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Acta Bio-medica : Atenei Parmensis Jul 2021Open tibial fractures are mostly the result of high-energy traumas and often involve severe injuries with extensive bone and soft tissue loss, damage of muscles and...
BACKGROUND
Open tibial fractures are mostly the result of high-energy traumas and often involve severe injuries with extensive bone and soft tissue loss, damage of muscles and neurovascular structures. Over recent- years, - the growth of Ortho-Plastic teams, as a well-coordinated bone, joint and soft tissue treatment, contributed to change the approach to these fractures and to achieve higher successful results in lower limb salvage. Unfortunately, many hospitals cannot benefit of a combined team in emergency, and the orthopedic surgeon is forced to manage personally these kinds of traumas.
METHODS
We retrospectively reviewed all the open tibial fractures treated at our Orthopaedic Department over the last 10 years, in order to assess the treatments performed (one-stage fixation with Intramedullary Nailing or Open Reduction Internal Fixation - ORIF, versus two/multiple-stage fixation with temporary External Fixation followed by nailing or ORIF) and the differences in the outcome between the different methods.
PURPOSE
Based on our experience and review of the literature, the purpose of this paper is to define what cases can be managed by a single-stage orthopaedic approach, and when the orthopaedist should lay down his arms in favor of other specialties.
Topics: Fracture Fixation; Fracture Fixation, Intramedullary; Fractures, Open; Humans; Retrospective Studies; Tibia; Tibial Fractures; Treatment Outcome
PubMed: 34313664
DOI: 10.23750/abm.v92iS3.11736 -
The Journal of Bone and Joint Surgery.... May 2009We report a case in which Ilizarov distraction osteogenesis was used to lengthen the portion of calcaneum that remained after a radical debridement for osteomyelitis....
We report a case in which Ilizarov distraction osteogenesis was used to lengthen the portion of calcaneum that remained after a radical debridement for osteomyelitis. The patient was able to walk normally in unmodified shoes at the end of his treatment.
Topics: Accidents, Traffic; Aged; Calcaneus; Debridement; Fractures, Open; Humans; Ilizarov Technique; Male; Osteogenesis, Distraction; Osteomyelitis; Treatment Outcome
PubMed: 19407304
DOI: 10.1302/0301-620X.91B5.21938 -
The Pan African Medical Journal 2019Management of open fractures poses a constant challenge to Orthopaedic surgeons in Nigeria. Our aim is to determine the epidemiological pattern of open fractures in our...
INTRODUCTION
Management of open fractures poses a constant challenge to Orthopaedic surgeons in Nigeria. Our aim is to determine the epidemiological pattern of open fractures in our centre and share our experiences on the initial management and problems encountered.
METHODS
This was an 18 month prospective study of patients that presented with open fractures at our emergency room. Already prepared data collection sheets were used to collect relevant data directly from patients and patients' files.
RESULTS
There were 58 open fractures in 52 patients (31 males and 21 females). Mean age of patients was 36.4 ± 12.2 years. Most patients (82.7%) fell within the age group of 20-49 years. Traders (28.9%) and students (19.6%) were mostly affected. Most open fractures (88.5%) were due to road traffic accidents. The tibia and fibula were the most frequently affected (44.4%). Most injuries were Gustilo types IIIA & IIIB (79.3%) open fractures. Patients had initial resuscitation followed by debridement in 42 cases (72%). Fractures were initially stabilized with external fixators in 23 cases (39.7%) and cast slabs in 19 cases (32.8%). The average time between presentation and debridement was 30 hours and average hospital stay was 36 days. Forty two point five per cent of wounds were infected.
CONCLUSION
Open fractures were mostly due to road traffic accidents and affected the tibia and fibula most frequently with Gustilo types IIIA and IIIB forming the bulk of the injuries. Management was challenging with late presentations, scarcity of resources and consequent high rate of infections, prolonged morbidity and hospital stay. These problems were worsened by delay in antibiotic commencement and initial debridement, sub-optimal treatment at peripherial hospitals and mis-management by traditional bone setters.
