Management of severe open tibial fractures

Abstract

Although it is widely accepted that grade IIIB open tibial fractures require combined specialised orthopaedic and plastic surgery, the majority of patients in the UK initially present to local hospitals without access to specialised trauma facilities. The aim of this study was to compare the outcome of patients presenting directly to a specialist centre (primary group) with that of patients initially managed at local centres (tertiary group). We reviewed 73 consecutive grade IIIB open tibial shaft fractures with a mean follow-up of 14 months (8 to 48). There were 26 fractures in the primary and 47 in the tertiary group. The initial skeletal fixation required revision in 22 (47%) of the tertiary patients. Although there was no statistically-significant relationship between flap timing and flap failure, all the failures (6 of 63; 9.5%) occurred in the tertiary group. The overall mean time to union of 28 weeks was not influenced by the type of skeletal fixation. Deep infection occurred in 8.5% of patients, but there were no persistently infected fractures. The infection rate was not increased in those patients debrided more than six hours after injury. The limb salvage rate was 93%. The mean limb functional score was 74% of that of the normal limb. At review, 67% of patients had returned to employment, with a further 10% considering a return after rehabilitation. The times to union, infection rates and Enneking limb reconstruction scores were not statistically different between the primary and tertiary groups. The increased complications and revision surgery encountered in the tertiary group suggest that severe open tibial fractures should be referred directly to specialist centres for simultaneous combined management by orthopaedic and plastic surgeons.

The effect of early versus delayed surgical debridement on the outcome of open long bone fractures at Bugando Medical Centre, Mwanza, Tanzania

“…Late surgical debridement can be explained by late presentation to the hospital due to logistical constraints and poor general condition of the patients that requires pre-operative resuscitation. The overall rate of SSI among the study population (6.3 %) is low and comparable to other studies from USA, Egypt, Canada, UK and Germany where the rates were 14, 11.6, 9.3, 8.5 and 6.6–8 % respectively [15, 18, 27, 30, 34]. The slightly higher infection rates in these countries as opposed to the present study may be related to prolonged follow up period which ranged from 3 to 36 months.…”

“…The anatomical relation of tibia, its subcutaneous orientation with precarious blood supply reiterated on its preponderance involvement in this and other studies [1, 27]. In the present study, nearly two third of patients had Gustilo–Anderson grade II and this is similar to other studies [16, 18] but contrary to a study in Rwanda where Gustilo grade III was the most frequent grade [26].…”

Experience of managing open fractures of the lower limb at a major trauma centre

“…2,3,8,10,11 However, there remains scope for expediting definitive soft tissue coverage both in our centre and in other MTCs through a process determined by local structural constraints. 12 The 'fix and flap' protocol is regarded as the gold standard for treatment.…”

A Decision Analysis of Amputation Versus Reconstruction for Severe Open Tibial Fracture from the Physician and Patient Perspectives

“…ASRM members were chosen because as reconstructive surgery has become more an integral part of open fracture treatment, these surgeons are gaining an intimate understanding of the outcomes following lower leg trauma. 4,5 Members were numbered in alphabetical order and a random number generator was used to select a sample of 200 surgeons. After sample selection, we discovered that one prospective participant had died.…”

“…3 The advancement of microsurgical techniques allowed cooperative efforts between orthopedic and plastic surgeons to reconstruct severe open fractures and achieve predictable limb salvage. 4,5 Most recently, wound care technology has further increased surgeons’ ability to treat open tibial fractures. 3 …”