Open tibial fractures are limb-threatening injuries. While limb loss is rare in children, deep infection and nonunion rates of up to 15% and 8% are reported, respectively. We manage these injuries in a similar manner to those in adults, with a combined orthoplastic approach, often involving the use of vascularised free flaps. We report the orthopaedic and plastic surgical outcomes of a consecutive series of patients over a five-year period, which includes the largest cohort of free flaps for trauma in children to date. Data were extracted from medical records and databases for patients with an open tibial fracture aged < 16 years who presented between 1 May 2014 and 30 April 2019. Patients who were transferred from elsewhere were excluded, yielding 44 open fractures in 43 patients, with a minimum follow-up of one year. Management was reviewed from the time of injury to discharge. Primary outcome measures were the rate of deep infection, time to union, and the Modified Enneking score.Aims
Methods
Type IIIB open tibial fractures are devastating high-energy injuries. At initial debridement, the surgeon will often be faced with large bone fragments with tenuous, if any, soft-tissue attachments. Conventionally these are discarded to avoid infection. We aimed to determine if orthoplastic reconstruction using mechanically relevant devitalized bone (ORDB) was associated with an increased infection rate in type IIIB open tibial shaft fractures. This was a consecutive cohort study of 113 patients, who had sustained type IIIB fractures of the tibia following blunt trauma, over a four-year period in a level 1 trauma centre. The median age was 44.3 years (interquartile range (IQR) 28.1 to 65.9) with a median follow-up of 1.7 years (IQR 1.2 to 2.1). There were 73 male patients and 40 female patients. The primary outcome measures were deep infection rate and number of operations. The secondary outcomes were nonunion and flap failure.Aims
Patient and Methods
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.
open tibia fractures are best treated in an orthopaedic-plastic surgical multidisciplinary setting. 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.Summary
Introduction
The literature states pre-operative angiography of open tibial fractures (OTFs) should only be considered if abnormal pedal pulses are present. Does pre-operative angiography of OTFs benefit patient management? 43 patients were admitted with OTFs to Charing Cross Hospital, London between 3/2004 and 6/2005. Pedal pulses were documented and routine pre-operative angiography performed following primary surgical debridement. At definitive operation, data was collected prospectively assessing vasculature and the microsurgical findings. All patients underwent free flap reconstruction or amputation. Comparison was made with angiographic findings and whether surgical management had been affected. Retrospective audit of all angiograms was performed by a consultant radiologist establishing the sensitivity/specificity.Aim
Method
The aims of this study were to review the management of open tibial fractures in our specialist ortho-plastic centre and to assess whether our practice concurred with the BAO/BAPS guidelines. A retrospective note review of patients with open tibial fractures was undertaken. Data was collected on time to referral to the plastic surgery unit and time to definitive soft tissue cover. Return of limb function was assessed using the Enneking score. Forty five consecutive patients (27M vs. 18F), with an age range of 11–86 yrs (median age of 42 years), were treated using strict protocols. Seventeen cases were referred by the on-site orthopaedic unit, and 28 patients were from 7 neighbouring units. Time from injury to initial plastic surgery assessment ranged from 0 to 19 days, with a median of 4 days. Time from injury to definitive soft tissue cover ranged from 0 to 21, with a median of 5 days. 41/45 cases had definitive surgery within 5 days of initial plastics assessment. 5 patients with definitive treatment at days 4, 4, 7, 7, 12 developed superficial wound infection. Patients referred from neighbouring units underwent on average 1 extra operation. We failed to detect any significant difference in return of function between the 2 groups indicating that referral to a specialist centre may produce equivalent functional return even if there is a delay in definitive treatment. Open tibial fractures should be managed in a specialist centre, manned with dedicated lower limb plastic and orthopaedic reconstructive surgeons and followed up in a combined ortho-plastic clinic. However, more emphasis should be put on improved communication between referring units and the specialist centre.
The formation of restrictive adhesions around the musculotendinous unit after injury is one of the most vexing processes faced by the surgeon. In flexor tendons it has been shown that the synovial tissue is the source of aggressive fibroblasts which contribute to this process. Using a rabbit model, we have examined the effects of treating the synovial sheath with the antimetabolite 5-fluorouracil (5-FU) for five minutes. Inflammatory, proliferative and molecular markers were compared in the response of the treated and control tendons to injury. Compared with a control group we found that the proliferative and inflammatory responses were significantly reduced (p <
0.001) in the treated tendons. Not only was there a reduction in the cellular and cytokine response, but there also was a significant (p <
0.001) reduction in the level of activity of the known pro-scarring agent, transforming growth factor beta 1 (TGF-β1). These pilot studies indicate that the formation of restrictive adhesions may be modulated using a simple single-touch technique in the hope of producing a better return of function.
