Risk factors for deep infection in secondary intramedullary nailing after external fixation for open tibial fractures

BACKGROUND: Risk factors for deep infection in secondary intramedullary nailing (IMN) after external fixation (EF) for open tibial fractures were investigated by multivariate analysis following univariate analyses. METHODS: Forty-two open tibial fractures were treated with secondary IMN after EF. The open tibial fractures were classified according to the criteria proposed by Gustilo et al.: type II, 11; type IIIA, 8; type IIIB, 22 and type IIIC, 1. Locked IMNs with limited reaming were performed in 27 patients, and locked IMNs without reaming in 15 patients. The following factors contributing to deep infection were selected for analysis: age, gender, Gustilo type (II or III), fracture grade by AO type (A or B+C), fracture site, existence of multiple trauma (Injury Severity Score, ISS<18 or ISS> or = 18), existence of floating knee injury, debridement time (< or = 6 h or > 6 h), reamed (R) versus unreamed (UR) nailing, duration of external fixation (< or = 3 weeks or >3 weeks), interval between removal of EF and IMN (< or = 2 weeks or >2 weeks), skin closure time (< or = 1 week or >1 week), existence of superficial infection (+ or -) and existence of pin tract infection (+ or -). The relationship between deep infection and the above factors was evaluated by univariate analyses. RESULTS: Seven (16.7%) of the 42 open tibia fractures developed deep infections. All deep infections occurred in Gustilo type III (22.6%, 7/31). Only the skin closure time was a significant factor affecting the occurrence of deep infection on the present analysis (p = 0.006). CONCLUSION: The present evaluation showed that early skin closure within 1 week is the most important factor in preventing deep infections when treating open tibial fractures with secondary IMN after EF.     

Intramedullary nailing for open fractures of the femoral shaft: evaluation of contributing factors on deep infection and nonunion using multivariate analysis

The purpose of this study was to use multivariate analysis to evaluate contributing factors affecting deep infection and nonunion of open femoral fractures treated with locked intramedullary nailing (IMN). We examined 89 open femoral fractures (88 patients) treated with immediate or delayed locked IMN in static fashion at the Kitasato University Hospital from 1988 to 2001. Multiple regression models were derived to determine predictors of deep infection and nonunion. The following predictive variables of deep infection were selected for analysis: age, sex, Gustilo type (I+II or III), fracture grade by AO type (A or B+C), fracture site (proximal site+distal site or middle site), timing or method of IMN, reamed or unreamed nailing (R versus UR), debridement time (< or =6 h or >6 h), existence of polytrauma (ISS<18 or ISS> or =18), and existence of floating knee injury (+ or -). The predictive variables of nonunion selected for analysis were the same as those for deep infection, with the addition of deep infection (+ or -). Five fractures (5.6%) developed deep infections: one Gustilo type II and four type III. Multivariate analysis revealed that only Gustilo type significantly correlated with occurrence of deep infection (p<0.05). Nonunion occurred in 12 fractures (14.1%). Multivariate analysis revealed that only fracture grade by AO type significantly correlated with occurrence of nonunion (p<0.02).     

The ortho-plastic management of Gustilo grade IIIB fractures of the tibia in children: A systematic review of the literature

Background

The challenges of managing Gustilo IIIB tibial fractures in children are unique. A multi-disciplinary, evidence based approach is needed. We aimed to evaluate the evidence for the ortho-plastic management of Gustilo grade IIIB open tibial shaft fractures in children based on a review of all published data in order to rationalise the orthopaedic and plastic surgical approach to these complex injuries.

Method

A systematic review of the literature was performed. Gustilo grade IIIB tibial shaft fractures in pre-adolescent and adolescent children were identified and evaluated with regard to both the skeletal and soft tissue management, and the outcome.

Results

Of 54 children with grade IIIB tibial fractures, a mean union time of 31 weeks included 33 weeks for 42 adolescents and 23 weeks for 12 pre-adolescents. Faster union time in pre-adolescents tended towards significance. Delayed union occurred in 22%, nonunion in 13%, mostly in adolescents. Two of 45 covered by vascularised flaps and 3 of 9 treated without flaps developed deep infection (p = 0.028). There was no correlation between method of skeletal fixation and union time.

