Orthopaedic Trauma Association: Open Fracture Study Group. A new classification scheme for open fractures

Soft tissue coverage for IIIB fractures: from timing to coverage options

Open tibia fractures are the most common open long bone injury. Most of these injuries involve a high-energy mechanism. Many standards for management have been created to provide guidance and a baseline for quality. There are several factors that must be considered when determining the timing of coverage for an open fracture with soft tissue compromise. Understanding the available options for soft tissue coverage, including local/rotational flaps and free tissue transfer, will allow for a tailored approach based on the personality of the injury. The aim of this review was to characterize the critical window of treatment based on the current literature and to provide a review of the available soft tissue coverage options.

Classification of open tibia fractures: the rationale for a new classification system

Open tibial shaft fractures are one of the most common long bone injuries encountered. Current existing classifications are designed to characterize the nature of the injury and guide clinical decision making. However, despite these advancements, there are areas in our current classification system that can be improved to not only make reliability more producible but also create prognostic factors that can help guide treatment.

Optimising the Orthopaedic Trauma Society Open Fracture Classification system: a proposal for modification in the context of high civilian gunshot fractures

OBJECTIVES

Uniformly classifying long bone open fractures is challenging. The purpose of this study was to propose a modified Orthopaedic Trauma Society (OTS) Open Fracture Classification System, developed in a setting with a high incidence of civilian gunshot fractures.

METHODS

From our prospectively collected database, we identified all patients with open tibia and femur fractures treated with intramedullary nailing over a 4 year period. All open fractures were retrospectively reclassified from the Gustilo-Anderson Classification system to the OTS Open Fracture Classification System.

RESULTS

One hundred and thirty-seven cases were identified. Ninety per cent of subjects were males. Their mean age was 34 years. The most common mechanism of injury was low-velocity civilian gunshot wounds (GSW) in 54.7% of cases. Soft tissue management was primary closure in 23.4% and soft tissue reconstruction in 24.1%. In 52.6% of cases (these all being secondary to civilian GSW), soft tissue management was healing via secondary intention. This is not included as a soft tissue management option in the OTS classification system. Fracture reclassification using the OTS Open Fracture Classification System was only possible in 47.5% of cases (Simple in 23.4%, Complex B in 24.1%).

CONCLUSION

We conclude that the OTS Open Fracture Classification System is not inclusive of all open tibia and femur fractures as it does not cater for gunshot fractures. We propose a modification as follows: alter 'wound debridement' to 'appropriate wound care' and to subcategorise 'Simple' into type A and B: healing via secondary intention and primary closure, respectively.

Unplanned reoperation is common following intramedullary nailing of open femoral shaft fractures: A retrospective review

Background

The objective of this study is to investigate the incidence of unplanned reoperation, nonunion and infection following open femoral shaft fractures treated with an intramedullary nail and correlate these occurrences with patient variables and injury characteristics.

Methods

A retrospective review of open femur fractures from a level 1 trauma center between 2012 and 2020 was performed. Ninety-five patients who sustained an open femur fracture, were treated definitively with an intramedullary nail, and had at least 3 months of follow-up were included in the analysis for surgical site infection. Seventy-three of these patients had at least one year of follow-up. After excluding planned bone grafting for segmental defects, 67 patients were included in the analysis of unplanned reoperation.

Results

The rate of unplanned reoperation was 31.3 %, with 57 % of these operations occurring to address nonunion. The overall nonunion rate was 18 %. In patients who did not require reoperation to obtain union, the median time to union for the cohort was 6 months, with an interquartile range of 3-7.5 months. Post-operative surgical site infection occurred in 11.6 % of patients.

Conclusions

In conclusion, unplanned reoperation following intramedullary nailing of open femur fractures occurs in nearly 1/3rd of patients and the rates of nonunion and surgical site infection may be higher than previously reported in the literature. Reoperation most closely correlates with the OTA Open Fracture Classification System. Patients with open femur fractures should be counseled that reoperation is often required to obtain fracture union, with soft tissue and fracture injury severity predicting complications.

Does the OTA Open Fracture Classification Align With the Gustilo-Anderson Classification? A Study of 2215 Open Fractures

OBJECTIVES

To characterize the Orthopaedic Trauma Association Open Fracture Classification (OTA-OFC) and Gustilo-Anderson classification of open extremity fractures and determine if there is meaningful alignment between these grading systems.

METHODS

DESIGN

Retrospective case series.

SETTING

Level I academic trauma center.

PATIENT SELECTION CRITERIA

Adult patients with at least 1 operatively treated open extremity fracture and surgeon-assigned OTA-OFC and Gustilo-Anderson classification.

OUTCOME MEASURES AND COMPARISONS

Frequency, distribution, and association measures of OTA-OFC category scores and Gustilo-Anderson classification types.

RESULTS

Two thousand twenty-seven patients (mean age, 43.1 ± 17.5 years) with 2215 fractures were included. Gustilo-Anderson type I or II fractures (n = 961; 43%) most frequently had the least severe scores for all OTA-OFC categories. Type IIIA fractures (n = 978; 44%) were most often assigned intermediate scores for OTA-OFC Bone Loss (n = 564; 58%). Type IIIB fractures (n = 204, 9%) were most often assigned intermediate OTA-OFC Skin scores (n = 120; 59%). Type IIIC fractures (n = 72; 3%) were most often assigned the most severe OTA-OFC Arterial score (n = 60; 83%). In the multivariable model, OTA-OFC Contamination scores showed little association (β = 0.05; 95% confidence interval [CI], 0.01-0.09) with Gustilo-Anderson classification severity. Conversely, higher OTA-OFC Arterial (β = 0.50; 95% CI 0.44-0.56) and Skin (β = 0.46; 95% CI, 0.40-0.51) scores were strongly associated with more severe Gustilo-Anderson classifications.

CONCLUSIONS

OTA-OFC Contamination scores were weakly associated with Gustilo-Anderson classification severity for open fractures. The study findings suggest that the current Gustilo-Anderson classification does not adequately account for injury contamination, a known predictor of infection.

LEVEL OF EVIDENCE

Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Type III Gustilo-Anderson open fracture does not justify routine prophylactic Gram-negative antibiotic coverage

Postoperative surgical site infection (SSI) is common in open long bone fractures, so early administration of prophylactic antibiotics is critical to prevent SSI. However, the necessity of initial broad-spectrum coverage for Gram-positive and -negative pathogens remains unclear. The purpose of this study was to clarify the effectiveness of prophylactic broad-spectrum antibiotics in a large, national-wide sample. We reviewed an open fracture database of prospectively collected data from 111 institutions managed by our society. A retrospective cohort study was designed to compare the rates of deep SSI between narrow- and broad-spectrum antibiotics, which were initiated within three hours after injury. A total of 1041 type III fractures were evaluated at three months after injury. Overall deep SSI rates did not differ significantly between the narrow-spectrum group (43/538, 8.0%) and broad-spectrum group (49/503, 9.8%) (p = 0.320). During propensity score-matched analysis, 425 pairs were analyzed. After matching, no significant difference in the SSI rate was seen between the narrow- and broad-spectrum groups, with 42 SSIs (9.9%) and 40 SSIs (9.4%), respectively (p = 0.816). The probability of deep SSI was not reduced by broad-spectrum antibiotics compared with narrow-spectrum antibiotics in type III open long bone fractures.

