The aim of this study was to determine medium term functional outcomes in military casualties undergoing limb salvage for severe open tibia fractures, and compare them to trans-tibial amputees. Cases of severe open diaphyseal tibia fractures sustained in combat between 2006 – 2010 were contacted and interviewed. These results were compared to a similar cohort of 18 military patients who sustained a unilateral trans-tibial amputation in the same period. Forty-nine patients with 57 severe open tibia fractures met the inclusion criteria, of which 30 patients (61%) were followed-up. Ten of the 30 patients required revision surgery, 3 of which involved conversion to a circular frame. Twenty-two of the 30 patients (73%) recovered sufficiently to complete a basic military fitness test. The median physical component score of SF-36 in the limb salvage group was 46 (IQR 35–54) which was similar to the trans-tibial amputation cohort (p=0.3057, Mann-Whitney). There was no significant difference in the proportion of patients in either the amputation or limb salvage group reporting pain (p=0.1157, Fisher's exact test) or with respect to SF-36 physical pain scores (p=0.5258, Mann-Whitney). This study demonstrates that medium term outcomes for military patients are similar following trans-tibial amputation or limb salvage following combat trauma

The aim of this study was to establish medium term outcomes in military casualties following severe open tibia fractures. Cases from a previously published series were contacted and assessed with the SF-36 outcome tool. Their results were then compared to a similar study of military trans-tibial amputees. Of the original data set of 49 patients, 30 patients were followed up and completed an SF-36 (61%) with a median follow-up of 4 years (49 months, IQR 397–63). Ten of the 30 required revision surgery, 3 of which involved conversion from initial fixation to a circular frame. Twenty-two of the 30 patients recovered sufficiently to complete a military basic fitness test. The median physical component of SF-36 in the tibia fracture group was 46 (IQR 35–54) which was similar to the trans-tibial amputation cohort (p=0.3057, Mann-Whitney). Similarly there was no difference in mental component scores (p=0.1595, Mann-Whitney). There was no significant difference in the proportion of patients in the amputation or fracture group reporting pain (p= 0.1157, Fisher's exact test) or with respect to SF-36 physical pain scores (p=0.5258, Mann-Whitney). We present the patient reported outcomes following combat open tibia fracture and show that they are similar to those achieved after trans-tibial amputation

We compared early post-operative rates of wound infection in HIV-positive and -negative patients presenting with open tibial fractures managed with surgical fixation.

The wounds of 84 patients (85 fractures), 28 of whom were HIV positive and 56 were HIV negative, were assessed for signs of infection using the ASEPIS wound score. There were 19 women and 65 men with a mean age of 34.8 years. A total of 57 fractures (17 HIV-positive, 40 HIV-negative) treated with external fixation were also assessed using the Checkett score for pin-site infection. The remaining 28 fractures were treated with internal fixation. No significant difference in early post-operative wound infection between the two groups of patients was found (10.7% (n = 3) vs 19.6% (n = 11); relative risk (RR) 0.55 (95% confidence interval (CI) 0.17 to 1.8); p = 0.32). There was also no significant difference in pin-site infection rates (17.6% (n = 3) vs 12.5% (n = 5); RR 1.62 (95% CI 0.44 to 6.07); p = 0.47).

The study does not support the hypothesis that HIV significantly increases the rate of early wound or pin-site infection in open tibial fractures. We would therefore suggest that a patient’s HIV status should not alter the management of open tibial fractures in patients who have a CD4 count > 350 cells/μl.

Cite this article: Bone Joint J 2013;95-B:1703–7.

