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Aljuhani WS, Alshabi YA, Alanazi AM, Alothri MA, Almutairi SA, Aljaafri ZA, Alzahrani AM. Risk of infection and conversion time from external to definitive fixation in open tibial fracture. J Orthop Surg Res 2024; 19:867. [PMID: 39710740 PMCID: PMC11665134 DOI: 10.1186/s13018-024-05350-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2024] [Accepted: 12/08/2024] [Indexed: 12/24/2024] Open
Abstract
BACKGROUND An open fracture of the tibia is one of the most common and dangerous type of open fractures. In the management of these injuries, the primary focus is on reducing the infection rate, as this is crucial for achieving the best clinical outcomes. This study aims to explore how provisional external fixation duration influences the rates of infection and union in open tibial shaft fractures. METHODS A retrospective study with a total of 55 patients who received temporary external fixation. Groups A (less than 12 days), B (12-24), C (25-36), and D (more than 36) were the four groups into which they were split according to the conversion time. RESULTS 12.8%, 18.2%, 50%, and 100% of the infections were found in Groups A, B, C, and D, respectively. Significant (P < 0.05) differences were found throughout the four groups. The conversion time from external to definitive fixation was found to have a relationship with the occurrence of an infection (P = 0.004). A higher prevalence of infection was observed over time. However, no association was observed between infection and antibiotic duration or initial debridement time (P = 0.689 and P = 0.963, respectively). CONCLUSIONS Results of this study demonstrate that the likelihood of infection increases when the change from external fixation to definitive internal fixation is delayed. Therefore, it is important to convert to definitive internal fixation immediately when the local and general conditions are favorable for doing so.
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Affiliation(s)
- Wazzan S Aljuhani
- Department of Orthopedic Surgery, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Yasir A Alshabi
- Department of Orthopedic Surgery, King Fahad Hospital, Ministry of Health, Madinah, Saudi Arabia
| | - Abdullah M Alanazi
- Department of Orthopedic Surgery, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Meshal A Alothri
- Department of Orthopedic Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Saleh A Almutairi
- Department of Orthopedic Surgery, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Ziad A Aljaafri
- Department of Orthopedic Surgery, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia.
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Abdullah M Alzahrani
- Department of Orthopedic Surgery, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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Le Baron M, Maman P, Volpi R, Flecher X. External fixation as definitive treatment or external fixation followed by early fixation in open fractures of the tibial shaft: A descriptive study. Injury 2024; 55 Suppl 1:111477. [PMID: 39069345 DOI: 10.1016/j.injury.2024.111477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 02/08/2024] [Accepted: 02/25/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION Treatment options for open tibial shaft fractures include external fixation with or without early conversion to internal fixation. OBJECTIVES The aim of this study was to describe 1) early conversion to internal fixation and definitive external fixation and 2) in case of conversion, to identify risk factors for complications. METHODS Seventy-two external fixations of open fractures of the tibial shaft (Gustilo classification, 7 fractures (9.7 %) grade I, 25 fractures (34.7 %) grade II, 40 fractures (55.6 %) grade III (31 grade IIIA and 9 grade IIIB)) were included in a continuous non-randomised study. Thirty-three fractures without infection signs were converted to internal fixation at a mean time of 40.5 +/-15 days (IF group). External fixation was maintened in the remaining 39 fractures (EF group). RESULTS In the "IF" group, the union rate was 69.7 % at 6.3 +/-3.6 months (3-16). All patients had complete union at 16 months, requiring 2.8 +/-0.8 reoperations. Fixation with external fixation only ("EF" group) showed a union rate of 51.3 % at 8.9 +/-4 (5-22) months and 96 % at 16 months after 3.7 +/-0.9 reoperations. Superficial infection (12.1 %; p = 0.011) and numerous surgeries (2.76; p = 0.004) were found to be risk factors for deep infection. Time to wound closure >7 days (p = 0.049), time to reoperation >28 days (p = 0.00), numerous surgeries (2.76; p = 0.004) and deep infection (6.1 %; p = 0.027) were found to be union failure factors. CONCLUSION Early conversion of external fixation to internal fixation is an effective option to achieve bone union of open tibial fractures in selected patients.
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Affiliation(s)
- Marie Le Baron
- Centre de Chirurgie orthopédique et traumatologie, Centre Hospitalo-Universitaire Nord, Marseille, Hôpital Nord, Chemin des Bourrely, 13915, Marseille, France.
| | - Pascal Maman
- Centre de Chirurgie orthopédique et traumatologie, Centre Hospitalo-Universitaire Nord, Marseille, Hôpital Nord, Chemin des Bourrely, 13915, Marseille, France
| | - Richard Volpi
- Centre de Chirurgie orthopédique et traumatologie, Centre Hospitalo-Universitaire Nord, Marseille, Hôpital Nord, Chemin des Bourrely, 13915, Marseille, France
| | - Xavier Flecher
- Centre de Chirurgie orthopédique et traumatologie, Centre Hospitalo-Universitaire Nord, Marseille, Hôpital Nord, Chemin des Bourrely, 13915, Marseille, France
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Shen M, Tejwani N. Open tibial shaft fracture fixation strategies: intramedullary nailing, external fixation, and plating. OTA Int 2024; 7:e316. [PMID: 38840705 PMCID: PMC11149753 DOI: 10.1097/oi9.0000000000000316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/17/2023] [Accepted: 12/18/2023] [Indexed: 06/07/2024]
Abstract
Tibial shaft fractures are one of the most common orthopaedic injuries. Open tibial shaft fractures are relatively common because of the paucity of soft tissue surrounding the bone. Despite the prevalence of these injuries, the optimal fixation strategy is still a topic of debate. The purpose of this article was to review the current literature on open tibial shaft fracture fixation strategies including intramedullary nailing, external fixation, and plating.
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Affiliation(s)
- Michelle Shen
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - Nirmal Tejwani
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
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Adesope Adesina S, Olusayo Amole I, Owolabi JI, Oyewusi OO, Goodness Adefokun I, Uwale Eyesan S. Locked intramedullary nailing of open fractures in resource-poor settings: a prospective observational study of challenges and functional outcomes in 101 fractures at Ogbomoso, Nigeria. BMC Musculoskelet Disord 2023; 24:170. [PMID: 36882725 PMCID: PMC9990318 DOI: 10.1186/s12891-023-06271-7] [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] [Received: 11/15/2022] [Accepted: 02/24/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Trauma is now one of the fastest growing epidemics globally but low and middle-income countries (LMICs) are more severely affected in terms of cost, disability and death. The high-energy trauma of road traffic accidents and violence often produces open fractures which can be difficult to manage in resource-poor settings. Adequate stabilization, such as provided by locked nails, has been found to ensure better outcome for open fractures. There is dearth of published studies on the use of locked intramedullary nail in the treatment of open fractures in Nigeria. METHODS This is a prospective observational study of all the 101 open fractures of the humerus, femur and tibia treated over a period of 92 months with Surgical Implant Generation Network (SIGN) nail. Fracture severity was classified according to the modified Gustilo-Anderson system. The intervals between fracture and antibiotics administration, débridement and definitive fixation, as well as surgery duration and method of fracture reduction were noted. Outcomes measured at follow-up included infection, ongoing radiographic healing, knee flexion/shoulder abduction beyond ninety degrees (KF/SA > 900), full weight bearing (FWB), painless squatting (PS&S)/shoulder abduction-external rotation (SAER). RESULTS Most of the patients fall between ages 20 and 49 years; 75.5% of them were males. There were more Gustilo-Anderson type IIIA fractures than other types but nine type IIIB tibia fractures were also nailed. The overall infection rate was 15%, contributed mostly by the type IIIB fractures. By the 12th post-operative week, at least 79% had ongoing radiographic healing and had achieved all of KF/SA > 900, FWB, and PS&S/SAER. CONCLUSION The SIGN nail's solid construct reduces the risk of infection and allows earlier use of the limb, making it particularly suitable in LIMCs where socioeconomic functioning often requires an unhindered use of the limbs.
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Affiliation(s)
| | - Isaac Olusayo Amole
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria.,Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
| | - James Idowu Owolabi
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria.,Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
| | | | | | - Samuel Uwale Eyesan
- Bowen University Teaching Hospital, P. O. Box 15, Ogbomoso, Oyo State, Nigeria.,Bowen University, P.M.B 284, Iwo, Osun State, Nigeria
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Type III Open Tibia Fractures Treated With Single-Stage Immediate Medullary Nailing and Attempted Primary Closure Yield Low Rates of Flap Coverage. J Am Acad Orthop Surg 2023; 31:252-257. [PMID: 36729759 DOI: 10.5435/jaaos-d-22-00469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 10/23/2022] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE The purpose of this study was to determine whether type III open high-energy tibia fractures treated with immediate intramedullary nailing (IMN) and primary closure yield low rates of flap coverage. METHODS Patients with high-energy type IIIA open tibia (OTA/AO42/43) fractures treated with IMN over a 10-year period at a level 1 academic center with at least 90 days of in-person postoperative follow-up were included. Single-stage reamed IMN with acute primary skin closure using Allgower-Donati suture technique was utilized in patients without notable skin loss. The primary outcome was treatment failure of acute primary skin closure requiring subsequent soft-tissue coverage procedures. RESULTS A total of 111 patients with type IIIA tibia fractures met inclusion criteria. Of 107 of the 111 patients (96%) with skin closure at the index surgery, 95 of the 107 patients (89%) healed their soft-tissue envelop uneventfully. Among the patients who failed primary closure (11%), five required free tissue transfers, five required local rotational flaps, and two underwent split thickness skin grafting only. Patients who failed acute primary closure declared within an average of 8 weeks postoperatively. DISCUSSION Treatment of type IIIA open high-energy tibia fractures with immediate IMN and primary closure using meticulous soft-tissue handling yields low rates of flap coverage.