Conclusion

Gustilo IIIB tibial shaft fractures in pre-adolescents tended towards faster healing with fewer complications, irrespective of the method of skeletal fixation. In adolescents, healing times were similar to adults. Soft tissue closure without flaps was associated with deep infection in one-third of patients, requiring debridement and flap cover. Adequate debridement and flap cover is suggested in all cases, irrespective of age.     

Management of open fractures of the tibial shaft in multiple trauma

Background:

The work presents the assessment of the results of treatment of open tibial shaft fractures in polytrauma patients.

Materials and Methods:

The study group comprised 28 patients who underwent surgical treatment of open fractures of the tibial shaft with locked intramedullary nailing. The mean age of the patients was 43 years (range from 19 to 64 years). The criterion for including the patients in the study was concomitant multiple trauma. For the assessment of open tibial fractures, Gustilo classification was used. The most common concomitant multiple trauma included craniocerebral injuries, which were diagnosed in 12 patients. In 14 patients, the surgery was performed within 24 h after the injury. In 14 patients, the surgery was delayed and was performed 8–10 days after the trauma.

Results:

The assessment of the results at 12 months after the surgery included the following features: time span between the trauma and the surgery and complications in the form of osteomyelitis and delayed union. The efficacy of gait, muscular atrophy, edema of the operated limb and possible disturbances of its axis were also taken under consideration. In patients operated emergently within 24 h after the injury, infected nonunion was observed in three (10.8%) males. These patients had grade III open fractures of the tibial shaft according to Gustilo classification. No infectious complications were observed in patients who underwent a delayed operation.

Conclusion:

Evaluation of patients with open fractures of the tibial shaft in multiple trauma showed that delayed intramedullary nailing performed 8–10 days after the trauma, resulted in good outcome and avoided development of delayed union and infected nonunion. This approach gives time for stabilization of general condition of the patient and identification of pathogens from wound culture.     

Incidence of infection after early intramedullary nailing of open tibial shaft fractures stabilized with pinless external fixators

Background:

A major drawback of conventional fixator system is the penetration of fixator pins into the medullary canal. The pins create a direct link between the medullary cavity and outer environment, leading to higher infection rates on conversion to intramedullary nailing. This disadvantage is overcome by the AO pinless fixator, in which the trocar points are clamped onto the outer cortex without penetrating it. This study was designed to evaluate the role of AO pinless fixators in primary stabilization of open diaphyseal tibial fractures that received staged treatment because of delayed presentation or poor general condition. We also analyzed the rate of infection on early conversion to intramedullary nail.

Materials and Methods:

This study is a retrospective review of 30 open diaphyseal fractures of tibia, which were managed with primary stabilization with pinless fixator and early exchange nailing. Outcome was evaluated in terms of fracture union and rate of residual infection. The data were compared with that available in the literature.

Results:

All the cases were followed up for a period of 2 years. The study includes Gustilo type 1 (n=10), 14 Gustilo type 2 (n=14), and type3 (n=6) cases. 6 cases (20%) had clamp site infection, 2 cases (6.7%) had deep infection, and in 28 cases (93%) the fracture healed and consolidated well.

Conclusion:

This study has highlighted the valuable role of pinless external fixator in the management of open tibial fractures in terms of safety and ease of application as well as the advantage of early conversion to intramedullary implant without the risk of deep infection.     