Open tibia fractures are common injuries in our paediatric population and are often associated with high-energy trauma such as pedestrian-vehicle accidents. At our institution, these injuries are routinely treated with debridement and mono-lateral external fixation. The purpose of this study was to determine the outcome of open tibia fractures treated according to this protocol, as well as the complication rate and factors contributing to the development of complications. We performed a retrospective folder review of all patients with open tibia fractures that were treated according to our protocol from 2015–2019. Patients treated by other means, who received primary treatment elsewhere, and with insufficient data, were excluded. Data was collected on presenting demographics, injury characteristics, management, and clinical course. Complications were defined as pin tract infections, delayed- or non-union, malunion, growth arrest, and neurovascular injury. Appropriate statistical analysis was performed. One-hundred-and-fifteen fractures in 114 children (82 males) with a median age of 7 years (IQR 6–9) were included in the analysis. Pedestrian vehicle accidents (PVA's) accounted for 101 (88%) of fractures, and the tibial diaphysis was affected in 74 cases (64%). Fracture severity was equally distributed among the Gustillo-Anderson grades. The median Abbreviated Injury Score was 4 (IQR 4;5). Ninety-five fractures (83%) progressed to uneventful union within 7 weeks. Twenty patients (17%) developed complications, with delayed union and fracture site infections being the most common complications. Gustillo-Anderson Grade 3 fractures, an increased Abbreviated Injury Score, and the need for advanced wound closure techniques were risk factors for developing complications. Surgical debridement and external fixation in a simple mono-lateral frame is an effective treatment for open tibia fractures in children and good outcomes were seen in 83% of patients. More severe injuries requiring advanced wound closure were associated with the development of complications

The August 2023 Trauma Roundup. 360. looks at: A comparison of functional cast and volar-flexion ulnar deviation for dorsally displaced distal radius fractures; Give your stable ankle fractures some AIR!; Early stabilization of rib fractures – an effective thing to do?; Locked plating versus nailing for proximal tibia fractures: A multicentre randomized controlled trial; Time to flap coverage in open tibia fractures; Does tranexamic acid affect the incidence of heterotropic ossification around the elbow?; High BMI – good or bad in surgical fixation of hip fractures?

Introduction. Open fractures of the tibia are disabling injuries with a significant risk of deep infection. Treatment involves early antibiotic administration, early and aggressive surgical debridement, and may require complex soft tissue coverage techniques. The extent of disruption to the skin and soft-tissue envelope often varies, with ‘simple’ open fractures (defined by the Orthopaedic Trauma Society (OTS) open fracture severity classification) able to be closed primarily, whilst others may require shortening or soft-tissue reconstruction. This study aimed to determine whether OTS simple tibial open fractures received different rates of adequate debridement and plastic surgical presence at initial debridement, compared with OTS complex injuries, and whether rates of fracture-related infection, nonunion, or reoperation differed between the groups. Materials & Methods. A consecutive series of open tibia fractures managed at a tertiary UK Major Trauma Centre between January 2021 and November 2022 were included. Patient demographics, injury characteristics, timing of antibiotic delivery, timing and method of definitive fixation, and frequency of plastic surgical presence at initial debridement were retrospectively collected. The delivery of bone ends at initial debridement was used as a proxy for adequacy of surgical debridement. The primary outcome measure was rate of fracture-related infection, secondary outcomes included rates of reoperation, nonunion, and amputation. Chi2 Tests and independent samples T-tests were used to assess nominal and continuous outcomes respectively between simple and complex injuries. Ordinal data was assessed using nonparametric equivalent tests. Results. 79 patients with open fractures of the tibia were included. 70.8% of patients were male, with mean age 50.4 years (SD 19.2) and BMI 26.4 Kg/m2 (SD 6.0). Injuries were mostly sustained by low-energy falls (n = 28, 35.4%) and from road traffic accidents (n = 26, 32.9%). 27 (34.2%) were OTS simple open fractures. Simple open fractures were most commonly Gustillo-Anderson grade 1 (38.5%), or 2 (30.8%), whilst complex open fractures were mostly grade 3B (66.7%) (p < 0.001). Fracture-related infection rates in OTS simple and complex open fractures were 25.9% and 25.5% respectively (p = 0.967), and nonunion rates were 32% and 37.8% (p = 0.637). Primary amputation was less common in simple (0%) than in complex open fractures (20%, p = 0.012), there were no differences in delayed amputation rates (7.4% and 6% respectively, p = 0.811). Simple open fractures were less likely to have plastic surgeons present at initial debridement compared to complex open fractures (18.5% and 44%, p = 0.025), and less likely to have bone ends delivered through the skin at initial debridement (25.9% and 61.2%, p = 0.003). There were no differences in patient age, delays to antibiotic administration, or reoperation rates between OTS simple and OTS complex fractures (p > 0.05). Conclusions. Despite involving less significant soft tissue injury, OTS simple open tibia fractures had comparable deep infection and nonunion rates to complex fractures and received early plastic surgical input and adequate debridement less frequently. The severity of open fractures with less significant soft tissue injury may be underrecognized and therefore undertreated, although further prospective study is needed