Management of open pelvic ring injuries

Open pelvic ring injuries are rare clinical entities that require multidisciplinary care. Due to the scarcity of this injury, there is no well-defined treatment algorithm. As a result, conflicting evidence surrounding various aspects of care including wound management and fecal diversion remain. Previous studies have shown mortality reaching 50% in open pelvic ring injuries, nearly five times higher than closed pelvic ring injuries. Early mortality is due to exsanguinating hemorrhage, while late mortality is due to wound sepsis and multiorgan system failure. With advancements in trauma care and ATLS protocols, there has been an improved survival rate reported in published case series. Major considerations when treating these injuries include aggressive resuscitation with hemorrhage control, diagnosis of associated injuries, prevention of wound sepsis with early surgical management, and definitive skeletal fixation. Classification systems for categorization and management of bony and soft tissue injury related to pelvic ring injuries have been established. Fecal diversion has been proposed to decrease rates of sepsis and late mortality. While clear indications are lacking due to limited studies, previous studies have reported benefits. Further large-scale studies are necessary for adequate evaluation of treatment protocols of open pelvic ring injuries. Understanding the role of fecal diversion, avoidance of primary closure in open pelvic ring injuries, and importance of well-coordinated care amongst surgical teams can optimize patient outcomes.

AAOS Clinical Practice Guideline Summary: Prevention of Surgical Site Infection After Major Extremity Trauma

Prevention of Surgical Site Infections After Major Extremity Trauma Evidence-Based Clinical Practice Guideline is based on a systematic review of current scientific and clinical research. This clinical practice guideline (CPG) is designed to assist qualified physicians and clinicians when making treatment decisions for adults (18 years or older) who have sustained major extremity trauma. The CPG workgroup defined major extremity trauma as an open fracture, a major/high-energy closed fracture, a degloving injury, Morel-Lavallée lesions, a low-energy or high-energy gunshot injury, a crush injury, a blast injury, or any other moderate-energy to high-energy injury. This guideline contains 14 recommendations that evaluate preoperative, perioperative, and postoperative interventions to limit the risk of surgical site infections after major extremity trauma while also identifying and evaluating potential patient-specific risk factors to consider. Another six options formulated with either low-quality evidence, no evidence, or conflicting evidence are also presented and discussed in the CPG. These include the use of incisional negative-pressure wound therapy for high-risk surgical incisions, the implementation of an orthoplastic team, the possible role of hyperbaric O2, the value of various preoperative skin preparations, and select modifiable and administrative risk factors.

Evaluation of the orthopaedic trauma association open fracture classification (OTA-OFC) as an outcome prediction tool in open tibial shaft fractures

INTRODUCTION

It was the goal of this study to determine if the Orthopaedic Trauma Association Open Fracture Classification (OTA-OFC) correlates with complication rates and to determine if it can be used as a predictive tool in the treatment of open tibial shaft fractures.

MATERIALS AND METHODS

Retrospective review from two high-volume level 1 trauma centers of open tibial shaft fractures over a 5 year period. Variables of interest included OTA-OFC, type of wound closure, 90-day wound complication, unplanned re-operation, non-union, and amputation.

RESULTS

501 consecutive open tibial shaft fractures. 57.3% (n = 287) were closed primarily; local soft tissue advancement/rotational flap was used in 9.6% (n = 48); free soft tissue transfer used in 22.8% (n = 114); 8.6% (n = 43) required amputation. Of those followed for 90 days (n = 419), 45 (9.0%) had a wound complication, of which 40 (8%) required an unplanned reoperation. 40 (8.0%) patients went on to a documented non-union. All OTA-OFC classification groups significantly correlated with type of definitive closure (r = 0.18-0.81, p < 0.05) with OTA-OFC skin showing the strongest correlation (r = 0.81). OTA-OFC bone loss weakly correlated with wound complication (r = 0.12, p = 0.02) and no OTA-OFC classification correlated with the need for an unplanned secondary procedure. OTA-OFC skin, muscle and arterial all weakly correlated with non-union (r = 0.18-0.25, p < 0.05). OTA-OFC muscle was predictive of non-union (OR = OR = 2.2, 95% CI = 1.2-4.1) and amputation (OR 9.3, 95% CI = 3.7-23.7). OTA-OFC arterial was also predictive of amputation (OR 4.8, 95% CI = 2.5-9.3).

CONCLUSIONS

The OTA-OFC correlates variably with the type of definitive closure, the development of a 90-day wound complication, and the occurrence of a non-union. Importantly, OTA-OFC muscle classification is predictive of non-union while both OTA-OFC muscle and arterial were predictive of amputation.

Current Concept Review: Risk Factors for Infection Following Open Fractures

Infection following open fracture is a significant source of morbidity and mortality. Therefore, a central tenet of treatment is to minimize the risk of infection. The initial risk of infection is determined by wound characteristics, such as size, soft tissue coverage, vascular injury, and contamination. While no consensus exists on optimal antibiotic regimen, early administration of prophylactic antibiotics, within an hour of injury, when possible, has been shown definitively to decrease the risk of infection. Infection risk is further reduced by early irrigation with normal saline and aggressive debridement of devitalized tissue. Patient factors that increase risk of infection following open fracture include diabetes mellitus, smoking, male gender, and lower extremity fracture.

A pragmatic randomized trial evaluating pre-operative aqueous antiseptic skin solutions in open fractures (Aqueous-PREP): statistical analysis plan

Background

Approximately 1 in 10 patients with a surgically treated open fracture will develop a surgical site infection. The Aqueous-PREP trial will investigate the effect of 10% povidone-iodine versus 4% chlorhexidine in aqueous antiseptic solutions in reducing infections after open fracture surgery. The study protocol was published in April 2020.

Methods and design

The Aqueous-PREP trial is a pragmatic, multicenter, open-label, randomized multiple period cluster crossover trial. Each participating cluster is randomly assigned in a 1:1 ratio to provide 1 of the 2 study interventions on all eligible patients during a study period. The intervention periods are 2 months in length. After completing a 2-month period, the participating cluster crosses over to the alternative intervention. We plan to enroll a minimum of 1540 patients at 14 sites.

Results

The primary outcome is surgical site infection guided by the Centers for Disease Control and Prevention’s National Healthcare Safety Network reporting criteria (2017). All participants’ surgical site infection surveillance period will end 30 days after definitive fracture management surgery for superficial infections and 90 days after definitive fracture management surgery for deep incisional or organ/space infections [1]. The secondary outcome is an unplanned fracture-related reoperation within 12 months of the fracture.

Conclusion

This manuscript serves as the formal statistical analysis plan (version 1.0) for the Aqueous-PREP trial. The statistical analysis plan was completed on February 28, 2022.