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Adesina S, Amole I, Akinwumi A, Adegoke A, Owolabi J, Adefokun I, Durodola A, Awotunde O, Eyesan S. Infection complicating locked intramedullary nailing of open lower-extremity fractures: incidence, associated risk factors, and lessons for improving outcome in a low-resource setting. J Bone Jt Infect 2023; 8:71-79. [PMID: 38774303 PMCID: PMC11106765 DOI: 10.5194/jbji-8-71-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 01/24/2023] [Indexed: 05/24/2024] Open
Abstract
Introduction: Infection is the chief complication that makes open fractures difficult to treat. Most low- and middle-income countries (LMICs) are missing out on modern management techniques developed to achieve better outcomes in high-income countries (HICs). One of these is the use of locked intramedullary (IM) nails. This study aimed to determine the factors associated with infection of open fractures treated with the surgical implant generation network (SIGN) nail at a Nigerian tertiary hospital. Methods: Data were collected prospectively on 101 open fractures of the femur and tibia over an 8-year period. Active surveillance for infection was done on each patient. Infection was diagnosed as the presence of wound breakdown or purulent discharge from (or near) the wound or surgical incision. Potential risk factors were tested for association with infection. Results: There were 101 fractures in 94 patients with a mean age of 37.76 years. The following treatment-related factors demonstrated significant associations with infection - timings of antibiotic administration (p < 0.001 ) and definitive fracture fixation (p = 0.002 ); definitive wound closure (p < 0.001 ), fracture-reduction methods (p = 0.005 ), and surgery duration (p = 0.007 ). Conclusions: Although this study has limitations precluding the drawing up of final conclusions, the findings suggest that the risk factors for infection of nailed open fractures in LMICs are similar to those in HICs. Consequently, outcomes can potentially improve if LMICs adopt the management principles used in HICs in scientifically sound ways that are affordable and socially acceptable to their people. Further studies are suggested to establish our findings.
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Affiliation(s)
| | - Isaac O. Amole
- Department of Family Medicine, Bowen University, Iwo, 232102, Nigeria
| | - Akinsola I. Akinwumi
- Department of Family Medicine, Afe Babalola University, Ado-Ekiti,
360101, Nigeria
| | | | | | - Imri G. Adefokun
- Department of Surgery, Bowen University Teaching Hospital, Ogbomoso, 210001, Nigeria
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Timing of Flap Coverage With Respect to Definitive Fixation in Open Tibia Fractures. J Orthop Trauma 2021; 35:430-436. [PMID: 34267149 DOI: 10.1097/bot.0000000000002033] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES We conducted a large, U.S wide, observational study of type III tibial fractures, with the hypothesis that delays between definitive fixation and flap coverage might be a substantial modifiable risk factor associated with nosocomial wound infection. DESIGN A retrospective analysis of a multicenter database of open tibial fractures requiring flap coverage. SETTING Fourteen level-1 trauma centers across the United States. PATIENTS Two hundred ninety-six (n = 296) consecutive patients with Gustilo III open tibial fractures requiring flap coverage at 14 trauma centers were retrospectively analyzed from a large orthopaedic trauma registry. We collected demographics and the details of surgical care. We investigated the patient, and treatment factors leading to infection, including the time from various points in care to the time of soft-tissue coverage. INTERVENTION Delay definitive fixation and flap coverage in tibial type III fractures. MAIN OUTCOME MEASUREMENTS (1) Results of multivariate regression with time from injury to coverage, debridement to coverage, and definitive fixation to coverage in the model, to determine which delay measurement was most associated with infection. (2) A second multivariate model, including other factors in addition to measures of flap delay, to provide the estimate between delay and infection after adjustment for confounding. RESULTS Of 296 adults (227 M: 69 F) with open Gustilo type III tibial fractures requiring flap coverage, 96 (32.4%) became infected. In the multivariate regression, the time from definitive fixation to flap coverage was most predictive of subsequent wound infection (odds ratio 1.04, 95% confidence interval 1.01 to 1.08, n = 260, P = 0.02) among the time measurements. Temporary internal fixation was not associated with an increased risk of infection in both univariate (P = 0.59) or multivariate analyses (P = 0.60). Flap failure was associated with the highest odds of infection (odds ratio 6.83, 95% confidence interval 3.26 to 14.27, P < 0.001). CONCLUSION Orthoplastic teams that are dedicated to severe musculoskeletal trauma, that facilitate coordination of definitive fixation and flap coverage, will reduce the infection rates in Gustilo type III tibial fractures. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Patel KH, Logan K, Krkovic M. Strategies and outcomes in severe open tibial shaft fractures at a major trauma center: A large retrospective case-series. World J Orthop 2021; 12:495-504. [PMID: 34354937 PMCID: PMC8316841 DOI: 10.5312/wjo.v12.i7.495] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/16/2021] [Accepted: 06/03/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Severe open tibia fractures are challenging to treat with a lack of published clear management strategies. Our aim was to provide an overview of the largest single-center experience in the literature, with minimum 1-year follow-up, of adult type 3 open tibial shaft fractures at Cambridge University Hospitals (a United Kingdom major trauma center). We sought to define patient characteristics and our main outcome measures were infection, union and re-fracture. AIM To retrospectively define patient and injury characteristics, present our surgical methods and analyze our outcomes-namely infection, union and re-fracture rates. METHODS Consecutive series of 74 patients with 75 open tibial fractures treated between 2014 and 2020 (26 classified as Gustilo-Anderson 3A, 47 were 3B and two were 3C). Nine patients underwent intramedullary nailing (IMN), 61 underwent Taylor spatial frame (TSF) fixation and 5 were treated with Masquelet technique (IMN and subsequent bone grafting). RESULTS Mean follow-up was 16 mo (IMN) and 25 mo (TSF). We had an infection rate of 6.7% (5), non-union rate of 4% (3) and re-fracture rate of 2.7% (2). Average time to union was 22 wk for IMN and 38.6 wk for TSF. Thirty-three cases had a bone defect with a mean of 5.4 cm (2-11). Patient age, sex, diabetes, smoking status or injury severity did not have a significant effect on union time with either fixation method. Our limb salvage rate was 98.7%. CONCLUSION Grade 1 to 3A injuries can effectively be treated with reamed or unreamed IMN. Grade 3B/C injuries are best treated by circular external fixators as they provide good, reproducible outcomes and allow large bone defects to be addressed via distraction osteogenesis.
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Affiliation(s)
- Kavi H Patel
- Department of Trauma & Orthopaedics, Cambridge University Hospitals NHS Trust, Cambridge CB2 0QQ, United Kingdom
| | - Karl Logan
- Department of Trauma & Orthopaedics, Cambridge University Hospitals NHS Trust, Cambridge CB2 0QQ, United Kingdom
| | - Matija Krkovic
- Department of Trauma & Orthopaedics, Cambridge University Hospitals NHS Trust, Cambridge CB2 0QQ, United Kingdom
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Helfen T. [38/m-occupational accident : Preparation for the medical specialist examination-Part 12]. Unfallchirurg 2020; 124:27-31. [PMID: 33001369 DOI: 10.1007/s00113-020-00874-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- T Helfen
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Klinikum der Universität München, Nußbaumstr. 20, 80336, München, Deutschland.
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Extremitätentrauma in der Schockraumphase. Notf Rett Med 2020. [DOI: 10.1007/s10049-020-00745-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Orthopedic injuries in patients with multiple injuries: Results of the 11th trauma update international consensus conference Milan, December 11, 2017. J Trauma Acute Care Surg 2020; 88:e53-e76. [PMID: 32150031 DOI: 10.1097/ta.0000000000002407] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND In blunt trauma, orthopedic injuries are often associated with cerebral and torso injuries. The optimal timing for definitive care is a concern. The aim of the study was to develop evidence-based guidelines for damage-control orthopedic (DCO) and early total care (ETC) of pelvic and long-bone fractures, closed or open, and mangled extremities in adult trauma patients with and without associated injuries. METHODS The literature since 2000 to 2016 was systematically screened according to Preferred Reporting Items for Systematic Reviews and meta-analyses protocol. One hundred twenty-four articles were reviewed by a panel of experts to assign grade of recommendation and level of evidence using the Grading of recommendations Assessment, Development, and Evaluation system, and an International Consensus Conference, endorsed by several scientific societies was held. RESULTS The choice between DCO and ETC depends on the patient's physiology, as well as associated injuries. In hemodynamically unstable pelvic fracture patient, extraperitoneal pelvic packing, angioembolization, external fixation, C-clamp, and resuscitative endovascular balloon occlusion of the aorta are not mutually exclusive. Definitive reconstruction should be deferred until recovery of physiological stability. In long bone fractures, DCO is performed by external fixation, while ETC should be preferred in fully resuscitated patients because of better outcomes. In open fractures early debridement within 24 hours should be recommended and early closure of most grade I, II, IIIa performed. In mangled extremities, limb salvage should be considered for non-life-threatening injuries, mostly of upper limb. CONCLUSION Orthopedic priorities may be: to save a life: control hemorrhage by stabilizing the pelvis and femur fractures; to save a limb: treat soft tissue and vascular injuries associated with fractures, stabilize fractures, recognize, and prevent compartmental syndrome; to save functionality: treat dislocations, articular fractures, distal fractures. While DCO is the best initial treatment to reduce surgical load, ETC should be applied in stable or stabilized patients to accelerate the recovery of normal functions. LEVEL OF EVIDENCE Systematic review of predominantly level II studies, level II.
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Clinical outcome of conversion from external fixation to definitive internal fixation for open fracture of the lower limb. J Orthop Sci 2019; 24:888-893. [PMID: 30772125 DOI: 10.1016/j.jos.2019.01.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 01/06/2019] [Accepted: 01/10/2019] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Few reports have examined the outcomes and complications of temporary bridging external fixation (EF) in open fracture of the lower limb followed by conversion to open reduction internal fixation (ORIF). The purpose of this study was to evaluate healing rates and complications in patients treated with conversion from external fixation to definitive internal fixation for open fracture of the lower limb. METHOD Patients who underwent temporary bridging EF and subsequent conversion to internal fixation (IF) for open fracture of the lower limb, with follow-up period ≥12 months were included in this study. Demographic data, Gustilo-Anderson classification, fracture type, duration to definitive surgery, surgical procedure, perioperative complications, and additional procedures for cases with complications were obtained. RESULTS In total, 58 patients (43 males, 15 females), 63 fractures were included in this study. Four fractures (6.3%) were Gustilo grade I, 11 fractures (17.5%) were grade II, 34 fractures (54.0%) were grade IIIa, 12 fractures (19.0%) were grade IIIb, and two fractures (3.2%) were grade IIIc. Mean duration of the application of EF was 12.4 days (range, 3-45 days) until conversion to definitive IF. Rates of deep infection and nonunion were both 9.5%, with two cases showing concomitant infection and nonunion. Rates of infection were 8.8% (3/34) in grade IIIa and 25% (3/12) in grade IIIb. Rates of nonunion were 9.1% (1/11) in grade II, 2.9% (1/34) in grade IIIa and 33% (4/12) in grade IIIb. CONCLUSION Temporary EF for open fracture of the lower limb followed by conversion to IF, as early as soft tissue and general condition permit, may be a safe and effective procedure for patients with lower-limb open fracture of Gustilo grade IIIa or less. LEVEL OF EVIDENCE Level IV, Case series.