This study aimed to investigate the outcomes of open tibia shaft fractures at a level one trauma center in a developing world setting. Specific objectives were to determine the association of time delay to antibiotic administration, surgical debridement, definitive skeletal stabilisation and soft tissue reconstruction, and the development of fracture-related infection (FRI). A retrospective cohort study included all adult patients with open tibia shaft fractures from July 2014 to June 2016 and January 2018 to December 2019. Patients who were skeletally immature at the time of injury, those with pathological fractures and who did not complete follow-up of at least three months were excluded. Patients were identified from hospital records. Data was captured in Microsoft Excel and analysed using STATISTICA. A Chi-squared was used to detect significant differences between groups. No association between infection and antibiotic administration was observed when patients were treated within or after 3 hours (p=0.625) or if patients had their first surgical debridement in theatre before or after 24 hours (p=0.259). Patients who waited more than five days for definitive skeletal fixation or soft tissue reconstruction had a significant increase in FRI (OR 4.7, 95% CI 2.0 – 10.9 and OR 4.7, 95% CI 2.0 – 11.0, respectively). Patients who underwent more than two formal debridements had a higher risk of developing FRI (OR 15.6, 95% CI 5.8 – 41.6). Whilst administration of antibiotics within 3 hours of presentation to the emergency unit had no impact on the development of FRI, time delays in managing open tibia shaft fractures are associated with an increased risk for FRI. Definitive soft tissue reconstruction and skeletal stabilization should not be delayed for more than five days

Background:. There are multiple risk factors regarding the outcome of open tibia fractures treated with surgical fixation. In this study we have looked at delay to debridement and HIV infection as risk factors in the outcome of open tibia fractures. Methods:. We present a prospective study of 89 patients with open tibia fractures treated with surgical fixation with a significant delay to first debridement and a high prevalence of HIV infection. Primary outcome of this study was time to union and wound infection in the first 3 months. All patients admitted in our hospital between February 2011 and October 2012 with open fractures of the tibia requiring surgical fixation were included in the study. Patients were tested for HIV infection and multiple clinical parameters were documented, including; Gustilo-Anderson classification, ASEPSIS wound score, New Injury Severity Score(NISS), comorbidities, time to 1st debridement, time to 1st dose of antibiotics, pin site score, level of contamination, level training of the surgeon, high energy injuries, time to union and socio-economic parameters. Patients were followed to union. Results:. Twenty-five (28%) of the 89 patients were HIV positive. Forty-six (52%) patients had a delay to debridement of more than 24 hours. Eight (9%) patients developed wound infection in the first 3 months. Seventeen (19%) patients had a delayed union of more than 6 months. This study was underpowered to show a relation between wound infection and the clinical parameters of our patients. A logistic regression analysis showed that grade 3 Gustilo-Anderson injuries were associated with delayed union. We did not find an association between delayed union and; – HIV status, NISS, time to 1st debridement, high energy injuries, level of contamination and time to 1st dose of antibiotics. Conclusion:. This study suggests that delay to 1st debridement and HIV status are not significant risk factors for wound infection and delayed union in patients with open tibia fractures. There was a significant association between Gustilo-Anderson grade 3 open fractures of the tibia and delayed union. We stress the importance of good clinical judgment in the surgical treatment of open tibia fractures in a setting with high rates of HIV infection and limited resources