Intramedullary nailing versus proximal plating in the management of closed extra-articular proximal tibial fracture: a randomized controlled trial

BackgroundExtra-articular proximal tibial fractures account for 5–11 % of all tibial shaft fractures. In recent years, closed reduction and minimally invasive plating and multidirectional locked intramedullary nailing have both become widely used treatment modalities for proximal and distal tibial metaphyseal fractures. This study was performed to compare plating and nailing options in proximal tibia extra-articular fractures.ResultsPostoperative hospital stay (p = 0.035), time to full weight-bearing, and union time (p = 0.004) were significantly less in the IMN group than in the PTP group, but there was no clear advantage of either technique in terms of operative time (p = 0.082), infection rate (p = 0.738), range of motion of the knee (p = 0.462), or degrees of malunion and nonunion.ConclusionBoth implants have shown promising results in extra-articular proximal tibial fractures, and provide rigid fixation that prevents secondary fracture collapse.

Level of evidence

Level 2, randomized controlled trial.     

Treatment of distal tibial shaft fractures by three different surgical methods: a randomized,prospective study

Purpose

A few studies focused on the methods of treatment for displaced distal tibial shaft fractures have been published, all of which compared two different methods. In this randomized, prospective study, we aimed to compare minimally invasive plate osteosynthesis, locking intramedullary nail stabilization and external fixation combined with limited open reduction and absorbable internal fixation for distal tibial shaft fractures by assessing complications and secondary procedures.

Methods

From November 2002 to June 2012, 137 skeletally mature patients with displaced distal tibial shaft fractures with or without fibula fracture were randomized to be treated by minimally invasive plate osteosynthesis (group A, n = 46), locking intramedullary nail (group B, n = 46) or external fixation combined with limited open reduction and absorbable internal fixation (group C, n = 45). Age, gender, mechanism of injury, fracture pattern and presence of open fracture were equally distributed among the three groups. Indexes for evaluation included hospital stay, operative time, time to radiographic union, union status, infection and the incidence of re-operation. Mazur ankle score was introduced for functional evaluation. Statistics Analysis System (SAS) 9.2 was used for analysis.

Results

A total of 121 patients were included in the final analysis (group A 42, group B 40 and group C 39) and evaluated after a mean of 14.8 months follow-up. There was no significant difference (P > 0.05) in hospital stay, time to radiographic union and the incidence of union status among the three groups. Although group C was associated with less secondary procedures versus groups A and B, it was related with more pin tract infections (15.4 %). Anterior knee pain occurred frequently after locking intramedullary nailing (37.5 %) and the irritation symptoms were more frequently encountered in group A (59.5 %). There was no difference in ankle function between the three methods after operation (P > 0.05).

Conclusions

We consider that the minimally invasive plate osteosynthesis, locking intramedullary nail stabilization and external fixation combined with limited open reduction and absorbable internal fixation techniques are all efficient methods for treating distal tibia fractures. With its wide indications, external fixation combined with limited open reduction and absorbable internal fixation leads to minimal soft tissue complication, good functional result and no local soft tissue irritation or implant removal.     

Minimally Invasive Plate Osteosynthesis for Open Fractures of the Proximal Tibia

Background

Relatively few studies have addressed plate osteosynthesis for open proximal tibial fractures by now. The purpose of this study was to assess the results of minimally invasive plate osteosynthesis (MIPO) for open fractures of the proximal tibia.

Methods

Thirty-four patients with an open proximal tibial fracture were treated by MIPO. Thirty of these, who followed for over 1 year, constituted the subject of this retrospective study. According to the AO Foundation and Orthopaedic Trauma Association (AO-OTA) classification, there were 3 patients of type 41-C, 6 of type 42-A, 8 of type 42-B, and 13 of type 42-C. In terms of the Gustilo and Anderson''s open fracture grading system, 11 patients were of grade I, 6 were of grade II, and 13 were of grade III (III-A, 6; III-B, 6; III-C, 1). After thorough debridement and wound cleansing, when necessary, a soft tissue flap was placed. Primary MIPO (simultaneous plate fixation with soft tissue procedures) was performed in 18 patients, and staged MIPO (temporary external fixation followed by soft tissue procedures and subsequent conversion to plate fixation after soft tissue healing) was performed in 12 patients. Results were assessed according to the achievement and time to union, complications (including infections), and function of the knee joint using Knee Society scores. Statistical analysis was performed to identify factors influencing results.