A multicentre cross-sectional survey study on acute wound classification in the emergency department and its interobserver variability

Annually, a vast number of patients visits the emergency department for acute wounds. Many wound classification systems exist, but often these were not originally designed for acute wounds. This study aimed to assess the most frequently used classifications for acute wounds in the Netherlands and the interobserver variability of the Gustilo Anderson wound classification (GAWC) and Red Cross wound classification (RCWC) in acute wounds. This multicentre cross-sectional survey study employed an online oral questionnaire. We contacted emergency physicians from eleven hospitals in the south-eastern part of the Netherlands and identified the currently applied classifications. Participants classified ten fictitious wounds by applying the GAWC and RCWC. Afterwards, they rated the user-friendliness of these classifications. We examined the interobserver variability of both classifications using a Fleiss’ kappa analysis, with a subdivision in RCWC grades and types representing wound severity and injured tissue structures. The study included twenty emergency physicians from eight hospitals. Fifty percent of the participants reported using a classification for acute wounds, mostly the GAWC. The interobserver variability of the GAWC (κ = 0.46; 95% CI 0.44–0.49) and RCWC grades (κ = 0.56; 95% CI 0.53–0.59) was moderate, and it was good for the RCWC types (κ = 0.69; 95% CI 0.66–0.73). Participants considered both classifications helpful for acute wound assessment when the emergency physician was less experienced, despite a moderate user-friendliness. The GAWC was only of additional value in wounds with fractures, whereas the RCWC’s additional value in acute wound assessment was independent of the presence of a fracture. Emergency physicians are reserved to use a classification for acute wound assessment. The interobserver variability of the GAWC and RCWC in acute wounds is promising, and both classifications are easy to apply. However, their user-friendliness is moderate. It is recommended to apply the GAWC to acute wounds with underlying fractures and the RCWC to major traumatic injuries. Awareness should be raised of existing wound classifications, specifically among less experienced healthcare professionals.

Analysis of feline humeral fracture morphology and a comparison of fracture repair stabilisation methods: 101 cases (2009-2020)

OBJECTIVES

The aims of this study were to describe the type, presentation and prognostic factors of feline humeral fractures over a 10-year period and to compare three stabilisation systems for feline humeral diaphyseal fractures.

METHODS

In total, 101 cats with humeral fractures presenting to seven UK referral centres between 2009 and 2020 were reviewed. Data collected included signalment, weight at the time of surgery, fracture aetiology, preoperative presentation, fixation method, surgical details, perioperative management and follow-up examinations. Of these cases, 57 cats with humeral diaphyseal fractures stabilised using three different fixation methods were compared, with outcome parameters including the time to radiographic healing, time to function and complication rate.

RESULTS

The majority of the fractures were diaphyseal (71%), with only 10% condylar. Of the known causes of fracture, road traffic accidents (RTAs) were the most common. Neutered males were over-represented in having a fracture caused by an RTA (P = 0.001) and diaphyseal fractures were significantly more likely to result from an RTA (P = 0.01). Body weight had a positive correlation (r = 0.398) with time to radiographic healing and time to acceptable function (r = 0.315), and was significant (P = 0.014 and P = 0.037, respectively). Of the 57 humeral diaphyseal fractures; 16 (28%) were stabilised using a plate-rod construct, 31 (54%) using external skeletal fixation and 10 (18%) using bone plating and screws only. Open diaphyseal fractures were associated with more minor complications (P = 0.048). There was a significant difference between fixation groups in terms of overall complication rate between groups (P = 0.012). There was no significant difference between fixation groups in time to radiographic union (P = 0.145) or time to acceptable function (P = 0.306).

CONCLUSIONS AND RELEVANCE

All three fixation systems were successful in healing a wide variety of humeral diaphyseal fractures. There was a significantly higher overall complication rate with external skeletal fixators compared with bone plating; however, the clinical impact of these is likely low.

IDCRP Combat-Related Extremity Wound Infection Research

INTRODUCTION

Extremity trauma is the most common battlefield injury, resulting in a high frequency of combat-related extremity wound infections (CEWIs). As these infections are associated with substantial morbidity and may impact wounded warriors long after initial hospitalization, CEWIs have been a focus of the Infectious Disease Clinical Research Program (IDCRP). Herein, we review findings of CEWI research conducted through the IDCRP and discuss future and ongoing analyses.

METHODS

Military personnel with deployment-related trauma sustained between 2009 and 2014 were examined in retrospective analyses through the observational Trauma Infectious Disease Outcomes Study (TIDOS). Characteristics of wounded warriors with ≥1 open extremity wound were assessed, focusing on injury patterns and infection risk factors. Through a separate trauma-associated osteomyelitis study, military personnel with combat-related open fractures of the long bones (tibia, femur, and upper extremity) sustained between 2003 and 2009 were examined to identify osteomyelitis risk factors.

RESULTS

Among 1,271 wounded warriors with ≥1 open extremity wound, 16% were diagnosed with a CEWI. When assessed by their most severe extremity injury (i.e., amputation, open fracture, or open soft-tissue wound), patients with amputations had the highest proportion of infections (47% of 212 patients with traumatic amputations). Factors related to injury pattern, mechanism, and severity were independent predictors of CEWIs during initial hospitalization. Having a non-extremity infection at least 4 days before CEWI diagnosis was associated with reduced likelihood of CEWI development. After hospital discharge, 28% of patients with extremity trauma had a new or recurrent CEWI during follow-up. Risk factors for the development of CEWIs during follow-up included injury pattern, having either a CEWI or other infection during initial hospitalization, and receipt of antipseudomonal penicillin for ≥7 days. A reduced likelihood for CEWIs during follow-up was associated with a hospitalization duration of 15-30 days. Under the retrospective osteomyelitis risk factor analysis, patients developing osteomyelitis had higher open fracture severity based on Gustilo-Anderson (GA) and the Orthopaedic Trauma Association classification schemes and more frequent traumatic amputations compared to open fracture patients without osteomyelitis. Recurrence of osteomyelitis was also common (28% of patients with open tibia fractures had a recurrent episode). Although osteomyelitis risk factors differed between the tibia, femur, and upper extremity groups, sustaining an amputation, use of antibiotic beads, and being injured in the earlier years of the study (before significant practice pattern changes) were consistent predictors. Other risk factors included GA fracture severity ≥IIIb, blast injuries, foreign body at fracture site (with/without orthopedic implant), moderate/severe muscle damage and/or necrosis, and moderate/severe skin/soft-tissue damage. For upper extremity open fractures, initial stabilization following evacuation from the combat zone was associated with a reduced likelihood of osteomyelitis.

CONCLUSIONS

Forthcoming studies will examine the effectiveness of common antibiotic regimens for managing extremity deep soft-tissue infections to improve clinical outcomes of combat casualties and support development of clinical practice guidelines for CEWI treatment. The long-term impact of extremity trauma and resultant infections will be further investigated through both Department of Defense and Veterans Affairs follow-up, as well as examination of the impact on comorbidities and mental health/social factors.

The injury characteristics of open pilon fractures predictive of complications

OBJECTIVE

Determine predictive injury factors for wound complications in open pilon fractures (OTA/AO 43B and 43C).

DESIGN

Retrospective Case Series.

SETTING

Level I Trauma Center.

PATIENTS/PARTICIPANTS

A total of 61 open pilon fractures in 60 patients were evaluated after meeting inclusion and exclusion criteria.

INTERVENTION

The majority of injuries underwent a staged protocol with immediate antibiotics, debridement, irrigation and external fixation. Following soft tissue stabilization, internal fixation was performed and wound closure achieved in a coordinated fashion depending on the type of closure required.

MAIN OUTCOME MEASUREMENTS

Early amputation rate, 90-day major (wound dehiscence or deep infection requiring operative intervention) and minor (superficial infection) wound complications.

RESULTS

Four patients incurred early amputations, 11 had major wound complications and 5 had minor wound complications. An early amputation was more likely if they presented with an OTA Open Fracture Classification (OTA-OFC) Bone Loss Grade 3. A major wound complication was more likely if they presented with a fall from > 3 m, a multifragmentary articular surface, a segmental fibula fracture, or an OTA-OFC Contamination Grade 3. A multifragmentary articular surface was also predictive of developing any wound complication.