To describe clinical situations for use of modified VAC in POC based on: diagnosis, comorbidities, BMI, wound size in cm, days following trauma when VAC was first applied, total duration of uninterrupted use, frequency of change, settings, bacterial growth, outcomes. To report the outcomes of mVAC use in POC within 6 months to help improve and standardize its application in the institution. This study involves data gathering from inpatients handled by orthopedic surgeons in training and subspecialty rotations in POC. The data collected are highly dependent on the doctors-in-charge's complete charting, thorough reporting and accurate documentation. Modified Vacuum Assisted Closure (mVAC) is used frequently in this study and is defined as a form of revised, adapted and reformed use of VAC based on available materials in the involved institution. The materials that are included are, but not limited to the following: sterile Uratex™ blue foam, nasogastric or suction tubing, phlegm suction machine, Bactigras™ and Opsite™ or Ioban™. A total of 58 patients were included in the study. The average age of the population was 35 and are predominantly male. The most common mechanism of injury was motorcycle accident and 37 of the patients were diagnosed with an open fracture of the lower extremity with open tibia fractures (22) being the most common. Average wound area measured was 24.12 cm. 3. All patients yield a bacteria growth with e. coli being the most frequent. Average during of uninterrupted use was 39 days. Of the 58 included in the study, 8 patients underwent STSG, 2 had a flap coverage surgery, 4 patients eventually underwent amputation and 33 with complete resolution of soft tissue defect after conversion to biologic dressing post-mVAC. The rest of the population were still ongoing mVAC at the end of the study. mVAC is an alternative temporary medium for soft tissue coverage for cases with or without concomitant fractures. mVAC promotes removal of exudate from the wound, supports wound apposition and granulation bed proliferation. Usage mVAC helps prepare for skin coverage procedure and on some cases leads to full resolution of defect

Open tibial fractures can be difficult to manage, with a range of factors that could affect treatment and outcome. We present a large cohort of patients, and analyse which factors have significant associations with infection outcome. Elucidation will allow clinicians to strive for treatment optimisation, and patients to be advised on likely complications. Open tibia fractures treated at a major trauma centre between 2015-2021 were included. Mean age at injury was 55.4 (range 13-102). Infection status was categorized into no infection, superficial infection, and osteomyelitis. Age, mode of injury, polytrauma, fibula status, Gustilo-Anderson (GA) classification, wound contamination, time from injury to: first procedure/definitive plastics procedure/definitive fixation, type of definitive fixation, smoking and diabetic status, and BMI, were collected. Multicollinearity was calculated, with highly correlated factors removed. Multinomial logistic regression was performed. Chi Squared testing, with Post Hoc Bonferroni correction was performed for complex categorical factors. Two hundred forty-four patients with open tibial fractures were included. Forty-five developed superficial infection (18.4%), and thirty-nine developed osteomyelitis (16.0%). Polytrauma, fibula status, and type of definitive fixation were excluded from the multivariate model due to strong multicollinearity with other variables. With reference to the non-infected outcome; superficial infection patients had higher BMI (p<0.01), higher GA grade (p<0.01), osteomyelitis patients had longer time to definitive fixation (p=0.049) and time to definitive plastics procedure (p=0.013), higher GA grade (p<0.01), and positive wound contamination(p=0.015). Poc hoc analysis showed “no infection” was positively associated with GA-I (p=0.029) and GA-II (p<0.01), and negatively associated with GA-IIIC (p<0.01). Osteomyelitis was positively associated with GA-IIIc (p<0.01). This study investigated the associations between the injury and presentation factors that may affect infection outcome. The variables highlighted are the factors clinicians should give extra consideration to when treating cases, and take preventative measures to optimize treatment and mitigate infection risk

