Outcomes following the delayed management of open tibial fractures

AIMS

National guidelines set standards for the definitive management of open fractures within 72 h. This study aims to investigate our outcomes where this timeline was unachievable for most cases due to a split-site orthoplastic service.

PATIENTS & METHODS

116 consecutive Gustilo-Anderson grade IIIB & IIIC open tibial fractures presenting to our major trauma centre (MTC) between September 2012 and April 2018 were reviewed. The mean follow up was 46 months (17 to 88). 110 (95%) were grade IIIB and 6 (5%) grade IIIC. The most common injury mechanism included road traffic accidents (59%) and falls (28%). Primary outcomes were recorded according to; timing of initial debridement and definitive cover, rates of superficial and deep infection, non-union and amputation. Subgroups were statistically analysed according to time to initial debridement, definitive soft-tissue cover and injury severity score (ISS).

RESULTS

The mean time to initial debridement was 11.3 h (2.9 to 38.9) and definitive soft-tissue cover 9.9 days (0 to 37). We recorded rates of: superficial infection; 42 cases (36%), deep infection; 14 cases (12%) and non-union requiring revision; 19 cases (16%). There were 20 amputations (17%) with 9 (8.6%) performed early and 11 (9.5%) delayed. Subgroup analysis showed higher rates of superficial infection (50%, p = 0.002) and amputation (26.6%, p = 0.01) for those debrided <12 h. A greater presenting ISS related to a delay to definitive cover >7 days (p = 0.05). Primary outcomes trended worse for those covered >7 days but did not reach significance.

CONCLUSION

Major trauma patients are particularly vulnerable to poor outcomes resulting from the delay in definitive management of open fractures. MTC's need resources and a co-located orthoplastic service to achieve national standards and better outcomes. Current guidelines do not advise for the management of patients where a delay in definitive surgery is anticipated.

Management of neglected open extremity fractures in low-resource settings: Experience of the French Army Medical Service in Chad

INTRODUCTION

The purpose of this study was to report the experience of the French Army Medical Service in the management of neglected open extremity fractures and related-complications in Chad.

HYPOTHESIS

Delayed treatment of open extremity fractures is possible in a low-resource setting.

METHODS

An observational prospective study was performed in a French Forward Surgical Team deployed in N'Djamena for six months.

RESULTS

Twenty-seven patients, 24 men and three women, mean age 30 years old with an open fracture that was managed more than 24 hours after it occurred were included. The mean treatment delay was 83 days. Fractures were located in the tibia in 20 cases. There were 15 non-infected and twelve infected fractures. The number of cases of debridement, flap coverage, and the overall number of procedures were higher in the group with infection, but the difference was not significant. Treatment of infected fractures was complicated by six early recurrent infections, while there were no complications in the group without infection. The mean follow-up was 4.4 months. Infection was controlled in eleven cases, however evaluation of fracture healing was limited because of the short follow-up in the group with infection. Functional outcome of the lower extremities was often complicated by knee stiffness.

DISCUSSION

Delayed management of open fractures depends on the available resources. In low-resource settings, the goals of surgery should be modest. Treatment of non-infected injuries and osteomyelitis is possible. On the other hand, treatment of infected fractures and septic nonunions should be undertaken with caution if all the necessary aspects of treatment, in particular extended antibiotic treatment and sequential procedures are not possible.

LEVEL OF EVIDENCE

level IV.