Topics: Accidents, Traffic; Adolescent; Adult; Aged; Child; Debridement; Emergency Service, Hospital; External Fixators; Female; Fracture Fixation; Fractures, Open; Hospitals, Teaching; Humans; Male; Middle Aged; Nigeria; Prospective Studies; Surgical Wound Infection; Time Factors; Young Adult
PubMed: 31692766
DOI: 10.11604/pamj.2019.33.234.18141 -
European Journal of Orthopaedic Surgery... Jul 2023Open extremity fractures can be life-changing events. Clinical guidelines on the management of these injuries aim to standardise the care of patients by presenting... (Review)
Review
INTRODUCTION
Open extremity fractures can be life-changing events. Clinical guidelines on the management of these injuries aim to standardise the care of patients by presenting evidence-based recommendations. We performed a scoping systematic review to identify all national clinical practice guidelines published to date.
MATERIALS AND METHODS
A PRISMA-compliant scoping systematic review was designed to identify all national or federal guidelines for the management of open fractures, with no limitations for language or publication date. EMBASE and MEDLINE database were searched. Article screening and full-text review was performed in a blinded fashion in parallel by two authors.
RESULTS
Following elimination of duplicates, 376 individual publications were identified and reviewed. In total, 12 clinical guidelines were identified, authored by groups in the UK, USA, the Netherlands, Finland, and Malawi. Two of these focused exclusively on antibiotic prophylaxis and one on combat-related injuries, with the remaining nine presented wide-scope recommendations with significant content overlap.
DISCUSSION
Clinical practice guidelines serve clinicians in providing evidence-based and cost-effective care. We only identified one open fractures guideline developed in a low- or middle-income country, from Malawi. Even though the development of these guidelines can be time and resource intensive, the benefits may outweigh the costs by standardising the care offered to patients in different healthcare settings. International collaboration may be an alternative for adapting guidelines to match local resources and healthcare systems for use across national borders.
Topics: Humans; Antibiotic Prophylaxis; Cost-Effectiveness Analysis; Databases, Factual; Extremities; Fractures, Open
PubMed: 35819519
DOI: 10.1007/s00590-022-03324-w -
Annals of the Royal College of Surgeons... Mar 2018Introduction We aimed to identify population demographics of motorcyclists and pillion passengers with isolated open lower-limb fractures, to ascertain the impact of the...
Introduction We aimed to identify population demographics of motorcyclists and pillion passengers with isolated open lower-limb fractures, to ascertain the impact of the revised 2009 British Orthopaedic Association/British Association of Plastic Reconstructive and Aesthetic Surgeons joint standards for the management of open fractures of the lower limb (BOAST 4), in terms of time to skeletal stabilisation and soft-tissue coverage, and to observe any impact on patient movement. Methods Retrospective cohort data was collected by the Trauma Audit and Research Network (TARN). A longitudinal analysis was performed between two timeframes in England (pre-and post-BOAST 4 revision): 2007-2009 and 2010-2014. Results A total of 1564 motorcyclists and 64 pillion passengers were identified. Of these, 93% (1521/1628) were male. The median age for males was 30.5 years and 36.7 years for females. There was a statistically significant difference in the number of patients who underwent skeletal stabilisation (49% vs 65%, P < 0.0001), the time from injury to skeletal stabilisation (7.33 hours vs 14.3 hours, P < 0.0001) and the proportion receiving soft-tissue coverage (26% vs 43%, P < 0.0001). There was no difference in the time from injury to soft-tissue coverage (62.3 hours vs 63.7 hours, P = 0.726). The number of patients taken directly to a major trauma centre (or its equivalent) increased between the two timeframes (12.5% vs, 41%, P < 0.001). Conclusions Since the 2009 BOAST 4 revision, there has been no difference in the time taken from injury to soft-tissue coverage but the time from injury to skeletal stabilisation is longer. There has also been an increase in patient movement to centres offering joint orthopaedic and plastic care.