Introduction: The addition of recombinant human bone morphogenetic protein-2 (rhBMP-2) showed significant reduction of secondary intervention, fracture healing time and infection rates compared with intramedullary nailing alone in open tibia fractures. However, the upfront price of approx. 3000 € is a barrier to its regular use. The goal of the study was to determine potential cost savings and cost-effectiveness of rhBMP-2 in grade III open tibia fractures from the perspective of the UK National Health Service (NHS) and the German Health Care System and to derive conclusions for other European health care systems. Materials and Methods: Clinical data from a previously published randomised controlled study with 450 patients (“BESTT study”) were used to generate total treatment costs for each patient for the control and the 1.5 mg/ml BMP-2 group based on the current German-DRG and the NHS for UK. The analysis was performed from a health care system and a societal perspective for a one year time horizon. Furthermore, assessment of the cost-effectiveness of BMP-2 was done by utility analysis. Results: The use of BMP-2 for grade III open tibia fractures is leading to cost savings of 3183 € per case and, therefore, to net savings for the German health care system. The main driver for cost savings is faster fracture healing with faster resumption of work and reduced expenses for sickness leave payments. For the UK rhBMP-2 is a cost-effective strategy with a cost-effectiveness ratio of approx. £11,000/QALY which is well below the standard £30,000 benchmark for the NHS. From a societal perspective, rhBMP-2 is a cost-saving treatment. Conclusions: BMP-2 leads to net savings in grade III open tibia fractures in Germany which can be expected for other European countries where sickness payments are provided by health care insurers. For countries like UK where sickness are provided by third parties BMP-2 is a cost-effective treatment strategy from a health care system perspective and a cost-saving treatment from a societal perspective

Open tibia fractures are often associated with delayed union and non-union. The use of recombinant human bone morphogenetic protein-2 (rhBMP-2) to treat acute, open tibial shaft fractures has been approved in both Europe (InductOs) and the United States (INFUSE Bone Graft). These approvals were based on the results of a prospective, randomized study of 450 patients with open tibia fractures that has already been published (. Govender et al. 2002. ). Material and Methods: A sub-group of patients from the above study with Gustilo Grade IIIA and IIIB open tibia fractures was separately analyzed. Patients treated with the standard of care (intramedullary nail fixation and routine soft-tissue management [the control group]) were compared to those that received the standard of care and an implant containing the approved concentration of rhBMP-2 (1.50 mg/mL). The primary outcome measured was the incidence of secondary intervention to promote bone healing during the twelve months of follow-up. Fischer’s exact test was used to compare the two groups. Results: There were 55 patients in the control group and 59 patients in the rhBMP-2 group. The combined incidence of nail dynamization (those both performed and from broken screws) was higher in the control group 28/55 than the rhBMP-2 group 18/59. Significantly more control patients required autologous bone grafting because of delayed union or non-union as compared to the rhBMP-2 group [10/55 (18%) versus 1/59 (2%), respectively; p=0.0033]. More patients in the control group 15/55 required invasive secondary interventions to promote bone healing than those in the rhBMP-2 group 6/59 (p=0.0283). Fewer infections were observed in the rhBMP-2 group 14/59 as compared to the control group 23/55. In addition, the average time to full weight bearing for patients was 34 days sooner when rhBMP-2 was used (96 versus 130 days). Conclusions: The addition of rhBMP-2 to the treatment of open tibia fractures represents a significant improvement over the standard of care. Treatment of Grade III tibia fractures with rhBMP-2 was shown to reduce the incidence of both invasive secondary interventions and infections. The additional expense of using rhBMP-2 can be justified for these severe fractures, by the potential to eliminate of the cost required to treat these complications

