Introduction. Management of open fractures is challenging and requires a multidisciplinary team approach. Gustilo Anderson Type IIIB fractures reportedly have a higher infection rate (up to 52%) and up to 16% amputation rate. This study aims to evaluate outcomes of using Adjuvant Local Antibiotic Hydroxyapatite Bio-Composite in management of Open Gustilo-Anderson IIIB fractures. Materials and Methods. We reviewed a prospective data of 80 patients who presented with Gustilo Anderson Type IIIB Open Fracture to a single ortho-plastic centre. Only patients who were managed with single-stage “Fix and Flap” along with intra-operative Adjuvant Local Antibiotic Bio-Composite were included. Results. Mean follow-up time was 22 months. The mean time from injury until definitive surgery was 7.73 days (1–30 days). Primary union achieved in 88.3% within 32 weeks on average. The delayed union reported in 7.8% of patients, for the bone healing stimulated by injecting the fracture site with Autologous Bone Marrow Aspirate Concentrate. Subsequent follow-up showed signs of successful fracture healing at 60 weeks post-injury. Three patients (3.9%) had non-union. Limb salvage rate was 96.25%, and only 1.25% deep infection rate. Conclusions. Our results highlight that low infection rates, high limb salvage rates and high union rates can be achieved in these complex injuries with a combined OrthoPlastic approach, MDT input, meticulous technique and the use of adjuvant local antibiotic bio-composite. Delay in definitive surgery, gentamicin resistance and smoking were not associated with any increased deep infection or non-union in our series. At 22 months of follow-up, deep infection rate was 1.25%, limbs salvage rate was 96.25%, fracture union rate was 96.1%, and reoperation rate 18.75%

Introduction

Open fractures are fortunately rare but pose an even greater challenge due to poor soft tissues, in addition to poor bone quality. Co-morbidities and pre-existing medical conditions, in particular, peripheral vascular diseases make them often unsuitable for free flaps. We present our experience in treating severe open fractures of tibia with Acute Intentional Deformation (AID) to close the soft tissues followed by gradual correction of deformity to achieve anatomical alignment of the tibia and fracture healing with Taylor Spatial Frame.

Grade III Open fractures of the tibia represent a serious injury. It is recognised that combined management of these cases by experienced orthopaedic and plastic surgeons improves outcomes. Previous studies have not considered the timing of definitive soft tissue cover in relation to the definitive orthopaedic management. We reviewed medical notes of 73 patients with 74 Grade III Open tibia fractures (minimum 1 year follow up), to compare deep infection rates in patients who had a) a single-stage definitive fixation and soft tissue coverage vs. those who had separate operations, and b) those who had definitive treatment completed in < 72 hours vs. > 72 hours.

Of subjects that underwent definitive fixation and coverage in a single procedure, 4.2% developed deep infections, compared with 34.6 % deep infection(p<0.001) in those who underwent definitive treatment at separate operations. Of patients who had definitive treatment completed in < 72-hours, 20.0% developed deep infections a compared with 12.2%(p=0.4919) in the >72-hour group.

Patients with Gustilo III open tibial fractures have lower rates of deep infection if definitive fixation and coverage are performed in a single-stage procedure. Emphasis should be placed on timely transfer to a specialist centre, aiming for a single-stage combined orthoplastic surgery.

