Pedestrian tibial injuries

From August 1980 through May 1984, 102 adult pedestrian patients with 130 tibial fractures were admitted to the Shock Trauma Center of the Maryland Institute for Emergency Medical Services Systems. We reviewed their records for admission status, procedures performed, and results: 32 patients who died, underwent primary amputation, or were lost to followup were excluded, leaving 70 patients with 86 tibial fractures as the base study group. We grouped the data by year of admission and analyzed it in terms of the effects of changes in the treatment protocol on results, specifically the time to union. For the first year, the existing treatment protocol included: antibiotics, debridement and irrigation with a bulb syringe, stabilization according to wound size and surgeon preference, split-thickness skin graft, and bone grafting in response to delayed or nonunion. The average time to union for Grade III fractures was 58.39 weeks; average time overall was 53.95 weeks. In the fourth year, the altered treatment protocol included: antibiotics, debridement and jet lavage, scheduled rebridement, external fixation for open fractures, judicious use of open reduction/internal fixation for closed fractures, early free flap soft-tissue coverage, and early bone grafting by history and fracture pattern. The average time to union for Grade III fractures was 37.65 weeks; average time overall was 34.46 weeks. From the first to the fourth year, time to union for Grade III fractures decreased by 64.5% and time to union overall decreased by 63.9%. We feel the decrease is a direct result of early bone grafting, the fixator construct used, and judicious use of open reduction/internal fixation.     

Early prophylactic bone grafting of high-energy tibial fractures

Fifty-three high-energy tibial fractures treated with early prophylactic posterolateral bone grafting were retrospectively reviewed. The bone-grafting procedures were performed at a mean of ten weeks following injury and at a mean of eight weeks following soft-tissue coverage. Ninety-six percent of the fractures had associated injuries with a mean injury severity score of 20.9. Seventy-nine percent of the fractures were classified as Grade III open fractures, and 40% had bone loss greater than 50% of the cortical circumference. Ninety-six percent of the fractures healed at a mean time of 43 weeks after injury. Segmental bone loss and soft-tissue injury requiring flap coverage were the best predictors of prolonged time to union. Comparison with a matched historical control group of tibial fractures not receiving early bone grafts revealed a mean reduction in time to union of 11.7 weeks (p = 0.03). The incidence of chronic osteomyelitis was 1.9%. These results are attributed to early and repeated aggressive debridement, immediate rigid external fixation, early soft-tissue coverage, and early posterolateral bone grafting. Recommendations include posterolateral cancellous bone grafting two weeks following wound closure by delayed primary closure, split-thickness skin graft, or local rotational myoplasty. A six-week delay following freely vascularized soft-tissue coverage prior to bone grafting is suggested.     

Acute unreamed intramedullary nailing and soft tissue reconstruction with muscle flaps for the treatment of severe open tibial shaft fractures

BACKGROUND: The treatment of open tibial shaft fractures remains controversial. Important considerations in surgical management include surgical timing, fixation technique and soft tissue coverage. This study was performed to evaluate the results of acute surgical debridement, unreamed nailing and soft tissue reconstruction in the treatment of severe open tibial shaft fractures. PATIENTS AND METHODS: During a 10-year period between January 1993 and July 2002, 927 tibial shaft fractures were treated with interlocking intramedullary nails. Among them, there were 19 consecutive patients with Gustilo type IIIB to IIIC open tibial shaft fractures with extensive soft tissue injury needing a muscle flap coverage and being suitable for intramedullary nailing. All 19 patients were called for a late follow-up which was conducted with a physical examination and a radiographic and functional outcome assessment. The radiographs were reviewed to determine the fracture healing time and the final alignment. RESULTS: All 19 open fractures with severe soft tissue injury healed without any infection complications. The fractures united in a mean of 8 months. Nine patients had delayed fracture healing (union time over 24 weeks). One of these patients needed exchange nailing, one patient autogenous bone grafting and dynamisation on the nail and seven patients needed dynamisation of the nail before the final fracture healing. In all patients, the alignment was well maintained. However, seven patients had shortening of the tibia by 1-2 cm and two of them also external rotation of 10 degrees . The functional outcome was good in 18/19 patients. INTERPRETATION: Acute surgical debridement, unreamed interlocking intramedullary nailing and soft tissue reconstruction with a muscle flap appear to be a safe and effective method of treatment for Gustilo type IIIB open tibial shaft fractures.     

