosis, and the total survival rate was 91%. Infection at the donor site was found in two cases. The complication incidence rate was 4%. All patients were followed up for 7-42 months, with an average of 19 months. The fracture healing time averaged 43.5 weeks, and the LEFS score averaged 54 points. According to the seven indexes of flap function, the results were excellent in 11 cases, good in 29 cases, fair in four cases, and poor in two cases, with an excellent and good rate of 87%. Conclusion Free flap transplantation can achieve satisfactory efficacy in treating Gustilo type IIIB and IIIC of tibia and fibula combined with soft tissue defects, with high limb salvage rate and good function recovery. Key words: Leg injuries; Fractures, open; Surgical flap

Plate fixation in the treatment of complex forearm open fractures

Objectives: We aimed to evaluate the safety and outcomes of plate-screw fixation used for the immediate treatment of type-IIIC open fractures of forearm bones with complex soft tissue injuries. Methods: A total of 22 patients (mean age: 31.6, range: 24-60) treated between 2004-2010 were retrospectively analyzed. All injuries resulted from high-energy traumas and fractures were classified using AO classification. All patients had vascular and nerve injuries, and four had skin defects associated with double fractures of the forearm. All patients were operated on within the first eight hours following injury. Six patients with comminuted fractures or with bone defects underwent primary bone grafting, and one patient was treated with shortening. Primary skin closure was achieved in 17 patients and three patients underwent immediate repair using skin grafts, while two patients were repaired with immediate transposition flaps. Bony unions, complications, and functional results via a DASH questionnaire were investigated. Results: Mean follow-up was 28 months (range: 14-70). In all patients, radius bone union was achieved. Two patients underwent a Sauve-Kapandji procedure, utilizing the fractured segment of the ulnar diaphysis as a graft for radius. In one patient, osteosynthesis was repeated after 6 months because of nonunion. Mean period to bony union was 4.59 months (range: 3-6). Superficial infection developed in three patients after the operation, and was resolved with antibiotic therapy. The mean DASH score after surgery was 25.6. Conclusion: In high nergy traumas of the upper extremity associated with complex injuries and Type-IIIC forearm fractures, severity of soft tissue injuries determined the functional results in patients, demonstrating it is possible to achieve a safe and efficient fixation with immediate plate-screw osteosynthesis.

The Management of Soft Tissue and Bone Loss in Type IIIB and IIIC Pediatric Open Tibia Fractures.

Type III B and C open tibia fractures in children pose a challenge to the orthopaedic surgeon. Limb salvage is the initial goal for the majority of patients, but managing soft-tissue defects and bone loss can be a challenge. The purpose of this study was to evaluate the use of circular external fixation in the management of these injuries. In this retrospective review, we examined children with type IIIB and IIIC open tibial fractures treated with circular external fixation and soft-tissue coverage between 1990 and 2010. Chart review included: mechanism and severity of injury, degree of bone and soft-tissue loss, technique and duration of external fixation, additional procedures, clinical and radiographic outcomes, and complications. Eight patients were identified whose average age at the time of injury was 10.4 years (range, 3.8 to 15.3 y). There were 7 type IIIB and 1 type IIIC fractures. All patients received free or rotational soft-tissue flaps. Average bone loss was 5.4 cm (range, 0 to 12 cm). Three techniques of circular external fixation were used, including: (1) static stabilization to allow for soft-tissue coverage and fracture healing, (2) acute shortening with plan for later limb lengthening, and (3) stabilization of the extremity for soft-tissue coverage and intended bone transport. Seven of 8 limbs were salvaged. Of those 7, all were followed to skeletal maturity and ambulating without assistive devices at final follow-up. Three patients had a clinically relevant leg-length discrepancy (≥2 cm). Four of 8 patients required secondary or contralateral procedures. Pediatric type IIIB and IIIC tibia fractures are limb-threatening injuries that require dynamic thinking and management as the bone and soft-tissue injuries evolve. We have proposed a general algorithm to guide the treatment of these severe injuries. In our experience, circular external fixation, in conjunction with this algorithm, provides the appropriate stability and environment for managing soft tissue and bone loss and can facilitate limb salvage. Level IV.