Results

Primary union was achieved by 24 of the 30 study subjects. Early bone grafting was performed in 6 cases with a massive initial bone defect expected to result in non-union. No patient had malalignment greater than 10°. The mean Knee Society score was 88.7 at final follow-up visits, 23 patients achieved an excellent result, and 7 a good result. There were 3 superficial and 5 deep infections, but none required early implant removal. Functional results were similar for primary and staged MIPO (p = 0.113). Fracture pattern (p = 0.089) and open fracture grade (p = 0.079) were not found to influence the results.

Conclusions

If soft tissue coverage is adequately performed, MIPO could be regarded as an acceptable method for the treatment of open proximal tibial fracture.     

Taylor spatial frame in the treatment of open tibial shaft fractures

Background:

The Taylor spatial frame (TSF) is a modern multiplanar external fixator that combines the ease of application and computer accuracy in the reduction of fractures. A retrospective review of our prospective TSF database for the use of this device for treating open tibial fractures in pediatric, adolescent, and adult patients was carried out to determine the effectiveness and complications of TSF in the treatment of these fractures.

Materials and Methods:

Nineteen male patients with open tibial fractures were included. Of these fractures, 10 were Gustilo Type II, five were Gustilo Type IIIA (two had delayed primary closure and three had split thickness skin grafting), and four were Gustilo Type IIIB (all had rotational flaps). Twelve of our patients presented immediately to the emergency room, and the remaining seven cases presented at a mean of 3 months (range, 2.2-4.5 months) after the initial injury. The fractures were located in proximal third (n=1), proximal/middle junction (n=2), middle third (n=3), middle/distal junction (n=8), distal third (n=3), and segmental fractures (n=2). Patients were of an average age of 26 years (range, 6-45years). Mean duration of follow-up was 3.5 years.

Results:

All fractures healed over a mean of 25 weeks (range, 9-46 weeks). All were able to participate in the activities of daily living without any difficulty and most were involved in sports during the last follow-up. Postoperative complications included pin tract infection in 12 patients.

Conclusion:

The TSF is an effective definitive method of open tibial fracture care with the advantage of early mobilization, ease of soft tissue management through gradual fracture reduction, and the ability to postoperatively manipulate the fracture into excellent alignment.     

Early unreamed intramedullary nailing without a safety interval and simultaneous flap coverage following external fixation in type IIIB open tibial fractures: a report of four successful cases

The conversion method from external fixation (EF) to intramedullary nailing (IMN) for open tibia fractures, especially to Gustilo type IIIB open tibia fractures, have potentially high risk of infections. We document a report of a more progressive approach in four consecutive cases of type IIIB open tibial fractures successfully managed with early unreamed IMN without a safety interval and simultaneous flap coverage following EF. The mean patients age at the time of injury was 43.8 years (range 23-64 years), and three patients were male. The timing from EF to IMN without safety interval combined with well-vascularised flap (free latissimus dorsi flaps in two patients and pedicled soleus flaps in two patients) ranged 48 to 72 hours. Average time to union was 14 months (range 9-21 months). There was one nonunion patient whose fracture healing was gained by reamed IMN without bone grafting. However, there were no infections. The functions in all patients were satisfactory. This early unreamed IMN without a safety interval and with simultaneous flap coverage following EF is a useful and effective option for treating type IIIB open tibial fractures.     

Time to Initial Debridement and wound Excision (TIDE) in severe open tibial fractures and related clinical outcome: A multi-centre study

