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Hasan YO, Bourget-Murray J, Page P, Penn-Barwell JG, Handley R. Tibiotalar nailing using an antegrade intramedullary tibial nail: a salvage procedure for unstable distal tibia and ankle fractures in the frail elderly patient. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:847-852. [PMID: 37742301 DOI: 10.1007/s00590-023-03735-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/10/2023] [Indexed: 09/26/2023]
Abstract
AIM This article describes the technique of tibiotalar nailing performed using an antegrade tibial nail for salvage of distal tibia and ankle fractures in elderly patients. MATERIALS AND METHODS We report indications, surgical technique, and the clinical outcomes and complication rate in our series to date. A retrospective review was performed at our level 1 major trauma centre. Patient demographics, comorbidities, and 12-month post-operative course were collected. Fractures were classified using the OTA/AO and modified Gustilo-Anderson classification. Fifteen patients underwent the procedure. We present data with a minimum 12-month follow-up. The median age of the patients in this cohort was 83 years (range, 51-102). Five patients were diabetic. Six patients (6/15; 40%) presented with an open fracture. RESULTS At final follow-up, fourteen patients reported painless walking and had returned to baseline activity. CONCLUSION This technique may serve as a salvage procedure, with indications similar to those for tibio-talar-calcaneal arthrodesis. Indications would include non-constructible pilon fractures, comminuted intra-articular fractures in low-demand patients, or patients at high risk of wound complications. LEVEL OF CLINICAL EVIDENCE 3.
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Affiliation(s)
- Yusuf Omran Hasan
- Oxford Trauma Unit, John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom.
- Orthopaedic Department, Salmaniya Medical Complex, Manama, Kingdom of Bahrain.
| | - Jonathan Bourget-Murray
- Oxford Trauma Unit, John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
- Division of Orthopaedic Surgery, Royal Inland Hospital, Kamloops, Canada
| | - Piers Page
- Oxford Trauma Unit, John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Jowan G Penn-Barwell
- Oxford Trauma Unit, John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Robert Handley
- Oxford Trauma Unit, John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
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Minehara H, Maruo A, Amadei R, Contini A, Braile A, Kelly M, Jenner L, Schemitsch GW, Schemitsch EH, Miclau T. Open fractures: Current treatment perspective. OTA Int 2023; 6:e240. [PMID: 37533445 PMCID: PMC10392445 DOI: 10.1097/oi9.0000000000000240] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 12/16/2022] [Indexed: 08/04/2023]
Abstract
Severe open fractures present challenges to orthopaedic surgeons worldwide, with increased risks of significant complications. Although different global regions have different resources and systems, there continue to be many consistent approaches to open fracture care. Management of these complex injures continues to evolve in areas ranging from timing of initial operative debridement to the management of critical-sized bone defects. This review, compiled by representative members of the International Orthopaedic Trauma Association, focuses on several critical areas of open fracture management, including antibiotic administration, timing of debridement, bone loss, soft tissue management, and areas of need for future investigation.
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Affiliation(s)
- Hiroaki Minehara
- Department of Traumatology, Fukushima Medical University, Trauma and Reconstruction Center, Shin-yurigaoka General Hospital, Kawasaki, Japan
| | - Akihiro Maruo
- Department of Orthopaedic Surgery, Harima-Himeji General Medical Center, Himeji, Japan
| | - Rafael Amadei
- Orthopaedics Trauma Unit, Cuenca Alta Cañuelas Hospital, Buenos Aires, Argentina
| | - Achille Contini
- Orthopedics and Traumatology Department, ASL 1 “Ospedale del Mare” Hospital, Napoli, Italy
| | - Adriano Braile
- Orthopedics and Traumatology Department, ASL 1 “Ospedale del Mare” Hospital, Napoli, Italy
- Multidisciplinary Department of Orthopedic and Dentistry Specialties, Università della Campania “Luigi Vanvitelli,” Napoli, Italy
| | | | | | | | - Emil H. Schemitsch
- Department of Surgery, University of Western Ontario, London Health Sciences Centre, London, ON, Canada; and
| | - Theodore Miclau
- Department of Orthopaedic Surgery; Orthopaedic Trauma Institute; University of California, San Francisco, CA