Topics: Accidents, Traffic; Adolescent; Adult; Aged; Aged, 80 and over; Bones of Lower Extremity; Child; Child, Preschool; England; Female; Fracture Fixation; Fractures, Open; Guideline Adherence; Humans; Longitudinal Studies; Male; Middle Aged; Motorcycles; Outcome and Process Assessment, Health Care; Patient Transfer; Practice Guidelines as Topic; Practice Patterns, Physicians'; Plastic Surgery Procedures; Retrospective Studies; Time Factors; Young Adult
PubMed: 29364004
DOI: 10.1308/rcsann.2017.0222 -
International Journal of Surgery... May 2018Though several systematic reviews concerned have been published, controversy still exists. The current systematic review was designed to clarify the detailed advantages... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Though several systematic reviews concerned have been published, controversy still exists. The current systematic review was designed to clarify the detailed advantages and disadvantages of the negative pressure wound therapy (NPWT) in treatment of open fractures in comparison with the conventional wound dressings.
METHODS
A systematic search was performed in Pubmed, Cochrane Library, Embase, and Google Scholar for the published relevant clinical studies. Unpublished studies were searched in Clinicaltrials, ICTRP and ISRCTN. The outcome measures included presence of infection, wound healing process, length of the patient hospital stay, flap issues, frequency of amputation, and patient life quality.
RESULTS
In the 8 randomized controlled trials (RCTs) (421 patients) and the 6 retrospective cohort studies (488 patients), NPWT resulted in a significantly lower infection rate, significantly shorter wound coverage time, wound healing time and hospital stay length, and the lower amputation rate. However, no statistically significant difference was found in the need for flap surgery, the proportion of free flaps, the flap failure rate or the fracture non-union rate. Only 1 RCT was reported to have a higher physical component score of short form 36 in the infected patients.
CONCLUSION
NPWT can significantly reduce the risk of infection in treatment of open fractures and accelerate their wound healing process. Some but not much evidence suggests that NPWT may possibly help reduce the severity of the limb injury and therefore provide a chance for the limb to avoid amputation. Use of NPWT in the flap area is probably safe, but should be carried out with caution. The advantage of NPWT over the conventional wound dressings still requires to be confirmed in the other aspects.
Topics: Amputation, Surgical; Bandages; Fractures, Open; Humans; Negative-Pressure Wound Therapy; Postoperative Complications; Retrospective Studies; Surgical Flaps; Treatment Outcome; Wound Healing
PubMed: 29555530
DOI: 10.1016/j.ijsu.2018.02.064 -
Annals of the Royal College of Surgeons... Jan 2012The management of open tibial shaft fractures remains challenging. Intramedullary nailing and external fixation are the most commonly used fixation techniques although... (Comparative Study)
Comparative Study Review
INTRODUCTION
The management of open tibial shaft fractures remains challenging. Intramedullary nailing and external fixation are the most commonly used fixation techniques although the optimal fixation technique remains unresolved. In this article the outcomes of these two surgical techniques are compared.
METHODS
A comprehensive literature search was conducted through MEDLINE(®) using Ovid(®) and MeSH (Medical Subject Heading) terms for articles published in the English literature between 1999 and 2009. The outcome measures compared were time to fracture union, infection rates and complications.
RESULTS
Forty-one studies were identified, of which only three met the inclusion criteria. The average time to union was variable. Delayed union and non-union appeared to be more prevalent in the external fixator group although this was not statistically significant. Both techniques were associated with secondary procedures as well as infection.