CONCLUSIONS

Open pilon fractures are severe, limb-threatening injuries and are at risk for wound complications. Patients presenting with these injuries and a predictive factor should be counseled regarding the possibility of early limb loss or experiencing a wound complication that will require additional treatment.

LEVEL OF EVIDENCE

Level III.

Severe Open Dislocation of the Hip with Exposed Femoral Head: A Case Report

CASE

A 54-year-old woman was brought to our emergency department with an inferomedial open hip dislocation without fracture secondary to a railway trauma. We performed hip reduction, wound debridement, and stabilization with external fixation. After 7 months, hip arthroplasty was performed for severe hip instability and avascular necrosis of the femoral head.

CONCLUSION

Open hip dislocation is an uncommon injury that is caused by high-energy trauma. It may be associated with serious management problems and complications, including infection and avascular necrosis of the femoral head.

Open tibial fractures: An overview

Open tibial fractures are complex injuries with multifactorial outcomes and variable prognosis. The close proximity of the tibia to the skin makes it prone to extensive soft tissue damage and subsequent detrimental complications, such as infection and non-union. Thus, they were historically associated with high rates of amputation, sepsis, or even death. The advancement of surgical instruments and techniques, along the emergence of evidence-based guidance, have resulted in a significant reduction in complications. Peculiarly though, modern management strategies have a strong foundation in practices described in the ancient times. Nevertheless, post-operative complications are still a challenge in the management of open tibial fractures. Efforts are actively being made to refine the surgical approaches used, while noteworthy is the emergence of the Orthoplastic approach. The aim of this review is to summarise and discuss the historical perspective of the management of open tibial fractures, their epidemiology and classification, up-to-date principles of surgical management and outcomes following injury.

Evolution in the Acute Management of Open Fracture Treatment? Part 1

INTRODUCTION

Despite decades of advancement in wound debridement, prophylactic antibiotic therapy, fracture stabilization, and soft tissue reconstruction, infection remains a serious complication after open fracture. Inconclusive historical data and new challenges with resistant organisms and antimicrobial stewardship having created a difficult environment within which to develop sound, evidence-based treatment protocols that can be applied universally. The first part of this 2-part series will synthesize the historical perspective along with the current concepts surrounding bacteriology and antibiotic use/stewardship. Part 2 will analyze and summarize the current literature regarding the management of open fracture and prevention of subsequent infection.Numerous authors from Hippocrates to Larrey noted that superior results were obtained with an early aggressive debridement of necrotic tissue after wounding.1-7 Historically, the usual outcome after open fracture was infection, sepsis, amputation, and death before the introduction of antibiotics.8-11 As recently as the first half of the 20th century, surgeons argued that if an appropriate debridement was performed, antibiotics were not necessary and advocated against their routine use over concern for resistant organisms.The current period of open fracture treatment (starting in the 1970s) heralded a more scientific era with critical evaluation of antibiotics, surgical debridement, and the development of standardized evidence-based protocols. This era began with 3 classic articles by Patzakis and Gustilo that, to this day, remain central to the discussion of infection prevention after open fractures.12-14.

LEVEL OF EVIDENCE

Therapeutic Level V. See Instructions for Authors for a Complete description of levels of evidence.

Unique closure of Gustilo IIIA fracture with a hard-to-heal lower extremity wound

Consistently achieving wound closure requires a broad understanding of wound physiology, anatomy and wound healing phases. The multifaceted principles of wound closure are comprised of: perfusion evaluation; diabetes control; nutritional optimisation; infection control; mechanical stress avoidance; oedema management; wound bed preparation; and community care. Optimisation of each element is crucial to timely and durable resolution of acute and hard-to-heal wounds. This objective is realisable only through an interdisciplinary approach to wound healing. The reconstructive ladder represents the graduation of complex wound management as applied by the specialty of plastic surgery. The approach to reconstruction typically begins with the least invasive option, which is considered reliable. However, there are instances when the most reliable option on the reconstructive ladder is not a viable option and creative solutions for wound closure are required. The following case report demonstrates a unique approach to lower extremity salvage in a subacute compound fracture surgical site infection using a limited reconstructive ladder.

Successful Limb Salvage Using an Orthoplastic Approach of Type IIIB Open Injuries of the Shoulder: A Report of 3 Cases

CASE

We report 3 adult men (aged 28, 34, and 71 years) with successfully salvaged mangled injuries around the shoulder with high threshold for amputation. Assessment by Mangled Extremity Severity Score, Ganga Hospital Open Injury Severity Score, and Orthopaedic Trauma Association-Open Fracture Classification open injury scores predicted amputation. However, extended salvage was performed by orthoplastic approach. Two of them had superior shoulder suspensory complex (SSSC) injury. The QuickDASH score was high in 2 patients with SSSC injury and a good score in the third patient who achieved good shoulder motion.

CONCLUSION

"Orthoplastic approach" achieves successful limb salvage in severely mangled shoulder injuries. Volume of muscle crush injury and double disruption of SSSC injury were the main determinants of outcome.

Classification of Bone Defects: An Extension of the Orthopaedic Trauma Association Open Fracture Classification

OBJECTIVES

To develop a post-traumatic bone defect classification scheme and complete a preliminary assessment of its reliability.

DESIGN

Retrospective classification.

SETTING

Tertiary referral trauma center.

PATIENTS/PARTICIPANTS

Twenty open fractures with bone loss.

INTERVENTION

Assignment of a bone defect classification grade.

MAIN OUTCOME MEASUREMENTS

Open fractures were classified based on orthogonal radiographs, assessing the extent and local geometry of bone loss, including D1-incomplete defects, D2-minor/subcritical (complete) defects (<2 cm), and D3-segmental/critical-sized defects (≥2 cm). Incomplete defects (D1) include D1A-<25% cortical loss, D1B-25%-75% cortical loss, and D1C->75% cortical loss. Minor/subcritical (complete) defects (<2 cm) (D2) include D2A-2 oblique ends allowing for possible overlap, D2B-one end oblique/one end transverse, and D2C-2 transverse ends. Segmental/critical-sized Defects (≥2 cm) include D3A-moderate defects, 2 to <4 cm; D3B-major defects, 4 to <8 cm; and D3C-massive defects, ≥8 cm. Reliability was assessed among 3 independent observers using Fleiss' kappa tests.

RESULTS

Interobserver reliability demonstrated the classification scheme has very good agreement, κ = 0.8371, P < 0.0005. Intraobserver reliability was excellent, κ = 1.000 (standard error 0.1478-0.1634), P < 0.00001. Interobserver reliability for the distinction between categories alone (D1, D2, or D3) was also excellent, κ = 1.000 (standard error 0.1421-0.1679), P < 0.00001.

CONCLUSIONS

This classification scheme provides a robust guide to bone defect assessment that can potentially facilitate selection of the most appropriate treatment strategy to optimize clinical outcomes.

Advancements in Reconstructive Surgery Broaden Opportunities for Salvage of the Injured Lower Extremity

Advancements in microsurgery have made lower extremity reconstruction possible even after major soft tissue loss or tibial nerve disruption. There is an ongoing paradigm shift in the indications for amputation versus salvage and in flap selection protocols for different areas of the lower extremity. Initial evaluation, patient selection, triage, and timing of reconstruction are essential factors that can influence functional and aesthetic outcomes. The emergence of perforator flaps and the application of new concepts such as free-style flaps, propeller perforator flaps, thinning of free flaps, and supermicrosurgery have provided reconstructive surgeons with many techniques to decrease donor-site morbidity and improve outcomes. This includes options for reconstruction on extremities with single or no adequate runoff vessels. We present a review of the major advancements in reconstructive surgery for salvage of the traumatic lower extremity.

