Analysis of the characteristics of patients with open tibial fractures of Gustilo and Anderson type III

Evaluation of Tibia Bone Healing by Infrared Thermography: A Case Study

Background

Thermal imaging has been used as a clinical follow-up technique in several medical specialties.

Purpose

The aim of this study was to investigate the feasibility of using medical thermography in the diagnosis and follow-up assessment of a severe orthopedic trauma that requires the use of an external circular fixator.

Patients and Methods

Twenty clinical follow-ups of thermal imaging correlated with X-ray images were performed in a male volunteer, diagnosed with bone nonunion, during 11 months of treatment, in the hospital trauma and reconstruction department. Data were acquired in the regions of interest of the proximal tibia, diaphysis and distal, with a Flir T530 medical grade infrared camera from Flir Systems^®, and the data processed by the Matlab^® 2019 custom made software.

Results

Statistical analysis was performed by Wilcoxon signed-rank test. The results showed a median temperature of 22.2°C, and thus some periods of interruption in the healing process between the third and twentieth clinical follow-up, and a significant increase of the temperature to 34.6°C synchronous with a diagnosis of bone infection by the eleventh clinical follow-up. The thermal images acquired during the 20 clinical follow-ups allow a correlation with the data from the X-ray exams and also with the contralateral limb of the evaluated patient, showing thermal alterations greater than 0.3°C, which are significant of physiological abnormality.

Conclusion

The thermography exam can be a useful tool for applying on the follow-up of patients after trauma or bone fracture. The results showed important physiological data related to the vascularization necessary for bone repairing, being therefore a good indicator of the healing process. In addition, as infrared thermography does not use ionizing radiation, it can be used countlessly, in complement to the traditional X-ray exams that focus on anatomical data analysis.

Amputation Rates in More Than 175,000 Open Tibia Fractures in the United States

Open tibia fractures are often associated with considerable soft tissue injuries. Management of open tibia fractures can be challenging, and some patients require amputation. The patient and treatment factors have not been described on a population level in the United States. A retrospective analysis was completed using the 2000 to 2011 Nationwide Inpatient Sample. Amputation rates during the index hospitalization after open tibia fracture were computed based on injury, patient, and hospital characteristics in patients 18 years or older. The overall amputation rate in open tibia fractures during the index hospitalization was 2.2% (n=3769). Patients with midshaft tibia fractures comprised the largest portion of patients undergoing amputation (46.8% of total amputations) compared with distal tibia (34.0%) and proximal tibia (19.3%) fractures. Patients with no neurovascular injury comprised the largest portion of patients undergoing amputation (85.9%), followed by isolated arterial injury (11.1%), combined neurovascular injury (1.9%), and isolated nerve injury (1.1%). Amputation rates were significantly increased for midshaft tibia fractures with neurovascular injury (odds ratio, 12.39; 95% CI, 5.52-27.83) and distal tibia fractures with neurovascular injury (odds ratio, 5.45; 95% CI, 1.73-17.19) compared with tibia fractures with no neurovascular injury while controlling for confounders. On the basis of a review of the Nationwide In-patient Sample during the past decade, the authors have shown that the early amputation rate in open tibia fractures for all-comers is 2.2%. Rates of amputation varied based on fracture site, associated neurovascular injury, medical comorbidities, and hospital location. [Orthopedics. 2021;44(1):48-53.].

Open fractures: epidemiological pattern, initial management and challenges in a sub-urban teaching hospital in Nigeria

Introduction

Management of open fractures poses a constant challenge to Orthopaedic surgeons in Nigeria. Our aim is to determine the epidemiological pattern of open fractures in our centre and share our experiences on the initial management and problems encountered.

Methods

This was an 18 month prospective study of patients that presented with open fractures at our emergency room. Already prepared data collection sheets were used to collect relevant data directly from patients and patients' files.

Results

There were 58 open fractures in 52 patients (31 males and 21 females). Mean age of patients was 36.4 ± 12.2 years. Most patients (82.7%) fell within the age group of 20-49 years. Traders (28.9%) and students (19.6%) were mostly affected. Most open fractures (88.5%) were due to road traffic accidents. The tibia and fibula were the most frequently affected (44.4%). Most injuries were Gustilo et al. types IIIA & IIIB (79.3%) open fractures. Patients had initial resuscitation followed by debridement in 42 cases (72%). Fractures were initially stabilized with external fixators in 23 cases (39.7%) and cast slabs in 19 cases (32.8%). The average time between presentation and debridement was 30 hours and average hospital stay was 36 days. Forty two point five per cent of wounds were infected.

Conclusion

Open fractures were mostly due to road traffic accidents and affected the tibia and fibula most frequently with Gustilo et al. types IIIA and IIIB forming the bulk of the injuries. Management was challenging with late presentations, scarcity of resources and consequent high rate of infections, prolonged morbidity and hospital stay. These problems were worsened by delay in antibiotic commencement and initial debridement, sub-optimal treatment at peripherial hospitals and mis-management by traditional bone setters.