CONCLUSIONS
The current literature indicates little evidence to suggest the superiority of one fixation technique over another for open tibial fractures.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; External Fixators; Fracture Fixation, Intramedullary; Fracture Healing; Fractures, Open; Humans; Middle Aged; Postoperative Complications; Tibial Fractures; Time Factors; Treatment Outcome; Young Adult
PubMed: 22524923
DOI: 10.1308/003588412X13171221498668 -
The Bone & Joint Journal Jun 2022This study estimated trends in incidence of open fractures and the adherence to clinical standards for open fracture care in England.
AIMS
This study estimated trends in incidence of open fractures and the adherence to clinical standards for open fracture care in England.
METHODS
Longitudinal data collected by the Trauma Audit and Research Network were used to identify 38,347 patients with open fractures, and a subgroup of 12,170 with severe open fractures of the tibia, between 2008 and 2019 in England. Incidence rates per 100,000 person-years and 95% confidence intervals were calculated. Clinical care was compared with the British Orthopaedic Association Standards for Trauma and National Major Trauma Centre audit standards.
RESULTS
In total, 60% of all open fractures occurred in males; the median age was 48 years (interquartile range (IQR) 29 to 68). Between 2012 and 2019, the overall incidence in England was 6.94 per 100,000 person-years. In males, the highest incidence observed was in those aged 20 to 29 years (11.50 per 100,000 person-years); in females, incidence increased with age, peaking at 32.11/100,000 person-years at 90 years of age and over. Among those with severe open fractures of the tibia, there was a bimodal distribution in males, peaking at 20 to 29 years (3.71/100,000 person-years) and greater than 90 years of age (2.84/100,000 person-years) respectively; among females, incidence increased with age to a peak of 9.91/100,000 person years at 90 years of age and over. There has been variable improvement with time in the clinical care standards for patients with severe open fractures of the tibia. The median time to debridement was 13.0 hours (IQR 6.4 to 20.9); almost two-thirds of patients underwent definitive soft-tissue coverage within 72 hours from 2016 to 2019.
CONCLUSION
This is the first time the incidence of all open fractures has been studied using data from a national audit in England. While most open fractures occurred in young males, the incidence increased with age in females to a much greater level than observed in older males. The degree of missing data in the national audit is startling, and limits the certainty of inferences drawn concerning open fracture care. Cite this article: 2022;104-B(6):736-746.
Topics: Aged; Aged, 80 and over; Cohort Studies; Female; Fractures, Open; Humans; Incidence; Male; Middle Aged; Tibial Fractures; Trauma Centers
PubMed: 35638205
DOI: 10.1302/0301-620X.104B6.BJJ-2021-1097.R2 -
Journal of the American Academy of... Sep 2022Open tibial shaft fractures are high-risk injuries for developing acute infection. Prior research has focused on injury characteristics and treatment options associated...
INTRODUCTION
Open tibial shaft fractures are high-risk injuries for developing acute infection. Prior research has focused on injury characteristics and treatment options associated with acute inpatient infection in these injuries without primary analysis of host factors. The purpose of this study was to determine the patient comorbidities associated with increased risk of acute infection after open tibial shaft fractures during initial hospitalization.
METHODS
A total of 147,535 open tibial shaft fractures in the National Trauma Data Bank from 2007 to 2015 were identified that underwent débridement and stabilization. Infection was defined as a superficial surgical site infection or deep infection that required subsequent treatment. The International Classification of Diseases, ninth revision codes were used to determine patient comorbidities. Comparative statistical analyses including odds ratios (ORs) for patient groups who did develop infection and those who did not were conducted for each comorbidity.
