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

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

Introduction. Today, Uganda has the second highest rate of road accidents in Africa and the world after Ethiopia. According to the World Health Organization's Global Status Report on Road Safety 2013, Uganda is named among countries with alarmingly high road accident rates. If such trend of traffic accidents continues to increase, the health losses from traffic injuries may be ranked as the second to HIV/AIDS by 2020. These road traffic accidents often result in terrible open injuries. Open fractures are complex injuries of bone and soft tissue. They are orthopedic emergencies due to risk of infection secondary to contamination and compromised soft tissues and sometimes vascular supply and associated healing problems. Any wound occurring on the same limb should be suspected as result of open fracture until proven otherwise. The principles of management of open fracture are initial evaluation and exclusion of life threatening injuries, prevention of infection, healing of fracture and restoration of function to injured extremity. Because of the poor hygienic circumstances and the high rate of cross-infection due to the crowded patient-wards, the risk of getting a post-operative infection is relatively high. Osteoset-T® (Wright Medical) is a medical grade calcium sulfate bone graft substitute which is enhanced for use in infected sites by incorporating 4% tobramycin sulfate. The tobramycin is released locally, allowing therapeutic antibiotic levels at the graft site, while maintaining low systemic antibiotic levels. This local treatment of infection allows new bone formation in the defect site, while decreasing potential systemic effects. Purpose/aim. Prevention and treatment of postoperative osteomyelitis by introducing alcoholic hand-sanitizers and the use of wound debridement and implantation of a medicated bone graft substitute. Materials and Methods. We treated some existing osteomyelitis cases and some open fractures with the medicated bone graft substitutes, at Kilembe Mines Hospital, Uganda. A proper debridement with sequestrectomy when needed was performed after which the pellets were implanted and the wound was closed. A preoperative X-ray was taken as well as clinical pictures. Post-operative x-rays were obtained at 6 weeks post-operative and 6 months post-operative when possible. The case presented in this abstract is a 25year old nurse with a bilateral open tibia fracture due to a motorcycle accident. A proper debridement and plate and screw osteosynthesis was performed after which the pellets were implanted underneath the plate. After surgery systemic antibiotics were given and the wound-dressings were changed when dirty. Results. The case presented is currently 6 months post-operatively and is able to walk without support. The fracture is fully consolidated and the wounds are healed without any sign of infection. Conclusion. Even though the clinical follow-up is not easy in this developing country setting, we were able to evaluate some patients postoperatively. By introducing better hand hygiene (by use of alcoholic hand sanitizers) and medicated bone graft substitutes, we hope to be able to prevent osteomyelitis after open fractures and also to treat chronic osteomyelitis cases. More people are being treated at the moment and a case-control study will be started soon

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

Purpose:. To examine the performance of a novel blood plasma-based bone putty for augmenting the treatment of open tibia fractures. The putty was manufactured from pooled blood plasma and contains a concentration of both plasma and platelet-derived regenerative factors. Based on clinical reports of the use of autologous platelet-rich plasma to treat injuries, we hypothesized that the putty would accelerate healing of fractures and surrounding soft tissues. Methods:. Two-arm, randomized controlled study including 20 treatment patients and 10 controls. Follow-up examinations occurred at 14, 30, 60, 90, 180, and 365 days. The product was provided in a syringe containing 3 cc of putty in a double-pouched, sterile box. The putty was placed at the fracture site during open fracture reduction and mechanical stabilization. Results:. Both treatment and control groups were well balanced with a mean age of 35. Seventy percent were Gustillo IIIA and IIIB injuries, 67% were active smokers, and 70% received external fixation. No adverse events related to the use of the putty were noted. The use of the putty significantly reduced infections at 90 days (p = 0.002), accelerated bone bridging at 90 and 180 days, and provided more rapid wound closure at 30 days. In the subset of patients with IIIA/IIIB injuries, the putty group demonstrated more significantly reduced infections (p = 0.0007), with accelerated bone healing and wound closure approaching statistical significance. There were statistically fewer adverse events with the putty (42.1%) compared to controls (80.0%). Conclusions:. The potential for using a concentration of natural plasma and platelet-derived regenerative factors to augment the healing of traumatic injuries makes this first-in-man study relevant and exciting. The putty performed as expected, promoting more rapid healing of both fractures and wounds. The dramatic reduction in infections was unanticipated and is likely related to antimicrobial peptides in plasma and platelets