The use of external fixation in open tibia fractures with severe soft tissue injury is the most preferred and safe treatment. The primary allograft application is doubtful due to high infection risk. The evaluation of the results of open tibia fractures type II and III according Gustillo-Anderson that were treated with simultaneous external fixation and allograft application. From 2005–2007, twenty nine open tibia shaft fractures in 27 patients (2 bilateral) with mean age of 35 years-old were treated. According Gustillo-Anderson classification, there were 20 GII, 6GIIIa and 3GIIIb open tibia shaft fractures without severe bone loss. All patients were treated with thorough and extensive surgical debridment, external fixation and simultaneous application of allograft and double antibiotic scheme. The patients were followed up initially weekly till stitches removal and every second week till the external fixation removal without developing any signs of infection. Overall, there were uncomplicated union in 23 cases (18 GII, 3GIIIa and 2GIIIb) whereas in 5 cases we had to change method of treatment (3 GII and 2GIIIa) due to union delay or non acceptable fracture angulations. There were also a case that developed deep infection and septic pseudarthrosis. The simultaneous external fixation and allograft application seems to provide a small advantage in open fracture consolidation despite the established wisdom for allograft use on a later stage. The proper initial open fracture estimation, the right surgical treatment, the surgeon’s experience and a strict patient’s follow up schedule are fundamental for a good final outcome

Objective: 57 open tibia fractures treated with external fixation during the period 1996–2001 are presented. Material and Methods: 57 open tibia fractures concerning 52 patients (45 males, 12 females) were treated with external fixation during the period 1996–2001. Fracture classification according Gustilo included 5 type I fractures, 14 type II fractures, 18 type IIIA fractures and 20 type IIIB fractures. The following external fixation devices were used: STAR in 3 patients, EXFIRE in 9 patients, HOFFMANN in 18 patients, ORTHOFIX in 27 patients. All open wounds were left to heal at secondary intention. The devices were fully functional within 4 to 8 weeks in 37 patients depending on the type of the fracture. Results: 39 fractures were completely healed in a mean time of 16 weeks. Nine fractures had delayed union and finally were completely healed without using alternate devices. In 8 cases there was pseudarthrosis; internal fixation with intramedullary nail was used in seven of these cases, and 2 cases were treated with grafts. One case was complicated with septic pseudarthrosis that was treated by bone transfer in a tertiary centre. Wound healing was achieved in 45 cases. Delayed skin surgical closure was needed in 12 cases. Needle infection rate was 27%, while in 4 cases there was deep infection and needles were removed. Conclusion: For the vast majority of open tibia fractures, external fixation can be used as a permanent way of treatment. Clinicians should set external fixation with this permanent prospective

The aim of this study was to characterise severe open tibial shaft fractures sustained by UK military personnel over 10-years of combat and to determine the infection rate and factors that influence it. The UK military Joint Theatre Trauma Registry was searched and X-rays, clinical notes and microbiological records were reviewed for all patients. One hundred GA III open tibia fractures in 89 patients were identified. Three fractures were not followed up for 12-months and were therefore excluded. Twenty-two (23%) of the remaining 97 tibial fractures were complicated by infection requiring surgical treatment, with S. aureus being the causative agent in 13/22 infected fractures (59%). Neither injury severity, mechanism, the use of an external fixator, the need for vascularised tissue transfer or smoking status were significantly associated with infection. Bone loss was significantly associated with subsequent infection (p<0.0001). Most infection in combat open tibia fractures is caused by familiar organisms i.e. S. aureus. The use of external fixators to temporarily stabilise fractures is not associated with an increased risk of subsequent infection. While the overall severity of a casualty's injuries was not associated with infection, the degree of bone loss from the fracture was