Open fractures of the lower limb in Nigeria

During an 18-month period we studied prospectively 63 consecutive patients (42 males, 21 females) with an open fracture of the lower limb. Their mean age was 32 years (range: 4-78 years) and 58 patients with 59 fractures were available until the conclusion of the study. Forty-seven had tibial fractures, 12 had femoral fractures and the majority of the patients were either students or traders. According to Gustilo and Anderson's grading, 21 fractures were of type II and 16 of type IIIA. On arrival all the wounds were irrigated and debrided and the patients also received tetanus prophylaxis and intravenous antibiotics. Of the 47 tibial fractures 39 were managed with an above-knee plaster of Paris cast which was windowed so as to allow wound care. Of the 12 femoral fractures ten were treated with skeletal traction on a Bohler frame. The time taken for soft tissue healing was not significantly different between the tibial and femoral fractures. There were, however, significant differences with respect to (1) the time interval between injury and debridement, (2) the incidence of wound infection, (3) the occurrence of osteomyelitis, (4) fracture union time, and (5) time spent in hospital. The most common complications were wound infections (27 cases) and delayed union (26 cases). The time interval between injury and wound debridement was a major prognostic factor.     

Reamed nailing of Gustilo grade-IIIB tibial fractures

Reamed intramedullary nailing was carried out on R57 Gustilo grade-IIIB tibial fractures in 55 patients. After debridement, there was substantial bone loss in 28 fractures (49%). The mean time to union was 43 weeks (14 to 94). When there was no bone loss, the mean time to union was 32 weeks; it was 45 weeks if there was bone loss. Fractures complicated by infection took a mean of 53 weeks to heal. Revision nailing was necessary in 13 fractures (23%) and bone grafting in 15 (26%). In ten fractures (17.5%) infection developed, in four within six weeks of injury and in six more than four months later. Of these, nine were treated successfully, but one patient required an amputation because of osteomyelitis. Our results indicate that reamed intramedullary nailing is a satisfactory treatment for Gustilo grade-III tibial fractures.     

局部肌瓣转移和自体红骨髓注射治疗胫骨骨折骨不连

目的报告局部转移肌瓣和注射自体红骨髓治疗胫骨骨折不连接的效果。方法对15例伤后10～42个月,平均22个月仍不连接的胫骨骨折实施切开复位、带锁髓内钉固定、髂骨植骨和局部转移肌瓣覆盖,术后12～15d局部注射自体红骨髓治疗。结果随访表明所有病例骨折均得到连接,术后3～11个月(平均4.8个月)愈合,除2例术后出现切口皮缘小块坏死经换药愈合外,创口均一期愈合,没有发生感染和内固定失败。结论在稳固内固定和植骨以外,局部转移肌瓣和注射自体红骨髓治疗胫骨骨折不愈合能取得满意疗效。     

Is delayed reconstruction using the latissimus dorsi free flap a worthy option in the management of open IIIB tibial fractures?

Early reconstruction of severe open fractures, performed within 7 days of the injury, has a better outcome than closure after 7 days. However, the uncertain demarcation of damaged tissue often results in delayed reconstruction. In this article, we report our surgical outcomes of delayed reconstruction using latissimus dorsi free flap with internal fixation. Twenty‐three patients with Gustilo type IIIB open tibial fractures Between March 2009 and May 2012 were included in this study. There were 16 cases of distal 1/3 fracture of the tibia, 4 of midshaft fracture, 1 of proximal 1/3 fracture, and 2 of segmental fracture. Serial debridement with application of negative pressure wound therapy (NPWT) was performed before the final operation. All patients underwent internal fixation of the bone and reconstruction of soft tissue defect using latissimus dorsi free flap. The number of serial debridements, excluding those performed during emergency and finial operation, ranged from 1 to 5 (mean 2.69) times. Mean time from injury to final operation was 10.65 (range, 7–22) days. All flaps survived without complications. Three cases (13%) were infected, and three cases required further bone graft surgery to facilitate bone union (13%). Bone union was achieved after a mean 6.3 (range, 3–12) months. Mean follow‐up period was 16.34 (range, 12–26) months. During follow‐up, all patients were able to ambulate without use of an aid. In cases of severe open fracture, treatment should emphasize soft tissue coverage rather than rushing to achieve definitive fixation in the setting of poor surrounding tissues. When delayed reconstruction is inevitable, radical debridement is performed first, then NPWT is used as bridging therapy, and free flap could be considered for definite soft tissues coverage. © 2015 Wiley Periodicals, Inc. Microsurgery 36:453–459, 2016.     