Fracture-related outcome study for operatively treated tibia shaft fractures (F.R.O.S.T.): registry rationale and design

Background

Tibial shaft fractures (TSFs) are among the most common long bone injuries often resulting from high-energy trauma. To date, musculoskeletal complications such as fracture-related infection (FRI) and compromised fracture healing following fracture fixation of these injuries are still prevalent. The relatively high complication rates prove that, despite advances in modern fracture care, the management of TSFs remains a challenge even in the hands of experienced surgeons. Therefore, the Fracture-Related Outcome Study for operatively treated Tibia shaft fractures (F.R.O.S.T.) aims at creating a registry that enables data mining to gather detailed information to support future clinical decision-making regarding the management of TSF’s.

Methods

This prospective, international, multicenter, observational registry for TSFs was recently developed. Recruitment started in 2019 and is planned to take 36 months, seeking to enroll a minimum of 1000 patients. The study protocol does not influence the clinical decision-making procedure, implant choice, or surgical/imaging techniques; these are being performed as per local hospital standard of care. Data collected in this registry include injury specifics, treatment details, clinical outcomes (e.g., FRI), patient-reported outcomes, and procedure- or implant-related adverse events. The minimum follow up is 12 months.

Discussion

Although over the past decades, multiple high-quality studies have addressed individual research questions related to the outcome of TSFs, knowledge gaps remain. The scarcity of data calls for an international high-quality, population-based registry. Creating such a database could optimize strategies intended to prevent severe musculoskeletal complications. The main purpose of the F.R.O.S.T registry is to evaluate the association between different treatment strategies and patient outcomes. It will address not only operative techniques and implant materials but also perioperative preventive measures. For the first time, data concerning systemic perioperative antibiotic prophylaxis, the influence of local antimicrobials, and timing of soft-tissue coverage will be collected at an international level and correlated with standardized outcome measures in a large prospective, multicenter, observational registry for global accessibility.

Trial registration

ClinicalTrials.gov: NCT03598530.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-020-03930-x.

Resect or Retain Bone Fragments in Children and Teenagers with Severe Open Fractures?: A Case Report

CASE

A 14-year-old pedestrian was hit by a car and encountered similar bilateral Gustilo IIIB open tibial fractures. The right tibial fracture involved a large borderline vital butterfly fragment without periosteal contact, which was retained and proceeded to sufficient healing within 12 weeks. The left tibial fracture was treated according to the principles for the treatment of severe open fractures in adults, involving resection of devitalized fragments and bone transport, and healed within 15 months.

CONCLUSIONS

Teenagers do possess larger bone healing potential than adults. Therefore, a rapid bone union can be achieved even with apparently devitalized bone fragments if sufficient soft-tissue closure and stable fracture fixation is established early in the treatment of open limb fractures.

Soft tissue management in open tibial shaft fractures: A comparison of institutional preferences and resultant early clinical outcomes

Aims

To compare results of institutional preferences with regard to treatment of soft tissues in the setting of open tibial shaft fractures.

Methods

We present a retrospective review of open tibial shaft fractures at two high-volume level 1 trauma centres with differing practices with regard to the acute management of soft tissues. Site 1 attempts acute primary closure, while site 2 prefers delayed closure/coverage. Comparisons include percentage of primary closure, number of surgical procedures until definitive closure, percentage requiring soft tissue coverage, and percentage of 90-day wound complication.

Results

Overall, there were 219 patients at site 1 and 282 patients at site 2. Differences in rates of acute wound closure were seen (168 (78%) at site 1 vs 101 (36%) at site 2). A mean of 1.5 procedures for definitive closure was seen at site 1 compared to 3.4 at site 2. No differences were seen in complication, nonunion, or amputation rates. Similar results were seen in a sub-analysis of type III injuries.

Conclusion

Comparing outcomes of open tibial shaft fractures at two institutions with different rates initial wound management, no differences were seen in 90-day wound complications, nonunion rates, or need for amputation. Attempted acute closure resulted in a lower number of planned secondary procedures when compared with planned delayed closure. Providers should consider either acute closure or delayed coverage based on the injury characteristics, surgeon preference and institutional resources without concern that the decision at the time of index surgery will lead to an increased risk of complication.

Cite this article: Bone Joint Open 2020;1-8:481–487.

Does muscle improve validated outcome measures in open tibial fractures? New insights from a cohort study of the anterolateral thigh flap (ALT) versus ALT-Vastus lateralis flaps

The benefits of the muscle in open lower limb fractures remain to be determined. This study compared statistically equivalent groups of open tibial fractures treated by free anterolateral thigh (ALT) flaps or ALT flaps incorporating muscle (ALT-Vastus lateralis/ALT- VL). Method and Results: Chang Gung Memorial Hospital, Taiwan, 2004-2008, 49 free flaps in open lower limb fractures (38 open tibial) were specifically reconstructed with free ALT or ALT-VL flaps. Risk factors for non-union: equivalent between the two groups, with no differences in smoking, steroids, diabetes, time to flap and the AO classification of soft tissue and bone injury. Comparison of union rates: no difference was noted between groups in the Radiographic Union Score in Tibial Fractures (RUST) at 3, 6, 9 and 12 months. The only factor significantly associated with non-union was presence of a SPRINT trial defined 'critical' bone defect with odds ratio 14.4 (95% CI 1.36 - 131.5), with no association with AO bone classification, flap type, comorbidity or flap size. Patient-reported outcomes: the ALT-VL group showed improved patient satisfaction (p = 0.01, Cohen's d = 1.1). Functional outcomes (Enneking score) were not statistically significant, but the ALT-VL group trended towards significance in function and skin quality domains. Conclusions: Based on the results of this study, one can conclude that the degree of bone injury (specifically a 'critical' defect) is of greater relevance than flap choice with regard to fracture consolidation. Muscle does not result in improvements to union, the speed of union or deep infection. However, better PROMs may be related to the inclusion of the muscle around the fracture site.

Delays to Surgery and Coronal Malalignment Are Associated with Reoperation after Open Tibia Fractures in Tanzania

BACKGROUND

Treatment of diaphyseal open tibia fractures often results in reoperation and impaired quality of life. Few studies, particularly in resource-limited settings, have described factors associated with outcomes after these fractures.

QUESTIONS/PURPOSES

(1) Which patient demographic, perioperative, and treatment characteristics are associated with an increased risk of reoperation after treatment of open tibia fractures with intramedullary nailing or an external fixation device in Tanzania? (2) Which patient demographic, perioperative, and treatment characteristics are associated with worse 1-year quality of life after treatment of open tibia fractures with intramedullary nailing or an external fixation device in Tanzania?