Aims. Following the introduction of national standards in 2009, most major paediatric trauma is now triaged to specialist units offering combined orthopaedic and plastic surgical expertise. We investigated the management of open tibia fractures at a paediatric trauma centre, primarily reporting the risk of infection and rate of union. Patients and Methods. A retrospective review was performed on 61 children who between 2007 and 2015 presented with an open tibia fracture. Their mean age was nine years (2 to 16) and the median follow-up was ten months (interquartile range 5 to 18). Management involved IV antibiotics, early debridement and combined treatment of the skeletal and soft-tissue injuries in line with standards proposed by the British Orthopaedic Association. Results. There were 36 diaphyseal fractures and 25 distal tibial fractures. Of the distal fractures, eight involved the physis. Motor vehicle collisions accounted for two thirds of the injuries and 38 patients (62%) arrived outside of normal working hours. The initial method of stabilisation comprised: casting in nine cases (15%); elastic nailing in 19 (31%); Kirschner (K)-wiring in 13 (21%); intramedullary nailing in one (2%); open reduction and plate fixation in four (7%); and external fixation in 15 (25%). Wound management comprised: primary wound closure in 24 (39%), delayed primary closure in 11 (18%), split skin graft (SSG) in eight (13%), local flap with SSG in 17 (28%) and a free flap in one. A total of 43 fractures (70%) were Gustilo-Anderson grade III. There were four superficial (6.6%) and three (4.9%) deep infections. Two deep infections occurred following open reduction and plate fixation and the third after K-wire fixation of a distal fracture. No patient who underwent primary wound closure developed an infection. All the fractures united, although nine patients required revision of a mono-lateral to circular frame for delayed union (two) or for altered alignment or length (seven). The mean time to union was two weeks longer in diaphyseal fractures than in distal fractures (13 weeks versus 10.8 weeks, p = 0.016). Children aged > 12 years had a significantly longer time to union than those aged < 12 years (16.3 weeks versus 11.4 weeks, p = 0.045). The length of stay in hospital for patients with a Gustilo-Anderson grade IIIB fracture was twice as long as for less severe injuries. . Conclusion. Fractures in children heal better than those in adults. Based on our experience of deep infection we discourage the use of internal fixation with a plate for open tibial fractures in children. We advocate aggressive initial wound debridement in theatre with early definitive combined orthopaedic and plastic surgery in order to obtain skeletal stabilisation and soft-tissue cover. Cite this article: Bone Joint J 2017;99-B:544–53

Summary. open tibia fractures are best treated in an orthopaedic-plastic surgical multidisciplinary setting. Introduction. Open fractures of the leg represent a severe trauma. It is often stated that combining the skills of Plastic and Orthopaedic surgeons can optimise the results of limb salvage in complex limb injury. The multidisciplinary approach, shared between plastic and orthopaedic surgeons, is likely to provide the optimal treatment of these injuries, although this mutidisciplinary simultaneous treatment is not routinely performed. Given the relatively low incidence of these traumas, a multicentric recruitment of these patients can contribute in providing an adequately numerous cohort of patients to be evaluated through the long process of soft tissue and bone healing following an open tibia fracture. We compared three centres with different protocols for management of these challenging cases. Patients & Methods. The following trauma centres, either orthoplastic or orthopaedic, were involved in a prospective observational study: Rizzoli Orthopaedic Institute/University of Bologna (leading centre) and Maggiore Hospital (Bologna), Frenchay Hospital (Bristol, Regno Unito), Jinnah Hospital (Lahore, Pakistan), a centre in the developing world who have adopted an Ortho-Plastic approach. From 01/01/2012, all patients consecutively hospitalised in the mentioned centres due to Gustilo grade 3 tibial open fractures were included in the study and propspectively followed. Demographics, mechanism of the trauma, type of lesion, timing and way of transfer to the trauma centre, as well as timing and techniques of bone and soft tissue treatment were recorded. The considered outcome measures were duration of hospitalization (main outcome measure), rate of reintervention, Enneking score at 3, 6 and 12 months, the incidence of osteomyelitis, non union, amputation and other complications. Results. The number of patients included in the first 6 months was 42. Mechanism, severity of injury and techniques regarding definitive bone reconstruction were similar accross the three centres. The main difference occured in soft-tissue management with VAC therapy being utilised by the Italian centre compared to vascularised tissue transfer in Pakistan and Britain. The mean duration of hospital stay in the Italian centre was 72 days compared with 24 days in Pakistan and 25 days in Britain. Patients treated in a centre with an orthoplastic team, therefore, spent an average of 46 fewer days in hospital (P<0.005, 95% CI −69 to −24days). Discussion. From an initial analysis of data, the duration of hospitalization is strongly influenced by the fact that a plastic procedure is performed or not. The first evaluations on the hospital management of these injuries show a relevant advantage deriving from a combined orthoplastic approach, evenwhen applied into a comparatively hostile cohort