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Nasser AAH, Fenton P, Bose D. Single stage versus two-stage orthoplastic management of bone infection. Injury 2022; 53:984-991. [PMID: 35063261 DOI: 10.1016/j.injury.2022.01.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Bone infection cases with major soft tissue loss have conventionally been treated with a staged orthoplastic approach, addressing the infection first followed by definitive management to achieve bony stability and soft tissue cover. In the last few decades, specialist centers have advocated for single stage bony stabilization with soft tissue coverage. We aimed to investigate the outcomes of patients that underwent a single stage versus a two-stage orthoplastic intervention. METHODS Using an existing 2009-2019 database from a single major trauma centre, we identified all adults with a diagnosis of fracture related infection (FRI) or osteomyelitis (OM). The primary outcome was resolution of infection. Secondary outcomes included time to bony union, amputation, failure of orthopaedic fixation, mortality, and return to theatre. RESULTS A total of 96 patients were included. 71 patients (74%) underwent a single stage procedure; out of which 61 were FRI. 25 patients (26%) underwent a two-stage procedure; out of which 24 were FRI. The average follow up for the single stage and two-stage cohorts was 32.1 and 30.3 months, respectively. Resolution of infection without the need for an amputation was achieved in 67 (94.4%) patients in the single stage cohort and in 23 (92%) patients in the two-stage cohort. When compared to the two-stage group, the single stage cohort had less recurrence of infection (9.9% versus 12%, p = 0.72), lower rates of amputation (8.5% versus 12%, p = 0.69), lower rates of failure of orthopaedic fixation (11.1% versus 13%, p = 0.82), but higher average time to bony union (15.25 months versus 12.35, p = 0.42). The differences were not statistically significant. A total of 37 patients (52.1%) had an unplanned return to theatre in the single stage compared to 12 (48%) in the two-stage cohort. In subgroup analysis of FRI cases, open fractures had a longer time to bony union when compared to closed fractures (19.7 versus 11.6 months, p = 0.01). No mortality was observed in both cohorts. CONCLUSIONS The single stage orthoplastic approach to bone infection is effective if planned carefully with clinical outcomes comparable to the two-stage approach. Further research should examine factors associated with unplanned return to theatre and any variation in treatment of bone infection across regions.
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Affiliation(s)
- Ahmed A H Nasser
- Ortho-Plastic Extremity Trauma Unit, Trauma and Orthopaedic Specialty Registrar, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Mindelsohn Way, Birmingham B15 2TH, UK.
| | - Paul Fenton
- Ortho-Plastic Extremity Trauma Unit, Trauma and Orthopaedic Specialty Registrar, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Mindelsohn Way, Birmingham B15 2TH, UK
| | - Deepa Bose
- Ortho-Plastic Extremity Trauma Unit, Trauma and Orthopaedic Specialty Registrar, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Mindelsohn Way, Birmingham B15 2TH, UK
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Png ME, Petrou S, Bourget-Murray J, Knight R, Trompeter AJ, Costa ML. Association between the Orthopaedic Trauma Society classification of open fractures and economic costs. Bone Joint J 2022; 104-B:408-412. [PMID: 35227087 DOI: 10.1302/0301-620x.104b3.bjj-2021-1237.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to investigate the relationship between the Orthopaedic Trauma Society (OTS) classification of open fractures and economic costs. METHODS Resource use was measured during the six months that followed open fractures of the lower limb in 748 adults recruited as part of two large clinical trials within the UK Major Trauma Research Network. Resource inputs were valued using unit costs drawn from primary and secondary sources. Economic costs (GBP sterling, 2017 to 2018 prices), estimated from both a NHS and Personal Social Services (PSS) perspective, were related to the degree of complexity of the open fracture based on the OTS classification. RESULTS Adjusted mean total NHS and PSS costs were £13,785 following treatment of complex fractures and £3,550 following treatment of simple fractures, where the open fracture wound is closed at the end of the first wound debridement, generating a mean difference of £10,235 (95% confidence interval £8,074 to £12,396). CONCLUSION Following previous work correlating clinical outcomes with the OTS classification of open fractures, this study suggests that the new OTS classification also correlates with economic costs estimated from alternative study perspectives. Cite this article: Bone Joint J 2022;104-B(3):408-412.
