Single-stage orthoplastic reconstruction of Gustilo–Anderson Grade III open tibial fractures greatly reduces infection rates

doi:10.1016/j.injury.2015.08.027

Injury

Volume 46, Issue 11, November 2015, Pages 2263-2266

https://doi.org/10.1016/j.injury.2015.08.027 Get rights and content

Abstract

Background

Grade III open fractures of the tibia represent a serious injury. It is recognised that combined management of these cases by experienced orthopaedic and plastic surgeons improves outcomes. Previous studies have not considered the timing of definitive soft tissue cover in relation to the definitive orthopaedic management. This paper reviews the outcomes in patients treated in an orthoplastic unit where the emphasis was on undertaking the definitive orthopaedic and plastic surgical procedures in a single stage, following initial debridement and temporary stabilisation as necessary.

Methods

We reviewed medical notes of 73 consecutive patients with 74 Grade III open tibia fractures (minimum 1 year follow up), to compare deep infection rates in patients who had (a) a single-stage definitive fixation and soft tissue coverage vs. those who had separate operations, and (b) those who had definitive treatment completed in <72 h vs. >72 h.

Results

(a) Combined Single-stage Orthoplastic Fixation and Coverage: 48 fractures were managed with definitive orthopaedic fixation and plastic surgical coverage performed at the same time, whilst 26 had these performed at separate stages. Of those subjects that had definitive fixation and coverage in one procedure 2 (4.2%) developed deep infections, compared with 9 (34.6%) deep infections (p < 0.001) in those who underwent definitive fixation and coverage at separate operations. (b) Timing of surgery: Of the fractures that had definitive fixation and coverage completed within 72 h of injury, 5 (20%) developed deep infections, compared with 6 (12.2%) deep infections (p = 0.492) in those whose definitive fixation/coverage was completed at later than 72 h.

Conclusion

Joint orthoplastic operating lists facilitate simultaneous definitive fixation and cover that greatly reduces infection rates. Based on our experience presented in this paper, we believe that emphasis should be placed on timely transfer to a specialist centre, aiming for a single-stage combined orthoplastic procedure to achieve definitive fixation and soft tissue coverage and optimal outcomes.

Introduction

Fractures of the tibial diaphysis are common with an incidence of 20 per 100,000 population per year [1]. Approximately 23.5% of these are open [2]. Godina's landmark paper [3] outlined the advantages of early microvascular reconstruction of open fractures and it is now recognised that combined management of these cases by experienced orthopaedic and plastic surgeons has distinct advantages [4]. In 2009 standards for the management of open fractures of the lower limb in the United Kingdom were suggested by a working party combining orthopaedic (British Orthopaedic Association (BOA)) and plastic surgery (British Association of Plastic and Reconstructive Surgery (BAPRAS)) expertise [5]. This publication also outlined the appropriate infrastructure and personnel required to run a comprehensive ‘orthoplastic’ service and included microbiologists, interventional radiologists, rehabilitation specialists, limb prosthetic services and psychologists.

The fourth of the British Orthopaedic Association Standards for Trauma (BOAST 4) [6] was also published in 2009. It went further in defining the criteria for management of open tibial fractures suggesting the aim to definitively treat these injuries within 72 h. This part of the standard was then adopted as the orthopaedic measure in the Trauma Audit and Research Network (TARN), a UK based database for trauma patients. In many centres dealing with open fractures the availability of the appropriate plastic surgical expertise makes this target very difficult to achieve. In Britain, even in centres where there is appropriate orthopaedic and plastic expertise, the limited availability of resources such as operating list provision mean that the target is often challenging.

This paper reviews the outcomes in patients treated in an orthoplastic unit where the emphasis was on undertaking the definitive orthopaedic and plastic surgical procedures in a single stage, following initial debridement and temporary stabilisation as necessary.

The research question was: ‘Is there a difference in the rate of deep infection in patients with Gustilo–Anderson (GA) Grade III open tibial fractures, who have single-stage combined definitive skeletal fixation and soft tissue coverage, compared with those who have definitive orthopaedic and plastic surgery in separate operations?’ The study also looked at this in relation to the 72 h BOA standard.