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Risk Factors for Infection After Intramedullary Nailing of Open Tibial Shaft Fractures in Low- and Middle-Income Countries. J Orthop Trauma 2019; 33:e234-e239. [PMID: 30702501 DOI: 10.1097/bot.0000000000001441] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES (1) To determine the infection rate after fixation of open tibial shaft fractures using the Surgical Implant Generation Network (SIGN) intramedullary nail in low- and middle-income countries (LMICs) and (2) to identify risk factors for infection. DESIGN Prospective cohort study using an international online database. SETTING Multiple hospitals in LMICs worldwide. PATIENTS/PARTICIPANTS A total of 1061 open tibia fractures treated with the SIGN nail in LMICs between March 2000 and February 2013. INTERVENTION Intravenous antibiotic administration, surgical debridement, and definitive intramedullary nailing within 14 days of injury. MAIN OUTCOME MEASUREMENTS Deep or superficial infection at follow-up, implant breakage/loosening, angular deformity >10 degrees, repeat surgery, radiographic union, weight bearing, and ability to kneel. RESULTS The overall infection rate was 11.9%. Infection rates by the Gustilo and Anderson classification were type 1: 5.1%, type II: 12.6%, type IIIa: 12.5%, type IIIb: 29.1%, and type IIIc: 16.7% (P = 0.001 between groups). Patients who developed infection had a longer mean time from injury to definitive surgery (4.7 vs. 3.9 days, P = 0.03) and from injury to wound closure (13.7 vs. 3.6 days, P < 0.001). Distal fractures had a higher infection rate than midshaft fractures (13.3% vs. 8.2%, P = 0.03). Infection rates were not associated with time from injury to initial debridement, time from injury to initial antibiotic administration, or total duration of antibiotics. CONCLUSIONS Open tibia fractures can be managed effectively using the SIGN intramedullary nail in LMICs with an overall infection rate of 11.9%. Risk factors for infection identified include more severe soft-tissue injury, delayed nailing, delayed wound closure, and distal fracture location. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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14
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Goodwin AI, Haws BE, Knio ZO, Moerk PK, Miller AN. Isokinetic Strength Testing Following Intramedullary Nailing of Tibial Shaft Fractures Predicts Time to Recovery and Return of Muscle Strength in the Injured Extremity: A Prospective Case Series. HSS J 2018; 14:266-270. [PMID: 30258331 PMCID: PMC6148580 DOI: 10.1007/s11420-018-9611-y] [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] [Received: 12/26/2017] [Accepted: 03/02/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The speed and degree of functional recovery over time after surgery for tibial shaft fracture has been previously described using subjective methods. QUESTIONS/PURPOSE This study aimed to quantitatively measure recovery of isokinetic strength in the injured leg after surgical repair of isolated closed tibial shaft fracture. METHODS In this prospective case series, patients were recruited after intramedullary nailing for isolated closed tibial shaft fracture at an academic medical center from January 2012 to December 2015. Recovery of isokinetic strength was quantified using an isokinetic dynamometer. Eight measures of isokinetic strength at 3, 6, and 12 months' follow-up were used to compare strength in the injured leg to the healthy leg. RESULTS In 36 patients recruited, there was a significant difference in strength between the healthy and injured legs at 3 months for seven of the eight metrics used, at 6 months for five of the eight metrics, and at 12 months for none of the eight metrics. Observing recovery of strength longitudinally, we saw significant improvement between 3 and 6 months for four of eight metrics and overall between 3 and 12 months for five of the eight metrics. All four metrics that showed a significant improvement between 3 and 6 months involved plantar flexion. No metrics showed significant improvement between 6 and 12 months. CONCLUSIONS Patients exhibited equal strength between their healthy and injured legs at 12 months after surgery. Improvement in strength occurred to a greater extent between 3 and 6 months after surgery than between 6 and 12 months. Plantar flexion appeared to improve more rapidly than dorsal extension.
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Affiliation(s)
| | - Brittany E. Haws
- Wake Forest University School of Medicine, Winston-Salem, NC 27157 USA
| | - Ziyad O. Knio
- Wake Forest University School of Medicine, Winston-Salem, NC 27157 USA
| | | | - Anna N. Miller
- Washington University School of Medicine, St. Louis, MO 63110 USA
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Kortram K, Bezstarosti H, Metsemakers WJ, Raschke MJ, Van Lieshout EM, Verhofstad MH. Risk factors for infectious complications after open fractures; a systematic review and meta-analysis. INTERNATIONAL ORTHOPAEDICS 2017; 41:1965-1982. [DOI: 10.1007/s00264-017-3556-5] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 06/23/2017] [Indexed: 01/20/2023]
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Özdemir G, Yılmaz B, Kömür B, Şirin E, Karahan N, Ceyhan E. Treatment preferences in Turkey for open fracture of the tibial diaphysis. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2017; 51:133-137. [PMID: 28131638 PMCID: PMC6197301 DOI: 10.1016/j.aott.2016.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 08/24/2016] [Accepted: 11/11/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate different treatment methods employed by orthopedic surgeons for open tibial fracture in adults. METHODS Survey of 12 questions regarding treatment of open tibial fracture was conducted with 285 orthopedics and traumatology specialists in Turkey in personal interviews and using web-based technique. RESULTS Of all survey participants, 99.6% responded that tetanus prophylaxis is necessary emergency procedure in cases of adult open tibial diaphysis fracture. In addition, 96.5% considered antibiotics administration necessary, 85.6% also selected irrigation with saline, 55.4% included debridement, and 45.3% temporary fixation. Only 4 (1.3%) respondents did not use aminoglycoside antibiotics. While 29.8% of those surveyed preferred external fixator as a definitive treatment method, 75.8% use intramedullary nail and 13.7% preferred plate method. CONCLUSION A wide variation was observed among orthopedics and traumatology specialists in Turkey regarding treatment of open tibial diaphysis fracture in adults. Data obtained from this study together with the available literature may be useful to further develop therapeutic approaches.
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Affiliation(s)
- Güzelali Özdemir
- Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey.
| | - Barış Yılmaz
- Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Baran Kömür
- Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Evrim Şirin
- Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Nazım Karahan
- Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Erman Ceyhan
- Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
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Comparison of closed reduction and expert tibial nailing with open reduction and plate and screw fixation in the treatment of two segmental tibial fractures. Chin J Traumatol 2017; 18:219-22. [PMID: 26764543 DOI: 10.1016/j.cjtee.2015.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To compare the outcomes of closed reduction and expert tibial nailing (ETN) versus open reduction and plate and screw fixation in treating two segmental tibial fractures. METHODS This study included 53 cases of two segmental fractures of the tibial shaft. They were admitted to our department between March 2010 and June 2013 and treated respectively by closed reduction and ETN (ETN group, n=31) or open reduction fixation with plate and screws (PS group, n=22). The general data of two groups including gender, age, injury cause, fracture type, etc showed no significant difference (p>0.05). To compare the therapeutic effects between two groups, the intraoperative condition, post- operative function and related complications were investigated. RESULTS All the patients were successfully followed up. The period was 19.2 months for ETN group and 20.5 months for PS group. All the fractures in ETN group had union without complications such as malunion, infection, or osteofascial compartment syndrome; whereas there were 3 cases of superficial infection cured by repeated dressing change and 2 cases of delayed union in PS group. The total incidence of complication in PS group was 22.7% (5/22), much higher than that in ETN group (p<0.05). Moreover, ETN group showed a better result in terms of intraoperative blood loss, operation time, postoperative weight bearing time and fracture union time. In ETN group, at one-year follow-up, Johner-Wruhs' criteria was adopted to assess the postoperative function, which was reported as excellent in 18 cases, good in 10 cases and fair in 3 cases in ETN group (100% excellent-good rate). While in PS group, the result was excellent in 10 cases, good in 7 cases, fair in 3 cases and poor in 2 cases (77.3% excellent-good rate). The comparison was insignificant (p>0.05). CONCLUSION Compared with plate and screw fixation, ETN fixation has the advantages of fewer complications, shorter operation time, being less invasive, earlier postoperative rehabilitation and weight bearing, quicker fracture union and better functional recovery, thus being an effective way to treat two segmental tibial fractures.
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Yıldırım A, Kapukaya A, Mertsoy Y, Yiğit Ş, Çaçan MA, Atiç R. Management of open fractures using a noncontact locking plate as an internal fixator. Indian J Orthop 2017; 51:312-317. [PMID: 28566784 PMCID: PMC5439318 DOI: 10.4103/0019-5413.205686] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The treatment of open fractures leads to major problems which may be due to various reasons. It mainly causes soft tissue problems due to the absorption of a large amount of energy by the soft tissues and bone tissues. Although some recent treatment protocols have eliminated many problems regarding delayed soft tissue closure, it still remains a big challange. This study uses a method called the internal fixator technique with noncontact locking plate (NC-LP) which involves the use of a combination of advantages of open and closed fixation techniques. MATERIALS AND METHODS 42 patients (32 men and 10 women) having a mean age of 34.11 years (range 17-56 years) with open fractures operated using internal fixator technique between 2007 and 2012 were included in this study. A retrospective chart review was conducted to record the following: age, gender, anatomic region of fractures, fracture etiology, classification of open fractures by Gustilo-Anderson and AO classification, surgeries, length of hospitalization, location and pattern of fracture, length of followup, and complications. RESULTS The fractures were caused by traffic accidents, shotgun injuries, falls from heights, and industrial crush injuries. Based on the Gustilo-Anderson classification, 31 fractures were Type III and 11 were Type II, where 23 were localized in the tibia and 19 in the femur. Patients delay for a mean of 13.5 h (range 6-24 h) for operation and the mean followup interval was 27.8 months (range 16-44 months). The mean union time was 19.7 weeks (range 16-29 weeks). One patient had delayed union and implant failure, one patient had osteomyelitis, five suffered from surface skin necrosis, and one patient had an angulation of 17° in the sagittal plane, for which no additional intervention was performed. CONCLUSIONS This case series demonstrates that an "internal fixator technique" is an acceptable alternative to the management of open fractures of the femur or tibia in adult patients. The NC-LP method provided opportunities to achieve a stable fixation with noncontact between the implant and the bone tissues, and the fractures were sufficiently stabilized to allow union with a low complication rate.