Immediate Soft-Tissue Reconstruction for Chronic Infected Tibia Nonunions Treated with an Ilizarov Frame

There are multiple options available for the management of large tibial defects. The Ilizarov frame is one of the most widely used techniques due to the physiological bone growth and the symmetrical distribution of axial forces permitting adequate bone distribution. However, disadvantages still remain including obtaining additional soft-tissue access for defect coverage. We present our experience with soft-tissue reconstruction for chronic infected tibial nonunions using free tissue transfers simultaneously with Ilizarov device placement. A retrospective review was performed from 2014 to 2016 of patients presenting with a chronically infected tibia nonunion and treated by our senior orthopedic and plastic surgeons. Demographic data, comorbidities, intraoperative details and postoperative outcomes were collected. A total of 6 patients were identified with a mean age of 46.2 ± 11.6 years. Complete flap survival and resolved active infection were achieved in 5 of our patients, 4 demonstrated body union on imaging, and all of them reached complete ambulance. Flap revisions with allografting for partial flap loss were performed in 1 patient. Preoperative planning is critical for immediate lower extremity reconstruction in the setting of an Ilizarov frame. From our institutional experience, free tissue transfer can safely be placed after frame placement.

Functional and radiological outcome in management of compound tibia diaphyseal fracture with AO monolateral fixator versus Limb reconstruction system

Introduction

Tibia being the most common fractured long bone represents 36.7% of all long bone fractures in adults with open fracture comprises 23.5% of all tibial shaft fracture. The lack of the muscular covering over anteromedial aspect of the tibia and poor blood supply predispose open tibial fractures to a 10-20 fold increased risk of developing infection than open fracture in any other anatomical areas and a nonunion rate as high as 28% has been reported in the literature.

Methods

We did a prospective study at our institute from 2014-2016 comprising 40 patients with compound tibia diaphyseal fracture managed with AO monolateral external fixator (Group 1) (n = 20) and Limb reconstruction system (Group 2) (n = 20) as primary and definitive tool. Final assessment for bone results and functional results were done using ASAMI (Association of the study and application of the method of Ilizarov) score.

Results

In our study bony outcome by ASAMI score shows 6 (30%) patients had Excellent, 5 (25%) patients had Good and 9 (45%) had Poor bony outcome from Group I. In group II, 12 (60%) patients had Excellent, 4 (20%) patients had Good, 2 (10%) patients had Fair, and 2 (10%) had Poor bony outcome. The functional outcome by ASAMI score shows 3 (15%) patients had Excellent, 8 (40%) patients had Good, 5 (25%) patients had Fair, 3 (15%) had Poor bony outcome from Group I. In group II, 9 (45%) patients had Excellent, 7 (35%) patients had Good, 2 (10%) patients had Fair, and 2 (10%) had Poor functional outcome.

Conclusion

Limb reconstruction system (LRS) offers several advantage over AO monolateral external fixator such as ease of application, versatility, stronger fixation, less fixator related complications, early weight bearing and early bony union for management of compound tibia diaphyseal fracture as primary and definitive tool.

Treating open lower limb fractures successfully; thoughts and current practice on therapy and centralization in The Netherlands

Introduction

The British Orthopedic Association (BOA) and British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) updated the evidence-based guidelines for the treatment and care of open lower limb fractures (BOAST 4). Following this, a Dutch version has been developed. The main points are multidisciplinary care, planning, and treatment of these injuries. Early osteosynthesis (within 7–14 days) combined with soft-tissue coverage results in more efficient care and less complications.

Aim

To study the variation in treatment and thoughts among trauma, orthopedic, and plastic surgeons.

Materials and methods

In this cross-sectional study 94 surgeons (57 trauma, 23 plastic, and 14 orthopedic surgeons) working at 46 centers completed an online questionnaire, consisting of 5 demographic, 14 hospital-related, 8 BOAST 4-related, and 2 centralization-related questions.

Results

There was a strong agreement among surgeons about the best moment for multidisciplinary consultation, which was before initial debridement, while in practice, this often does not occur. All surgeons agreed that the initial debridement should be performed immediately by any surgeon, but not solely by trainees. Plastic surgeons responded that the definitive stabilization and wound cover should not exceed 7 days, while half of the trauma and orthopedic surgeons agreed that it should not exceed 14 days. Finally, most surgeons agreed that Gustilo 3 fractures should be centralized. However, there was disagreement on the need for centralization of Gustilo 2 fractures.

Discussion

Surgeons agree on better and earlier multidisciplinary treatment of open lower limb fractures and the centralization of Gustilo 3 fractures.