The role of an Ilizarov external fixator in the treatment of post-traumatic tibial nonunion in children

Background Tibial fractures are the third most common long bone fractures in children. Acutely, they can be treated conservatively with cast immobilization and also surgically with external fixation, plate, and screws' fixation or intramedullary implants. Post-traumatic tibial pseudoarthrosis as a complication is relatively uncommon in children. This article reports our experience with the use of the Ilizarov external fixator in the treatment of post-traumatic tibial nonunion in children. Patients and methods Between 2003 and 2010, 14 child with post-traumatic tibial nonunion were treated in our department. The ages of the patients ranged from 4 to 13 years (mean 8 years, 6 months). All patients had open physes at the time of injury. Twelve patients were boys and two were girls. Twelve fractures involved the diaphysis, where two were confined to the distal metaphysis. There were 10 open fractures. There were five type IIIA, four type IIIB, and one type IIIC fractures, according to the classification of Gustilo. Of the 14 patients, three had infected nonunion. In this study, stabilization with a bifocaI Ilizarov external fixator (acute shortening and compression at the nonunion site, and distraction osteogenesis of the tibia through metaphyseal corticotomy) was performed in all cases. Results The average duration of follow-up was 20 months (range 12-36). Union was achieved in all cases. Time to union ranged between three debridement of the nonunion site and only one bone to 9 months, with an average of 5.5 months. Six patients had a gap range of 2-4 cm after transport was grafted using an autogenous graft from the iliac crest. All the patients had almost equal leg lengths (leg-length discrepancy Conclusion Treatment of post-traumatic tibial nonunion in children by an Ilizarov external fixator is effective in restoring length, correcting alignment, and achieving solid bony union through a one-stage operation.

Timing of Wound Closure in Open Fractures Based on Cultures Obtained After Debridement

The timing of wound closure in open fractures has remained an inexact science. Numerous recommendations have been made for the management of these injuries regarding the optimal time to perform competent wound closure, with all advice based on subjective parameters. The purpose of this study was to determine the utility of a prospective protocol with use of wound cultures obtained after irrigation and debridement as a guide to the timing of wound closure following an open fracture of an extremity. Four hundred and twenty-two open fractures had emergency irrigation and debridement, fracture stabilization, and open wound management. Wound cultures were obtained for aerobic and anaerobic analysis following debridement. At forty-eight hours after debridement, patients were again returned to surgery. If the initial culture results were positive, a repeat irrigation and debridement was carried out, and additional cultures were obtained after debridement. This procedure was repeated, and the wound was not closed until negative culture results were achieved. Of the 422 open fractures, 346 were available for long-term follow-up. The overall deep infection rate was 4.3%. Gustilo Type-II fractures had a deep infection rate of 4%, and Type-III fractures had an infection rate of 5.7%. Type-III fractures demonstrated differences among the fracture patterns within this type, as infection developed in 1.8% of Type-IIIA injuries, 10.6% of Type-IIIB fractures, and 20% of Type-IIIC fractures. Fractures requiring multiple debridement procedures and those in patients with diabetes or an increased body mass index demonstrated higher rates of infection. With the numbers studied, fractures in which the wound was closed in the presence of positive cultures (a protocol breach) did not have a significantly increased risk of deep infection (p = 0.0501). The use of this standardized protocol was shown to achieve a very low rate of deep infection compared with historical controls. An increased number of irrigation and debridement procedures are required to achieve this improved outcome. Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Short-Term Outcomes of Severe Open Wartime Tibial Fractures Treated with Ring External Fixation

The treatment of complex open tibial fractures sustained in combat remains controversial. This study investigated the short-term outcomes of type-III tibial shaft fractures treated at our institution with ring external fixation. A retrospective review identified sixty-seven type-III tibial shaft fractures in sixty-five consecutive patients treated between April 2004 and January 2007. Of these, forty-five tibiae in forty-three patients received fracture fixation with ring external fixation. The cases of thirty-six patients, who received treatment for thirty-eight tibial shaft fractures to completion with a standardized protocol, were reviewed. A blast mechanism accounted for thirty-five injuries, and three injuries were from high-velocity gunshot wounds. There were twenty-one type-IIIA, thirteen type-IIIB, and four type-IIIC fractures. Rotational or free soft-tissue flap coverage was performed on fifteen patients. Eighteen patients received planned delayed bone-grafting, and nine had only bone morphogenetic protein placed at the fracture site at the time of final wound closure. All fractures healed with <5 degrees of malalignment. One patient underwent elective delayed amputation. The average time to union with frame removal was 221 days (range, 102 to 339 days). Treatment of severe open wartime tibial fractures with a protocol-driven approach to wound management and placement of ring external fixation can result in a low rate of complications and a relatively high rate of fracture union. Most complications can be successfully managed without frame removal.

A systematic review of outcomes and complications of reconstruction and amputation for type IIIB and IIIC fractures of the tibia.

