Retrospective Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Jul 18, 2021; 12(7): 495-504
Published online Jul 18, 2021. doi: 10.5312/wjo.v12.i7.495
Strategies and outcomes in severe open tibial shaft fractures at a major trauma center: A large retrospective case-series
Kavi H Patel, Karl Logan, Matija Krkovic
Kavi H Patel, Karl Logan, Matija Krkovic, Department of Trauma & Orthopaedics, Cambridge University Hospitals NHS Trust, Cambridge CB2 0QQ, United Kingdom
Author contributions: Patel K performed the data collection, analysis and writing the paper; Logan K performed the data collection and analysis; Krkovic M edited the manuscript; all authors read and reviewed the final manuscript.
Institutional review board statement: This study was reviewed and approved by the Cambridge University Hospital NHS Trust. No patients were involved or contacted in this study as data was derived from an electronic hospital database.
Informed consent statement: Informed consent is not required.
Conflict-of-interest statement: The authors declare that they have no conflict of interest and no funding was received for this study.
Data sharing statement: No consent for data sharing was given as all data was anonymized and there is no risk of identification.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Kavi H Patel, MBBS, MSc, Doctor, Department of Trauma & Orthopaedics, Cambridge University Hospitals NHS Trust, Hills Road, Cambridge CB2 0QQ, United Kingdom.
Received: February 9, 2021
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
Research background

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.

Research motivation

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.

Research objectives

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.

Research methods

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.

Research results

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%

Research conclusions

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.

Research perspectives

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.