METHODS

A prospective study was completed in parallel to a similarly conducted RCT at a tertiary referral center in Tanzania that enrolled adult patients with diaphyseal open tibia fractures from December 2015 to March 2017. Patients were treated with either a statically locked intramedullary nail or external fixator and examined at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year postoperatively. The primary outcome, reoperation, was any deep infection or nonunion treated with a secondary intervention. The secondary outcome was the 1-year EuroQol-5D (EQ-5D) index score. There were 394 patients screened and ultimately, 267 patients enrolled in the study (240 from the primary RCT and 27 followed for the purposes of this study). Of these, 90% (240 of 267) completed 1-year follow-up and were included in the final analysis. This group comprised 110 patients who underwent IMN and 130 who had external fixation; follow-up was similar between study groups. Patients were an average of 33 years old and were primarily males who sustained road traffic injuries resulting in AO/Orthopaedic Trauma Association (OTA) classification type A or B fractures. There were 51 reoperations. For the purposes of analysis, all patients were pooled to identify all other factors, in addition to treatment type, associated with increased risk of reoperation and 1-year quality of life. An exploratory bivariable analysis identifying various factors associated with reoperation risk and EQ-5D was subsequently included in a multivariate modeling procedure to control for confounding of effect on our primary outcome. Multivariable modeling was performed using standard hierarchical modeling simplification procedures with log-likelihood ratios. Alpha levels were set to 0.05.

RESULTS

After controlling for potentially confounding variables such as gender, smoking status, mechanism of injury, and treatment type, the following factors were independently associated with reoperation: Time from hospital presentation to surgery more than 24 hours (odds ratio 7.7 [95% confidence interval 2.1 to 27.8; p = 0.002), AO/OTA fracture classification Type 42C fracture (OR 4.2 [95% CI 1.2 to 14.0]; p = 0.02), OTA-Open Fracture Classification muscle loss (OR 7.5 [95% CI 1.3 to 42.2]; p = 0.02), and varus coronal angle on an immediate postoperative AP radiograph (OR 4.8 [95% CI 1.2 to 14.0]; p = 0.002). After again controlling for confounding variables such as gender, smoking status, mechanism of injury, and treatment type factors independently associated with worse 1-year EQ-5D scores included: Wound length ≥ 10 cm (ß = [change in EQ-5D score] -0.081 [95% CI -0.139 to -0.023]; p = 0.006), OTA-Open Fracture Classification muscle loss (ß = -0.133 [95% CI -0.215 to -0.051]; p = 0.002), and OTA-Open Fracture Classification bone loss (ß = -0.111 [95% CI -0.208 to -0.013]; p = 0.03). We observed a modest, but independent association between reoperation and worse 1-year EQ-5D scores (ß = -0.113 [95% CI -0.150 to -0.077]; p < 0.001).

CONCLUSIONS

We found two potentially modifiable factors associated with the risk of reoperation: reducing time to surgical treatment and avoiding varus coronal angulation during definitive stabilization. Hospitals may be able to minimize time to surgery, and thus, reoperation, by increasing the number of available operative personnel and space and emphasizing the importance of open tibia fractures as an injury requiring emergent orthopaedic management. Given the lack of fluoroscopy in the study setting and similar settings, surgeons should emphasize appropriate fracture alignment, even into slight valgus, to avoid varus angulation and subsequent reoperation risk.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Comparing the performance of different open injury scores in predicting salvage and amputation in type IIIB open tibia fractures

BACKGROUND

Various open injury scores have been devised to aid the difficult decision of salvage or amputation following open fractures of the lower limb. Our aim of the study was to compare the performance of mangled extremity severity score (MESS), limb salvage index (LSI), orthopaedic trauma association-open fracture classification (OTA-OFC) and Ganga hospital score (GHS) in our population of type IIIB injuries.

MATERIALS AND METHODS

A total of 219 patients with 225 type IIIB open fractures of the tibia were studied prospectively between July 2016 and June 2017. The decision of salvage or amputation was taken by a combined consensus of senior orthopaedic and plastic surgeons, blinded to the scores. All four open injury scores were calculated by an independent reviewer following initial debridement. The follow-up period was one to two  years.

RESULTS

After final follow-up, there were 193 (85.7%) successfully salvaged limbs, 19 primary amputations without attempt of debridement (8.4%), three primary delayed amputations within 72 hours (1.3%) and six secondary amputations after 72 hours from initial debridement (2.7%). Of these, four patients died within one  year and were excluded. All four scores performed well for salvage, while GHS was superior when considering amputation. MESS, LSI and OTA-OFC underscored amputations, since these scoring systems award more points for vascular injuries. There were both salvaged and amputated patients around the threshold value of amputation for all scores, which was only acknowledged by GHS in its unique 'grey zone'. It includes patients who are neither easily salvageable nor definitely requiring amputation.

CONCLUSION

The performance of the GHS was superior to MESS, LSI and OTA-OFC in our study, since it was developed for type IIIB injuries and includes the 'grey zone', where decisions need to be undertaken on a case to case basis.

CLINICAL RELEVANCE

GHS has an improved ability to determine amputation in IIIB open tibia fractures.

Surgical timing for open fractures: Middle of the night or the light of day, which fractures, what time?

Controversy exists over the optimal management of open fractures as new clinical studies question open fracture management dogma. Open fractures are complex injuries requiring the orthopaedic surgeon to consider both the bone injury as well as associated soft tissue injury. Early intravenous antibiotics and tetanus prophylaxis remain instrumental in infection prevention. However, the “six-hour rule” for initial open fracture debridement and revascularization has come into question. New evidence supports initial debridement within 24 hours with the appropriate surgical team. Additionally, orthopaedic surgeons and vascular surgeons should collaborate on the sequence of management of open fractures with associated vascular injury. Whereas debates on the optimal irrigation pressure and solution have been answered by multicenter randomized controlled trials, further research is required to determine the optimal irrigation volume and timing of wound closure. With advances in management of open fractures, the utility of well-known classification systems including the Gustilo-Anderson classification and Mangled Extremity Severity Score need to be re-evaluated in favor of up-to-date classification systems which better guide management and predict prognosis.

Slobogean G. Effect of Extended Prophylactic Antibiotic Duration in the Treatment of Open Fracture Wounds Differs by Level of Contamination

OBJECTIVE

To determine the association between prophylactic antibiotic duration after the definitive wound closure of an open fracture and deep surgical site infection (SSI).

DESIGN

Retrospective cohort study.

SETTING

41 clinical sites in the United States, Canada, Australia, Norway, and India.

PARTICIPANTS

Patients (N = 2400) with open fractures of the extremities who participated in the Fluid Lavage of Open Wounds (FLOW) trial.

INTERVENTION

Extended antibiotic prophylaxis, defined as more than 72 hours of continuous antibiotic use after definitive wound closure.

MAIN OUTCOME MEASUREMENT

Deep SSI diagnosed within 1 year of enrollment.

RESULTS

Forty-two percent of participants received extended antibiotic prophylaxis. Deep SSI prevalence was 5%, 8%, and 23% for wounds with mild, moderate, and severe contamination, respectively. In open fractures with mild contamination, extended antibiotic use showed a trend toward increased odds [adjusted odds ratio (aOR) = 1.39; 95% confidence interval (CI), 0.92-2.11] of deep SSI compared with shorter use. No association was found among patients with moderate contamination (aOR = 1.09; 95% CI, 0.53-2.27). By contrast, extended antibiotic prophylaxis was strongly protective (aOR = 0.20; 95% CI, 0.07-0.60) against deep SSI in patients with severe contamination. Propensity score sensitivity analysis results were consistent with these findings.

CONCLUSIONS

The evidence suggests differential effects of extended postclosure antibiotic duration on SSI odds contingent on the degree of contamination in open fracture wounds. Although extended antibiotic duration resulted in lower odds of SSI among patients with severely contaminated wounds, we observed a trend toward higher odds of SSI in mildly contaminated wounds.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Osteomyelitis Risk Factors Related to Combat Trauma Open Upper Extremity Fractures: A Case-Control Analysis

OBJECTIVE

To determine risk factors for osteomyelitis in US military personnel with combat-related, extremity long bone (humerus, radius, and ulna) open fractures.