The question of whether to recommend amputation or salvage after type IIIB and IIIC tibial fractures remains unanswered. The purpose of this study was to conduct a systematic review to derive evidence-based recommendations concerning primary amputation versus limb salvage for type IIIB and IIIC open tibial fractures. Articles from Medline, Cinahl, and Embase that met predetermined criteria were included. Outcomes of interest included length of hospital stay, complications, rehabilitation time, quality of life, limb function, pain, and return to work data. Pooling of statistical data was performed when possible. The authors reviewed 1947 articles, and 28 observational studies were included. Length of hospital stay was 56.9 days for salvage patients and 63.7 days for amputees. The most common complications after salvage attempt were osteomyelitis (17.9 percent), nonunion (15.5 percent), secondary amputation (7.3 percent), and flap failure (5.8 percent). Rehabilitation time for salvaged patients was reported as time to union (10.2 months) and time to full weight-bearing (8.1 months). Pain, quality of life, and limb function outcomes were assessed differently among studies and could not be combined. The proportion of patients who returned to work was 63.5 percent for salvage patients and 73 percent for amputees. The current literature offers no evidence to support superior outcomes of either limb salvage or primary amputation for type IIIB and IIIC tibial fractures. When outcomes are similar between two treatment strategies, economic analysis that incorporates cost and preference (utility) may define an optimal treatment strategy to guide physicians and patients.

Long Bone Fractures Caused by Penetrating Injuries in Terrorists Attacks

High-energy penetrating injuries are increasingly common in the civilian setting. During the years 2000 to 2003, more than 70 suicide bombing attacks occurred in Israel. These were characterized by high numbers of casualties, primarily caused by blast injuries. Injury caused by a blast can be either a primary blast effect of acceleration-deceleration of the blast wave or a secondary effect of metal fragments deliberately placed in explosives, causing severe penetrating injuries. The latter type of injury may result in severe open limb fractures. We identified and reviewed 91 patients with 117 long bone fractures caused by penetrating terror-related injuries treated in our institution during 2000 to 2003. The patients were divided according to the mechanism of injury, i.e., either gunshot injury or blast injuries; several parameters were compared. Patients in the blast injury group included more children and elderly patients than the gunshot injury group did. This group also had a significantly higher Injury Severity Score and a higher number of associated injuries, including multiple fractures and mortality. The treatment modalities for the fractures were similar for both groups, as was the fracture final outcome. Local soft tissue injury was more severe in the gunshot injury group, as demonstrated by a higher number of type IIIC fractures, as well as more nerve injuries. Terror attacks may produce several modes of severe penetrating injuries causing high-grade open fractures. These should be aggressively treated by physicians remaining cognizant of other systemic and general implications of such a severe trauma.

Microvascular Composite Tissue Transfer for the Management of Type IIIB and IIIC Fractures of the Distal Leg and Compound Foot Fractures

The publisher regrets a typographical error in the name spelled “Bassem El-Hassan” in the above article in Journal of Reconstructive Microsurgery, Volume 15, Number 7, 1999, p. 501. The corrected spelling appears above.

Is Staged External Fixation a Valuable Strategy for War Injuries to the Limbs?

High-energy weapons or blast injuries usually result in substantial tissue damage and are serious medical and public health problems. We report our experience with staged external fixation for war injuries to the extremities. Forty-seven patients with 64 high-energy limb fractures caused by war weapons were retrospectively reviewed. The fractures were associated with severe soft tissue damage. There were 14 Gustilo-Anderson Type IIIA fractures, 40 Type IIIB fractures, and 10 Type IIIC fractures. Soft tissue débridement followed by axial realignment of the fractured bones with immediate skeletal stabilization using the AO/ASIF unilateral tubular external fixator was performed on the day of admission. The primary tubular fixators were exchanged 5 to 7 days later for Ilizarov frames. Delayed primary closure, skin grafts, or flaps were used for soft tissue coverage. The mean followup was 40 months, and the Ilizarov/hybrid external fixator was the definitive treatment in all patients. Bone union was achieved at an average of 8 months in 58 (90.6%) fractures. Three patients had nonunions and one patient required an amputation. Two patients were lost to followup. Staged external fixation is a valuable strategy for treatment of war injuries to the extremities. Therapeutic study, Level IV. See the Guidelines for Authors for a complete description of levels of evidence.