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Affiliation(s)
- Azad Yıldırım
- Department of Orthopaedics and Traumatology, Gazi Yaşargil Training and Research Hospital, Diyarbakır, Turkey,Address for correspondence: Dr. Azad Yıldırım, Gazi Yaşargil Training and Research Hospital, Diyarbakır, Turkey. E-mail:
| | - Ahmet Kapukaya
- Department of Orthopaedics and Traumatology, Medical Faculty, Dicle University, Diyarbakır, Turkey
| | - Yılmaz Mertsoy
- Department of Orthopaedics and Traumatology, Gazi Yaşargil Training and Research Hospital, Diyarbakır, Turkey
| | | | - Mehmet Akif Çaçan
- Department of Orthopaedics and Traumatology, Medical Faculty, Dicle University, Diyarbakır, Turkey
| | - Ramazan Atiç
- Department of Orthopaedics and Traumatology, Medical Faculty, Dicle University, Diyarbakır, Turkey
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The Gustilo–Anderson classification system as predictor of nonunion and infection in open tibia fractures. Eur J Trauma Emerg Surg 2016; 43:651-656. [DOI: 10.1007/s00068-016-0725-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 09/10/2016] [Indexed: 02/06/2023]
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Uchiyama Y, Kobayashi Y, Ebihara G, Hamahashi K, Watanabe M. Retrospective comparison of postoperative infection and bone union between late and immediate intramedullary nailing of Gustilo grades I, II, and IIIA open tibial shaft fractures. Trauma Surg Acute Care Open 2016; 1:e000035. [PMID: 29766068 PMCID: PMC5891691 DOI: 10.1136/tsaco-2016-000035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 08/16/2016] [Accepted: 08/17/2016] [Indexed: 12/17/2022] Open
Abstract
Background The optimal method of skeletal stabilization is still controversial. Therefore, we examined the clinical outcomes associated with late (L) versus immediate intramedullary nailing (IMN). Methods This was a retrospective comparative study of trauma registry data from an emergency medical care center (university hospital). We examined 85 open tibial shaft fractures (85 patients) treated with L or immediate (I) IMN from January 2004 to December 2010. The L and I groups comprised 37 (33 men, 4 women) and 48 (44 men, 4 women) patients, respectively. The postoperative infection rate, time to bone union, and delayed union/non-union were evaluated. Results The mean ages at the time of trauma in the L and I groups were 41.8 (18-79) and 42.0 (18-71) years, respectively; the mean follow-up periods were 15.0 (6-39) and 18.3 (8-36) months, respectively. A higher rate of postoperative infection was found in the L group than in the I group (p=0.004). Superficial/deep infection developed at a higher rate in the L group than in the I group (p=0.042 and 0.045, respectively). Among patients with Gustilo grade IIIA fractures, postoperative infection occurred at a higher rate in the L group than in the I group (p=0.008). However, the delayed union rate, non-union rate, and time to bone union were not significantly different between the groups. Conclusions Gustilo grade IIIA fractures had a high infection rate, which is likely due to various factors, including pin-site infection after external fixation. We think that I IMN is safer than L IMN, and it should be the treatment of choice. Level of evidence Retrospective comparative study, level III.
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Affiliation(s)
- Yoshiyasu Uchiyama
- Department of Orthopedic Surgery, Surgical Science, Tokai University School of Medicine, Kanagawa, Japan
| | - Yuka Kobayashi
- Department of Orthopedic Surgery, Surgical Science, Tokai University School of Medicine, Kanagawa, Japan
| | - Gro Ebihara
- Department of Orthopedic Surgery, Surgical Science, Tokai University School of Medicine, Kanagawa, Japan
| | - Kosuke Hamahashi
- Department of Orthopedic Surgery, Surgical Science, Tokai University School of Medicine, Kanagawa, Japan
| | - Masahiko Watanabe
- Department of Orthopedic Surgery, Surgical Science, Tokai University School of Medicine, Kanagawa, Japan
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Flexible Intramedullary Nailing of Unstable and/or Open Tibia Shaft Fractures in the Pediatric Population. J Pediatr Orthop 2016; 36 Suppl 1:S19-23. [PMID: 27078231 DOI: 10.1097/bpo.0000000000000754] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Tibial shaft fractures are common injuries in the pediatric population, and can be treated conservatively the vast majority of the time. Yet, it is important to recognize that open and/or unstable tibial shaft fractures represent a different entity. Rigid intramedullary devices are generally contraindicated because of the skeletal immaturity of these patients, and external fixation is associated with a high complication rate. As a result, flexible nailing is being utilized with increasing frequency. It is essential for the clinician to understand the pearls and pitfalls associated with the utilization of these flexible nails; particularly in regards to their immediate use in the context of open fractures and the risk of compartment syndrome postoperatively after fixation.
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Reaming Does Not Affect Functional Outcomes After Open and Closed Tibial Shaft Fractures: The Results of a Randomized Controlled Trial. J Orthop Trauma 2016; 30:142-8. [PMID: 26618662 PMCID: PMC4761270 DOI: 10.1097/bot.0000000000000497] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES We sought to determine the effect of reaming on 1-year 36-item short-form general health survey (SF-36) and short musculoskeletal function assessment (SMFA) scores from the Study to Prospectively Evaluate Reamed Intramedullary Nails in patients with Tibial Fractures. DESIGN Prospective randomized controlled trial.1319 patients were randomized to reamed or unreamed nails. Fractures were categorized as open or closed. SETTING Twenty-nine academic and community health centers across the US, Canada, and the Netherlands. PATIENTS/PARTICIPANTS One thousand three hundred and nineteen skeletally mature patients with closed and open diaphyseal tibia fractures. INTERVENTION Reamed versus unreamed tibial nails. MAIN OUTCOME MEASUREMENTS SF-36 and the SMFA. Outcomes were obtained during the initial hospitalization to reflect preinjury status, and again at the 2-week, 3-month, 6-month, and 1-year follow-up. Repeated measures analyses were performed with P < 0.05 considered significant. RESULTS There were no differences between the reamed and unreamed groups at 12 months for either the SF-36 physical component score [42.9 vs. 43.4, P = 0.54, 95% Confidence Interval for the difference (CI) -2.1 to 1.1] or the SMFA dysfunction index (18.0 vs. 17.6, P = 0.79. 95% CI, -2.2 to 2.9). At one year, functional outcomes were significantly below baseline for the SF-36 physical componentf score, SMFA dysfunction index, and SMFA bothersome index (P < 0.001). Time and fracture type were significantly associated with functional outcome. CONCLUSIONS Reaming does not affect functional outcomes after intramedullary nailing for tibial shaft fractures. Patients with open fractures have worse functional outcomes than those with a closed injury. Patients do not reach their baseline function by 1 year after surgery. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Does Participation in a Randomized Clinical Trial Change Outcomes? An Evaluation of Patients Not Enrolled in the SPRINT Trial. J Orthop Trauma 2016; 30:156-61. [PMID: 27326429 DOI: 10.1097/bot.0000000000000533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the extent to which knowledge from clinical trial protocols is transferred to nonparticipating patients. DESIGN Retrospective review of prospectively collected data from a large clinical trial. SETTING Six level-1 international trauma centers. METHODS We compared rates and timing of reoperation in a subset of patients enrolled in the Study to Prospectively evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) to concurrent patients who were eligible but not enrolled. This was a retrospective review of prospectively collected trial data. The records of 6 of the original SPRINT centers were searched for non-SPRINT patients who underwent intramedullary nailing of a closed tibial fracture. The rate and timing of reoperation were compared. A P < 0.05 was considered significant. RESULTS One hundred fourteen non-SPRINT patients were compared with 328 patients enrolled in SPRINT from those same sites. There were 7 reoperations (6.1%) in non-SPRINT patients versus 18 (5.2%) in SPRINT patients [odds ratio (OR) 1.19, 95% confidence interval (CI) 0.41 to 3.13; P = 0.811]. There was no difference in the time to reoperation between the SPRINT and non-SPRINT patients (6.2 vs. 6.8 months, 95% CI of the difference -3.8 to 2.6; P = 0.685) or in the proportion of patients who underwent reoperation before 6 months (29% vs. 43%; OR 1.75; 95% CI 0.18 to 15.41; P = 0.647). CONCLUSIONS Patients not enrolled in SPRINT had similarly low rates of reoperation for nonunion, and the average time to reoperation for both groups was longer than 6 months. A 6-month waiting period may have allowed slow-to-heal fractures adequate time to heal, thereby reducing the rate of diagnosis of nonunion. As such, this waiting period could contribute to lower-than-expected reoperation rates for nonunion. It is possible that clinical trials may beneficially influence the care of nonenrolled patients.
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Silver ion doped ceramic nano-powder coated nails prevent infection in open fractures: In vivo study. Injury 2016; 47:320-4. [PMID: 26589596 DOI: 10.1016/j.injury.2015.10.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 10/05/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite improvement in operative techniques and antibiotic therapy, septic complications still occur in open fractures. We developed silver ion containing ceramic nano powder for implant coating to provide not only biocompatibility but also antibacterial activity to the orthopaedic implants. QUESTIONS/PURPOSES We hypothesised silver ion doped calcium phosphate based ceramic nano-powder coated titanium nails may prevents bacterial colonisation and infection in open fractures as compared with uncoated nails. METHODS 33 rabbits divided into three groups. In the first group uncoated, in the second group hydroxyapatite coated, and in the third group silver doped hydroxyapatite coated titanium nails were inserted left femurs of animals from knee regions with retrograde fashion. Before implantation of nails 50 μl solution containing 10(6)CFU/ml methicillin resistance Staphylococcus aureus (MRSA) injected intramedullary canal. Rabbits were monitored for 10 weeks. Blood was taken from rabbits before surgery and on 2nd, 6th and 10th weeks. Blood was analysed for biochemical parameters, blood count, C-reactive protein and silver levels. At the end of the 10 weeks animals were sacrificed and rods were extracted in a sterile fashion. Swab cultures were taken from intramedullary canal. Bacteria on titanium rods were counted. Liver, heart, spleen, kidney and central nervous tissues samples were taken for determining silver levels. Histopathological evaluation of bone surrounding implants was also performed. RESULTS No significant difference was detected between the groups from hematologic, biochemical, and toxicological aspect. Microbiological results showed that less bacterial growth was detected with the use of silver doped ceramic coated implants compared to the other two groups (p=0.003). Accumulation of silver was not detected. No cellular inflammation was observed around the silver coated prostheses. No toxic effect of silver on bone cells was seen. CONCLUSION Silver ion doped calcium phosphate based ceramic nano powder coating to orthopaedic implants may prevents bacterial colonisation and infection in open fractures compared with those for implants without any coating.