Section snippets

Methods

Between March 2010 and January 2013, 81 patients presented to our major trauma centre with GA Grade III tibial open fractures. Case notes and follow up clinic letters were reviewed. 8 patients were found to have follow-up out of region and were excluded. This left us with complete notes and datasets for 73 patients with 74 GA Grade III open tibial fractures. The GA classification was made after the first debridement undertaken.

The diagnosis of ‘deep Infection’ was based on the criteria

Protocol

The unit aimed to achieve the transfer of patients with open tibia fractures from referring hospitals as soon as possible. On arrival at our centre, patients were placed on a trauma list for debridement and temporary stabilisation as appropriate, with senior plastic surgeons present. If required, patients were taken back to theatre for further reviews and debridements prior to definitive reconstruction. If there was a delay in hospital transfer, the initial wound debridement and temporary

Statistical analysis

Study groups were analysed using Fisher's exact test. P-values <0.05 were considered significant (SPSS Version 19; IBM; New York).

Results

30 patients presented directly to the Emergency Department of the study centre. 43 attended peripheral hospitals initially and were then referred.

There were 25 males and 48 females with an age range from 16 to 95 years (mean = 46¼ years). The severity of the injury was recorded using the Gustilo and Anderson (GA) classification system: there were 5 Grade IIIa fractures, 66 Grade IIIb fractures and 3 Grade IIIc fractures. Definitive soft tissue coverage were provided in a number of ways, as per

Discussion

In this study over 90% of the patients analysed had GA Grade IIIB and IIIC injuries. The data demonstrates that, using a combined orthopaedic and plastic approach to definitively treat these severe injuries at the same surgery, the deep infection rate can be substantially reduced (4.2% versus 34.6%; p < 0.001). This supports the concept that joint ‘orthoplastic’ operating lists facilitate simultaneous definitive fixation and cover. Accordingly, the emphasis of treatment should be a simultaneous

Limitations

With any retrospective review there is always the risk of encountering missing information in patient notes or inadequate follow up. The patients included represent a consecutive cohort. Exclusions were made from this cohort on the basis of missing or incomplete case notes. However reliable, complete data was available for over 90% of the cohort.

Follow up of these patients was in a combined orthoplastic clinic. Patients within the trauma network and even many from outwith this are referred back

Conclusion

This study presents a safe, practical protocol for the management of severe open tibial fractures. Joint ‘orthoplastic’ operating lists facilitate simultaneous definitive fixation and cover that appears to greatly reduce infection rates. The stated BOA standard aim for treatment within 72 h remains laudable but requires specific additional resources that may not be readily available in many centres. Based on our experience, presented in this paper, we believe that the emphasis should be placed

Conflict of interest

None.

References (12)

C.M. Court-Brown et al.
Epidemiology of adult fractures a review
Injury
(2006)
U. Khan et al.
Orthoplastics: an integral evolution within comprehensive trauma care
Injury
(2011)
C. Court-Brown et al.
The epidemiology of tibial fractures
J Bone Joint Surg Br
(1995)
M. Godina
Early microsurgical reconstruction of complex trauma of the extremities
Plast Reconstr Surg
(1986)
S.B. Naique et al.
Management of severe open tibial fractures: the need for combined orthopaedic and plastic surgical treatment in specialist centres
J Bone Joint Surg Br
(2006)
BOA/BAPRAS Standards for the management of open fractures of the lower limb....

There are more references available in the full text version of this article.

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Single-stage orthoplastic reconstruction of Gustilo–Anderson Grade III open tibial fractures greatly reduces infection rates

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Protocol

Statistical analysis

Results

Discussion

Limitations

Conclusion

Conflict of interest

Injury

Injury

The epidemiology of tibial fractures

J Bone Joint Surg Br

Early microsurgical reconstruction of complex trauma of the extremities

Plast Reconstr Surg

Management of severe open tibial fractures: the need for combined orthopaedic and plastic surgical treatment in specialist centres

J Bone Joint Surg Br