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Affiliation(s)
- May E Png
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Ruth Knight
- Centre for Statistics in Medicine, Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Alex J Trompeter
- Orthopaedic Trauma and Limb Reconstruction Unit, St George's University Hospital, London, UK
| | - Matt L Costa
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie Centre, University of Oxford, Oxford, UK
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Tierny C, Casoli V, Chadefaux G, Dauchy FA, Fabre T, Belaroussi Y, Delgove A. Management of Chronic Osteomyelitis by an Orthoplastic Team: 7-Year Experience of a University Hospital. Plast Reconstr Surg 2021; 148:443-453. [PMID: 34181596 DOI: 10.1097/prs.0000000000008175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Treating chronic osteomyelitis of the lower extremities is challenging. The treatment of acute lower limb trauma by orthoplastic teams has shown good results over the past few decades. This study aimed to characterize surgical outcomes of leg and heel chronic osteomyelitis by an orthoplastic team. METHODS The cases of 113 consecutive leg and heel chronic osteomyelitis patients undergoing soft-tissue reconstruction with an orthopedic procedure were reviewed in this retrospective single-center observational study. The main objective was to assess surgical outcomes of skin healing and gait recovery at the 1-year follow-up. The secondary objective was to evaluate the global success rate at the last follow-up. RESULTS The median follow-up was 19.7 months. A free flap was performed for 33 patients (29.2 percent) and a locoregional flap was used in 79 patients (69.9 percent). Seventy-two patients (63.7 percent) had chronic osteomyelitis on continuous bone. The others had a septic pseudarthrosis with a mean bone defect length of 42.9 mm. Forty-four patients (38.9 percent) underwent curettage only, eight (7.1 percent) underwent curettage and cement, 20 (17.7 percent) underwent curettage and bone fixation, and 39 (34.5 percent) underwent the Masquelet technique. At the 1-year follow-up, 72 patients (63.7 percent) had achieved skin healing and had recovered their gait. The success rate at all follow-up time points was 82.3 percent. The median time to achieve skin healing was 6.5 months and that to bone union in cases of septic pseudarthrosis was 7.9 months. CONCLUSION Orthoplastic management of leg and heel chronic osteomyelitis patients with combined soft-tissue reconstruction using an orthopedic procedure was a viable strategy that offered good results even though the time to complete healing was long. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
- Chloé Tierny
- From the Plastic Surgery and Burns Unit, Centre FX Michelet, Bordeaux University Hospital; Surgery School, University of Bordeaux; Department of Anesthesiology and Critical Care, Bordeaux University Hospital; Department of Infectious and Tropical Diseases and South-Western France Referral Center for Complex Bone and Joint Infections (Crioac GSO), Bordeaux University Hospital; Department of Orthopedic Surgery, Bordeaux University Hospital; and Department of Thoracic Surgery, Bordeaux University Hospital
| | - Vincent Casoli
- From the Plastic Surgery and Burns Unit, Centre FX Michelet, Bordeaux University Hospital; Surgery School, University of Bordeaux; Department of Anesthesiology and Critical Care, Bordeaux University Hospital; Department of Infectious and Tropical Diseases and South-Western France Referral Center for Complex Bone and Joint Infections (Crioac GSO), Bordeaux University Hospital; Department of Orthopedic Surgery, Bordeaux University Hospital; and Department of Thoracic Surgery, Bordeaux University Hospital
| | - Grégoire Chadefaux
- From the Plastic Surgery and Burns Unit, Centre FX Michelet, Bordeaux University Hospital; Surgery School, University of Bordeaux; Department of Anesthesiology and Critical Care, Bordeaux University Hospital; Department of Infectious and Tropical Diseases and South-Western France Referral Center for Complex Bone and Joint Infections (Crioac GSO), Bordeaux University Hospital; Department of Orthopedic Surgery, Bordeaux University Hospital; and Department of Thoracic Surgery, Bordeaux University Hospital
| | - Frédéric-Antoine Dauchy