BackgroundRecent national (NICE) guidelines in England recommend that initial debridement and wound excision of open tibial fractures take place within 12 h of the time of injury, a change from the previous target of 24 h. This study aims to assess the effect of timing of the initial debridement and wound excision on major infective complications, the impact of the new guidance, and the feasibility of adhering to the 12 h target within the infrastructure currently existing in four major trauma centres in England.MethodsA retrospective review was performed of Gustilo-Anderson grade 3B open tibial fractures presenting acutely to four Major Trauma Centres (MTCs) in England with co-located plastic surgery services over a ten-month period. The incidence of deep infective complications was compared between patients who underwent initial surgery according to the new NICE guidance and those who did not. Patients warranting emergency surgery for severely contaminated injury, concomitant life-threatening injury and neurovascular compromise were excluded. Multi-variable logistic regression analysis was performed to assess the effect of timing of surgical debridement on development of deep infective complications.Results112 patients with 116 fractures were included. Six fractures (5.2%) developed deep infective complications. 38% (n = 44) underwent primary debridement within 12 h and 90% within 24 h. There was no significant difference in the incidence of major infective complications if debrided in less than or greater than 12 h (4.5% vs 5.6%, p = 1.00). Logistic regression found no significant relationship between timing of wound excision and development of deep infection. There was no significant decrease in mean time to debridement following introduction of new national guidance (13.6 vs 16.1 h) in these four MTCs.ConclusionOverall, the rate of deep infection in high energy open tibial fractures managed within the four major trauma centes is low. Achieving surgical debridement within 12 h is challenging within the current infrastructure, and it is unclear whether adhering to this target will significantly affect the incidence of severe infective complications. Debridement within 24 h appears achievable. If a 12-h target is to be met, it is vital to ensure dedicated orthoplastic capacity is adequately resourced.     

Utilization of the less-invasive stabilization system internal fixator for open fractures of the proximal tibia: A multi-center evaluation

Background:

Locked plating has become popular and has clear biomechanical advantages when compared with conventional plating. When combined with minimally invasive surgical techniques, locked plating may cause substantially less iatrogenic tissue damage when compared with conventional plating. These characteristics may make locked plating an attractive option for treating open fractures of the tibial plateau and proximal tibia for which coverage over the plate can be obtained. The purpose of this study was to evaluate the use of the Less-Invasive Stabilization System (LISS) for high-energy open fractures involving either the tibial plateau or proximal tibia.

Materials and Methods:

This study is a retrospective evaluation of a consecutive multicenter series of 52 consecutive patients operated by seven surgeons, who used LISS plating in open proximal tibia or tibial plateau fractures seen at one of four Level I Trauma Centers. All patients were treated using a locked plating system that was implanted using minimally invasive submuscular surgical techniques. The primary outcome measure was the incidence of deep and superficial infection.

Results:

Fifty-two patients with open fractures have been evaluated, with a mean follow-up of 16.8 (12–36) months. Three patients (5.8%) developed deep infections. Two patients (6.3%) with tibial plateau and one (4.3%) of patients with a tibial shaft fracture developed deep infections. Fifteen patients required flap coverage of their open wounds. The incidence of deep infection as per Gustilo and Anderson classification was Type I and II – 0 (0%); Type IIIA – 2 (7.7%); Type IIIB – 1 (7.1%); and Type IIIC – 0 (0%).

Conclusions:

Biomechanically, the LISS functions as an “internal-external fixator” rather than a plate. Traditional plate osteosynthesis has yielded rates of infection between 18% and 35%. Our data indicate that locked plating using minimally invasive techniques yield deep infections rates that are no worse than published series using intramedullary nails or external fixators. Technical difficulties that can be encountered with the LISS system revolve primarily around obtaining and maintaining reduction while performing a minimally invasive procedure. Additional difficulties can include “cold welding” of screws to the plate and malposition of the plate leading to failure in the diaphysis. High-energy open fractures involving the tibia shaft or plateau remain high-risk injuries, but LISS is an acceptable alternative for treatment of these fractures.     

Soft tissue coverage in open fractures of tibia

Background:

The treatment of Gustilo Anderson type 3B open fracture tibia is a major challenge and it needs aggressive debridement, adequate fixation, and early flap coverage of soft tissue defect. The flaps could be either nonmicrovascular which are technically less demanding or microvascular which has steep learning curve and available only in few centers. An orthopedic surgeon with basic knowledge of the local vascular anatomy required to harvest an appropriate local or regional flap will be able to manage a vast majority of open fracture tibia, leaving the very few complicated cases needing a free microvascular flap to be referred to specialized tertiary center. This logical approach to the common problem will also lessen the burden on the higher tertiary centers. We report a retrospective study of open fractures of leg treated by nonmicrovascular flaps to analyze (1) the role of nonmicrovascular flap coverage in type 3B open tibial fractures; (2) to suggest a simple algorithm of different nonmicrovascular flaps in different zones and compartment of the leg, and to (3) analyze the final outcome with regards to time taken for union and complications.