Outcomes in Open Tibia Fractures: Relationship between Delay in Treatment and Infection

Emergent irrigation and debridement has been accepted as a mainstay of open fracture treatment. The purpose of this study was to evaluate the infectious outcome of open tibia fractures relative to the time from injury to operative irrigation and debridement. One hundred seventy-eight patients with 191 consecutive fractures were retrospectively reviewed. Of these, 103 patients with 106 fractures were available for this study, with an average follow-up of 10.23 months. Results revealed 21.7% type I fractures, 43.4% type II fractures, 16.0% type IIIa fractures, 11.3% type IIIb fractures, and 7.5% type IIIc fractures. Of all fracture types, 22.6% became infected and 5.7% went on to have osteomyelitis. The average time to treatment was not significantly different in infected versus noninfected fractures across fracture types. No infection occurred when the time to surgery was within 2 hours; however, no significant increase in infection was discovered with respect to patients treated after 6 hours compared with those treated within 6 hours. The results support the Gustilo grading system of open fractures as a significant prognostic indicator for infectious complication. We continue to support the emergent treatment of open tibia fractures.

Vascularized composite tissue transfers or open fractures with massive soft-tissue defects in the lower extremities.

From 1982 to 1998, we treated 39 patients with type IIIB and IIIC fractures in the lower extremities by vascularized composite tissue transfers. Thirty-four of the lesions affected the lower leg, and 5 the foot and ankle. The peroneal flap was used in 25 cases, the latissimus dorsi musculocutaneous flap in 12, the scapula flap in 1, and the gracilis muscle flap in 1. In cases with a peroneal flap transfer, 18 cases used osteocutaneous flap with a fibula. Postoperative circulatory disturbances resulted in revision surgery in 9 patients. Eventually, grafting was successful in 37 patients. In patients with a lower leg reconstruction, additional bone grafting was performed in 7 of 16 patients with cutaneous or musculocutaneous flap transfers. No patient with osteocutaneous flap transfers required an additional bone grafting. The mean periods between injury and time to bone union were 11.7 months in patients with cutaneous flap transfers, and 7.5 months in patients with osteocutaneous flap transfers.

Type III open tibial fractures in children

The management of open tibial fractures in children differs from that in adult patients. We present a retrospective study of Type III open fractures of the tibia in children treated in our facility.A total of 16 Type III open fractures of the tibia were retrospectively studied. Of the 16 fractures, 11 were Type IIIA fractures, three Type IIIB, and two Type IIIC, according to the classification of Gustilo et al. The average age of the patients was 7 years and 5 months (range, 4 to 13 years). Nine fractures were initially stabilized by external fixation, one by pinning, and six by external immobilization. The average follow-up period was 4 years.Infection occurred in four patients (two superficial and two “deep” infections). Three infections were successfully treated with antibiotics, re-debridement, split-thickness skin graft, and local skin flap. However, one Type IIIC fracture with osteomyelitis required an amputation because of circulatory failure associated with infection. The average time to union was 13.3 weeks (range 7 to 24 weeks). One defective nonunion was observed, and was treated by tibio-fibular synostosis. Three fractures healed with angular deformity of more than 10 degrees at the time of union. However, spontaneous correction and remodeling of the bone resulted in deformities of 10 degrees or less. Unfortunately, both of the Type IIIC fractures ultimately required secondary amputation.Overall, with the exception of one type IIIB case requiring tibio-fibular synostosis and two type IIIC cases needing amputations, the cases should positive outcomes. Aggressive wound irrigation and appropriate fracture management during initial treatment would prevent the complications of Type III open fractures in children.

Microvascular composite tissue transfer for the management of type IIIB and IIIC fractures of the distal leg and compound foot fractures.

Patients who sustain high-energy, compound fractures with severe contamination and soft tissue loss, face high rates of delayed union, nonunion, infection and, in some instances, amputation. The authors reviewed 18 patients with compound foot fractures and IIIB and IIIC tibial fractures. All patients were treated by early free-flap coverage and simultaneous bone reconstruction. Corticocancellous bone grafting, composite osteocutaneous free flaps, or bone transport techniques were utilized, as required. Bony union was achieved in all cases; rehabilitation and return to work occurred within 12 to 18 months, with no major complications. The authors believe that the reconstruction ladder usually followed should be altered in certain cases in which severe periosteal stripping and soft-tissue contamination necessitate distant free composite tissue transfer, particularly those cases involving the distal third of the leg and foot. Simultaneous reconstruction is superior to other methods of wound management in providing early coverage of extensive wounds, a barrier against bacterial contamination, prevention of osteomyelitis, and enhanced union of the fractures.