- From the Plastic Surgery and Burns Unit, Centre FX Michelet, Bordeaux University Hospital; Surgery School, University of Bordeaux; Department of Anesthesiology and Critical Care, Bordeaux University Hospital; Department of Infectious and Tropical Diseases and South-Western France Referral Center for Complex Bone and Joint Infections (Crioac GSO), Bordeaux University Hospital; Department of Orthopedic Surgery, Bordeaux University Hospital; and Department of Thoracic Surgery, Bordeaux University Hospital
| | - Thierry Fabre
- From the Plastic Surgery and Burns Unit, Centre FX Michelet, Bordeaux University Hospital; Surgery School, University of Bordeaux; Department of Anesthesiology and Critical Care, Bordeaux University Hospital; Department of Infectious and Tropical Diseases and South-Western France Referral Center for Complex Bone and Joint Infections (Crioac GSO), Bordeaux University Hospital; Department of Orthopedic Surgery, Bordeaux University Hospital; and Department of Thoracic Surgery, Bordeaux University Hospital
| | - Yaniss Belaroussi
- From the Plastic Surgery and Burns Unit, Centre FX Michelet, Bordeaux University Hospital; Surgery School, University of Bordeaux; Department of Anesthesiology and Critical Care, Bordeaux University Hospital; Department of Infectious and Tropical Diseases and South-Western France Referral Center for Complex Bone and Joint Infections (Crioac GSO), Bordeaux University Hospital; Department of Orthopedic Surgery, Bordeaux University Hospital; and Department of Thoracic Surgery, Bordeaux University Hospital
| | - Anaïs Delgove
- From the Plastic Surgery and Burns Unit, Centre FX Michelet, Bordeaux University Hospital; Surgery School, University of Bordeaux; Department of Anesthesiology and Critical Care, Bordeaux University Hospital; Department of Infectious and Tropical Diseases and South-Western France Referral Center for Complex Bone and Joint Infections (Crioac GSO), Bordeaux University Hospital; Department of Orthopedic Surgery, Bordeaux University Hospital; and Department of Thoracic Surgery, Bordeaux University Hospital
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Emam A, Machhada A, Tilston T, Colavitti G, Katsanos D, Chapman T, Wright T, Khan U. Free tissue versus local tissue: A comparison of outcomes when managing open tibial diaphyseal fractures. Injury 2021; 52:1625-1628. [PMID: 33648742 DOI: 10.1016/j.injury.2021.02.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 02/04/2021] [Accepted: 02/06/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Open lower extremity fractures pose a challenge for treating surgeons. All surgical strategies have the common aim to facilitate fracture healing. Fracture union, however, should be critically considered in the context of functional recovery and not in isolation. Both local and free tissue transfer have benefits and drawbacks. AIM This study aims to compare the functional outcomes of open tibial diaphyseal fractures managed with internal fixation, comparing outcomes of those receiving free tissue transfer as opposed to local flaps METHODS: This study follows the STrengthening the Reporting of Observational studies in Epidemiology (STROBE) criteria. Data were collected retrospectively from a prospectively maintained database at our institution. Inclusion criteria included a non-comminuted Gustilo type-IIIB open tibial diaphyseal fracture requiring intramedullary nailing. Forty three patients with local flaps and 180 patients with free flaps were included RESULTS AND CONCLUSION: 233 patient underwent reconstruction for open fracture using local flaps (n=43) or free flaps (n=180). In the context of Gustilo type-IIIB non-comminuted, mid-tibial diaphyseal fractures treated with intramedullary nailing, free fasciocutaneous flap reconstructions leads to significantly improved functional outcomes in patients of all ages when compared to local fasciocutaenous flaps. (77 ± 19 v 50 ± 22 % for local flaps; P < 0.001).
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Affiliation(s)
- Ahmed Emam
- Southmead Hospital, North Bristol NHS Trust, City of Bristol, UK
| | - Asif Machhada
- Southmead Hospital, North Bristol NHS Trust, City of Bristol, UK
| | - Thomas Tilston
- Southmead Hospital, North Bristol NHS Trust, City of Bristol, UK
| | - Giulia Colavitti
- Southmead Hospital, North Bristol NHS Trust, City of Bristol, UK
| | | | - Thomas Chapman
- Southmead Hospital, North Bristol NHS Trust, City of Bristol, UK
| | - Thomas Wright
- Southmead Hospital, North Bristol NHS Trust, City of Bristol, UK
| | - Umraz Khan
- Southmead Hospital, North Bristol NHS Trust, City of Bristol, UK.