Materials and Methods:

One hundered and fifty one cases of Gustilo Anderson type 3B open fracture tibia which needed flap cover for soft tissue injury were included in the study. Ninety four cases were treated in acute stage by debridement; fracture fixation and early flap cover within 10 days. Thirty-eight cases were treated between 10 days to 6 weeks in subacute stage. The rest 19 cases were treated in chronic stage after 6 weeks. The soft tissue defect was treated by various nonmicrovascular flaps depending on the location of the defect.

Results:

All 151 cases were followed till the raw areas were covered. In seven cases secondary flaps were required when the primary flaps failed either totally or partially. Ten patients underwent amputation. Twenty-two patients were lost to followup after the wound coverage. Out of the remaining 119 patients, 76 achieved primary acceptable union and 43 patients went into delayed or nonunion. These 43 patients needed secondary reconstructive surgery for fracture union.

Conclusion:

open fracture of the tibia which needs flap coverage should be treated with high priority of radical early debridement, rigid fixation, and early flap coverage. A majority of these wounds can be satisfactorily covered with local or regional nonmicrovascular flaps.     

Dynamic osteosynthesis by modified Kuntscher nail for the treatment of tibial diaphyseal fractures

Background:

We evaluated a series of diaphyseal fractures of the tibia using low-cost, Indian-made modified Kuntscher nail (Daga nail) with the provision of distal locking screw for the management of the tibial diaphyseal fractures.

Materials and Methods:

One hundred and fifty one consecutive patients with diaphyseal fractures of tibia with 151 fractures who were treated by Daga nail were enrolled. One of the patients who had died because of cancer, and the two patients who were lost to follow-up at 3 months were excluded from the study.Therefore data of 148 patients with one hundred and fortyeight fractures is described. One hundred twenty closed fractures, 20 open Grade I fractures, and eight open Grade II fractures as per Gustilo and Anderson classification were included in this study. One hundred fourteen men and 34 women, with a mean age of 38.4 years, were studied. The result were analysed for Surgical time, duration of hospitalisation, union time, union rate, complication rate, functional recovery and crutch walking time. The fractures were followed at least until the time of solid union.

Results:

The follow-up period averaged 15 months (range, 6–26 months). Union occurred in 140 cases (94.6%). The mean time to union was 13 weeks for closed fractures,17.8 weeks for Grade I open fractures, and 21.6 weeks for Grade II open fractures. Compartment syndrome occurred in two patients. Superficial infection occurred in five cases of Grade I and II compound fractures. Three closed fractures and one case of Grade I compound fracture required bone grafting for delayed union. Two cases of Grade II compound fracture with nonunion required revision surgery and bone grafting. Twelve cases resulted in acceptable malalignment due to operative technical error. In four cases, the distal screw breakage was seen, but none of these complications interfered with fracture healing. Recovery of joint motion was essentially normal in those patients without knee or ankle injury.

Conclusion:

Unreamed distally locked dynamic tibial nailing (modified Kuntscher nail/Daga nail) can produce excellent clinical results for diaphyseal tibial fractures. It has the advantages of technical simplicity, minimal cost, user-friendly instrumentation, and a short learning curve.     

Open fractures of the tibia in children.