The introduction of new treatments needs to be both clinically effective and cost effective. Clinicians tend to be unaware of the importance of the latter, and how health economic assessments are undertaken, especially in a public health system where the inclusion of funded treatments is made on a national basis. The purpose of this study was to determine the cost savings from a societal perspective in the use of recombinant human Bone Morphogenetic Protein -2 (rhBMP-2) in grade III A and B open tibia fractures treated with a locked intramedullary nail and soft-tissue management in the UK, Germany, and France. Healthcare system (direct healthcare costs) and costs for productivity losses (indirect health-care costs) were calculated using the raw data from the Bone Morphogenetic Protein Evaluation Group in Surgery for Tibial Trauma “BESTT study”. Return-to-work time for estimation of productivity losses was assumed to correspond with the time of fracture healing. For calculation of secondary interventions costs and productivity losses the respective 2007/08 national tariffs for surgical procedures and average national wages for the UK, Germany, and France were used. From a societal perspective, overall savings per case of €7911 for the UK, €9270 for Germany, and €9291 were calculated. Those savings largely offset the upfront price of rhBMP-2 of €2266(£1,790) in the UK, €2970 in Germany, and €2950 in France. Total net savings can be estimated to be €9.6 million for the UK, €14.5 million for Germany, and €11.4 million for France. For all three countries reduced productivity losses are the key driver for the overall savings. In summary, despite the apparent high direct cost of rhBMP-2 in grade III A and B open tibia fractures, at a national level there are net cost-savings from a societal perspective for all three countries

Background: In this retrospective study our purpose was to compare two treatment alternatives clinically. Methods: Forty-five patients having grade I or II open tibia fractures were consisted in this study. Twenty-five of them, treated via minimal invasive plate osteosynthesis (MIPO), comprised group I. The latter 20 cases, treated via partial reamed intramedullary nailing (PR-IMN), called as group II. Aggressive debridement of all necrotic soft tissue and bone was performed primarily for all cases in the emergency room at admission to hospital. Definitive fixation was performed on average 3rd days (0 – 5) for group I and 2.5th days (0 – 4) for group II. Clinical evaluation was made on the basis of modified Ketenjian’s criteria. Results: There were no significant differences between groups for demographic data (age, gender) and fracture type (p> 0.05). Full weight bearing periods of the group I and II were 21 and 22.4 weeks respectively. Non-union in one case of group I was revised by using circular external fixator. In another case implant removal was performed due to chronic osteomyelitis. Mal-union was detected in another case. In group II, two cases needed implant revision with intramedullary nail in one and circular external fixator in another for non-union. Mal-union in one case and chronic osteomyelitis in another were late complications of group II. At the last follow up satisfaction rates were as; 21/25 in group I and 18/20 in group II clinically. There was no significant difference between both groups with regard to clinical evaluation (p> 0.05). Conclusion: The clinical results of both groups were similar to each other. Although intramedullary nailing is the first choice, MIPO can be an alternative method for open tibia fractures

Purpose. To examine the management and outcome of patients suffering complex paediatric lower limb injuries with bone and soft tissue loss. Method. A retrospective review was conducted identifying patients from our trauma database. Inclusion criteria were age (4–17 years) and open lower-limb trauma. Outcome measures included time to soft tissue coverage, surgical techniques, trauma impact scores, health-related quality of life, union and complication rates. Results. We identified 26 patients. 24 patients had open tibia fractures including 10 patients with bone loss. In 9 patients primary skin closure was achieved by acute shortening. 17 patients required soft tissue coverage including 14 free vascularised muscle flaps (89% within 48 hours). The surgical techniques applied were: circular fine wire frame (16), external fixateur (5) and open reduction internal fixation (5). Median follow up time was 8 (3–45) months. The trauma impact scores showed one in three patients were at risk of PTSD. All fractures went on to unite over a median time of 4.2 (2–9) months. No deep infections occurred. Conclusion. All our patients had limb salvage, fracture union and near normal levels of physical scores in the short term. Close psychological follow up is advisable to minimise the risk of PTSD