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Grade 3 open tibial shaft fractures treated with a circular frame, functional outcome and systematic review of literature. Injury 2015; 46:751-8. [PMID: 25648287 DOI: 10.1016/j.injury.2015.01.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 01/12/2015] [Accepted: 01/13/2015] [Indexed: 02/02/2023]
Abstract
We report on the surgical and functional outcome of 22 patients with Grade 3 open tibial fractures treated with circular frame. All cases united and there were no re-fractures or amputations. All patients were assessed at a minimum of 1-year post frame removal. Assessment included clinical examination, IOWA ankle and knee scores, Olerud and Molander ankle score and EuroQol EQ-5D. Clinical scores were either good or excellent in over half of the patients in all knee and ankle scores. There was a significant positive correlation between functional outcomes and the EQ-5D score. The EQ-5D mean health state visual analogue score was comparable to the general UK population despite patients scoring less than the average UK population in three of the five domains. 36% reported some difficulties in walking and 41% had problems with pain. 14% had difficulties with self-care and 46% had difficulties with their usual activities. 14% had problems with anxiety or depression. Systematic review of the literature suggests, in the management of open tibial fractures, circular frames provide equivalent or superior surgical outcomes in comparison with other techniques. Our study finds the application of a circular frame also results in a good functional outcome in the majority of cases.
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Metsemakers WJ, Handojo K, Reynders P, Sermon A, Vanderschot P, Nijs S. Individual risk factors for deep infection and compromised fracture healing after intramedullary nailing of tibial shaft fractures: a single centre experience of 480 patients. Injury 2015; 46:740-5. [PMID: 25583638 DOI: 10.1016/j.injury.2014.12.018] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 12/07/2014] [Accepted: 12/17/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Despite modern advances in the treatment of tibial shaft fractures, complications including nonunion, malunion, and infection remain relatively frequent. A better understanding of these injuries and its complications could lead to prevention rather than treatment strategies. A retrospective study was performed to identify risk factors for deep infection and compromised fracture healing after intramedullary nailing (IMN) of tibial shaft fractures. MATERIALS AND METHODS Between January 2000 and January 2012, 480 consecutive patients with 486 tibial shaft fractures were enrolled in the study. Statistical analysis was performed to determine predictors of deep infection and compromised fracture healing. Compromised fracture healing was subdivided in delayed union and nonunion. The following independent variables were selected for analysis: age, sex, smoking, obesity, diabetes, American Society of Anaesthesiologists (ASA) classification, polytrauma, fracture type, open fractures, Gustilo type, primary external fixation (EF), time to nailing (TTN) and reaming. As primary statistical evaluation we performed a univariate analysis, followed by a multiple logistic regression model. RESULTS Univariate regression analysis revealed similar risk factors for delayed union and nonunion, including fracture type, open fractures and Gustilo type. Factors affecting the occurrence of deep infection in this model were primary EF, a prolonged TTN, open fractures and Gustilo type. Multiple logistic regression analysis revealed polytrauma as the single risk factor for nonunion. With respect to delayed union, no risk factors could be identified. In the same statistical model, deep infection was correlated with primary EF. CONCLUSIONS The purpose of this study was to evaluate risk factors of poor outcome after IMN of tibial shaft fractures. The univariate regression analysis showed that the nature of complications after tibial shaft nailing could be multifactorial. This was not confirmed in a multiple logistic regression model, which only revealed polytrauma and primary EF as risk factors for nonunion and deep infection, respectively. Future strategies should focus on prevention in high-risk populations such as polytrauma patients treated with EF.
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Affiliation(s)
- W-J Metsemakers
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium.
| | - K Handojo
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium
| | - P Reynders
- Brugmann University Hospital, Department of Orthopaedic and Trauma Surgery, B-1000 Brussels, Belgium
| | - A Sermon
- KU Leuven - University of Leuven, Department Development and Regeneration, B-3000 Leuven, Belgium; University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium
| | - P Vanderschot
- KU Leuven - University of Leuven, Department Development and Regeneration, B-3000 Leuven, Belgium; University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium
| | - S Nijs
- KU Leuven - University of Leuven, Department Development and Regeneration, B-3000 Leuven, Belgium; University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium
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Mundi R, Chaudhry H, Niroopan G, Petrisor B, Bhandari M. Open Tibial Fractures: Updated Guidelines for Management. JBJS Rev 2015; 3:01874474-201502000-00001. [PMID: 27490746 DOI: 10.2106/jbjs.rvw.n.00051] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Raman Mundi
- Division of Orthopaedic Surgery, McMaster University, 293 Wellington Street North, Suite 110, Hamilton, ON L8L 8E7, Canada
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Xu X, Li X, Liu L, Wu W. A meta-analysis of external fixator versus intramedullary nails for open tibial fracture fixation. J Orthop Surg Res 2014; 9:75. [PMID: 25124047 PMCID: PMC4237860 DOI: 10.1186/s13018-014-0075-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 07/27/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To compare the clinical outcomes of external fixator (EF) and intramedullary nails (IN) in the treatment of open tibial fractures. METHODS We searched seven electronic databases (PubMed, MEDLINE, EMBASE, OVID, Cochrane library, CNKI, and CBM) for trials of tibial fracture fixation published from 1980 to 2013. The indicators including postoperative infection, malunion, nonunion, soft tissue injury, delayed healing, and healing time were used for quantitative outcome assessments. RESULTS A total of nine trials involving 532 patients (EF, n = 253; IN, n = 279) with open tibia fractures were included in this meta-analysis. The results indicated that the patients undergoing IN had lower incidence of postoperative infection (risk radio [RR] = 3.85; 95% confidence intervals [CI], 2.67-5.54; P < 0.0001), malunion (RR = 2.31; 95% CI, 1.40-3.81; P = 0.001), nonunion (RR = 1.41; 95% CI, 1.06-1.88; P = 0.02) and less healing time (weighted mean difference [WMD] = 6.19; 95% CI, 1.42-10.96; P = 0.01) compared with EF. However, regarding to the soft tissue injury (RR = 0.74; 95% CI, 0.34-1.62; P = 0.45) and delayed healing (RR = 1.38; 95% CI, 0.79-2.43; P = 0.26), there is no significantly difference between EF and IN approach. CONCLUSION In conclusion, the use of IN is more effective than EF and may be considered as first-line approach in fixation of open tibial fractures.
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Affiliation(s)
| | | | | | - Wei Wu
- Department of Traumatic Orthopedics, East Hospital, No,150 Jimo Road, Pudong New District, Shanghai 200120, China.
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Percutaneous grafting with bone marrow autologous concentrate for open tibia fractures: analysis of forty three cases and literature review. INTERNATIONAL ORTHOPAEDICS 2014; 38:1845-53. [PMID: 24728310 DOI: 10.1007/s00264-014-2342-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 03/23/2014] [Indexed: 12/14/2022]
Abstract
PURPOSE Tibial fractures are the most common lower limb fractures. Some criteria such as open fractures and increasing open stage are known to be associated with high delayed union and pseudarthrosis rate. In cases of delayed or nonunion, classical treatment is autologous cancelous bone graft which is associated with high morbidity rate. The ideal treatment would be a percutaneous harvesting and grafting technique. As bone marrow autologous concentrate (BMAC) presents both advantages, we evaluated this technique from 2002 to 2007. METHODS This was a retrospective study of 43 cases of open tibial fractures with initial surgical treatment. The criteria of inclusion were open fracture and nonunion, delayed union or suspicion of delayed union. RESULTS In 23 cases (53.5 %) BMAC was successful. The success group had received significantly more CFU-F than the failure group (469 vs 153.10(3), p = 0.013). A threshold of 360.10(3) CFU-F grafted could be established over which there was 100 % success. BMAC done before 110 days after fracture had 47 % success and BMAC done since 110 days after fracture had 73 % success. BMAC success rate decreased with increasing initial fracture skin open stage. There was no BMAC success in cases of a fracture with a remaining gap of more than 4 mm. We had no complications with the technique at the iliac harvesting zone and tibia injection point. CONCLUSION BMAC is a technique that should be considered as one of the different alternatives for management of long-bone delayed and nonunion because of its effectiveness, low complication rate, preservation of bone stock and low cost.
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Abstract
High-energy open fractures of the tibia have traditionally been fraught with challenges to include bone comminution or loss, soft tissue loss, nonunion, and infection. A number of techniques have been implemented to treat the severe soft tissue loss typically involving the anteromedial surface of the tibia to include wet-to-dry dressings or Papineau techniques, negative pressure wound therapy, acellular dermal matrices, and rotational or free tissue transfer with Masquelet technique, primary shortening, and distraction osteogenesis to address bone loss. We present a novel technique and subsequent case series that obviates the need of free tissue transfer while treating high-energy type IIIB open tibia fractures by performing an acute shortening and angulation of the tibia and rotational muscle flap coverage and split-thickness skin grafting of the soft tissue defect. Distraction histiogenesis with circular external fixation is then used to correct the residual osseous deformity while stretching the rotational muscle flap.
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Makridis KG, Tosounidis T, Giannoudis PV. Management of infection after intramedullary nailing of long bone fractures: treatment protocols and outcomes. Open Orthop J 2013; 7:219-26. [PMID: 23919097 PMCID: PMC3731810 DOI: 10.2174/1874325001307010219] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 02/12/2013] [Accepted: 04/21/2013] [Indexed: 11/25/2022] Open
Abstract
Implant related sepsis is a relatively unusual complication of intra-medullary nail fixation of long bone fractures. Depending on the extent of infection, timing of diagnosis and progress of fracture union, different treatment strategies have been developed. The aim of this review article is to collect and analyze the existing evidence about the incidence and management of infection following IM nailing of long bone fractures and to recommend treatment algorithms that could be valuable in everyday clinical practice. After searching the P u b M e d /Medline databases, 1270 articles were found related to the topic during the last 20 years. The final review included 28 articles that fulfilled the inclusion criteria. Only a few prospective studies exist to report on the management of infection following IM nailing of long-bone fractures. In general, stage I (early) infections only require antibiotic administration with/without debridement. Stage II (delayed) infections can be successfully treated with debridement, IM reaming, antibiotic nails, and administration of antibiotics. Infected non-unions are best treated with exchange nailing, antibiotic administration and when infection has been eradicated with graft implantation if it is needed. Debridement, exchange nailing and systemic administration of antibiotics is the best indication for stage III (late) infections, while stage III infected non-unions can successfully be treated with nail removal and Ilizarov frame, especially when large bone defects exist.