Introduction. The reconstruction of segmental long bone defects remains one of the holy grails of orthopaedic surgery. The optimal treatment of which remains a topic of great debate. This study aimed to evaluate the outcomes following the management of critical-sized bone defects using a classification-based treatment algorithm. Materials & Methods. A retrospective review of all patients undergoing treatment for segmental diaphyseal defects of long bones at a tertiary-level limb reconstruction unit was performed. The management of the bone defect was standardised as per the classification by Ferreira and Tanwar (2020). Results. A total of 96 patients (mean age 39.8, SD 15.2) with a minimum six months follow-up were included. Most bone defects were the result of open fractures (75/96) with 67% associated with Gustilo-Anderson IIIB injuries. There was a statistical difference in the likelihood of union between treatment strategies with more than 90% of cases undergoing acute shortening and bone transport achieving union and only 72% of cases undergoing the induced membrane technique consolidating (p=0.049). Of those defects that consolidated, there was no difference in the time to bone union between strategies (p=0.308) with an overall median time to union 8.33 months (95% CI 7.4 — 9.2 months). The induced membrane technique was associated with a 40% risk of sepsis. Conclusions. This study reported the outcomes of a standardised approach to the management of critical-sized bone defects. Whilst overall results were supportive of this approach, the outcomes associated with the induced membrane technique require further refinement of its indications in the management of critical-sized bone defects

Introduction. Open tibial fractures typically occur as a consequence of high energy trauma in patients of working age resulting in high rates of deep infection and poor functional outcome. Whilst improved rates of limb salvage, avoidance of infection and better ultimate function have been attributed to improved centralisation of care in orthoplastic units, there remains no universally accepted method of definitive management of these injuries. The aim of this study is to the report the experience of a major trauma centre utilising circular frames as definitive fixation in patients sustaining Gustilo-Anderson (GA) 3B open fractures. Materials & Methods. A prospectively maintained database was interrogated to identify all patients. Case notes and radiographs were reviewed to collate patient demographics and injury factors . The primary outcome of interest was deep infection rate with secondary outcomes including time to union and secondary interventions. Results. 247 open tibial fractures with a soft tissue manipulation in order to achieve skin cover, of which 203 had a minimum follow up of 2 years. Mean age was 43.2 years old, with 72% males, 34% smokers and 3% diabetics. Total duration of frame management averaged 6.4 months (SD 7.7). Nine (4.4%) patients developed a deep infection and 41 (20%) exhibited signs of a pin site infection. Seventy-five (37%) of patients had a secondary intervention of which; 8 comprised debridement of deep infection, 1 amputation for deep infection and the remainder adjustments of frames. Conclusions. Orthoplastic care including circular frame fixation for GA 3B fractures of the tibia results in a low rate of deep infection, around a quarter of contemporary literature for internal fixation

Objectives. Open fracture classification systems are limited in their use. Our objective was to classify open tibia and femur fractures using the OTS classification system in a region with high incidence of gunshot fractures. One hundred and thirty-seven patients with diaphyseal tibia and femur open fractures were identified from a prospectively collected cohort of patients. This database contained all cases (closed and open fractures) of tibial and femoral intramedullary nailed patients older than 18 years old during the period of September 2017 to May 2021. Exclusion criteria included closed fractures, non-viable limbs, open fractures > 48 hours to first surgical debridement and patients unable to follow up over a period of 12 months (a total of 24). Open fractures captured and classified in the HOST study using the Gustilo-Anderson classification, were reviewed and reclassified using the OTS open fracture classification system, analysing gunshot fractures in particular. Ninety percent were males with a mean age of 34. Most common mechanism was civilian gunshot wounds (gsw) in 54.7% of cases. In 52.6% of cases soft tissue management was healing via secondary intention, these not encompassed in the classification. Fracture classification was OTS Simple in 23.4%, Complex B in 24.1% and 52.6% of cases unclassified. The OTS classification system was not comprehensive in the classification of open tibia and femur fractures in a setting of high incidence of gunshot fractures. An amendment has been proposed to alter acute management to appropriate wound care and to subcategorise Simple into A and B subdivisions; no soft tissue intervention and primary closure respectively. This will render the OTS classification system more inclusive to all open fractures of all causes with the potential to better guide patient care and clinical research

