TEMPORARY EX-FIX IN OPEN TIBIAL FRACTURES: ROOM FOR IMPROVEMENT?

Abstract

Aims: To investigate adequacy of temporary ex-fix in grade III open fractures of the tibia, prior to definitive treatment by Flap & Frame at 2 UK trauma centres.

Methods: Between 2000 and 2006 all open fractures of the tibia treated by the Ilizarov Method at our two institutions were entered onto the Flap & Frame database. The database was searched for all temporary external fixators placed prior to definitive Ilizarov fixation. Data collected – ex-fix type, whether revision was necessary, reasons for revision.

Results:

• 97 grade III open fractures in 95 patients

• 64 required temporary spanning ex-fix: 23 applied at trauma centre/41 at DGH

• 14/64 ex-fixes required revision (prior to definitive Ilizarov): poor plastics access(6)/instability(2)/both(6)

• All 14 revised had been applied in a DGH, i.e. 14/41 DGH ex-fix needed revision (34%)

• Ex fixes revised after application at trauma centre vs. DGH = 0/23 vs. 14/41, p< 0.01 ×2

• Revision of Hoffman hybrid vs. monolateral ex fix = 4/4 vs. 10/60 p< 0.001 ×2

• Non modular system (Orthofix) vs. modular systems (Hoffman II/AO) = 7/17 vs. 0/39 p< 0.001

Discussion: Recently Naique and Pearse showed a revision rate of skeletal fixation of 48% in grade IIIb open fractures referred to their tertiary centre. In our series 34% of temporary external fixators needed revision. Modular systems such as Hoffman II and AO required no revision, irrespective of whether they were applied at trauma centre or DGH.

All Hoffman hybrids needed revision, due to both instability and plastics access. Significantly more non modular (Orthofix) ex-fixes required revision compared to modular (Hoffmann II/AO), due to poor plastics access.

Conclusion: We recommend modular external fixation systems such as Hoffman II or AO if problems of temporary external fixation of open tibial fractures are to be avoided. Hybrid temporary external fixation should be abandoned as temporary fixation in such an injury