Treatment of open fractures is complex and controversial.

The purpose of the present study is to add evidence to the management of open tibial fractures, where tissue loss necessitates cover with a free flap. We identified factors that increase the risk of complications. We questioned whether early flap coverage improved the clinical outcome and whether we could improve our antibiotic treatment of open fractures. From 2002 to 2013 we treated 56 patients with an open tibial fracture covered with a free flap. We reviewed patient records and databases for type of trauma, smoking, time to tissue cover, infection, amputations, flap loss and union of fracture. We identified factors thatincrease the risk of complications. We analyzed the organisms cultured from open fractures to propose the optimal antibiotic prophylaxis.

Follow-up was minimum one year. Primary outcome was infection, bacterial sensitivity pattern, amputation, flap failure and union of the fracture.

When soft tissue cover was delayed beyond 7 days, infection rate increased from 27% to 60% (p<0.04). High-energy trauma patients had a higher risk of amputation, infection, flap failure and non-union. Smokers had a higher risk of non-union and flap failure. The bacteria found were often resistant to Cefuroxime, aminoglycosides or amoxicillin, but sensitive to Vancomycin or Meropenem.

Flap cover within one week is essential to avoid infection. High-energy trauma and smoking are important predictors of complications. We suggest antibiotic prophylaxis with Vancomycin and Meropenem until the wound is covered in these complex injuries.

The authors wish to thank Christian E Forrestal for secretarial assistance, spreadsheets and figures, MD Maria Petersen for academic feedback and typography.

Table: Culture results. Depicts the organisms isolated from the wounds, their number N and the number of bacteria that were fully susceptible to antibiotics according to the culture results in falling order on day 2–30 from the trauma. Most organisms were resistant to Cefuroxime. A blank space denotes that the organism was not tested against this antibiotic. A “0” denotes that the organism was not fully sensitive to the antibiotic.

Open tibial fractures have a high infection risk making treatment difficult and expensive. Delayed skin closure (beyond 7 days) has been shown to increase the infection rate in several studies (1).

We aim to calculate the cost of infection as a complication of open tibial fractures and to determine the effect of delayed skin closure on this cost.

We retrospectively reviewed all records of patients treated with a free flap in our institution for an open tibial fracture from 2002 to 2013.

We calculated direct costs of treatment by the DRG-values (2014 figures), based on length of stay (LOS), diagnosis, orthopaedic and plastic surgical procedures and the corresponding reimbursement.

The primary goal was to establish the extra cost incurred by an infection, compared to treating an uninfected open tibial fracture. The cost efficiency saving of early soft tissue cover was also investigated.

We analysed 45 injuries in 44 patients. All patients were treated with debridement, stabilization, prophylactic antibiotics and free flap cover. Infection increased the mean total LOS in hospital from 28.0 to 63.8 days. The presence of an infection increased the cost of treatment from a mean of €49.301 for uninfected fractures compared to a mean of €67.958 for infected fractures.

Achieving skin cover within 7 days of injury decreased the infection rate from 60% to 27% (total series rate 48%). The provision of early soft tissue cover (before 7 days) for all patients would have saved an average of €18.658 per patient.

The development of an infection after a severe open tibial fracture greatly increases the cost of treatment. Early soft tissue cover is one aspect of care which has been shown to improve clinical outcomes. This study confirms that it will also reduce the cost of treating these complex fractures – underscoring the need for rapid referral and an ortho-plastic setup to handle them.

We have only calculated the direct costs of treatment. Infected fractures will also consume extra costs in rehabilitation and absenteeism from later infection recurrence and non-union. Therefore, our estimate of the potential saving is likely to be conservative.

Background:

Segmental defects of long bones are notoriously demanding and difficult to treat. We evaluate nine cases where the Masquelet induced membrane technique to substitute bone loss has been used. We discuss the method compared to other types of bone reconstruction and share our tips and tricks to reduce treatment time and improve patient comfort.

Since the approval of parathyroid hormone (PTH) as an anabolic treatment for osteoporosis, PTH has increasingly been investigated for other potential clinical uses such as bone repair and regeneration. The microstructure of newly formed bone during distraction osteogenesis enhanced by PTH treatment has yet to be studied. Therefore, the purpose of the study was to investigate the effects of intermittent parathyroid hormone PTH (1–34) treatment on the microstructure of regenerated bone during distraction osteogenesis in rabbits. After tibial mid-diaphyseal osteotomy the callus was distracted 1 mm/day for 10 days. The rabbits were divided in to 3 groups, which daily received a PTH injection for 30 days, a saline injection for 10 days and a PTH injection for 20 days, or a saline injection for 30 days. The new-trabecular structure of the regenerate callus was assessed by micro computed tomography (μCT). In all 51 specimen obtained from the lengthened tibia were scanned and evaluated morphometrically using three different volume of interests. The investigated μCT parameters included trabecular number Tb.N*, trabecular thickness Tb.Th*, trabecular separation Tb.Sp*, bone volume fraction (BV/TV), bone volume (BV), connectivity density (CD), and degree of anisotropy (DA). The results showed that intermittent treatment with PTH during distraction osteogensis resulted in a significantly higher Tb.N*, a more isotropic trabecular orientation, a higher connectivity density, and a higher bone mass. We also found preliminary evidence suggesting that the newly regenerated calluses treated with PTH were more mature than the non-treated calluses. In conclusion: the study demonstrated that treatment with PTH resulted in an enhanced microstructure of the newly regenerated bone indicating that PTH has a potential role as a stimulating agent for distraction osteogenesis.

The re-establishment of vascularity is an early event in fracture healing; upregulation of angiogenesis may therefore promote the formation of bone. We have investigated the capacity of vascular endothelial growth factor (VEGF) to stimulate the formation of bone in an experimental atrophic nonunion model.

Three groups of eight rabbits underwent a standard nonunion operation. This was followed by interfragmentary deposition of 100 μg VEGF, carrier alone or autograft.

After seven weeks, torsional failure tests and callus size confirmed that VEGF-treated osteotomies had united whereas the carrier-treated osteotomies failed to unite. The biomechanical properties of the groups treated with VEGF and autograft were identical. There was no difference in bone blood flow.

We considered that VEGF stimulated the formation of competent bone in an environment deprived of its normal vascularisation and osteoprogenitor cell supply. It could be used to enhance the healing of fractures predisposed to nonunion.