Introduction. Open tibial fractures (OTF) rank first among lower limb fractures in sub-Saharan Africa and bone infection remains the main challenge. The aim of this study was to identify the factors associated with chronic bone infection after OTF in a limited-resource setting. Methods. Patients aged 18 years and older, who underwent OTF treatment in a tertiary care hospital during the period from December 2015 to December 2020 were included in this retrospective study. Patients were contacted via phone calls and invited for a final clinical and radiological evaluation. Patients who met diagnostic criteria of chronic osteomyelitis were identified. Logistic regression was used to determine the predictive factors of OTF related chronic osteomyelitis. Results. With a mean follow-up period of 29.5±16.6 months, 33 patients out of 105 (31.4%) presented with chronic osteomyelitis. We found that time to first debridement within 6 hours (OR=0.18, 95% CI: 0.05 – 0.75, p=0.018) and severity of OTF according to Gustilo-Anderson classification (OR=2.06, 95% CI:1.34 – 3.16, p=0.001) were the independent predictive factors of chronic bone infection. Neither age, gender, socio-economic level, polytrauma, HIV status, diabetes mellitus, time to definitive surgery, were associated with chronic osteomyelitis. Conclusion. The rate of chronic bone infections after OTF is still high in the sub-Saharan African context. In addition to the overall improvement in the management of open leg fractures in those settings, emphasis should be placed on very early initial debridement to reduce the burden of these infections. Keys words. open tibial fractures, chronic bone infection, predictive factors

Introduction. Pain after trauma has received relatively little research attention compared with surgical techniques and functional outcomes, but is important to patients. We aimed to describe nerve dysfunction and pain characteristics using tibial fractures as a model. We hypothesized that early nerve dysfunction was associated with neuropathic and chronic pain. Materials and Methods. Adult patients with isolated open or closed tibial diaphyseal fractures were prospectively observed for 1-year in 5 Major Trauma Centres. Nerve dysfunction was assessed using Semmes-Weinstein monofilaments, acute pain with the visual numerical rating scale (VNRS), neuropathic pain with the doleur neuropathique-4 score and quality of life (QOL) using the EQ-5D score. Results. Of 77 included patients, twenty-six (33.8%) had Gustilo-Anderson grade II or worse injuries. Forty-six (63.0%) had operative repair; 0 operation notes reported nerve injury. Mean VNRS pain scores one week post-injury were 4.6/10 (SD 2.4). Seventeen patients (23.3%) presented with impaired sensation, persisting in 11 (15.1%) at 3-months. Neuropathic pain affected 16 (20.8%) patients one week post-injury; a further 20 (26.0%) had >2 symptoms of nerve pain. Only four (11.1%) received anti-neuropathic drugs. At 6-months, twenty-three (31.5%) reported mobility problems, 21 (28.8%) difficulty completing normal activities, 25 (34.2%) pain and 15 (20.5%) anxiety and depression. Conclusions. Nerve dysfunction and neuropathic pain are common early features in patients with tibial fractures, but are poorly recognised and inadequately treated. Pain has long-term effects on patients’ QOL. Future work should aim to improve identification and management of neuropathic pain

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

Since its approval by the FDA two decades ago, Negative Pressure Wound Therapy (NPWT) has become a valuable asset in the management of open fractures with significant soft tissue damage as those seen in high velocity gunshot injuries. These lesions are often associated with grossly contaminated wounds and require a prompt and effective approach. Wound dehiscence and surgical site infection are two of the most common post-operative complications, with poor results when treated with standard gauze dresses. NPTW comes as a legitimate resource promoting secondary intention healing through increased granulation and improved tissue perfusion, as well as continuous local wound drainage preventing bacterial growth and further infection. Recent evidence-based guidelines are still limited for use of NPWT in the treatment of Gustilo-Anderson type IIIB open fractures and there are few cases in literature reporting the management of upper extremity injuries. We present and discuss a successful case of a type IIIB open humeral fracture wound treated with NPWT. A 38-years-old male was admitted to the Emergency Room with a type IIIB open humeral fracture as a result of a gunshot with extensive soft tissue damage. IV antibiotic therapy was promptly started followed by surgical stabilization by intramedullary nailing with primary wound closure. The patient presented an early surgical site infection with wound dehiscence requiring secondary debridement with poor subsequent healing and deficient soft tissue coverage. After ineffective 28 days of standard gauze dresses we started NPWT. NPTW was applied using foam coverage over the dehiscence area with visible results after 13 days and complete granulation of the skin defect by the 28th day. The wound healed completely after 14 weeks of NPWT. The fracture evolved into a painless pseudarthrosis revealing an excellent functional recovery and an acceptable aesthetic result. NPTW is a valuable, effective, and well tolerated resource in the treatment of open fractures with extensive soft tissue damage such as Gustilo-Anderson type IIIB fractures. It should be considered not just as a salvage procedure but as well as a primary option especially in grossly contaminated wounds. No benefits in any form have been received from a commercial party