DESIGN

Retrospective observational case-control study.

SETTING

US military regional hospital in Germany and tertiary care military hospitals in the United States (2003-2009).

PATIENTS/PARTICIPANTS

Sixty-four patients with open upper extremity fractures who met diagnostic osteomyelitis criteria (medical record review verification) were classified as cases. Ninety-six patients with open upper extremity fractures who did not meet osteomyelitis diagnostic criteria were included as controls.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASUREMENTS

Multivariable odds ratios (ORs; 95% confidence interval [CI]).

RESULTS

Among patients with surgical implants, osteomyelitis cases had longer time to definitive orthopaedic surgery compared with controls (median: 26 vs. 11 days; P < 0.001); however, there was no significant difference with timing of radiographic union. Being injured between 2003 and 2006, use of antibiotic beads, Gustilo-Anderson [GA] fracture classification (highest with GA-IIIb: [OR: 22.20; CI: 3.60-136.95]), and Orthopaedic Trauma Association Open Fracture Classification skin variable (highest with extensive degloving [OR: 15.61; CI: 3.25-74.86]) were independently associated with osteomyelitis risk. Initial stabilization occurring outside of the combat zone was associated with reduced risk of osteomyelitis.

CONCLUSIONS

Open upper extremity fractures with severe soft-tissue damage have the highest risk of developing osteomyelitis. The associations with injuries sustained 2003-2006 and location of initial stabilization are likely from evolving trauma system recommendations and practice patterns during the timeframe.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.

Is Bone Loss or Devascularization Associated With Recurrence of Osteomyelitis in Wartime Open Tibia Fractures?

BACKGROUND

During recent wars, 26% of combat casualties experienced open fractures and these injuries frequently are complicated by infections, including osteomyelitis. Risk factors for the development of osteomyelitis with combat-related open tibia fractures have been examined, but less information is known about recurrence of this infection, which may result in additional hospitalizations and surgical procedures.

QUESTIONS/PURPOSES

(1) What is the risk of osteomyelitis recurrence after wartime open tibia fractures and how does the microbiology compare with initial infections? (2) What factors are associated with osteomyelitis recurrence among patients with open tibia fractures? (3) What clinical characteristics and management approaches are associated with definite/probable osteomyelitis as opposed to possible osteomyelitis and what was the microbiology of these infections?

METHODS

A survey of US military personnel injured during deployment between March 2003 and December 2009 identified 215 patients with open tibia fractures, of whom 130 patients developed osteomyelitis and were examined in a retrospective analysis. No patients with bilateral osteomyelitis were included. Twenty-five patients meeting osteomyelitis diagnostic criteria were classified as definite/probable (positive bone culture, direct evidence of infection, or symptoms with culture and/or radiographic evidence) and 105 were classified as possible (bone contamination, organism growth in deep wound tissue, and evidence of local/systemic inflammation). Patients diagnosed with osteomyelitis were treated with débridement and irrigation as well as intravenous antibiotics. Fixation hardware was retained until fracture union, when possible. Osteomyelitis recurrence was defined as a subsequent osteomyelitis diagnosis at the original site ≥ 30 days after completion of initial treatment. This followup period was chosen based on the definition of recurrence so as to include as many patients as possible for analysis. Factors associated with osteomyelitis recurrence were assessed using univariate analysis in a subset of the population with ≥ 30 days of followup. Patients who had an amputation at or proximal to the knee after the initial osteomyelitis were not included in the recurrence assessment.

RESULTS

Of 112 patients meeting the criteria for assessment of recurrence, 31 (28%) developed an osteomyelitis recurrence, of whom seven of 25 (28%) had definite/probable and 24 of 87 (28%) had possible classifications for their initial osteomyelitis diagnosis. Risk of osteomyelitis recurrence was associated with missing or devascularized bone (recurrence, 14 of 31 [47%]; nonrecurrence, 22 of 81 [28%]; hazard ratio [HR], 3.94; 1.12-13.81; p = 0.032) and receipt of antibiotics for 22-56 days (recurrence, 20 of 31 [65%]; nonrecurrence: 37 of 81 [46%]; HR, 2.81; 1.05-7.49; p = 0.039). Compared with possible osteomyelitis, definite/probable osteomyelitis was associated with localized swelling at the bone site (13 of 25 [52%] versus 28 of 105 [27%]; risk ratio [RR], 1.95 [1.19-3.19]; p = 0.008) and less extensive skin and soft tissue injury at the time of trauma (9 of 22 [41%; three definite/probably patients missing data] versus 13 of 104 [13%; one possible patient missing data]; RR, 3.27 [1.60-6.69]; p = 0.001). Most osteomyelitis infections were polymicrobial (14 of 23 [61%; two patients with missing data] for definite/probable patients and 62 of 105 [59%] for possible patients; RR, 1.03 [0.72-1.48]; p = 0.870). More of the definite/probable patients received vancomycin (64%) compared with the possible patients (41%; p = 0.046), and the duration of polymyxin use was longer (median, 38 days versus 16 days, p = 0.018). Time to definitive fracture fixation was not different between the groups.

CONCLUSIONS

Recurrent osteomyelitis after open tibia fractures is common. In a univariate model, patients with an intermediate amount of bone loss and those treated with antibiotics for 22 to 56 days were more likely to experience osteomyelitis recurrence. Because only univariate analysis was possible, these findings should be considered preliminary. Osteomyelitis recurrence rates were similar, regardless of initial osteomyelitis classification, indicating that diagnoses of possible osteomyelitis should be treated aggressively.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Osteomyelitis Risk Factors Related to Combat Trauma Open Tibia Fractures: A Case-Control Analysis

OBJECTIVES

We assessed osteomyelitis risk factors in US military personnel with combat-related open tibia fractures (2003-2009).

METHODS

Patients with open tibia fractures who met the diagnostic criteria of osteomyelitis were identified as cases using Military Health System data and verified through medical record review. Controls were patients with open tibia fractures who did not meet osteomyelitis criteria. The Gustilo-Andersen fracture classification scheme was modified to include transtibial amputations (TTAs) as the most severe level. Logistic regression multivariable odds ratios [ORs; 95% confidence intervals (CI)] were assessed.

RESULTS

A total of 130 tibia osteomyelitis cases and 85 controls were identified. Excluding patients with TTAs, osteomyelitis cases had significantly longer time to radiographic union compared with controls (median: 210 vs. 165 days). Blast injuries, antibiotic bead utilization, ≥ Gustilo-Andersen-IIIb fractures [highest risk with TTA (OR: 15.10; CI: 3.22-71.07)], and foreign body at the fracture site were significantly associated with developing osteomyelitis. In a separate model, the Orthopaedic Trauma Association Open Fracture Classification muscle variable was significant with increasing risk from muscle loss (OR: 5.62; CI: 2.21-14.25) to dead muscle (OR: 8.46; CI: 3.31-21.64). When TTAs were excluded, significant risk factors were similar and included sustaining an injury between 2003 and 2006.

CONCLUSIONS

Patients with severe blast trauma resulting in significant muscle damage are at the highest risk for osteomyelitis. The period association coincides with a time frame when several trauma system practice changes were initiated (eg, increased negative pressure wound therapy, decreased high-pressure irrigation, and reduced crystalloid use).