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Affiliation(s)
- Kostas G Makridis
- Academic Department of Trauma and Orthopaedics, Leeds General Infirmary, Clarendon Wing, Level A, Great George Street, LS1 3EX Leeds, UK
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Abstract
BACKGROUND Flexible nailing has become the preferred implant for pediatric patients with tibial shaft fractures that require operative fixation. Immediate definitive fracture fixation with flexible nails in patients with high-energy, open fractures has not been examined. The purpose of our study was to determine if immediate flexible nailing of open pediatric tibial shaft fractures is safe and efficacious from a bone healing, wound, and infectious standpoint. METHODS A retrospective review of 26 tibial shaft fractures consecutively treated with flexible nailing at our institution from 2003 to 2010 was performed. Age, mechanism of injury, associated injuries, presence of compartment syndrome, antibiotic administration, systemic insults, time to union, as well as bone healing (nonunion, delayed union, malunion, leg length discrepancy, growth arrest), wound, and infectious complications were collected. Comparisons were made between patients with open fractures and those with closed fractures. RESULTS We identified 14 patients with open fractures and a control group of 12 patients with closed injuries who underwent flexible nailing. Patients with open fractures were more likely to have polytraumatic injuries (71.0% vs. 25.0%, P = 0.04). There was no difference (P = 1.0) in the rates of compartment syndrome (open = 14.0%, closed = 17.0%) between the 2 groups. Systemic complications (pulmonary compromise and increased intracranial pressure) were noted in 2 patients who underwent immediate nailing of their open fractures; both of whom had closed head injuries. There was no difference (P = 1.0) in the rates of wound/infectious complications between the open (7.0%) and closed (4.0%) fractures groups, with no cases of wound breakdown or osteomyelitis. There was an increased rate (P = 0.02) of bone healing complications in the open fracture group (21.0% vs. 4.0%); all in patients with Gustilo type 2 or 3 injuries. All patients achieved radiographic union at final follow-up. CONCLUSIONS Immediate flexible nailing of open pediatric tibial shaft fractures can be safely performed with minimal risk of wound or infectious complications. Clinicians should understand that prolonged bone healing (particularly in Gustilo type 2 or 3 injuries) should be expected in patients who undergo immediate flexible nailing of their open fractures. Open tibial shaft fractures are high-energy injuries, and should be seen as surrogate markers of polytrauma in the pediatric population. The risk of compartment syndrome is high regardless of whether a patient has a closed or open tibia fracture, and caution should be used in performing flexible nailing in patients who may have closed head injury due to a risk of systemic complications. LEVEL OF EVIDENCE Level III, therapeutic study, retrospective cohort.
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Abstract
OBJECTIVE Assess a cohort of combat-related type III open tibia fractures with peripheral nerve injury to determine the injury mechanism and likelihood for recovery or improvement in nerve function. DESIGN Retrospective study. SETTING Three military medical centers. PATIENTS AND PARTICIPANTS Out of a study cohort of 213 type III open tibia fractures, 32 fractures (in 32 patients) with a total of 43 peripheral nerve injuries (peroneal or tibial) distal to the popliteal fossa met inclusion criteria and were available for follow-up at an average of 20 months (range, 2-48 months). MAIN OUTCOME MEASUREMENTS Clinical assessment of motor and sensory nerve improvement. RESULTS There was a 22% incidence of peripheral nerve injury in the study cohort. At an average follow-up of 20 months (range, 2-48 months), 89% of injured motor nerves were functional, whereas the injured sensory nerves had function in 93%. Fifty percent and 27% of motor and sensory injuries demonstrated improvement, respectively (P = 0.043). With the numbers available, there was no difference in motor or sensory improvement based on mechanism of injury, fracture severity or location, soft tissue injury, or specific nerve injured. In the subset of patients with an initially impaired sensory examination, full improvement was related to fracture location (P = 0.0164). CONCLUSIONS Type III open tibia fractures sustained in combat are associated with a 22% incidence of peripheral nerve injury, and the majority are due to multiple projectile penetrating injury. Despite the severe nature of these injuries, the vast majority of patients had a functional nerve status by an average of 2-year follow-up. Based on these findings, discussions regarding limb salvage and amputation should not be overly influenced by the patient's peripheral nerve status. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Fang X, Jiang L, Wang Y, Zhao L. Treatment of Gustilo grade III tibial fractures with unreamed intramedullary nailing versus external fixator: a meta-analysis. Med Sci Monit 2012; 18:RA49-56. [PMID: 22460106 PMCID: PMC3560815 DOI: 10.12659/msm.882610] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Unreamed Intramedullary nailing and external fixation are 2 major treatments widely used in Gustilo grade III open tibial fractures, but the difference in effectiveness and complication remains controversial. We retrieved original publications of comparative studies from medical literature databases and selected 9 of them for a meta-analysis. Observation items include malunion and deep infection rate, non-union and comparison of time to union. The analysis showed a lower malunion rate using unreamed intramedullary nailing than external fixation. No significant differences were revealed in deep infection/nonunion rate and time to union. More studies of larger scale and better design are needed to reach an ultimate and definite conclusion.
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Affiliation(s)
- Xiao Fang
- Changzheng Hospital, 2nd Military Medical University, Shanghai, China
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Li Y, Liu L, Tang X, Pei F, Wang G, Fang Y, Zhang H, Crook N. Comparison of low, multidirectional locked nailing and plating in the treatment of distal tibial metadiaphyseal fractures. INTERNATIONAL ORTHOPAEDICS 2012; 36:1457-62. [PMID: 22310971 PMCID: PMC3385886 DOI: 10.1007/s00264-012-1494-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Accepted: 01/13/2012] [Indexed: 02/05/2023]
Abstract
PURPOSE The aim of this study was to compare the results of a new technique for low, multidirectional locked nailing with closed reduction and minimally invasive plating in the treatment of distal tibial metadiaphyseal fractures. METHODS Forty-six matched patients were divided according to age, gender, Injury Severity Score, and fracture pattern into group A (expert tibial nailing) and group B (minimally invasive plating). Then, the patients were followed up, and the clinical and radiographic results were retrospectively analysed. RESULTS The mean followed-up was 24.7±2.7 months in group A and 25.8±2.8 months in group B. No patient had nonunion, shortening, hardware breakdown, or deep-seated infection. Patients in group A had a significantly shorter mean operating time, hospital stay, full weight-bearing time and union time (76±16.6 vs. 90±20.3 minutes, p=0.000; 5.8±2.1 vs. 8.9±3.1 days, p=0.000; 9.0±1.4 vs. 11.1±1.7 weeks, p=0.000; and 21.3±3.5 vs. 23.1±3.6 weeks, p=0.047, respectively). Three patients in group A and one patient in group B presented with malalignment (p=0.608). The mean Olerud-Molander Ankle score was 89.0±7.1 in group A and 87.6±8.4 in group B (p=0.478). CONCLUSIONS Distal tibia metadiaphyseal fractures may be treated successfully with low, multidirectional locked nails or plates. However, low, multidirectional locked nailing may represent a superior surgical option, since it offers advantages in terms of mean operating time, hospital stay, full weight-bearing time and union time.
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MESH Headings
- Adult
- Bone Malalignment/etiology
- Bone Nails
- Bone Plates
- Female
- Fracture Fixation, Internal/adverse effects
- Fracture Fixation, Internal/instrumentation
- Fracture Fixation, Internal/methods
- Fractures, Closed/classification
- Fractures, Closed/diagnosis
- Fractures, Closed/surgery
- Fractures, Open/classification
- Fractures, Open/diagnosis
- Fractures, Open/surgery
- Humans
- Length of Stay
- Male
- Middle Aged
- Minimally Invasive Surgical Procedures
- Outcome Assessment, Health Care
- Postoperative Complications/etiology
- Retrospective Studies
- Tibial Fractures/classification
- Tibial Fractures/diagnosis
- Tibial Fractures/surgery
- Time Factors
- Trauma Severity Indices
- Treatment Outcome
- Weight-Bearing
- Young Adult
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Affiliation(s)
- Yong Li
- Department of Orthopaedic Surgery, West China Hospital of Sichuan University, No.37, Guo-xue-xiang, Chengdu, 610041 People’s Republic of China
| | - Lei Liu
- Department of Orthopaedic Surgery, West China Hospital of Sichuan University, No.37, Guo-xue-xiang, Chengdu, 610041 People’s Republic of China
| | - Xin Tang
- Department of Orthopaedic Surgery, West China Hospital of Sichuan University, No.37, Guo-xue-xiang, Chengdu, 610041 People’s Republic of China
| | - Fuxing Pei
- Department of Orthopaedic Surgery, West China Hospital of Sichuan University, No.37, Guo-xue-xiang, Chengdu, 610041 People’s Republic of China
| | - Guanglin Wang
- Department of Orthopaedic Surgery, West China Hospital of Sichuan University, No.37, Guo-xue-xiang, Chengdu, 610041 People’s Republic of China
| | - Yue Fang
- Department of Orthopaedic Surgery, West China Hospital of Sichuan University, No.37, Guo-xue-xiang, Chengdu, 610041 People’s Republic of China
| | - Hui Zhang
- Department of Orthopaedic Surgery, West China Hospital of Sichuan University, No.37, Guo-xue-xiang, Chengdu, 610041 People’s Republic of China
| | - Nicolas Crook
- Department of Burn and Plastic Surgery, West China Hospital, Sichuan University, Chengdu, 610041 People’s Republic of China
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LeCronier DJ, Papakonstantinou JS, Gheevarughese V, Beran CD, Walter NE, Atkinson PJ. Development of an interlocked nail for segmental defects in the rabbit tibia. Proc Inst Mech Eng H 2012; 226:330-6. [DOI: 10.1177/0954411912439825] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Previous animal models have been developed to study intramedullary nailing for challenging segmental defects in the tibia. In large animals, interlocked nail fixation created a stable environment suitable to study new bone growth technologies placed in the defect. To our knowledge, there are no comparable interlocked tibial defect models for the rabbit in which new technologies could be evaluated. Such a model would be helpful since the rabbit is a popular initial model for orthopedic research studies owing to its wide availability and low cost. While numerous studies have nailed the rabbit tibia, all were non-locked implants that allowed some degree of instability between the fracture fragments. In addition, the non-locked nails were constructed of stainless steel, whereas human nails are increasingly made from titanium alloy. In the current study, an interlocked titanium nail was developed for the rabbit tibia. It was implanted in cadaver tibiae and subjected to fatigue cycling in combined compression and bending at physiologic levels to 21,061 cycles. This duration is estimated to represent 12 weeks of gait by the animal. Before and after fatigue cycling, monotonic testing was performed in compression and bending at physiologic levels. The intact contralateral limbs served as controls. All limbs completed the cycling; the instrumented limbs exhibited interfragmentary cyclic strain amplitudes during fatigue (616 ± 139 microstrain), which was significantly greater than the control limbs (136 ± 35 microstrain). Monotonic strain amplitudes for the test limbs in bending and compression were 4839 ± 1028 and 542 ± 122 microstrain, respectively; corresponding values for the control bones were 407 ± 118 and 95 ± 38 microstrain, respectively. These data are similar to those presented in prior studies in larger bone models. The current study presents one method for interlocked nail fixation for this complex tibial shaft fracture in a small animal.