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Yang Z, Xu C, Zhu YG, Li J, Wu ZX, Zou JW, Xue BB, Miao DM, Shang L, Zhao GY. Radical treatment of severe open fractures of extremities by orthoplastic surgery: a 10-year retrospective study. J Orthop Surg Res 2021; 16:340. [PMID: 34044870 PMCID: PMC8157635 DOI: 10.1186/s13018-021-02479-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 05/11/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE This study aimed to retrospectively analyze clinical data of a series of patients with severe open fractures of extremities (Gustilo IIIb or IIIc), who achieved a satisfactory outcome through radical orthoplastic surgery, so as to provide a reference for determining the treatment of severe open fractures of extremities. METHODS The clinical data of 41 consecutive patients with severe open fracture (Gustilo IIIb or IIIc) of the limb, who underwent successful surgical debridement, fixation, and soft tissue reconstruction in one stage between January 2008 and January 2019, were retrospectively reviewed. Postoperative indicators, including infection rate and union time, were acquired by a regular follow-up and analyzed. RESULTS The mean (±SD) age of the patients was 38 ± 16 years. A total of 90 open fractures and severe soft tissue damages were analyzed. The soft tissue cover was achieved within 72 h. The overall rate of infection was 14.6% (6/41). Sex and the Mangled Extremity Severity Score were associated with infection. The median union time of 40 patients (one amputation) was 32 weeks. CONCLUSION The overall rate of infection exhibited a lower tendency in this study compared with previous studies on high-grade open fractures following a two-stage orthopedic approach. The consequence of infection rate and union time was similar to that in previous studies. These results indicated that the single-stage radical orthoplastic treatment was an effective and reliable option for reconstructing severe open fractures.
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Affiliation(s)
- Zhao Yang
- Department of Military Medical Psychology, Air Force Military Medical University, No. 169 Changle Xi Road, Xi'an, Shaanxi Province, 710032, People's Republic of China
| | - Chao Xu
- Department of Orthopeadic Surgery, Xijing Hospital, Air Force Military Medical University, No. 127 Changle Xi Road, Xi'an, Shaanxi Province, 710032, People's Republic of China
| | - Yong-Gang Zhu
- Department of Orthopeadic Surgery, Xijing Hospital, Air Force Military Medical University, No. 127 Changle Xi Road, Xi'an, Shaanxi Province, 710032, People's Republic of China
| | - Jun Li
- Department of Orthopeadic Surgery, Xijing Hospital, Air Force Military Medical University, No. 127 Changle Xi Road, Xi'an, Shaanxi Province, 710032, People's Republic of China
| | - Zi-Xiang Wu
- Department of Orthopeadic Surgery, Xijing Hospital, Air Force Military Medical University, No. 127 Changle Xi Road, Xi'an, Shaanxi Province, 710032, People's Republic of China
| | - Ji-Wei Zou
- Department of Orthopeadic Surgery, Xijing Hospital, Air Force Military Medical University, No. 127 Changle Xi Road, Xi'an, Shaanxi Province, 710032, People's Republic of China
| | - Bao-Bao Xue
- Department of Orthopeadic Surgery, Xijing Hospital, Air Force Military Medical University, No. 127 Changle Xi Road, Xi'an, Shaanxi Province, 710032, People's Republic of China
| | - Dan-Min Miao
- Department of Military Medical Psychology, Air Force Military Medical University, No. 169 Changle Xi Road, Xi'an, Shaanxi Province, 710032, People's Republic of China.
| | - Lei Shang
- Department of Health Statistics, Faculty of Preventive Medicine, Air Force Military Medical University, No. 169 Changle Xi Road, Xi'an, Shaanxi Province, 710032, People's Republic of China.
| | - Guang-Yue Zhao
- Department of Orthopeadic Surgery, Xijing Hospital, Air Force Military Medical University, No. 127 Changle Xi Road, Xi'an, Shaanxi Province, 710032, People's Republic of China.