RESULTS
The rate of acute inpatient infection was 0.27% with 396 patients developing infection during hospital management of an open tibial shaft fracture. Alcohol use (OR, 2.26, 95% confidence interval [CI], 1.73-2.96, P < 0.0001), bleeding disorders (OR, 4.50, 95% CI, 3.13-6.48, P < 0.0001), congestive heart failure (OR, 3.25, 95% CI, 1.97-5.38, P < 0.0001), diabetes (OR, 1.73, 95% CI, 1.29-2.32, P = 0.0002), psychiatric illness (OR, 2.17, 95% CI, 1.30-3.63, P < 0.0001), hypertension (OR, 1.56, 95% CI, 1.23-1.95, P < 0.0001), obesity (OR, 3.05, 95% CI, 2.33-3.99, P < 0.0001), and chronic obstructive pulmonary disease (OR, 2.09, 95% CI, 1.51-2.91, P < 0.0001) were all associated with increased infection rates. Smoking (OR, 0.957, 95% CI, 0.728-1.26, P = 0.722) and drug use (OR, 1.11, 95% CI, 0.579-2.11, P = 0.7607) were not associated with any difference in infection rates.
DISCUSSION
Patients with open tibial shaft fractures who have congestive heart failure, bleeding disorders, or obesity are three to 4.5 times more likely to develop an acute inpatient infection than patients without those comorbidities during their initial hospitalization. Patients with diabetes, psychiatric illness, hypertension, or chronic obstructive pulmonary disease are 1.5 to 2 times more likely to develop subsequent infection compared with patients without those comorbidities. Patients with these comorbidities should be counseled about the increased risks. Furthermore, risk models for the infectious complications after open tibial shaft fractures can be developed to account for this more at-risk patient population to serve as modifiers when evaluating surgeon/hospital performance.
CONCLUSION
Patient comorbidities are associated with increased risk of acute inpatient infection of open tibial shaft fractures during hospitalization.
Topics: Comorbidity; Fracture Fixation, Intramedullary; Fractures, Open; Heart Failure; Humans; Hypertension; Obesity; Pulmonary Disease, Chronic Obstructive; Retrospective Studies; Tibial Fractures
PubMed: 36155604
DOI: 10.5435/JAAOSGlobal-D-22-00196 -
Journal of Orthopaedic Surgery (Hong... 2019Traditional anteromedial incision for pilon fractures would further increase the damage to the subcutaneous tissues anterior and medial to tibia. In this study, we...
BACKGROUND
Traditional anteromedial incision for pilon fractures would further increase the damage to the subcutaneous tissues anterior and medial to tibia. In this study, we retrospectively evaluated the method and the outcomes of lateral approach for surgical treatment of Gustilo type-I and type-II open pilon fractures with medial soft tissue injuries.
METHODS
From May 2014 to September 2017, 35 patients with Gustilo type-I and type-II open pilon fractures were treated with standard protocol using a lateral approach. The initial wound debridement and application of a spanning external fixator or traction of calcaneal tubercle were performed within 24 h and a definitive fixation was performed when the wound was healed. The mean time from primary surgery to definite surgery was 11.8 (range: 8-16) days. Postoperative radiographs, complications, bone union, and American Orthopedic Foot and Ankle Society (AOFAS) ankle/hind foot score were recorded.
RESULTS
The mean follow-up period was 17 months (range: 13-23). The average time to bone union was 22 weeks (range: 18-25). In 35 patients, 2 patients had a superficial wound infection and another 1 patient showed limitation of ankle joint motion. No cases of deep infection, skin necrosis, and symptomatic implant reported. The mean AOFAS score was 89.8 (range: 84-95). On final outcome, 25 patients come under excellent and 10 patients had good result.
CONCLUSION
From the results of this study, we can conclude that the lateral approach to treat Gustilo type-I and type-II open pilon fractures was a safe option with a low complication rate. On the other hand, it provides sufficient exposure to restore anatomic articulation, which is worthy of clinical recommendation.
Topics: Adult; External Fixators; Female; Follow-Up Studies; Fracture Fixation, Internal; Fractures, Open; Humans; Male; Middle Aged; Open Fracture Reduction; Radiography; Retrospective Studies; Tibial Fractures; Time Factors; Treatment Outcome
PubMed: 31366284
DOI: 10.1177/2309499019864722