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Affiliation(s)
| | | | | | | | | | - Patrick J Atkinson
- Mechanical Engineering Department, Kettering University, USA
- McLaren Regional Medical Center, USA
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Cerqueira IS, Petersen PA, Júnior RM, Silva JDS, Reis P, Gaiarsa GP, Morandi M. ANATOMICAL STUDY ON THE LATERAL SUPRAPATELLAR ACCESS ROUTE FOR LOCKED INTRAMEDULLARY NAILS IN TIBIAL FRACTURES. REVISTA BRASILEIRA DE ORTOPEDIA (ENGLISH EDITION) 2012; 47:169-72. [PMID: 27042617 PMCID: PMC4799382 DOI: 10.1016/s2255-4971(15)30082-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Accepted: 09/19/2011] [Indexed: 11/20/2022]
Affiliation(s)
- Italo Scanavini Cerqueira
- Resident in Orthopedics and Traumatology, Institute of Orthopedics and Traumatology, HC-FMUSP, São Paulo, SP, Brazil
- Correspondence: Rua Dr. Ovidio Pires de Campos 333, Cerqueira Cesar, 05403-010 São Paulo, SP, BrazilCorrespondence: Rua Dr. Ovidio Pires de Campos 333Cerqueira CesarSão PauloSP05403-010Brazil
| | - Pedro Araujo Petersen
- Resident in Orthopedics and Traumatology, Institute of Orthopedics and Traumatology, HC-FMUSP, São Paulo, SP, Brazil
| | - Rames Mattar Júnior
- Associate Professor in the School of Medicine, University of São Paulo, and Head of the Hand and Microsurgery Group, Institute of Orthopedics and Traumatology, HC-FMUSP, São Paulo, SP, Brazil
| | - Jorge dos Santos Silva
- Attending Physician and Head of the Traumatology Group, Institute of Orthopedics and Traumatology, HC-FMUSP, São Paulo, SP, Brazil
| | - Paulo Reis
- Attending Physician in the Traumatology and Reconstruction Group, Institute of Orthopedics and Traumatology, HC-FMUSP, São Paulo, SP, Brazil
| | - Guilherme Pelosini Gaiarsa
- Attending Physician in the Traumatology and Reconstruction Group, Institute of Orthopedics and Traumatology, HC-FMUSP, São Paulo, SP, Brazil
| | - Massimo Morandi
- Head of the Trauma Service, Henry Ford Hospital, Detroit, USA
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Papakostidis C, Kanakaris NK, Pretel J, Faour O, Morell DJ, Giannoudis PV. Prevalence of complications of open tibial shaft fractures stratified as per the Gustilo-Anderson classification. Injury 2011; 42:1408-15. [PMID: 22019355 DOI: 10.1016/j.injury.2011.10.015] [Citation(s) in RCA: 198] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Revised: 10/12/2011] [Accepted: 10/12/2011] [Indexed: 02/02/2023]
Abstract
The aim of the present study was to comparatively analyse certain outcome measures of open tibial fractures, stratified per grade of open injury and method of treatment. For this purpose, a systematic review of the English literature from 1990 until 2010 was undertaken, comprising 32 eligible articles reporting on 3060 open tibial fractures. Outcome measures included rates of union progress (early union, delayed union, late union and non-union rates) and certain complication rates (deep infection, compartment syndrome and amputation rates). Statistical heterogeneity across component studies was detected with the use of Cochran chi-square and I(2) tests. In the absence of significant statistical heterogeneity a pooled estimate of effect size for each outcome/complication of interest was produced. All component studies were assigned on average a moderate quality score. Reamed tibial nails (RTNs) were associated with significantly higher odds of early union compared with unreamed tibial nails (UTNs) in IIIB open fractures (odds ratio: 12, 95% CI: 2.4-61). Comparing RTN and UTN modes of treatment, no significant differences were documented per grade of open fractures with respect to both delayed and late union rates. Surprisingly, nonunion rates in IIIB open fractures treated with either RTNs or UTNs were lower than IIIA or II open fractures, although the differences were not statistically significant. Significantly increased deep infection rates of IIIB open fractures compared with all other grades were documented for both modes of treatment (RTN, UTN). However, lower deep infection rates for IIIA open fractures treated with RTNs were recorded compared with grades I and II. Interestingly, grade II open tibial fractures, treated with UTN, presented significantly greater odds for developing compartment syndrome than when treated with RTNs. Our cumulative analysis, providing for each grade of open injury and each particular method of treatment a summarised estimate of effect size for the most important outcome measures of open tibial fractures, constitutes a useful tool of the practicing surgeon for optimal decision making when operative treatment of such fractures is contemplated.
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Affiliation(s)
- Costas Papakostidis
- Department of Trauma and Orthopaedics, Hatzikosta General Hospital, Ioannina, Greece.
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40
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[Fractures of the extremities with severe open soft tissue damage. Initial management and reconstructive treatment strategies]. Unfallchirurg 2011; 113:647-70; quiz 671-2. [PMID: 20680241 DOI: 10.1007/s00113-010-1801-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The successful management of open extremity injuries continues to represent a surgical challenge requiring a structured and multidisciplinary treatment concept. The treatment strategy depends on specific parameters, including the overall injury severity, life threatening trauma components, the degree oft soft tissue injury, the ischemia time, the contamination of the wound as well as the age and accompanying diseases of the patient. The treatment of fractures with a high-grade open soft tissue injury is guided by the severity of soft tissue damage including neurovascular damages, type of the fracture, overall state of the patient and is based on a clearly defined reconstructive algorithm sequentially employing initial wound treatment (debridement), stabilisation of the fracture and soft tissue coverage. The initial wound management includes radical and serial debridements and vessel reconstruction, followed by the gradual reconstruction of bone, tendons and nerves and a subsequent plastic soft tissue coverage.The sequential and priority-orientated implementation of these treatment steps is decisive for the long term outcome, which ideally results in an regular healing of bone and soft tissue without the presence of infection and good regain of extremity function.
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Abstract
Definitive treatment of open fractures of the tibial diaphysis is challenging. The high-energy nature of these fractures, as well as the contamination of the fracture site and devitalization of the soft-tissue envelope, greatly increases the risk of infection, nonunion, and wound complications. The goals of definitive treatment include wound coverage or closure; prevention of infection; restoration of length, alignment, rotation, and stability; fracture healing; and return of function. Advances in orthobiologics, modern plastic surgical techniques, and fracture stabilization methods, most notably locked intramedullary nailing, have led to improved prognosis for functional recovery and limb salvage. Despite improved union and limb salvage rates, the prognosis for severe type III open fracture of the tibial shaft remains guarded, and outcomes are often determined by patient psychosocial variables.
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Intramedullary nailing of proximal tibia fractures--an anatomical study comparing three lateral starting points for nail insertion. Injury 2010; 41:220-5. [PMID: 19880112 DOI: 10.1016/j.injury.2009.10.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Revised: 09/13/2009] [Accepted: 10/05/2009] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Intramedullary nailing is challenging in proximal tibia fractures, associated with high rates of malalignment. To date, no studies report the potential of lateral tibia nail insertion to correct primary valgus malalignment, commonly seen in proximal quarter fractures. MATERIALS AND METHODS 18 fresh-frozen cadaver lower extremities were used to simulate an AO/OTA 41-A3 fracture. Six nails (Expert Tibial Nailing System, Synthes, Salzburg, Austria) were inserted at the lateral third, six nails at the middle third and six nails at the medial third of the lateral tibia plateau. After nail insertion, alignment in the coronal plane was recorded. RESULTS Mean varus malalignment was dependent on the entry point at the lateral tibia plateau. Mean varus malalignment was 16 degrees if nails were inserted at the lateral third, 10 degrees at the middle third and 4 degrees after nail insertion at the medial third. If nails were inserted from the medial third, valgus malalignment was recorded in two specimens. DISCUSSION The effect of correction of coronal malalignment in proximal tibia fractures is dependent on the point of nail entry at the lateral plateau. Primary valgus deformation up to 20 degrees can be corrected by inserting tibia nails at the lateral third of the lateral tibia plateau. Surgeons should be aware of possible varus deformity and valgus malalignment despite lateral nail insertion.
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Eardley WGP, Taylor DM, Parker PJ. Training in the practical application of damage control and early total care operative philosophy--perceptions of UK orthopaedic specialist trainees. Ann R Coll Surg Engl 2009; 92:154-8. [PMID: 19995485 DOI: 10.1308/003588410x12518836440045] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Despite improvements in the outcome of individuals sustaining significant injury, the optimum management of fractures in traumatised patients remains an area of debate and publication. There is, however, a paucity of studies regarding the specifics of acquired experience and training of junior orthopaedic surgeons in the practical application of these skills. Our null hypothesis is that, despite alteration in surgical training, the perceived confidence and adequacy of training of UK orthopaedic specialist trainees in the application of damage control orthopaedics (DCO) and early total care (ETC) philosophy is unaffected. SUBJECTS AND METHODS A web-based survey was sent to a sample of orthopaedic trainees. From 888 trainees, 222 responses were required to achieve a 5% error rate with 90% confidence. RESULTS A total of 232 responses were received. Trainees reported a high level of perceived confidence with both external fixation and intramedullary devices. Exposure to cases was sporadic although perceived training adequacy was high. A similar pattern was seen in perceived operative role with the majority of trainees expecting to be performing such operations, albeit under varying levels of supervision. In a more complicated case of spanning external fixation for a 'floating knee, trainees reported a decreased level of perceived confidence and limited exposure. One-third of trainees reported never having been involved in such a case. In contrast to nationally collated logbook data, exposure to and perceived confidence in managing cases involving ETC and DCO were similar. CONCLUSIONS Despite changes in the training of junior orthopaedic surgeons, trainee-reported confidence and adequacy of training in the practical application of DCO and ETC was high. Exposure to cases overall was, however, seen to be limited and there was a suggestion of disparity between current operative experiences of trainees and that recorded in the national trainee logbook.
