Published online Jul 18, 2021. doi: 10.5312/wjo.v12.i7.495
Peer-review started: February 9, 2021
First decision: May 3, 2021
Revised: May 16, 2021
Accepted: June 3, 2021
Article in press: June 3, 2021
Published online: July 18, 2021
Open tibial fractures are a challenging injury to treat. They are often associated with high energy trauma and multiply injured patients. There is also a spectrum of severity of injury which makes it a challenge to establish clear treatment guidelines.
The motivation for this study was to assess the outcomes of a single surgeon treating open fractures in a level one trauma center. These injuries remain a challenge to manage and various treatment options are available and indeed used over the period studies.
We aimed to review the results of the treatment of these severe injuries. We chose infection, union and re-fracture rates as our primary outcome measures. We also sought to compare the outcomes of intramedullary nailing (IMN), Taylor spatial frame (TSF) and the Masquelet technique.
This was a case series of 75 open tibial fractures in 74 patients treated over the course of six years by a single trauma surgeon in level one trauma center. We reviewed fracture type, mechanism of injury, timing and number of operations, time to union, infection, re-fracture and complication rates. Mann-Whitney U test and Spearman’s correlation coefficients were used for statistical analysis. Follow up time was 16 mo for intramedullary nails and 25 mo for TSF.
Of 26 injuries were classified as Gustilo-Anderson 3A, 47 were 3B and two were 3C. Nine patients underwent IMN, 61 underwent TSF fixation and 5 were treated with Masquelet technique. Infection rate was 6.7%, non-union rate was 4% and re-fracture rate was 2.7%. Average time to union was 22 wk for IMN and 38.6 wk for TSF fixation. Limb salvage rate was 98.7%
Meticulous and aggressive debridement of Gustilo-Anderson type 3 fractures by experienced orthopaedic and plastic surgeons is paramount. Grade 1 to 3A injuries can effectively be treated with reamed or unreamed IMN. Grade 3B/C injuries are best treated using circular external fixation as this provide good if not superior outcomes to other limb salvage techniques and allows large bone defects to be addressed via distraction osteogenesis. In addition, this approach offers the advantages of postoperative adjustability.
Further studies should be prospective, and ideally include patient recorded outcome measures, particularly if comparing the results of different treatments available for the fixation of open tibial fractures.