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Abstract
AIMS To describe a new objective classification for open fractures of the lower limb and to correlate the classification with patient-centred outcomes. METHODS The proposed classification was investigated within a cohort of adults with open fractures of the lower limb who were recruited as part of two large clinical trials within the UK Major Trauma Network. The classification was correlated with patient-reported Disability Rating Index (DRI) and EuroQol five-dimension questionnaire (EQ-5D) health-related quality of life in the year after injury, and with deep infection at 30 days, according to the Centers for Disease Control and Prevention definition of a deep surgical site infection. RESULTS A total of 748 participants were included in the analysis. Of these, 288 (38.5%) had a simple open fracture and 460 (61.5%) had a complex fracture as defined by the new classification system. At 12 months, the mean DRI in the simple fracture group was 32.5 (SD 26.8) versus 43.9 (SD 26.1) in the complex fracture group (odds ratio (OR) 8.19; 95% confidence interval (CI) 3.69 to 12.69). At 12 months the mean health-related quality of life (EQ-5D utility) in the simple fracture group was 0.59 (SD 0.29) versus 0.56 (SD 0.32) in the complex fracture group (OR -0.03; 95% CI -0.09 to 0.02). The differences in the rate of deep infection at 30 days was not statistically significant. CONCLUSION The Orthopaedic Trauma Society open fracture classification is based upon objective descriptors of the injury and correlates with patient-centred outcomes in a large cohort of open fractures of the lower limb. Cite this article: Bone Joint J 2020;102-B(11):1469-1474.
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Affiliation(s)
- Alex J Trompeter
- Orthopaedic Trauma/Limb Reconstruction Unit, St George's University Hospital, London, UK
| | - Ruth Knight
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Nick Parsons
- Statistics and Epidemiology Department, Warwick Medical School, University of Warwick, Coventry, UK
| | - Matthew L Costa
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Two-Stage Combined Ortho-Plastic Management of Type IIIB Open Diaphyseal Tibial Fractures Requiring Flap Coverage: Is the Timing of Debridement and Coverage Associated With Outcomes? J Orthop Trauma 2019; 33:591-597. [PMID: 31211717 DOI: 10.1097/bot.0000000000001562] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To delineate whether timing to initial debridement and definitive treatment had an effect on patient outcomes in those undergoing 2-stage ortho-plastic management of Gustilo-Anderson type IIIB open tibial diaphyseal fractures. DESIGN Retrospective comparative cohort study over a 2-year period. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS A total of 148 patients were identified. After exclusion of ankle fractures, nondiaphyseal fractures and those who did not undergo 2-stage ortho-plastic management, 45 patients were eligible for final analysis. INTERVENTION Time to initial debridement and definitive management. MAIN OUTCOME MEASUREMENT Deep infection. Secondary outcomes being nonunion and flap failure. Multiple linear regression was used for outcomes. We assumed a priori that P values of less than 0.05 were significant. RESULTS Mean age was 54 years (SD 23.0), with 28 men and 17 women. Over a mean 2-year follow-up, there were 4 (4/45) deep infections, 2 infection-associated flap failures, and 1 vascular flap failure. All patients progressed to union. The mean time to initial debridement for the whole cohort was 19 hours (SD 12.3), and the mean time to definitive reconstruction was 65 hours (SD 51.7). Longer time to both initial debridement and definitive reconstruction was not found to be significantly associated with deep infection, infected flap failure, or nonunion. CONCLUSIONS Using a 2-stage ortho-plastic operative algorithm, timing to initial debridement and definitive fixation with soft-tissue coverage was not associated with negative outcomes. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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A Retrospective Comparative Cohort Study Comparing Temporary Internal Fixation to External Fixation at the First Stage Debridement in the Treatment of Type IIIB Open Diaphyseal Tibial Fractures. J Orthop Trauma 2019; 33:125-130. [PMID: 30779724 DOI: 10.1097/bot.0000000000001362] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare the rates of deep infection, flap failure, and nonunion after temporary internal fixation (TIF) with temporary external fixation (ex-fix) in the management of Gustilo-Anderson type IIIB open tibia fractures. DESIGN Retrospective comparative cohort study. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS Sixty-four consecutive patients with a Gustilo-Anderson type IIIB open diaphyseal tibia fracture (OTA/AO 42) were treated between May 2014 and May 2016. Forty-seven patients (TIF = 24; ex-fix = 23) met the inclusion criteria and underwent 2-stage reconstruction. Definitive fixation was with an intramedullary nail. INTERVENTION Temporary fracture stabilization at the first-stage debridement was achieved with either TIF with a plate or ex-fix. MAIN OUTCOME MEASUREMENT The main outcome measure was deep infection. RESULTS There were 4 complications in the ex-fix group (3 infection and 1 nonunion) and 2 complications in the TIF group (1 infection and 1 flap failure). Multiple regression modeling revealed that infection (P = 0.610), nonunion (P = 0.918), and flap failure (P = 0.112) were not significantly associated with the mode of temporary fixation or other demographic and treatment variables. The odds ratio of patients treated with TIF developing an infection compared with those treated with an ex-fix was 0.29 (95% confidence interval, 0.03-3.01). CONCLUSIONS TIF of type IIIB open diaphyseal tibial fractures seems to be a safe alternative to conventional external fixation. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Abstract
Avoiding the development of deep bone infection following open long bone fractures remains the aim when managing such injuries. Standards of care have been developed in the UK, and adopted by others, that are effective at avoiding bone infection in these cases. However, despite these strict standards, cases of infection do develop and these must be dealt with aggressively and decisively.