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Baldwin KD, Babatunde OM, Russell Huffman G, Hosalkar HS. Open fractures of the tibia in the pediatric population: a systematic review. J Child Orthop 2009; 3:199-208. [PMID: 19343389 PMCID: PMC2686810 DOI: 10.1007/s11832-009-0169-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2008] [Accepted: 03/16/2009] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The management of open fractures of the tibia in a pediatric population represents a challenge to the clinician. Several case series over the course of many years have been performed describing the results of treating these injuries. It remains unclear, however, whether there is a preferred modality of treatment for these injuries, if a more severe injury confers a greater risk of infection, and if time to union is affected by Gustilo type, although trends seem to exist. The purpose of this study was to assemble the available data to determine (1) the risk of infection and time to union of various subtypes of open tibia fractures in children and (2) the changes in treatment pattern over the past three decades. METHODS A systematic review of the available literature was performed. Frequency weighted mean union times were used to compare union times for different types of open fractures. Mantel Haentzel cumulative odds ratios were used to compare infection risk between different types of open fractures. Linear regression by year was used to determine treatment practices over time. RESULTS No significant change in practice patterns was found for type I and III fractures, although type II fractures were more likely to be treated closed in the later years of the study compared to the earlier years. Type III fractures conferred a 3.5- and 2.3-fold greater odds of infection than type I and type II fractures, respectively. There was no significant difference in odds of infection between type I and II fractures. There was a significant delay in mean time to union between type I and type II fractures, and between type II and type III fractures. CONCLUSIONS With the exception of type II fractures, the philosophy of treatment of open fractures of the tibia has not significantly changed over the past three decades. Closed treatment or internal fixation are both viable options for type II fractures based on their relatively low incidence of infection. This study also demonstrates a strong relationship between Gustillo sub-types and odds of infection in this population. Not surprisingly, union rates are also delayed with increasing injury severity.
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Affiliation(s)
- Keith D. Baldwin
- />Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 34th and Spruce, 2nd Floor, Silverstein Building, Philadelphia, PA 19104 USA
| | - Oladapo M. Babatunde
- />University of Pennsylvania School of Medicine, 3620 Hamilton Walk, Philadelphia, PA 19104 USA
| | - G. Russell Huffman
- />Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 34th and Spruce, 2nd Floor, Silverstein Building, Philadelphia, PA 19104 USA
| | - Harish S. Hosalkar
- />Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 34th and Spruce, 2nd Floor, Silverstein Building, Philadelphia, PA 19104 USA
- />Department of Orthopaedic Surgery, Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, 2nd Floor, Wood Building, Philadelphia, PA 19104 USA
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Micromotion at the Fracture Site After Tibial Nailing With Four Unreamed Small-Diameter Nails—A Biomechanical Study Using a Distal Tibia Fracture Model. ACTA ACUST UNITED AC 2009; 66:1391-7. [DOI: 10.1097/ta.0b013e31818b4c8e] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Soft Tissue and Bone Reconstruction in Severe Open Fractures of the Lower Extremity. Eur J Trauma Emerg Surg 2009; 35:1. [DOI: 10.1007/s00068-008-9001-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Keeling JJ, Gwinn DE, Tintle SM, Andersen RC, McGuigan FX. Short-term outcomes of severe open wartime tibial fractures treated with ring external fixation. J Bone Joint Surg Am 2008; 90:2643-51. [PMID: 19047709 DOI: 10.2106/jbjs.g.01326] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The treatment of complex open tibial fractures sustained in combat remains controversial. This study investigated the short-term outcomes of type-III tibial shaft fractures treated at our institution with ring external fixation. METHODS A retrospective review identified sixty-seven type-III tibial shaft fractures in sixty-five consecutive patients treated between April 2004 and January 2007. Of these, forty-five tibiae in forty-three patients received fracture fixation with ring external fixation. The cases of thirty-six patients, who received treatment for thirty-eight tibial shaft fractures to completion with a standardized protocol, were reviewed. RESULTS A blast mechanism accounted for thirty-five injuries, and three injuries were from high-velocity gunshot wounds. There were twenty-one type-IIIA, thirteen type-IIIB, and four type-IIIC fractures. Rotational or free soft-tissue flap coverage was performed on fifteen patients. Eighteen patients received planned delayed bone-grafting, and nine had only bone morphogenetic protein placed at the fracture site at the time of final wound closure. All fractures healed with <5 degrees of malalignment. One patient underwent elective delayed amputation. The average time to union with frame removal was 221 days (range, 102 to 339 days). CONCLUSIONS Treatment of severe open wartime tibial fractures with a protocol-driven approach to wound management and placement of ring external fixation can result in a low rate of complications and a relatively high rate of fracture union. Most complications can be successfully managed without frame removal.
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Affiliation(s)
- John J Keeling
- Department of Orthopaedic Surgery, National Naval Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA.
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Thermal necrosis complicating reamed intramedullary nailing of a closed tibial diaphysis fracture: a case report. J Orthop Trauma 2008; 22:737-41. [PMID: 18978551 DOI: 10.1097/bot.0b013e31818ccddf] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A case report of thermal necrosis of the tibia after reamed intramedullary nailing is presented. Given the consequences of this complication, the proper use of reaming technique and equipment is emphasized.
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Abstract
OBJECTIVE We conducted a study to evaluate the long-term functional outcomes of patients with an isolated tibial shaft fracture treated with locked intramedullary nailing. DESIGN Prospective cohort and retrospective clinical and radiographic assessment. SETTING A level 1 trauma and tertiary referral center. PATIENTS/PARTICIPANTS We identified 250 eligible patients with isolated tibia fractures from the Center's prospectively enrolled orthopaedic trauma database between 1987 and 1992. A total of 56 patients agreed to participate. We had a median follow-up of 14 years, with a range from 12 to 17 years. INTERVENTION All enrolled patients were initially acutely treated with locked intramedullary nailing of their tibia. MAIN OUTCOME MEASUREMENTS All enrolled patients were evaluated with the SF-36 and Short Musculoskeletal Functional Assessment functional questionnaires and an injury-specific questionnaire focusing on knee pain and symptoms of venous insufficiency. A subgroup of patients were evaluated radiographically and by physical examination. RESULTS The mean normalized SF-36 scores (physical composite score-PCS 48.9, mental composite score-MCS 51.8) and the mean normalized Short Musculoskeletal Functional Assessment scores (50.7) (bothersome index, functional index) were not statistically different (P > 0.05) from reference population norms. Of the questionnaire group (n = 56), only 15 (26.7%) denied knee pain with any activity whereas 41 patients (73.2%) had at least moderate knee pain. With respect to swelling, 19 (33.9%) reported asymmetrical swelling affecting the injured limb. However, of the 33 physically examined patients, only 6 (18.2%) had objective evidence of venous stasis. Knee range of motion was equivalent to the unaffected side in all but two patients (93.9%) whereas 14 (42.4%) had a restricted range of motion of the ankle. Nine patients (27.3%) had persistent quadriceps atrophy, and the same rate was observed for calf atrophy. Twenty-five patients (75.8%) had no tenderness to anterior knee palpation. Of the 31 radiographically examined patients, 11 patients (35.4%) showed evidence of arthritis despite the absence of radiographic malalignment. Five patients (16.1%) had at least mild osteoarthritis of at least one knee compartment, 5 (16.1%) had at least mild osteoarthritis of the tibio-talar joint, and 1 (3.2%) had osteoarthritis of both, despite the absence of malunion. Self-reported knee pain was not correlated with the presence of a tibial nail or radiographic nail prominence. Similarly, knee tenderness on examination was not correlated with these factors. CONCLUSIONS At a median 14 years after tibial nailing of isolated tibial fractures, patients' function is comparable to population norms, but objective and subjective evaluation shows persistent sequelae which are not insignificant. This study is the first to describe the long-term functional outcomes after tibial shaft fractures treated with intramedullary nailing nails. It may allow surgeons to better inform patients on the expected long-term function after intramedullary nailing of a tibia fracture. It may also prove useful when comparing intramedullary nailing nailing to other treatment techniques.
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Yokoyama K, Itoman M, Uchino M, Fukushima K, Nitta H, Kojima Y. Immediate versus delayed intramedullary nailing for open fractures of the tibial shaft: a multivariate analysis of factors affecting deep infection and fracture healing. Indian J Orthop 2008; 42:410-9. [PMID: 19753228 PMCID: PMC2740339 DOI: 10.4103/0019-5413.43385] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate contributing factors affecting deep infection and fracture healing of open tibia fractures treated with locked intramedullary nailing (IMN) by multivariate analysis. MATERIALS AND METHODS We examined 99 open tibial fractures (98 patients) treated with immediate or delayed locked IMN in static fashion from 1991 to 2002. Multivariate analyses following univariate analyses were derived to determine predictors of deep infection, nonunion, and healing time to union. The following predictive variables of deep infection were selected for analysis: age, sex, Gustilo type, fracture grade by AO type, fracture location, timing or method of IMN, reamed or unreamed nailing, debridement time (< or =6 h or >6 h), method of soft-tissue management, skin closure time (< or =1 week or >1 week), existence of polytrauma (ISS< 18 or ISS> or =18), existence of floating knee injury, and existence of superficial/pin site infection. The predictive variables of nonunion selected for analysis was the same as those for deep infection, with the addition of deep infection for exchange of pin site infection. The predictive variables of union time selected for analysis was the same as those for nonunion, excluding of location, debridement time, and existence of floating knee and superficial infection. RESULTS Six (6.1%; type II Gustilo n=1, type IIIB Gustilo n=5) of the 99 open tibial fractures developed deep infections. Multivariate analysis revealed that timing or method of IMN, debridement time, method of soft-tissue management, and existence of superficial or pin site infection significantly correlated with the occurrence of deep infection (P< 0.0001). In the immediate nailing group alone, the deep infection rate in type IIIB + IIIC was significantly higher than those in type I + II and IIIA (P = 0.016). Nonunion occurred in 17 fractures (20.3%, 17/84). Multivariate analysis revealed that Gustilo type, skin closure time, and existence of deep infection significantly correlated with occurrence of nonunion (P < 0.05). Gustilo type and existence of deep infection were significantly correlated with healing time to union on multivariate analysis (r(2) = 0.263, P = 0.0001). CONCLUSION Multivariate analyses for open tibial fractures treated with IMN showed that IMN after EF (especially in existence of pin site infection) was at high risk of deep infection, and that debridement within 6 h and appropriate soft-tissue managements were also important factor in preventing deep infections. These analyses postulated that both the Gustilo type and the existence of deep infection is related with fracture healing in open fractures treated with IMN. In addition, immediate IMN for type IIIB and IIIC is potentially risky, and canal reaming did not increase the risk of complication for open tibial fractures treated with IMN.
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Affiliation(s)
- Kazuhiko Yokoyama
- Department of Orthopaedic Surgery, Machida Municipal Hospital, Machida, Tokyo, Japan,Correspondence: Dr. Kazuhiko Yokoyama, Department of Orthopedic Surgery, Machida Municipal Hospital, 2-15-41 Asahi-Machi, Machida, Tokyo 194-0023, Japan. E-mail:
| | - Moritoshi Itoman
- School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Masataka Uchino
- School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Kensuke Fukushima
- School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Hiroshi Nitta
- School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Yoshiaki Kojima
- School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
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