前腕開放骨折の検討

Between 1986 and 1997, 28 forearm open fractures were treated at the Tamana Central Hospital. The fracture type was classified according to Gustilo et al.: 2 type I, 14 type II, 6 type III-A, 3 type III-B, and 3 type III-C fractures. All fractures were treated surgically within 6 hours. Immediate internal fixation was performed for 17 fractures, and 8 fractures were treated with delayed fixation. The rate of infection in this series was 7.1%. All fractures showed bony union eventually. One type II patient and 1 type III-C had delayed union, and bone graft and replating were added for these patients. The fracture of the type I and type II cases, healed in an average of 90 days, and that of type III, in an average of 162 days. Patients were clinically evaluated according to a rating system based on fracture union and pronation-supination of the forearm (Grace and Eversmann). Ninety-two per cent (11) of the type II fractures showed excellent or good results and 1 poor. Sixty per cent (6) of the type III fractures showed excellent or good results and 5 fractures acceptable or poor. Patients, except type III-C fractures, had good functional results.

The functional outcome of lower-extremity fractures with vascular injury.

Salvage of lower-extremity Gustilo type IIIC fractures is difficult, time-consuming for the patients and physicians, and not universally successful because of poor functional outcomes. Even if successful with limb salvage, the functional result may be unsatisfactory because of mutilating injuries to muscle and nerve, bone loss, and the presence of chronic infection. From July 1991 until July 1994, revascularizations of open IIIC fractures were attempted for wounds with Mangled Extremity Severity Score (MESS) < or = 10. The functional results were evaluated at 2 years after injury. Thirty-six lower-extremity revascularizations were performed on 34 patients, including 1 patient with bilateral distal tibial IIIC fractures and a child with IIIC femoral fracture accompanied by ipsilateral distal tibial amputation. Excluded were patients with below-ankle IIIC fractures as well as patients who underwent immediate amputation at admission. After the revascularization, seven patients with IIIC fractures (7 of 36, 19.4%) underwent secondary amputation within 1 week. At the 2-year follow-up, the overall secondary amputation rate was 25% (9 of 36) and the salvage rate was 75% (27 of 36). Those were no deaths. Of the 29 salvaged limbs among these 27 patients, 23 limbs (23 of 29, 79.3%) required secondary coverage procedures that included 12 free flap transfers (12 of 29, 41.4%). Every patient needed subsequent reconstructive surgery to achieve an acceptable functional result. In this series, MESS was able to predict the secondary amputation rate and the functional result. Sixteen of the 17 limb-salvaged patients with MESS < or = 7 were able to achieve minimal functional requirements, whereas 3 of the 10 patients with MESS = 8 to 10 failed to achieve minimal functional requirements at the 2-year follow-up. Using statistical analysis, we found that the salvaged limbs with MESS < or = 9 exhibited a significant difference in achieving adequate function compared with limbs with MESS > 9. Using our protocol for treatment for IIIC fractures, the threshold for immediate amputation can be raised from MESS = 7 to MESS = 9. Our conclusions are (1) more severely injured limbs have poor functional results, (2) every patient needs subsequent reconstructive surgery, and (3) the MESS may be helpful in decision-making.

Arterial injury in the lower limb from blunt trauma.

The present study was performed to identify the factors associated with amputation in patients with blunt injuries to the lower limb associated with arterial injury. The ability of a scoring system to predict the outcome was tested. There were 122 lower limb arterial injuries in 119 patients treated at the Royal Adelaide Hospital in the years 1962-1994. Prognostic factors considered were the site of the injury, the severity of the soft-tissue injury and shock, the presence of associated injuries and a description of the bone or joint injury. The mangled extremity severity score (MESS) was calculated retrospectively for each patient. The outcome was primary amputation in 27 patients, delayed amputation in 36 patients and limb salvage in 59 patients. The seven deaths were all due to associated injuries. Factors associated with amputation were the severity of shock and soft-tissue injury (P < 0.01), and tibial artery injury compared with more proximal injury (P < 0.001). Factors that did not affect outcome included delay before repair, method of fracture fixation, or performance of fasciotomy. Amputation was performed in 48/71 (68%) patients with Gustilo type-IIIC fractures of the tibia. Applying the MESS to our patients resulted in a positive predictive value (PPV) of 71%, a negative predictive value (NPV) of 84% and an overall accuracy of prediction of 75%. The major factor determining outcome was the severity of the soft-tissue injury. Progressive necrosis and infection was a major cause of late amputation. The MESS is not sufficiently precise to allow the decision regarding amputation to be made at the initial operation.