We describe the results of treatment of open tibial fractures in 92 children; 22 fractures were Gustilo type I, 51 type II and 19 type III. All children received tetanus prophylaxis, systemic antibiotics for 48 hours and thorough debridement and irrigation of the wound. Fifty-one wounds with minimal soft-tissue injury were closed primarily. The other 41 were initially left open; of these, 18 small wounds were allowed to heal secondarily and 23 larger wounds required split skin grafts or soft-tissue local or microvascular free flaps. Stable fractures were reduced and immobilised in an above-knee plaster cast (71%) and external fixation (28%) was used for unstable fractures, extensive soft-tissue injury and multiple injuries. Short-term complications included compartment syndrome (4%), superficial infection (8%), deep infection (3%), delayed union (16%), nonunion (7.5%) and malunion (6.5%): these incidences are similar to those reported in adults. Selective primary closure of wounds did not increase the incidence of infection. External fixation was associated with a greater occurrence of delayed and nonunion than plaster immobilisation, but this technique was used most often for the more severe injuries. Late review, at 1.5 to 9.8 years, showed a high incidence of continuing morbidity including pain at the healed fracture site (50%), restriction of sporting activity (23%), joint stiffness (23%), cosmetic defects (23%) and minor leg-length discrepancies (64%). Open tibial fractures in children are associated with a high incidence of early and late complications, which are more frequent in children with Gustilo type III injuries. The Gustilo classification was a useful guide for predicting the outcome and planning treatment.     

Intramedullary nailing versus external fixation in Gustilo type III open tibial shaft fractures: a meta-analysis of randomised controlled trials

Open tibial shaft fractures are the most common of long-bone open fractures. Management of the fracture is either by intramedullary nailing (IMN) or by external fixation (EF). Since the literature does not indicate clearly which is more effective, a meta-analysis was conducted to establish which approach is more suitable to treat Gustilo type III fractures. MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE and CINAHL databases were searched for randomised controlled trials (RCT) describing IMN and EF treatment of Gustilo type III fractures. As of 15 November 2012, five RCT involving 239 patients had been published; the outcomes examined in this study are their surgical complications. Data analysis led complications to be grouped into infection, fracture healing problems (non-union, malunion) and “other complications” (vascular injury, revision surgery, soft tissue damage, mechanical failure and tibial malalignment). IMN was associated with lower rates of infection and fracture healing problems; the differences between the two approaches for “other complications” were not significant. The data indicate that IMN is the treatment of choice for Gustilo type III fractures.     

Open distal tibial shaft fractures: a retrospective comparison of medial plate versus nail fixation

Purpose

Studies comparing open reduction internal fixation (ORIF) vs. intramedullary nailing (IMN) for distal tibia shaft fractures focus upon closed injuries containing small patient series with open fractures. As such, complication rates for open fractures are unknown. To characterize complications associated with ORIF vs. IMN, we compared complications based on surgical approach in a large patient series of open distal tibia shaft fractures.

Methods

Through retrospective analysis at an urban level I trauma center, 180 IMN and 36 ORIF patients with open distal tibia fractures from 2002 to 2012 were evaluated. Patient charts were reviewed to identify patient demographics, fracture grade (G), patient comorbidities, and postoperative complications including nonunion, malunion, infection, hardware-related pain, and wound dehiscence. Fisher’s exact tests compared complications between ORIF and IMN groups. Multivariate regression identified risk factors with statistical significance for the development of a postoperative complication.

Results

One hundred and eighty IMN (G1 22, G2 79, and G3 79) and 36 ORIF (G1 10, G2 16, and G3 10) patients were included for analysis. ORIF patients had a higher rate of nonunion (25.0 %, n = 9) compared with IMN patients (10.6 %, n = 20, p = 0.03). No additional complication had a significant statistical difference between groups. Multivariable analysis shows only surgical method influenced the development of complications: ORIF patients had 2.52 greater odds of developing complications compared with IMN patients (95 % CI 1.05–6.02; p = 0.04).

Conclusions

ORIF leads to higher rates of nonunion and significantly increases the odds of developing a complication compared with IMN for open distal tibia fractures. This is the first study investigating complication rates based on surgical approach in a large cohort of patients with exclusively open distal tibia fractures.

     

Soft tissue management of children's open tibial fractures �C a review of seventy children over twenty years

INTRODUCTION

The management of open tibial fractures in children represents a unique reconstructive challenge. The aim of the study was to evaluate the management of paediatric open tibial fractures with particular regard to soft tissue management.