Aim. Duration of perioperative antimicrobial prophylaxis (PAP) remains controversial in prevention of fracture-related infection (FRI) – with rates up to 30% - in open fracture (OF) management. Objectives were to investigate the impact of the PAP duration exclusively in or related to long bone OF trauma patients and the influence of augmented renal clearance (ARC), a known phenomenon in trauma patients, as PAP consists of predominantly renally eliminated antibiotics. Method. Trauma patients with operatively treated OF, admitted between January 2003 and January 2017 at the University Hospitals Leuven, were retrospectively evaluated. FRI was defined following the criteria of the consensus definition of FRI. A logistic regression model was conducted with FRI as outcome. Results were considered statistically significant when p< 0.05. Results. Forty (8%) from the 502 patients developed a FRI, with 20% FRIs in Gustilo-Anderson (GA) III OFs. Higher GA grade and polytrauma were independently associated with the occurrence of FRI. The heterogeneity in OF management, especially with regard to the applied PAP regimens and duration, was striking and consequently hampering the investigation on the impact of PAP duration. To overcome this issue, a subgroup analysis was performed in patients treated with the two PAP regimens as defined in the hospitals' guidelines – i.e. cefazolin, with metronidazole and tobramycine when extensive contamination was present -, revealing flap coverage and relative duration of augmented renal ARC as independently associated factors. Conclusions. For the first time, a definition based on diagnostic criteria was used to objectively include patients with a FRI. In order to support clinicians in establishing strategies to prevent FRI in long bone OFs, further prospective large randomized controlled trials with clearly predefined PAP regimens are needed to provide reliable recommendations regarding the impact of duration of PAP and ARC

Aim. Determine the incidence of surgical site infections (SSI) after intramedullary nailing (IN) of femoral and tibial diaphyseal fractures and evaluate possible risk factors. Method. Prospective observational cohort study. SSI was defined according to CDC-NHSN criteria and surveillance period for the occurrence of infection was 12 months instead of the 90 days currently recommended. Incidence was calculated as the ratio between the number of patients with SSI and total number of patients. Analysis of potential risk factors included patients-related factors (age, gender, body mass index, active foci of infection, immunosuppressive conditions, ASA score, alcohol or illicit drug abuse, smoking, polytrauma, etiology of fracture, type of fracture if closed or open, classification of fracture according to Müller AO, Tcherne classification for closed fractures, Gustilo-Anderson classification and duration of bone exposure for open fractures, previous stay in other healthcare services, use of external fixator, previous surgical manipulation at same topography of fracture, use of blood products); environmental and surgical-related factors (surgical wound classification, duration of surgery, hair removal, intraoperative contamination, antimicrobial use, presence of drains, hypothermia or hypoxia in the perioperative period, type of IN used, reaming, need for muscle or skin flap repair, use of negative pressure therapy) and microbiota-related factors (presence of preoperative colonization by Staphylococcus aureus or Acinetobacter baumannii). Results. 221 patients were included and completed the 12-month follow-up period. Incidence of SSI was 11.8% after 12-month follow-up, but would be 8.59% if used the 90-day vigilance period currently recommended. In the initial analysis by unadjusted logistic regression, following factors were associated SSI: Müller AO classification of the fracture morphology groups 2 or 3, previous use of external fixator, presence of drains, use of negative pressure therapy and need for muscle or skin flap repair. Preoperative colonization by S. aureus or A. baumannii was not associated with occurrence of infection. In the multiple logistic regression-adjusted analysis, only previous use of external fixator and need for muscle or skin flap repair remained associated with SSI. Conclusions. Incidence of SSI associated with IN for femoral and tibial diaphyseal fractures was 11.8%, but currently recommended vigilance period would be less sensitive for SSI detection after fracture fixation. Previous use of external fixators and need for muscle or skin flap repair were factors associated with occurrence of IN related infection