Infected fractures of the distal tibial metaphysis and plafond: achievement of limb salvage with free muscle flaps, bone grafting, and ankle fusion

Infection after fractures of the tibial plafond is a challenging problem that may even result in amputation. The current study evaluates a limb salvage protocol and the associated long term functional outcome in 6 patients (mean age 46 years) who were treated for infection after a fracture of the distal tibial metaphysis and plafond. Our limb salvage protocol included 3 stages: 1) radical debridement and stabilization of the ankle with a bridging external fixator, 2) soft tissue coverage with free muscle flaps, and 3) ankle fusion using iliac crest bone graft for filling the existing defects measuring 4.2 cm on average. At a mean followup of 5.5 years (range, 2-10.5 years), limb-salvage and eradication of infection was accomplished in all extremities. Fusion of the ankle joint was achieved in all patients, with one patient requiring a supplemental bone grafting procedure for delayed healing of the fusion site. All patients are able to walk without assistive devices and five of six patients are pain free. Limb salvage with free muscle flaps, bone grafting, and ankle fusion is a viable option for the treatment of infected tibial metaphysis and plafond fractures.     

Percutaneous bone grafting in the treatment of the delayed union and non-union of tibial fractures

The classic method of open bone grafting in the treatment of un-united tibial fractures has been associated with some complications. A novel, minimally invasive, percutaneous technique of bone grafting is described. Forty-one consecutive patients with delayed union or non-union of a tibial fracture was treated with percutaneous bone grafting from 1993 to 1999. The mean age of the patients was 41 (15-86) years. Twenty-seven patients had grade I-III open fractures. The fractures had initially been treated in a cast (n=26), external fixator (n=14) or intramedullary nail (n=1). Two patients had an earlier unsuccessful Phemister-Charnley-type bone-grafting procedure for delayed union. The mean interval from injury to percutaneous bone grafting was 21 (13-66) weeks. Thirty-seven of the 41 un-united fractures healed in 13 (10-48) weeks after the percutaneous bone grafting. The mean hospital stay was 1 day. No infections, bleeding or neural complications existed. Percutaneous bone grafting appeared to be as effective as open techniques, and possessed considerable advantages. It is safe, time saving and economical, it involves minimal trauma at the fracture site and it avoids major donor site problems.     

Treatment of 2d and 3d degree complicated tibial shaft fractures with the PMMA bead pouch technic

In a consecutive series of 222 compound fractures treated at the University of Louisville Level I Trauma Center from November 1984 to January 1987, 21 severe compound tibia shaft fractures in 20 patients were managed with the antibiotic bead pouch technique. There were 5 tibia shaft fractures and 16 tib-fib fractures. There were 9 type II and 12 type III (4 III A and 8 III B) open tibias. The patients' ages ranged from 16 to 50 years; the mean age was 29 years. There were 19 men and 1 woman. The Injury Severity Score (I.S.S.) ranged from 9 to 34; the mean I.S.S. was 14.4. Porous plastic film (Opsite) is placed over the soft tissue defect to establish a "closed" bead - hematoma - fracture environment containing high local levels of antibiotic at the fracture site. All patients had external skeletal fixation, serial wound débridement, and parenteral systemic antibiotics (cefazolin, penicillin, tobramycin). An aggregate of 46 bead pouch changes were performed in the 21 tibia fractures. During these changes, 86 cultures were taken, 5 of which were positive. One patient developed a wound infection, which was caused by tobramycin-resistant Pseudomonas and Enterococcus. No cases of osteomyelitis were observed at the fracture site. Wound closure was obtained in 9 fractures with delayed primary closure, and in 12 fractures with flap coverage and/or split thickness skin grafting. All patients underwent autogenous cancellous bone grafting after wound closure was established. The mean follow-up was 26 months (range 13-43 months). At final follow-up, 4 results were rated excellent, 11 good, 3 fair and 3 poor.(ABSTRACT TRUNCATED AT 250 WORDS)     

抗生素骨水泥珠链结合外固定架治疗感染性骨折不愈合

目的：探讨抗生素骨水泥珠链植入结合外固定架固定治疗感染性骨折不愈合的疗效。,方法：回顾分析22例感染性骨折不愈合患者,男20例,女2例;年龄21±74岁,平均（34．7±11．6）岁。骨折部位：股骨粗隆间3例、股骨干6例、股骨髁上2例、胫骨干9例、肱骨干2例。治疗过程分为3个步骤：先取出内固定物,清创后植入抗生素骨水泥珠链,Ⅰ期闭合伤口;1周后再次清创,更换抗生素骨水泥珠链,行外固定架固定;3个月后取出抗生素骨水泥珠链,取髂骨植骨。结果：随访15～28个月,平均（19．98±4．16）个月。1例胫骨干骨折和1例股骨粗隆问骨折患者分别于植骨术后2、3个月感染复发,其余20例患者感染控制良好。22例患者骨折全部愈合,愈合时间为植骨术后8-24周,平均（15．09±4．13）周。结论：彻底清创、抗生素骨水泥珠链植入结合外固定架固定及Ⅱ期植骨是治疗感染性骨折不愈合简单而有效的方法、     