A high volume of trauma and limited resources means that traditional methods of bone reconstruction are not feasible in parts of Africa. We present the management and outcomes of using Masquelet's concept, of an induced membrane and secondary morcellised cancellous bone grafting, in patients with severe lower limb trauma. Eleven patients were treated in an orthopaedic department in rural southern Africa between 2011 and 2012. This is a subgroup that is part of a larger study of open fractures that received ethical approval. All patients were male, with ten aged between 20 and 35 and one aged 70. Two were HIV positive. There were three open femur and eight open tibia fractures. Three required fasciocutaneous flaps and one required a muscle flap to achieve adequate soft tissue coverage. Eight cases were performed as the primary treatment and three were to treat septic non-unions. Bone defects ranged from 4 to 10 cm. Definitive bony stabilisation was maintained by mono-lateral external fixator in three patients. In other cases this was converted to a circular frame or internal fixation. The results have been mixed. In three patients bone grafting was delayed due to wound or pin site problems. In one case the bone graft was lost due to infection but repeating the procedure produced a good result. Time to bony union in each case is difficult to quantify. However, there is clear evidence of new bone forming in most cases. Four patients are weight bearing with external fixation removed, as are five patients with internal fixation. In a few cases bony union appears to be taking significantly longer, if at all. Masquelet technique is a welcome addition to the options available in bone reconstruction. However, time to achieve bony union is unpredictable. Refinement of the technique for use in the developing world is needed

Introduction. The optimal treatment of high-energy tibia fractures remains controversial. The role of external fixators has been shown to be crucial. This study aimed to compare the effectiveness of using either Taylor Spatial Frame (TSF) or Ilizarov frames in treatment of high-energy tibia fractures in a tertiary trauma referral centre. Methodology. Retrospective review of consecutive series identified two treatment groups; Group 1(TSF) and Group 2 (Ilizarov). Time in frame (healing time) was defined as time from insertion to removal of frame. All patients with incomplete data secondary to loss to follow-up or death were eliminated. Results. Data was available for 112 patients (Group 1 N37 and Group 2 N85) with average ages for of 46.43 and 44.64 years respectively and a male to female ratio of 23:14 and 63:22. 7 open tibial fractures and 24 distal tibia fractures were treated in Group 1 with 18 open tibia fractures and 24 pilon fractures in Group 2. Average healing time was 174.35 (124–340) and 176.41 (102–555) days respectively. Smoker's average healing time was 181.86 and 213.86 days per group. Non-smokers average healing time was 161.86 and 174 days for the two groups. N5 and N26 patients were recorded as high-energy injuries with associated other multiple fractures or visceral injuries with average frame times of 192.2 and 194.69 days respectively. All fractures went to union with only one infection in the Ilizarov group. Conclusion. Smoking and associated high-energy injuries lead to an increase in healing time for both groups. Despite the rigid nature of TSF, healing time is similar to Ilizarov frame

Introduction. 47 yrs male patient had a prior history. 2005 Fx. proximal tibia (open Fx.). 2007 Metal removal. 2008 Arthroscopic debridement (2 times). He visited out hospital with severe pain and tenderness X-ray (Fig 1) and MRI (Fig 2) findings as follows. Conclusively, He had a chorinic osteomylitis of proximal tibia with soft tissue absess. 1st Surgery. I did arthroscopic debridement Arthroscopic finding shows synovitis, meniscus tear and chondromalacia. I did meticulous debridement (irrigation & curettage). 2nd Surgery. He did primary total knee arthro-plasty instead of two-stage exchange arthroplasty in may, 2010 at the another hospital. 3rd Surgery. After 7 months since he had did total knee arthroplasty, he visited to my hospital again with sudden onset of painful swelling & heating sensation. 4th Surgery. I did second stage reimplantation for infected total Knee arthroplasty after 7 weeks. Now he got a pain relief & ROM restroration. Results. Follow up 12 months X-ray showing all implants to be well-positioned and stable. Clinically, there was no implant considered to be loose. In this study, the knee society and functional scores at final follow up were 82 and 68. Conclusion. The infection after sequales of open proximal tibia fracture is treated by two-stage exchange total knee arthroplasty instead of primary total knee arthroplasty. Two-stage reimplantation of an infected total knee arthroplasty using a static antibiotic-cement spacer achieved an infection control and improvement in the clinical result 3). We use an antibiotic-loaded cement spacer(ALACS) preserved knee function between stages, resulting in effective treatment of infection, facilitation of reimplantation, and improved patient satisfaction 1). The principle surgical technique used for two-stage revision of infected total knee including: (1) exposure, (2) implant removal and debridement, and (3) construction of both static and mobile antibiotic spacers 2