Aim. Open fractures with bone defects and skin lesions carry a high risk of infection potentially leading to prolonged hospitalization and complication requiring revision procedures. Treatment options for diaphyseal fractures with soft tissue lesions are one- or two-stage approaches using external fixation or intramedullary nailing. We describe a surgical technique combining intramedullary nailing with an antibiotic-eluting biphasic bone substitute (BBS) applied both at the fracture site, for dead-space management and infection prevention, and on the nail surface for the prophylaxis of implant-related infection. Method. Adult patients with an increased risk of bony infection (severe soft tissue damage and open fractures of Gustilo-Anderson grades I and II) were treated with debridement followed by application on the intramedullary nail surface, in the canal and at the fracture site of a BBS with prolonged elution (to 28 days) of either gentamicin or vancomycin. All patients also received systemic antibiotic prophylaxis following surgery. Data on infections and other adverse events were collected throughout the follow-up period. Bone union was determined by radiographic assessment of 4 cortices in radiographs obtained 1 year after surgery. Results. In this prospective, non-randomized case series a total of 6 patients were treated: 4 tibia (2 male, 2 female), 1 femur (female) and 1 humerus (male). The mean age of the patients was 28 years (range 18–51 years). Two patients had a history of smoking and 1 patient had a history of diabetes. Minimal Follow up was 12 months (range: 12 – 30 months). One to two weeks postoperatively, partial load bearing (20 kg) was allowed with free mobility of joints. Bone samples from the fracture site following debridement showed the presence of bacteria in 2 cases. No infections were observed during follow-up. Radiographs showed that the bone substitute was resorbed and also a gradual bony union of the fractures. All patients had good clinical outcomes. Conclusions. The addition of a BBS which elutes antibiotic locally in the dead-space of exposed fractures and at the implant surface prevents bacterial colonization and biofilm formation. The injectable composite we used enhances safety in higher risk patients, is easy to use in combination with intramedullary nailing and offers the opportunity for a one-stage procedure. Local administration of antibiotics at the fracture site provides an additional tool to manage difficult-to-treat complex fractures and implant-related infections. Larger studies are needed to confirm these results. *CERAMENT G or V, BONESUPPORT AB

Introduction. Open tibial fractures are associated with an increased risk of infection. The infection rate increases with increasing severity and grade of fracture. Various management options available for fracture treatment are in turn associated with complications including infection. Circular fine-wire fixators cause minimal intra-operative soft tissue disruption and possibly have a better outcome and low complication rates. Objectives. To analyse the effectiveness of circular fine-wire fixators in managing open tibial fractures and to determine the incidence of complications, particularly infection associated with use of these fixators. Methods. A retrospective review of 34 open tibial fractures treated with circular fine-wire fixators [Ilizarov and Taylor Spatial Frame (TSF)] in a teaching hospital. Results. We treated 34 patients (n=34) with fine-wire fixators. An Ilizarov frame was used for 19 (56%) and TSF was used for 16 (44%) patients. Mean patient age was 47.1 years. Seventy four percent had high energy while 26% had low energy injury. Consequently 4 (12%) had grade I, 3 (9%) had grade II, 6(17%) had grade IIIA and 21(62%) had grade IIIB injury as per the Gustilo-Anderson Classification. Forteen percent of patients had proximal, 17% had mid-shaft, 67% had distal tibial fractures respectively. Average time to union was 28.9 weeks. Grade IIIB fractures healed in 29.6 weeks. Fifty percent of these patients were full weight bearing immediately after surgery. 17 required soft tissue coverage and only two developed skin graft complications. Twelve (35%) had pin-site infection treated with antibiotics. There was one case of non-union and no reported mal-union or deep infections. Conclusion. We report fewer complications with the use of fine-wire fixators. The infection rate is low and only limited to superficial tissues. Healing time is considerably reduced and patients are full weight bearing almost immediately. These devices are particularly effective in management of grade IIIB open distal tibial fractures with decreased time to union of tibia