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Unified classification of open fractures: Based on Gustilo and OTA classification schemes

BACKGROUND

The Orthopaedic Trauma Association (OTA) classification scheme for open fractures has improved precision, validity and reliability over the modified Gustilo classification system. However, it needs to be modified into a simple and practical classification system to gain widespread acceptance and application.

MATERIAL AND METHODS

We devised a new "unified" classification of open fractures based on the Gustilo and OTA classification systems. The new classification was tested for interobserver reliability on five different fractures classified by 15 surgeons each using the Krippendorff's alpha. Preference of surgeons for the Gustilo, OTA and unified classifications was assessed.

RESULTS

The new classification showed excellent interobserver reliability (α = 0.93). A significantly higher number of surgeons expressed preference for the new over the Gustilo and OTA classifications for routine clinical use.

CONCLUSION

The new "unified" classification of open fractures has good validity, reliability and acceptability, and has the potential to replace all other existing classification systems.

Outcomes of tibia shaft fractures caused by low energy gunshot wounds

BACKGROUND

The purpose of this project was to compare the rates of infections, nonunions, malunions, and secondary operations in tibia fractures resultant from low energy GSWs versus those seen in open and closed tibia fractures resultant from blunt trauma. A secondary objective was to assess the utility of using the traditional Gustilo-Anderson classification system for open fractures to describe fractures secondary to low energy GSW.

METHODS

A retrospective review of 327 patients with tibia shaft fractures was conducted at our level I trauma center. Patients underwent a variety of interventions depending on their injury. Standard fixation techniques were utilized. Outcome measures include: mechanism of injury, rates of superficial and deep infection, nonunion, malunion, and secondary operations.

RESULTS

Deep infection after low energy GSW tibia fractures was uncommon and seen in only 2.3% of patients. Rates of infection after low energy GSWs were similar to low and high energy closed tibia fractures resultant from blunt trauma, but significantly less than that seen in open type II (25%, p < 0.05), type IIIA (19.5%, p < 0.05), and type IIIB fractures (47%, p < 0.01). There were no nonunions following GSW fractures, versus 3.7% after closed tibia fractures from blunt trauma (p = 0.2). Nonunions were more common after open fractures from blunt trauma (11%, p < 0.05) versus GSWs. Differences in infection and nonunion were associated with more secondary operations (18%, p < 0.01) in the open tibia fracture group compared with GSWs (2.3%) and closed fractures (7.9% p = 0.19).

CONCLUSIONS

While GSWs are traditionally thought of as open injuries, low energy GSW tibia fractures had a low rate of infection and no nonunions, and resulted in a reoperation rate similar to closed blunt tibia shaft fractures and significantly lower than open tibia fractures.

Open fractures of the lower extremity: Current management and clinical outcomes

Open fractures of the lower extremity are the most common open long bone injuries, yet their management remains a topic of debate.

This article discusses the basic tenets of management and the subsequent impact on clinical outcome. These include the rationale for initial debridement, antimicrobial cover, addressing the soft-tissue injury and definitive skeletal management.

The classification of injury severity continues to be a useful tool in guiding treatment and predicting outcome and prognosis. The Gustilo-Anderson classification continues to be the mainstay, but the adoption of severity scores such as the Ganga Hospital score may provide additional predictive utility.

Recent literature has challenged the perceived need for rapid debridement within 6 hours and the rationale for prolonged antibiotic therapy in the open fracture. The choice of definitive treatment must be decided against known efficacy and injury severity/type.

Recent data demonstrate better outcomes with internal fixation methods in most open tibial fractures, but external fixation continues to be an appropriate choice in more severe injuries. The incidence of infection and non-union has decreased with new treatment approaches but continues to be a source of significant morbidity and mortality.

Assessment of functional outcome using various measures has been prevalent in the literature, but there is limited consensus regarding the best measures to be used.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170072

Gustilo IIIB Open Tibial Fractures: An Analysis of Infection and Nonunion Rates

BACKGROUND

Gustilo IIIB tibial fractures are associated with high rates of infection and nonunion. This study evaluates the impact of factors such as patient demographics, mechanism of injury, time to the first debridement, and time to flap coverage on the union and infection rates.

MATERIALS AND METHODS

A retrospective analysis was performed on all patients with open tibial fractures who presented to our tertiary trauma center over 13 years from April 2000 to August 2013. All patients were followed for at least 6 months and continued till radiographic evidence of union (maximum 72 months). Time to fracture union was based on radiological evidence of callus bridging at least three cortices. Information on infection rates and the presence of microbes were evaluated.

RESULTS

A total of 120 patients were analyzed. The mean time to fracture union was 33.8 weeks. Younger age was associated with a lower risk of nonunion with the mean age being 30.4 years in union group compared to 38.2 in the delayed-union group. Smoking was associated with an increased risk of delayed union with revision surgery being needed in 61.5% of smokers compared to 36.4% in nonsmokers. Rates of infection were high at 30.3%. Smoking was associated with an increased risk of infection (65.4% vs. 24.7%).

CONCLUSION

High-energy open tibia fractures required an average of 8.5 months to heal and delayed or nonunion at an earlier juncture cannot be assumed.

Magnitude of Soft-Tissue Defect as a Predictor of Free Flap Failures: Does Size Matter?

OBJECTIVES

To examine the relationship between the magnitude of soft-tissue defect and the risk of free-flap and limb-salvage complications/failures.

DESIGN

Retrospective cohort.

SETTING

Level I Trauma Center.

PATIENTS

One hundred twelve patients with free tissue transfers between January 2009 and June 2015.

INTERVENTION

A standardized approach using a consistent team of 2 orthopaedic microvascular surgeons was used for each free-flap reconstruction.

MAIN OUTCOME MEASURE

Soft tissue defect size, total or partial flap failure, and unplanned reoperations.

RESULTS

Of 112 free-flap reconstructions, 57 complications occurred in 43-cases (38%) including 5 total flap failures (4.5%), 7 partial flap failures (6%), and 8 early (7%) and 38 delayed complications (33%). There was a significant correlation between the large defect size (≥200 cm) and partial/total flap failure (n = 80, P = 0.023). There was also a significant correlation between large soft tissue defect size and any complication that is, total or partial failure and early or delayed unplanned return to the operating room (n = 80, P = 0.002). Of the flaps used, multivariate analysis revealed that latissimus flaps had higher odds for failure.

CONCLUSIONS

Soft-tissue defect size ≥200 cm can be associated with a higher rate of total or partial flap failure and any complication in acute trauma setting, which may be due to a larger zone of injury, a higher level of difficulty in achieving complete debridement, and a more complex microvascular dissection. Current and future efforts will need to continue to focus on risk stratification for limb salvage efforts because an accurate assessment of risk is important to the patient, health care provider, and the health care system in general.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

"Iatrogenic" Segmental Defect: How I Debride High-Energy Open Tibial Fractures

High-energy, open tibial shaft fractures may result in significant comminution, bone loss, and soft tissue injuries. Early, thorough debridement of all nonviable tissue is of critical importance in treating these fractures as an inadequate initial debridement increases the risk of infection and nonunion. Large iatrogenic bone and soft tissue defects can result from debridement and will require subsequent reconstruction by both orthopaedic and plastic surgeons. Although a variety of approaches exist to address these reconstructions, successful management of bone defects remains a considerable challenge. In this article, we detail our approach to debridement and reconstruction of segmental tibial defects and provide a review on the literature on this topic.