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Boriani F, Ul Haq A, Baldini T, Urso R, Granchi D, Baldini N, Tigani D, Tarar M, Khan U. Orthoplastic surgical collaboration is required to optimise the treatment of severe limb injuries: A multi-centre, prospective cohort study. J Plast Reconstr Aesthet Surg 2017; 70:715-722. [DOI: 10.1016/j.bjps.2017.02.017] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 01/30/2017] [Accepted: 02/17/2017] [Indexed: 02/08/2023]
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Mathews JA, Ward J, Chapman TW, Khan UM, Kelly MB. Single-stage orthoplastic reconstruction of Gustilo-Anderson Grade III open tibial fractures greatly reduces infection rates. Injury 2015; 46:2263-6. [PMID: 26391592 DOI: 10.1016/j.injury.2015.08.027] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 08/12/2015] [Accepted: 08/15/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND 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. This paper reviews the outcomes in patients treated in an orthoplastic unit where the emphasis was on undertaking the definitive orthopaedic and plastic surgical procedures in a single stage, following initial debridement and temporary stabilisation as necessary. METHODS We reviewed medical notes of 73 consecutive 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 <72h vs. >72h. RESULTS (a) Combined Single-stage Orthoplastic Fixation and Coverage: 48 fractures were managed with definitive orthopaedic fixation and plastic surgical coverage performed at the same time, whilst 26 had these performed at separate stages. Of those subjects that had definitive fixation and coverage in one procedure 2 (4.2%) developed deep infections, compared with 9 (34.6%) deep infections (p<0.001) in those who underwent definitive fixation and coverage at separate operations. (b) Timing of surgery: Of the fractures that had definitive fixation and coverage completed within 72h of injury, 5 (20%) developed deep infections, compared with 6 (12.2%) deep infections (p=0.492) in those whose definitive fixation/coverage was completed at later than 72h. CONCLUSION Joint orthoplastic operating lists facilitate simultaneous definitive fixation and cover that greatly reduces infection rates. Based on our experience presented in this paper, we believe that emphasis should be placed on timely transfer to a specialist centre, aiming for a single-stage combined orthoplastic procedure to achieve definitive fixation and soft tissue coverage and optimal outcomes.
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Affiliation(s)
- J A Mathews
- Departments of Trauma & Orthopaedics/Plastic Surgery, North Bristol Trust, Bristol, UK.
| | - J Ward
- Departments of Trauma & Orthopaedics/Plastic Surgery, North Bristol Trust, Bristol, UK
| | - T W Chapman
- Departments of Trauma & Orthopaedics/Plastic Surgery, North Bristol Trust, Bristol, UK
| | - U M Khan
- Departments of Trauma & Orthopaedics/Plastic Surgery, North Bristol Trust, Bristol, UK
| | - M B Kelly
- Departments of Trauma & Orthopaedics/Plastic Surgery, North Bristol Trust, Bristol, UK
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Filobbos G, Salim F, Khan U. Is the Injury Severity Score Relevant in Complex Lower Limb Trauma? ACTA ACUST UNITED AC 2013. [DOI: 10.1308/147363513x13588739440816] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
First described by Baker et al in 1974, the injury severity score (ISS) is an anatomical scoring system that provides an overall score for patients with multiple injuries. It was developed initially to evaluate motor vehicle victims with multiple injuries, with an original study group of 2,128 patients. The ISS is an established score to assess trauma severity and its application has extended beyond motor vehicle injuries to cover all aspects of trauma.
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Affiliation(s)
- G Filobbos
- Plastic Surgery Registrar, North Bristol NHS Trust
| | - F Salim
- Plastic Surgery Registrar, North Bristol NHS Trust
| | - U Khan
- Consultant Plastic Surgeon, North Bristol NHS Trust
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