Introduction. Primary wound closure in open tibial fractures has not been recommended. Traditionally initial debridement with fracture stabilisation and delayed wound closure was the accepted treatment. However this practice was developed before the use of prophylactic intravenous antibiotics and improved techniques for fracture stabilisation. Studies suggest that infections are not caused by the initial contamination but the organisms acquired in the hospital. Subsequent primary wound closure after adequate wound care and fracture stabilisation should be a safe concept and should not increase the rate of complications. Material/methods. In a retrospective study we analysed 95 patients with open tibial fractures Gustilo-Anderson Type 1-3a treated at two different teaching hospitals with primary fracture stabilisation and delayed wound closure as group I and primary fracture stabilisation and primary wound closure as group II. Exclusion criteria to the study were the following conditions: Grade 3b and 3c fractures, polytrauma, other fractures, significant medical history, previous surgery 6 months prior to admission. In group I 46 patients (38 males, 8 females) with a mean age of 30.2 years (16-56) were included. 19 sustained Grade 1 open, 16 Grade 2 open, 4 Grade 3a open and 7 gunshot fractures to the shaft of the tibia. In group II 49 patients (36 males, 13 females) with a mean age of 33.4 (18-69) were included. 19 sustained Grade 1 open, 19 Grade 2 open, 3 Grade 3a open and 8 gunshot fractures. The mean follow-up in group 1 was 11.5 (9-18) and 11.7 (8-16) months. The criteria for post-operative infection were clinical/radiological. Results. The mean operating time in group 1 was 96 (45-180) minutes, in group II 101 (40-170) minutes. The hospital stay in group 1 was 8.6 (3-20) days and in group 2 15.4 (4-52) days. One infectious case in group 1 was seen (2%) and two cases in group 2 (4.3%) were found. On further analysis one case in group 2 in our opinion should not have been treated with primary fixation and wound closure. He only had 3 doses of a first generation cephalosporin and was operated 20 hrs after admission to hospital. The corrected sepsis rate in group 2 should therefore should be calculated without that case and then is 2.1%. Discussion. Our results support recent findings that primary wound closure after thorough debridement in Grade 1+2 open fractures does not increase the infection rate in comparison to the standard treatment. It shortens hospital stay and is cost effective treatment. We conclude that primary wound closure is safe. Prospective multicentre studies are needed to further evaluate and result in change of the current practice

We report the results of six trauma and orthopaedic projects to Kenya in the last three years. The aims are to deliver both a trauma service and teaching within two hospitals; one a district hospital near Mount Kenya in Nanyuki, the other the largest public hospital in Kenya in Mombasa. The Kenya Orthopaedic Project team consists of a wide range of multidisciplinary professionals that allows the experience to be shared across those specialties. A follow-up clinic is held three months after each mission to review the patients. To our knowledge there are no reported outcomes in the literature for similar projects.

A total of 211 operations have been performed and 400 patients seen during the projects. Most cases were fractures of the lower limb; we have been able to follow up 163 patients (77%) who underwent surgical treatment. We reflect on the results so far and discuss potential improvements for future missions.