PATIENTS AND METHODS

A retrospective case-note analysis was performed for all children presenting with an open tibial fracture at a single institution over a 20-year period for 1985 to 2005.

RESULTS

Seventy children were reviewed of whom 41 were males and 29 females. Overall, 91% (n = 64) of children suffered their injury as a result of a vehicle-related injury. The severity of the fracture with respect to the Gustilo classification was: Grade I, 42% (n = 29); Grade II, 24% (n = 17); Grade III, 34% (n = 24; 7 Grade 3a, 16 Grade 3b, 1 Grade 3c). The majority of children were treated with external fixation and conservative measures, with a mean hospital in-patient stay of 13.3 days. Soft tissue cover was provided by plastic surgeons in 31% of all cases. Four cases of superficial wound infection occurred (6%), one case of osteomyelitis and one case of flap failure. The limb salvage was greater than 98%.

CONCLUSIONS

In this series, complications were associated with delayed involvement of plastic surgeons. Retrospective analysis has shown a decreased incidence of open tibial fractures which is reported in similar studies. Gustilo grade was found to correlate with length of hospital admission and plastic surgery intervention. We advocate, when feasible, the use of local fas-ciocutaneous flaps (such as distally based fasciocutaneous and adipofascial flaps), which showed a low complication rate in children.     

Predisposing factors for early infection in patients with open fractures and proposal for a risk score

BackgroundThe primary goals of orthopedic treatment of open fractures are to prevent infection, stabilize bone injury and restore limb function. The objective of the current study was to identify risk factors associated with infection in patients suffering from open fractures, using the strength of association of these factors to propose a score that enables risk stratification in initial care.ResultsThirty-one patients out of 122 were infected (25.4 %). Infection was significantly associated with exposure time up to 24 h (mean 30.3 h; p = 0.007). Fractures classified as Gustilo III had a greater chance of infection (74.2 %; p = 0.042), especially type IIIB (41.9 %). Fractures classified as Tscherne II and III had a greater chance of infection (48.4 and 25.8 %, respectively; p = 0.001).ConclusionsIt was possible to show that the exposure time and the types of fracture classified as Gustilo III and Tscherne II and III are associated with the outcome of infection. It was also possible to create a risk score (IRS) for predicting infection in these types of fractures, which can be used in the initial care of the patient, with a sensitivity of 0.840, specificity of 0.544, cut-off of 6.5 and area under the curve of 0.709 (p = 0.002).

Level of evidence

Level III.     

Obesity is associated with increased postoperative complications after operative management of tibial shaft fractures

ObjectivesTo assess the association of obesity and postoperative complications after operative management of tibial shaft fractures.MethodsPatients who underwent operative management of a tibial shaft fracture were identified in a national database by Current Procedural Terminology (CPT) codes for: (1) open reduction and internal fixation (ORIF) and (2) intramedullary nailing (IMN) procedures in the setting of International Classification of Diseases, Ninth Revision (ICD-9) codes for tibial shaft fracture. These groups were then divided into non-obese, obese, and morbidly obese cohorts using ICD-9 codes. Each cohort was then assessed for grouped complications within 90 days, removal of implants within 6 months, and nonunion within 9 months postoperatively. Odds ratios and 95% confidence intervals were calculated.ResultsFrom 2005 to 2012, 14,638 patients who underwent operative management of tibial shaft fractures were identified, including 4425 (30.2%) ORIF and 10,213 (69.8%) IMN. Overall, 1091 patients (7.4%) were coded as obese and 820 (5.6%) morbidly obese. In each operative group, obesity and morbid obesity was associated with a substantial increase in the rate of major and minor medical complications, venous thromboembolism, infection, procedures for implant removal, and nonunion.ConclusionsIn patients who undergo either ORIF or IMN for tibial shaft fractures, obesity and its related medical comorbidities are associated with significantly increased rates of postoperative medical complications, infection, nonunion, and implant removal compared to non-obese patients.