Segmental tibial fractures: an assessment of procedures in 27 cases

Twenty-seven patients (two women) with segmental tibial fractures (19 open) were treated in our institution with a mean age of 38.9 years (range 22-67 years) and a mean Injury Severity Score of 11.5 (9-34). Sixteen fractures were stabilised initially with an interlocking nail, seven with an external fixator, one with a hybrid external fixator, two cases were plated and one was treated in plaster. The mean size of the segment was 11.5 cm (range 4-20 cm). Soft tissue coverage was required in 17 cases. There were three cases of compartment syndrome, six cases of superficial infection and four deep infection cases (two of which required amputation). In four cases, excision of the non-viable segment was necessary. Overall, 13 patients were subjected to a second operative procedure (OP) (four external fixators were replaced with the AO solid tibial nail, two Ilizarov bone transports following excision of the dead bone segment, 2 below knee amputations, 3 exchange reamed nailings, 1 LISS plate application for stability and 1 ring fixator for compression of a fracture). Five patients underwent third procedure (two Ilizarov for bone transport, two exchange nailing, and one bone grafting). The mean time to union of the proximal segment was 38.8 weeks (range 10-78 weeks) and 41.4 weeks (range 12-65 weeks) for the distal segment, respectively. The treatment of segmental tibial fractures poses many problems to the surgeon due to the precarious blood supply of the intermediate segment. The risk of non-union delayed union, infection and additional procedures is high as seen in this series of patients.     

One-stage open cancellous bone grafting of infected fracture and nonunion

Nineteen patients with either infected fractures or nonunions were managed by a one-stage protocol consisting of thorough debridement of the septic focus, followed by stabilization with an external fixator or a cast and fresh autogenous cancellous bone grafting; the wound was then left open. Nineteen fractures were healed and free of infection at an average of 3.5 years follow-up. Some considerations, including debridement, stabilization, bone grafting, and wound coverage, are discussed. Received for publication on Dec. 11, 1997; accepted on June 17, 1998     

Segmental tibial fractures treated with interlocking nails: A retrospective study of 33 cases

We treated 33 segmental tibial fractures with interlocking nails between 1986 and 1991. All fractures were managed with calcaneal traction, closed reduction, reaming and fixation with a Grosse-Kempf interlocking nail. The patients were followed for at least 15 months. The mean duration to union was 17 (12-20) weeks for the distal fractures and 20 (12-34) weeks for the proximal ones. There were only 3 cases of delayed union of the proximal fracture, 2 of which united after dynamization by removal of distal screws and 1 after autogenous bone grafting. There were 2 cases of deep infection, which were diagnosed 'after the fractures were united. The infection was treated with removal of the nail, reaming, and antibiotic treatment intravenously for 2 weeks and orally for 4 weeks. All patients returned to their previous activity level. We conclude that segmental tibial fractures can be treated with an interlocking nail and have a high rate of union and a low complication rate.     

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.     

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.     

Role of early Ilizarov ring fixator in the definitive management of type II, IIIA and IIIB open tibial shaft fractures

We evaluated the results of patients with Gustilo types II, IIIA and IIIB open tibial fractures managed early with the Ilizarov external fixator (IEF). Sixty patients (51 males, nine females; age range 20–62 years; mean age 32.8 years) with type II (11 patients), type IIIA (13) and type IIIB (36) tibial diaphyseal fractures underwent emergency debridement and minimal bone fixation (with external fixator), followed by definite fixation with the IEF after three to five days. Average duration of the hospital stay was 8.6 days. All fractures united with an average union time of 21.1 weeks (standard deviation [SD] 3.18) in type II, 21.7 weeks (SD 3.57) in IIIA and 24. 9 weeks (SD 5.14) in IIIB fractures. The difference between union time in type II and IIIA was not significant (p > 0.05), but that between IIIA (and also type II) and IIIB was significant (p < 0.05). The healing index in patients who underwent lengthening was 1.5 months/cm. The wounds in 27 patients were managed by delayed primary closure, in 19 patients with second intent (all IIIB), in 11 patients with skin grafting (mostly type IIIB fractures) and in three patients with musculocutaneous flaps. The most common complications of the procedure were pin tract infection and pain at the fracture site. Most of the patients were able to achieve good knee and ankle range of motion. Early application of the Ilizarov fixator constitutes an excellent management of open tibial fractures, especially types II, IIIA and IIIB, due to good functional and radiological results. Despite the technical difficulties and some complications (which are mostly minor) IEF may be the preferred method in open tibial fractures, especially types II and III.     

