External fixation for type III open tibial fractures

Court-Brown, C. M.; Wheelwright, E.F.; Christie, James H.; McQueen, M. M.

doi:10.1302/0301-620x.72b5.2211760

Cited by 116 publications

(62 citation statements)

References 16 publications

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“…We note that similar incidences of these difficulties have been reported by others. 6,7,9,10 In common with Hansen, 30 we consider that our aims are sequential namely to achieve limb salvage by the healing of soft tissues without infection, followed by early bony union. It is fortunate that the initial implant used to produce skeletal stability in order to resist infection was also effective in obtaining bony union in so many cases.…”

Section: Discussionmentioning

confidence: 99%

“…[3][4][5] While limb salvage is the initial aim, medium-and long-term problems with soft-tissue cover, infection and union are all too common and result in serious disability. 1,2,[6][7][8][9][10] The unique anatomy of the tibia with its associated soft tissues and their vulnerability to severe injury produces most of these problems. 11,12 Most orthopaedic surgeons work outside a referral centre and although called on to manage these injuries, with subsequent referral to a department of plastic surgery for delayed softtissue reconstruction, individually they usually have limited personal experience of the more serious injuries.…”

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confidence: 99%

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Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia

Gopal¹,

Majumder

Batchelor

et al. 2000

The Journal of Bone and Joint Surgery. British volume

286

133

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We performed a retrospective review of the case notes of 84 consecutive patients who had suffered a severe (Gustilo IIIb or IIIc) open fracture of the tibia after blunt trauma between 1990 and 1998. All had been treated by a radical protocol which included early soft-tissue cover with a muscle flap by a combined orthopaedic and plastic surgery service. Our ideal management is a radical debridement of the wound outside the zone of injury, skeletal stabilisation and early soft-tissue cover with a vascularised muscle flap. All patients were followed clinically and radiologically to union or for one year.After exclusion of four patients (one unrelated death and three patients lost to follow-up), we reviewed 80 patients with 84 fractures. There were 67 men and 13 women with a mean age of 37 years (3 to 89). Five injuries were grade IIIc and 79 grade IIIb; 12 were site 41, 43 were site 42 and 29 were site 43. Debridement and stabilisation of the fracture were invariably performed immediately. In 33 cases the soft-tissue reconstruction was also completed in a single stage, while in a further 30 it was achieved within 72 hours. In the remaining 21 there was a delay beyond 72 hours, often for critical reasons unrelated to the limb injury. All grade-IIIc injuries underwent immediate vascular reconstruction, with an immediate cover by a flap in two. All were salvaged. There were four amputations, one early, one mid-term and two late, giving a final rate of limb salvage of 95%. Overall, nine pedicled and 75 free muscle flaps were used; the rate of flap failure was 3.5%. Stabilisation of the fracture was achieved with 19 external and 65 internal fixation devices (nails or plates). Three patients had significant segmental defects and required bone-transport procedures to achieve bony union. Of the rest, 51 fractures (66%) progressed to primary bony union while 26 (34%) required a bone-stimulating procedure to achieve this outcome. Overall, there was a rate of superficial infection of the skin graft of 6%, of deep infection at the site of the fracture of 9.5%, and of serious pin-track infection of 37% in the external fixator group. At final review all patients were walking freely on united fractures with no evidence of infection.The treatment of these very severe injuries by an aggressive combined orthopaedic and plastic surgical approach provides good results; immediate internal fixation and healthy soft-tissue cover with a muscle flap is safe. Indeed, delay in cover (>72 hours) was associated with most of the problems. External fixation was associated with practical difficulties for the plastic surgeons, a number of chronic pin-track infections and our only cases of malunion. We prefer to use internal fixation. We recommend primary referral to a specialist centre whenever possible. If local factors prevent this we suggest that after discussion with the relevant centre, initial debridement and bridging external fixation, followed by transfer, is the safest procedure. J Bone Joint Surg [Br] 2000;82-B:959-66.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia

Gopal¹,

Majumder

Batchelor

et al. 2000

The Journal of Bone and Joint Surgery. British volume

286

133

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“…External fixators provide rigid fixation and have a low infection rate, but the disadvantages are frequent pin tract infection and loss of reduction with malunion and pseudoarthrosis [6,12,25]. Conventional intramedullary reamed locking nailing offers better control of alignment, rotation, and shortening, and better stability.…”

Section: Discussionmentioning

confidence: 99%

“…Conventional intramedullary reamed locking nailing offers better control of alignment, rotation, and shortening, and better stability. However, reaming destroys the endosteal circulation adding impairment to the blood flow to the already damaged bone [6,22], and also increases pressure in the adjacent compartments [18,19,26]. This is the reason why many authors dislike using this technique for open fractures and attribute a high infection rate to it [3,24].…”

Section: Discussionmentioning

confidence: 99%

Unreamed intramedullary locking nailing for open tibial fractures

García-López

Marco

López-Durán

1998

International Orthopaedics

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“…A rapidez para aplicação, ausência da necessidade de equipamentos sofisticados, pequeno custo financeiro, componentes modulares, conferir estabilidade mecânica ao segmento fraturado e ausência de novas lesões às partes moles adjacentes são características que tornam a osteossíntese com o fixador externo indicada no tratamento inicial de certas fraturas, sobretudo como medida nos serviços de emergência (1)(2) , indispensável nas lesões de maior gravidade (1)(2)(3)(4) .…”

Section: Discussionunclassified