开放植骨治疗感染性骨折不愈合

目的介绍开放植骨治疗感染性骨折不愈合的手术方法,总结疗效,探讨提高治疗成功率的因素。方法126例感染性骨折不愈合或骨缺损患者,男98例,女28例;年龄15～71岁,平均35岁。胫骨骨折96例,股骨骨折12例,肱骨骨折5例,尺骨骨折6例,桡骨骨折2例,尺桡骨双骨折5例。骨缺损1.5～6.5cm,平均3.5cm。患处彻底清创,切除失活的软组织和骨组织,直至骨折端点状出血。对于轻度骨质疏松、稳定性骨折且预期病程短者可使用双臂单边单平面外固定架;对于明显骨质疏松、不稳定性骨折和(或)预期病程长者使用单臂双平面外固定架;对于严重骨质疏松者,使用单臂双平面外固定架固定并辅以石膏托外固定;邻近关节骨折,可考虑跨关节外固定架和(或)石膏固定。一期或择期植入带皮质的自体松质骨骨条,直径<5mm,开放伤口。术后严格无菌换药。静脉滴注敏感抗生素,平均用药11d。结果平均随访2.4年(8个月～4.5年)。术后平均8周移植骨质表面覆盖肉芽组织,14例于术后5周行游离植皮闭合创面,112例于术后平均10周瘢痕自行愈合。123例骨折于术后平均7个月愈合,9个月去除外固定;3例骨折未愈合。4例出现窦道,2例感染复发。结论开放植骨术是治疗感染性骨折不愈合和骨缺损的简单、积极而有效的方法。与传统方法相比,疗程缩短,手术次数减少。感染并非植骨     

Immediate internal fixation of high-energy open forearm fractures

Eighteen patients with Gustilo and Anderson Grade III A (7), III B (8) or III C (3) open diaphyseal forearm fractures were treated with a protocol consisting of extensive primary debridement, immediate open reduction, dynamic compression plate fixation, and vascular repair when indicated. This was followed by routine redebridement at 24 to 48-h intervals until wound status allowed completion of soft tissue reconstruction. Bone grafting was performed at 8 to 10 weeks following obtainment of a closed soft tissue envelope for injuries with extensive comminution or bone loss (5 patients, 7 fractures). Subsequent procedures such as tendon transfers, scar revision, joint arthrodesis, or secondary nerve reconstruction were required in 8 of 18 patients. Minor complications related to delayed wound healing occurred in 3 individuals (15%). One deep infection of a fractured radius occurred in a patient with a floating elbow and failed free flap. Salvage with debridement, retention of hardware, and a second free flap resulted in fracture union. One patient required a second bone graft to obtain union of a segmental forearm defect. Amputation was performed in one patient following failed forearm replantation with greater than 8 h warm ischemia time. Immediate debridement and plate fixation of Grade III forearm fractures performed in conjunction with aggressive soft tissue management provided good or excellent results in 12 patients (66%) and is an acceptable treatment alternative in these difficult injuries.     

THE UNREAMED TIBIAL ROD IN OPEN TIBIAL FRACTURES

Background: Open tibial fractures may be managed surgically by either external fixation or the intramedullary rod. If a rod is used, the delayed removal of the locking screws has been advocated to enhance fracture healing. The aim of the present study was to report the results of closed unreamed locked tibial rods in open fractures and evaluate the effect of locking screw removal. Methods : Fifty-one patients with open tibial fractures were treated by debridement, intravenous antibiotics, soft-tissue coverage and closed, unreamed, locked intramedullary rods. Forty-six patients were available for review at an average of 13.7 months after surgery. Results: Union occurred at a mean of 240 days (168.1–312.3 CI). Five (10.8%) patients required bone grafting (two required a bone graft alone, three with exchange rods). Deep infection occurred in three (6.5%) cases, and malunion occurred in seven (15.2%) cases. Locking screw failure occurred in five (11%) cases. There was no significant association between removal of the locking screws, injury type and time to union when comminution was controlled for (P= 0.54). Conclusions: These results compare favourably to other methods of treatment for open fractures and suggest that removal of locking screws does not alter the time to union.